Shoulder & Elbow

Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location.

Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases “suprapectoral,” “subpectoral,” “tenodesis,” and “long head of biceps tendon”. Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded.

From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis.

Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area.

Level of evidence: IV.

The Latarjet procedure reduces recurrent glenohumeral instability but has potential hardware and graft complications. The procedure has been modified to use various screw types as well as suture buttons. Biomechanical studies have evaluated the effect of these implants on construct strength. With varying results it is unclear whether there is an optimal implant to use.

We conducted a systematic review of human cadaveric biomechanical studies evaluating Latarjet ultimate failure load. Two independent reviewers screened articles and included them after full text review. Additional factors including implants used, graft orientation, cortices engaged, drill diameter, and screw characteristics were recorded. Meta-regression was performed on the 145 specimens from eight studies that met inclusion criteria.

Screw fixation resulted in a 396.8 N (95% CI, 149.8–643.7) N higher ultimate failure load against shear stresses than suture buttons (p = 0.002). There were no differences between implants for ultimate failure load against tensile forces. Tensile strength was significantly affected by drill diameter with each millimeter of increase reducing the mean ultimate failure load by 127.4 N (95% CI, 41.2–213.6) N (p = 0.004).

These results suggest that using screw fixation and minimizing drill diameter can obtain the maximum ultimate failure load against both shear and tensile forces in a Latarjet construct.

Deltoid muscle function is paramount to the success of reverse total shoulder arthroplasty. The purpose of this study was to investigate the role of deltoid volume on shoulder range of motion and patient-reported outcomes following reverse total shoulder arthroplasty in rotator cuff-intact and rotator cuff-deficient conditions.

Retrospective review of records identified 107 patients who met inclusion criteria. The rotator cuff integrity was evaluated by two musculoskeletal-trained radiologists. Volumetric deltoid measurements were calculated from preoperative computed tomography or magnetic resonance imaging scans. Satisfactory outcomes were defined as forward elevation of at least 135°, external rotation of at least 35°, and American Shoulder and Elbow Surgeons and Single Assessment Numerical Evaluation scores of at least 70.

Mean total deltoid muscle volume was significantly higher in patients with satisfactory forward elevation (57.8 ± 18.1 cm³) versus unsatisfactory forward elevation (48.6 ± 19.5 cm³) (p = 0.013). When separated by rotator cuff integrity, total deltoid volume was significantly higher (p = 0.030) in patients who achieved satisfactory forward elevation in the rotator cuff-deficient group but not the rotator cuff-intact group (p = 0.533).

Preoperative deltoid volume directly correlated with achieving satisfactory forward elevation after reverse total shoulder arthroplasty in rotator cuff-deficient conditions and may be one factor in determining the ability to achieve satisfactory outcomes in the rotator cuff-deficient patient.

The objective of this study was to compare the biomechanics of using a double layered human dermal allograft to a single layered human dermal allograft in superior capsular reconstruction.

Five cadaveric shoulders were tested. The superior translation of the humerus and the subacromial contact pressure were measured at 0°, 30° and 60° of glenohumeral abduction in the following six conditions: (1) intact rotator cuff, (2) irreparable supraspinatus tear, (3) superior capsular reconstruction using a double layered human dermal allograft with and (4) without posterior suturing, (5) superior capsular reconstruction using a single human dermal allograft with and (6) without posterior suturing.

There was a significant increase in superior translation of the humerus and subacromial contact pressure when comparing torn supraspinatus to intact shoulder. All superior capsular reconstruction repairs lead to a reduction in superior translation and subacromial contact pressures compared to after the supraspinatus tear except for single layered superior capsular reconstruction repair without posterior suturing. There was no difference in superior translation and subacromial contact pressures comparing the intact shoulder to any of the superior capsular reconstruction constructs.

Superior capsular reconstruction using a single or double layered human dermal allograft improves superior translation after supraspinatus repair. There is some biomechanical benefit of a double layered human dermal allograft technique over a single layered graft technique in superior capsular reconstruction.

