Anand M. Murthi

Two-part and three-part fractures of the proximal humerus treated with suture fixation.

Objective To evaluate the radiographic and clinical outcomes of patients with displaced proximal humerus fractures (two-part and three-part) treated with nonabsorbable rotator cuff–incorporating sutures. Design Retrospective. Setting University hospital. Patients There were 27 patients (28 shoulders) with displaced proximal humerus fractures. There were 13 greater tuberosity (GT) and 9 surgical neck (SN) two-part fractures and 6 GT/SN three-part fractures. The average age was 64 years (range 38 to 84 years). The average follow-up was 4.4 years (range 1.0 to 11.5 years). Intervention All patients were surgically treated solely with heavy polyester nonabsorbable sutures. Main Outcome Measurements Functional assessment was obtained using the American Shoulder and Elbow Surgeons (ASES) score and Neers criteria, which grade outcomes as excellent, satisfactory, or unsatisfactory. Results Overall, there were 22 (78%) excellent, 3 (11%) satisfactory, and 3 (11%) unsatisfactory results, and the average ASES score was 87.1 (range 35.0 to 100.0). All shoulders healed radiographically without evidence of avascular necrosis of the humeral head. Twenty-four shoulders (86%) had anatomic alignment on postoperative radiographs. Of four shoulders with nonanatomic alignment, three had ASES scores of ≥90, with excellent Neer scores. When comparing patients with isolated two-part GT fractures (n = 13) with patients having two-part SN or three-part SN/GT fractures (n = 15), there were no statistically significant differences with respect to range of motion (P > 0.05) and outcome measures (P > 0.05). All patients who had unsatisfactory outcomes were noncompliant with physical therapy, with ASES scores averaging 39.4 (range 35.0 to 43.3). Conclusion Two-part and three-part GT and SN fractures can be treated satisfactorily with heavy nonabsorbable rotator cuff–incorporating sutures, particularly in elderly patients. Hardware-associated complications are obviated. Patients with SN fractures treated with sutures can have outcomes similar to patients with two-part GT fractures. Although the goal is to reconstruct a “one-part” fracture pattern, some residual deformity does not preclude an excellent outcome. A compliant patient is crucial for a successful result.

Shoulder dislocation in the older patient.

Abstract Approximately 20% of all shoulder dislocations occur in patients aged >60 years. Older patients who sustain a primary shoulder dislocation are much less likely than younger patients to suffer from recurrence. However, older patients are more likely than younger patients to sustain injuries to the rotator cuff, axillary nerve, or brachial plexus. Rotator cuff tears are significantly more common than nerve palsies, and rotator cuff tears can be mistaken for nerve palsies. Older patients with persistent shoulder pain and dysfunction after dislocation should be carefully evaluated for rotator cuff pathology. Although dislocation is a common injury in the older population, these concomitant injuries—especially of the rotator cuff—are often missed.

Reverse total shoulder arthroplasty for irreparable rotator cuff tears and cuff tear arthropathy.

Based on the available literature, we believe that reverse shoulder arthroplasty is a reasonable treatment modality in patients with CTA and massive irreparable cuff tears. RSA has been shown to increase patient function and decrease pain. There are still a high number of complications related to this procedure; however, with stringent patient selection criteria and meticulous technique, high patient satisfaction scores are typically achieved in these patients, at least in the short term. Further studies are required to evaluate the efficacy these devices in the long term.

Varus Posteromedial Instability.

Varus posteromedial instability of the elbow is a result of traumatic injury to the medial facet of the coronoid and usually the lateral collateral ligament. Treatment of these fractures is usually surgical; poor outcomes have been described with nonoperative treatment. Surgical management consists of coronoid fracture fixation with plates, screws, or sutures and radial collateral ligament repair. Outcomes of these injuries are mixed, but most series report fair to good objective scores. The purpose of this article is to describe the pathophysiology of varus posteromedial instability, discuss the management of this injury, and report the outcomes of treatment.

Lacertus Fibrosis versus Achilles Allograft reconstruction for Chronic Distal Biceps Tears A Biomechanical Study

