Theodore A. Blaine

Brachial Plexus Blocks for Upper Extremity Orthopaedic Surgery

Abstract Regional anesthesia of the upper extremity has several clinical applications and is reported to have several advantages over general anesthesia for orthopaedic surgery. These advantages, such as improved postoperative pain, decreased postoperative opioid administration, and reduced recovery time, have led to widespread acceptance of a variety of regional nerve blocks. Interscalene block is the most commonly used block for shoulder surgery. Other brachial plexus nerve blocks used for orthopaedic surgery of the upper extremity are supraclavicular, infraclavicular, and axillary. Several practical and theoretical aspects of regional nerve blocks must be considered to optimize the beneficial effects and minimize the risk of complications.

Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study.

BACKGROUNDnStemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S.nnnMETHODSnOne hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively.nnnRESULTSnOne hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components.nnnCONCLUSIONSnThe study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components.nnnLEVEL OF EVIDENCEnTherapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shoulder Injuries in Men’s Collegiate Lacrosse, 2004-2009

Background: Men’s lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no dedicated analysis of these injuries with which to better inform injury prevention strategies. Study Design: Descriptive epidemiology study. Methods: All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury Surveillance System for intercollegiate men’s lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome, and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to Poisson distribution. Results: There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707 shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries, with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring ≥10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season. Conclusion: Shoulder injuries are common in NCAA men’s lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve protective equipment and develop injury prevention.

Long Head Biceps Tenodesis With a Knotless Cinch Suture Anchor: A Biomechanical Analysis

PURPOSEnThe purpose of this study was to evaluate the initial fixation strength of 3 techniques of arthroscopic tenodesis of the long head of the biceps (LHB).nnnMETHODSnEighteen human cadaveric shoulders were randomly assigned to one of 3 simulated arthroscopic biceps tenodesis techniques-simple suture (SS), Krakow stitch (KS), or lasso loop (LL)-combined with a knotless fixation implant (3.5-mm Piton Anchor; Tornier, Minneapolis, MN). Biomechanical parameters were evaluated by cyclic loading and load to failure.nnnRESULTSnThe mean failure load (Pxa0= .007) was 158.3 ± 32.2 N, 109.8 ± 41.1 N, and 46.6 ± 3.8 N for the KS, SS, and LL techniques, respectively. Mean stiffness was greater (statistically significant) in the KS (21.4 ± 3.0 N/mm) and SS (20.7 ± 7.9 N/mm) treatment groups compared with the LL group (4.5 ± 1.5 N/mm) (Pxa0= .011).nnnCONCLUSIONSnBiceps tenodesis performed with a more secure tendon suturing technique, such as the Krakow technique, provides superior ultimate and fatigue strength and thus may be more secure in clinical application and yieldxa0better clinical results. The mechanical properties of the LL technique were especially poor in comparison.nnnCLINICAL RELEVANCEnAlthough more complex suturing techniques for arthroscopic biceps tenodesis can be technically challenging, more secure tendon fixation may improve clinical outcomes.

Shoulder impingement in the United States military

BACKGROUNDnLittle is known about the incidence and characteristics of primary, or external, shoulder impingement in an occupationally and physically active population. A longitudinal, prospective epidemiologic database was used to determine the incidence and risk factors for shoulder subacromial impingement in the United States (U.S.) military. Our hypothesis was that shoulder impingement is influenced by age, sex, race, military rank, and branch of service.nnnMETHODSnThe Defense Medical Epidemiology Database was queried for all shoulder impingement injuries using International Classification of Disease, Ninth Addition, Clinical Modification code 726.10 within a 10-year period from 1999 through 2008. An overall injury incidence was calculated, and a multivariate analysis performed among demographic groups.nnnRESULTSnIn an at-risk population of 13,768,534 person-years, we identified 106,940 cases of shoulder impingement resulting in an incidence of 7.77/1000 person-years in the U.S. military. The incidence of shoulder impingement increased with age and was highest in the group aged ≥40xa0years (incidence rate ratio [IRR], 4.90; 95% confidence interval [CI], 4.61-5.21), was 9.5% higher among men (IRR, 1.10, 95% CI, 1.06-1.13), and compared with service members in the Navy, those in the Air Force, Army, and Marine Corps were associated with higher rates of shoulder impingement (IRR, 1.46 [95% CI, 1.42-1.50], 1.42 [95% CI, 1.39-1.46], and 1.31 [95% CI, 1.26-1.36], respectively).nnnCONCLUSIONSnThe incidence of shoulder impingement among U.S. military personnel is 7.77/1000 person-years. An age of ≥40xa0years was a significant independent risk factor for injury.

Posterior Sternoclavicular Dislocations: A Brief Review and Technique for Closed Management of a Rare But Serious Injury

Posterior sternoclavicular dislocations are rare but serious injuries. The proximity of the medial clavicle to the vital structures of the mediastinum warrants caution with management of the injury. Radiographs are the initial imaging test, though computed tomography and magnetic resonance imaging are essential for diagnosis and preoperative planning. This paper presents an efficient diagnostic approach and effective technique of closed reduction of posterior sternoclavicular dislocations with a brief review of open and closed reduction procedures.

Factors Expressed in an Animal Model of Anteroinferior Glenohumeral Instability.

