Michael J. DeFranco

Posterior humeral avulsion of the glenohumeral ligament as a cause of posterior shoulder instability. A case report.

Traumatic forces applied to the shoulder during sports activities often result in glenohumeral instability. Frequently, the main reason for instability is the lack of soft-tissue restraint to the translation of the humeral head on the glenoid. Approximately 5% of the cases of glenohumeral instability have been reported to involve posterior instability of the shoulder1. Studies have shown that posterior instability has several soft-tissue-related etiologies, including capsulolabral detachment, capsular laxity, and rotator interval lesions1,2. Anterior avulsion of the humeral attachment of the glenohumeral ligaments has been shown to account for 7.5% (forty-one of 547) to 9.4% (six of sixty-four) of the cases of anterior instability3,4. To date, the case of one patient who was treated because of posterior humeral avulsion of the glenohumeral capsule has been reported in the orthopaedic literature and two series of such patients without reference to treatment have been reported in the radiology literature5,6. In the present report, we describe the case of a patient who had traumatic posterior glenohumeral instability secondary to humeral detachment of the posterior capsule and the posterior portion of the inferior glenohumeral ligament. Arthroscopic repair of this posterior lesion resulted in a successful outcome. Our patient was informed that data concerning the case would be submitted for publication. Anineteen-year-old, left-hand-dominant man presented to our clinic with a two-year history of intermittent clicking and pain in the left shoulder. The symptoms started after he sustained a blow to the anterior aspect of the left shoulder while trying to tackle another player during a high-school football game. The patient reported that the left shoulder had slipped out of place and then spontaneously returned to its normal position. Since then, he continued to experience intermittent clicking, pain, and “looseness” of the …

The floating shoulder.

Abstract The floating shoulder is an uncommon but important injury pattern. Although it is frequently defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligament disruption associated with a scapular neck fracture contributes to the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Determining the specific injury patterns indicates the potential for significant instability, and correlating these patterns with clinical outcome is a challenge. Because the degree of ligament disruption is difficult to assess on radiographs, indications for nonsurgical and surgical management are not well defined. Minimally displaced fractures typically do well with nonsurgical care. However, the degree of fracture displacement and ligament disruption that results in less predictable outcomes after nonsurgical treatment is uncertain, and the indications for surgery can be controversial. Internal fixation of a displaced clavicle fracture restores the contour of the shoulder, regulates soft‐tissue tension, and often indirectly reduces the scapular neck fracture. Fixation of both fractures is recommended in certain fracture patterns. Because these controversies cannot be resolved by current evidence, surgeons must choose an individualized approach based on an understanding of the pathoanatomy and personal experience.

New Therapies in Tendon Reconstruction

Despite the use of various types of grafts, no surgical treatment currently exists to restore a tendon to its normal condition. Tissue engineering techniques are being used to develop therapies for tendon reconstruction. Biologic and synthetic scaffolds can both repair tendon defects and improve healing by allowing for the regeneration of the tendons natural biologic composition to restore its mechanical capacity. This process can be further enhanced through augmentation methods such as cell seeding, growth factor implantation, and gene therapy.

Subscapularis Management in Open Shoulder Surgery

&NA; Management of the subscapularis in open shoulder surgery is a controversial topic. Subscapularis tenotomy has been the traditional approach, but other techniques have recently been developed to preserve the integrity of the subscapularis tendon. These include subscapularis peel, subscapularis split, and lesser tuberosity osteotomy. The biologic healing and biomechanical properties associated with each surgical approach must be evaluated to determine the best option for each patient. A strong, anatomic repair is required to achieve optimal clinical outcomes.

Natural Extracellular Matrix Grafts for Rotator Cuff Repair

The results of open or arthroscopic repair of the rotator cuff vary widely in the literature.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 The factors that have been shown to affect outcome relate to the technique of surgery,3,9,16, 17, 18 the size of the tear,9, 10, 11 the quality of the tissue and age of the patient,10,11,15 the chronicity of the tear,9, 10, 11,19,20 the degree of muscle atrophy, and the degree of tendon retraction.9, 10, 11,20 In many cases, the size of the tear is correlated with the degree of tendon retraction, muscle atrophy, and loss of tissue quality. Postoperative care influences outcome and is dependent upon the length and type of protection in the first 6 weeks after surgery,9,17,21 as well as the progression of the rehabilitation program from passive range of motion through active motion and resistance exercises. The larger and more chronic the tear, the more likely the patient will benefit from an abduction brace or pillow and a slower progression of the rehabilitation program.

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears in Active Patients Younger Than 40 Years: 2- to 5-Year Clinical Outcomes

This study characterized injury patterns and reported clinical outcomes of all-arthroscopic management of full-thickness rotator cuff tears among military patients younger than 40 years. A retrospective review was performed of prospective data for 42 patients younger than 40 years who underwent arthroscopic rotator cuff repair and, in some cases, concomitant labral repair. Preoperative and postoperative evaluations (minimum follow-up, 2 years; mean, 41 months; range, 24-66 months) included range of motion, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. Of the patients, 97.6% (41 of 42) had improved VAS, SST, and ASES scores. Mean VAS score improved from 8.09±1.51 to 1.19±1.85 (P<.01). Mean SSV improved from 47.88±19.56 to 89.45±14.04 (P<.01). Mean ASES score improved from 38.97±12.70 to 89.88±14.26 (P<.01). No difference for VAS, SSV, and ASES scores was noted between (1) all 42 patients, (2) the 26 patients who had rotator cuff repair but not labral repair, and (3) the 16 patients who had both rotator cuff repair and labral repair. Complications (7.1%; 3 of 42) included 2 postoperatively frozen shoulders and 1 retear of the rotator cuff. Of the patients, 95.2% (40 of 42) returned to their preoperative level of recreational and military job activity. Military patients younger than 40 years who have a full-thickness rotator cuff tear have a high prevalence of concomitant shoulder injury, especially labral tear. For patients younger than 40 years, arthroscopic rotator cuff repair, with or without labral repair, resulted in excellent clinical outcomes, a low risk of complications, and a high rate of return to the preoperative level of recreational and military job activity. [Orthopedics. 2018; 41(1):e52-e57.].