Surena Namdari

Defining functional shoulder range of motion for activities of daily living

INTRODUCTIONnThe 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).nnnMATERIALS AND METHODSnThe 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.nnnRESULTSnAverage 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°.nnnCONCLUSIONnAlthough 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.

Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: A Systematic Review

BACKGROUNDnMassive and irreparable posterior-superior rotator cuff tears present a difficult treatment problem. The purpose of this systematic review was to critically examine the outcomes of latissimus dorsi tendon transfers for the treatment of irreparable rotator cuff tears.nnnMETHODSnA systematic review of the literature was performed via a search of electronic databases. Two reviewers independently assessed the methodological quality of, and extracted relevant data from, each included study. In cases in which the outcomes data were similar between studies, data were pooled for the purposes of generating summary outcomes through the use of frequency-weighted values.nnnRESULTSnTen studies that fulfilled all inclusion and exclusion criteria were included. The frequency-weighted mean age was 58.7 years. Patients were followed for a frequency-weighted mean of 45.5 months (range, twenty-four to 126 months). Patients had a frequency-weighted mean adjusted Constant score of 45.9 preoperatively compared with 73.2 postoperatively (p < 0.001). The frequency-weighted mean active forward elevation improved from 101.9° preoperatively to 137.4° postoperatively (p < 0.001), and the frequency-weighted mean active external rotation improved from 16.8° to 26.7° (p < 0.001). Subscapularis muscle insufficiency, advanced teres minor muscle atrophy, and the need for revision surgery were correlated with poor functional outcomes in some studies.nnnCONCLUSIONSnCompiled data and frequency-weighted means demonstrated improvement in shoulder function, range of motion, strength, and pain relief after latissimus dorsi tendon transfer for irreparable rotator cuff tears. Patients and physicians should not expect an outcome of normal function or complete pain relief.

Range of motion limitation after rotator cuff repair

HYPOTHESISnThis study was conducted to identify preoperative factors correlating with limited motion after rotator cuff repair (RCR) and to evaluate the affect of loss of motion on outcome. We hypothesized that patients with preoperative ROM loss, diabetes, and workmans compensation claims would exhibit postoperative ROM loss at 3 months.nnnMATERIAL AND METHODSnPreoperative and postoperative evaluations, including outcomes assessment and physical examination parameters, were reviewed for 345 patients who underwent RCR. Correlations between demographic, physical examination, and surgical variables and postoperative limitation of motion and need for capsular release were determined.nnnRESULTSnAt 3-month follow-up, mean active forward elevation (AFE), active external rotation (AER), and passive internal rotation (PIR) were 90%, 78%, and 80% of the contralateral side. Limitation of preoperative motion correlated with limitation of postoperative AFE, AER, and PIR (P < .001). Forty-seven patients considered clinically stiff were followed at 1 year postoperatively. Three patients required arthroscopic capsular release for persistent range of motion loss.nnnCONCLUSIONnEarly postoperative limitation of motion after RCR is associated with restricted preoperative motion. Other factors, including diabetes mellitus and workers compensation claim, are also associated with range of motion loss. Most shoulders with early motion loss recover motion and rarely require capsular release.

Fifty most cited articles in orthopedic shoulder surgery

BACKGROUNDnThe number of times an article has been cited has been used as a marker of its influence in a medical specialty. The purpose of this study was to determine the 50 most cited articles in shoulder surgery and their characteristics.nnnMETHODSnScience Citation Index Expanded was searched for citations of articles published in any of the 61 journals in the category Orthopedics. Each of the journals was searched to determine the 50 most often cited articles specific to shoulder surgery. The following characteristics were determined for each article: authors, year of publication, source journal, geographic origin, article type, and level of evidence for clinical articles. Citation density (total number of citations/years since publication) was also determined.nnnRESULTSnThe number of citations ranged from 1211 to 192. The 50 most often cited articles were published in 8 journals. The majority of the articles (42) were clinical, with the remaining representing some type of basic science research. The most common level of evidence was IV (23). The mean number of citations for methodologic articles (437 citations per article) was greater than that for non-methodologic articles (301 citations per article) (P = .034).nnnCONCLUSIONSnArticles that introduced instruments for outcome evaluation or that introduced classification systems (methodologic) were highly cited regardless of the date of publication. The top 50 list presented provides residency and fellowship directors with a group of classic articles in the subspecialty of orthopedic shoulder surgery that can be included in reading curriculums for their trainees.

Changes in the number of resident publications after inception of the 80-hour work week.

BackgroundSince the inception of resident work-hour regulations, there has been considerable concern regarding the influence of decreased work hours on graduate medical education. In particular, it is unclear whether implementation of work-hour restrictions has influenced resident academic performance as defined by quantity of peer-reviewed publications while participating in graduate medical education.Questions/purposesWe determined the impact of work-hour changes on resident involvement in the number of published clinical studies, laboratory research, case reports, and review articles.MethodsWe conducted a PubMed literature search of 139 consecutive orthopaedic surgery residents (789 total resident-years) at one institution from academic years 1995–1996 to 2008–2009. This represented a continuous timeline before and after implementation of work-hour restrictions. The number of resident publications before and after implementation of work-hour changes was compared.ResultsThere was a greater probability of peer review authorship in any given resident-year after work-hour changes than before. Average publications per resident-year increased for total articles, clinical articles, case reports, and reviews. There was an increased rate of publications in which the resident was the first author.ConclusionsSince implementation of work-hour changes, total resident publications and publications per resident-year have increased.

