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1.  Arthroscopic double row cuff repair with suture-bridging and autologous conditioned plasma injection: Functional and structural results 
The double row cuff repair with suture bridging is commonly used for arthroscopic rotator cuff repair (RCR). Despite its biomechanical qualities, the rate of iterative tears with this technique is important. The aim of our study was to evaluate the effect of autologous conditioned plasma (ACP) on functional results and on the rate of iterative tears after RCR by suture bridging.
Materials and Methods:
A consecutive series of 65 patients who underwent arthroscopic double-row suture bridge (Speed-Bridge, Arthrex) primary cuff repair of symptomatic full-thickness supraspinatus tear (retraction <3 in the Patte classification) were evaluated. Mean patient age was 60 (+/-8). The supraspinatus was repaired by knot-less bridging (SwiveLock, Arthrex) with suture tape material. 2 homogenous groups were created (A: 33 patients, B: 32 patients). In group A, all patients received, besides the cuff repair, an intra-tendinous ACP injection. Constant scores and Simple Shoulder Tests (SST) were measured pre-operatively and after a minimum follow-up period of 12 months post-operatively. Structural integrity of the repairs was evaluated by MRI according to the Sugaya classification. Sugaya >4 were considered as iterative tears.
Mean follow-up was 19 months (+/−42) in the 2 groups. The mean quantity of ACP injected was 6ml. (+/−1.5) and no specific complication of the injection was found. Mean preoperative Constant-Murley scores were 41,2 (±7,7) and 38 (±11)in group B. Mean normalized Constant-Murley score increased from 41 points (±7) pre-operatively to 70 points (±8) post-operatively in group A and from 38 points (±11) to 73 points (±11) in group B. There were no significative differences between the two groups (P > 0.05). In group A, 31 repairs were Sugaya 1-3 (94%), vs. 30 in group B (93%), and 1 was type 4 in group A (5%) vs. 2 in group B (8%).
In both groups, RCR with suture bridging gave successful functional outcomes, with a low rate of iterative tear. In this preliminary study, the adjuvant effect of ACP injections could not be showed on both functional and structural results. Longer follow-up is needed to evaluate potential differences.
PMCID: PMC4262864  PMID: 25538428
Double row; platelet-rich plasma; rotator cuff tear; suture-bridging
2.  Assessment of function in patients with rotator cuff tears: Functional test versus self-reported questionnaire 
The rotator cuff tears (RCT) are a well-known cause of shoulder pain and loss of upper extremity function. The purpose of this study was to evaluate the upper extremity function using two different methods in patients with RCT and to determine the parameters that influence the upper extremity function.
Materials and Methods:
A sample of 38 patients (27-76 years; 10 men and 28 women) who were diagnosed with a chronic full-thickness RCT, confirmed by magnetic resonance imaging (MRI), was studied. Upper extremity function was determined using Western Ontario Rotator Cuff Index (WORC) and 9 Hole Peg Test (9PEG). Other assessments included active range of motion (ROM), muscle strength, shoulder pain, and scapular dyskinesis.
There was a weak association between WORC scores and 9PEG. A statistically significant, negative relationship was found between 9PEG and ROM in supination, as well as muscle strength of shoulder extensors, adductors, internal and external rotators.
In addition to the weak association between WORC and 9PEG, the difference between the parameters related to each method suggests that they should not be used interchangeably to determine the upper extremity function. We recommend the utilization of 9PEG instead of WORC in assessing the upper extremity function in the setting of loss of muscle strength.
Level of Evidence:
Level IV, Therapeutic study.
PMCID: PMC4262865  PMID: 25538429
9 Hole Peg Test; function; rotator cuff tear; upper extremity; Western Ontario Rotator Cuff Index
3.  Intra-articular infiltration therapy for patients with glenohumeral osteoarthritis: A systematic review of the literature 
Conservative treatments are especially in patients with glenohumeral osteoarthritis (GH-OA) important, since shoulder arthroplasty has its limitations. In this systematic review, we will evaluate the current evidence regarding the efficacy of intra-articular (IA) infiltration treatment options in patients with GH-OA.
