Wayne Z. Burkhead

Occult cervical spine injuries in fatal traffic accidents.

Post-mortem radiographs as well as careful inspection at autopsy of 100 consecutive traffic accident victims revealed an incidence of cervical spine injury of 24%. All but four of the 24 fractures and/or dislocations were localized to the level between the occiput and the axis. One half of the cases were not clinically suspected of having spine injuries before the detailed postmortem search. Seventeen of the 24 cervical spines were resected en bloc and the pathologic anatomy of the injuries was determined. The high incidence of cervical spine injuries and the anatomic findings at dissection have clinical implications for physicians who manage multiply traumatized patients. The need for immobilization and early radiographic evaluation of patients with cervical spine injuries is emphasized.

Nonoperative treatment of rotator cuff tears.

Rotator cuff tears and subacromial impingement are second only to acromioclavicular joint disorders as the most common causes of shoulder pain. Although most orthopedic surgeons are willing to initially treat shoulder impingement syndrome conservatively, they are reluctant to manage rotator cuff tears-especially full-thickness tears-nonoperatively. The purpose of this article is to explain the biomechanical rationale of nonoperative treatment, review the literature pertaining to nonoperative treatment of full-thickness rotator cuff tears, and describe a nonoperative treatment program.

The rotator cuff-deficient arthritic shoulder: diagnosis and surgical management.

&NA; The symptomatic rotator cuff‐deficient, arthritic glenohumeral joint poses a complex problem for the orthopaedic surgeon. Surgical management can be facilitated by classifying the disorder in one of three diagnostic categories: (1) rotator cuff‐tear arthropathy, (2) rheumatoid arthritic shoulder with cuff deficiency, or (3) degenerative arthritic (osteoarthritic) shoulder with cuff deficiency. If it is not possible to repair the cuff defect, surgical management may include prosthetic arthroplasty, with the recognition that only limited goals are attainable, particularly with respect to strength and active motion. Glenohumeral arthrodesis is a salvage procedure when other surgical measures have failed. Arthrodesis is also indicated in patients with deltoid muscle deficiency. Humeral hemiarthroplasty avoids the complications of glenoid loosening and is an attractive alternative to arthrodesis, resection arthroplasty, and total shoulder arthroplasty. The functionally intact coracoacromial arch should be preserved to reduce the risk of anterosuperior subluxation. Care should be taken not to “overstuff” the glenohumeral joint with a prosthetic component. In cases of significant internal rotation contracture, subscapularis lengthening is necessary to restore anterior and posterior rotator cuff balance. If the less stringent criteria of Neers “limited goals” rehabilitation are followed, approximately 80% to 90% of patients treated with humeral hemiarthroplasty can have satisfactory results.

The radiographic study in the relationship of the glenohumeral joint

Accurate reproduction of anatomic relationship is important in non‐constrained prosthetic arthroplasty. The accurate lateral glenohumeral offset, which indicates a parameter of the lever arm of the deltoid and supraspinatus muscles, is one of the most important elements in achieving the efficient shoulder functions after prosthetic reconstruction. However, to our knowledge, there has been no detailed study on the influence of minute changes in the neck shaft angle, within the normal range, on lateral glenohumeral offset. In this study, we evaluated the relationship between the neck shaft angle and various geometric measurement values in the glenohumeral joint.

A novel double-row rotator cuff repair exceeds strengths of conventional repairs.

Double-row rotator cuff repairs are becoming popular because of their ability to improve initial ultimate failure load for full-thickness rotator cuff tears, especially in middle-aged to elderly patients. We hypothesized a quasi-double-row repair using a combination of transosseous sutures, anchors, and double knots (TOAK technique) would exceed the clinically relevant 250-N load threshold and the initial mean ultimate failure loads of anchor-only and transosseous suture-only fixation. In simulated full-thickness supraspinatus tears in cadavers (mean age, 62 years; range, 50-77 years), failure loads of two repair techniques were compared with a TOAK repair using sutures and bioabsorbable anchors. Radiographic densitometry was conducted on all humeral heads. Testing was performed at 6 mm per minute in 18 bones in the following three groups (n = 6 per group): (1) transosseous suture-only with weave-type stitch and single-knot fixation; (2) anchor-only with horizontal mattress stitch and single-knot fixation; and (3) TOAK. The mean ultimate failure load was 238 N for the transosseous suture-only group and 215 N for the anchor-only group. Although the bones had lower density, TOAK specimens failed at 55% to 67% higher loads (mean, 404 N) than the other groups. These data support further evaluation of the TOAK technique for full-thickness supraspinatus tears in middle-aged to elderly patients.

