Search

Background: Reverse total shoulder arthroplasty (rTSA) typically restores active arm elevation. Prior studies in patients with rTSA during tasks that load the arm had limitations that obscured underlying three-dimensional (3D) kinematic changes and the origins of motion restrictions. Understanding the scapulothoracic and glenohumeral contributions to loaded arm elevation will uncover where functional deficits arise and inform strategies to improve rTSA outcomes.Questions/purposes: In a cohort of patients who had undergone rTSA and a control cohort, we asked: (1) Is there a difference in maximum humerothoracic elevation when scapular plane elevation (scaption) is performed with and without a handheld weight? (2) Is maximum humerothoracic elevation related to factors like demographics, patient-reported outcome scores, isometric strength, and scapular notching (in the rTSA group only)? (3) Are there differences in underlying 3D scapulothoracic and glenohumeral motion during scaption with and without a handheld weight?Methods: Ten participants who underwent rTSA (six males, four females; age 73 ± 8 years) were recruited at follow-up visits if they were more than 1 year postoperative (24 ± 11 months), had a BMI less than 35 kg/m 2 (29 ± 4 kg/m 2 ), had a preoperative CT scan, and could perform pain-free scaption. Data from 10 participants with a nonpathologic shoulder, collected previously (five males, five females; age 58 ± 7 years; BMI 26 ± 3 kg/m 2 ), were a control group with the same high-resolution quantitative metrics available for comparison. Participants in both groups performed scaption with and without a 2.2-kg handheld weight while being imaged with biplane fluoroscopy. Maximum humerothoracic elevation and 3D scapulothoracic and glenohumeral kinematics across their achievable ROM were collected via dynamic imaging. In the same session the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and isometric strength were collected. Data were compared between weighted and unweighted scaption using paired t-tests and linear mixed-effects models.Results: When compared with unweighted scaption, maximum humerothoracic elevation decreased during weighted scaption for patients who underwent rTSA (-25° ± 30°; p = 0.03) but not for the control group (-2° ± 5°; p = 0.35). In the rTSA group, maximum elevation correlated with the ASES score (r = 0.72; p = 0.02), and weighted scaption correlated with BMI (r = 0.72; p = 0.02) and the SST (r = 0.76; p = 0.01). Scapular notching was observed in three patients after rTSA (Grades 1 and 2). Four of 10 patients who underwent rTSA performed weighted scaption to less than 90° humerothoracic elevation using almost exclusively scapulothoracic motion, with little glenohumeral contribution. This manifested as changes in the estimated coefficient representing mean differences in slopes in the humerothoracic plane of elevation (-12° ± 2°; p < 0.001) and true axial rotation (-16° ± 2°; p < 0.001), scapulothoracic upward rotation (7° ± 1°; p < 0.001), and glenohumeral elevation (-12° ± 1°; p < 0.001), plane of elevation (-8° ± 3°; p = 0.002), and true axial rotation (-11° ± 2°; p < 0.001). The control group demonstrated small differences between scaption activities (< |2°|), but a 10° increase in humerothoracic and glenohumeral axial rotation (both p < 0.001).Conclusion: After rTSA surgery, maximum humerothoracic elevation decreased during weighted scaption by up to 88° compared with unweighted scaption, whereas 4 of 10 patients could not achieve more than 90° of elevation. These patients exhibited appreciable changes in nearly all scapulothoracic and glenohumeral degrees of freedom, most notably a near absence of glenohumeral elevation during weighted scaption. Patients with rTSA have unique strategies to elevate their arms, often with decreased glenohumeral motion and resultant compensation in scapulothoracic motion. In contrast, the control group showed few differences when lifting a handheld weight.Clinical Relevance: Functional deficiency in activities that load the shoulder after rTSA surgery can affect patient independence, and they may be prevalent but not captured in clinical studies. Pre- or postoperative rehabilitation to strengthen scapular stabilizers and the deltoid should be evaluated against postoperative shoulder function. Further study is required to determine the etiology of deficient glenohumeral motion after rTSA, and the most effective surgical and/or rehabilitative strategies to restore deficient glenohumeral motion after rTSA. [ABSTRACT FROM AUTHOR]

Background: The purpose of the present study was to analyze the association between sex hormone deficiency and rotator cuff repair (RCR) with use of data from a large United States insurance database.Methods: A retrospective analysis of insured subjects from the Truven Health MarketScan database was conducted, collecting data for RCR cases as well as controls matched for age, sex, and years in the database. Multivariable logistic regression models adjusted for matching variables were utilized to compare RCR status with estrogen deficiency status and testosterone deficiency status. These associations were confirmed with use of data from the Veterans Genealogy Project database, with which the relative risk of RCR was estimated for patients with and without sex hormone deficiency.Results: The odds of RCR for female patients with estrogen deficiency were 48% higher (odds ratio, 1.48; 95% confidence interval, 1.44 to 1.51; p < 0.001) than for those without estrogen deficiency. The odds of RCR for males with testosterone deficiency were 89% higher (odds ratio, 1.89; 95% confidence interval, 1.82 to 1.96; p < 0.001) than for those without testosterone deficiency. Within the Veterans Genealogy Project database, the relative risk of estrogen deficiency among RCR patients was 2.58 (95% confidence interval, 2.15 to 3.06; p < 0.001) and the relative risk of testosterone deficiency was 3.05 (95% confidence interval, 2.67 to 3.47; p < 0.001).Conclusions: Sex hormone deficiency was significantly associated with RCR. Future prospective studies will be necessary to understand the pathophysiology of rotator cuff disease as it relates to sex hormones.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Case: A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery. Conclusion: Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty. [ABSTRACT FROM AUTHOR]

