High satisfaction rate and range of motion can be expected in frozen shoulder after awake manipulation with brachial plexus block.

BACKGROUND: Adhesive capsulitis (AC) is a disease of the glenohumeral joint that is characterized by pain and both passive and active global stiffness with a slow and insidious onset. The disease can occur spontaneously (primary AC) or it can be secondary to other comorbidities, surgery, or trauma, such as fracture or dislocation. Multiple treatment approaches have been suggested: intra-articular steroid injection, physical therapy, manipulation under total anesthesia, and arthroscopic or open surgery. Shoulder manipulation under anesthesia is usually proposed to patients that suffer from severe AC and have already undergone several nonoperative treatments without benefit. Different techniques have been proposed. This study presents our manipulation technique and the clinical results we achieved after shoulder mobilization under brachial plexus block in patients with phase III primary AC. MATERIALS AND METHODS: A retrospective cohort study was performed on a sample of 110 patients with phase III AC who were treated with this manipulation and followed up for 1 year. Patients underwent two assessments-before the procedure (T0) and 4 months after it (T1)-based on the Numerical Rating Scale, Simple Shoulder Test, and joint range of motion to assess shoulder pain, function, and joint articulation, respectively. Furthermore, the patients had to express their degree of satisfaction with the procedure and the results achieved. RESULTS: Positive and statistically significant results were recorded in terms of pain reduction (ΔNPRS = - 5.4; p < 0.01) and improved functionality (Simple Shoulder Test Δ = 5; p < 0.01). Passive range of motion was statistically significantly increased for each movement at T1. Large increases were observed in extrarotation range of motion (ROM): R1 (Δ = 77.5°) and R2 (Δ = 70°), whereas little improvements were observed in intrarotation ROM. Patients achieved satisfying functional and articular recovery in all cases. Complications that needed further treatment occurred in three cases: a brachial plexus injury, a glenoid flake fracture, and persistent pain and stiffness. CONCLUSIONS: In this study, we proposed a standardized method of manipulation under brachial plexus block for patients affected by phase III adhesive capsulitis. The technique was applied among a large cohort of patients, who reported a high satisfaction rate and range-of-motion recovery after 4 months. This could represent an alternative treatment to surgery that has a shorter timeline and does not require patient hospitalization. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Custom-made reverse shoulder arthroplasty for severe glenoid bone loss: review of the literature and our preliminary results.

The treatment of severe glenoid bone loss in shoulder arthroplasty represents a challenge, and the results of current prosthetic designs with only glenoid fixation still remain unsatisfactory. In the past decade, customized glenoid prostheses have been developed to address severe glenoid arthritis and in the revision setting. In this review, we analyzed the current surgical options, the classification limits, past literature evidence, and our preliminary results of 6 patients (3 male, 3 female) treated with a reverse implant and custom-made glenoid implant (ProMade; LimaCorporate, Italy). Computer analysis of the residual shape and the amount of glenoid bone stock in association with new classifications could help the surgeon to obtain good clinical and radiological outcomes. The development of navigation systems could improve the adequacy of the implant and, thus, the reliability and longevity of the implant itself.

Technology applications in shoulder replacement.

The advancement of technologies in orthopaedic surgery should provide the surgeon with precise and trustworthy support for pre-operative planning, intra-operative guidance and post-operative follow-up. The request for greater accuracy, predictable results and fewer complications, is the engine of digital evolution in pre-operative planning and computer-assisted surgery (CAS). It is an evolution rather than a revolution, and in the last few years these developments have begun to involve shoulder replacement surgery, too.

A new method to evaluate the influence of the glenosphere positioning on stability and range of motion of a reverse shoulder prosthesis.

