Arthroscopic Suture Bridge Anchor Repair of Comminuted Greater Tuberosity Fracture With Double-Row Biceps Tenodesis in Elderly Osteoporotic Patients.

Isolated greater tuberosity fractures with displacement require usually open reduction and fixation to prevent poor outcomes, but high levels of morbidity have been reported. Recently, newer techniques describe arthroscopic fixation of greater tuberosity fracture for young patients; however, in elderly patients with comminuted osteoporotic fractures, this entity is more complex. A new arthroscopic technique is described through a minimally invasive approach that allows the evaluation of the glenohumeral joint and the treatment of associated pathology. These comminuted fractures can be treated using suture bridge technique. Postoperatively, rehabilitation consists of a similar regimen to that of a rotator cuff repair. With the appropriate surgical technique, good clinical outcomes can be obtained.

Irreducible anterior shoulder dislocation with interposition of the lesser tuberosity and subscapularis.

Anterior shoulder dislocation is the most common joint dislocation, unreducible dislocations however are a rare occurrence. The causes of the irreducibility vary, with interposition of soft tissues or bony fragments within the glenohumeral joint being the usual culprits. We present the case of an irreducible anterior shoulder dislocation with concomitant greater and lesser tuberosity fractures, with interposition of the subscapularis and lesser tuberosity thereby preventing reduction. We present the case of a 54-year-old female presenting with a left shoulder fracture dislocation after a fall from a 1.8-meter ladder. Patient was taken to the operating room after undergoing a CT scan. Attempts of closed reduction after administration of general anesthesia were unsuccessful. Open reduction and internal fixation with plate and screws was done through a deltopectoral approach. Intra-operatively, the lesser tuberosity and the subscapularis were found to be the cause of the irreducibility of the dislocation. At the latest follow up at 6 months post-op, the patient had regained a normal ROM with a good function. The vast majority of shoulder fracture dislocations are easily reducible, with only a limited number of case reports discussing irreducible fracture-dislocations. The causes of the irreducibility comprise interposition of soft tissue or bony fragments within the glenohumeral joint such as avulsed labrum or tendons, glenoid or humeral bony fragments interposition, and tensioning of nerves or tendons such as the biceps or subscapularis around the humeral head. CT scans are in our opinion very important for proper surgical planning when needed and for possible identification of an irreducible dislocation. Orthopedic surgeons should be aware that difficult closed reductions of the glenohumeral joint, whenever encountered, should raise the possibility of interposition of bony fragments or soft tissues where surgical treatment might be mandatory.

A rare case of an anatomical variation of bilateral long head of the biceps brachii tendons identified within the substance of bifid subscapularis tendons.

The long head of the biceps tendon is stabilized in the intertubercular groove by several anatomical structures. Dislocation or identification of the biceps tendon into or within the subscapularis tendon is very rarely mentioned in the literature. This is the first reported case of bilateral identification of the long head of the biceps tendons within the lateral subscapularis tendon. This report presents the case of a 51-year-old male patient who presented for bilateral shoulder pain. After failure of conservative treatment, MRIs were done which identified bilateral biceps tendons within the subscapularis tendons, with a concomitant supraspinatus tear on the right side. He underwent right shoulder arthroscopic biceps tenotomy, with supraspinatus repair. The symptoms of the left shoulder diminished as a result of the continuation of conservative treatment. The long head of the biceps tendon normally travels through the intertubercular groove and is stabilized by soft tissue and bony structures. Medial dislocation of the tendon is affected by the medial wall angle and by the integrity of the soft tissue stabilizers; most importantly the coracohumeral ligament in the proximal part of the groove. Dislocation of the biceps tendon into the substance of the subscapularis has been rarely mentioned in the literature; and as far as we know, bilateral occurrence without any identifiable subscapularis tears has never been previously mentioned. The bilateral occurrence with the absence of subscapularis lesions indicates that this is a congenital anomaly.

Arthroscopic management of anterior labrum periosteal sleeve avulsion (ALPSA) lesions: A case series with improved clinical outcomes using a modified technique.

