Humeral head cysts: association with rotator cuff tears and age.

The objective of this study was to retrospectively evaluate the prevalence of the cystic changes at rotator cuff footprint on proximal humeral tuberosities and investigate their relationship with rotator cuff tears and patient age. Magnetic resonance (MR) images of 657 patients who underwent shoulder arthroscopy for treatment of rotator cuff disorders were reviewed to localize the cystic changes at anterior (supraspinatus insertion) and posterior (infraspinatus insertion) aspects of greater tuberosity (GT) and lesser tuberosity (subscapularis insertion). Preoperative MR reports as well as cyst size and locations on MR images were correlated with arthroscopic records of rotator cuff pathology (tear type, size, location and tendon involvement) and patient age. The prevalence of cystic changes was 9.1% (60 patients) in the study population. Anterior GT cysts were found in 56% of patients and were strongly associated with full-thickness (p<.001) and articular-sided partial-thickness rotator cuff tears (p=.02). Posterior GT and lesser tuberosity cysts were found in 27 and 17% of patients, respectively, and were not significantly related to rotator cuff tears, although there was an increased trend of posterior cysts in patients with infraspinatus tears (p=.09). A significant relation was found between patient age and the cyst size (p=.01), while none of the cyst localizations were statistically related to age. Anterior GT cysts were more common in this patient group and demonstrated a strong association with rotator cuff disorders regardless of age. Posterior GT and lesser tuberosity cysts were less common and showed no association with rotator cuff pathology or patient age.

The role of radiological subacromial distance measurements in the subacromial impingement syndrome.

Subacromial impingement is one of the most common causes of painful shoulder in the middle aged and elderly population. Since Neer's first description of the process, many investigators have researched this condition in an effort to gain a better understanding of the disease etiology. The aim of this study was to investigate the relationship between the radiological subacromial distance measurements and the subacromial impingement syndrome in a series of patients from our institution. For this purpose, 44 patients scheduled for a unilateral shoulder arthroscopy were investigated prospectively. The acromio-glenoid angle, supraspinatus-glenoid angle (from coronal MR images) and acromial index (from true anterior-posterior shoulder X-ray images) were measured as the implications of the subacromial distance, and the degree of subacromial impingement was graded according to intraoperative findings. Statistical data analysis revealed no significant correlations between the radiological measurements and the severity of subacromial impingement (p > 0.05). On the other hand, there was a significant correlation (p = 0.0049) between the patient age and subacromial impingement. These results suggest that the radiological subacromial distance measurements do not have enough clinical significance as predictive markers in the subacromial impingement syndrome.

Intra-articular variations of the long head of the biceps tendon.

PURPOSE: The long head of the biceps tendon (LHBT) generally runs free through its course in the glenohumeral joint. It can rarely be seen as attached to the joint capsule or the rotator cuff in different patterns. Although these variations are usually considered harmless in the literature, they may occur in conjunction with the labral pathologies. This study was designed to determine their prevalence and investigate their relationship with intra-articular pathologies encountered during arthroscopy. METHODS: Out of a patient population of 671 arthroscopies performed in one center, the data regarding the LHBT variations and labral pathologies were collected retrospectively. RESULTS: Fifty patients (7.4%) of this total population were included as possible LHBT variants. Categorized into seven groups ranging from the simple vinculum, cord, and pulley types to the synovial tunnel types partially or totally fused to the capsule and to more complex types adherent to the capsule or the rotator cuff, their association with the labral pathologies was analyzed. The labral pathology prevalence was significantly higher in this group of 50 patients with LHBT variants compared to the total population (32 vs. 13%; P < 0.001). In the pulley-type variant group, the labral pathologies were also encountered at a significantly higher rate than the total population (62.5%; P = 0.026). CONCLUSION: The prevalence of embryological variations of the biceps tendon may be higher than common presumptions, and a particular type of these variants displays an increased association with labral pathologies.

Arthroscopic repair of type II superior labrum anterior posterior (SLAP) lesions in patients over the age of 45 years: a prospective study.

