Matthew L. Ramsey

PLACEMENT OF PEDICLE SCREWS IN THE THORACIC SPINE. PART I: MORPHOMETRIC ANALYSIS OF THE THORACIC VERTEBRAE

We studied the morphology of the thoracic vertebrae in the spines of seventeen human cadavera in order to define parameters that could be used as guidelines for the placement of hooks and screws in the pedicles to obtain internal fixation. We also reviewed computerized tomographic scans of nineteen thoracic spines in living patients who had no evidence of any vertebral deformity. The transverse diameter of the pedicle, which helps to determine the size of the screw, ranged from a mean (and standard deviation) of 4.5 +/- 1.2 millimeters in the fourth thoracic vertebra to a mean of 7.8 +/- 2.0 millimeters in the twelfth thoracic vertebra. The pedicles were inclined anteromedially throughout the thoracic spine, and the angle ranged from 0.3 degree toward the midline in the twelfth thoracic vertebra to 13.9 degrees in the fourth thoracic vertebra. The morphometric data revealed wide variations in the dimensions of the pedicles, demonstrating the importance of accurate preoperative imaging with transaxial computerized tomographic scans to visualize the precise osseous margins and angles of insertion of the thoracic pedicles.

Prevalence and projections of total shoulder and elbow arthroplasty in the United States to 2015

HYPOTHESIS This study examined national trends and projections of procedure volumes and prevalence rates for shoulder and elbow arthroplasty in the United States (U.S.). This study hypothesized that the growth in demand for upper extremity arthroplasty will be greater than the growth in demand for hip and knee arthroplasty and that demand for these procedures will continue to grow in the immediate future. MATERIALS AND METHODS The Nationwide Inpatient Sample (1993-2007) was used with U.S. Census data to quantify primary arthroplasty rates as a function of age, race, census region, and gender. Poisson regression was used to evaluate procedure rates and determine year-to-year trends in primary and revision arthroplasty. Projections were derived based on historical procedure rates combined with population projections from 2008 to 2015. RESULTS Procedure volumes and rates increased at annual rates of 6% to 13% from 1993 to 2007. Compared with 2007 levels, projected procedures were predicted to further increase by between 192% and 322% by 2015. The revision burden increased from approximately 4.5% to 7%. During the period studied, the hospital length of stay decreased by approximately 2 days for total and hemishoulder procedures. Charges, in 2007 Consumer Price Index-adjusted dollars, increased for all 4 procedural types at annual rates of

Distal biceps tendon injuries: diagnosis and management

900 to

Efficacy of platelet-rich plasma for chronic tennis elbow: a double-blind, prospective, multicenter, randomized controlled trial of 230 patients.

1700. CONCLUSION The growth rates of upper extremity arthroplasty were comparable to or higher than rates for total hip and knee procedures. Of particular concern was the increased revision burden. The rising number of arthroplasty procedures combined with increased charges has the potential to place a financial strain on the health care system.

Arthroscopic capsular release for the treatment of refractory postoperative or post-fracture shoulder stiffness

Rupture of the distal biceps tendon occurs most commonly in the dominant extremity of men between 40 and 60 years of age when an unexpected extension force is applied to the flexed arm. Although previously thought to be an uncommon injury, distal biceps tendon ruptures are being reported with increasing frequency. The rupture typically occurs at the tendon insertion into the radial tuberosity in an area of preexisting tendon degeneration. The diagnosis is made on the basis of a history of a painful, tearing sensation in the antecubital region. Physical examination demonstrates a palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination. The ability to palpate the tendon in the antecubital fossa may indicate partial tearing of the biceps tendon. Plain radiographs may show hypertrophic bone formation at the radial tuberosity. Magnetic resonance imaging is generally not required to diagnose a complete rupture but may be useful in the case of a partial rupture. Early surgical reattachment to the radial tuberosity is recommended for optimal results. A modified two-incision technique is the most widely used method of repair, but anterior single-incision techniques may be equally effective provided the radial nerve is protected. The patient with a chronic rupture may benefit from surgical reattachment, but proximal retraction and scarring of the muscle belly can make tendon mobilization difficult, and inadequate length of the distal biceps tendon may necessitate tendon augmentation. Postoperative rehabilitation must emphasize protected return of motion for the first 8 weeks after repair. Formal strengthening may begin as early as 8 weeks, with a return to unrestricted activities, including lifting, by 5 months.

