Andrew S. Neviaser

Adhesive capsulitis of the shoulder.

&NA; Adhesive capsulitis is characterized by painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule. Other shoulder pathology can produce a similar clinical picture, however, and must be considered. Management is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. Subtle clues in the history and physical examination can help differentiate adhesive capsulitis from other conditions that cause a stiff, painful shoulder. The natural history of adhesive capsulitis is a matter of controversy. Management of true capsular restriction of motion (ie, true adhesive capsulitis) begins with gentle, progressive stretching exercises. Most patients improve with nonsurgical treatment. Indications for surgery should be individualized. Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is a general guideline for surgical intervention. Diligent postoperative therapy to maintain motion is required to minimize recurrence of adhesive capsulitis.

Classification of proximal humeral fractures based on a pathomorphologic analysis

BACKGROUND The purpose of this study was to analyze the pathomorphology of proximal humeral fractures to determine relevant and reliable parameters for fracture classification. METHODS A total of 100 consecutive acute proximal humeral fractures in adult patients were analyzed by 2 non-independent observers from a single shoulder department using a standardized protocol based on biplane radiographs and 3-dimensional computed tomography scans. A fracture classification system based on the most reliable key features of the pathomorphologic analysis was created, and its reliability was tested by 6 independent shoulder experts analyzing another 100 consecutive proximal humeral fractures. RESULTS The head position in relation to the shaft (varus, valgus, sagittal deformity) and the presence of tuberosity fractures showed a higher interobserver reliability (κ > 0.8) than measurements for medial hinge, shaft, and tuberosity displacement, metaphyseal extension, fracture impaction, as well as head-split component identification (κ < 0.7). These findings were used to classify nondisplaced proximal humeral fractures as type 1, fractures with normal coronal head position but sagittal deformity as type 2, valgus fractures as type 3, varus fractures as type 4, and fracture dislocations as type 5. The fracture type was further combined with the fractured main fragments (G for greater tuberosity, L for lesser). Interobserver and intraobserver reliability analysis for the fracture classification revealed a κ value (95% confidence interval) of 0.700 (0.631-0.767) and 0.917 (0.879-0.943), respectively. CONCLUSION The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans.

Open Bankart repair for revision of failed prior stabilization: outcome analysis at a mean of more than 10 years

BACKGROUND The purpose of this study was to analyze the outcome of open Bankart repair for failed stabilization surgery at a mean follow-up of >10 years. MATERIALS AND METHODS Thirty patients underwent revision open Bankart repair by a single surgeon for failed prior stabilization surgery, with a standard technique and postoperative rehabilitation. All patients were referred by other surgeons. Evaluation was by an independent examiner, at a mean follow-up of 10.2 years. Evaluation included a history, physical examination for range of motion, outcome scores, recurrence, return to athletics, and radiographic examination. RESULTS All cases had persistent Bankart and Hill-Sachs lesions. Failures included 14 patients with a failed single arthroscopic Bankart repair; 1 patient with 2 failed arthroscopic Bankart repairs; 1 patient with an arthroscopic failure and an open Bankart repair; 7 patients with failed open Bankart repairs; and 1 patient with a failed open Bankart repair, then a failed arthroscopic attempt. Two patients had had thermal capsulorrhaphy; 2 others had staple capsulorrhaphy, 1 with an open capsular shift and 1 after a failed arthroscopic Bankart repair, an open Bankart repair, and then a coracoid transfer. All arthroscopic Bankart repairs had anchors placed medial and superior on the glenoid neck. Mean motion loss compared with the normal contralateral side was as follows: elevation 1.15°, abduction 4.2°, external rotation at the side 3.2°, external rotation in abduction 5.1°, and internal rotation 0.6 vertebral levels (NS). No patient had an apprehension sign, pain, or instability. Of 23 who played sports, 22 resumed after. Outcomes scores were as follows: American Shoulder and Elbow Surgeons, 89.44; Rowe, 86.67; Western Ontario Shoulder Instability Index, 476.26. On radiographic examination, there were 13 normal radiographs and 7 with mild, 2 with moderate, and 0 with severe arthritic changes. CONCLUSION The open Bankart repair offers a reliable, consistently successful option for revision of failed stabilizations.