BACKGROUND: Superior labrum anterior posterior (SLAP) lesions are a well-defined cause of shoulder pain and disability and may occur in conjunction with rotator cuff tears. This study was designed to prospectively evaluate the minimum 2 year results of arthroscopic repair of type II SLAP lesions in patients over the age of 45 years with and without rotator cuff tears. PATIENTS AND METHODS: Thirty-five patients with symptomatic type II SLAP lesions were enrolled in the study. All patients underwent arthroscopic SLAP repair and simultaneous repairs were carried out in 17 of these patients who had concomitant full-thickness rotator cuff tears. Patients were grouped into two with regard to the presence of rotator cuff tears. The outcome was assessed by University of California at Los Angeles (UCLA) score and clinical examination (forward flexion/internal rotation/external rotation). RESULTS: At an average follow-up of 2.5 years, both groups displayed significant improvements in UCLA score (31.2 vs. 11.8; p < 0.01) and range of motion. Compared with the group that had SLAP and concomitant rotator cuff tears, patients in isolated SLAP group had significantly better scores in function (9.4 vs. 8.6; p = 0.045) and patient satisfaction (4.9 vs. 4.5; p = 0.039). No significant difference was found between two groups with respect to range of motion. CONCLUSIONS: The arthroscopic repair of symptomatic type II SLAP lesions yields favorable outcomes in patients over 45 years of age and the presence of accompanying rotator cuff tears has a negative effect on the results.

The infants who have mature hip on ultrasonography but have risk factors of developmental dysplasia of the hip are required radiographic examination.

OBJECTIVES: This study aims to evaluate the short-term results of infants who were radiologically diagnosed with developmental dysplasia of the hip (DDH), but in whom hip development was normal ultrasonographically. PATIENTS AND METHODS: Between January 2018 and September 2020, a total of 15 infants (2 males, 13 females; median age: 5 months; range, 4 to 6 months) who were diagnosed with DDH radiologically and treated were retrospectively analyzed. Hip ultrasonography was used for early diagnosis, treatment, and for follow-up in infants up to six months of age. While the ultrasonographic findings were normal, radiography was performed in infants between four to six months of age who were at risk for DDH. RESULTS: Fifteen patients (22 hips) were diagnosed with DDH radiologically and treated. Radiologic dysplasia continued in seven hips of five patients during short-term follow-up. CONCLUSION: These results suggest that ultrasonographic hip maturation may not be consistent with normal hip development in infants, particularly in those who are at risk for DDH. In infants with DDH which is confirmed by radiography (less than 6 months of age), the diagnosis may be missed on ultrasonographic examination.

Anatomical variations of the anterosuperior labrum: prevalence and association with type II superior labrum anterior-posterior (SLAP) lesions.

BACKGROUND: Anterosuperior labrum variations have been generally described as innocent anatomical variations without clinical significance. This study was intended to determine their prevalence and reveal their possible relationship with type II SLAP lesions. MATERIALS AND METHODS: A total of 713 consecutive shoulder arthroscopies were evaluated retrospectively for anterosuperior labrum variations and co-existing labral pathologies. Twenty two of these were excluded from the study due to the interobserver variability in the categorization process. The relationship of both these anatomic variants and shoulders with a normal appearing anterosuperior labrum to intra-articular pathology was analyzed statistically and compared with each other. RESULTS: Found in 98 patients (14.18%), the anatomic variations in the anterosuperior labrum were classified into 3 groups as the sublabral recess (2.46%), the sublabral foramen (7.67%), and absent anterosuperior labrum with a cord-like middle glenohumeral ligament (4.05%). The latter 2 of these groups displayed a statistically significant relationship with type II SLAP lesions (21 of 53 and 23 of 28 patients; P = .0028 and P < .0001, respectively). DISCUSSION: Although mostly considered as simple morphological variations, the anatomic variants of the anterosuperior labrum may predispose the shoulder to labrum pathologies by altering the intra-articular biomechanics. CONCLUSION: As previously suggested in the literature, certain anatomic variants of the anterosuperior labrum are associated with the development of SLAP lesions.

The forelock sign: A new arthroscopic finding in partial subscapularis tears.