Background: Muscle volume is important in shoulder function. It can be used to estimate shoulder muscle balance in health, pathology, and repair and is indicative of strength based on muscle size. Although prior studies have shown that muscle area on two-dimensional (2-D) images correlates with three-dimensional (3-D) muscle volume, they have not provided equations to predict muscle volume from imaging nor validation of the measurements.Questions/purposes: We wished to create an algorithm that quickly, accurately, and reliably estimates the volume of the shoulder muscles using cross-sectional area on MR images with low error. Specifically, we wished to (1) determine which MR imaging planes provide the highest correlation between shoulder muscle cross-sectional area and volume; (2) derive equations to predict muscle volume from cross-sectional area and validate their predictive capability; and (3) quantify the reliability of muscle cross-sectional area measurement.Methods: Three-dimensional MRI was performed on 10 cadaver shoulders, with sample size chosen for comparison to prior studies of shoulder muscle volume and in consideration of the cost of comprehensive analysis, followed by dissection for muscle volume measurement via water displacement. From each MR series, 3-D models of the rotator cuff and deltoid muscles were generated, and 2-D slices of these muscle models were selected at defined anatomic landmarks. Linear regression equations were generated to predict muscle volume at the plane(s) with the highest correlation between volume and area and for planes identified in prior studies of muscle volume and area. Volume predictions from MR scans of six different cadaver shoulders were also made, after which they were dissected to quantify muscle volume. This validation population allowed the calculation of the predictive error compared with actual muscle volume. Finally, reliability of measuring muscle areas on MR images was calculated using intraclass correlation coefficients for inter-rater reliability, as measured between two observers at a single time point.Results: The rotator cuff planes with the highest correlation between volume and area were the sum of the glenoid face and the midpoint of the scapula, and for the deltoid, it was the transverse plane at the top of the greater tuberosity. Water and digital muscle volumes were highly correlated (r ≥ 0.993, error < 4%), and muscle areas correlated highly with volumes (r ≥ 0.992, error < 2%). All correlations had p < 0.001. Muscle volume was predicted with low mean error (< 10%). All intraclass correlation coefficients were > 0.925, suggesting high inter-rater reliability in determining muscle areas from MR images.Conclusion: Deltoid and rotator cuff muscle cross-sectional areas can be reliably measured on MRI and predict muscle volumes with low error.Clinical Relevance: Using simple linear equations, 2-D muscle area measurements from common clinical image analysis software can be used to estimate 3-D muscle volumes from MR image data. Future studies should determine if these muscle volume estimations can be used in the evaluation of patient function, changes in shoulder health, and in populations with muscle atrophy. Additionally, these muscle volume estimation techniques can be used as inputs to musculoskeletal models examining kinetics and kinematics of humans that rely on subject-specific muscle architecture. [ABSTRACT FROM AUTHOR]