Recombinant bone morphogenic protein-2 in orthopaedic surgery: a review

Bone morphogenic proteins (BMPs) are pleiotropic regulators of bone volume, skeletal organogenesis and bone regeneration after a fracture. They function as signaling agents to affect cellular events like proliferation, differentiation and extracellular matrix synthesis. Clinically utilized rhBMP-2 combines rhBMP-2 with an osteoconductive carrier to induce bone growth and acts as a bone graft substitute. rhBMP-2, initially released in 2002, has been used primarily in spinal fusions in the lumbar and cervical regions. Recently, the application of rhBMP-2 has extended into the orthopedic trauma setting with increased application in open tibia fractures. This review outlines the history of development, molecular characteristics, toxicity and clinical applications.

Does obesity affect early outcome of rotator cuff repair

BACKGROUNDnObesity is linked to major health conditions and poor surgical outcomes. The impact of obesity on self-perceived outcome after rotator cuff repair (RCR) is unclear.nnnMATERIALS AND METHODSnWe studied 154 patients who underwent RCR. Obesity was considered a body mass index (BMI) greater than 30. Preoperative and postoperative evaluations included the Disabilities of the Arm, Shoulder and Hand (DASH), Simple Shoulder Test, and visual analog scales for pain, function, and quality of life. Obese and control patients were compared for baseline demographics, surgical findings, and postoperative outcomes.nnnRESULTSnOur overall population had a mean BMI of 28.4 (95% confidence interval, 27.7-29.1). There were 57 obese patients (BMI >30) and 97 nonobese patients with 1- or 2-tendon rotator cuff tears. Mean follow-up was 54.8 weeks (range, 52.0-88.7 weeks). Preoperative DASH score was 45.2 for obese patients and 43.4 for control patients (P = .524). The mean improvement in DASH score was 30.7 for obese patients and 26.1 for nonobese patients (P = .152). There were no significant differences in the Simple Shoulder Test and visual analog scale scores. Worse follow-up DASH scores in both groups were associated with workers compensation status (P = .003) and total comorbidities (P < .001). Multiple linear regression analysis showed that BMI (continuous) and obesity (dichotomous) were not significantly related to outcome after we controlled for confounding variables.nnnCONCLUSIONSnAlthough obesity is considered a risk factor for poor postoperative outcomes after some surgical procedures, in our experience, obesity does not have an independent, significant effect on self-reported early outcomes after RCR.

Myotendinous lengthening of the elbow flexor muscles to improve active motion in patients with elbow spasticity following brain injury

BACKGROUNDnThe objective of this study was to evaluate the outcomes of a novel technique of fractional myotendinous lengthening of the elbow flexors in patients with volitional motor control and spastic elbow flexion deformities after brain injury.nnnMETHODSnA retrospective review of 42 consecutive patients with spastic elbow flexion deformities and upper motor neuron (UMN) syndrome was performed. Each patient had volitional motor control but limited elbow extension and underwent myotendinous lengthening of the elbow flexor muscles. Outcome measures included pre and post-operative active and passive arc of motion, Modified Ashworth Scale (MAS) of spasticity, and complications.nnnRESULTSnThere were 26 men and 16 women. The etiologies of UMN syndrome were stroke (30 patients), traumatic brain injury (11 patients), and cerebral palsy (1 patient). Average duration between injury and surgery was 6.6 years. At an average follow-up of 14 months, improvements were noted in active extension (42° to 20°; P < .001). In addition, active arc of motion increased from 77° (range of motion [ROM]: 42° to 119°) to 113° (ROM: 20° to 133°) (P < .001) and passive arc of motion increased from 103° (ROM: 24°-127°) to 131° (ROM: 8°-139°) (P < .001). Significant improvement in MAS was also noted after surgery (2.7 to 1.9; P < .001). Superficial wound dehiscence occurred in 2 patients and was successfully treated nonoperatively.nnnCONCLUSIONnIn patients with spastic elbow flexion deformities and active motor control, fractional myotendinous lengthening of the elbow flexors safely improves active extension and the overall arc of motion while affording immediate postoperative elbow motion.nnnLEVEL OF EVIDENCEnLevel IV, Case Series, Treatment Study.

Limb Salvage After Infected Knee Arthroplasty With Bone Loss and Extensor Mechanism Deficiency Using a Modular Segmental Replacement System

Multiple total knee arthroplasty revisions pose significant surgical challenges, such as bone loss and soft tissue compromise. For patients with bone loss and extensor mechanism insufficiency after total knee arthroplasty, arthrodesis is a treatment option for the avoidance of amputation. However, arthrodesis is both difficult to achieve in situations with massive bone loss and potentially undesirable due to the dramatic shortening that follows. Although intramedullary nailing for knee arthrodesis has been widely reported, this technique has traditionally relied on the achievement of bony union. We report a case of a patient with massive segmental bone loss in which a modular intercalary prosthesis was used for arthrodesis to preserve limb length without bony union.

Primary Total Joint Arthroplasty Performed in Operating Rooms Following Cases of Known Infection

No study has examined infection rates in clean cases following dirty cases. This study evaluated patients undergoing elective primary total joint arthroplasties performed in operating rooms following cases of known infection for development of postoperative infection. A retrospective review of all elective primary total joint arthroplasties performed over a 5-year period at our institution was conducted. Patients who underwent primary total joint arthroplasties that followed cases of known infection in the same operating room were examined (minimum follow-up of 1 year) to determine the occurrence of infection based on culture data and subsequent procedures. Thirty-nine total joint arthroplasties (27 total knee arthroplasties and 12 total hip arthroplasties) in 35 patients were performed following cases of known infection in the same operating room. Of these patients, 1 (2.6%) developed a periprosthetic joint infection. The infecting organism (Propionibacterium acnes) was the same as that isolated from the preceding dirty case. Further investigation is necessary to determine whether performing primary total joint arthroplasties immediately following dirty cases increases risk of infection.