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To report the clinical and radiological outcomes of arthroscopic suture bridge repair for the GT fractures of the shoulder joint.From March 2008 to July 2013, we performed arthroscopic suture bridge repair of the GT fractures displaced more than 5 mm superiorly or posteriorly, but less than 2 cm in 40 cases [20 men, 20 women; mean age, 56 (27-80) years] with the average 32 (24-48) months follow-up. At the final follow-up, clinical (ASES, UCLA, SST, KSS score and range of motions) and radiological outcomes using post-operative MRI or CT scan were evaluated. Associated injuries occurred in 21 cases (52.5%): 8 rotator cuff tears; 7 SLAP lesions; 3 glenoid rim fractures; 3 Bankart lesions; 5 biceps tendon tears; 1 partial subscapularis tear; 1 combined subscapularis and biceps tendon tear, and 1 brachial plexus injury.At the final follow-up, the mean VAS score improved from 7 to 1; ASES, to 92; UCLA, to 32; KSS, to 90; and SST, to 10. Mean forward flexion, abduction, external rotation at the side, and internal rotation at the back were improved to 157°, 157°, 37° and T11, respectively. Mean residual superior and posterior displacement of the fracture was 0 (range -5 to 3.3) mm and 0.1 (-5.5 to 3.2) mm, respectively, compared to pre-operative displacement of 4.9 (0-14) mm and 4.5 (0-20) mm, respectively (p 0.001). Complications included anchor protrusion in five cases.Arthroscopic suture bridge repair was useful for the treatment of displaced GT fractures with or without comminution and the management of the combined lesions. At the final follow-up, meaningful remodeling of the GT fracture and satisfactory clinical outcomes could be achieved.

Hypothesis The combination of suprascapular nerve block (SSNB) and axillary nerve block (ANB) has been reported to provide safe and effective analgesia for arthroscopic shoulder surgery. This study was designed to identify anatomic landmarks of the suprascapular nerve (SSN) and axillary nerve (AN) and to evaluate the effects of SSNB and ANB using the identified landmarks. Materials and Methods This study included 52 cadaveric shoulders and 30 patients in the anatomic and clinical studies, respectively. After the exact location of the SSN and AN was identified from the cadavers, the clinical study at the end of the operation and at 8, 16, 24, 32, 40, and 48 hours postoperatively was performed in 2 groups: without both SSNB and ANB (group I) and with both SSNB and ANB (group II). Results The SSN was located at a length of one-half (2/5-3/5, 88%) from the anterior tip of the acromion to the superior angle of the scapula and at a length of two-fifths (1/3-1/2, 100%) from the anterior tip of the acromion to the medial border of the spine. The AN was located at a length of three-fifths (2/5-4/5, 98%) from the acromial angle to the inferior insertion of the teres major muscle. The depth from the skin was 3.20 ± 0.58 cm for the SSN and 2.07 ± 0.45 cm for the AN. The clinical study showed that the total amount of analgesic for patient-controlled anesthesia was markedly decreased at the end of the operation and at 8 hours postoperatively in group II compared with group I. Conclusions The SSNB and ANB were considered to provide safe and effective analgesia in terms of early postoperative pain in arthroscopic shoulder surgery.

We present two patients with open pilon fractures with large bone defects treated successfully with fibular strut allografts. The patients were initially treated by massive irrigation, wound debridement, and temporary external fixation. After complete wound healing, the bone defects were managed. Because autologous iliac crest or fibular bone grafts were impossible to be harvested due to multiple fractures, the bone defects were reconstructed with fibular strut allografts. Fixation was performed with a periarticular distal tibia locking plate. At 2 months postoperatively, the patients ambulated with partial weight-bearing; at 6 months, they had full range of motion of the ankle joint and full weight-bearing.