PURPOSE: Shoulder instability and reduced range of motion are two common complications of a total reverse shoulder arthroplasty. In this work, a new approach is proposed to estimate how the glenoid component positioning can influence the stability and the range of motion of a reverse shoulder prosthesis. MATERIALS AND METHODS: A standard reverse shoulder prosthesis has been analysed. To perform virtual simulation of the shoulder-prosthesis assembly, all the components of the prosthesis have been acquired via a 3D laser scanner and the solid models of the shoulder bones have been reconstructed through CT images. Loads on the shoulder joint have been estimated using anatomical models database. A new virtual/numerical procedure has been implemented using a 3D parametric modelling software to find the optimal position of the glenosphere. RESULTS: Several analyses have been performed using different configurations obtained by changing the glenoid component tilt and the lateral position of the glenosphere, modified through the insertion of a cylindrical spacer. For the analysed case study, it was found that the interposition of a spacer (between the baseplate and the glenoid) and 15° inferior tilt of the glenosphere allow improving the range of motion and the stability of the shoulder. CONCLUSIONS: Some common complications of the reverse shoulder arthroplasty could be effectively reduced by a suitable positioning of the prosthesis components. In this work, using a new method based on virtual simulations, the influence of the glenosphere positioning has been investigated. An optimal configuration for the analysed case study has been found. The proposed approach could be used to find, with no in vivo experiments, the optimal position of a reverse shoulder prosthesis depending on the different dimensions and shape of the bones of each patient.

Comparison of CFR-PEEK and conventional titanium locking plates for proximal humeral fractures: a retrospective controlled study of patient outcomes.

BACKGROUND: Metal plates are the fixation devices used most frequently to proximal humeral fractures (PHFs). However, in recent years carbon fiber-reinforced polyetheretherketone (CFR-PEEK) plates have become increasingly common. This study compares the clinical and radiographic outcomes of 42 Neer three- and four-part PHFs treated with CFR-PEEK or metal (titanium) plates. MATERIALS AND METHODS: Forty-two PHF patients were managed with CFR-PEEK plates (n = 21, males/females 9/12; mean age 57.4 years; mean follow-up 30.7 months; CFR-PEEK group) or metal plates (n = 21; males/females 7/14; mean age 55.8 years; mean follow-up 52.7 months; Metal group). Active shoulder mobility (anterior elevation, lateral elevation, external rotation, and internal rotation), the Constant-Murley Score, the Simple Shoulder Test Score, and the pain score were recorded. Preoperative computed tomography scans and X-rays were obtained. Postoperative fracture healing and displacement, tuberosity resorption and/or malposition, hardware position, and cortical thinning (CT) under the plate were assessed radiographically. RESULTS: Shoulder mobility, clinical, and pain scores were similar in both patient groups. CT was significantly greater in CFR-PEEK patients (mean difference, 1.14 mm; p = 0.0003). In both groups, incomplete or poor calcar reduction was associated to a significantly higher complication rate, especially stiffness and muscle weakness (p = 0.016). The rate of tuberosity resorption was significantly higher in the Metal group (p = 0.040). Two patients required revision to a hemiarthroplasty (CFR-PEEK) and reverse arthroplasty (Metal group). CONCLUSIONS: CFR-PEEK plates provide a viable alternative to conventional titanium plates in PHFs, ensuring similar clinical outcomes and a lower rate of tuberosity resorption, but they involve higher stress shielding under the plate.

Age-Related Changes of Elastic Fibers in Shoulder Capsule of Patients with Glenohumeral Instability: A Pilot Study.

BACKGROUND: Recurrent shoulder dislocations occur much more frequently in adolescents than in the older population but a clear explanation of this incidence does not exist. The aim of the present study was to define the age-related distribution of the elastic fibers (EFs) in the shoulder capsule's extracellular matrix as a factor influencing shoulder instability. MATERIALS AND METHODS: Biopsy specimens were obtained from the shoulder capsule of patients divided preoperatively into three groups: Group 1 consisted of 10 male patients undergoing surgery for unidirectional traumatic anterior instability (TUBS); Group 2 consisted of 10 male patients undergoing surgery for multidirectional instability (MDI); Group 3 represents the control, including 10 patients with no history of instability. In addition to the group as a whole, specific subgroups were analyzed separately on the basis of the age of subjects: > 22 or < to 22 years. All the samples were analyzed by histochemical (Weigert's resorcinol fuchsin and Verhoeff's iron hematoxylin), immunohistochemical (monoclonal antielastin antibody), and histomorphometric methods. RESULTS: Both the elastin density and the percentage of area covered by EFs were significantly higher in younger subjects (<22 years old). Furthermore, the elastin density and the percentage of area covered by EFs were significantly higher in specimens of group of patients affected by multidirectional shoulder instability in comparison to the other two groups. CONCLUSION: Data of the present study confirmed the presence of an age-related distribution of EFs in the human shoulder capsule. The greater amount of EFs observed in younger subjects and in unstable shoulders could play an important role in predisposing the joint to first dislocation and recurrence.

Assessment of return to play in professional overhead athletes subjected to arthroscopic repair of rotator cuff tears and associated labral injuries using the Italian version of the Kerlan-Jobe Orthopedic Clinic Shoulder and Elbow score.

BACKGROUND: The self-administered Kerlan-Jobe Orthopedic Clinic (KJOC) Shoulder and Elbow questionnaire is a reliable and sensitive outcome tool to assess upper extremity athletic performance and functional changes affecting return to play in overhead athletes. We report the results of a study of return to sport in professional overhead athletes at a mean follow-up of 2 years after arthroscopic repair of rotator cuff tears and associated labral injuries using the Italian version of the score. MATERIALS AND METHODS: A total number of 38 patients completed the 10-item questionnaire before and after surgery. They were also asked (1) whether they had returned to play; (2) how many months after the operation they had done so; (3) the level of postoperative performance (preinjury or less); and (4) whether they had had to change sport due to their shoulder problems. RESULTS: Significant differences were found (1) between preoperative and postoperative scores; (2) between the scores of patients who returned to play at preinjury level and those who merely returned to competition; and (3) between the postoperative subscores of 8/10 items, which were higher in the patients who returned to preinjury performance than in those who merely returned to play; the two items that were not significantly different between these subgroups concerned pain and joint stability. Even though item analysis highlighted a major role for athletic performance in recovery of preinjury performance, it also stressed that the athlete's relationship with coach, agent, and staff and his/her feeling of the extent to which the arm affects current performance significantly contribute to the final score. CONCLUSIONS: The KJOC Shoulder and Elbow score provides an accurate and exhaustive assessment of the recovery of the athlete's shoulder in relation to preinjury performance and provides the surgeon with key information on the pros and cons of surgical management.

The experience of the RIPO, a shoulder prosthesis registry with 6-year follow-up.

BACKGROUND: Implant registries have proved valuable in assessing the outcomes of arthroplasty procedures. Moreover, by identifying lesser quality implants they have indirectly improved the quality of care. The registry of prosthetic shoulder implants was established in 2008. METHODS: It records information on all types of primary and revision arthroplasty procedures involving the glenohumeral joint, including reverse and total arthroplasty, hemiarthroplasty, resurfacing, removal, and any other surgical procedures that are required to manage these patients. The collected data include patient demographics, weight, height, operated side, cuff status, and diagnosis/reason for revision surgery, information on previous surgical procedures involving either shoulder, comorbidities, antibiotic and thromboembolic prophylaxis, blood transfusions, surgical approach, cuff repair procedures performed during arthroplasty, bone grafts, drains, and perioperative complications, and data about the prosthetic components implanted, including the fixation method. RESULTS: Procedures were performed on 3754 shoulders. They included 2226 RSA, 320 TSA, 730 HA, 233 resurfacing procedures, 245 revisions, and 77 "other" procedures. The survival curves of the implants are greater than 90%, and no differences were found among prosthesis from different manufacturers. The diagnosis that prompted to arthroplasty was: osteoarthritis in 60.9% of cases and fractures, bone necrosis, sequelae of fracture and rotator cuff tear arthropathy for the rest of implants. DISCUSSION AND CONCLUSION: This study describes the epidemiological data and mid-term implant outcomes of the shoulder arthroplasty procedures performed in our region, from 2008 to 2014, and compares them with published data from national registries of similar size. LEVEL OF EVIDENCE: III.

Deltoid muscle activity in patients with reverse shoulder prosthesis at 2-year follow-up.

PURPOSE: The reverse shoulder prosthesis (RSP) was developed to relieve pain and improve functional outcomes in patients with glenohumeral arthritis and deficiency of the rotator cuff. Even if clinical and functional outcomes regarding the use of the RSP were reported by literature, data concerning progressive deltoid adaptation to this non-anatomic implant are still missing. The purpose of our study was to correlate clinical and functional outcomes with deltoid fibers activity and muscle fatigability in patients with reverse shoulder prosthesis at 2 years follow-up. METHODS: Twenty patients with reverse shoulder prosthesis due to symptomatic deficient or nonfunctional rotator cuff associated with osteoarthritis were referred by Cervesi Hospital Shoulder and Elbow Surgery Unit. Exclusion criteria were: axillary nerve palsy, a nonfunctioning deltoid muscle, diabetes, previous trauma, malignancy. Furthermore patients who received the RSP for revision arthroplasty, proximal humerus fractures were excluded. All the patients underwent clinical and functional evaluation with the support of electromyography measurement focused on deltoid activity. RESULTS: RSP surgical treatment in shoulder osteoarthritis confirms his good outcome in terms of pain relief. At 2 years anterior and lateral deltoid electromyographic activity was significantly lower compared with contralateral side (p < 0.001). Posterior deltoid activity was no detectable. Range of motion at 2 years of follow-up decreased in terms of forward flexion (p = 0.045), abduction (p = 0.03) and external rotation (p < 0.001). CONCLUSIONS: Our study demonstrates that even if the patients remain pain-free, progressive deterioration of the deltoid activity is unavoidable and may lead to poor functional outcomes overtime.

Glenohumeral and scapulohumeral kinematic analysis of patients with traumatic anterior instability wearing a shoulder brace: a prospective laboratory study.

PURPOSE: To assess the effectiveness of a novel glenohumeral joint immobilizer, the S2 Shoulder Stabilizer®, by evaluating shoulder kinematics with a stereophotogrammetry system. METHODS: Participants in this prospective laboratory study were recruited from patients with anterior traumatic instability awaiting arthroscopic glenohumeral stabilization. Glenohumeral and scapulohumeral kinematic data (arm abduction-adduction and internal-external rotation, and scapular pronation-retraction and mediolateral rotation) were collected twice, without and with the brace, using a VICON™ motion capture system, and processed with MATLAB® software. RESULTS: The tests showed a significantly lower joint angle during abduction-adduction (p = 0.0022) and external rotation (p = 0.0076) and a significantly lower (p = 0.0022) mediolateral scapular rotation angle in the limbs wearing the immobilizer. Humeral head translation during abduction-adduction and internal-external rotation was also lower in the patients wearing the brace. CONCLUSIONS: The immobilizer significantly limited joint excursion in all planes of movement except internal rotation. The narrower humeral head translation with respect to the trunk, measured in the tests with the brace, demonstrates that the immobilizer achieves the goal of preserving joint stability in the movements that are at risk of dislocation.

Bilateral coronoid hyperplasia: a report of six cases.

Bilateral coronoid process hyperplasia is a rare condition defined as an abnormal elongation of the mandibular coronoid process, formed of histologically normal bone. Coronoid process hyperplasia usually develops progressively, and the clinical symptoms are often similar to those of temporomandibular joint disorders (TMD). Therefore, it is often misdiagnosed as TMD initially. From 2013 to 2016, six patients were referred to our maxillofacial surgery unit by their dentist, to evaluate mouth opening with suspected TMJ disorder. Average age was 30 years No hypertrophy of the masseter muscles was found and the patient had no history of pain and/or dysfunction of the temporomandibular joint. Average maximal incisal opening was 16.3 mm. (Rance 13-20 mm). At the end of surgery the average mouth opening achieved was of 40.3 mm. After 6 months from surgery an average mouth opening of 41 mm was obtained, with no recidivism in the coronoid process growth or decrease in the mouth opening. The only successful treatment to restore the mouth opening caused by coronoid process hyperplasia is surgical correction of coronoid-malar interference by coronoidectomy or coronoidotomy. Commencement of physiotherapy is recommended to begin between three days and one week after surgery. We also recommend the use of the TeraBite®, a simple manual physiotherapy device.

Can posterior capsular stretching rehabilitation protocol change scapula kinematics in asymptomatic baseball pitchers?

PURPOSE: Scapular dyskinesis is a recognized cause of shoulder pain in the throwing shoulder of baseball pitchers and athletes who participate in overhead sports. Past studies have assessed scapular kinematics using electromagnetic tracking devices and have shown a correlation between posterior shoulder tightness and forward scapular posture. The purpose of our study is to evaluate the scapular kinematics, before and after a 4-week posterior stretching protocol in asymptomatic pitchers. METHOD: Eleven asymptomatic collegiate baseball pitchers were involved in the study and divided into group A (6 pitchers) underwent 4 weeks of a regimented therapy protocol and group B (5 pitchers) did not receive any treatment. Each pitcher was tested on two separate days: at the first day of the study (S1) and after 4 weeks (S2). RESULTS: The results demonstrate that there are statistically significant differences in the kinematics of several athletes from the "treated group" (group A) between S1 and S2. It is also important to notice that variations in group A occurred in both flexextension and ab/adduction movements, strengthening the conclusion that the variation was real. CONCLUSION: The results of the study can indicate that, in order to prevent the pathologic cascade linked to these sports activities, this physical training protocol might become integral part of the normal daily exercises of baseball pitchers and overhead athletes. Level of evidence II.

The Porcellini test: a novel test for accurate diagnosis of posterior labral tears of the shoulder: comparative analysis with the established tests.

QUESTIONS/PURPOSES: Although the posterior labral tears of the shoulder are known for their disabling clinical course, especially in overhead athletes, no clinical test used in isolation can diagnose it accurately in the preoperative period. We wanted to: (1) introduce "Porcellini test" with its radiological verification furnishing the anatomical basis of its mechanism; (2) determine its accuracy; and (3) compare its accuracy with that of the other established tests for diagnosing posterior labral tears of the shoulder. METHODS: To determine the anatomical basis, we initially performed radiological verification of our test. Then, we evaluated its accuracy in a retrospective case-controlled study on 310 consecutive patients who underwent shoulder arthroscopic procedures at our hospital between January 2013 and December 2013. All patients were examined preoperatively for Porcellini test, and the presence of posterior labral tear was confirmed on arthroscopy. Later, in a cohort study on 91 consecutive patients who underwent shoulder arthroscopic procedures, we compared its accuracy with O'Brien's test, the Kim test, the Jerk test, and the Load and Shift test. The accuracy was interpreted in terms of sensitivity, specificity, and predictive values. RESULTS: The radiological verification conferred the anatomical basis for the mechanism of the Porcellini test. This new test showed high accuracy for posterior labral tears with sensitivity of 100 %, specificity of 99.3 %, the positive and negative predictive values of 92.6 and 100 %, respectively. Also, it had superior accuracy results than every other test. The interexaminer reliability for all test results was found to be >0.80. CONCLUSIONS: We propose "Porcellini test" as a simple, accurate, reproducible, and reliable test for the preoperative diagnosis of posterior labral tears of shoulder.

Total shoulder arthroplasty with a second-generation tantalum trabecular metal-backed glenoid component: Clinical and radiographic outcomes at a mean follow-up of 38 months.

AIMS: We evaluated clinical and radiographic outcomes of total shoulder arthroplasty (TSA) using the second-generation Trabecular Metal (TM) Glenoid component. The first generation component was withdrawn in 2005 after a series of failures were reported. Between 2009 and 2012, 40 consecutive patients with unilateral TSA using the second-generation component were enrolled in this clinical study. The mean age of the patients was 63.8 years (40 to 75) and the mean follow-up was 38 months (24 to 42). METHODS: Patients were evaluated using the Constant score (CS), the American Shoulder and Elbow Surgeons (ASES) score and routine radiographs. RESULTS: Significant differences were found between the pre- and post-operative CS (p = 0.003), ASES (p = 0.009) scores and CS subscores of pain (p < 0.001), strength (p < 0.001) and mobility items (p < 0.05). No glenoid or humeral components migrated. Posterior thinning of the keel and slight wear at the polyethylene-TM interface was observed in one patient but was asymptomatic. Radiolucent lines were found around three humeral (< 1.5 mm) and two glenoid components (< 1 mm) and all were asymptomatic. DISCUSSION: TSA with the second-generation TM Glenoid component results in satisfactory to excellent clinical performance, function, and subjective satisfaction at a mean follow-up of about three years. Radiographic changes were few and did not affect the outcome. TAKE HOME MESSAGE: This paper highlights that the second generation Trabecular Metal Glenoid has better outcomes than those reported with the first-generation component.

Arthroscopic joint debridement and capsular release in primary and post-traumatic elbow osteoarthritis: a retrospective blinded cohort study with minimum 24-month follow-up.

