Amanda Pennings

Venous thromboembolism after shoulder arthroplasty: a systematic review.

BACKGROUND Shoulder arthroplasty (SA) is a common orthopaedic procedure that is being performed on a more and more frequent basis. Venous thromboembolism (VTE) as a complication has received little attention when it occurs after SA. The literature lacks a comprehensive summary of the incidence, risk factors, and prophylaxis of VTE in this population of patients. METHODS Literature on VTE after SA has been identified from 5 scientific databases: EMBASE, MEDLINE, Web of Science, CINAHL, and Cochrane. All primary full-text articles reporting at least 1 case of deep vein thrombosis or pulmonary embolism after SA were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, thromboprophylaxis, diagnosis, and management of VTE after SA. RESULTS This study included 14 articles. The reported incidence of VTE after SA was 0.2% to 16.0%. The most serious risk factors for development of VTE included history of VTE, thrombophilia, major surgery, advanced age, current malignant disease, immobility, and bed confinement. Diagnosis was typically determined by duplex scan and chest computed tomography scan. VTE prophylaxis was used in 6 (43%) of the included studies, with the ideal method of prophylaxis unknown. CONCLUSIONS Although variability exists in the reported incidence of VTE, surgeons should still be aware of the potential for this serious complication after SA. We recommend assessing the risk factors and estimating the VTE risk status for all patients undergoing SA. The ideal method of prophylaxis for this population of patients remains unknown and should be investigated in future high-quality clinical studies.

Metacarpophalangeal joint extensor tendon subluxation: a reconstructive stabilization technique.

Extensor tendon subluxation can result from a disruption to the extensor retinacular system and/or the sagittal band at the metacarpophalangeal joint. When conservative treatment is insufficient to correct the subluxation, surgical treatment is necessary and various surgical techniques exist. We present a novel stabilization technique to centralize the extensor tendon using a junctura tendinum to lengthen an extensor digitorum communis tendon graft. This technique is simple and effective, creating a strong repair without associated stiffness. To achieve a less morbid, stable repair, we mimicked normal anatomy with minimal disruption to local soft tissue structures. This technique seems to offer biomechanical advantages over previously described techniques and shows successful treatment in the illustrated patient.

A 3-Dimensional Anatomic Study of the Distal Biceps Tendon: Implications for Surgical Repair and Reconstruction

Background Complete rupture of the distal biceps tendon from its osseous attachment is most often treated with operative intervention. Knowledge of the overall tendon morphology as well as the orientation of the collagenous fibers throughout the musculotendinous junction are key to intraoperative decision making and surgical technique in both the acute and chronic setting. Unfortunately, there is little information available in the literature. Purpose To comprehensively describe the morphology of the distal biceps tendon. Study Design Descriptive laboratory study. Methods The distal biceps terminal musculature, musculotendinous junction, and tendon were digitized in 10 cadaveric specimens and data reconstructed using 3-dimensional modeling. Results The average length, width, and thickness of the external distal biceps tendon were found to be 63.0, 6.0, and 3.0 mm, respectively. A unique expansion of the tendon fibers within the distal muscle was characterized, creating a thick collagenous network along the central component between the long and short heads. Conclusion This study documents the morphologic parameters of the native distal biceps tendon. Reconstruction may be necessary, especially in chronic distal biceps tendon ruptures, if the remaining tendon morphology is significantly compromised compared with the native distal biceps tendon. Knowledge of normal anatomical distal biceps tendon parameters may also guide the selection of a substitute graft with similar morphological characteristics. Clinical Relevance A thorough description of distal biceps tendon morphology is important to guide intraoperative decision making between primary repair and reconstruction and to better select the most appropriate graft. The detailed description of the tendinous expansion into the muscle may provide insight into better graft-weaving and suture-grasping techniques to maximize proximal graft incorporation.

Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial.

Objective:To compare the short-term effectiveness of precut kinesiology tape (PCT) to a nonsteroidal anti-inflammatory drug (NSAID) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement. Design:Randomized, controlled assessor-blind parallel-design trial with 3 groups. Setting:Academic-community hospital. Patients:One hundred patients (mean age: 48 ± 12.3, 61 men, 39 women) with a diagnosis of subacromial impingement (SAI) syndrome were randomized to a treatment group from October 2009 to June 2012. Eighty-one patients completed the study. Interventions:Patients were randomized to one of the 3 treatment groups: PCT and Exercise (n = 33), NSAID and Exercise (n = 29), or Exercise only (n = 38) for a 4 session 2-week intervention with a registered physiotherapist. Main Outcome Measures:Numeric pain rating scales for pain at rest and pain with arm elevation, the Simple Shoulder Test (SST), and the Constant Score were assessed pretreatment and post-treatment. Results:A statistically significant reduction in pain at rest and pain with arm elevation, as well as improvement in SST and Constant Score were observed in all 3 treatment groups, with minimal clinically important differences shown on pain with elevation and SST scores. Between-group differences on all outcome measures were not statistically significant or clinically meaningful. Conclusions:The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone. If adjuvant treatment is desired, PCT seems to be better tolerated than an NSAID, although the difference did not reach significance. Clinical Relevance:The routine addition of adjuvant treatment is not supported by the results of this study. As adjuvant therapy, PCT seems to be better tolerated than an NSAID. If desired, clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome.

Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears

Background: Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment. Purpose: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the “military press” starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique. Results: Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76). Conclusion: The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

Unrecognized Isolated Medial Trochlear Fracture Leading to Malunion

Case:A twenty-year-old woman presented with an isolated intra-articular fracture of the medial part of the trochlea twelve weeks after a traumatic fall. The fracture had gone undetected during the initial twelve weeks following injury, resulting in an anteriorly and superiorly displaced malunion and severe range-of-motion restrictions of the elbow. Conclusion:Vigilant clinical examination is imperative to avoid missing this uncommon fracture pattern and complication. Prompt surgical management is necessary to ensure that adequate healing is achieved and to avoid unnecessary complications. This case report demonstrates that an excellent clinical outcome can be achieved with intra-articular osteotomy and anatomic fixation of the malunited segment.

Surgical Treatment of Chronic Perilunate Dislocation for Prevention of Attritional Flexor Tendon Rupture

A 25-year-old man presented with a chronic perilunate dislocation. While awaiting surgery, he developed flexor tendon rupture. The authors present an indication to proceed to emergently prioritize surgical treatment of even chronic perilunate dislocation. A delay in treatment may lead to attritional flexor tendon rupture.

Venous thromboembolism after shoulder arthroplasty: a report of three cases

Venous thromboembolism after shoulder arthroplasty is considered a rare phenomenon, but can be a dangerous and life-threatening condition. We report three cases of venous thromboembolism sustained after shoulder arthroplasty. One of the patients had a non-fatal pulmonary embolism. The other two had deep vein thrombosis, one in the operated upper extremity, and the other in a lower extremity. The cases are described in detail and discussed to reveal the possible contributing risk factors. The purpose of this case series is to increase awareness of this relatively rare, but potentially serious complication.

Intraosseous Fifth Carpometacarpal Dislocation Associated with a Coronal Hamate Fracture

Fractures of the hamate are relatively uncommon, accounting for approximately 2% to 7% of all carpal bone fractures, with injuries of the hamate body being the most rare variant1,2. These injuries typically are referred to as hamatometacarpal fracture-dislocations when associated with fracture-dislocations of the fourth and/or fifth metacarpals, as is often the case3,4. The original classification system of hamatometacarpal dislocations was developed by Cain et al. and was based on the orientation of the hamate fracture line3. Coronal fractures of the hamate body were identified as type-III injuries (Table I); however, this classification system was limited by its definition that hamatometacarpal fracture-dislocation includes a fracture of the fourth metacarpal as well as a fifth carpometacarpal (CMC) injury3. Advances in diagnostic imaging have allowed for more accurate assessment of injuries to the hamatometacarpal complex, which has resulted in the development of novel classification systems. These new classification systems have focused on more specific features of these injuries, such as the presence of metacarpal base fractures and the size of the intra-articular hamate fracture fragment (Table I)4,5. View this table: TABLE I Classification Systems for Hamatometacarpal Fracture-Dislocation* Treatment options for coronal fractures of the hamate range from conservative immobilization to operative internal fixation with Kirschner wires and/or interfragmentary screw fixation. To date, treatment guidelines have largely been based on individual case reports or small case series6. Wharton et al. suggested that any displaced coronal fractures of the hamate or coronal fractures associated with metacarpal subluxation or fracture should be treated with open reduction and internal fixation to reduce the incidence of CMC subluxation6. We describe a coronal plane cleavage fracture of the hamate with intraosseous impaction of the fifth metacarpal base proximally into the hamate, …

Kinesiology Tape Compared to NSAIDS in the Treatment of Rotator Cuff Impingement.

Objectives: To determine if kinesiology tape is as effective as nonsteroidal anti-inflammatory drugs (NSAIDS) when used as an adjunctive therapy to exercise at reducing pain and improving function in patients with rotator cuff impingement. Methods: A prospective, single-blind, randomized control trial was conducted. One hundred patients (average age: 48 ± 12.3, 61 males, 39 females) with a diagnosis of subacromial impingement syndrome were recruited and randomly assigned to one of three treatment groups: taping and exercise (n=33), NSAIDs and exercise (n=29), or exercise only (n=38). All patients completed a two-week (four sessions) exercise program guided by a registered physiotherapist. The physiotherapist applied the kinesiology tape to the patients in the taping and exercise group who wore the tape full time for an average of 3.5 days. Patients were assessed pre and post treatment by a research assistant who was blinded to each patient’s assigned treatment group. Patients were provided with a usage diary to record their compliance with the treatment protocol. Shoulder pain and function were assessed using a Numeric Pain Rating Scale, the Simple Shoulder Test (SST), and the Constant Score. Results: A significant improvement in pain with arm elevation, SST, and Constant Scores was observed in all the groups: taping and exercise group (1.2±2.5, 1.6±2.2, 7.8±8.1, respectively; p<0.05), NSAIDs and exercise group (2.1±2.4, 1.5±2.7, 11.0±11.7; respectively; p<0.05), and the exercise only group (1.3±2.6, 1.4±2.2, 6.3±10.9, respectively; p<0.05). A significant improvement in activities of daily living and functional arm level was observed in the taping and exercise group (0.8±1.2, 1.6±2.2 respectively; p<0.05) and the NSAIDS and exercise group (1.0±1.6, 0.8±2.0 respectively; p<0.05). Between-group differences were not statistically significant. Although all treatment groups showed a slight trend toward increased strength, the results were not significant. Patients were more compliant with the kinesiology tape (100%) than the NSAIDS treatment regime (84%). 88.5% of participants reported on average less than 2/10 discomfort with the tape. Conclusion: Kinesiology tape is as effective as NSAIDs as an adjuvant therapy to exercise at reducing shoulder pain and improving function in patients with subacromial impingement. Patients demonstrated increased compliance with the addition of kinesiology tape to an exercise program as compared to NSAIDS. Kinesiology tape appears to be well-tolerated and may prove to be a safer alternative to NSAIDs in the conservative treatment of shoulder impingement pain and dysfunction.