Mehmet Ugur Ozbaydar

Acromioclavicular joint injuries: diagnosis and management.

&NA; Acromioclavicular joint injuries represent nearly half of all athletic shoulder injuries, often resulting from a fall onto the tip of the shoulder with the arm in adduction. Stability of this joint depends on the integrity of the acromioclavicular ligaments and capsule as well as the coracoclavicular ligaments and the trapezius and deltoid muscles. Along with clinical examination for tenderness and instability, radiographic examination is critical in the evaluation of acromioclavicular joint injuries. Nonsurgical treatment is indicated for type I and II injuries; surgery is almost always recommended for type IV, V, and VI injuries. Management of type III injuries remains controversial, with nonsurgical treatment favored in most instances and reconstruction of the acromioclavicular joint reserved for symptomatic instability. Recommended techniques for stabilization in cases of acute and late symptomatic instability include screw fixation of the coracoid process to the clavicle, coracoacromial ligament transfer, and coracoclavicular ligament reconstruction. Biomechanical studies have demonstrated that anatomic acromioclavicular joint reconstruction is the most effective treatment for persistent instability.

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.

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.

Long-term results of conservative treatment for thoracolumbar compression fractures

OBJECTIVES We evaluated the radiologic and clinical outcomes of conservative treatment for thoracolumbar compression fractures. METHODS Forty-three patients (28 males, 15 females; mean age 39 years; range 24 to 54 years) were treated conservatively for 47 thoracolumbar compression fractures. All the patients were assessed by plain radiograms and computed tomography. According to the Denis classification, there were eight type A, 20 type B, 12 type C, and seven type D fractures. Involvement was at L1 in 30, L2 in five, and T12 in 12 fractures. There were no neurological deficits. Treatment involved use of a body cast for two months, followed by a thoracolumbosacral orthosis for four months. Radiographically, local kyphosis angle and sagittal index were measured before treatment, after casting, and at the final follow-ups. Pain and functional scales proposed by Denis et al. were also utilized. The mean follow-up was 7.5 years (range 6 to 11 years). RESULTS The mean local kyphosis angle and sagittal index were measured as 12.6 and 13.7 degrees before treatment, and 5.9 and 7.0 degrees after casting, respectively (p<0.05). However, both did not differ significantly from the baseline at the final measurements (12.7 and 13.9, respectively; p>0.05). The mean pain and functional scores were 1.4 and 1.6, respectively. Four patients had moderate to severe back pain despite mean kyphosis angles of 12 (baseline), 13.5 (after casting), and 14.8 (final). Two patients required substitution of the body cast for orthosis due to excessive sweating, and three patients received local treatment for skin problems secondary to the use of orthosis. CONCLUSION If the kyphosis angle is less than 30 degrees, compression fractures are supposed to be stable to be treated conservatively with satisfactory clinical results. Functional results seem to be unaffected from the fact that casting does not improve radiographic parameters in the long-term.

Scapulothoracic fusion for clavicular insufficiency. A report of two cases.

Scapulothoracic fusion is an uncommon procedure performed to stabilize the scapula to the chest wall. It is usually used to treat painful refractory winging of the scapula1-4, and it has been described principally in patients with fascioscapulohumeral muscular dystrophy, since tendon transfers in this population are usually unsuccessful2-8. Other indications include salvage of failed tendon transfer procedures to treat spinal accessory nerve palsy1,9,10 or long thoracic nerve palsy3,9-12. Additionally, disabling scapular winging secondary to loss of the medial clavicular strut support is a very rare indication that has not been reported previously. We report our experience with two patients in whom excision of the medial portion of the clavicle resulted in subsequent loss of scapular control and severe pain. Both patients were successfully managed with scapulothoracic fusion. Between 2000 and 2006, eight patients (ten shoulders) underwent scapulothoracic fusion at our institution. There were four men and four women, with a mean age of 38.4 years (range, nineteen to sixty-one years). The most common indications for surgery were refractory symptomatic scapular winging secondary to fascioscapulohumeral muscular dystrophy in five shoulders, anterior serratus muscle paralysis secondary to long thoracic nerve palsy in one shoulder, and trapezius muscle paralysis secondary to spinal accessory nerve injury in two shoulders. In two of the eight patients (two shoulders), the procedure was performed to treat symptoms following resection of the medial portion of the clavicle. The presentation of these two patients was markedly different from that of the other patients, and their degree of disability and pain was profound. We are not aware of any similar cases that have been published previously in the literature. The two patients were informed that data concerning the case would be …

Die arthroskopische Rekonstruktion der Rotatorenmanschette

ZusammenfassungDie arthroskopische Rekonstruktion der Rotatorenmanschette hat sich in den letzten Jahren zum Goldstandard entwickelt und ist heute die bevorzugte Methode zur Rekonstruktion der Rotatorenmanschette weltweit. Entscheidend für ein gutes postoperatives Ergebnis ist neben der Erfahrung des Operateurs und der richtigen arthroskopischen Technik, eine sorgfältige Patientenselektion und ein adäquates postoperatives Management. Werden diese Faktoren berücksichtigt, liegt die Erfolgsrate bei über 90%, basierend sowohl auf objektiven Kriterien als auch der subjektiven Patientenzufriedenheit. Das Ziel dieser Arbeit ist die Vermittlung der Indikationsstellung, der operativen Technik, der Nachbehandlung und der Ergebnisse bei arthroskopischer Rekonstruktion der Rotatorenmanschette.AbstractArthroscopic rotator cuff repair has become the gold standard, and is now accepted throughout the world as the method of choice, for rotator cuff repair. As well as an experienced surgeon and meticulously correct arthroscopic technique, careful patient selection and adequate postoperative management are of decisive importance if a good postoperative outcome is to be achieved. With due consideration for all these factors the success rate is over 90%, as measured not only with reference to objective criteria, but also by patients’ reports of their how satisfied they are with the result. This paper aims to report the indications, arthroscopic technique and postoperative protocol, and also the results of arthroscopic rotator cuff repair.