Operative treatment of failed repairs of the rotator cuff.

Thirty-one patients had a repeat repair after a failure of a previously performed repair of the rotator cuff, and the causes of the original failure and the results of the repeat repair were analyzed. The clinical situation was complex, with multiple factors contributing to the failures. A large or massive tear of the cuff in thirty patients (97 per cent) and persistent subacromial impingement in twenty-eight patients (90 per cent) were the most common factors associated with failure. The over-all result of the repeat repair was satisfactory in sixteen patients (52 per cent) and unsatisfactory in fifteen (48 per cent). Twenty-five patients (81 per cent) had satisfactory relief of pain. However, fourteen patients (45 per cent) had persistent weakness that led to an unsatisfactory result. The factors that were associated with a better result were an intact acromion, an intact origin of the deltoid muscle, and the finding that the remaining tissue of the rotator cuff was of good quality. The factors that were associated with an inferior result were a previous lateral acromionectomy, a previously detached origin of the deltoid muscle, and the finding that the tissue of the rotator cuff that was available at the time of the repeat operation was of poor quality. Persistent pain is the primary indication for a repeat repair. The functional results are not as predictable, especially when the tissue of the cuff is poor and the deltoid origin has been detached previously.

Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability.

Thirty-five shoulders in thirty-four patients were treated with a superior shift of the posteroinferior aspect of the capsule because of recurrent posterior glenohumeral subluxation and dislocation. The physical examination revealed three types of posterior instability in these patients preoperatively: unidirectional (six shoulders), bidirectional (posterior and inferior) (seven shoulders), and multidirectional (posterior and inferior dislocation with anterior subluxation) (twenty-two shoulders). Eleven shoulders had had previous operative procedures. At the time of the index operation, the most common abnormal findings in these shoulders were capsular redundancy and excessive volume of the glenohumeral joint. Complete detachment of the posterior aspect of the labrum was found in only four shoulders. There was no excessive glenoid retroversion in these patients. All thirty-four patients were available for follow-up at an average of five years (range, two to twelve and a half years) postoperatively. Over-all, the result for seventeen of the thirty-five shoulders was rated as excellent; eleven, as good; one, as fair; and six, as poor. Four shoulders became unstable again. Six of the seven unsatisfactory results were in shoulders that had had previous attempts at stabilization. A successful result was achieved in twenty-three of the twenty-four shoulders in which the superior shift of the posteroinferior aspect of the capsule was the initial repair.

Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus.

Twelve patients, ranging in age from thirty-four to seventy-two years (average, fifty-three years), were evaluated an average of five years (range, two to eight years) after open reduction and internal fixation of a two-part displaced fracture of the greater tuberosity of the proximal part of the humerus. The indication for operative reduction was one centimeter or more of displacement of the fracture as seen on the diagnostic radiographs. The anterosuperior deltoid-splitting approach, combined with rotation of the humerus, allowed adequate exposure of the retracted tuberosity. Internal fixation of the greater tuberosity with heavy, non-absorbable sutures and careful repair of the rotator cuff permitted early passive motion. All fractures healed without postoperative displacement. Six patients had an excellent result and six had a good result; active elevation averaged 170 degrees. There was one partial, transient palsy of the axillary nerve.

Surgical treatment of complete acromioclavicular dislocations.

Forty-four patients, ranging in age from 17 to 57 years (average, 32), were evaluated an average of 4 years (range, 2 to 9) after surgical reconstruction for Allman-Tossy Grade III acromioclavicular dislocations. Twenty-seven patients underwent repair for acute injuries (< 3 weeks after injury) and 17 patients underwent reconstructions for chronic injuries (> 3 weeks). Coracoclavicular fixation with heavy nonabsorbable sutures was used to correct superior displacement in all cases. In addition, transfer of the coracoacromial ligament to the distal clavicle was performed in 15 of the 27 early repairs and 17 of the 17 late reconstructions. Overall, 26 of 27 (96%) early repairs and 13 of 17 (77%) late reconstructions achieved satisfactory results. There was a trend for better results and return to sports or heavy labor with early repairs; however, this was not statistically significant (P = 0.065). When the results of early repairs were compared with those of late reconstructions performed more than 3 months after injury, the results of the shoulders undergoing early repair were significantly better (P < 0.01). Overall, 39 of 44 (89%) patients achieved a satisfactory result. Surgical reconstruction for acromioclavicular dislocation provides reliable results including use of the arm for sports or repetitive work.

Anterior acromioplasty for subacromial impingement in patients younger than 40 years of age.