Tendon ruptures about the shoulder.

Although degeneration and strain of musculotendinous structures are frequent causes of shoulder pain, sudden violent injuries in young individuals can lead to complete musculotendinous ruptures. Some of these conditions lend themselves well to nonoperative treatment. This article will enable the physician to determine the clinical diagnosis and formulate a treatment plan for each patient as an individual. Some patients may be satisfied with an accurate diagnosis only, while others demand more aggressive operative care.

TECHNIQUE FOR REPAIR OF THE SUBSCAPULARIS TENDON

Patients with sudden loss of active motion after an external rotation or hyperextension injury should be viewed with a high index of suspicion for a subscapularis tear. Exaggerated external rotation and the presence of a positive lift off or belly press test on physical examination combined with appropriate imaging studies will lead to an early diagnosis. Careful surgical repair combined with a thoughtful rehabilitation program will lessen both the length and degree of disability from this clinical entity.

Radiographic morphometry and densitometry predict strength of cadaveric proximal humeri more reliably than age and DXA scan density.

Methods are needed for identifying poorer quality cadaver proximal humeri to ensure that they are not disproportionately segregated into experimental groups for fracture studies. We hypothesized that measurements made from radiographs of cadaveric proximal humeri are stronger predictors of fracture strength than chronological age or bone density values derived from dual‐energy x‐ray absorptiometry (DXA) scans. Thirty‐three proximal humeri (range: 39–78 years) were analyzed for: (1) bone mineral density (BMD, g/cm2) using DXA, (2) bulk density (g/cm3) using DXA and volume displacement, (3) regional bone density in millimeters of aluminum (mmAl) using radiographs, and (4) regional mean (medial+lateral) cortical thickness and cortical index (CI) using radiographs. The bones were then fractured simulating a fall. Strongest correlations with ultimate fracture load (UFL) were: mean cortical thickness at two diaphyseal locations (ru2009=u20090.71; pu2009<u20090.001), and mean mmAl in the humeral head (ru2009=u20090.70; pu2009<u20090.001). Weaker correlations were found between UFL and DXA‐BMD (ru2009=u20090.60), bulk density (ru2009=u20090.43), CI (ru2009=u20090.61), and age (ru2009=u2009−0.65) (p values <0.01). Analyses between UFL and the product of any two characteristics showed six combinations with r‐values >0.80, but none included DXA‐derived density, CI, or age. Radiographic morphometric and densitometric measurements from radiographs are therefore stronger predictors of UFL than age, CI, or DXA‐derived density measurements.

Reusing Cadaveric Humeri for Fracture Testing After Testing Simulated Rotator Cuff Tendon Repairs

Abstract The financial cost of using human tissues in biomedical testing and surgical reconstruction is predicted to increase at a rate that is disproportionately greater than other materials used in biomechanical testing. Our first hypothesis is that cadaveric proximal humeri that had undergone monotonic failure testing of simulated rotator cuff repairs would not differ in ultimate fracture loads or in energy absorbed to fracture when compared to controls (i.e., bones without cuff repairs). Our second hypothesis is that there can be substantial cost savings if these cadaveric proximal humeri, with simulated cuff repairs, can be re-used for fracture testing. Results of fracture tests (conducted in a backwards fall configuration) and cost analysis support both hypotheses. Hence, the bones that had undergone monotonic failure tests of various rotator cuff repair techniques can be re-used in fracture tests because their load-carrying capacity is not significantly reduced.

Transosseous Anchor Double Knot (TOAK) Technique for Rotator Cuff Repair

Since the time of Codman, surgeons have sought to provide a secure surgical construct for the repair of rotator cuff tears that allows both structural healing and improvement in function. With advancements in suture materials and suturing techniques, numerous peerreviewed reports have documented the improved outcomes in patients who maintain a diagnostically proven, structurally intact tendon repair at long term followup. Gerber et al reported a significantly reduced failure rate in massive rotator cuff repairs, from 74% to 34%, with the use of modified Mason–Allen sutures and bone augmentation with a plate. Over a several year time period after the advent of suture anchors, the senior author has developed a biomechanically confirmed strong and secure cuff fixation that eliminates the potential risk for loose hardware in the subacromial space. This open surgical technique, the Trans-Osseous Anchor Double Knot (TOAK) technique, utilizes a unique combination of single-row suture anchor fixation and concomitant transosseous sutures.