절에서발생한화농성관절염과결핵성관절염에대한수술 술기와치료결과를보고하고자한다. 증례1 (결핵성관절염). 61세가정주부가약3개월전부터발생한우측흉쇄관절부위의압통과종창을주소로내원하였다. 흉쇄관절의종창으로개인병원에서2차례절제술을시행한후, 조직검사소견에서만성육아성염증인결핵성관절염으로확진되어전원되었다. 내원시흉쇄관절의절개창이개방되어있는소견과함께장액성의분비물이관찰되었다(Fig. 1). 발열등의전신증상은 없었다.이학적검사상발적, 압통과종창소견을보였고있었으며, 견관절운동범위는전방거상140도, 외전130도외회전및내전은각각30도및제2요추수준으로감소되어있었다. 검사소견상적혈구침강속도74mm/hr, C-반응성단백질0.29 mg/dl로관찰되었다. 내원시시행한단순방사선검사상우측흉쇄관절의내측연에피질골의파괴소견이보이고(Fig. 2A)MRI 소견상흉쇄관절의흉골쇄골관절양골단에피질골파괴소견과함께조직액이증가되어있었으며(Fig. 2B), 전후방및상하부위로관절밖으로파급되는양상으로관찰되었다. 조영증강영상에서이병변들은다수의조영되지않는부분을갖는테두리조영증강(rim enhanced lesion with multifocal non-enhanced foci) 병변을보이는농양 (abscess)의소견이여러군데에서관찰되었다 (Fig. 2C). 수술전폐사진소견에서폐결핵소견도같이발견되어호흡기내과에서항결핵제투여요법으로치료하기로하였다.수술소견전신마취하에해변의자자세로환자를위치시킨후우측쇄골과흉쇄관절에걸쳐비스듬하게약5 cm 의절개를가하였다. 피하지방층과근막을절개하여박리한후, 흉골쇄골관절의뼈부위까지깊게절개창을넣어골막과관절부위를노출시켰다. 피하지방층으로부터광범위하게감염된노란색의육아성염증조직이관찰되었다. 흉골의전연을큐렛으로소파술을시행하자흉쇄관절과제1늑골의후연을따라노란색의치즈같은조직파편(debris)이 관찰되어이를절제하였다. 심한골파괴양상이흉골근위부, 제1 늑골과근위부쇄골말단부에서관찰되었다(Fig. 3). 각각의골 조직에서색깔변화와함께괴사되어있는골을론저 (rongeur)를이용하여변연절제술및소파술을시행하였다(Fig. 4). 6개월이상추시상배액관 (sinus tract)이나장액성분비물없이잘봉합되어치유된상처의소견을보여주었다. 항결핵제로 INH (Isoniazid) 300mg. RMP (Rifampin) 600 mg, MBT (Ethambu-tol) 1200 mg, PZ (Pyrazinamide) 1500 mg 을2개월간투약하였으며이후에는INH 300 mg, RMP600 mg, MBT 800 mg 으로1년간 투약하였으며1년4개월이추시상재발소견은관찰되지않고있다. 증례2 (화농성관절염). 43세여자환자가3일전부터발생한좌측흉쇄관절부위의통증및부종그리고견관절운동시악화되는통증을주소로내원하였다. 외상병력은없었고과거력

We reviewed 19 patients over 50 years of age who had rotator cuff tears com-bined with shoulder dislocation between October 2004 and October 2008. There were 7 males and 12females with a mean age 64.7 years (range, 50 to 78 years). The average follow-up duration was 22months (range, 8 to 56 months). We investigated the number of dislocations, the size of the cuff tear, thepresence of Bankart lesions and the time interval from dislocation to surgery. We also investigated theASES score, UCLA score, SST score, and shoulder range of motion before and after surgery. We ana-lyzed clinical outcomes and contributing factors.

Background: There has been a recent interest in the double row repair method for arthroscopic rotator cuff repair following favourable biomechanical results reported by some studies. The purpose of this study was to compare the clinical results of arthroscopic single row and double row repair methods in the full-thickness rotator cuff tears. Materials and Methods: 22 patients of arthroscopic single row repair (group I) and 25 patients who underwent double row repair (group II) from March 2003 to March 2005 were retrospectively evaluated and compared for the clinical outcomes. The mean age was 58 years and 56 years respectively for group I and II. The average follow-up in the two groups was 24 months. The evaluation was done by using the University of California Los Angeles (UCLA) rating scale and the shoulder index of the American Shoulder and Elbow Surgeons (ASES). Results: In Group I, the mean ASES score increased from 30.48 to 87.40 and the mean ASES score increased from 32.00 to 91.45 in the Group II. The mean UCLA score increased from the preoperative 12.23 to 30.82 in Group I and from 12.20 to 32.40 in Group II. Each method has shown no statistical clinical differences between two methods, but based on the sub scores of UCLA score, the double row repair method yields better results for the strength, and it gives more satisfaction to the patients than the single row repair method. Conclusions: Comparing the two methods, double row repair group showed better clinical results in recovering strength and gave more satisfaction to the patients but no statistical clinical difference was found between 2 methods.

Ganglion cysts of the shoulder are rare, and the pathogenesis is similar to that of meniscal cysts. We present details of two cases of isolated ganglion cyst of shoulder which were treated arthroscopically. Both patients following 1 year after the surgery, complained of nonspecific shoulder pain and magnetic resonance imaging revealed new SLAP lesion which was treated arthroscopically.

Greater tuberosity of the humerus malunion is relatively uncommon, and open techniques are the treatment of choice in most cases. Recent advances in arthroscopic techniques for treatment of greater tuberosity fractures have produced promising results. The use of arthroscopic techniques for the treatment of proximal humerus malunion, however, has been reported only rarely in the literature. This case report describes the malunited greater tuberosity fracture treated arthroscopically using the suture-bridge technique.

Pigmented villonodular synovitis (PVNS) rarely affects the shoulder. We describe two cases of PVNS arising from the shoulder joint, which caused rotator cuff tears and sub-acromial bony erosion, and which were treated arthroscopically. Sub-acromial erosion is frequently associated with various glenohumeral joint disorders, but it has not been reported in association with PVNS. We believe PVNS should also be considered in the differential diagnosis of patients who present with sub-acromial erosion.