IV

The purpose was to evaluate the relationship of component size and position to postoperative range of motion following reverse shoulder arthroplasty. The hypothesis was that increased lateralization, larger glenospheres, and a decreased acromiohumeral distance would be associated with excellent postoperative range of motion.

A retrospective multicenter study was performed at a minimum of one year postoperatively on 160 patients who underwent primary reverse shoulder arthroplasty with a 135° humeral component. Outcomes were stratified based on postoperative forward flexion and external rotation into excellent (n = 42), defined as forward flexion >140° and external rotation > 30°, or poor (n = 36), defined as forward flexion <100° and external rotation < 15°. Radiographic measurements and component features were compared between the two groups.

A larger glenosphere size was associated with an excellent outcome (p = 0.009). A 2-mm posterior offset humeral cup (p = 0.012) and an increased inferior glenosphere overhang (3.1 mm vs 1.4 mm; p = 0.002) were also associated with excellent outcomes. Humeral lateralization and distalization were not associated with an excellent outcome.

Conclusion: Larger glenosphere size and inferior positioning as well as posterior humeral offset are associated with improved postoperative range of motion following reverse shoulder arthroplasty.

Level 3, retrospective comparative study.

The purpose of this biomechanical simulator study was primarily to compare latissimus dorsi to lower trapezius tendon transfers for active external rotation and the pectoralis major transfer for internal rotation after reverse shoulder arthroplasty. Secondarily, the role of humeral component lateralization on transfer function was assessed.

Eight rotator cuff deficient cadavers underwent reverse shoulder arthroplasty with an adjustable lateralization humeral component. Latissimus dorsi and lower trapezius transfers were compared for active external rotation restoration and pectoralis major transfer for internal rotation restoration. Internal rotation/external rotation torques were measured for each lateralization at varying abduction and internal rotation/external rotation ranges-of-motion.

The lower trapezius transfer generated, on average, 1.6 ± 0.2 nm more torque than the latissimus dorsi transfer (p < 0.001). The internal rotation/external rotation torques of all tendon transfers decreased as abduction increased (p < 0.01). At 0° elevation, reverse shoulder arthroplasty humeral component lateralization had a significant positive effect on tendon transfer torque at 60° internal rotation and external rotation (p < 0.01).

Both the lower trapezius and the latissimus dorsi tendon transfers were effective in restoring active external rotation after reverse shoulder arthroplasty; however, the lower trapezius generated significantly more torque. Additionally, the pectoralis major transfer was effective in restoring active internal rotation. All tendon transfers were optimized with greater humeral component lateralization.

Glenoid version is the most variable parameter of the shoulder joint. No authors investigated if intrinsic genetic factors or influences from extrinsic sources are responsible for its variability.

We compared glenoid version between elderly monozygotic and dizygotic twins intending to separate the contributions of genetics from shared and unique environments.

Glenoid version of the dominant shoulder was assessed by MRI using Friedman’s method in 30 pairs of elderly twins (16 monozygotic–14 dizygotic; mean age ± SD: 63.72 ± 3.37, 53–72). Heritability was estimated as twice the difference between the intraclass correlation coefficients for monozygotic and dizygotic pairs. The influence of shared environment was calculated as the difference between monozygotic correlation coefficient and the heritability index. According to job category, one way analysis of variance was used to estimate the differences between groups in the total sample and within zygosity groups.

Glenoid version angle in monozygotic and dizygotic twins was −2° (SD: 2°) and −3° (SD: 3°), respectively (p = 0.334). Heritability index was 0.98, while the contributions of shared and unique environment were 0 and 0.02, respectively. According to working classes, no significant differences were found between the groups (p = 0.732, F = 0.31).

Glenoid version is mainly genetically determined and only marginally influenced by environments.

Level of evidence: III.

Lateral end clavicle fractures can be challenging due to the small and often comminuted lateral fragment, problems with union and stability and implant morbidity. We retrospectively reviewed outcomes of Tightrope device in isolation to treat lateral end clavicle fractures.