INTRODUCTION: Anterior labrum periosteal sleeve avulsion (ALPSA) is the avulsion of the labrum and of the non-disrupted periosteum with the subsequent healing of the labrum in a medialized nonfunctional position on the glenoid neck. OBEJCTIVE: In this study, a modified technique for arthroscopic repair of ALPSA lesions is presented, along with post operative clinical results and follow up. METHOD: 72 patients who underwent this procedure were included in this study. Patients with multidirectional instability, more than 20% of glenoid bone loss, and bony Bankart lesions were excluded. RESULTS AND CONCLUSION: It was concluded that with this modified technique, a lower recurrence rate post arthroscopic repair of ALPSA lesions was seen with only 4 patients having postoperative recurrence of glenohumeral dislocation which amounts to 5.6%. Moreover, the data also showed a statistically significant improvement of 35.23% between the pre- and postoperative ASES scores.

Modified Double-Row Suture Bridge Technique With Double-Row Biceps Tenodesis for Massive Rotator Cuff Tear.

This article aims to describe a modification of the arthroscopic suture bridge technique for repair of a massive (>3 cm) rotator cuff tear. The method uses 2 medial anchors and 2 lateral anchors for rotator cuff repair, as well as double-row biceps tenodesis. This operative modification may impart better tendon healing and fewer rupture complications than the traditional double-row repair techniques.

A spinoglenoid cyst compressing on the suprascapular nerve causing supraspinatus and infraspinatus muscle weakness: A case report.

INTRODUCTION: Spinoglenoid cysts are a rare cause of suprascapular neuropathy of compressive etiology in which the patient may present with shoulder pain and muscle hypotrophy. MRIs are the imaging modality of choice showing location, size, and extent of the lesion for preoperative assessment. Currently, surgical intervention is the preferred approach for the management of a spinoglenoid cyst with arthroscopy being favored over the open technique. CASE PRESENTATION: A 25-year-old male patient presenting with right posterior shoulder pain and decreased range of motion associated with the development of progressive weakness of the supraspinatus and infraspinatus muscles. Right shoulder MRI showed a posterior tear of the glenoid labrum and a spinoglenoid ganglion cyst. Preoperative electroneuromyography was suggestive of a suprascapular nerve impairment. FOLLOW-UP: Six months postoperatively, the patient has regained full range of motion of his right shoulder with no residue signs of muscle hypotrophy. CONCLUSION: Spinoglenoid cysts can cause compressive neuropathy with associated pain and muscle hypotrophy. MRI and EMG can help in establishing the diagnosis and in the pre-operative assessment. Surgical intervention with arthroscopy is currently the technique preferred by most surgeons.

Posterior shoulder instability due to isolated reverse HAGL lesion in a young gymnast: A rare mechanism of injury and surgical technique.

Humeral avulsion of the inferior glenohumeral ligament (HAGL) is a relatively important cause of shoulder instability, becoming a field of interest in the literature. Reverse HAGL lesions, a rare pathology compared to anterior disruptions; have been documented in only few cases as a notable cause of posterior instability. We describe in detail the mechanism of injury, diagnosis, arthroscopic repair and results.

Pan-labral tear of the shoulder joint in a non-athlete patient with six years history of recurrent shoulder subluxations and intraoperative findings of osteoarthritic changes: A case report.

The hypermobility of the glenohumeral joint accounts for its anatomic predisposition for instability and dislocation. The stability of the shoulder joint is dependent on static and dynamic soft tissue structures, among which is the labrum. Circumferential labral tears are a rare pathological entity of shoulder instability that have not been commonly reported in the literature. A detailed history and physical examination are crucial for accurate diagnosis since MRIs have a poor sensitivity. A 40-year-old male patient with a history of atraumatic recurrent left shoulder subluxations for 6 years. On physical examination, there was no evidence of motor or sensory deficit. MR images were suggestive of Hills-Sachs lesion with intact rotator cuffs. Pan-labral tear repair via arthroscopy presents a unique challenge, even for the skilled orthopedic surgeon. Hence, the repair demands accessory portals and percutaneous techniques for the adequate placement of anchors. The purpose of this case is the rare presentation of a pan-labral tear repaired arthroscopically.

Biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion without a Hill-Sachs lesion: A case report and review of the literature.

Combined injuries of the glenohumeral joint that involve biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion are extremely rare. As per our knowledge, this is the first case report that includes such combined injuries that were treated arthroscopically. We present the case of a 48-year-old male patient who sustained shoulder trauma after being thrown against the rocks by a wave, was found to have biceps tendon subluxation associated with isolated greater tuberosity fracture and bony Bankart lesion. The operative management resulted in complete restoration of the range of motion of the shoulder, and uneventful healing of the fracture. The patient recovered normal activity including his surfing.

Association of acromial morphological parameters and rotator cuff tears, and evaluation of the influence of age and gender on the parameters and impact on cuff tears: A study on a Middle Eastern population.

OBJECTIVE: The aim of this study is to evaluate the presence of significant differences regarding the lateral acromial angle, critical shoulder angle, and the acromial index between patients with and without rotator cuff tears. METHOD: The MRIs (Magnetic Resonnance Imaging) of 82 patients were studied. The rotator cuff tear group (RCT group) included 41 patients while the control group also included 41 patients without rotator cuff tears. Acromial parameters and demographical data were extracted for statistical analysis. RESULTS: No statistical significant difference was found in terms of the studied acromial parameters between patients with and without rotator cuff tears. No correlation was found between age and any of the studied parameters. LAA (Lateral Acromial Angle) was found to be significantly different between males and females of the studied sample. However, no difference was found between patients with and without rotator cuff tears when both genders were studied separately. Moreover, no statistical significant difference was found in terms of the studied acromial parameters between males and females when the RCT group and the control group were studied separately. When gender was the covariate in the one-way MANCOVA test, gender was not significantly dependent on the type of groups (RCT group vs control group). CONCLUSION: The results obtained from this study suggested that the studied acromial parameters in patients with rotator cuff tears were not different from the parameters found in patients without rotator cuff tears. Moreover, gender was not found to influence the acromial parameters, with no subsequent effect on the development of rotator cuff tears. Further studies may be required for better understanding on the biomechanics, taking into consideration age, gender, and the given population.

Is there an association between glenoid parameters and rotator cuff tears and the influence of gender: A retrospective study on a Middle Eastern population.

OBJECTIVE: This study aims to investigate the presence of any differences between the normal population and patients with rotator cuff tears in term of glenoid morphological parameters. METHOD: For the purpose of this study, 82 shoulder MRIs were evaluated. The individuals included in this study were divided into the patient group (cuff tear group, n = 41) and the control group (control group, n = 41) with respect to the inclusion and exclusion criteria. For the statistical analysis, SPSS software was used. RESULTS: Statistically significant difference was found between the patient group and the control group in terms of Glenoid Version Angle (GVA), Glenoid Axial Width (GAW), Glenoid Axial Depth (GAD), Glenoid Coronal Depth (GCD), and the Glenoid Inclination Angle (GIA). Age was found to have a positive linear correlation with the glenoid coronal height. Moreover, statistically significant difference was found between the males and females, between males with cuff tears and control males, and females with cuff tears and control females in terms of glenoid parameters. When gender was a covariate, statistically significant differences in glenoid parameters was still present between cuff tears patients and individuals with control shoulders. CONCLUSION: The results attained in this study are suggest that the GVA, GAW, GAD, GCD, and GIA in rotator cuff tear patients are different than those found in control patients. These measurements may be helpful in reaching the diagnosis in cases where the clinical diagnosis is equivocal. Moreover, these measurements may be helpful in planning tears management. The influence of gender on glenoid parameters and subsequent impact on shoulder pathology may help to better understand the biomechanism of rotator cuff tears and reach an individualized management for better patient care.

Simultaneous ORIF for bilateral comminuted proximal humerus fractures: Case report in an elderly patient.