Objectives: Chronic distal biceps tears can be difficult to treat as in many cases, the remaining biceps tendon is significantly retracted and an allograft may be required to provide length for reconstruction. The lacertus fibrosis (LF), being a local, stout, fibrous sheath, can potentially be used as a reconstruction graft, obviating the need for allograft tissue. The purpose of this study is to evaluate the strength of the lacertus fibrosis compared to achilles allograft (AA) for distal biceps reconstruction. Methods: 10 fresh-frozen matched cadaveric pairs of elbows were used in this study. The distal biceps tendon was isolated and 3 centimeters of tendon was resected. In Group 1, the LF was identified and released from its distal attachment, maintaining its attachment to the biceps muscle. This was then tubularized and repaired to the radius via button fixation. In Group 2, an AA tendon graft was sutured to the biceps muscle via Pulvertaft weave and similarly repaired to the ulna via button fixation. The prepared radii were rigidly mounted at a 45-degree angle in a MTS electromechanical test frame (MTS Systems, Eden Prairie, MN). The proximal biceps muscle was secured in a custom fabricated cryogenic grip and allowed to freeze for 60s prior to testing. Two differential variable reluctance transducers (DVRTs) were mounted on the specimens, one at the radius-soft tissue junction and the second in the muscle or muscle allograft tissue junction proximal to the repair. Specimens were then loaded at a displacement rate of 20 mm/min until failure. Failure was defined as a 3 mm displacement of the DVRT located at the radius-soft tissue junction. Stiffness was calculated from the initial linear portion of the load versus radial DVRT curve. A t-test was used to determine if any observed differences were significant (p≤0.05) Results: Load to failure, as defined as a 3mm gap formation by DVRT was similar between both groups. Load to failure in Group 1 (LF) was 20.17 ± 5.52 N versus 16.89 ±4.54 N in Group 2 (AA) (p=0.18). Stiffness of the construct was also not statistically different, with Group 1 (LF) averaging 12.32± 7.11 KPa versus 10.48 ± 5.66 KPa in Group 2 (AA) (p=0.34). Conclusion: Lacertus fibrosis reconstruction for chronic distal biceps tears was as strong biomechanically as the commonly used achilles tendon allograft in terms of load to failure and construct stiffness. This may be a reasonable alternative for chronic distal biceps reconstruction in which primary repair is not possible.

Are two plates necessary for extraarticular fractures of the distal humerus

Background:We compared the biomechanical stability of a standard precontoured two-plate locked construct with that of a single laterally placed locked plate for extraarticular supracondylar distal humeral fractures. Methods:Extraarticular supracondylar humeral fractures were created in matched pairs of nonosteoporotic cadaver humeri. Specimens were plated with a single locked plate placed posterolaterally or two precontoured locked plates placed orthogonally. Both constructs were instrumented in a hybrid manner with locking and nonlocking screws. Each sample underwent cyclic loading in flexion and varus to failure. Average cycles to failure, force to failure, displacement, and mechanical stiffness were compared. Results:Stiffness was 1072 N/mm for the single-plate construct and 722 N/mm for the two-plate construct (P=0.06). Average number of cycles to failure was 3586 for the single-plate and 2772 for the two-plate construct (P=0.42). Force to failure averaged 428 N for the single-plate and 380 N for the two-plate construct (P=0.56). All constructs failed through the plate-bone interface without failure of the devices. Conclusions:A single plate designed specifically for fractures of the distal humerus is biomechanically equivalent to two precontoured plates also designed for the distal humerus. The finding might be clinically significant because the single-plate technique potentially reduces surgical time and exposure to the posterior and medial aspects of the elbow. Decreased exposure, especially to the medial elbow, might reduce iatrogenic injury.

Split Pectoralis Major Transfer for Serratus Anterior Palsy

ABSTRACT Serratus anterior palsy, with the resulting scapular winging, can be a functionally devastating and painful injury to the shoulder girdle. We describe our preferred technique of directly transferring the sternal head of the pectoralis major to the inferior angle of the scapula through 2 limited incisions. This reduces the possibility of graft stretching, preventing the recurrence of winging, and accomplishes satisfactory cosmesis. Only in cases in which muscle length is inadequate despite sufficient mobilization do we use a graft. We have used the Graft Jacket (Wright Medical Technology, Arlington, TN) to supplement and augment the muscle transfer.

Treatment of Simple Elbow Dislocations

The elbow is the second most commonly dislocated joint. Elbow dislocations are often caused by falling onto an outstretched hand, resulting in application of a valgus, supinatory, and axially directed load to the elbow. Simple elbow dislocations are soft tissue injuries without an associated fracture. Multiple reduction techniques are described with the patient in both supine and prone positions. The definitive management of a simple elbow dislocation is primarily nonoperative with a splint for 7–10 days and active mobilization as soon as the splint is removed. This protocol minimizes complications such as a joint contracture and hastens a return to pre-injury activities. Surgical indications include a persistently unstable elbow, joint incongruency, and/or an open injury. Operative management may involve exploration, lateral ligament repair or reconstruction, and assessment of the need for medial ligament repair or reconstruction. Ulnar nerve transposition is not routinely performed. Joint contracture is the most common complication of an elbow dislocation, and other complications such as heterotopic ossification and neurovascular injury occur less frequently. Chronic instability after a simple elbow dislocation is very uncommon. The mechanism of injury, initial evaluation, imaging, and a treatment algorithm for these injuries will be reviewed.

Management of Failed Rotator Cuff Repair in Young Patients

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Arthroscopic Distal Clavicle Resection

Arthroscopic distal clavicle resection is a commonly performed surgical treatment for acromioclavicular arthritis recalcitrant to conservative measures. The following describes the work-up, including physical examination and imaging, and surgical technique for both the direct and indirect approaches as well as the postsurgical care for these patients.