Hemiarthroplasty Versus Reverse Total Shoulder Arthroplasty for Acute Proximal Humerus Fractures in Elderly Patients

Background: Elbow tenderness and pain with resisted wrist extension are common manifestations of lateral epicondylar tendinopathy, also known as tennis elbow. Previous studies have suggested platelet-rich plasma (PRP) to be a safe and effective therapy for tennis elbow. Purpose: To evaluate the clinical value of tendon needling with PRP in patients with chronic tennis elbow compared with an active control group. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study. A successful outcome was defined as 25% or greater improvement on the visual analog scale for pain. Results: Patient outcomes were followed for up to 24 weeks. At 12 weeks (n = 192), the PRP-treated patients reported an improvement of 55.1% in their pain scores compared with 47.4% in the active control group (P = .163). At 24 weeks (n = 119), the PRP-treated patients reported an improvement of 71.5% in their pain scores compared with 56.1% in the control group (P = .019). The percentage of patients reporting significant elbow tenderness at 12 weeks was 37.4% in the PRP group versus 48.4% in the control group (P = .143). Success rates for patients at 12 weeks were 75.2% in the PRP group versus 65.9% in the control group (P = .104). At 24 weeks, 29.1% of the PRP-treated patients reported significant elbow tenderness versus 54.0% in the control group (P = .009). Success rates for patients with 24 weeks of follow-up were 83.9% in the PRP group compared with 68.3% in the control group (P = .037). No significant complications occurred in either group. Conclusion: No significant differences were found at 12 weeks in this study. At 24 weeks, however, clinically meaningful improvements were found in patients treated with leukocyte-enriched PRP compared with an active control group.Methods: A total of 230 patients with chronic lateral epicondylar tendinopathy were treated at 12 centers over 5 years. All patients had at least 3 months of symptoms and had failed conventional therapy. There were no differences in patients randomized to receive PRP (n = 116) or active controls (n = 114). The PRP was prepared from venous whole blood at the point of care and contained both concentrated platelets and leukocytes. After receiving a local anesthetic, all patients had their extensor tendons needled with or without PRP. Patients and investigators remained blinded to the treatment group throughout the study.

Defining functional shoulder range of motion for activities of daily living

Background: Arthroscopic capsular release is used to treat idiopathic adhesive capsulitis (frozen shoulder) that is refractory to nonoperative treatment or manipulation under anesthesia. The role of arthroscopic capsular release in the treatment of frozen shoulder after shoulder surgery or fracture is less clearly understood. The purposes of this study were to define the outcome of arthroscopic capsular release in the management of frozen shoulder after surgery or fracture and to compare these results with those of arthroscopic capsular release in the treatment of idiopathic frozen shoulder. Methods: We evaluated the results of arthroscopic capsular release in three different groups of patients with shoulder contracture refractory to nonoperative management and manipulation under anesthesia. The three groups consisted of patients who had an idiopathic frozen shoulder, shoulder stiffness after surgery, or shoulder stiffness after fracture. We evaluated pain, function, patient satisfaction, and range of motion in all three groups before and after the study treatment. Results: At a mean of twenty months (range, twelve to forty-six months) after the operation, fifty patients were available for assessment of function and range of motion of the involved shoulder. At the time of follow-up, each group had a significant improvement in the scores for pain, patient satisfaction, and functional activity as well as in the overall outcome score (p < 0.01). Comparison of the scores among the different groups revealed that all had a similar degree of improvement in range of motion of the involved shoulder, but patients with postoperative frozen shoulder had significantly (p < 0.05) lower scores for pain (p < 0.03), patient satisfaction (p < 0.004), and functional activity (p < 0.002) than did those with idiopathic or post-fracture frozen shoulder. Conclusions: Arthroscopic capsular release was as effective for improving range of motion in patients with postoperative contracture of the shoulder as it was in patients with idiopathic and post-fracture contracture. However, there was less improvement in the subjective scores for pain, function, and patient satisfaction in the postoperative group.