Mid-term to long-term outcome of the open Bankart repair for recurrent traumatic anterior dislocation of the shoulder

BACKGROUND The purpose of this study was to assess the long-term outcome of the open Bankart repair for traumatic, recurrent anterior dislocation of the shoulder by evaluation of recurrence, range of motion, return to sports, arthritis, patient satisfaction, and outcome measures. METHODS Of 162 patients, 127 patients (mean age, 31 years) were evaluated at a mean follow-up of 17.1 years (5-24) after undergoing an open Bankart repair using suture anchors. An independent orthopedic surgeon obtained a history and examined each for range of motion. Radiographs for arthritis and osteolysis were obtained unless the patient refused. Questionnaires including return to sports and function as well as satisfaction and outcome measures were completed by all patients. RESULTS There was 1 recurrent dislocation (0.8%) and 1 recurrent subluxation (0.8%) but no pain or apprehension. All remaining shoulders were stable. Compared with the normal shoulder, there was statistical difference in external rotation in abduction and at the side as well as in internal rotation but not in forward elevation or abduction. However, no patient considered any measurable loss functionally significant. Of 107 patients who participated in sports, 98 returned to the sport; 7 of the remaining 9 discontinued for reasons other than the shoulder. There were 91 patients who agreed to radiography; 48 had normal findings, 34 had mild arthrosis, 9 had moderate arthrosis, and none had severe arthrosis. Mean postoperative outcome scores were as follows: American Shoulder and Elbow Surgeons, 93.53; Rowe, 91.41; and Western Ontario Shoulder Instability Index, 327.7. There were 125 patients who were satisfied and would undergo the procedure again. CONCLUSION The open Bankart procedure remains the standard by which other techniques can be measured for treatment of recurrent, traumatic anterior dislocation of the shoulder.

Enhancement of fracture healing in the rat, modulated by compounds that stimulate inducible nitric oxide synthase: Acceleration of fracture healing via inducible nitric oxide synthase.

Objectives We investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days. Materials and Methods Unilateral femoral osteotomies were created in 58 male rats and fixed with an intramedullary compression nail. Rats were treated daily either with vehicle, tadalafil or COMB-4. Biomechanical testing of the healed fracture was performed on day 42. The volume, mineral content and bone density of the callus were measured by quantitative CT on days 14 and 42. Expression of iNOS was measured by immunohistochemistry. Results When compared with the control group, the COMB-4 group exhibited 46% higher maximum strength (t-test, p = 0.029) and 92% higher stiffness (t-test, p = 0.023), but no significant changes were observed in the tadalafil group. At days 14 and 42, there was no significant difference between the three groups with respect to callus volume, mineral content and bone density. Expression of iNOS at day 14 was significantly higher in the COMB-4 group which, as expected, had returned to baseline levels at day 42. Conclusion This study demonstrates an enhancement in fracture healing by an oral natural product known to augment iNOS expression. Cite this article: R. A. Rajfer, A. Kilic, A. S. Neviaser, L. M. Schulte, S. M. Hlaing, J. Landeros, M. G. Ferrini, E. Ebramzadeh, S-H. Park. Enhancement of fracture healing in the rat, modulated by compounds that stimulate inducible nitric oxide synthase: Acceleration of fracture healing via inducible nitric oxide synthase. Bone Joint Res 2017:6:–97. DOI: 10.1302/2046-3758.62.BJR-2016-0164.R2.

The incidence of hypovitaminosis-D in hip fracture, a retrospective study

BackgroundHip fracture is a major and expanding problem faced by orthopaedic surgeons. Accepted risk factors for hip fracture include age, female sex, and osteoporosis. Emerging evidence suggests that hypovitaminosis-D, by contributing to osteoporosis, also may predispose to hip fracture. Despite this theorys obvious interest to orthopaedists, few related studies exist in the orthopaedic literature. MethodsWe hypothesized that most patients presenting to our institution with acute hip fracture would have suboptimal levels of vitamin-D, and we sought to identify the incidence of hypovitaminosis-D in this population. We undertook a retrospective chart review of 50 patients for whom vitamin-D levels were obtained after presenting to our institutions emergency department with acute hip fracture. Patients were stratified according to type of fracture, sex, and age. Standard statistical values were calculated. ResultsMost (80%) of the study population demonstrated insufficient (32%) or deficient (48%) levels of vitamin-D. ConclusionsInadequate vitamin-D likely is one of many interrelated risk factors for hip fracture. Further study and the attention of orthopaedists are indicated to detail the nature of this risk and to optimize interventions.

Open Repair of Severe Rotator Cuff Tears

For the purpose of this chapter, severe tears are defined as massive, acute tears that can be repaired or reconstructed. These are challenging and can be addressed via mini-open or open techniques. Ones that occur following a primary anterior dislocation often can be repaired acutely, while alternative techniques such as partial repairs, tendon transfers, and interpositional grafts may be necessary for those that cannot be restored to their original insertion. In addition to history and physical exam, MRI can be helpful preoperatively for planning which surgical approaches might be necessary.

Hemiarthroplasty for the Treatment of Proximal Humerus Fractures

Over the past decade, the indications for treating proximal humerus fractures with hemiarthroplasty have become more narrowed. Locking plates, reverse shoulder arthroplasty, and a better understanding of osteonecrosis have created a limited need for this procedure. Fractures which cannot be adequately reduced or in which adequate fixation cannot be achieved are candidates for joint replacement. Precise technique is required to produce good functional results. In inexperienced hand, outcomes are very inconsistent. This chapter reviews a method to achieve reliable results.