Charles L. Getz

Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients

Pathology involving the long head of the biceps tendon is a common and significant cause of shoulder pain. For active patients with refractory biceps tendinosis, tenodesis of the tendon to either soft tissue or the humerus is the preferred surgical treatment. 2,7,9,11 Subpectoral biceps tenodesis to the humeral diaphysis with an interference screw has been gaining popularity as an effective method for treating biceps pathology, as clinical studies have demonstrated favorable outcomes with low rates of postsurgical complications with this technique. 8,14 This procedure involves drilling a cortical hole distal to the bicipital groove for placement of the tendon and bioabsorbable screw. 9 The size, depth, and location of this hole create a stress riser effect in the humerus, which previously was thought to be insignificant; however, several case reports exist in the literature describing postoperative fracture through the humeral drill hole. 3,4,16 This report presents 2 patients with postoperative humeral fractures involving the subpectoral tenodesis drill hole that occurred within 6 months of surgery. This finding suggests that this complication may be more prevalent in active patients than previously thought.

Mechanical properties of the long‐head of the biceps tendon are altered in the presence of rotator cuff tears in a rat model

Rotator cuff tears are disabling conditions that result in changes in joint loading and functional deficiencies. Clinically, damage to the long‐head of the biceps tendon has been found in conjunction with rotator cuff tears, and this damage is thought to increase with increasing tear size. Despite its importance, controversy exists regarding the optimal treatment for the biceps. An animal model of this condition would allow for controlled studies to investigate the etiology of this problem and potential treatment strategies. We created rotator cuff tears in the rat model by detaching single (supraspinatus) and multiple (supraspinatus + infraspinatus or supraspinatus + subscapularis) rotator cuff tendons and measured the mechanical properties along the length of the long‐head of the biceps tendon 4 and 8 weeks following injury. Cross‐sectional area of the biceps was increased in the presence of a single rotator cuff tendon tear (by ∼150%), with a greater increase in the presence of a multiple rotator cuff tendon tear (by up to 220%). Modulus values decreased as much as 43 and 56% with one and two tendon tears, respectively. Also, multiple tendon tear conditions involving the infraspinatus in addition to the supraspinatus affected the biceps tendon more than those involving the subscapularis and supraspinatus. Finally, biceps tendon mechanical properties worsened over time in multiple rotator cuff tendon tears. Therefore, the rat model correlates well with clinical findings of biceps tendon pathology in the presence of rotator cuff tears, and can be used to evaluate etiology and treatment modalities.

After rotator cuff tears, the remaining (intact) tendons are mechanically altered

Although presumed, damage in the remaining (intact) rotator cuff tendons in the presence of an isolated supraspinatus tendon tear or multiple tendon tear has not been well studied. This study used an animal model of multiple rotator cuff tendon tears to investigate alterations in the remaining (intact) tendon mechanical properties at 4 and 8 weeks after injury. Twenty-four rats served as uninjured controls, whereas 72 were divided among 3 tendon detachment groups: supraspinatus tendon detachment, supraspinatus + infraspinatus tendon detachment, and supraspinatus + subscapularis tendon detachment. The remaining (intact) rotator cuff tendons had decreased mechanical properties in the presence of rotator cuff tears. The remaining (intact) subscapularis and infraspinatus tendon cross-sectional areas increased, whereas tendon modulus decreased after tears of both 1 and 2 tendons. The remaining (intact) tendon cross-sectional areas continued to increase with time after injury. These alterations could potentially lead to further tendon damage and tear progression.

Polyethylene wear in retrieved reverse total shoulder components

BACKGROUND Reverse total shoulder arthroplasty has been used to treat rotator cuff tear arthropathy and proximal humerus fractures, as well as for failed conventional total shoulder prostheses. It has been suggested that polyethylene wear is potentially higher in reverse shoulder replacements than in conventional shoulder replacements. The modes and degree of polyethylene wear have not been completely elucidated. The purpose of this study was to evaluate polyethylene wear patterns in 7 specimens retrieved at revision arthroplasty and identify factors that may be associated with increased wear. METHODS Reverse total shoulder components were retrieved from 7 patients during revision arthroplasty for loosening and/or pain. Preoperative glenoid tilt and placement and scapular notching were evaluated by use of preoperative radiographs. Polyethylene wear was evaluated via micro-computed tomography and optical microscopy. RESULTS Wear on the rim of the polyethylene humeral cup was identified on all retrieved components. The extent of rim wear varied from a penetration depth of 0.1 to 4.7 mm. We could not show a correlation between scapular notching and rim wear. However, rim wear was more extensive when the inferior screw had made contact with the liner. Metal-on-metal wear between the humeral component and the inferior screw of 1 component was also observed. Wear of the intended bearing surface was minimal. DISCUSSION Rim damage was the predominant cause of polyethylene wear in our retrieved specimens. Direct contact between the humeral component and inferior metaglene screws is concerning because this could lead to accelerated ultra-highmolecular weight polyethylene wear and also induce mechanical loosening of the glenoid component.

Alterations in function after rotator cuff tears in an animal model

HYPOTHESIS This study examined the effect of multiple rotator cuff tendon tears on shoulder function in an animal model. MATERIALS AND METHODS Forty-eight Sprague-Dawley rats were divided into uninjured control, supraspinatus tendon detachment, supraspinatus+infraspinatus tendon detachment, or supraspinatus+subscapularis tendon detachment groups. Functional assessment was determined through ambulatory parameters (paw and stride measures) and range of motion prior to tendon detachment and at various time points after tendon detachment. RESULTS Ambulatory parameters and total range of motion, representing measures of shoulder function, were significantly altered with rotator cuff tears. The addition of a second torn rotator cuff tendon (infraspinatus or subscapularis)had further detrimental effects on animal shoulder function compared to uninjured control. DISCUSSION This study demonstrated functional changes in a rat rotator cuff model. Many of the permanent functional changes were likely present because the required motion used for those actions can no longer be performed. For parameters that were transient, compensation with another limb or subsidence of pain may have occurred. CONCLUSION The findings in this study are consistent with the alterations in shoulder function observed with rotator cuff and other shoulder injuries in the human. Future studies using this model can begin to examine the root of the functional differences, whether it is pain, mechanical deficiency, or a combination of both, which cannot be fully studied clinically [corrected].