The floating shoulder: a biomechanical basis for classification and management.

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.

Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management.

INTRODUCTION The range of motion (ROM) in the wrist and elbow required for daily activities has been reported to be less than the normal anatomic ROM. This functional ROM has not been defined for the shoulder. Many shoulder outcome assessment tools use specific functional tasks of daily living to score functional results of treatment. This study quantified the total shoulder ROM required to perform the functional tasks of the American Shoulder and Elbow Surgeon (ASES), Simple Shoulder Test (SST), and University of Pennsylvania (U-Penn) Shoulder Score (PSS). MATERIALS AND METHODS The FASTRAK electromagnetic tracking system (Colchester, VT, USA) was used to test 40 shoulders in 20 volunteers with no shoulder pathology found on physical examination. Three sensors were used: 1 each on the T3 spinous process, the scapular spine, and the arm over the distal humerus. Subjects performed each functional task of the ASES, SST, and PSS while flexion, extension, abduction, adduction, external rotation, and internal rotation were recorded. RESULTS Average shoulder motions required to perform the 10 functional tasks were flexion, 121° ± 6.7°; extension, 46° ± 5.3°; abduction, 128° ± 7.9°; cross-body adduction, 116° ± 9.1°; external rotation with the arm 90° abducted, 59° ± 10°; and internal rotation with the arm at the side, 102° ± 7.7°. CONCLUSION Although attaining full motion is a reasonable goal of all shoulder treatment, our results indicate that less ROM is required to perform the functional tasks used in common outcome tools.

Periprosthetic shoulder infection in the United States: incidence and economic burden.

Background: The floating shoulder (ipsilateral fractures of the clavicular shaft and the scapular neck) is thought to be an unstable injury pattern requiring operative stabilization in most instances. This recommendation has been made with little biomechanical data to support it. The purpose of this study was to determine the osseous and ligamentous contributions to the stability of experimentally created scapular neck fractures in a cadaver model. Methods: Standardized scapular neck fractures were made in twelve fresh-frozen human cadaveric shoulders. Each specimen was mounted in a specially designed testing apparatus and secured to a standard materials testing device. In group 1 (six shoulders), resistance to medial displacement was determined following sequential creation of an ipsilateral clavicular fracture, coracoacromial ligament disruption, and acromioclavicular capsular disruption. In group 2 (six shoulders), resistance to medial displacement was determined following sequential sectioning of the coracoacromial and coracoclavicular ligaments. Results: The average measured force for all specimens (groups 1 and 2) after scapular neck fracture was 183 ± 3.3 N (range, 166 to 203 N). The addition of a clavicular fracture (group 1) resulted in an average measured force of 128 ± 10.5 N (range, 83 to 153 N), which corresponds to only a 30% loss of stability. Subsequent sectioning of the coracoacromial and acromioclavicular capsular ligaments yielded an average force of 126 ± 9.1 N (range, 114 to 144 N), a 31% loss of stability, and 0 N, a complete loss of stability, respectively. Sectioning of the coracoacromial and coracoclavicular ligaments after scapular neck fracture (group 2) resulted in an average force of 103 ± 8.4 N (range, 89 to 118 N), a 44% loss of stability, and 0 N, a complete loss of stability, respectively. Conclusions: Ipsilateral fractures of the scapular neck and the clavicular shaft do not produce a floating shoulder without additional disruption of the coracoacromial and acromioclavicular capsular ligaments. These and other unstable combined injury patterns are likely to be accompanied by substantial medial displacement of the glenoid fragment. Clinical Relevance: Operative stabilization of ipsilateral fractures of the scapular neck and the clavicular shaft may not be necessary in the absence of concomitant injury to the coracoacromial and acromioclavicular ligaments characterized by marked medial displacement.