Background: Although glenoid morphology has been associated with fatty infiltration of the rotator cuff in arthritic shoulders, the association of rotator cuff muscle area with specific patterns of glenoid wear has not been studied. The purpose of our study was to assess the associations of glenoid deformity in primary glenohumeral osteoarthritis and rotator cuff muscle area.Methods: A retrospective study of 370 computed tomographic (CT) scans of osteoarthritic shoulders was performed. Glenoid deformity according to the modified Walch classification was determined, and retroversion, inclination, and humeral-head subluxation were calculated using automated 3-dimensional software. Rotator cuff muscle area was measured on sagittal CT scan reconstructions. A ratio of the area of the posterior rotator cuff muscles to the subscapularis was calculated to approximate axial plane potential force imbalance. Univariate and multivariate analyses to determine associations with glenoid bone deformity and rotator cuff measurements were performed.Results: Patient age and sex were significantly related to cuff muscle area across glenoid types. Multivariate analysis did not find significant differences in individual rotator cuff cross-sectional areas across glenoid types, with the exception of a larger supraspinatus area in Type-B2 glenoids compared with Type-A glenoids (odds ratio [OR], 1.5; p = 0.04). An increased ratio of the posterior cuff area to the subscapularis area was associated with increased odds of a Type-B2 deformity (OR, 1.3; p = 0.002). Similarly, an increase in this ratio was significantly associated with increased glenoid retroversion (beta = 0.92; p = 0.01) and humeral-head subluxation (beta = 1.48; p = 0.001). Within the Type-B glenoids, only posterior humeral subluxation was related to the ratio of the posterior cuff to the subscapularis (beta = 1.15; p = 0.001).Conclusions: Age and sex are significantly associated with cuff muscle area in arthritic shoulders. Asymmetric glenoid wear and humeral-head subluxation in osteoarthritis are associated with asymmetric atrophy within the rotator cuff transverse plane. Increased posterior rotator cuff muscle area compared with anterior rotator cuff muscle area is associated with greater posterior glenoid wear and subluxation. It is unclear if the results are causative or associative; further research is required to clarify the relationship.Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Humeral bone loss is commonly encountered during revision shoulder arthroplasty and anticipating humeral bone defects can help the revision surgeon make appropriate plans to achieve adequate fixation and stability. No validated classification system exists to characterize humeral bone loss in the setting of revision shoulder arthroplasty.Questions/purposes: The purposes of this study were (1) to create a classification system for humeral bone loss in revision shoulder arthroplasty; (2) to determine the classification system's reliability; and (3) to determine whether humeral bone loss type is associated with intraoperative humeral-related reconstruction characteristics.Methods: This was a comparative retrospective radiographic study. First, six surgeons from five centers collaborated to create a classification by consensus. Second, two surgeons from two other centers who had fellowship training in shoulder and elbow surgery, who were blinded to each other's grades and all patient details other than plain radiographs, and who were not involved in creation of the system, classified true AP, AP, and lateral (axillary and/or scapular-Y) radiographs from 108 revision (413 radiographs) from one center that were performed between November 15, 2006, and January 4, 2018. Interobserver reliability was calculated by comparing those two reviews and determining Cohen's κ. In addition, one reviewer repeated his assessments twice, 4 months apart, to determine intraobserver reliability using Cohen's κ. Third, we performed a retrospective chart study of these same revisions to determine intraoperative humeral-related reconstruction characteristics such as the use of greater tuberosity fixation, stem length, humeral bone grafting, and the use of proximal humeral replacement or total humeral replacement; at the center where these revisions were performed during that timespan, no attempt to classify bone loss was made. During that period, the general indications for greater tuberosity fixation included the absence of a stable osseous connection between the greater tuberosity and the shaft of the humerus with a tuberosity amendable to repair; the general indications for use of longer stems were inability to obtain a minimum of two cortical widths of overlap between the implant and the humeral diaphysis and/or loss of the greater tuberosity; and the general indications for proximal and total humeral replacement were bone loss that was felt to be too severe to allow reconstruction with allograft.Results: The classification system consists of three types of humeral bone loss: Type 1 is loss of the epiphysis with subtypes for loss of the calcar and loss of the greater tuberosity; Type 2 is loss of the metadiaphysis above the deltoid attachment with a subtype for cortical thinning; and Type 3 is bone loss extending below the deltoid attachment with a subtype for cortical thinning. We studied 108 revisions: 38 (35%) without bone loss, 34 (31%) Type 1, 27 (25%) Type 2, and nine (8%) Type 3. For reliability, interrater κ was 0.545 and in 71% (77 of 108) of revisions, the two raters agreed on a numeric type. Intrarater κ was 0.615 and in 77% (83 of 108) of revisions, the rater agreed with himself as to the numeric type. Stem length increased with class type (Type 1 median [range] 130 [70-210], Type 2 150 [70-210], Type 3 190 [70-240], p = 0.005). Most greater tuberosity fixation for intraoperative fracture was in Types 1 and 2 (13 of 18 compared with the five of 18 of greater tuberosity fixation that was within Types 0 and 3, p = 0.043). Most bone grafting was in Types 2 and 3 (eight of 13 compared with five of 13 of bone grafting was in Types 0 and 1, p = 0.044). Most proximal humeral and total humeral replacements were in Type 3 (three of four compared with one of four, p < 0.001).Conclusions: We developed the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) system, which has adequate, if imperfect, reliability to classify humeral bone loss in the setting of revision shoulder arthroplasty. This classification system may be useful to anticipate the complexity of humeral reconstruction. Further validation incorporating advanced imaging and further evaluators will be necessary.Level Of Evidence: Level III, diagnostic study. [ABSTRACT FROM AUTHOR]

The article discusses several studies related to shoulder and elbow injury from April 2017 to March 2018. These studies include one on radiographic progression of primary osteoarthritis, another on patients who underwent anatomic total shoulder arthroplasty using a Trabecular Metal-backed glenoid component, and one on shoulder arthroplasty patients with regard to the factors associated with the development of deep operative infection.

