Bassem T. Elhassan

Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old.

BACKGROUND Soft-tissue resurfacing of the glenoid, with arthroplasty of the humeral head, has been proposed as a viable treatment option for younger patients with symptomatic osteoarthritis of the shoulder. The purpose of this study was to evaluate our results with soft-tissue resurfacing of the glenoid in patients with glenohumeral arthritis who were less than fifty years of age, as we were concerned that this type of procedure was leading to poor outcomes. METHODS Between 2000 and 2006, thirteen patients with an average age of thirty-four years underwent soft-tissue resurfacing of the glenoid and humeral head arthroplasty. Achilles tendon allograft was used in eleven patients; fascia lata autograft, in one; and anterior shoulder joint capsule, in one. Three patients had resurfacing of the humeral head with a stemless resurfacing implant, and ten patients had a hemiarthroplasty. The patients were followed for a minimum of two years or until failure, and the duration of follow-up averaged forty-eight months. The results were graded with a visual analog pain scale, the subjective shoulder value, and the Constant and Murley score. Radiographic review was performed in order to determine the degree of joint space loss and glenoid erosion. RESULTS Ten of the thirteen patients required a revision total shoulder arthroplasty at a mean of fourteen months (range, six to thirty-four months) postoperatively. The principal reasons for revision were persistent pain and a decreased range of motion. Radiographic evaluation at the time of the revision surgery demonstrated loss of joint space and glenoid erosion in all cases. At the revision surgery, the allograft was found to be absent, and thick scar tissue, which may have been a graft remnant, was found at the perimeter of the glenoid. Of the three patients who did not have a revision arthroplasty, one had good function, pain relief, and an improved range of motion; however, the postoperative course of the other two was complicated by infection. One of them had a salvage with early irrigation and débridement as well as intravenous antibiotics, whereas the other underwent resection arthroplasty because of persistent infection. CONCLUSIONS Soft-tissue resurfacing of the glenoid with an Achilles tendon allograft combined with humeral head arthroplasty is not a reliable method of treatment of glenohumeral arthritis in an active patient younger than fifty years of age, as the clinical outcome is poor. Moreover, we found no evidence that the graft acts as a durable bearing surface.

Results of Arthroscopic Capsulolabral Repair: Bankart Lesion Versus Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion

PURPOSE The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. METHODS This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences. RESULTS At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P = .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P < .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P > .05 for all). CONCLUSIONS Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Transfer of pectoralis major for the treatment of irreparable tears of subscapularis: DOES IT WORK?

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of pectoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

A comparison of single-versus double-row suture anchor techniques in a simulated repair of the rotator cuff: AN EXPERIMENTAL STUDY IN RABBITS

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process. A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks. The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012). The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.

Arthroscopic capsular release for refractory shoulder stiffness: A critical analysis of effectiveness in specific etiologies

HYPOTHESIS The purpose of this study is to report and compare the outcome of arthroscopic capsular release in patients with shoulder stiffness with post-traumatic, postsurgical, and idiopathic etiologies. We hypothesize that patients with idiopathic or post-traumatic stiffness have better outcomes after arthroscopic capsular release than those with shoulder stiffness with a postsurgical etiology. MATERIALS AND METHODS A retrospective review of 115 patients who underwent arthroscopic capsular release for refractory shoulder stiffness was performed. There were 60 men and 55 women with a mean age of 49 years (range, 27 to 81 years). The patients were divided into 3 groups according to the etiology of stiffness: post-traumatic (26 patients), postsurgical (48 patients), and idiopathic (41 patients). Arthroscopic capsular release was performed in all patients after a mean of 9 months of physical therapy (range, 6 to 13 months). RESULTS At a mean follow-up of 46 months (range, 25 to 89 months), the overall subjective shoulder value in all groups improved from 29% to 73% and the age- and gender-adjusted Constant score improved from 35% to 86%. The mean pain score decreased from 7.5 to 1, and mean active forward flexion, external rotation, and internal rotation increased from 97 degrees , 14 degrees , and the L5 vertebral level, respectively, to 135 degrees , 38 degrees , and the T11 vertebral level, respectively (P < .0001). There was no significant difference between the outcomes of idiopathic and post-traumatic stiffness (P = .7). However, the Constant score and subjective shoulder value were significantly lower in the postsurgical group compared with the idiopathic and post-traumatic groups (P = .0001 and P = .006, respectively). CONCLUSIONS Arthroscopic capsular release is an effective treatment for refractory shoulder stiffness. Patients with idiopathic and post-traumatic shoulder stiffness have better outcomes than patients with postsurgical stiffness.