Materials and Methods:
The following databases are searched: Pubmed/Medline, Cochrane Clinical Trial Register, Embase and the WHO clinical trial register. All IA injection products used for the treatment of shoulder OA in humans are included.
A total of 8 studies could be included in this review. Hyaluronic acid (HA) showed effect sizes of 2.07, 2.02 and 2.11 at 6, 12 and 26 weeks follow-up, respectively. Placebo (1.60, 1.82 and 1.68) also showed stable effect sizes at the same time points. The efficacy of corticosteroids (CS) decreased rapidly at follow-up (1.08, 0.43 and 0.19). Although statistical significant, the maximum difference in effect sizes between HA and placebo was only 0.43 with absolute values between 2.0 and 6.4 on a 100-point visual analogue score for pain.
IA treatment with HA has a good efficacy at follow-up compared to baseline. However, the difference in efficacy between HA and placebo never reaches the minimal clinically important difference at any of the follow-up points. We are not able to give clear recommendations for the use of IA CS injections in patients with GH-OA. In future research, we recommend focusing on sufficiently powered randomized trials to compare the efficacies of HA, CS, placebo and other IA treatment options in patients with GH-OA.
PMCID: PMC4262866  PMID: 25538430
Anesthetics; corticosteroid; hyaluronic acid; hyaluronan; osteoarthritis; shoulder; sodium hyaluronate; systematic review; viscosupplementation
4.  Association between screw prominence and vascular complications after clavicle fixation 
Fixation of clavicle fractures has become more common to prevent symptomatic malunion and nonunion. The subclavian and axillary vessels are in close proximity to the medial two-thirds of the clavicle, placing them at risk from prominent metalware. Injury to these major vessels has the potential to be life or limb-threatening. Despite this anatomical risk, iatrogenic vascular injury associated with clavicle fixation is rare.
The aim of this study was to identify risk factors associated with modern fixation techniques in reported cases of vascular injury after clavicle fixation.
Materials and Methods:
A literature search was performed, and all identified cases of iatrogenic vascular injury associated with prominent clavicle fixation were analyzed. Clinical details, the total length of the prominent screws and the distance that they protruded from the far cortex were recorded.
Five cases were identified; there were four pseudoaneurysms and one arteriovenous fistula. The total length of the offending screw was identifiable in two cases, measuring 26 and 30 mm. The length of screw prominence was identifiable in 3 cases (8, 10 and 10 mm). The pseudoaneurysms presented at 2-10 years following clavicle fixation. Three of these cases developed limb-threatening ischemia.
Vascular complications associated with clavicle fixation are uncommon but potentially limb-threatening. Several associated factors are identified. The authors provide a number of detailed recommendations aimed at preventing these complications.
PMCID: PMC4262867  PMID: 25538431
Arteriovenous fistula; axillary artery; clavicle fracture; complication; internal fixation; risk factor; subclavian artery
5.  Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results 
Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.
PMCID: PMC4262868  PMID: 25538432
Glenoid bone loss; the iliac crest allograft; shoulder instability
6.  Age-related joint space narrowing independent of the development of osteoarthritis of the shoulder 
It is commonly accepted that the glenohumeral joint space remains unchanged until the onset of osteoarthritis, at which point progressive degenerative changes, and joint space narrowing occur. The aim of this study was to evaluate the radiographic width of the glenohumeral joint space in patients of different ages: Those with otherwise normal radiographs, those with a history of instability, those with calcific tendonitis, and those with a radiologic diagnosis of osteoarthritis.
Materials and Methods:
In this retrospective study, two independent investigators measured the glenohumeral joint width on true anteroposterior and axillary views of standardized shoulder radiographs taken from 2002 to 2009. The digital image resolution was 0.01 mm. Group I comprised 60 patients with normal shoulder radiographs, Group II comprised 53 patients with instability but normal radiographs, Group III comprised 109 patients with radiologically proven calcific tendonitis, and Group IV comprised 120 patients with manifest osteoarthritis.
The interobserver reliability (r) was 0.621-0.862. The mean joint space width was significantly different among Groups I-IV (central anteroposterior: 4.28 ± 0.75 mm, 3.12 ± 0.73 mm, 2.87 ± 0.80 mm, and 1.47 ± 1.07 mm, respectively; P = 0.001; central axillary: 6.12 ± 1.09 mm, 3.92 ± 0.77 mm, 3.34 ± 0.84 mm, and 1.08 ± 1.12 mm, respectively; P = 0.001). There was a significant negative correlation between the joint space width and age at all measured levels in both projections (P < 0.001).