What's new in shoulder and elbow surgery.

This annual update on shoulder and elbow surgery is based on a review of presentations at meetings of the Arthroscopy Association of North America (Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-fifth Annual Meeting, May 18 to 21, 2006, Hollywood, Florida), the American Shoulder and Elbow Surgeons (Twenty-second Open Meeting, Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-third Closed Meeting, September 13 to 15, 2006, Chicago, Illinois), The American Orthopaedic Society for Sports Medicine (Specialty Day, March 25, 2006, Chicago, Illinois), the American Academy of Orthopaedic Surgeons (Seventy-third Annual Meeting, March 22 to 25, 2006, Chicago, Illinois), and the Orthopaedic Research Society (Fifty-second Annual Meeting, March 19 to 22, 2006, Chicago, Illinois). ### Rotator Cuff #### Basic Science Park proposed a transosseous equivalent rotator cuff repair technique and performed a biomechanical study to evaluate footprint contact pressure in a variety of repair configurations. A “suture-bridging” technique utilizing medial anchors with suture limbs traversing over the cuff to a lateral interference screw attachment was compared with a double-row anchor repair. A four-limb suture bridge (two medial anchors with four limbs over the cuff laterally) established a significantly higher mean contact pressure area (72.3%) compared with a two-limb suture bridge (57.3%) and a double-row repair (35.1%) (p < 0.05). The authors concluded that increasing footprint contact pressure may aid in rotator cuff healing. #### Impingement Milano investigated the influence of acromioplasty on outcome following arthroscopic rotator cuff repair. Eighty patients were prospectively randomized into two groups, with half undergoing rotator cuff repair with acromioplasty and half undergoing rotator cuff repair without acromioplasty. The outcome measures that were evaluated were the Constant score and the Quick-DASH and Work-DASH self-administered questionnaires. Comparison between the two groups failed to demonstrate a significant difference at two years of follow-up. The authors concluded that acromioplasty does not affect the outcome of arthroscopic rotator cuff repair. …

Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with End-stage Shoulder Arthritis

BackgroundYoung patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment.Questions/purposesWe asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society?MethodsThe incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with “satisfactory” or “excellent” outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States.ResultsDuring the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient).ConclusionsTreatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old.Level of EvidenceLevel II, economic and decision analysis study.

Open Reduction and Internal Fixation of Distal Humerus Fractures

ABSTRACT The goal in the management of distal humerus fractures is to obtain rigid internal fixation that allows immediate rehabilitation of the extremity. The advent of anatomic plating systems as well a systematic approach to these injuries facilitates these goals. This article outlines our approach to these complex problems from injury through rehabilitation.

Prevalence of rotator cuff tears in operative proximal humerus fractures

Proximal humerus fractures and rotator cuff tears have been shown to have increasing rates with advancing age, theoretically leading to significant overlap in the 2 pathologies. The goal of this study was to examine the prevalence, associated factors, and effect on treatment of rotator cuff tears in surgically treated proximal humerus fractures. A retrospective review was performed of all patients who had surgery for a proximal humerus fracture from January 2007 to June 2012 in the shoulder department of a large academic institution. Patient demographics, the presence and management of rotator cuff tears, and surgical factors were recorded. Regression analysis was performed to determine which factors were associated with rotator cuff tears. This study reviewed 349 fractures in 345 patients. Of these, 30 (8.6%) had concomitant rotator cuff tears. Those with a rotator cuff tear were older (average age, 68.7 vs 63.1 years), were more likely to have had a dislocation (40% vs 12.5%), and were more likely to have undergone subsequent arthroscopic repair or reverse total shoulder arthroplasty than those without a rotator cuff tear. Most (22 of 30) were treated with suture repair at the time of surgery, but 5 patients underwent reverse total shoulder arthroplasty based primarily on the intraoperative finding of a significant rotator cuff tear. A concomitant rotator cuff tear in association with a proximal humerus fracture is relatively common. Rotator cuff tears are associated with older patients and those with a fracture-dislocation. In rare cases, these cases may require the availability of a reverse shoulder prosthesis.

Distal Biceps Tendon Repair: 1-Incision Versus 2-Incision Techniques

ABSTRACT Treatment options for distal biceps tendon ruptures include nonoperative and operative approaches. Candidates for conservative nonoperative management include elderly low-demand patients, those in whom surgery is contraindicated because of medical comorbidities, and those who are unable to adhere to the strict postoperative rehabilitation regimen. Data have clearly shown the superiority of operative over nonoperative management of these injuries. Currently, the most commonly used approaches are the 2-incision modified Boyd-Anderson approach and the limited 1-incision anterior approach. Transosseus suture fixation is typically combined with the 2-incision technique, whereas alternative fixation methods, such as the suture anchor or Endobutton techniques, are combined with the 1-incision technique. The clinical evidence reported in the literature to date does not support a clear single approach that should be used as the standard of care for distal biceps tendon ruptures. In fact, the data that are available show good to excellent results with both procedures and only relatively minor differences in outcomes. Thus, at this point in time, the decision of the technique to use for repair of these injuries should be based on surgeon preference, surgeon training, and comfort level with the approaches.