Darren J. Friedman

Proximal Biceps Tendon: Injuries and Management

The long head of the biceps tendon is a known pain generator of the shoulder. There are numerous pathologic entities that may affect this tendon, including tendonitis, partial tearing, and subluxation. These conditions are often associated with rotator cuff tears, especially those involving the subscapularis. Operative interventions include tenotomy and tenodesis. Tenodesis can be preformed in a proximal or distal location. Subpectoral tenodesis may have a lower recurrence rate than proximal-based techniques.

Suprascapular neuropathy in a shoulder referral practice.

HYPOTHESIS Suprascapular neuropathy (SSN) is considered a rare condition, and few studies have analyzed how commonly it is encountered in practice. Electrophysiologic studies are the gold standard for diagnosis; however, there is no consensus on diagnostic criteria. We hypothesized that SSN would be frequently diagnosed by electrophysiologic testing in a subset of patients with specific clinical and radiographic findings suggestive of the pathology. This study characterizes SSN in an academic shoulder referral practice and documents the electrodiagnostic findings that are currently being used to diagnose the condition. MATERIALS AND METHODS A retrospective review of a 1-year period was used to identify all patients who completed electrodiagnostic studies to evaluate the suprascapular nerve. Clinical exam findings and associated shoulder pathology was documented. The specific electromyography (EMG) and nerve conduction studies (NCS) findings were analyzed. RESULTS Electrodiagnostic results were available for 92 patients, and 40 (42%) had confirmed SSN. Patients with a massive rotator cuff tear were more likely to have an abnormal study than those without a tear (P = .006). The most common electrodiagnostic abnormalities were abnormal motor unit action potentials (88%), whereas only 33% had evidence of denervation. The average latency in studies reported as diagnostic of SSN was 2.90 ± 0.08 milliseconds for the supraspinatus and 3.78 ± 0.14 milliseconds for the infraspinatus. DISCUSSION An electrodiagnostically confirmed diagnosis of SSN was seen in 4.3% of all new patients and in 43% of patients with clinical or radiographic suspicion of SSN. Clinical evaluation may be difficult because other shoulder pathology can have overlapping symptoms. CONCLUSION Shoulder surgeons should consider electrophysiologic evaluation of patients with clinical or radiographic signs of SSN and be cognizant of the parameters that constitute an abnormal study.

Arthroscopic Single-Row Supraspinatus Tendon Repair With a Modified Mattress Locking Stitch: A Prospective, Randomized Controlled Comparison With a Simple Stitch

PURPOSE Our purpose was to compare the clinical results and failure rates of arthroscopic rotator cuff repair by use of a modified mattress locking stitch (MMLS) repair versus a simple stitch repair. METHODS Between December 2004 and January 2006, 78 cases of arthroscopically repaired full-thickness rotator cuff tears were evaluated prospectively. All tears were between 1.5 and 3 cm in size. The mean age of the patients was 53.4 years (range, 39 to 68 years), and the mean follow-up duration was 31.1 months (range, 24 to 37 months). Thirty-nine individuals underwent arthroscopic repair by use of an MMLS (group I). Thirty-nine individuals underwent arthroscopic repair by use of a simple stitch (group II). Postoperative visual analog scale scores for pain, scores for activities of daily living, and University of California, Los Angeles (UCLA) scores were obtained at a mean of 12 months (range, 6 to 36 months). We compared the results statistically by Mann-Whitney U test. In both groups magnetic resonance imaging scans were obtained at 6 to 36 months after repair. RESULTS Between groups, the visual analog scale scores for pain, scores for activities of daily living, and University of California, Los Angeles scores were not significantly different (P > .05 for all). Of the patients, 92.3% in group I and 89.7% in group II showed excellent or good results at the final follow-up (P > .05). The satisfaction rate was 94.9% (37 cases) in group I and 89.7% (34 cases) in group II (P < .05). Radiographic failure was seen in 6 of 36 cases in group I (16.7%) and 9 of 30 cases in group II (27.4%) (P < .05). CONCLUSIONS Arthroscopic repair of medium-sized (1.5- to 3-cm) full-thickness rotator cuff tears by use of an MMLS improves patient satisfaction rates and radiographic repair integrity in comparison to simple stitch repair. LEVEL OF EVIDENCE Level II, lesser-quality randomized controlled trial.