Shoulder Tendon Transfer Options for Adult Patients With Brachial Plexus Injury

Enhancement of upper-extremity function, specifically shoulder function, after brachial plexus injury requires a good understanding of nerve repair and transfer, with their expected outcome, as well as shoulder anatomy and biomechanics enabling the treating surgeon to use available functioning muscles around the shoulder for transfer, to improve shoulder function. Surgical treatment should address painful shoulder subluxation in addition to improvement of function. The literature focuses on improving shoulder abduction, but improving shoulder external rotation should take priority because this function, even if isolated, will allow patients to position their hand in front of their body. With a functional elbow and hand, patients will be able to do most activities of daily living. The lower trapezius has been shown to be a good transfer to restore external rotation of the shoulder. Other parts of the trapezius, levator scapulae, rhomboids, and, when available, the latissimus dorsi, pectoralis major, teres major, biceps, triceps, and serratus anterior muscles can all be used to replace the rotator cuff and deltoid muscle function. To optimize the results, a close working relationship is required between surgeons reconstructing brachial plexus injury and shoulder specialists.

Trapezius transfer to restore external rotation in a patient with a brachial plexus injury. A case report.

Persistent shoulder paralysis after brachial plexus injury is a challenging and difficult problem to treat1,2. Deltoid and rotator cuff muscle recovery has been reported to be incomplete, resulting in loss of abduction and little to no external rotation3,4. The resulting muscle weakness leads to a “hand-on-belly” internally rotated position that limits positioning of the hand anterior to the coronal plane with elbow flexion. For patients who do not receive timely and successful nerve reconstruction, complete axillary and suprascapular nerve paralysis can result in painful inferior glenohumeral subluxation2. As the majority of periscapular muscles are generally paralyzed, there may be few functioning muscles about the shoulder available for tendon transfer. In these instances, upper trapezius transfer has been attempted to restore shoulder abduction, with variable results reported5-15. Transfers of the latissimus dorsi and/or teres major muscles, which have been described for the treatment of upper plexus (Erb-Duchenne pattern) palsy to improve external rotation and abduction, typically do not function with global injury6. The need to restore external rotation in particular is important because it enables the patient to position the hand away from the body, especially when elbow flexion has been restored. Despite the important need for external rotation, we know of no report describing external rotation transfers for patients with a complete brachial plexus palsy, especially for those who present late. We report the preliminary findings of a novel technique of transferring the middle and lower segments of the trapezius muscle, extended with a tendon allograft, to restore external rotation of the shoulder. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-five-year-old, right-hand-dominant man was seen with residual paralysis in the right shoulder eighteen …

Feasibility of latissimus and teres major transfer to reconstruct irreparable subscapularis tendon tear: an anatomic study.

BACKGROUND Several tendon transfers have been described to reconstruct irreparable subscapularis (SS) tears, but their outcomes are variable and unsatisfactory in the presence of anterior glenohumeral subluxation. We evaluated the anatomic feasibility of the latissimus dorsi (LD) or teres major (TM) muscle tendon transfer to reconstruct an irreparable SS tendon tear. MATERIALS AND METHODS The dimensions of the LD and TM tendons and the distance between their insertion and the SS tendon insertion were determined In 20 cadaveric shoulders. Feasibility of the isolated LD and TM tendon transfer to 3 locations on the SS tendon insertion, transfer of the LD to the proximal half, TM to the lower half of the SS tendon, and combined transfer of the LD/TM tendon to the central aspect of the SS tendon was assessed. RESULTS The LD and TM were an average length of 5.9 cm and 2.3 cm and an average width of 2.2 cm and 2.4 cm, respectively. The mean distances from the center of the LD and TM tendons insertion to the central aspect of the SS tendon insertion was 4.0 cm and 4.7 cm, respectively. All of the tendon transfers were feasible, and the risk of nerve compression was low, except for the combined tendon LD/TM transfer to the proximal third of the SS tendon. CONCLUSIONS This study shows that transfer of the LD/TM to the lesser tuberosity to reconstruct an irreparable SS tear is feasible, with a low risk of nerve compression, with the exception of the combined LD/TM and more proximal TM tendon transfers.