Os acromiale is the rare shoulder disease and its treatment is controversial. Despite conservative treat-ments for 6 months include medication, exercise, physical therapy and subacromial steroid injections,operative treatment for uncontrolled symptomatic Os acromiale is considered the treatment of choice.Operative treatment includes excision, arthroscopic or open reduction and internal fixation with a bonegraft. Open reduction with tension band wiring and a bone graft is now the preferred treatment.We experienced 8 patients with symptomatic Os acromiale from March, 2001 to March, 2006. The aver-age patient’s age was 45 years and the man and women ratio were 2: 6. All 8 cases of symptomatic Osacromiale of the mesoacromion were treated with open reduction and internal fixation using tension-bandwiring. The preoperative ASES(47.3 ±24.4) and UCLA (16.65.8)scores were improved to 88.87.3 and 31.5±1.9,respectively, at the 2 year follow up. The overall UCLA score showed 1 excellent result and 7 good results. Wethink that symptomatic Os acromiale is a specific disease entity, and open reduction and internal fixation usingtension-band wiring with K-wire is a good treatment modality.

Partial thickness of rotator cuff tears is considered as a common cause of shoulder disability. Various techniques for arthroscopic repair of partial thickness tear of rotator cuff have been reported in the literature. These techniques have addressed the articular side partial thickness cuff tear. We present an arthroscopic repair of partial thickness tear of rotator cuff involving both articular and bursal surfaces without converting into a full thickness tear. Each side of the tear was repaired with suture anchors separately.

However, no cases of secondaryinstability have been reported so far. We report acase of anterior dislocation of shoulder joint afterarthroscopic pancapsular release and subscapularistenotomy which was treated successfully withclosed reduction using K-wires and showed noinstability during 2 years of follow up.

We report a case of Baker's cyst that induced compression of both the tibial and common peroneal nerves. The patient presented with calf atrophy and foot drop over a 6-month period. These signs and symptoms could have been mistaken for those of spinal origin. Based on an electrodiagnostic study and magnetic resonance imaging, compression of nerves by an asymptomatic Baker's cyst measuring 6x4 cm was confirmed. This cyst communicated with the articular joint which was also associated with a medial meniscal lesion. We treated the patient arthroscopically by performing partial medial meniscectomy, and through the posterolateral and the posteromedial portal, decompression of the Baker's cyst was performed. Approximately 6 weeks after the arthroscopic decompression, the cyst recurred. Therefore open resection was performed. At 1-year follow-up, the patient had considerable improvement in motor as well as sensory function and showed no evidence of recurrence. Although the electrodiagnostic studies showed an improvement in symptoms, the patient continued to complain of lower leg weakness owing to delayed diagnosis and cyst decompression. We believe that Baker's cysts should also be considered in the differential diagnoses of patients who present with neuromuscular dysfunction in the calf and leg.

Chronic proximal interphalangeal joint (PIPJ) instability of the finger is rare, and when it occurs usually requires surgical reconstruction. Complications arising from failed ligament reconstruction may result in a situation more difficult to address than the initial reconstruction. This situation is more likely for the finger than other orthopaedic reconstructions because the phalangeal bones are so small. We present a case of chronic radial PIPJ instability of the finger and severe bony defect caused by multiple failed ligament reconstructions that was treated successfully using a modification of the bone-ligament-bone graft technique.

Chronic proximal interphalangeal joint (PIPJ) instability of the finger is rare, and when it occurs usually requires surgical reconstruction. Complications arising from failed ligament reconstruction may result in a situation more difficult to address than the initial reconstruction. This situation is more likely for the finger than other orthopaedic reconstructions because the phalangeal bones are so small. We present a case of chronic radial PIPJ instability of the finger and severe bony defect caused by multiple failed ligament reconstructions that was treated successfully using a modification of the bone-ligament-bone graft technique.

— Surgical Treatment of Neglected Adult Monteggia Fracture - 2 Cases Report - Hyun-Chul Shon, M.D. � , Weon-Yoo Kim, M.D., Sang-Eun Park, M.D., Young-Yul Kim, M.D., Jong-Seoung Yoon, M.D., Jong-Hun Ji, M.D.* Department of Orthopedic Surgery, Chungbuk National University College of Medicine � ,Daejon St. Mary ’ s Hospital, The Catholic University of Korea College of Medicine, Korea Neglected adult Monteggia fracture could induce the pain, instability and malformation of elbow. Especially, com-pared with the chronic Monteggia fracture of child, that of adult is difficult to treat and could concur with valgusinstability and deformity, limitation of range of motion and tardy ulnar nerve palsy. But recently, the chronic Mon-teggia fracture of adult could be treated by the 3.5 mm compression plate (DCP) or 3.5 mm pelvic reconstructionplate, so that the result improved more and more. The treatment of choice of the chronic Monteggia fracture of adultis the corrective osteotomy and reduction of radial head or resection of radial head. We experienced two patients whohad neglected Monteggia fracture over 1 year 6 months and 25 years respectively and we want to report the result ofsurgical treatment of chronic Monteggia fracture of adult.