Background: There is little information on the molecular factors important in healing and changes that occur in the glenoid labrum in response to injury. Using a novel animal model of acute anterior shoulder dislocation, this study characterizes the factors expressed in the glenoid labrum in response to injury and correlates their expression to glenohumeral stability. Purpose: To study the response of the glenoid labrum to injury both biomechanically and with immunohistochemical testing. Methods: An injury to the anteroinferior labrum was surgically induced in 50 male Lewis rats. Rats were sacrificed at 3, 7, 14, 28, or 42 days. Immunolocalization experiments were performed to localize the expression of growth factors and cytokines. For biomechanical testing, dynamic stiffness for anterior and posterior laxity, load to failure, stiffness, and maximum load were recorded. Statistical differences were determined at P < .05. Study Design: Descriptive laboratory study. Results: Expression of interleukin–1 beta (IL-1β), transforming growth factor–beta 1 (TGF-β1), matrix metalloproteinase 3 (MMP3), and matrix metalloproteinase 13 (MMP13) were increased in injured compared with uninjured specimens. Collagen III expression was increased early and decreased with time. Biomechanical testing verified instability by demonstrating increased anterior displacement and decreased stiffness in injured shoulders at all time points. Conclusion: This novel animal model of acute anterior shoulder dislocation showed increased expression of IL-1β, TGF-β1, MMP3, MMP13, and collagen III in the injured labral tissue at early time points. Increased anterior laxity and decreased stiffness and maximum load to failure were seen after anterior labral injury, supporting the model’s ability to re-create anterior glenohumeral instability. These data provide important information on the temporal changes occurring in a rat model of anterior glenohumeral dislocation. Clinical Relevance: Identification of factors expressed in the anterior capsule and glenoid labrum in response to injury may lead to the development of novel agents that can be used to augment glenoid labrum healing and ultimately improve both surgical and nonsurgical treatment of this common shoulder injury.

Orthopaedic Injuries in Equestrian Sports A Current Concepts Review

Background: Despite the common nature of orthopaedic injuries in equestrian sports, there is no published review to specifically characterize orthopaedic injuries in equestrian athletes. Purpose: To characterize orthopaedic injury patterns in equine sports–related injuries and their treatment. Study Design: Systematic review; Level of evidence, 4. Methods: This review was performed through a PubMed, EMBASE, and Scopus query (from 1978 to June 2014) in the English literature using search terms “(equine-related OR equestrian-related OR horse-related OR equestrian OR equestrians) AND (injury OR injuries).” Only full-text studies reporting on orthopaedic injury patterns pertinent to equestrian sports in the United States (US) and the United Kingdom (UK) were included. Orthopaedic injuries were defined as those resulting in a fracture or dislocation. In all, 182 studies were excluded, leaving a total of 27 studies for evaluation. The studies included were analyzed for demographic and epidemiological data for orthopaedic injuries, including fractures and dislocations. Cranial and facial injuries were excluded from analysis. Results: The majority of those injured in the US were female (64.5%). The leading cause of injury in the US was falling from a horse. The use of protective equipment seemed to vary widely, with helmet use ranging from less than 6% up to 66.7%. In the UK, fractures were found to account for 17.4% of reported injures, compared with 33.6% of injuries in the US. The majority of fractures in US riders occurred in the upper extremities (50.7%). Conclusion: This review helps characterize the epidemiology of equestrian injuries based on currently available data.

Lateral Epicondylitis: An Internal Comparison in the Same Patient

Chronic lateral epicondylitis is a common painful condition affecting the elbow. Many treatments have been proposed to alleviate the pain. Surgical treatment options include open, arthroscopic, and percutaneous debridement techniques, while nonoperative modalities have traditionally included physical therapy, bracing, and cortisone injections. Platelet-rich plasma injections have recently gained popularity as an additional treatment option, with early reports of success in elite athletes. The largest study of platelet-rich plasma injections for treatment of lateral epicondylitis showed improvement by platelet-rich plasma compared to corticosteroid injections. This article presents a case of a 55-year-old right-hand-dominant woman with bilateral lateral epicondylitis refractory to multiple corticosteroid injections and physical therapy, treated with platelet-rich plasma injection in the right elbow and concomitant arthroscopic extensor carpi radialis brevis tendon release and debridement in the left elbow. At 4-month follow-up, her visual analog scale was 80/100 in the elbow receiving platelet-rich plasma compared to 10/100 on her operative side, and platelet-rich plasma treatment was considered a failure. The patient then underwent arthroscopic debridement of the right elbow for recalcitrant pain. At 1-year follow-up, both elbows were improved after operative treatment (visual analog scale 10/100 right and 0/100 left), consistent with several studies that have reported improvements from arthroscopic extensor carpi radialis brevis debridement as high as 95%. In our experience, arthroscopic extensor carpi radialis brevis debridement is a safe and efficacious method for treating chronic lateral epicondylitis. Further studies are required to define the role of platelet-rich plasma injections in the treatment of this condition.

Biologic treatments for shoulder pain

Shoulder pain is a common musculoskeletal complaint that can result from a variety of pathologic processes, including arthritis, bursitis and rotator cuff disease. Physicians often initiate treatment of shoulder pain with oral medications and progress to injectable medications for patients with more severe pain. Several promising new therapies for shoulder pain have emerged in recent years. These treatment modalities, which include cytokines, growth factors, platelet rich plasma, and stem cells, could provide physicians with powerful medications to treat patients with severe shoulder pain. This article provides a review of the biologic treatments available to physicians treating patients with shoulder pain and highlights some of the research and newest developments in the use of cytokines, growth factors, platelet rich plasma and stem cells for shoulder pathology.