The glenohumeral joint space width decreases with increasing age beginning in early adulthood, and this effect is enhanced by osteoarthritis.
Level of Evidence:
Level II, retrospective study.
PMCID: PMC4262869  PMID: 25538427
Aging; cartilage; joint space; osteoarthritis; radiograph; shoulder
7.  Decreased scapular notching with lateralization and inferior baseplate placement in reverse shoulder arthroplasty with high humeral inclination 
Scapular notching is a radiographic finding of unknown clinical significance following reverse total shoulder arthroplasty (RTSA). The purpose of this study was to determine how baseplate position affects the incidence of scapular notching and measure the clinical outcomes.
We hypothesized that low base plate position on the glenoid and new prosthesis design with a higher humeral inclination angle would decrease the incidence of notching at 2 years follow-up.
Materials and methods:
A total of 54 patients with an average follow-up of 30 months met inclusion criteria and underwent radiographic analysis of scapular notching and radiographic measures to determine glenoid component placement. Clinical measures including visual analog score, American Shoulder and Elbow Surgeons (ASES) scores, and range of motion (ROM) were prospectively collected.
Thirty-nine of the 54 patients had no notching. 7 had Grade 1 notching, 7 had Grade 2 notching, one had Grade 3, and one had Grade 4 notching. Notching was associated with higher placement of the glenoid component as measured by peg-glenoid rim distance and base plate distance. All patients with no evidence of notching at 1-year, continued to have no notching after multi-year follow-up. Clinical outcome measures including ASES scores, ROM, and visual analog pain scores were improved at follow-up.
We concluded that lower neck-shaft angle and low baseplate positioning led to a low incidence of significant scapular notching as only 6 out of 57 (16%) patients had notching Grade 2 and above. At short-term follow-up, this RTSA results in excellent clinical outcomes and a significantly lower scapular notching rate than traditional techniques.
PMCID: PMC4168654  PMID: 25258496
Reverse shoulder arthroplasty; rotator cuff arthropathy; scapular notching
8.  Short stem shoulder replacement 
It is agreed that it is important to anatomically reproduce the proximal humeral anatomy when performing a prosthetic shoulder replacement. This can be difficult with a long stemmed prosthesis, in particular if there is little relationship of the metaphysis to the humeral shaft. The ‘short stem’ prosthesis can deal with this problem.
A prospective study assessed the results of total shoulder arthroplasty using a short stem humeral prosthesis, a ceramic humeral head, and a pegged cemented polyethylene glenoid.
Materials and methods:
Patients with primary shoulder osteoarthritis were recruited into this prospective trial and pre-operatively had the ASES, Constant, SPADI, and DASH scores recorded. The patients were clinically reviewed at the two weeks, eight weeks, one year, and two year mark with completion of a data form. Radiological evaluation was at the eight week, one year and two year follow-up. At the one and two year follow-up the satisfaction rating, the range of passive and active motion, Constant, ASES, SPADI, DASH and pain results were recorded and analysed with SPPS 20.
During the study period 97 short stem, ceramic head total shoulder replacements were carried out. At the time of follow-up 12 were two years from operation and 38 one year from operation. Active elevation was overall mean 160 degrees. Constant scores were 76 at 1 year, and 86 at 2 years, ASES 88 and 93, and satisfaction 96% and 98% respectively at one and 2 year follow up. There were no problems during insertion of the humeral prosthesis, or any radiolucent lines or movement of the prosthesis on later radiographs.
The short stem prosthesis had no complications, and on follow up radiographs good bone fixation. These fairly short term clinical results were overall good.
PMCID: PMC4168655  PMID: 25258497
Ceramic prosthesis; short stem humeral prosthesis; shoulder arthroplasty; shoulder replacement; stemless
9.  Long-term functional results and isokinetic strength evaluation after arthroscopic tenotomy of the long head of biceps tendon 
The objective of this study is to evaluate the biomechanical function of the upper arm after arthroscopic long head of biceps (LHB) tenotomy at long-term follow-up.