Most pigmented villonodular synovitis (PVNS) is occurred in knee joint and finger of hand. PVNS is rarely occurred in shoulder joint. In English and French literatures, less than 30 cases were reported. We report 3 PVNS cases with rotator cuff tears, which was treated by arthroscoic extensive synovectomy, debridement and rotator cuff repair. The PVNS with rotator cuff tear in shoulder joint was rarely reported in the Korean literature.

Background We studied combined effect of change in humeral neck shaft angle and retroversion on shoulder ROM in reverse total shoulder arthroplasty using 3-dimensional simulations. Methods Using a 3D model construct based on the CT scans of 3 males and a 3-dimensional analysis program, a humeral component of reverse total shoulder arthroplasty was implanted in 0°, 10°, 20°, 30°,40° retroversion and 135°, 145°, and 155° neck shaft angle. Total horizontal range of motion (sum of horizontal adduction and abduction) at 30° and 60° scaption, adduction in the scapular plane and IR behind the back were measured for various combinations of neck shaft angle and retroversion. Findings Change in retroversion didn't show any effect on total horizontal range of motion. Total horizontal range of motion at both 30° and 60° scaption, showed maximum values at 135° neck shaft angle and minimum values at 155° neck shaft angle. With any combination of retroversion angles, adduction deficit was maximum at 155° neck shaft angle and no adduction deficit at 135° neck shaft angle. Every 10° decrease in neck shaft angle resulted in an average 10.4° increase in adduction. For every 10° increase in retroversion, there was loss of internal rotation behind the back up to at least one vertebral level. Interpretation 135° neck shaft angle resulted in maximum total horizontal range of motion both at 30° and 60° scaption regardless of retroversion angles. 135° neck shaft angle also reduced the chances of scapular impingement. Decrease in retroversion angle resulted in more amount of internal rotation behind the back.

Olecranon bursitis rarely Progresses to septic arthritis. In our case, the 24 year old woman was visited due to progressing right elbow pain, despite antibiotic treatment of chronic olecranon bursitis caused by elbow laceration 2 months ago. Pus draining sinus, localized heating and swelling could be seen on physical examination. Septic arthritis and pathologic fracture was diagnosed under arthroscopic examination. Arthroscopic irrigation and synovectomy for elbow joint, olecranon bursectomy and curettage of olecranon bone was done. In the operation field, the elbow and draining sinus over olecranon was communicated each other on saline irrigation test. The patient was treated for 3 weeks with intravenous antibiotics. At postoperative 4 weeks, bone graft was done. The possibility of chronic osteomyelitis and septic arthritis must be considered in a patient with chronic olecranon bursitis.

The purpose of this study was to document the distribution of the articular branch of the lateral pectoral nerve (LPN) to the shoulder and to identify a suitable point for its blockade. This study involved the dissection of 43 shoulders of 22 unembalmed cadavers (6 male and 16 female) to identify the LPN and its articular branch to the shoulder. To identify the suitable anatomical point for blocking the articular branch of the LPN, several anatomical landmarks around the shoulder were measured. The articular branch of the LPN to the shoulder was present in 29 of 43 cases (67.4 %). The appropriate point to block the articular branch of the LPN was identified at a mean distance of 1.5 cm below the clavicle, on the line connecting the closest points between the clavicle and the coracoid process, and at a mean depth of 1.0 cm from the skin. The articular branch of the LPN to the shoulder, as well as the muscular and cutaneous branches of the LPN, covers a portion of the shoulder joint with suprascapular and axillary nerves. Surgeons might consider a peripheral block of the suprascapular, axillary, and LPNs to provide maximum block coverage after shoulder joint surgery.

To analyze the clinical and radiologic outcomes of arthroscopic cyst decompression and labral repair in patients with inferior paralabral cysts with chronic shoulder pain.Between March 2006 and September 2012, 16 patients who were identified as having inferior paralabral cysts presented with chronic shoulder pain. All patients underwent a thorough physical examination and preoperative magnetic resonance arthrographic evaluation. The mean age was 30 years (range, 17 to 50 years). The mean follow-up period was 38 months (range, 16 to 60 months). Clinical outcome scores (American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test) and passive shoulder range of motion were evaluated at last follow-up. Follow-up magnetic resonance imaging was performed at a mean of 8 months to determine the labral healing status and assess for cyst recurrence.The incidence of isolated inferior paralabral cysts was 0.6% (16 of 2,656 cases). Of the patients, 8 had multiple cysts and 8 had a single cyst. The mean length and width of the cysts were 1.0 cm and 0.4 cm, respectively. Eight cases had a history of trauma, and 13 patients were involved in sports activities. Seventy-five percent of cases showed a positive relocation test. The mean American Shoulder and Elbow Surgeons; University of California, Los Angeles; and Simple Shoulder Test scores improved from 64, 22, and 8.7, respectively, preoperatively to 83, 31, and 10, respectively (P.001), at final follow-up. Shoulder range of motion did not show any significant improvement. The location of the labral tear was as follows: anteroinferior tear in 5 cases, posteroinferior tear in 8 cases, and combined anteroinferior and posteroinferior tear in 3 cases. All cysts were found to be in association with a labral tear. A mean of 2.7 anchors were used for inferior labral repair. These cysts were found only in male patients. None of the patients showed any evidence of cyst recurrence on follow-up magnetic resonance imaging.Inferior labral tears treated with cyst decompression and labral repair showed satisfactory clinical results without any recurrence. Inferior paralabral cysts should be considered in the differential diagnosis in patients presenting with chronic shoulder pain, particularly active male patients.Level IV, therapeutic case series.