A Prospective Therapeutic Comparison of Simple Suture Repairs to Massive Cuff Stitch Repairs for Treatment of Small- and Medium-Sized Rotator Cuff Tears

PURPOSE The purpose of this study was to compare the massive cuff stitch (MCS) with the simple stitch in terms of integrity at 2 years after surgery when used to repair small-sized to medium-sized full-thickness rotator cuff tears. METHODS Seventy-one patients underwent arthroscopic repair of full-thickness rotator cuff tears between December 2004 and June 2006. The tear sizes ranged from 0.5 to 1.5 cm. The mean patient age was 53 years (range, 40 to 69 years), and the mean follow-up time was 33 months (range, 24 to 41 months). Group I (n = 35) underwent MCS repair, and group II (n = 36) underwent simple stitch repair. Results were analyzed by use of the Wilcoxon signed rank test and the Mann-Whitney test. Follow-up ultrasound was performed 24 to 41 months after repair. RESULTS All patients showed improvements in the visual analog scale for pain, activities of daily living, and University of California, Los Angeles scores (P < .05), but there were no significant differences in scores between groups (P > .05). The satisfaction rating was similar for group I (4.7) and group II (4.3) (P > .05). The failure (retear) rate was significantly lower in group I (14.3%) than in group II (27.8%) (P < .05). CONCLUSIONS The clinical outcomes between the MCS and simple stitch were not significantly different, but the MCS was superior to the simple stitch in maintaining repair integrity on ultrasound evaluation after arthroscopic repair of small-sized to medium-sized full-thickness rotator cuff tears. LEVEL OF EVIDENCE Level III, prospective therapeutic comparative study.

Triceps Tendon Ruptures: A Systematic Review

Background: Triceps tendon ruptures (TTR) are an uncommon injury. The aim of this systematic review was to classify diagnostic signs, report outcomes and rerupture rates, and identify potential predisposing risk factors in all reported cases of surgical treated TTR. Methods: A literature search collecting surgical treated cases of TTR was performed, identifying 175 articles, 40 of which met inclusion criteria, accounting for 262 patients. Data were pooled and analyzed focusing on medical comorbidities, presence of a fleck fracture on the preoperative lateral elbow x-ray film (Dunn-Kusnezov Sign [DKS]), outcomes, and rerupture rates. Results: The average age of injury was 45.6 years. The average time from injury to day of surgery was 24 days while 10 patients had a delay in diagnosis of more than 1 month. Renal disease (10%) and anabolic steroid use (7%) were the 2 most common medical comorbidities. The DKS was present in 61% to 88% of cases on the lateral x-ray film. Postoperatively, 89% of patients returned to preinjury level of activity, and there was a 6% rerupture rate at an average follow-up of 34.6 months. The vast majority (81%) of the patients in this review underwent repair via suture fixation. Conclusions: TTR is an uncommon injury. Risks factors for rupture include renal disease and anabolic steroid use. Lateral elbow radiographs should be scrutinized for the DKS in patients with extension weakness. Outcomes are excellent following repair, and rates of rerupture are low.

Atypical Pectoralis Major Muscle Wasting in a Recreational Weight Lifter

Pectoralis major injuries are relatively uncommon and can pose a diagnostic challenge. Deformity and weakness of this muscle in weight lifters is typically due to traumatic tendon rupture and often requires surgical repair. However, there are other less common etiologies that can mimic the clinical presentation of pectoralis major wasting and weakness that require different treatment approaches. This article describes a case of a 48-year-old recreational weight lifter who presented with severe pectoralis major wasting and weakness secondary to isolated mononeuropathy of the lateral pectoral nerve possibly due to Parsonage Turner syndrome. The patient was treated nonoperatively and achieved full recovery 18 months after onset. Parsonage Turner syndrome should be included in the differential diagnosis of patients with atraumatic weakness and wasting of the pectoralis major muscle and dysfunction. [Orthopedics. 2016; 39(4):e756-e759.].

The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States

BACKGROUND There is a growing population of patients with history of solid organ transplant (SOT) surgery among total joint patients. Patients with history of SOT have been found to have longer lengths of stay and higher inpatient hospital costs and complications rates after hip and knee arthroplasty. The purpose of this study was to determine whether this is true for shoulder arthroplasty in SOT patients. METHODS The Nationwide Inpatient Sample was queried to describe relative demographic, hospital, and clinical characteristics, perioperative complications, length of stay, and total costs for patients with a history of SOT (International Classification of Diseases-9th Edition-Clinical Modificiation V42.0, V42.1, V42.7, V42.83) undergoing shoulder arthroplasty (81.80, 81.88) from 2004 to 2014. RESULTS A weighted total of 843 patients (unweighted frequency = 171) and 382,773 patients (unweighted frequency = 77,534) with and without history of SOT, respectively, underwent shoulder arthroplasty. SOT patients were more often younger and more likely to be male, have Medicare, and undergo surgery in a large teaching institution in the Midwest or Northeast (P < .001). SOT patients had higher or similar comorbid disease prevalence for 27 of 29 Elixhauser comorbidities. The risk of any complication was significantly higher among SOT patients (15.5% vs. 9.3%, P = .007). SOT patients experienced inpatient admissions an average 0.27 days longer (P < .001) and

Prevalence of Cerebrovascular Events During Shoulder Surgery and Association With Patient Position

1103 more costly (P = .06) than non-SOT patients. CONCLUSIONS Patients with history of SOT undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization.