Deepak N. Bhatia

Prosthetic component relationship of the reverse Delta III total shoulder prosthesis in the transverse plane of the body

The Delta III (DePuy International Ltd, Leeds, UK) reverse total shoulder prosthesis has provided a successful functional outcome in cuff tear arthropathy (CTA); however, internal and external rotation remain compromised. Positioning of the prosthetic components in the transverse plane has theoretically been suggested to affect rotation. Twenty-seven patients who received a Delta III reversed total shoulder prosthesis for CTA were analyzed (mean follow-up, 43 months) using standard radiographs and computed tomography. The position of the prosthetic components and the possible influence of scapular rotation was analyzed using a uniform spatial reference system using axes in reference to the sagittal or coronal plane. We assessed impingement of the humeral component on the glenoid neck in neutral and internal rotation. An increase in the anterior divergence of the glenoid and humeral prosthetic components correlates with an increase in radiologically measured internal rotation (r = 0.932, P < .001). The uniformity of the reference system used seems to allow accurate positioning of the components intraoperatively and can be useful for analysis of the prosthetic component relationship postoperatively.

The “bench-presser’s shoulder”: an overuse insertional tendinopathy of the pectoralis minor muscle

Background: Tendinopathies of the rotator cuff muscles, biceps tendon and pectoralis major muscle are common causes of shoulder pain in athletes. Overuse insertional tendinopathy of pectoralis minor is a previously undescribed cause of shoulder pain in weightlifters/sportsmen. Objectives: To describe the clinical features, diagnostic tests and results of an overuse insertional tendinopathy of the pectoralis minor muscle. To also present a new technique of ultrasonographic evaluation and injection of the pectoralis minor muscle/tendon based on use of standard anatomical landmarks (subscapularis, coracoid process and axillary artery) as stepwise reference points for ultrasonographic orientation. Methods: Between 2005 and 2006, seven sportsmen presenting with this condition were diagnosed and treated at the Cape Shoulder Institute, Cape Town, South Africa. Results: In five patients, the initiating and aggravating factor was performance of the bench-press exercise (hence the term “bench-presser’s shoulder”). Medial juxta-coracoid tenderness, a painful active-contraction test and bench-press manoeuvre, and decrease in pain after ultrasound-guided injection of a local anaesthetic agent into the enthesis, in the absence of any other clinically/radiologically apparent pathology, were diagnostic of pectoralis minor insertional tendinopathy. All seven patients were successfully treated with a single ultrasound-guided injection of a corticosteroid into the enthesis of pectoralis minor followed by a period of rest and stretching exercises. Conclusions: This study describes the clinical features and management of pectoralis minor insertional tendinopathy, secondary to the bench-press type of weightlifting. A new pain site-based classification of shoulder pathology in weightlifters is suggested.

Direct Arthroscopy of the Bicipital Groove: A New Approach to Evaluation and Treatment of Bicipital Groove and Biceps Tendon Pathology

Assessment of the intra-articular and intertubercular regions of the long tendon of the biceps forms an important aspect of routine glenohumeral arthroscopic examination. We describe a new technique of direct visualization of the bicipital groove and tendon by positioning the arthroscope in linear alignment with the bicipital groove. A 4.5-mm cannula is introduced through a superior-medial (Neviaser) portal, into the glenohumeral joint, parallel and adjacent to the superior aspect of the biceps tendon, and is used as a viewing portal. The arm is then positioned in abduction, external rotation, and forward flexion, to align the groove with the arthroscope, thereby attempting to look down the groove. The biceps tendon, as well as the structures forming its medial and lateral pulleys, can be evaluated from the glenohumeral and intertubercular aspects. A greater length of the medial and lateral lips and the floor and roof of the bicipital groove can be visualized by advancing the arthroscope deeper within the groove. A fat pad along the lateral wall of the groove serves as an anatomic landmark to limit dissection in this region, thereby preventing damage to the anterolateral ascending branch of the anterior circumflex artery. An extension of this technique, to facilitate instrumentation for arthroscopic biceps tenodesis, is described.

The “Subscapularis-Sparing” Approach: A New Mini-Open Technique to Repair a Humeral Avulsion of the Glenohumeral Ligament Lesion

Anterior approaches to the shoulder involve partial or complete detachment of the subscapularis muscle. We have developed a new technique that permits adequate access to the humeral attachment of the inferior glenohumeral ligament (IGHL) without any detachment of the subscapularis, and have used this to successfully repair humeral avulsions of glenohumeral ligament lesions. Preliminary diagnostic arthroscopy using air insufflation of the glenohumeral joint is used to identify and grade the lesion. A 1-inch axillary incision is used to access the subscapularis tendon through the deltopectoral approach. Thereafter, anatomic landmarks are identified to expose the lateral aspect of the inferior border of the subscapularis muscle. Blunt dissection is used to separate the musculocapsular plane, and the subscapularis is retracted in an anterosuperior direction. Adequate exposure for visualization and repair of the avulsed IGHL is possible in a majority of cases where this approach is attempted. The use of arthroscopic instruments and suture anchors facilitates suture passage through the mid and posterior regions of the IGHL. If exposure is inadequate, the approach can be easily converted to a conventional L-shaped tenotomy approach through the lower or upper region of the subscapularis.

Shoulder injuries in rugby players

Glenohumeral joint The shoulder joint itself may be injured during a direct fall onto the shoulder or when the horizontally abducted arm is forced posteriorly (‘straight-arm tackle’). After an analysis of patients’ descriptions of their falls and close examination of video clips of rugby games, we have come to the conclusion that this specific mechanism may be one of the causes for the high frequency of bony lesions in shoulder instability of rugby players. Another frequent cause of anterior dislocation is when a player falls forward with the elbow flexed, and the elbow contacts the ground first; as the body falls forwards, the arm is forced posteriorly and this results in an anterior dislocation. Anterior dislocations with bone loss, resulting in engaging Hill-Sachs lesions with anteroinferior loss of the glenoid bone (‘inverted-pair glenoid’), are often seen in rugby. Simple Bankart lesions do not seem to be a frequent occurrence in rugby. HAGL (humeral avulsion of the glenohumeral ligaments) lesions are not uncommon in rugby. The mechanism is not entirely clear, but some players report that with the arm in forward elevation, an inferiorly directed force caused the onset of the pain and disability. It seems that in these players the mechanism causing the tearing of the inferior glenohumeral ligament may be an inferiorly directed force rather than the mechanism of abduction and external rotation. GLAD (glenolabral articular disruption) lesions occur commonly in rugby. The mechanism may be a direct fall onto the There has been an increase in the frequency and severity of shoulder injuries in rugby players in the recent years. This may be because the game has become more aggressive and intense and, over the years, the game has changed from being largely an amateur sport to one that is played at a professional level. Of equal importance is the fact that younger players are playing more competitively and aggressively, and there are specific injury patterns in these players with immature skeletal structures. Editorial

The "paraglider-wing" sign: an arthroscopic indicator of partial-thickness bursal-surface tears of the supraspinatus tendon.

Partial-thickness bursal-surface tears of supraspinatus tendon may be missed on preoperative investigations and can be overlooked at surgery if not specifically sought. The authors describe an arthroscopic sign to detect these tears, when they involve more than half the tendon fibres, from the articular-side of the joint. The “paraglider-wing” sign, visualized during diagnostic glenohumeral arthroscopy, is demonstrated as an upward bulge of the capsulo-tendinous layer through the bursal-surface tear, under pressure of the inflow fluid. A positive sign indicates (1) presence of a partial-thickness bursal-side tear of the supraspinatus tendon, (2) significant depth (stage II or III) of the tear, and (3) the medial extent of the tear along the length of the tendon. A meticulous subacromial bursoscopy and excision of the bursa is then performed to visualize the tear from the subacromial space. Repair of the tear is performed with a double-row suture anchor fixation technique; the medial row of sutures is passed through the intact region of the tendon using the “paraglider-wing” sign as a guide.

Shoulder surgeon and autologous cellular regeneration - From bench to bed: Part one- the link between the human fibroblast, connective tissue disorders and shoulder

The process of autologous cell regeneration (ACR) is a facet of cell therapy and regenerative medicine. It is initiated when activated autologous platelet rich plasma alone (PRP), containing cytokines or growth factors, is injected into the dermis or other structure in order to initiate a regenerative or antiaging process. The recipients resident cells at the target zone are activated by biologically active growth factors, derived from the activated platelets in the PRP through a paracrine effect. The platelet gel that contains the fibrin and clumped platelets, releases growth factors that influences activation of macrophages and stem cells in the recipient site. Tissue regeneration is facilitated by stem cell proliferation and differentiation. The PRP that has sealant and wound healing properties, may shift the wound healing cascade to the left, thereby speeding up tissue regeneration and remodelling by the use of the recipients own plasma. Both the fibroblast and myofibroblast play key roles in the wound healing cascade. The fibroblast, of mesenchymal origin, plays a pivotal role in the formation of the extracellular matrix and deposition of collagen. A failure of organised fibroblast function results in important and disabling disease processes and conditions such as chronic ischaemic heart disease and remodelling of the heart, lung fibrosis, fibromatosis, solar aged-face, keloids, hypertrophic scar formation, nodular fasciitis, inguinal hernia, Dupuytrens disease and scleroderma. More recent additions include frozen shoulder and the captured shoulder. In aesthetic medicine, one of the prime functions of fractional photothermolysis with lasers, intense pulsed light and radiofrequency devices, is to stimulate dermal fibroblast proliferation, by thermal energy thereby increasing collagen deposition which enhances facial rejuvenation. Platelet -rich plasma (REGENLAB PRP, REGENLAB-ACR) possesses unique growth factors that stimulate, fibroblast, keratinocyte and myoblasts ex vivo in tissue culture, allowing three-dimensional cell proliferation within the fibrin gel. PRP can be used as a cell carrier (i.e., keratinocytes, fibroblasts), may enhance cell retention at the point of treatment. REGENKIT is authorized for human use, ISO and CE marked. In this overview fibroblast morphology, tissue culture and cell biology relevant to the shoulder surgeon is reviewed.