BACKGROUND: Elbow osteoarthritis (OA) is a degenerative condition which in the advanced stage can severely impair joint mobility. Conservative treatment remains the first choice; surgery should be considered in case of failure in patients prepared to adhere to a demanding rehabilitation protocol. We assess the effectiveness of arthroscopic joint debridement and capsular release in a series of patients with primary and post-traumatic elbow arthritis. MATERIALS AND METHODS: Forty-eight subjects (40 males, eight females; mean age 48 years) with a preoperative diagnosis of primary (19, 40 %) or post-traumatic OA (29, 60 %) were evaluated at a mean follow-up of 44 months. Outcome measures were active range of motion (ROM), pain score, Oxford elbow score (OES), and Mayo elbow performance score (MEPS). OA severity was graded into three classes (I-III) based on X-ray findings. Statistical significance was set at 5 %. RESULTS: At the final follow-up evaluation, active flexion/extension increased significantly (p < 0.01); pronation and supination improved, but the difference was not significant (p > 0.05). The pain score improved from 7.2 to 4.3 (p < 0.01). Both OES and MEPS improved significantly (p < 0.001). Patients with post-traumatic OA had better ROM (p = 0.0391) and clinical scores (OES, p = 0.011; MEPS, p = 0.010). ROM and clinical scores were lower but not significantly so in class II than in class I patients. A smooth coronoid and olecranon fossa was found in 38 (79 %) patients and a preserved ulnotrochlear joint space in 40 (80 %). CONCLUSIONS: Elbow OA has become more common as a result of earlier diagnosis and an increased number of acute injuries involving the joint. Arthroscopy is an effective technique to treat OA which provides the best results with the correct indications. Prospective studies are needed to help develop guidelines enabling selection of the best treatment option.

Strength recovery after arthroscopic anterosuperior cuff repair: analysis of a consecutive series.

PURPOSE: The purpose of this study was to look at the functional outcomes of arthroscopic repair of anterosuperior rotator cuff tears. METHODS: Sixty-one patients who underwent arthroscopic repair of anterosuperior cuff tears were retrospectively reviewed. At a minimum 6 months of follow-up, shoulder functional outcome scores including the Constant score (CS), simple shoulder test (SST) and visual analogic scale (VAS) were collected. Strength recovery for supraspinatus and subscapularis was investigated. RESULTS: All patients (mean age 59 ± 7) were available at a mean follow-up of 18 ± 7 months. The average CS improved from 30.8 ± 10.2 preoperatively to 76.5 ± 12.0 postoperatively, average SST from 2.6 ± 2.0 to 8.8 ± 2.9 and average VAS pain scale from 3.8 ± 1 to 0.5 ± 0.5 (p < 0.0001). Strength at belly-press and Jobe tests significantly improved (p < 0.0001). All patients with the exception of one were satisfied with the intervention. CONCLUSIONS: Arthroscopic repair of anterosuperior rotator cuff tears provides a significant improvement in pain relief and shoulder function. Strength recovery is demonstrated in medium correlation with tendon healing.

Co-analgesic therapy for arthroscopic supraspinatus tendon repair pain using a dietary supplement containing Boswellia serrata and Curcuma longa: a prospective randomized placebo-controlled study.

BACKGROUND: The cuff tendon that is most prone to full-thickness rotator cuff tears is the supraspinatus (SSP). Arthroscopic SSP repair ensures good to satisfactory mid- to long-term clinical outcomes. However, the intense postoperative pain reduces rehabilitation compliance and is cause of patient dissatisfaction. Many natural compounds act by inhibiting inflammatory pathways in a similar way to anti-inflammatory drugs MATERIALS AND METHODS: This was a prospective randomized trial designed to assess the analgesic effect of a dietary supplement (DS) containing Boswellia serrata and Curcuma longa in a population of subjects with full-thickness SSP tendon tear treated by arthroscopy. Three weeks before surgery, patients were randomized to receive Tendisulfur(®) (group T) or a placebo (group P) for 2 months. The primary outcome measure was subjective VAS pain. Secondary outcomes measures were Constant-Murley score simple shoulder test, and patient global assessment (PGA) scores. Patients were assessed immediately at baseline and subsequently at 1, 2, 4, 6, 8, 12, and 24 weeks. RESULTS: Stratification of pain scores and subscores demonstrated significantly lower overall pain scores in group T versus group P at 1 week (p = 0.0477), and lower but not significantly different scores on week 2 (p = 0.0988); at subsequent time points, differences were not significant (p > 0.05). PGA scores were good in all subjects. CONCLUSIONS: In conclusion, this study provides objective data on the effect of a DS containing natural substances, added to standard analgesics, on postoperative RC pain. DS alleviated short and partially mid-term pain, while long-term pain was unchanged. This limitation can probably be addressed by a dosage increase over the first 4 weeks and by extending treatment by 1 or 2 months.