Materials and Methods:
Twenty-five male subjects ranging from 30 to 63 years old were evaluated at a mean follow-up of 7.0 years after tenotomy. Bilateral isokinetic testing was performed to obtain peak torque values, as well as total work done throughout the full range of elbow flexion and supination.
Magnetic resonance imaging scans revealed nine unrecognized LHB ruptures in the contralateral arm, leaving 16 subjects to complete the testing protocol. The mean quickDASH score was 8.1 (standard error [SE] 2.5). The mean oxford elbow score was 97.9 (SE 1.6). The tenotomy arm recorded a decrease in peak flexion torque of 7.0% (confidence interval [CI] 1.2-12.8), and a decrease in the peak supination torque of 9.1% (CI 1.8-16.4) relative to the contralateral arm. The total work carried out through the full range of joint motion was reduced in elbow flexion by 5.1% (CI −1.3-11.4) and in forearm supination by 5.7% (CI-2.4-13.9).
Maximum strength in elbow flexion and forearm supination is significantly reduced compared with the contralateral arm. However, this impairment is partially compensated for by relatively greater strength sustained through the latter stages of joint motion. This results in comparable total work measurements between the tenotomised and contralateral side, potentially accounting for ongoing high levels of patient satisfaction and clinical function in the long term after LHB tenotomy.
Level of Evidence IV:
Case series without comparison group.
PMCID: PMC4168656  PMID: 25258498
Biceps tenotomy; isokinetic strength; long-term
10.  Comparison of the cheese-wiring effects among three sutures used in rotator cuff repair 
The goal of this study was to compare the cheese-wiring effects of three sutures with different coefficients of friction.
Materials and Methods:
Sixteen human cadaveric shoulders were dissected to expose the distal supraspinatus and infraspinatus muscle tendons. Three sutures were stitched through the tendons: #2 Orthocord™ suture (reference #223114, DePuy Mitek, Inc., Raynham, MA), #2 ETHIBOND* EXCEL Suture, and #2 FiberWire® suture (FiberWire®, Arthrex, Naples, FL). The sutures were pulled by cyclic axial forces from 10 to 70 N at 1 Hz for 1000 cycles through a MTS machine. The cut-through distance on the tendon was measured with a digital caliper.
The cut-through distance in the supraspinatus tendons (mean ± standard deviation, n = 12) were 2.9 ± 0.6 mm for #2 Orthocord™ suture, 3.2 ± 1.2 mm for #2 ETHIBOND* suture, and 4.2 ± 1.7 mm for #2 FiberWire® suture. The differences were statistically significant analyzing with analysis of variance (P = 0.047) and two-tailed Student's t-test, which showed significance between Orthocord™ and FiberWire® sutures (P = 0.026), but not significant between Orthocord™ and ETHIBOND* sutures (P = 0.607) or between ETHIBOND* and FiberWire® sutures (P = 0.103).
The cheese-wiring effect is less in the Orthocord™ suture than in the FiberWire® suture in human cadaveric supraspinatus tendons.
Clinical Relevance:
Identification of sutures that cause high levels of tendon cheese-wiring after rotator cuff repair can lead to better suture selection.
PMCID: PMC4168657  PMID: 25258499
Biomechanics; cadaver study; cheese-wiring; supraspinatus tendon; suture
11.  Noncomminuted lateral end clavicle fractures associated with coracoclavicular ligament disruption: Technical considerations for optimal anatomic fixation and stability 
Distal clavicle fractures associated with coracoclavicular ligament disruption are potentially unstable and necessitate surgical treatment. Current fixation techniques are nonanatomic and do not address relevant aspects of the pathoanatomy. We have developed a technique that uses a unique combination of implants; this permits minimally invasive fixation and stable reduction with a lateral fragment size as small as 5 mm. The surgical technique consists of (1) neutralization of muscular forces on the proximal fragment using a minimally invasive ligament repair device (TightRope™, Arthrex, FL, USA) and (2) internal fixation using a contour-matched locking plate (2.4 mm LCP® Distal radius plates, Synthes, USA). Technical tips to optimize this new procedure are discussed. The technique can be extended to an “arthroscopic-assisted” method involving arthroscopic coracoclavicular fixation followed by a mini-open plate fixation of the clavicular fragments.