INTRODUCTION: Bilateral proximal humerus fractures are rather rare and occur due to high energetic traumas in young patients and even low energetic traumas in older patients having osteoporosis. Open reduction and internal fixation (ORIF) is the most popular treatment for this type of fracture while other types of treatment such as arthroplasty or conservative treatment are also, but less commonly used. PRESENTATION OF CASE: This report presents the case of an 80 years old female patient with bilateral proximal humerus fractures and a history of hypothyroidism. The patient was treated with simultaneous open reduction and internal fixation and presented a normal and full-range motion in both shoulders after follow-up. DISCUSSION: Frequency of proximal humerus fractures has increased with the increase in life expectancy. Osteoporotic people are at higher risk. Around five percent of all extremity fractures are humerus proximal end fractures for people below 40 years old and 76 % for cases of people over 40 years old, with females being more susceptible. ORIF is the treatment of choice for such fractures. Replacement arthroplasty, minimally invasive techniques and conservative management are other options depending on fracture characteristics. CONCLUSION: This is an interesting rare case of simultaneous bilateral proximal humerus fractures in an elderly female patient, treated operatively with satisfactory results on follow up.

Bipolar clavicular fracture on ipsilateral reverse shoulder prosthesis: Case report.

BACKGROUND: Bipolar clavicular fractures are extremely rare with no consensus on management. No previous cases of bipolar clavicular fracture on an ipsilateral reverse shoulder prosthesis have been reported. CASE PRESENTATION: We report a case of a 78y.o female patient with left bipolar clavicular fracture on ipsilateral reverse shoulder prosthesis, associated with multiple ribs fracture, that was treated with open reduction and internal fixation using k-wires and endobutton for the lateral part, while as the medial part was fixed with plate and screws. CONCLUSIONS: Any patient with a clavicle fracture, with a history of sequential forces to the clavicle, a bipolar injury should always be suspected. Attention should be given if any implants are present on the ipsilateral side of the injury, which could affect surgical planning and outcome.

Localized Pigmented Villonodular Synovitis of the Posterior Knee Compartment with Popliteal Vessel Compression: A Case Report of Arthroscopic Resection Using Only Anterior Knee Portals.

BACKGROUND: Pigmented villonodular synovitis is a rare pathology causing hyperplasia of the synovium. It mostly affects young populations and most commonly the knee joint. It rarely affects the posterior compartment of the knee as the case presented in this study. Open surgery is usually used to treat this condition; however, in our case it was excised arthroscopically despite the anatomical challenges of the posterior knee compartment. CASE PRESENTATION: This case presents a female patient with a complaint of posterior-region pain of her left knee post direct trauma post fall. This was directly followed by knee joint blockage for 1-week duration before presentation to the hospital. On MRI, she was found to have a multiloculated hemosiderin-containing structure of synovial origin within the femoral notch, extending beyond the joint capsule displacing the popliteal vessels. The patient underwent arthroscopic resection of the lesion, which was found to be pigmented villonodular synovitis on anatomopathological examination. On 6-month follow-up, the patient showed good clinical evolution with the absence of symptoms and back-to-normal daily activities. CONCLUSION: This is a rare case of PVNS affecting the posterior knee joint compartment of a middle-aged woman, which was successfully excised arthroscopically, with no residual affected tissue or recurrence on 6-month follow-up.

Technique for Arthroscopic Long Head of Biceps Tenodesis Using Anchor With Fork Tip Eyelet.

This article describes a method of arthroscopic subscapular tenodesis of the long head of the biceps tendon using a single anterolateral portal, making it a minimally invasive procedure. This method is done by using the Swivelock tenodesis anchor with forked tip PEEK Eyelet from Arthrex, which enables anatomically stable fixation of the biceps tendon with a relatively decreased rate of complications.

Lumbar spondylolysis in pediatric and adolescent soccer players.