Shoulder arthroscopy has become a common procedure in today’s orthopedic practice. The safety of this procedure has been well established, but there are some complications associated with every surgical procedure both minor and major. In the present era, with advanced arthroscopic instruments, it is rare to encounter the problem of instrument breakage during arthroscopic surgery. Here, we report an unusual case in which we found a detached arthroscopic lens within the shoulder joint. A 58-year-old male patient who was previously operated for shoulder arthroscopy for the treatment of impingement syndrome combined with shoulder stiffness. We performed shoulder arthroscopy again and removed the detached lens arthroscopically. This case warrants the need for the surgeon and the operating room staff to be well acquainted with the arthroscopic instruments and to check the instruments properly before and after the completion of the procedure. If the operating room staff would have identified the damage to the scope, encountered during the primary operation, we could have avoided the second procedure to remove the lens.

Synovial chondromatosis is classified as either primary or secondary. Primary synovial chondromatosis results from a proliferation of chondrocytes in the synovial membrane leading to the formation of cartilaginous loose bodies. Secondary synovial chondromatosis is a rare condition characterized by the growth of separated particles from the articular cartilage or osteophytes in joint diseases. The present article aims to report the secondary chondromatosis of the shoulder and to discuss the clinical manifestations, pathogenesis, diagnosis, histological findings and management of this condition.

The purpose of this study was to determine the anatomical and clinical outcomes of a biceps-incorporating rotator cuff repair without detaching the biceps origin from the glenoid in a large or massive rotator cuff tear, in which the biceps tendon could be incorporated into the cuff defect and help to provide tendon healing and prevent upward migration of the humeral head.Thirty-five consecutive patients with a mean age of 62 years (41-81 years) had primary arthroscopic repair of their large or massive rotator cuff in which biceps tendon incorporated into the cuff defect without detaching the biceps tendon from the glenoid was performed. Functional outcome was determined by the visual analog scale (VAS) for pain during motions, simple shoulder test (SST), the University of California, Los Angeles (UCLA) score, and the American Shoulder and Elbow Surgeons scores (ASES) (mean follow-up, 24 months). The continuity of rotator cuff mechanism was evaluated using the magnetic resonance imaging (MRI) among all the patients after 2 years.At the final follow-up, mean VAS scores increased significantly from 7.1 to 2.0 points, ASES scores from 35 to 83, UCLA scores from 14 to 30, and SST scores from 4 to 9, respectively (p0.05). Moreover, the range of motion was significantly increased except the external rotation from preoperative 27° to postoperative 33° (p = 0.183). MRI evaluation showed that 22 of 35 patients (63%) had heeled tendons and 7 patients (20%) had partial re-tear. Of 35 patients, 6 (17%) had a complete re-tear. Only 3 of these 6 patients were not satisfied with the result.Using this simple biceps-incorporating rotator cuff repair technique, we achieved good clinical and moderate anatomical results, and prevent superior migration of the humeral head in a large or massive rotator cuff tear.Level IV retrospective review.

The purpose of this retrospective study was to evaluate the early results of arthroscopic treatment in patients with missed occult greater tuberosity (GT) fracture of the humerus using the arthroscopic suture–bridge fixation technique. Between January 2007 and August 2010, we used arthroscopic suture–bridge fixation in 15 cases of missed occult GT fractures, which were referred to our department with persistent symptoms following trauma, despite physical therapy. Occult GT fracture was diagnosed with bone marrow edema seen on magnetic resonance imaging in all patients. There were 13 male and 2 female patients with a mean age of 45 years (range 31–67 years). Mean time period until the surgery following the initial trauma was 4 months (1.5–12 months). For the measurement of clinical outcomes, we assessed the range of motion and evaluated the University of California, Los Angeles (UCLA) American Shoulder and Elbow Surgeons (ASES) scores and simple shoulder test (SST). The early clinical results were evaluated in these patients at a mean of 24 months (range 14–36 months) after surgery. All the patients were satisfied with the surgery. The mean UCLA, ASES, and SST scores improved from preoperative 15, 39, and 2 to postoperative 33, 91, and 11, respectively (P