PMCID: PMC4168658  PMID: 25258500
Clavicle fracture; coracoclavicular ligaments; coracoid process; locking plate; shoulder
12.  Scapular spine stress fractures: To fix or not to fix, our experience in a patient with bilateral fractures and review of the literature 
We report a case of bilateral scapular spine stress fracture, treated conservatively on one side and operatively on the other side. Besides, we performed a literature review to establish management options. A 61-year-old right-handed gentleman came to our clinic with acute on chronic deterioration of shoulder pain and loss of arm function. Clinical assessment and investigations revealed long-standing bilateral rotator cuff tear and scapular spine stress fractures. The fracture on the right side united with conservative management for 2 months. However, his left side remained symptomatic with pain, abnormal mobility and no radiological evidence of union. The fracture progressed to union after fixation and bone grafting. At the final follow-up at 2 years, the patient was asymptomatic with regards to the fractures with Oxford Shoulder Score (OSS)-30 and Disabilities of the Arm, Shoulder and Hand (DASH)-30.8. Fracture union either by conservative or operative treatment is associated with good functional outcome and is supported by our review.
PMCID: PMC4168659  PMID: 25258501
Cuff tear arthropathy; scapula fracture; scapula spine stress fracture; stress fracture
13.  Fascia lata allograft bridging of a rotator cuff tear in a rabbit animal model 
Despite advances in surgical treatment options, large rotator cuff (r-c) tears still represent a challenge for orthopedic surgeons. The purpose of this study was to evaluate the temporary and spatial histological incorporation of fascia lata allografts, used for bridging artificially created defects of the r-c.
Materials and Methods:
Seventy-two rabbits were divided into two groups and a supraspinatus tendinous defect was created. Half of the rabbit population underwent repair only, while in the other half, the defect was bridged utilizing fascia lata allograft. The animals were euthanized at 2, 4, and 6 weeks postoperative. Half of the specimens were evaluated histologically and the other half underwent mechanical testing.
There was an increased remodeling activity, fibroblastic in growth and strong presence of collagen fibers observed at 6 weeks on both groups. A gradually increasing mechanical strength was noticed by week 6 and increased toughness was also found at the same time period. There was no significant difference observed between the two groups regarding their histological and mechanical properties.
In the difficult scenario of a large irreparable tear where the simple suture of the remaining r-c is impossible, allograft bridging, could be used with satisfactory results.
Clinical Relevance:
Treatment Study, Level 1.
PMCID: PMC4124672  PMID: 25114414
Biomechanics; fascia lata allograft patch; graft bridging; histology; massive or irreparable tears of the rotator cuff; rabbit shoulder; rotator cuff repair
14.  Complications after subpectoral biceps tenodesis using a dual suture anchor technique 
A variety of fixation techniques for subpectoral biceps tenodeses have been described including interference screw and suture anchor fixation. Biomechanical data suggests that dual suture anchor fixation has equivalent strength compared to interference screw fixation. The purpose of the study is to determine the early complication rate after subpectoral biceps tenodesis utilizing a dual suture anchor technique.
Materials and Methods:
A total of 103 open subpectoral biceps tenodeses were performed over a 3-year period using a dual suture anchor technique. There were 72 male and 31 female shoulders. The average age at the time of tenodesis was 45.5 years. 41 patients had a minimum of 6 months clinical follow-up (range, 6 to 45 months). The tenodesis was performed for biceps tendonitis, superior labral tears, biceps tendon subluxation, biceps tendon partial tears, and revisions of prior tenodeses.
There were a total of 7 complications (7%) in the entire group. There were 4 superficial wound infections (4%). There were 2 temporary nerve palsies (2%) resulting from the interscalene block. One patient had persistent numbness of the ear and a second patient had a temporary phrenic nerve palsy resulting in respiratory dysfunction and hospital admission. One patient developed a pulmonary embolism requiring hospital admission and anticoagulation. There were no hematomas, wound dehiscences, peripheral nerve injuries, or ruptures. In the sub-group of patients with a minimum of 6 months clinical follow-up, the only complication was a single wound infection treated with oral antibiotics.