OBJECTIVES: This study aims to identify the forelock sign of partial tears of the subscapularis and to compare the incidences of this sign and air bag sign. PATIENTS AND METHODS: One hundred and twenty patients (39 males, 81 females; mean age 51.3 years; range, 25 to 79) diagnosed as isolated subscapularis tear or isolated supraspinatus tear from among patients who underwent shoulder arthroscopy between January 2013 and January 2016 were divided into four groups of 30 patients each as the subscapularis tear (group 1), full-thickness supraspinatus tear (group 2), bursal-side supraspinatus tear (group 3), and articular-side supraspinatus tear (group 4) groups. All patients had video records of their operation. The integrity of the long head of biceps tendon (LHBT), Lafosse classification of the subscapularis tear, and the incidence of the forelock and air bag signs were evaluated. RESULTS: The incidence of the air bag sign in group 1 was 10% and that of the forelock sign was 60%. The forelock sign was significantly more frequent in group 1 than in the other groups (odds ratio 10.46: 3.9-27.8 with 95% confidence interval) and the air bag sign (p<0.001). The LHBT was mostly pathologic in this group, which was also statistically significant (p<0.01). The incidence of the forelock sign in group 1 was similar in each LHBT pathology and Lafosse subgroups. CONCLUSION: The forelock sign identified in this study was significantly frequent (60%) in partial subscapularis tendon tears with strong inter- and intra-observer consistency while the air bag sign was rare (10%). The LHBT disorders were strongly associated with subscapularis tears; however, the forelock sign was not an indicator of the condition of the LHBT and type of partial subscapularis tendon tear according to the Lafosse classification.

The relationship between the hindfoot angle and the medial longitudinal arch of the foot.

INTRODUCTION: The relationship of hindfoot valgus and the medial longitudinal arch (MLA) is a well-known parameter for the evaluation of the foot deformities. In this study, we evaluated the relationship between the hindfoot angle and the MLA and the effect of these parameters on the development and general joint laxity of the subjects. METHODS: Two-hundred-sixty-one volunteers who had no foot pain or major foot deformity were examined. The age range of the volunteers was 4 to 20 years. For each subject, the right foot was evaluated for the clinical hindfoot angle and footprint analysis. General ligamentous laxity also was recorded. Arch index and valgus index were used for the evaluation of the footprint analysis, and the valgus angle was measured clinically. RESULTS: The average heel valgus angle for all subjects was 5.2 (SD 3.3) degrees. The means of valgus index and arch index were 3.34 (SD, 5.6) and 0.7 (SD, 0.2), respectively. Although there was a positive correlation between the valgus angle and valgus index (p = 0.027), the arch index was not found to be correlated with these values. Positive correlation between joint laxity and arch height also was demonstrated (p < 0.05). CONCLUSIONS: We concluded that the hindfoot angle and MLA height must be considered separately in clinical practice, particularly in the management of childhood pes planus.

Effect of synthetic cell-binding peptide on the healing of cortical segmental bone defects.

OBJECTIVE: To determine the effect of inorganic bone matric/Pepgen P-15 (ABM/P-15) on the healing of a critical sized segmental defect in a rat radius using a radiological and histological grading system. METHODS: We carried out this study at the Research Laboratories, Gazi University School of Medicine in 2004. Critical sized segmental defects were created in the radius of 36 Wistar rats. Thirteen defects were filled with ABM/P-15 Flow (gel form), 12 defects were filled with ABM/P-15, and 11 defects were used as a control group. The rats were sacrificed at the tenth week, and healing of the defects was evaluated radiographically and histologically. RESULTS: The usage of ABM/P-15 and ABM/P-15 Flow were demonstrated to improve healing of segmental bone defects compared with the control group. Statistical evaluation showed that there were significant differences between control sites, and the sites treated with P-15 and P-15 Flow (p=0.011). The highest radiological and histological grades were achieved by P-15. CONCLUSION: Segmental cortical bone defects may be treated with ABM/P-15 instead of bone allografts, and autografts. According to the radiological and histological parameters measured in this study, the implantation of ABM/P-15 resulted in optimum healing of the segmental cortical bone defects. Pepgen P-15 has a positive effect on bone healing, without any immunogenic features and disease transmission risk. Therefore, ABM/P-15 can also be used for orthopedic surgery.