Subjective and objective measures were assessed for 29 patients. The subjective comprised of functional clinical scores: Oxford shoulder score and EuroQoL5D. The objective measures were maintenance of fracture reduction, bone healing and complications.

Median age was 36 years and 72% of cases were male patients. Average clinical follow up time was 21 months. Evaluation of latest radiographs showed that all reductions were maintained post-operatively. Twenty-two fractures had united and one patient had established non-union. Functional outcomes showed predominantly good results with Oxford shoulder score average of 41, EuroQoL5D index score of 0.78 and EuroQol Visual Analogue Scale 76. The overall post-operative complication rate was 10%; only one case requiring a secondary procedure.

In our series, using the Tightrope as the sole device to treat displaced lateral end of clavicle fractures resulted in good radiological and functional outcomes, with minimal complications requiring secondary procedures. We believe the Tightrope device is a good method of fixing these challenging fractures and advocate its use.

Distal humeral hemiarthroplasty has been performed for a variety of indications with the most common being management of distal humeral fractures. This systematic review evaluates the outcomes and complications of distal humeral hemiarthroplasty for this pathology.

We searched PubMed, EMBASE, and MEDLINE for studies reporting indications and outcomes of patients undergoing distal humeral hemiarthroplasty. Study screening, risk of bias assessment, and data extraction were performed. Summery statistics were provided.

We included 11 studies (N = 163) in this review. In all studies, the indication for distal humeral hemiarthroplasty was the presence of an intraarticular, comminuted, unreconstructable fracture. The mean post-operative MEPS, FullDASH, and QuickDASH (SD) scores were 83.6 (6.1) points, 25.4 (10.3), and 15.7 (7.4) points, respectively. The mean post-operative range of motion (SD) was 106° (11°) in the flexion and extension arc and 153° (19°) in the protonation and supination arc. The overall rate of adverse events and complication was 63%. The rate for major complications was 11%. The mean total revision rate was 4% (0% to 15) and total re-operation rate was 29% (0% to 88%).

Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates.

Despite good reported outcomes with open reduction and internal fixation of intra-articular distal humerus fractures, complication rates remain high. The objective of this work is to identify factors associated with reoperation.

Sixty-three patients treated with open reduction and internal fixation for intra-articular (Arbeitsgemeinschaft für Osteosynthesefragen type C) distal humerus fractures between 2004 and 2010 were identified using an institutional trauma registry, 62 of which were followed for a minimum of six months. Age, gender, fracture subclassification, open fracture presence, Injury Severity Score, time to definitive surgery, length of postoperative immobilization, and type of approach were recorded. Multivariate analysis was utilized to identify factors independently associated with reoperation.

Complications requiring reoperation developed in 25 (40.3%) elbows. The most common reasons were wound dehiscence or infection in nine elbows (14.5%) and symptomatic hardware in six (9.6%). During multivariate analysis, only olecranon osteotomy remained an independent predictor for reoperation (P = 0.043).

Despite improved internal fixation techniques, a high proportion of elbows require reoperation after open reduction and internal fixation for distal humerus fractures. Higher complication rates in fractures fixed through an olecranon osteotomy may reflect additional reoperations due to nonunion of the osteotomy or need to remove hardware from the ulna.

Prognostic Level III.

We assessed distal humeral column preservation effects on clinical, radiographic and patient reported outcomes following distal humerus hemiarthroplasty for acute unreconstructable fractures.

Thirty-seven consecutive patients (mean age, 75; range, 29–93 years) with an average follow-up of 61 months (range, 24–105 months) after distal humerus hemiarthroplasty using a triceps preserving approach were studied. QuickDASH and Oxford Elbow Score assessed patient reported outcomes. Clinical and radiographic assessments comprised range of motion, grip strength, instability, implant loosening, chondral wear, heterotopic ossification and condylar union.