Subpectoral biceps tenodesis utilizing a dual suture anchor technique has a low early complication rate with no ruptures or deep infections. The complication rate is comparable to those previously reported for interference screw subpectoral tenodesis and should be considered as a reasonable alternative to interference screw fixation.
Level of Evidence:
Level IV-Retrospective Case Series
PMCID: PMC4124673  PMID: 25114415
Biceps; complications; subpectoral; tenodesis Key Message: Subpectoral biceps tenodesis utilizing a dual suture anchor technique provides a low early complication rate comparable to previously reported rates for interference screw fixation. These early clinical findings are consistent with biomechanical data supporting that a dual suture anchor subpectoral technique has equivalent initial biomechanical strength compared to an interference screw.
15.  Sudden severe postoperative dyspnea following shoulder surgery: Remember inadvertent phrenic nerve block due to interscalene brachial plexus block 
Advanced imaging techniques, improved operative techniques, and instrumentation combined with better patient awareness and expectations have resulted in an exponential increase in upper limb surgical procedures during recent times. Surgical teams expect superior analgesia and regional blocks have matched these expectations quite often resulting in improved patient satisfaction and early rehabilitation to achieve best results. Ultrasound-guided interscalene brachial plexus block (ISB) is commonly used to provide analgesia for procedures involving shoulder girdle. We report a case of symptomatic hemi-diaphragmatic paresis (HDP) due to the phrenic nerve block following ISB for arthroscopic sub-acromial decompression of the shoulder presenting as severe postoperative dyspnea. There is strong evidence of HDP following ISB in anesthetic literature, but not reported in related surgical specialties such as orthopedics. We wish to inform upper-limb surgeons and educate junior doctors and other ancillary staff working in upper-limb units to be aware of this serious but reversible complication.
PMCID: PMC4124674  PMID: 25114416
Acute postoperative dyspnea; hemi-diaphragmatic paresis; interscalene brachial plexus block; phrenic nerve block
16.  Osteochondral humeral head fracture after posterior shoulder subluxation: A case report 
Traumatic posterior shoulder subluxations are rare entities which require clinical suspicion upon presentation. Although literature presents many sequels of posterior shoulder subluxations, we have not come across any shearing type osteochondral fracture in the literature. In this case report we present diagnosis, treatment and follow-up results of this rare fracture in a 26-year-old male following a fall from a motorcycle.
PMCID: PMC4124675  PMID: 25114417
Dislocation; humeral head; osteochondral; posterior; shoulder
17.  An unusual cause of mass in the shoulder: A primary hydatid cyst 
A hydatid cyst is a zoonotic infection which may affect any organ and tissue, particularly the liver and the lung. Primary muscular hydatid cysts comprise less than 0.7-3% of the cases. The hydatid cysts must be kept in mind to avoid a diagnostic puncture in cystic lesions to avoid the spreading of the disease. In this case report, we present an exceptionally rare case with an unusual localization of a primary hydatid cyst in the left deltoid muscle.
PMCID: PMC4124676  PMID: 25114418
Daughter cyst; deltoid muscle; germinative membrane; hydatid cyst; scolices
18.  Myositis ossificans of the humeral insertion of pectoralis major 
We report on a rare case of myositis ossificans of the humeral insertion of pectoralis major muscle following a single episode of trauma which, to our knowledge, has not previously been documented.
PMCID: PMC4124677  PMID: 25114419
Myositis ossificans; proximal humerus; pectoralis major
19.  An analysis of functional shoulder movements during task performance using Dartfish movement analysis software 
Video-based movement analysis software (Dartfish) has potential for clinical applications for understanding shoulder motion if functional measures can be reliably obtained. The primary purpose of this study was to describe the functional range of motion (ROM) of the shoulder used to perform a subset of functional tasks. A second purpose was to assess the reliability of functional ROM measurements obtained by different raters using Dartfish software.