[Anatomy, biomechanics, and pathophysiology of instability of the glenohumeral joint]. / Glenohumeral eklem instabilitesinin anatomik, biyomekanik ve patofizyolojik özellikleri.

The stability of the shoulder is dependent on both static and dynamic anatomic restraints. In most cases, there must be insufficiency of more than one restraint for the shoulder joint to become instable. Although the role of these restraints is largely known in maintaining shoulder stability, our information on their interactions is insufficient. This article reviews the anatomy and biomechanics of the shoulder and conditions causing instability of the glenohumeral joint.

[Shoulder instability: classification and methods of clinical examination]. / Omuz instabilitesinin siniflandirilmasi ve klinik muayene yöntemleri.

The shoulder is a complex joint whose stability relies on both dynamic and static factors. Dysfunction of one of these components gives rise to shoulder problems. Diagnosis of shoulder instability depends on a detailed history and appropriate physical examination. Despite the presence of many tests, none has proved to be purely diagnostic for shoulder instability. Therefore, these tests should be regarded as a part of the diagnostic procedure rather than a referral to diagnosis itself. Tests performed to assess laxity and instability are different in nature; thus, positive laxity tests do not necessarily show instability unless supported by further evidence. The reliability of the tests for superior labrum anterior-posterior lesions has not been adequately validated by clinical studies and few anatomical studies have examined the effect of these tests on the superior labral complex.

[Open surgical treatment of recurrent anterior instability of the shoulder]. / Tekrarlayan anterior omuz instabilitesinin açik cerrahi tedavisi.

Recurrent anterior gleonohumeral instability is the most frequent joint instability of the body. Because of the complex stability mechanisms and diverse instability patterns of the glenohumeral joint, most cases present with more than one anatomic cause. Thus, the treatment of recurrent anterior instability of the shoulder should be designed to treat these pathologies. Although arthroscopic repair has outweighed the use of open surgical methods especially for the first dislocations, recurrent dislocations still require open repair techniques to overcome capsular laxity accompanying a Bankart lesion.

[Multidirectional shoulder instability and open surgical procedures]. / Cokyönlü omuz instabilitesinde açik cerrahi girisim.

The principles and procedures for multidirectional instability do not substantially differ from those for anterior instability. Correct diagnosis is difficult, but it is important for a successful treatment. Conservative treatment should be attempted before surgery. Open surgical treatment using the inferior capsular shift procedure is the gold standard. It can be carried out either anteriorly or posteriorly. We prefer a laterally-based capsular shift because it facilitates capsular plication.

[Open surgical techniques for subacromial impingement syndrome]. / Subakromiyal sikisma sendromunda açik cerrahi yöntemler.

Various surgical techniques have been used for the treatment of subacromial impingement syndrome, ranging from complete acromionectomy to arthroscopic subacromial decompression. Following the recognition of the importance of the acromial arch in maintaining superior stability of the glenohumeral joint, attempts have been directed to minimize the amount of acromial excision. In this article, open surgical subacromial decompression techniques and the importance of the amount of acromial excision are discussed.

[Allogeneic blood transfusion policy in orthopedic surgery]. / Ortopedik cerrahide allojeneik kan transfüzyon politikasi.