Scapulothoracic arthroscopy for symptomatic snapping scapula: a prospective cohort study with two-year mean follow-up.

BACKGROUND: Snapping scapula is characterized by crepitus between the scapula and the chest wall due to abnormal tissue at this site. Surgical treatment, when needed, may be either open or arthroscopic. The aim of this study was to evaluate prospectively the clinical outcomes of arthroscopic decompression in ten subjects with symptomatic snapping scapula. PATIENTS AND METHODS: Ten subjects, five men and five women, mean age 24 years, were treated by arthroscopy after unsuccessful conservative management for 6 months. Clinical outcomes were evaluated with the Western Ontario Rotator Cuff (WORC) index, Constant-Murley score (CS), and simple shoulder test (SST). Follow-up was at 3 and 6 months; the final evaluation was conducted at a mean interval of 24 months. The final and preoperative X-rays were compared. RESULTS: The WORC index increased significantly at 3 (p < 0.05), 6 (p < 0.01), and 24 months (p < 0.01). Similar outcomes were found for the CS at all 3 follow-up points (3 months, p < 0.05; 6 months, p < 0.01; 24 months, p < 0.01). Mean "yes" responses on the SST were 9.8 ± 1.4 at 3 months (p < 0.05), 10.2 ± 1.2 at 6 months (p < 0.01), and 10.6 ± 1.2 at 24 months (p < 0.01). X-ray examination depicted flattening of the anterior surface of the superior-medial angle of the scapula in the five patients who had had bone resection, whereas no significant difference with preoperative imaging was detected in the five patients who were managed by bursectomy and debridement alone. CONCLUSIONS: Arthroscopy is a feasible and minimally invasive treatment for painful snapping scapula syndrome. Comparative clinical trials are needed to collect conclusive data to state that it is the most suitable treatment for this condition.

Elbow ulnar collateral ligament reconstruction: clinical, radiographic, and ultrasound outcomes at a mean 3-year follow-up.

BACKGROUND: Ulnar collateral ligament (UCL) has the main function to be stress-resistant to elbow valgus overload. Multilayer tears require a reconstruction with a tendon graft. In this study, we report the clinical, radiographic, and ultrasound outcomes after tendon graft reconstruction for symptomatic UCL insufficiency. MATERIALS AND METHODS: Among twenty-six subjects underwent elbow UCL reconstruction from 2006 to 2012, fifteen were available to be evaluated at a mean follow-up of 36 months. Preoperative assessment included clinical examination and MRI. The outcome measures were the Mayo Elbow Performance Score (MEPS); the Oxford Elbow Score (OES); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Conway-Jobe Scale. Overall population was postoperatively investigated with X-ray and ultrasound (US). Reconstruction was performed with autograft (palmaris longus) in five cases and allograft (semitendinosus) in ten cases using the figure-of-eight configuration (five cases), the docking technique (eight cases), or a fixation with screws (two cases). RESULTS: We found a significant improvement in postoperative MEPS, OES, and DASH scores (p < 0.01). One case was unsatisfied and required an additional procedure of ulnar nerve transposition 12 months after the reconstruction. X-ray showed calcifications along the graft in ten cases. At US examination, all the grafts assessed appeared anatomically intact without structural changes, and the dynamic examination showed a slight medial laxity with the valgus stress maneuver without pain or other sign of medial instability. CONCLUSIONS: This study confirms the efficacy of the graft reconstruction for chronic UCL insufficiency and introduces fresh insight on the role of musculoskeletal ultrasound to evaluate the reconstructed UCL.