Materials and Methods:
Ten healthy participants, mean age 29 ± 5 years, were videotaped while performing five tasks selected from the Disabilities of the Arm, Shoulder and Hand (DASH). Video cameras and markers were used to obtain video images suitable for analysis in Dartfish software. Three repetitions of each task were performed. Shoulder movements from all three repetitions were analyzed using Dartfish software. The tracking tool of the Dartfish software was used to obtain shoulder joint angles and arcs of motion. Test-retest and inter-rater reliability of the measurements were evaluated using intraclass correlation coefficients (ICC).
Maximum (coronal plane) abduction (118° ± 16°) and (sagittal plane) flexion (111° ± 15°) was observed during ‘washing one's hair;’ maximum extension (−68° ± 9°) was identified during ‘washing one's own back.’ Minimum shoulder ROM was observed during ‘opening a tight jar’ (33° ± 13° abduction and 13° ± 19° flexion). Test-retest reliability (ICC = 0.45 to 0.94) suggests high inter-individual task variability, and inter-rater reliability (ICC = 0.68 to 1.00) showed moderate to excellent agreement.
Key findings include: 1) functional shoulder ROM identified in this study compared to similar studies; 2) healthy individuals require less than full ROM when performing five common ADL tasks 3) high participant variability was observed during performance of the five ADL tasks; and 4) Dartfish software provides a clinically relevant tool to analyze shoulder function.
PMCID: PMC4049033  PMID: 24926157
Dartfish; DASH; functional range of motion; reliability; shoulder
20.  Oxford shoulder score in a normal population 
The function of the asymptomatic normal shoulder may differ according to gender and could also deteriorate with age. This may result in a disparity in the normal Oxford shoulder score (OSS) according to these variables. If a difference were to exist an adjusted OSS, for age and gender, could be calculated from the raw score using the expected normal score.
The aim of this study was to define a normal OSS in an asymptomatic population according to age and gender.
Materials and Methods:
During the study period 202 patients aged from 20 years to 99 years with subjectively asymptomatic shoulders completed an OSS. These patients presented to the study center during a 1 week period for management of disorders out with their shoulder girdle. Patients with a known prior shoulder pathology, injury, or polyarthropathy were excluded.
The mean OSS varied according age and gender. There was a significant correlation between age and the OSS, with an increasing score (worse) being associated with older age (r = 0.62, P < 0.0001). The mean OSS for females was 18.8 (12-42, SD 5.4) and for males was 16.3 (12-30, SD 4.5), this difference was significant (P = 0.0001). We propose that a normalized OSS could be calculated as a percentage by the using the expected normal for that patient's age and gender as demonstrated in this study ((raw score/normal score) × 100).
Our study provides normal data for an urban population presenting to orthopedic services and allows for a relative OSS to be calculated from the raw score.
PMCID: PMC4049034  PMID: 24926158
Normal; outcome; Oxford; score; shoulder
21.  Single-row, double-row, and transosseous equivalent techniques for isolated supraspinatus tendon tears with minimal atrophy: A retrospective comparative outcome and radiographic analysis at minimum 2-year followup 
The purpose of this study was to measure and compare the subjective, objective, and radiographic healing outcomes of single-row (SR), double-row (DR), and transosseous equivalent (TOE) suture techniques for arthroscopic rotator cuff repair.
Materials and Methods:
A retrospective comparative analysis of arthroscopic rotator cuff repairs by one surgeon from 2004 to 2010 at minimum 2-year followup was performed. Cohorts were matched for age, sex, and tear size. Subjective outcome variables included ASES, Constant, SST, UCLA, and SF-12 scores. Objective outcome variables included strength, active range of motion (ROM). Radiographic healing was assessed by magnetic resonance imaging (MRI). Statistical analysis was performed using analysis of variance (ANOVA), Mann — Whitney and Kruskal — Wallis tests with significance, and the Fisher exact probability test <0.05.
Sixty-three patients completed the study requirements (20 SR, 21 DR, 22 TOE). There was a clinically and statistically significant improvement in outcomes with all repair techniques (ASES mean improvement P = <0.0001). The mean final ASES scores were: SR 83; (SD 21.4); DR 87 (SD 18.2); TOE 87 (SD 13.2); (P = 0.73). There was a statistically significant improvement in strength for each repair technique (P < 0.001). There was no significant difference between techniques across all secondary outcome assessments: ASES improvement, Constant, SST, UCLA, SF-12, ROM, Strength, and MRI re-tear rates. There was a decrease in re-tear rates from single row (22%) to double-row (18%) to transosseous equivalent (11%); however, this difference was not statistically significant (P = 0.6).