Background: Instability is the most common complication after reverse total shoulder arthroplasty (rTSA). In the native glenohumeral joint, in addition to full dislocations, more subtle forms of instability exist. However, the incidence of more subtle forms of instability, the factors associated with instability, and the effect of instability on validated outcome scores after rTSA remain poorly understood.Questions/purposes: (1) After rTSA, what is the risk of instability, including more subtle forms of subjective instability? (2) What are the factors associated with instability? (3) Are more subtle forms of instability associated with lower American Shoulder and Elbow Surgeons (ASES) functional outcome scores than those patients without instability?Methods: A total of 168 rTSAs were performed during the study period. Six patients had died at the time of study initiation. Thirty patients were excluded, nine because rTSA was performed for an acute proximal humeral fracture, one because a lateralized humeral component was used, 17 because a retaining liner was used, and three because a lateralized glenosphere was used. One hundred thirty-two patients met inclusion and exclusion criteria. Thirty-five patients were lost to followup. Thus, 97 patients with a minimum of 2 years followup were included in the final cohort (74% of included patients). Followup was 47 ± 22 months (mean ± SD). The cohort included 23 men and 74 women with an age of 70 ± 9 years who underwent 78 primary and 19 revision rTSAs. Primary and revision patients were combined for subsequent analyses. A postoperative questionnaire was used to assess instability symptoms. Although it has not been validated, it is simple and we believe has high face validity. Briefly, it scored instability as (1) none; (2) feelings of instability; (3) probable dislocation/subluxation-self-reduced; and (4) dislocation with surgical reduction or dislocation with closed reduction (such as in the emergency department or the doctor's office). ASES scores were collected specifically for this study. The preoperative and postoperative β angle was measured to determine glenoid inclination. Larger β angles denote more superior inclination, whereas smaller β angles denote more inferior inclination. Thus, a positive change in β angle from preoperatively to postoperatively denotes a change into more superior inclination, whereas a negative change in β angle from preoperatively to postoperatively denotes a change into more inferior inclination. Associations between instability symptoms and patient, implant, and surgical factors were evaluated in a multivariate model that considered age, sex, body mass index, and whether it was a primary or a revision procedure.Results: A total of 13 of 97 (13%) patients reported some instability (Grades 2-4); four of 97 patients (4%) had full dislocations with reduction (Grade 4), four of 97 patients (4%) reported subluxations (Grade 3), and five of 97 patients (5%) reported feelings of instability or apprehension (Grade 2). After controlling for potential confounding variables like age, sex, body mass index, and revision versus primary procedure, the only factors associated with instability were greater superior baseplate inclination (larger β angle; odds ratio [OR], 1.15 [95% confidence interval {CI}, 1.042-1.258]; p = 0.005) and a greater change into superior inclination from preoperative to postoperative (greater positive change in ß angle; OR, 1.08 [1.009-1.165]; p = 0.027). Patients with any instability (Grades 2-4) reported lower final ASES scores than did patients without instability (Grade 1) (61 ± 16 versus 72 ± 19 mean difference 11 [95% CI, 0-22]; p = 0.032).Conclusions: When more subtle instability after rTSA is included, instability may occur in up to 13% of patients. Instability is associated with greater superior baseplate inclination and less inferior correction of the β angle and thus surgeons should consider inferiorly inclining the baseplate to avoid postoperative instability. Although our study only demonstrates an association and not causation, the authors hypothesize that superior baseplate inclination increases inferior impingement, which leads to instability. Instability negatively influences final ASES score.Level Of Evidence: Level III, therapeutic study. [ABSTRACT FROM AUTHOR]

Background: Patient-reported outcome measures have increasingly accompanied objective examination findings in the evaluation of orthopaedic interventions. Our objective was to determine whether a validated measure of mental health (Short Form-36 Mental Component Summary [SF-36 MCS]) or measures of tear severity on magnetic resonance imaging were more strongly associated with self-assessed shoulder pain and function in patients with symptomatic full-thickness rotator cuff tears. Methods: One hundred and sixty-nine patients with full-thickness rotator cuff tears were prospectively enrolled. Patients completed the Short Form-36, visual analog scales for shoulder pain and function, the Simple Shoulder Test (SST), and the American Shoulder and Elbow Surgeons (ASES) instrument at the time of diagnosis. Shoulder magnetic resonance imaging examinations were reviewed to document the number of tendons involved, tear size, tendon retraction, and tear surface area. Age, sex, body mass index, number of medical comorbidities, smoking status, and Workers' Compensation status were recorded. Bivariate correlations and multivariate regression models were calculated to identify associations with baseline shoulder scores. Results: The SF-36 MCS had the strongest correlation with the visual analog scale for shoulder pain (Pearson correlation coefficient, -0.48; p < 0.001), the visual analog scale for shoulder function (Pearson correlation coefficient, -0.33; p < 0.001), the SST (Pearson correlation coefficient, 0.37; p < 0.001), and the ASES score (Pearson correlation coefficient, 0.51; p < 0.001). Tear severity only correlated with the visual analog scale for shoulder function; the Pearson correlation coefficient was 0.19 for tear size (p = 0.018), 0.18 for tendon retraction (p = 0.025), 0.18 for tear area (p = 0.022), and 0.20 for the number of tendons involved (p = 0.011). Tear severity did not correlate with other scores in bivariate correlations (all p > 0.05). In all multivariate models, the SF-36 MCS had the strongest association with the visual analog scale for shoulder pain, the visual analog scale for shoulder function, the SST, and the ASES score (all p < 0.001). Conclusions: Patient mental health may play an influential role in patient-reported pain and function in patients with full-thickness rotator cuff tears. Further studies are needed to determine its effect on the outcome of the treatment of rotator cuff disease. [ABSTRACT FROM AUTHOR]