OBJECTIVES: This retrospective study was performed to evaluate transfusions in orthopedic surgery and, in the light of our successful practice, to contribute to the development of appropriate transfusion policies in Turkey. METHODS: In this study 1,811 female patients who underwent orthopedic elective or emergency surgery from January 1997 to December 1999 (group 1) and from January 2000 to December 2002 (group 2) were retrospectively evaluated with respect to ordered and transfused blood units. Autologous blood transfusions were not included. Group 1 consisted of 990 patients (mean age 50.4 years); group 2 consisted of 821 patients (mean age 53.3 years). Maximum surgical blood order schedule (MSBOS) ratios and preference for red blood cell transfusions were determined. Perioperative target hemoglobin level was 10 gr /dL in both groups. In group 2, allogeneic blood transfusions were performed according to the principles established in January 2000, which aimed (i) to more precisely estimate blood loss during surgical procedures and to prevent inappropriate use of blood products; (ii) to reduce the frequency of "standard one unit transfusion" through administration of crystalloids and colloids to the extent of complete elimination of transfusions; and (iii) to use blood components (erythrocyte suspensions) instead of whole blood. RESULTS: In both groups, the MSBOS ratios were below 2, being 1.83 in group 1, and 1.59 in group 2. The medians of requested and transfused blood units were 2 and 1 in group 1, and 3 and 2 in group 2, respectively, resulting in statistically significant differences (p<0.05). The "standard one unit transfusion" rate was 28.7% in group 1, and 18.9% in group 2. Preferences for red blood cell transfusions showed statistically significant increases over the consecutive years. The use of erythrocyte suspensions was found as 29.2% in group 1, and 95% in group 2. CONCLUSION: Our data demonstrated that the transfusion policy established for orthopedic surgical procedures at our center resulted in successful applications thanks to a good cooperation between relevant departments and achieved the level of international standards.

Does presence of anterior greater tuberosity cysts change the function in patients with chronic rotator cuff tear?

OBJECTIVES: This study aims to compare rotator cuff muscle atrophy with fatty degeneration, tear size, range of motion, shoulder muscle strength, pain and upper extremity function in patients with chronic rotator cuff tear, and with or without anterior greater tuberosity cyst. PATIENTS AND METHODS: A total of 101 patients (32 males, 69 females; mean age 51 ± 12.9 years; range 17 to 76 years) were evaluated in this study. Fifty-eight patients were excluded due to traumatic or acute rotator cuff tears and neck pain. Forty-three patients of chronic rotator cuff tear were divided into two groups as patients with (n=15) and without (n=28) an anterior greater tuberosity cyst. Patients were evaluated for range of motion, shoulder muscle strength, pain and upper extremity function, and radiologically. Statistical differences were investigated between two groups. RESULTS: The number of patients with tears larger than 1 cm and the number of patients who had muscle atrophy were higher in the group of patients with a cyst. Also, upper extremity function was reduced in the group of patients with a cyst (Western Ontario Rotator Cuff Index, p=0.03, Nine-Hole Peg Test, p=0.02). CONCLUSION: Our findings demonstrated that decreased function, larger cuff tears and muscle atrophy can be observed patients with anterior greater tuberosity cysts. Anterior greater tuberosity cysts can be detected by plain X-rays. The presence of these cysts should warn the physician regarding the possibility of decreased shoulder function, muscle atrophy and larger cuff tear before ordering a magnetic resonance imaging.

Periosteal adventitia is a valuable bone graft alternative.

BACKGROUND: Periosteal adventitia is believed to consist of fibrous tissue without any regenerative potential. This theory results in the assumption that surgically stripped periosteum which is also adventitial has no bone regeneration potential. We decided to test whether the periosteal adventitia is osteoinductive and whether it is suitable for a commonly faced clinical situation in an animal model. METHODS: This study used 24 femurs from 12 rabbits, which were separated into 3 groups. Lateral femoral condylar cavitary defects were created with a 5 mm drill bit. In group I, the defects were left empty as the control. In group II, the defects were only filled with ceramic graft particles. In group III, the defects were filled with a mixture of ceramic graft particles and autogenous, adventitial, periosteal particles. All animals were sacrificed at the end of the 6th week and were evaluated histologically. RESULTS: The microscopy of 3 different histologists suggested that group III had far superior healing when compared to the control group and group II. The statistical evaluation of the histomorphometrically gathered quantitative results revealed a meaningful increase in woven bone and a decrease in fibrous tissue in group III, confirming the histological analysis. CONCLUSIONS: In this study we observed that the composite graft obtained by mixing ceramics and free adventitial periosteal grafts offers healing potential surpassing both the ceramic-only group as well as the control group. We conclude that adventitial periosteal graft greatly facilitates new bone formation.

Does surgical repair of acute Achilles tendon rupture cause structural changes on 15-year follow-up?

