Moira Devereaux

A systematic review and comprehensive classification of pectoralis major tears.

BACKGROUND Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult. MATERIALS AND METHODS Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification. RESULTS We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PMs bilaminar tendon. CONCLUSIONS A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research.

Subacromial morphometric assessment of the clavicle hook plate

BACKGROUND Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications. MATERIALS AND METHODS Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures. RESULTS Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens. CONCLUSIONS The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Improving the Rapid and Reliable Diagnosis of Complete Distal Biceps Tendon Rupture A Nuanced Approach to the Clinical Examination

Background: Diagnosis of complete distal biceps tendon rupture (DBTR) is frequently missed or delayed on clinical examination. No single clinical test, including MRI, has demonstrated 100% efficacy in assessing the integrity of the distal biceps tendon. Hypothesis: Combining 3 validated clinical tests for identifying complete rupture can maximize a true-positive diagnosis for complete DBTR without the need for confirmatory soft tissue imaging when performed in concert with other important factors from the history and clinical examination. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The hook test, the passive forearm pronation (PFP) test, and the biceps crease interval (BCI) test were applied in sequence in conjunction with a standard patient history and physical examination on 48 patients with suspected distal biceps tendon injuries. If results on all 3 special tests were positive for complete rupture, the patient was referred for surgical repair; diagnosis was confirmed intraoperatively. If results on all 3 special tests were negative, diagnosis was confirmed with soft tissue imaging and patients were managed nonoperatively. If results of the 3 tests were not in agreement, soft tissue imaging was used to clarify the disagreement and to confirm the diagnosis. Results: Thirty-five patients had unequivocal results based on history, physical examination, and special tests. Thirty-two tested in agreement positive for complete rupture, which were confirmed intraoperatively. Three tested in agreement negative, with subsequent imaging confirming partial rupture. Thirteen patients had equivocal special test results; soft tissue imaging suggested complete rupture in 10 and partial rupture in 3. Conclusion: Application in sequence of the hook test, the PFP test, and the BCI test results in 100% sensitivity and specificity when the outcomes on all 3 special tests are in agreement.

Bone tunnel fixation for repair of tibialis anterior tendon rupture

Atraumatic rupture of the tibialis anterior tendon is rare, and due to the mild nature of pain symptoms, affected patients often present weeks or months after rupture. Surgical management is advocated to restore function in active patients, and historically suture anchors have been the preferred method for repairing the ruptured tendon directly to bone. We present a case of acute, atraumatic tibialis anterior tendon rupture that was anatomically repaired using a novel application of a bone tunnel fixation technique. We describe the surgical procedure and the outcome measures used to evaluate post-operative results in this case.

Short-Term Effectiveness of Precut Kinesiology Tape Versus an NSAID as Adjuvant Treatment to Exercise for Subacromial Impingement: A Randomized Controlled Trial.

Objective:To compare the short-term effectiveness of precut kinesiology tape (PCT) to a nonsteroidal anti-inflammatory drug (NSAID) as adjuvant treatment to exercise physiotherapy in improving pain and function in patients with shoulder impingement. Design:Randomized, controlled assessor-blind parallel-design trial with 3 groups. Setting:Academic-community hospital. Patients:One hundred patients (mean age: 48 ± 12.3, 61 men, 39 women) with a diagnosis of subacromial impingement (SAI) syndrome were randomized to a treatment group from October 2009 to June 2012. Eighty-one patients completed the study. Interventions:Patients were randomized to one of the 3 treatment groups: PCT and Exercise (n = 33), NSAID and Exercise (n = 29), or Exercise only (n = 38) for a 4 session 2-week intervention with a registered physiotherapist. Main Outcome Measures:Numeric pain rating scales for pain at rest and pain with arm elevation, the Simple Shoulder Test (SST), and the Constant Score were assessed pretreatment and post-treatment. Results:A statistically significant reduction in pain at rest and pain with arm elevation, as well as improvement in SST and Constant Score were observed in all 3 treatment groups, with minimal clinically important differences shown on pain with elevation and SST scores. Between-group differences on all outcome measures were not statistically significant or clinically meaningful. Conclusions:The improvements in pain and function observed with an NSAID or PCT as adjuvant treatments were no greater than with rehabilitation exercise alone. If adjuvant treatment is desired, PCT seems to be better tolerated than an NSAID, although the difference did not reach significance. Clinical Relevance:The routine addition of adjuvant treatment is not supported by the results of this study. As adjuvant therapy, PCT seems to be better tolerated than an NSAID. If desired, clinicians may consider incorporating PCT along with an exercise component in the conservative treatment of SAI syndrome.