Background The location and degree of bony defects that can affect clinical outcomes remains controversial in recurrent shoulder dislocation. The purpose of this study was to define the most common location of glenoid bony defects in patients with recurrent shoulder dislocation. Materials and methods We analyzed the shape and aspect ratio of 44 glenoids from deceased donors. Glenoid size was analyzed using a 3-dimensional (3D) computed tomography (CT) scan in 24 patients with recurrent shoulder dislocation who underwent arthroscopic Bankart repair. We measured the distances from the center of the longitudinal axis of the glenoid to the anterior glenoid rim at 9 positions, 10° apart, from 3:00 to 6:00 o'clock positions in the cadaver and patient groups. We compared the quantification of glenoid defects in the 24 patients using the 3D CT scan. A predictive model based on a discriminant analysis was developed. Results The largest length differences of the glenoid were at the 3:20 o'clock position. When percentage of bone antidefect of the 3:20 o'clock position was used, the model predicted the existence of a defect with 89.7% hit ratio. Conclusions The major direction of the glenoid defect was in a more anterior position rather than the anteroinferior glenoid in patients with recurrent shoulder dislocation. The 3:20 o'clock position was most common location of glenoid defect in shoulder instability. This pattern of bone loss should be considered by the surgeon when operating on these patients, especially when performing arthroscopic procedures for Bankart repair or bone block operations to the glenoid.

Biceps tenodesis provides reliable pain relief for patients with biceps tendon abnormality. Previous cadaver studies have shown that, for biceps tenodesis, an interference screw provides biomechanical strength to failure superior to that of suture anchors. This finding has led some providers to conclude that screw fixation for biceps tenodesis is superior to suture anchor fixation. The purpose of the current study was to test the hypothesis that the strength of a 2-suture-anchor technique with closing of the transverse ligament is equal to that of interference screw fixation for biceps tenodesis. In 6 paired, fresh-frozen cadaveric shoulder specimens, we excised the soft tissue except for the biceps tendon and the transverse ligament. We used 2 different methods for biceps tenodesis: (1) suture anchor repair with closing of the transverse ligament over the repair, and (2) interference screw fixation of the biceps tendon in the bicipital groove. Each specimen was preloaded with 5 N and then stretched to failure at 5 mm/sec on a materials testing machine. The load-to-failure forces of each method of fixation were recorded and compared. Mean loads to failure for the suture anchor and interference screw repairs were 263.2 N (95% confidence interval [CI], 221.7–304.6) and 159.4 N (95% CI, 118.4–200.5), respectively. Biceps tenodesis using suture anchors and closure of the transverse ligament provided superior load to failure than did interference screw fixation. This study shows that mini-open techniques using 2 anchors is a biomechanically comparable method to interference fixation for biceps tendon tenodesis.

Partial articular surface of the rotator cuff tendon tears has been recognized as a source of treatable shoulder pain and a precursory pathology for full-thickness tendon tears. Arthroscopic rotator cuff repair is a possible surgical method of treatment. Recent data have shown that the treating partial-thickness rotator cuff repairs with transtendon technique shows good clinical outcome. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact bursal part. In cases of high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff, subsequently revision surgery in these patients will be demanding. To mitigate these problems, we describe here a new arthroscopic transtendon repair technique with tenotomized long head biceps tendon augmentation for high grade partial articular rotator cuff tear with the goal of providing increase tendon healing, as well as to minimize the probability of failure of the construct and to improve the clinical outcomes. The clinical results of the first 39 consecutive patients are reported showing significant decrease in pain and improved shoulder scores, as well as the post-operative range of motion and with no cases of re-tear of the rotator cuff tendon.

One possible cause of shoulder pain is rotator cuff contact with the superior glenoid (cuff-glenoid contact) with the arm in flexion, as occurs during a Neer impingement sign. It has been assumed that the pain with a Neer impingement sign on physical examination of the shoulder was secondary to the rotator cuff making contact with the anterior and lateral acromion.We determined if the arm position where pain occurs with a Neer impingement sign would correlate with the position where the rotator cuff made contact with the superior glenoid, as determined by arthroscopic evaluation.We prospectively studied 398 consecutive patients with a positive Neer impingement sign during office examination and used a handheld goniometer to measure (in degrees of flexion) the arm position in which impingement pain occurred. During subsequent arthroscopy, the arm was moved into a similar position, and we measured the arm's position in flexion at the point the rotator cuff made contact with the superior glenoid using a handheld goniometer. We compared the degrees of flexion at which pain occurred preoperatively and at which there was cuff-glenoid contact.Among the 398 patients, 302 (76%) had arthroscopically documented cuff-glenoid contact, whereas 96 did not. For the 302 patients with a positive Neer sign preoperatively and with arthroscopically documented cuff-glenoid contact, the average preoperative impingement pain position was 120.1°±26.7°, similar to that of the average intraoperative cuff-glenoid contact position of 120.6°±14.7°.Our data suggest pain associated with a positive Neer sign more often relates to contact of the rotator cuff with the superior glenoid than to contact between the rotator cuff and acromion.Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Both intraneural lipoma and chondroid lipoma have been reported in the previous literature as a separate disease entity on rare occasions. But intraneural chondroid lipoma has not been ever reported till now. So we present such a patient with an intraneural chondroid lipoma localized to common peroneal nerve.