Background: Patients with shoulder and rotator cuff pathology who exhibit greater levels of psychological distress report inferior preoperative self-assessments of pain and function. In several other areas of orthopaedics, higher levels of distress correlate with a higher likelihood of persistent pain and disability after recovery from surgery. To our knowledge, the relationship between psychological distress and outcomes after arthroscopic rotator cuff repair has not been similarly investigated. Questions/purposes: (1) Are higher levels of preoperative psychological distress associated with differences in outcome scores (visual analog scale [VAS] for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (2) Are higher levels of preoperative psychological distress associated with less improvement in outcome scores (VAS for pain, Simple Shoulder Test, and American Shoulder and Elbow Surgeons score) 1 year after arthroscopic rotator cuff repair? (3) Does the prevalence of psychological distress in a population with full-thickness rotator cuff tears change when assessed preoperatively and 1 year after arthroscopic rotator cuff repair? Methods: Eighty-five patients with full-thickness rotator cuff tears were prospectively enrolled; 70 patients (82%) were assessed at 1-year followup. During the study period, the three participating surgeons performed 269 rotator cuff repairs; in large part, the low overall rate of enrollment was related to two surgeons enrolling only two patients total in the initial 14 months of the study. Psychological distress was quantified using the Distress Risk Assessment Method questionnaire, and patients completed self-assessments including the VAS for pain, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons score preoperatively and 1 year after arthroscopic rotator cuff repair. Fifty of 85 patients (59%) had normal levels of distress, 26 of 85 (31%) had moderate levels of distress, and nine of 85 (11%) had severe levels of distress. Statistical models were used to assess the effect of psychological distress on patient self-assessment of shoulder pain and function at 1 year after surgery. Results: With the numbers available, distressed patients were not different from nondistressed patients in terms of postoperative VAS for pain (1.9 [95% confidence interval {CI}, 1.0-2.8] versus 1.0 [95% CI, 0.5-1.4], p = 0.10), Simple Shoulder Test (9 [95% CI, 8.1-10.4] versus 11 [95% CI, 10.0-11.0], p = 0.06), or American Shoulder and Elbow Surgeons scores (80 [95% CI, 72-88] versus 88 [95% CI, 84-92], p = 0.08) 1 year after arthroscopic rotator cuff repair. With the numbers available, distressed patients also were not different from nondistressed patients in terms of the amount of improvement in scores between preoperative assessment and 1-year followup on the VAS for pain (3 [95% CI, 2.2-4.1] versus 2 [95% CI, 1.4-2.9], p = 0.10), Simple Shoulder Test (5.2 [95% CI, 3.7-6.6] versus 5.0 [95% CI, 4.2-5.8], p = 0.86), or American Shoulder and Elbow Surgeons scale (38 [95% CI, 29-47] versus 30 [95% CI, 25-36], p = 0.16). The prevalence of psychological distress in our patient population was lower at 1 year after surgery 14 of 70 (20%) versus 35 of 85 (41%) preoperatively (odds ratio, 0.36; 95% CI, 0.17-0.74; p = 0.005). Conclusions: Mild to moderate levels of distress did not diminish patient-reported outcomes to a clinically important degree in this small series of patients with rotator cuff tears. This contrasts with reports from other areas of orthopaedic surgery and may be related to a more self-limited course of symptoms in patients with rotator cuff disease or possibly to a beneficial effect of rotator cuff repair on sleep quality or other unrecognized determinants of psychosocial status. Level Of Evidence: Level I, prognostic study. [ABSTRACT FROM AUTHOR]

Elbow range of motion for functional tasks has been previously studied. Motion arcs necessary to complete contemporary tasks such as using a keyboard or cellular telephone have not been studied and could have implications on what is considered to be a functional arc of motion for these tasks. The purpose of this study was to determine elbow range of motion, including flexion-extension, pronation-supination, and varus-valgus angulation, with use of three-dimensional optical tracking technology for several previously described positional and functional tasks along with various contemporary tasks. Methods: Twenty-five patients performed six positional and eleven functional tasks (both historical and contemporary). Elbow flexion-extension, varus-valgus, and forearm rotation (pronation and supination) ranges of motion were measured. Results: Positional tasks required a minimum (mean and standard deviation) of 27° ± 7° of flexion and a maximum of 149° ± 50 of flexion. Forearm rotation ranged from 20.00 ± 18° of pronation to 104° ± 10° of supination. Varus and valgus angulations ranged between 2° ± 5° of varus to 9° ± 50 of valgus. For functional tasks, the maximum flexion arc was 130° ± 7°, with a minimum value recorded as 23° ± 6° and a maximum value recorded as 142° ± 3°. All of these were for the cellular telephone task. The maximum pronation-supination arc (103° ± 340) was found with using a fork. Maximum pronation was found with typing on a keyboard (65° ± 8°). Maximum supination was found with opening a door (77° ± 13°). Maximum varus-valgus arc of motion was 110 ± 40° Minimum valgus (0° ± 6°) was found with cutting with a knife, while maximum valgus (13° ± 6°) was found with opening a door. Conclusions: Functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks. [ABSTRACT FROM AUTHOR]