Kinesiology Tape Compared to NSAIDS in the Treatment of Rotator Cuff Impingement.

Objectives: To determine if kinesiology tape is as effective as nonsteroidal anti-inflammatory drugs (NSAIDS) when used as an adjunctive therapy to exercise at reducing pain and improving function in patients with rotator cuff impingement. Methods: A prospective, single-blind, randomized control trial was conducted. One hundred patients (average age: 48 ± 12.3, 61 males, 39 females) with a diagnosis of subacromial impingement syndrome were recruited and randomly assigned to one of three treatment groups: taping and exercise (n=33), NSAIDs and exercise (n=29), or exercise only (n=38). All patients completed a two-week (four sessions) exercise program guided by a registered physiotherapist. The physiotherapist applied the kinesiology tape to the patients in the taping and exercise group who wore the tape full time for an average of 3.5 days. Patients were assessed pre and post treatment by a research assistant who was blinded to each patient’s assigned treatment group. Patients were provided with a usage diary to record their compliance with the treatment protocol. Shoulder pain and function were assessed using a Numeric Pain Rating Scale, the Simple Shoulder Test (SST), and the Constant Score. Results: A significant improvement in pain with arm elevation, SST, and Constant Scores was observed in all the groups: taping and exercise group (1.2±2.5, 1.6±2.2, 7.8±8.1, respectively; p<0.05), NSAIDs and exercise group (2.1±2.4, 1.5±2.7, 11.0±11.7; respectively; p<0.05), and the exercise only group (1.3±2.6, 1.4±2.2, 6.3±10.9, respectively; p<0.05). A significant improvement in activities of daily living and functional arm level was observed in the taping and exercise group (0.8±1.2, 1.6±2.2 respectively; p<0.05) and the NSAIDS and exercise group (1.0±1.6, 0.8±2.0 respectively; p<0.05). Between-group differences were not statistically significant. Although all treatment groups showed a slight trend toward increased strength, the results were not significant. Patients were more compliant with the kinesiology tape (100%) than the NSAIDS treatment regime (84%). 88.5% of participants reported on average less than 2/10 discomfort with the tape. Conclusion: Kinesiology tape is as effective as NSAIDs as an adjuvant therapy to exercise at reducing shoulder pain and improving function in patients with subacromial impingement. Patients demonstrated increased compliance with the addition of kinesiology tape to an exercise program as compared to NSAIDS. Kinesiology tape appears to be well-tolerated and may prove to be a safer alternative to NSAIDs in the conservative treatment of shoulder impingement pain and dysfunction.

Economical and Efficacious Beach Chair Traction Positioning for Shoulder Arthroscopy

This study describes a modified beach chair technique that allows the application of continuous traction to the operative arm during arthroscopic shoulder surgery. The difference in costs for the equipment and resources, setup time, and overall procedure time for 33 cases performed using standard beach chair (SBC) positioning and 34 cases performed using a beach chair traction (BCT) technique was documented and compared. The incremental 1-time equipment setup cost for the BCT technique was

The Biceps Crease Interval for Diagnosing Complete Distal Biceps Tendon Ruptures

748 CDN, with an ongoing incremental cost of

The “bicipital aponeurosis flex test”: evaluating the integrity of the bicipital aponeurosis and its implications for treatment of distal biceps tendon ruptures

65 CDN per procedure. Setup time for the SBC group averaged 26±8 minutes compared with 28±8 minutes for the BCT group. The surgical procedure time was not significantly different and averaged 70±21 minutes for the SBC group and 65±17 minutes for the BCT group. The BCT technique produced a noticeable increase in both the glenohumeral and subacromial spaces by visual impression. The increased space resulted in improved scope of visualization and enhanced instrumentation maneuverability. This BCT technique combines the operative benefits of traction and lateral distraction during shoulder arthroscopy in the conventional and anatomically familiar beach chair position, with only minimal impact on cost and setup time.