The indications and results of anterior acromioplasty in patients older than 40 years of age are well documented; however, little is reported concerning this procedure in younger patients because the majority are treated conservatively. Over the last seven years, 26 patients younger than 40 years of age were treated by anterior acromioplasty for subacromial impingement resistant to conservative therapy. The indication for surgery was failed conservative therapy in 17 patients. Six patients had impingement despite previous surgery, such as failed acromioplasty, biceps tenolysis, and biceps tenodesis. Two patients had impingement secondary to greater tuberosity malunion. The average duration of symptoms was 27 months and of conservative therapy, 17 months. All patients had a bursectomy and anterior acromioplasty. In addition, eight had a complete acromioclavicular arthroplasty for concurrent acromioclavicular arthritis, four had a modified acromioclavicular arthroplasty for impingement under the acromioclavicular joint, three had calcium excisions, and one had a rotator cuff repair. The greater tuberosity malunions were advanced in one patient and excised in one. The results were 81% (21) excellent and good, 15% (four) fair, and 4% (one) poor. The average follow-up period was 33 months. The majority of younger patients with subacromial impingement can be successfully treated conservatively. In those patients with persistent symptoms, open acromioplasty can reliably give good results with regard to pain and function.

Isolated nerve injuries about the shoulder.

Infraclavicular nerve injuries are rare and potentially disabling problems. A retrospective study of 24 patients with 28 nerve injuries is presented, including 18 axillary, 7 suprascapular, and 3 musculocutaneous nerve injuries. Vague shoulder pain and weakness of the involved muscle groups were the main symptoms of nerve injury in these patients. All patients had atrophy of the specific muscles involved. Diagnosis of these nerve lesions can often be difficult because of this vague presentation. Followup from date of injury averaged 60 months and included evaluation by questionnaire, repeat physical examinations, and serial electromyograms. There were 21 complete or satisfactory nerve recoveries, while 7 patients had unsatisfactory results. The etiology of the injury appeared to be an important factor with respect to outcome. Eight of 10 nerve injuries secondary to blunt trauma went on to complete recovery, and 4 of 6 nerve injuries secondary to shoulder dislocation recovered completely. None of the 7 nerves injured during surgery recovered completely. No patient with spontaneous onset of nerve dysfunction had an unsatisfactory result. Poor results were noted in patients with initial total denervation as shown by electromyogram and in patients with intraoperative nerve damage.

Bilateral primary breast cancer.

Primary carcinoma of breast was treated in 967 patients from 1962 through 1972. Thirty-five of these patients had a second primary tumor of which 50% were discovered simultaneously. A family history for cancer was recorded in 26% of the patients with bilateral cancer. Patients found their tumor more often than the physician except in the simultaneous cases where the physician was more successful. Pathological examination showed 10% of the tumors were comedo, lobular carcinoma in situ, papillary, or tubular cancers. In the metachronous group, 50% of the axillae were involved on both sides. In the simultaneous cases the axilla was less frequently involved. Mammography, biopsies of the second breast, and prophylactic mastectomy in certain high-risk patients should improve survival rates.

Open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus.

Twenty-two patients aged 20 to 82 years (average 56 years) were followed for 1.1 to 8.9 years (average 3.3 years) after open reduction and internal fixation of two- and three-part displaced surgical neck fractures of the proximal humerus. There were 14 two-part displaced surgical neck fractures, seven three-part displaced greater tuberosity and surgical neck fractures, and one three-part displaced lesser tuberosity and surgical neck fracture. Fixation was achieved with heavy nonabsorbable sutures or wire that incorporated the rotator cuff tendons, tuberosities, and shaft. In cases with significant surgical neck comminution, humeral Enders nails were incorporated in a tension-band construct to provide longitudinal stability. Eighteen (82%) of the 22 patients had good or excellent results. Three (14%) of the 22 had satisfactory results, and one (5%) had an unsatisfactory result. The use of a technique of limited internal fixation for these displaced fractures without the use of plates and screws achieved fracture stability and a high percentage of acceptable results.

Prosthetic replacement in rotator cuff-deficient shoulders.

We reviewed a series of 30 shoulders in 25 patients who had glenohumeral arthritis and rotator cuff deficiency and who underwent prosthetic replacement. Nineteen shoulders underwent humeral head replacement, and 11 shoulders had total shoulder arthroplasty. Meticulous mobilization and reconstruction of the deficiencies in the thin atrophic rotator cuff tissues were attempted in all shoulders. Emphasis was placed on anteroposterior stability, and this was achieved in all shoulders; superior coverage was fully achieved in 15 shoulders and was partially achieved in 11. All shoulders had less pain after surgery, and 93% achieved satisfactory pain relief. Total shoulder arthroplasty and humeral hemiarthroplasty were found to provide similar results with respect to pain relief, functional improvement, and patient satisfaction. Shoulders with hemiarthroplasty gained significantly more active elevation (+52° vs + 2°) after surgery. Cuff repair was easier when a humeral head prosthesis alone was used because less lateralization of the humerus occurred. Also, operative time, anesthesia time, and blood loss were decreased with hemiarthroplasty. Because the lack of glenoid resurfacing did not adversely affect pain relief or function and avoided the potential problem of glenoid loosening, we favor humeral hemiarthroplasty as a treatment for glenohumeral arthritis in the rotator cuff-deficient shoulder.