Synovial lipoma arborescens (SLA) is a rare, benign, fat-containing synovial proliferative lesion that is typically known to affect the knee joint in adults, although it has also been described in other joints. SLA usually presents as a painless swelling and recurrent joint effusion, and the laboratory test results, including aspirated synovial fluid, are usually normal. We present here two cases of SLA of the knee, which presented as spontaneous recurrent hemarthroses in elderly patients with osteoarthritis (OA) with bloody aspirated synovial fluid. Magnetic resonance imaging (MRI) and arthroscopic synovectomy suggested the diagnosis of SLA; the histopathologic examination confirmed the diagnosis. One year later, both patients remain symptom-free and report no new episodes of hemarthrosis. We postulate that SLA should be included in the differential diagnosis of patients with recurrent joint effusions with hemarthrosis in elderly patients with OA. The clinical presentation, MRI findings, and treatment of SLA are described, and the entity is briefly reviewed.

Background It has been recognized that there is a distinction between shoulder laxity and shoulder instability and that there is a wide range of normal shoulder laxities. Our goals were (1) to evaluate if the ability to subluxate the shoulder over the glenoid rim in patients under anesthesia would be more prevalent than the inability to do so, (2) to determine if patients with a diagnosis of instability would have significantly more shoulder laxity in the operatively treated shoulder than in the contralateral shoulder, and (3) to evaluate the observation that higher grades of shoulder laxity would be related to a diagnosis of shoulder instability. We hypothesized that, on examination with the patient under anesthesia, most shoulders could be subluxated over the glenoid rim and that the degree of shoulder laxity would be related to diagnosis. Methods In the present study of 1206 patients undergoing shoulder surgery, we evaluated the symptomatic and contralateral shoulders with use of a modified anterior and posterior drawer test and a sulcus sign test, with the patients under anesthesia. The anterior and posterior translations were graded as no subluxation (Grade I), subluxation over the glenoid rim with spontaneous reduction (Grade II), or subluxation without spontaneous reduction (Grade III). The sulcus sign was graded as 2.0 cm (Grade III). Results When the patients were evaluated while under anesthesia, the humeral head could be subluxated over the rim anteriorly in 81.6% (984 of 1206) of the patients and posteriorly in 57.5% (693 of 1206) of the patients. When the patients were evaluated while under anesthesia, there was an increase in the laxity grade anteriorly, posteriorly, and inferiorly in 50.8%, 36.3%, and 15.8% of the patients, respectively, as compared with the preoperative assessment. For all laxity testing, the higher the grade of laxity in an anterior, posterior, or inferior direction, the greater the chance that the patient had a diagnosis of instability. Compared with Grade-I laxity, Grade-III laxity increased the odds of a diagnosis of instability in the anterior (odds ratio, 170), posterior (odds ratio, 32), and inferior (odds ratio, 10.3) directions. Compared with Grade-I laxity, Grade-II laxity increased the odds of a diagnosis of instability in the anterior (odds ratio, 9.8), posterior (odds ratio, 4.6), and inferior (odds ratio, 4.4) directions. Conclusions The ability to subluxate the humeral head over the glenoid rim in the patient who is undergoing shoulder surgery under anesthesia is common regardless of the diagnosis. Higher grades of shoulder laxity are associated with shoulder instability.

Purpose The purpose of this retrospective study was to evaluate the early results of arthroscopic treatment in patients with comminuted, displaced greater tuberosity (GT) fractures using the arthroscopic double-row suture anchor fixation (ADSF) technique. Methods Between August 2004 and December 2007, we used the ADSF technique in 16 cases of isolated comminuted, displaced GT fractures. The early clinical results were evaluated in these patients at a mean of 24 months (range, 16 to 51 months) after surgery. There were 11 male and 5 female patients with a mean age of 56.5 years (range, 27 to 82 years). These 16 cases had at least 5 mm of displacement of the fracture fragments in any plane. For measurement of clinical outcomes, we assessed range of motion and evaluated the visual analog scale score; the University of California, Los Angeles (UCLA) rating scale; and the shoulder index of the American Shoulder and Elbow Surgeons. Results At final follow-up, the visual analog scale score improved from 9.4 (range, 8 to 10 points) to 1.2 (range, 0 to 4 points), the mean UCLA score improved to 31 points (range, 21 to 35 points) postoperatively, and the American Shoulder and Elbow Surgeons score improved to 88.1 points (range, 81.5 to 100 points). According to the UCLA score, there were 3 excellent results, 11 good results, and 2 poor results. Mean forward flexion was 148.7° (range, 120° to 170°), mean abduction was 145° (range, 120° to 170°), mean external rotation in the neutral position was 24° (range, 10° to 40°), and internal rotation improved to the first lumbar vertebral level (from L3 to T7) at last follow-up. Conclusions The early results of the ADSF technique used for displaced, comminuted GT fractures are encouraging, and arthroscopists should attempt to expand the indications for arthroscopic treatment of these fractures. Level of Evidence Level IV, therapeutic case series.

Calcific tendinitis most commonly affects the rotator cuff and has not been previously reported affecting the biceps-labral complex. We report a case of calcific tendinitis of the biceps-labral complex attachment, a rare cause of acute, severe shoulder pain. Clinically, it can be misdiagnosed as supraspinatus tendinitis or septic arthritis of the shoulder joint. Non-operative treatment failed to resolve the symptoms. Arthroscopic debridement of the calcific deposit resulted in resolution of symptoms. Knowledge of this clinical condition and its imaging features is crucial for a correct diagnosis of this uncommon cause of shoulder pain.