Compared to preoperatively, arthroscopic rotator cuff repair, using SR, DR, or TOE techniques, yielded a clinically and statistically significant improvement in subjective and objective outcomes at a minimum 2-year follow-up.
Level of Evidence:
Therapeutic level 3.
PMCID: PMC4049035  PMID: 24926159
Outcomes; rotator cuff; shoulder; surgical techniques
22.  Bone properties of the humeral head and resistance to screw cutout 
Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.
Materials and Methods:
We examined the convex surface of the humeral head looking at the density and the topographical strength of the subchondral bone using mechanical testing of bone cylinders harvested from the humeral head. We also studied the osseous architecture of the subchondral bone and thickness of the boneplate of the humeral head using a 3-dimensional serial sectioning technique.
The bone strength and bone density correlated well and revealed large regional variations across the humeral head. Bone strength and stiffness of the trabecular bone came to a maximum in the most medial anterior and central parts of the humeral head, where strong textural anisotropy was also found. We found in particular a lower bone strength and density in the posterior and inferior regions of the humeral head. A rapid decline in bone strength within a few mm below a relatively thin subchondral plate was also reported.
Clinical Relevance:
We have in this paper explored some of the most important factors connected with screw stability at the cancellous bone level. We discovered large variations in bone density and bone strength across the joint surface rendering certain areas of the humeral head less suitable for screw placement. The use of rigid plate constructs with divergent screw directions will predictably place screws in areas of the humeral head comprising low density and low strength cancellous bone. New concepts of plates and plating techniques for the surgical treatment of complex fractures of the proximal humerus should take bone distribution, strength, and architecture into account.
PMCID: PMC4049036  PMID: 24926160
Bone architecture; bone strength; humeral head; screw cutout
23.  Combination of a floating clavicle and a posterior shoulder dislocation: An “Unhappy Triad” of the shoulder girdle 
We present a case of a 31-year-old man who suffered from a floating clavicle in combination with a reverse Hill-Sachs lesion of his right shoulder girdle after a bicycle accident. Operative treatment was performed using minimal-invasive and arthroscopically assisted techniques.
We strongly recommend an early CT scan with later 3-dimensional reconstruction to detect and fully understand these complex injuries.
PMCID: PMC4049037  PMID: 24926161
Floating clavicle; lateral clavicle fracture; posterior shoulder dislocation; reverse Hill-Sachs lesion
24.  Recurrent Fusobacterium pyogenic myositis of the rotator cuff A case report of recurrent Fusobacterium pyogenic myositis of the rotator cuff 
Pyogenic myositis is uncommon. It normally affects the large muscle groups in the lower limb or trunk and the most common causative organism is Staphylococcus aureus. We present a case of an immunocompetent man who, unusually, had a recurring form of the disease in subscapularis and teres minor. The causative organism was also highly unusual (Fusobacterium).
PMCID: PMC4049038  PMID: 24926162
Fusobacterium; pyomyositis; rotator cuff; Key Messages: Whilst uncommon, pyogenic myositis should be considered in patients presenting with signs and symptoms similar to those with septic joints
25.  Distal humerus shear-fractures: “Built-on” surgical technique 
When treating a distal humeral shear fracture, comminution of the lateral column may preclude the reconstruction of the lateral articular fragments.
In this article a new strategy for the management lateral column comminuted shear-fractures (LCCSF) is presented, called the “built-on” surgical technique. Three goals are obtained by this technique: (1) Restoration of the lateral column bone stock; (2) Provision of a solid scaffold for the repair of the lateral ulnar collateral ligament (LUCL); and (3) Provision of a sable platform for the reconstruction and fixation of the articular fragments.
We will obtain these goals through the following surgical steps:
1/ Reconstruction of the lateral trochlea.
2/ Reconstruction of the lateral column
3/ Fixation of the Capitellum
4/ Reconstruction of the LUCL
PMCID: PMC4049039  PMID: 24926163
Capitellar and trochlear fractures; distal humerus; fractures; lateral column; shear fractures

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