Open Versus Arthroscopic Acromioclavicular Joint Resection: A Retrospective Comparison Study

PURPOSE The purpose was to compare open and arthroscopic acromioclavicular joint (ACJ) resection. METHODS We retrospectively reviewed 103 patients (105 shoulders) who underwent ACJ resection between 2000 and 2005. There were 56 women and 47 men with a mean age of 48 years. The mean duration of follow-up was 51 months (range, 15 to 91 months). Arthroscopic ACJ resection by use of a direct approach was performed in 81 shoulders (group A), and open ACJ resection was performed in 24 shoulders (group B). Results were graded according to pain relief both subjectively and objectively with cross-body adduction testing and direct palpation of the ACJ, subjective shoulder value, Constant score, and improved function. RESULTS The Constant scores increased from 50 (range, 34 to 65) to 89 (range, 39 to 100) in group A (P < .0001) and from 46 (range, 22 to 63) to 87 (range, 43 to 100) in group B (P < .0001). There was no statistical difference in the postoperative normalized Constant score between group A and group B (P = .47). Pain with cross-body adduction testing and palpation of the ACJ improved in 76 shoulders (94%) in group A and 22 shoulders (92%) in group B. No patients had signs or symptoms of ACJ anteroposterior instability. Revision ACJ resection was performed in 5 patients (5 shoulders [6.2%]) in group A and 1 shoulder (4.2%) in group B (P = .37). The radiographs of the patients who underwent revision showed that 3 patients (3.7%) from group A had regrowth of the distal clavicle; in addition, 2 patients (2.5%) from group A and 1 patient (4.3%) from group B had incomplete distal clavicle excision. CONCLUSIONS This study did not show a significant difference in the outcome between arthroscopic and open ACJ resection. Incomplete excision and regrowth of the distal clavicle are the most common causes of revision. Although only the arthroscopic group showed a small percentage of patients (3.7%) with regrowth of the distal clavicle, the number is too small to assume that this complication is the result of the arthroscopic technique only. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Tendon Transfer Options About the Shoulder in Patients with Brachial Plexus Injury

BACKGROUND The purpose of this study was to evaluate the early outcome of shoulder tendon transfer in patients with brachial plexus injury and to determine the factors associated with favorable outcomes. METHODS Fifty-two patients with traumatic brachial plexus injury and a paralytic shoulder were included in the study. All patients were evaluated at a mean of nineteen months (range, twelve to twenty-eight months) postoperatively. Twelve patients had a C5-6 injury, twenty-two had a C5-7 injury, five had a C5-8 injury, and thirteen had a C5-T1 injury. Transfer of the lower portion of the trapezius muscle was performed either in isolation or as part of multiple tendon transfers to improve shoulder function. Additional muscles transferred included the middle and upper portions of the trapezius, levator scapulae, upper portion of the serratus anterior, teres major, latissimus dorsi, and pectoralis major. RESULTS All patients had a stable shoulder postoperatively. Shoulder external rotation improved substantially in all patients from no external rotation (hand-on-belly position) to a mean of 20° (p = 0.001). Patients who underwent additional transfers had marginal improvement of shoulder flexion, from a mean of 10° preoperatively to 60° postoperatively, and of shoulder abduction, from a mean of 10° to 50° (p = 0.01 for each). Mean pain on a visual analog scale improved from 6 points preoperatively to 2 points postoperatively. The mean Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 59 to 47 points (p = 0.001). The mean Subjective Shoulder Value improved from 5% to 40% (p = 0.001). Greater age, higher body mass index, and more extensive nerve injury were associated with a poorer DASH score in a multivariate analysis (p = 0.003). CONCLUSIONS Tendon transfers about the shoulder can improve shoulder function in patients with brachial plexus injury resulting in a paralytic shoulder. Significant improvement of shoulder external rotation but only marginal improvements of shoulder abduction and flexion can be achieved. The outcome can be expected to be better in patients with less severe nerve injury.