Paralabral cyst of the shoulder joint can be observed in 2% to 4% of the general population, particularly in men during the third and fourth decade. On average, these cysts measure 10 mm to 20 mm in diameter and are located preferentially on the postero-superior aspect of the glenoid. The MRI has increased the frequency of the diagnosis of paralabral cysts of the shoulder joint. Paralabral cysts of the shoulder joint usually develop in the proximity of the labrum. The relationship between shoulder instability and labral tears is well known, however, the association of shoulder instability with a paralabral cyst is rare. Shoulder instability may cause labral injury or labral injury may cause shoulder instability, and then injured tear develops paralabral cyst. In our patient, the inferior paralabral cyst may be associated with inferior labral tears and instability MRI.

The ''shrug sign'' (inability to lift the arm to 90 abduction without elevating the whole scapula or shoulder girdle) has been associated with a diagnosis of rotator cuff disease. Based on our clinical experience, we hypothesized the shrug sign is not a specific diagnostic sign for this condition, but rather is associated with various shoulder conditions and shoulder weakness and loss of range of motion. We retrospectively reviewed 982 con- secutive patients who had been examined preoperatively for the shrug sign. A positive shrug sign was present in 51.3% of the patients, and the average distance lost from the horizontal was 20.5 ± 2.2 (standard error of mean). Increasing age was associated with the presence of a shrug sign. The highest incidence was in patients with adhesive capsulitis (94.7%). The shrug sign was not sensitive for tendinosis, partial rotator cuff tears, or full-thickness or massive rotator cuff tears. The shrug sign was associated with weakness in abduction, night pain, and loss of range of motion, especially passive abduction. Although the shrug sign is useful as a general sign of shoulder abnor- mality, particularly when associated with stiffness, it was not specific or sensitive for rotator cuff problems. Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Reverse total shoulder arthroplasty is a treatment option for patients with symptomatic glenohumeral arthritis and a deficient rotator cuff. The reported complication rates vary from 0% to 68%. Given this variation, our purposes were to (1) determine the learning curve for the procedure, (2) identify complications and surgical pitfalls, and (3) compare our results with those of similar published series. We retrospectively reviewed 20 consecutive patients (mean age, 73 years; range, 45–88 years) who had reverse total shoulder arthroplasty by one surgeon, tabulating intraoperative and postoperative complications. Minimum followup was 3 months (average, 9 months; range, 3–21 months). The intraoperative complication rate for the first 10 patients was higher than that for the second 10 patients. There were 33 complications in 15 patients: 11 patients collectively had 22 intraoperative complications and eight patients collectively had 11 postoperative complications. At radiographic followup, 11 patients had scapular notching and nine patients had heterotopic ossification. Our complication rate was higher than published rates. Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Purpose: The purpose of this study was to analyze complications after reverse total shoulder arthroplasty and report the clinical outcomes with review of previously reported studies. Materials and Methods: Complications after reverse total shoulder arthroplasty were analyzed for 98 patients who underwent reverse total shoulder arthroplasty and were followed-up for at least 6 months. Of 98 patients, 22 were men and 76 were women. The mean age was 75.0±6.5 years (range, 59-92 years) with a mean follow-up period of 22±19 months (range, 6-74 months). The types and time of occurrence of complications, methods of treatment, and clinical outcomes at the final follow-up were analyzed. Results: Complications occurred in 18 of 98 patients (18.4%). Seven of them received operative treatment and 11 were treated conservatively. Two cases had postoperative dislocations and were addressed with open reduction. In 2 cases, periprosthetic fractures occurred and were treated with open reduction and plate fixation. Two acromial stress fractures and 8 cases of heterotopic ossification were managed conservatively. Infection and humeral component loosening occurred in one case, respectively, and were treated with revision arthroplasty. Glenoid component loosening occurred in 2 cases, one of which was treated with revision arthroplasty and the other was managed conservatively. At the final follow-up, clinical outcomes showed a statistically significant improvement. Compared to groups with no complications, there were no significant differences in final clinical outcomes. Scapular notching occurred in 43.9% (43/98 cases). No statistically significant differences of clinical outcomes were observed between the scapular notching group and the no notching group (p＞0.05). Conclusion: In our study, 18% of complications occurred after reverse total shoulder arthroplasty and final clinical outcomes of these complications showed significant improvement. Scapular notching developed in 44% and did not provide a significant clinical effect at short term follow-up.

f w F m cute, traumatic elbow dislocations can usually be educed by manual manipulation in most cases. Though are, cases of simple dislocation without associated fracures that cannot be reduced because of the interposition f ruptured ligaments or muscles within the joint have een reported. We present the case of a 70-year-old an with a posteromedial elbow dislocation in whom losed manipulative reduction was attempted on 2 ocasions, as well as under general anesthesia, but failed. uch a case has not yet been reported.