Thomas J. Neviaser

The frozen shoulder. Diagnosis and management.

The differentiation between the stiff and painful shoulder without any joint capsule involvement and with capsule involvement (true adhesive capsulitis) must be established before a rational treatment can be prescribed. Arthrography establishes the correct diagnosis of adhesive capsulitis. Treatment of the stiff and painful shoulder is through prevention and exercise. The treatment of adhesive capsulitis includes prevention, exercises, manipulation, and capsulotomy. Each treatment method is determined by specific criteria. Arthroscopy is not useful for either diagnosis or treatment of adhesive capsulitis but may be useful for recognition of the four stages of the disease.

Anterior Dislocation of the Shoulder and Rotator Cuff Rupture

Thirty-seven patients older than 40 years of age were seen after sustaining primary anterior dislocations of the shoulder. An associated rupture of the rotator cuff in each patient had been missed, often being mistaken for an axillary neuropathy. Eleven of these patients developed recurrent anterior instability that was due to rupture of the subscapularis and anterior capsule from the lesser tuberosity. In no patient was there a Bankart lesion. Repair of the capsule and subscapularis restored stability in all of the patients with recurrence.

The four-in-one arthroplasty for the painful arc syndrome.

The painful arc syndrome of the shoulder is a manifestation of rotator cuff tendinitis associated with tenosynovitis of the long head of the biceps under and just distal to the transverse humeral ligament. Eighty-nine patients with clinical signs of the painful arc syndrome were proven to have an associated biceps tenosynovitis by arthrography and at surgical treatment. The four-in-one arthroplasty consists of: (1) excision of the coracoacromial ligament; (2) acromioclavicular arthroplasty; (3) excision of the anterior inferior area of the acromion process; and (4) transfer and tenodesis of the long head of the biceps. The operation decompresses the acromial arch and also eliminates the biceps tenosynovitis by tenodesis. Almost invariably, there was relief of pain within four to five months of postoperative rehabilitation, and at an average follow-up of two to eight years.

Recurrent instability of the shoulder after age 40

Twelve patients who had recurrent instability of the shoulder with onset after age 40 were reviewed. Eleven had anterior instability, and one had a posterior dislocation. The average age of the patients was 62.7 years. Symptoms began soon after initial injury. All patients with anterior instability had ruptured the subscapularis and anterior capsule from the lesser tuberosity, whereas the posterior dislocator had torn the infraspinatus and upper teres minor with the posterior capsule from the greater tuberosity. No patient had a Bankart lesion. Stability was restored in all cases by reattaching the ruptured tendons and capsule to the tuberosities. Follow-up was from 2 to 13 years. One patient required a reoperation. All patients now have a stable shoulder. Recurrent instability of the shoulder after age 40 can be caused by rotator cuff and capsular rupture from the tuberosities without additional significant injury to the ligamentolabral complex. In such cases, repairing the torn structures is sufficient to restore stability.

Reoperation for failed rotator cuff repair: Analysis of fifty cases

Fifty patients who underwent reoperation for failure of previous repair of rotator cuff rupture were evaluated 24 to 84 months after final repair (mean 30 months). Forty-eight of these patients had undergone all previous attempts at repair elsewhere. Most patients had had one or two earlier attempts, but four patients had had three, and three patients had had four. Forty-six (92%) patients reported pain improvement, and four were unchanged. Twenty-six patients showed an average increase in elevation of 50° (range 10° to 130°). Twenty-two retained their preoperative motion, and two lost motion (mean 45°) but still had more than 90°. Overall mean elevation increased from 92° to 137°. Compared with 17 patients before surgery, only six had less than 90° motion after surgery-and all six had deltoid abnormalities. The size of the rupture, the number of previous operations, and dysfunction of the biceps did not affect the result. The following factors were associated with success: adequate decompression, closure of all defects with tendon-to-bone junctures (by direct repair, interpositional grafting, or local tendon transfers), avoiding use of weights or resistive exercises during the early (first 3 months) postoperative rehabilitation period, and an intact, functioning deltoid.

A Simple Technique for Internal of the Clavicle: A Long Term Evaluation

A simple, effective technique for internal fixation of the clavicle with Knowles threaded pins is described in 11 patients with 1 to 21 year results. The method is applicable to fresh fractures of non-union and provides secure compression-fixation. The threads prevent migration of the pin, reduce the period of external immobilization, and obviate the need for removal of the pin.

Observations on impingement

The combined interaction of four elements produces lesions of the rotator cuff, commonly known as impingement. The elements are: vascular, degenerative, traumatic, and mechanical or anatomic factors. The elements are interrelated, and each affects the tendons in a manner that contributes to tendon weakening. It is unlikely that any one element is solely responsible for cuff lesions; the nature of each lesion is determined by the factors that predominate in that individual case. The net result is degeneration of the tendons.