We describe a case, which gives an answer to the question of 'Does the surgical repair of the acute Achilles tendon ruptures cause the structural changes in the 15-year follow-up?' The only complaint of the patient was the feeling of that the size of the left foot is smaller than the right side. Dynamic pedobarography (EMED-SF, Novel, Munich) demonstrated that left foot has less total contact area, higher pressure values, lower arch index, more laterally located center of pressure, and higher medial arch than that of the right one.

Evaluation of DNA damage after tourniquet-induced ischaemia/reperfusion injury during lower extremity surgery.

Ischemia/reperfusion (I/R) injury represents a source of substantial morbidity and mortality in various statuses that is, coronary bypass, myocardial infarction, and so on. Oxygen free radicals, formed during I/R, have been proposed as one of the main causes of tissue injury and play important role in I/R injury. Leucocytes have been shown to play an important role in the development of tissue injury after I/R. Accordingly, numerous studies have shown that even short-time I/R-induced DNA damage can be investigated in human peripheral leucocytes using the alkaline single-cell gel-electrophoresis assay (comet assay). After ischaemia, the genotoxic damage detected in human peripheral leucocytes locally in the reperfused tissue results in numerical, morphologic and biochemical alterations of all circulating white blood cells in the human organism. It leads particularly to the release of substantial amounts of oxygen radicals and other reactive agents. Simultaneously, local ischaemia in the reperfused tissue is extended to the whole body systemically through these activated inflammatory cells and, possibly, results in secondary detectable tissue damage in endothelial cells of the systemic circulation inducing prolonged DNA damage even in the early reperfusion period. Thus, we aimed to investigate whether the I/R during the routinely practised operation causes DNA damage, since other published studies were on animal and in vitro models and did not exactly reflect the operation procedure in the clinic. We measured DNA damage (single-strand breaks, oxidised purines and pyrimidines) by modified alkaline comet assay using two bacterial enzymes (formamidopyrimidine glycosylase (Fpg), endonuclease III (EndoIII)), which recognise oxidised purines and pyrimidine bases, in patients who had lower extremity surgery. There was no statistically significant difference in DNA damage between time periods (before surgery, after I/R; T1, T2 and T3). According to our findings, we indicate that at the molecular level DNA is damaged due to the I/R during the routinely practised operation; however, this effect could not be determined phenotypically. Thus, we may suggest that the surgeons and anaesthetist/operation room personnel could be informed about that fact and encouraged to use antioxidants and/or apply prophylaxis. Our findings showed that I/R injury did not induce DNA damage. Further studies of this approach are needed.

Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients.

AIM: Our study reports long-term results and factors related to patient satisfaction in the case of primary hemiarthroplasty for humeral proximal end fractures. PATIENTS AND METHODS: We retrospectively evaluated 42 patients with humeral proximal end fractures who underwent primary hemiarthroplasty in our clinic from February 1994 to March 2004. Of the 42 patients, 14 (33%) were male and 28 (67%) female. The mean age was 68.9+/-5.57 years (age range: 59-81 years). The mean follow-up period was 78.8+/-26.6 months (range: 48-118 months). We evaluated the following parameters: fracture type according to the Neer classification, the time interval between the fracture and the operation, postoperative radiological examination, the Neer outcome assessment criteria for patient satisfaction and functions, according to the Constant and Murley Scoring (CMS) system. RESULTS: We found good-to-excellent outcomes in 36 (85.7%) and poor outcome in six (14.3%) patients according to the Neer criteria. The average values for CMS score, anterior elevation and external rotation were 73.59+/-17.95 (25-94), 121.30+/-42.99 degrees (range: 30-170 degrees ) and 30 degrees (range: 0-80 degrees ), respectively. The patients who had been operated in the early period (within 2 weeks) had better functional outcomes (p<0.001) and had significant pain relief. There was a strong positive correlation between the humeral offset (distance between the head and the tuberosities) and the degree of elevation (r=0.872, p<0.001). There was a strong negative correlation between the height of the humeral head and the degree of elevation (r=-0.853, p<0.001). CONCLUSION: In humeral proximal end fractures, primary hemiarthroplasty in the early period with the anatomic reconstruction of bone and soft tissues of the shoulder joint and long-term regular rehabilitation programme are important factors contributing to increased patient satisfaction.