Background: The minimal clinically important difference is the smallest difference in an outcome score that a patient perceives as beneficial. The purpose of this study was to determine the minimal clinically important difference in the American Shoulder and Elbow Surgeons (ASES) score and in the Simple Shoulder Test (SST) score for patients treated nonoperatively for rotator cuff disease. Methods: Eighty-one patients with tendinitis or a tear of the rotator cuff were treated with nonoperative modalities. Evaluation with the ASES score and the SST was performed at baseline and at a minimum of six weeks after treatment. At the follow-up evaluation, the minimal clinically important difference was estimated for the two scores with use of an anchor-based approach involving fifteen-item (pain and function) and four-item improvement questions. Results: The fifteen-item function and four-item assessments indicated, respectively, that a 2.05-point (p = 0.02) and 2.33-point (p = 0.0009) change in the SST score from baseline represented a minimal clinically important difference. The fifteen-item function, fifteen-item pain, and four-item assessments indicated that a 12.01-point (p = 0.03), 16.92-point (p = 0.004), and 16.72-point (p <0.0001) change in the ASES score from baseline represented a minimal clinically important difference. Age, sex, initial baseline scores, and hand dominance had no effect on the minimal clinically important differences (p > 0.05). A longer duration of follow-up after treatment was associated with a greater minimal clinically important difference in the ASES score (p < 0.05), although the duration of follow-up had no effect on the minimal clinically important difference in the SST score. Conclusions: Patients with rotator cuff disease who are treated without surgery and have a 2-point change in the SST score or a 12 to 17-point change in the ASES score experience a clinically important change in self-assessed outcome. These minimal clinically important differences can provide the basis for determining if significant differences in outcomes after treatment are clinically relevant. [ABSTRACT FROM AUTHOR]

Background: A genetic predisposition has been suggested to contribute to the risk for development of rotator cuff disease on the basis of observed family clusters of close relatives. We used a population-based resource combining genealogical data for Utah with clinical diagnosis data from a large Utah hospital to test the hypothesis of excess familial clustering for rotator cuff disease. Methods: The Utah Population Database contains combined health and genealogical data on over two million Utah residents. Current Procedural Terminology, Fourth Revision, codes (29827, 23412, 23410, and 23420) and International Classification of Diseases, Ninth Revision, codes (726.1, 727.61, and 840.4) entered in patient records were used to identify patients with rotator cuff disease. We tested the hypothesis of excess familial clustering using two well-established methods (the Genealogical Index of Familiality test and the estimation of relative risks in relatives) in the overall study group (3091 patients) and a subgroup of the study group diagnosed before the age of forty years (652 patients). Results: The Genealogical Index of Familiality test in patients diagnosed before the age of forty years showed significant excess relatedness for individuals with rotator cuff disease in close and distant relationships (as distant as third cousins) (p = 0.001). The relative risk of rotator cuff disease in the relatives of patients diagnosed before the age of forty years was significantly elevated for second degree (relative risk = 3.66, p = 0.0076) and third degree (relative risk = 1.81, p = 0.0479) relatives. Conclusions: We analyzed a set of patients with diagnosed rotator cuff disease and a known genealogy to describe the familial clustering of affected individuals. The observations of significant excess relatedness of patients and the significantly elevated risks to both close and distant relatives of patients strongly support a heritable predisposition to rotator cuff disease. Clinical Relevance: A better understanding of the familial risk of rotator cuff disease could lead to the identification of candidate genes predisposing individuals to rotator cuff disease. Gene identification will possibly allow the development of improved treatments, including biologic augmentations of rotator cuff repairs, which may improve tendon healing and repair outcomes. Level of Evidence: Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The author discusses the article "Implant Design Variations in Reverse Total Shoulder Arthroplasty Influence the Required Deltoid Force and Resultant Joint Load." Topics include the importance of reverse shoulder arthroplasty in the treatment of severe shoulder pathologies, the impact of the changes in implant variables on its biomechanics and function, and humeral lengthening and glenosphere lateralization are options to improve the stability of the implant. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated varying correlations between Workers' Compensation status and the outcome of rotator cuff repair. However, none of those studies have formally accounted for potential confounding factors with multivariable analysis. We hypothesized that patients with Workers' Compensation claims who undergo rotator cuff repair have worse outcomes, even after controlling for confounding factors. Methods: One hundred and twenty-five patients (including thirty-nine with Workers' Compensation claims) who underwent unilateral primary repair of a chronic rotator cuff tear by a single surgeon were studied prospectively and were evaluated one year postoperatively, prior to the settlement of any claims. Outcomes were assessed with the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) index; three visual analog scales (shoulder pain, shoulder function, and quality of life); and the Short Form-36 (SF-36). Results: Patients in the Workers' Compensation group were significantly younger, had greater work demands, and had lower marital rates, education levels, and preoperative expectations for the outcome of treatment as compared with those in the non-Workers' Compensation group (p = 0.001 to 0.016). Preoperatively, patients in the Workers' Com- pensation group had significantly lower scores on the SST, the SF-36 Physical Function scale, and the SF-36 Social Function scale (p = 0.01 to 0.038). One year postoperatively, those patients reported worse performance on the SST, the DASH, all three visual analog scales, and the SF-36 (p = 0.0007 to 0.05) and had worse improvement on the DASH, the visual analog scales for shoulder pain and function, and the SF-36 Bodily Pain and Role Emotional scales (p = 0.0028 to 0.038). Multivariable analysis controlling for age, sex, comorbidities, smoking, marital status, education, duration of symptoms, work demands, expectations, and tear size confirmed that Workers' Compensation status was an independent predictor of worse DASH scores. Conclusions: Patients with Workers' Compensation claims report worse outcomes, even after controlling for con- founding factors. The present study provides further evidence that the existence of a Workers' Compensation claim portends a less robust outcome following rotator cuff repair. Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: We are not aware of any previous studies of the relationship between patients' expectations regarding rotator cuff repair and the actual outcome. We hypothesized that preoperative expectations are predictive of the outcome of rotator cuff repair. Methods: One hundred and twenty-five patients who underwent unilateral primary repair of a chronic rotator cuff tear were included in the study. All operations were performed by a single surgeon. Each patient prospectively completed the Simple Shoulder Test (SST); the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; three visual analogue scales for shoulder pain, shoulder function, and quality of life; and the Short Form-36 (SF-36) preoperatively and at one year (mean and standard deviation, 54.1 ± 7.6 weeks) postoperatively. Preoperative expectations were quantified with use of six questions from the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) questionnaire. Results: Greater preoperative expectations correlated with better postoperative performance on the SST, DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.0001 to 0.03) as well as with greater improvement from the baseline scores on the DASH and SF-36 (p values ranging from <0.0001 to 0.018). A rigorous multivariate analysis controlling for age, gender, smoking, Workers' Compensation status, symptom duration, number of previous operations, number of comorbidities, tear size, and repair technique confirmed that greater expectations were a significant independent predictor of both better performance at one year and greater improvement on the SST, the DASH, each visual analogue scale, and the SF-36 (p values ranging from <0.001 to 0.042). Conclusions: Patients' preoperative expectations regarding rotator cuff repair are associated with their actual self-assessed outcome. Variations in patient expectations may help to explain divergent results in published series as well as among various patient populations. [ABSTRACT FROM AUTHOR]