Average QuickDASH was 14.9 (range, 0–63) and Oxford Elbow Score 40.35 (range, 25–48). Mean flexion arc was 108°, extension deficit 17° and pronosupination arc 155°. Average operative sided grip strength was 31.05 kg versus 31.13 kg contralaterally. Column preservation had no statistically significant effect on QuickDASH (p = 0.75), Oxford Elbow Score (p = 0.78), flexion–extension (p = 0.87), pronosupination (p = 0.78) or grip strength (p = 0.87). No progressive radiographic loosening or symptomatic chondral wear occurred. All fixed columns united. Three cases of immediate post-operative laxity fully resolved on elbow mobilisation. Four post-operative complications required further surgery: one ulnar neuropathy, one heterotopic ossification, one wound breakdown and one traumatic dislocation.

Medium-term outcome of distal humerus hemiarthroplasty for acute unreconstructable distal humeral fractures is reliable irrespective of condylar preservation.

This study aims to use the Dutch Arthroplasty Register data to report an overview of the contemporary indications and implant designs, and report the short-term survival of radial head arthroplasty.

From the Dutch Arthroplasty Register, data on patient demographics, surgery and revision were extracted for radial head arthroplasties performed from January 2014 to December 2019. Implant survival was calculated using the Kaplan–Meier method.

Two hundred fifty-eight arthroplasties were included with a median follow-up of 2.2 years. The most common indication was a fracture of the radial head (178, 69%). One hundred thirty-nine (68%) of the prostheses were of bipolar design, and the most commonly used implant type was the Radial Head System (Tornier; 134, 51%). Of the 258 included radial head arthroplasties, 16 were revised at a median of six months after surgery. Reason for revision was predominantly aseptic loosening (9). The overall implant survival was 95.8% after one year, 90.5% after three years and 89.5% after five years.

For radial head arthroplasties, acute trauma is the most common indication and Radial Head System the most commonly used implant. The implant survival is 89.5% after five years.

Glenoid rim fractures are uncommon and generally associated with high complication rates. The most common treatment techniques include screw or anchor fixation. Here, we introduce a new fixation method to treat Ideberg type 1 A fractures.

A retrospective analysis was performed on patients treated with open reduction and plate fixation for Ideberg type 1 A fractures. The active range of motion capacity of both shoulders was recorded postoperatively. Constant-Murley score and Oxford disability index scores were used as outcome tools.

Five patients (three men and two women) were evaluated; their mean age was 56 years (standard deviation (SD), 10 years). The mean follow-up period was 25 months (range, 6–69 months); all fractures healed radiologically during the follow-up period. The mean Constant-Murley score was 80.36 (SD 11.01); the mean Oxford disability index was 37 (SD 9). The subsequent flexion and external rotation of the injured shoulders were similar to those of the uninjured side (injured vs. uninjured side: flexion, 176 ± 5.4 vs. 178 ± 4.4; external rotation, 48 ± 10.9 vs. 60 ± 0). No patient showed signs of osteoarthritis, stiffness, instability, or chronic pain at the last follow-up.

Open reduction and internal fixation with a plate is suitable for Ideberg type 1A glenoid fractures.

Clinical coders are dependent on clear data regarding diagnoses and procedures to generate an accurate representation of clinical activity and ensure appropriate remuneration is received. The accuracy of this process may potentially be improved by collaboration with the surgical team.

Between November 2017 and November 2019, 19 meetings took place between the Senior Clinical Fellow of our tertiary Shoulder & Elbow Unit and the coding validation lead of our Trust. At each meeting, the Clinical Fellow assessed the operative note of cases in which uncertainty existed as to the most suitable clinical codes to apply and selected the codes which most accurately represented the operative intervention performed.

Over a 24-month period, clinical coding was reviewed in 153 cases (range 3–14 per meeting, mean 8). Following review, the clinical coding was amended in 102 (67%) of these cases. A total of £115,160 additional income was generated as a result of this process (range £1677–£15,796 per meeting, mean £6061). Only 6 out of 28 (21%) cases initially coded as arthroscopic sub-acromial decompressions were correctly coded as such.

Surgeon input into clinical coding greatly improves data quality and increases remuneration received for operative interventions performed.