BACKGROUND: Lumbar spondylolysis in young soccer players has not been studied extensively. PURPOSE: The purpose of this study was to review lumbar spondylolysis in young soccer players, describe the causes, and report the results of nonoperative treatment emphasizing the cessation of activity for 3 months. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors reviewed 57 child and adolescent soccer players (35 boys and 22 girls) with lumbar spondylolysis who came to their outpatient clinic for back pain evaluation. These patients received different modalities of nonoperative treatment, including cessation of sports and wearing a thoracolumbosacral orthosis. Soccer skills, field position, side of dominant leg, age, initiating event of low back pain, duration of symptoms, and nonoperative treatment were reviewed. Clinical outcome of treatment was assessed by the Steiner-Micheli criteria at the most recent follow-up (minimum 2 years). The Fisher exact test was used to compare all the data. RESULTS: Of the patients, 43% noticed that pain started after a high-velocity kick. Thirty-three (58%) of 57 patients had excellent results with no pain during sports, 20 (35%) good, 3 (5%) fair, and 1 (2%) poor. Subjects who ceased playing soccer for 3 months had better results than those who did not comply with this restriction. CONCLUSION: The authors recommend stopping sports for at least 3 months in cases of lumbar spondylolysis in young soccer players who hope to return to their previous level of play without back pain.

Effect of sports modification on clinical outcome in children and adolescent athletes with symptomatic lumbar spondylolysis.

OBJECTIVE: This cohort study aimed to report the compliance of young athletes with nonoperative treatment and to clarify the role of sports modification on clinical outcome of symptomatic spondylolysis. DESIGN: This study included patients with a chief complaint of low back pain participating in regular sports activity, having spondylolysis, and being treated and followed up between 1990 and 2002 in the authors' hospital. RESULTS: One hundred thirty-two athletes were included in this study: 78 males and 54 females. The mean age of the patients was 13 yrs (range, 7-18 yrs). Only 56 patients (42.4%) were compliant to nonoperative treatment. Eighty-six patients (65%) stopped all sports activities for at least 3 mos, and 46 patients (35%) stopped exercising for a variable period of less than 3 mos. The grading of clinical outcome after nonoperative treatment was as follows: excellent in 48 patients (36.4%), good in 74 patients (56.1), fair in 6 patients (4.5%), and poor in 4 patients (3%). The patients who stopped sports for at least 3 mos were 16.39 times more likely to have an excellent result than those who did not stop sports. Bony healing on radiographs did not correlate with clinical outcome. CONCLUSIONS: Timely cessation of sports activity for 3 mos is considered an effective method of nonoperative treatment for young athletes with symptomatic lumbar spondylolysis.

Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography.

STUDY DESIGN: Retrospective clinical study with radiographic and medical chart review. OBJECTIVE: To study the clinical characteristics and outcome of pediatric athletes with low back pain and unilateral tracer uptake on single photon emission computed tomography (SPECT) at the pars interarticularis but no defect on radiographs. SUMMARY OF BACKGROUND DATA: Some pediatric athletes with low back pain have no findings on plain radiographs but a unilateral SPECT uptake at the pars interarticularis. However, little is known about these patients. METHODS: Twenty-two pediatric athletes who had low back pain with increased tracer uptake on SPECT unilaterally at the pars interarticularis but no defect on plain radiograph were evaluated. The following criteria were used for evaluation: age, male-to-female ratio, duration of symptoms, vertebral level, and presence of spina bifida occulta or scoliosis. RESULTS: The average age was 12.3 +/- 2.5 years. The male-to-female ratio was 1.2:1. The average duration of symptoms was 21 +/- 23 weeks. Nineteen (86%) had increased uptake at L5. Six (27%) had spina bifida occulta and 8 (36%) had scoliosis. Eighteen (82%) patients showed an excellent outcome. The patients who presented with a longer history of symptoms or a concomitant spina bifida occulta had an increased risk of having occasional aching with vigorous activity when compared with the patients who did not (P < 0.05). CONCLUSIONS: Athletes who have low back pain and increased tracer uptake unilaterally at the pars interarticularis on SPECT are younger than those previously reported patients with spondylolysis proven by a defect on radiographs. Some of these lesions do progress to "frank" spondylolysis seen on radiographs, but favorable clinical outcomes from nonoperative treatment can be expected. Patients with a longer pain history or concomitant spina bifida occulta may need careful follow-up because they are at increased risk of having occasional low back pain.