Background: In a previous study, we found that medical comorbidities have a negative effect on preoperative pain, function, and general health status in patients with a chronic rotator cuff tear. In this study, we evaluated the relationship between medical comorbidities and the postoperative outcome of rotator cuff repair. Methods: One hundred and twenty-five patients were evaluated on the basis of a history (including medical comorbidities) and use of outcome tools preoperatively and at one year after rotator cuff repair. Outcome was evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire, the Simple Shoulder Test (SST), visual analog scales (pain, function, and quality of life), and the Short Form-36 (SF-36). Results: The mean number of medical comorbidities was 1.91 (range, zero to six). At one year after rotator cuff repair, there were no significant correlations between comorbidities and pain, shoulder function, or quality of life as determined with the SST, DASH, and visual analog scales (p > 0.05). A greater number of comorbidities was associated with a worse postoperative general health status (SF-36 role emotional [p = 0.045], SF-36 bodily pain [p = 0.032], SF-36 general health [p = 0.001], and SF-36 vitality [p = 0.033]). Nevertheless, a greater number of comorbidities was associated with greater improvement, compared with the preoperative status, in the pain score on the visual analog scale (p = 0.009), function as assessed with the visual analog scale (p = 0.022) and the DASH (p = 0.044), and quality of life as assessed with the visual analog scale (p = 0.041). Conclusions: Patients with more medical comorbidities have a worse general health status after rotator cuff repair. Interestingly, it also appears that these patients have greater improvement in overall shoulder pain, function, and quality-of-life scores compared with preoperative scores. Therefore, despite a negative effect of comorbidities on outcomes, patients with more comorbidities have greater improvement after the repair, to the point where postoperative shoulder function and pain are not significantly influenced by medical comorbidities. Consequently, a higher number of medical comorbidities should not be considered a negative factor in determining whether a patient should undergo rotator cuff repair. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

The article presents a case report of a patient in whom a compartment syndrome developed in the upper extremity as the result of prolonged application of considerable negative pressure, a phenomenon that is termed as subatmospheric pressure-induced compartment syndrome. The machine that caused the compartment syndrome in the patient is capable of generating enormous negative pressures. Such machines are commonly used in demolition and industrial cleaning work in which large volumes of heavy material need to be removed. Standard operating procedures to prevent workers from becoming entrapped in similar equipment should include working with a partner and maintaining a minimum distance between the vacuum intake and body parts.

Background: The results of preoperative assessment of factors that might affect the outcome of orthopaedic surgery have rarely been studied. In this study, we evaluated the relationship between the number of medical comorbidities and the preoperative performance on outcome assessment tools in patients with a chronic rotator cuff tear.Methods: One-hundred and ninety-nine patients (206 shoulders) with a chronic rotator cuff tear who were treated with surgery were evaluated preoperatively with a detailed history (including medical comorbidities), physical examination, and the following outcome instruments: (1) the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, (2) the Simple Shoulder Test, (3) visual analog scales (pain, function, and quality of life), and (4) the Short Form-36 (SF-36).Results: The patients had a mean of 2.07 comorbidities (range, zero to seven comorbidities). With use of univariate regression analysis, a greater number of comorbidities was associated with worse function (DASH [p = 0.0064], Simple Shoulder Test [p = 0.0001 for the best-case scenario and p = 0.0009 for the worst-case scenario], and visual analog scale for function [p = 0.0003] and increased pain [p = 0.05]) and with worse general health status (physical function [p < 0.0001], role-physical [p = 0.0286], general health [p < 0.0001], vitality [p = 0.0014], social function [p = 0.0004], role-emotional [p = 0.0003], and visual analog scale for quality of life [p = 0.0102]). These results were confirmed with significant associations (p < 0.05) between the number of comorbidities and the scores on the Simple Shoulder Test; DASH questionnaire; visual analog scales for function, pain, and quality of life; and seven of the eight items (all but mental health) on the SF-36 in a multivariate regression analysis, which included age, gender, Workers' Compensation status, number of previous operations, smoking history, size of the tear, duration of symptoms, and average patient expectations as possible confounding variables.Conclusions: Medical comorbidities have a negative impact on patient-reported preoperative baseline pain, function, and general health status associated with chronic rotator cuff tears. We postulate that this effect may ultimately influence the evaluation of the results of surgical treatment of rotator cuff tears and should be considered when treating patients and analyzing outcomes. [ABSTRACT FROM AUTHOR]

The article presents a study investigating the effectiveness of surgical and post-surgical interventions for the subacromial impingement syndrome (SIS) along with expert commentary. The data for the study was searched across the data resources including the Cochrane Library, PubMed and Embase on the topics including randomized controlled trial (RCT), shoulder impingement syndrome and rotator cuff impingement. Results indicated that a conservative intervention is the best technique for it.

The article presents commentary on an article in this issue by Sandro F. Fucentese and colleagues, "Evolution of Nonoperatively Treated Symptomatic Isolated Full-Thickness Supraspinatus Tears." The commentary praises the researchers for their work on determining the risk of tear progression in the shoulder joint's rotator cuff when injuries are treated nonoperatively.

The article focuses on the effectiveness of nonoperative treatment for frozen shoulder. It provides a detailed account on the randomized controlled studies that compare the results of surgical and nonsurgical treatments to clarify the benefits of these treatments and to justify their use. In addition, the results are similar to previous reported meta-analysis and reviews on the treatment of adhesive capsulitis.

Background: Odontoid fractures are the most common cervical spine fractures in elderly patients. Treatment options included operative fixation (OP) or nonoperative management with either a halo-vest (HV) or rigid cervical orthosis (CO). Our previous study suggested increased morbidity and mortality with the use of HV in the treatment of elderly patients with cervical spine fractures. We review a series of odontoid fractures in elderly patients and evaluate for predictors for in-hospital morbidity and mortality., Methods: There were 78 patients >65 years of age who sustained a type II or III odontoid fracture from January 1997 to June 2004 identified from the Rhode Island Hospital Trauma registry. Demographic, mechanism, injury pattern, treatment, and outcome data were recorded. Patients were analyzed according to treatment method., Results: The mean age was 80.7 +/- 0.9 years. There were 50 type II, 17 type III, and 11 combined fractures. There were 38 (49%) patients treated with HV: 34 with halo alone, and 4 after OP; 40 (51%) patients were treated without HV: 27 with CO, and 13 with OP. There was no difference in injury severity or baseline medical condition between HV and non-HV patients. There were 24 (31%) patients who died during their hospital stay. Of the HV patients, 42% died compared with 20% in the non-HV group (p = 0.03). Major complications occurred in 66% of HV patients compared with 36% of non-HV patients (p = 0.003)., Conclusion: Odontoid fractures are associated with significant morbidity and mortality in elderly patients. Outcomes after treatment with HV appear inferior to those achieved with CO or OP.

Background: Cervical spine fractures (CSFs) in elderly patients are increasingly common as the population ages. In many centers, halo vest immobilization (HVI) is the treatment of choice. Our anecdotal experience suggested that elderly patients treated with HVI have frequent bad outcomes. The purpose of this study was to compare the outcomes of elderly and younger CSF patients as related to treatment (HVI, surgery, or hard collar)., Methods: Registry data from our Level I trauma center were reviewed to identify patients admitted with CSFs during an 80-month period. We excluded those with Glasgow Coma Scale (GCS) score of 3 at admission or death within 24 hours of admission. Patients were grouped as OLD (aged > or = 66 years) or YNG (aged 18-65 years). Data were compared using chi and Student's t test, with p < 0.05 considered statistically significant., Results: One hundred twenty-nine OLD (aged 79.7 +/- 0.7 years) and 289 YNG (aged 38.3 +/- 0.8 years) patients met study criteria. Injury Severity Score was higher in YNG (18.9 +/- 0.8 vs. 14.8 +/- 1.0, p < 0.05), and GCS score was the same (OLD, 13.7 +/- 0.2; YNG, 13.0 +/- 0.2; p = 0.06) in both, but mortality was higher in OLD patients (21% vs. 5%, p < 0.05). OLD HVI patients had higher mortality than YNG HVI (40% vs. 2%). Among OLD patients, age, Injury Severity Score, GCS, and number of comorbidities were the same for each treatment subgroup. Despite this, mortality for the HVI subgroup was higher than either the surgery or collar subgroup. Of the OLD HVI patients that died, 14 died with pneumonia and 10 had a cardiac or respiratory arrest that preceded death., Conclusion: OLD patients with CSFs have higher mortality than YNG. HVI in OLD patients is associated with the worst outcomes, irrespective of injury severity, and should be considered a last resort. Further study is warranted to determine the optimal treatment for CSF in OLD patients.