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Biomedical subjects

E L Flatow

Publications and source records attributed to E L Flatow.

At least 19 recordsLinked to original sources
PubMed1999

Geographic variations in the rates of operative procedures involving the shoulder, including total shoulder replacement, humeral head replacement, and rotator cuff repair.

BACKGROUND: Although geographic variations in the rates of orthopaedic procedures have been well documented, considerable controversy remains regarding the factors that drive these variations, particularly the role of the availability of orthopaedic surgeons. Moreover, little attention has been specifically focused on variations in the rates of commonly performed shoulder procedures. METHODS: The current study documents state-to-state variations in the rates of total shoulder replacement, humeral head replacement, and rotator cuff repair and examines factors that might account for these variations. The regional incidences of these three procedures were analyzed with use of the Health Care Financing Administration Medicare database (MEDPAR, 1992). The rates were age-adjusted, and variations were measured with use of high:low ratios, variation coefficients, and systematic components of variation. Potential causes of variation were analyzed with use of Spearman and partial correlations as well as with Poisson regression. RESULTS: Rates for the three procedures that were studied varied from one state to another by as much as tenfold. Humeral head replacement had the lowest rate of variation according to all three measures. All three procedures were performed less often in states that were more densely populated. With the numbers available for study, no consistent, significant relationship was found between the density of orthopaedists and shoulder surgeons and the rates of any procedure. CONCLUSIONS: The striking variations that were noted for these commonly performed procedures showed that there is a clear need for well designed clinical research to further define the factors that account for the variations and to examine the effectiveness and appropriate indications for the procedures.

Aged↗
PubMed1997

Biology of the rotator cuff tendon.

Tendons are complex composite material composed primarily of water, collagen, proteolycans, and cells, designed to transmit tensile loads from muscle to bone. Although rotator cuff tendons differ in many ways from other tendons in the body, a knowledge of basic tendon structure and function is helpful in understanding rotator cuff tendon biology, injury, and repair. In addition to type I collagen, rotator cuff tendons contain small amounts of type III collagen, which play a role in healing and repair. In comparison with other tendons, the increased glycosaminoglycan and proteoglycan content seen in rotator cuff tendons may be adaptive, pathologic, or both. The etiology of rotator cuff pathology is probably related to trauma, aging, and degeneration. As our understanding of these processes increases, we will be able to develop and implement improved preventative and therapeutic interventions for rotator cuff pathology.

Animals↗
PubMed1997

Biomechanics of the rotator cuff.

Thorough understanding of rotator cuff mechanics is important for effective treatment and/or prevention of cuff injuries. This understanding is achieved through knowledge of normal cuff structure and mechanics. Only then, can the effects of injuries and pathologic processes on normal cuff function be carefuly assessed. Rotator cuff structures are viewed and analyzed on a number of different levels. This article presents current knowledge of rotator cuff mechanics through review of cuff structure and anatomy, corocoacromial arch structure and biomechanics, and biomechanical models.

Acromion↗
PubMed1997

The rotator cuff. Full-thickness tears. Mini-open repair.

Arthroscopically assisted rotator cuff repair, through a mini-open, deltoid-splitting approach, is an effective treatment for small- to medium-sized full-thickness tears of the rotator cuff. Advantages over traditional open repair include relative deltoid preservation, the ability to assess and treat coexisting intra-articular pathology, shorter hospitalization, reduced early morbidity, easier and quicker rehabilitation, and a smaller scar. Standard open repair is preferred for larger tears with a greater degree of tendon retraction or when the subscapularis tendon is involved in the tear.

Arthroscopy↗
PubMed1997

The rotator cuff. Commentary.

To add clinical perspective to the articles of this two-issue collection, eight prominent shoulder surgeons discuss their approach to the treatment of rotator cuff disease. There is broad agreement in many areas, however, significant controversies remain.

Adult↗
PubMed1997

Split pectoralis major transfer for serratus anterior palsy.

The results of split pectoralis major tendon transfer (sternal head) for symptomatic scapular winging because of palsy of the serratus anterior muscle were reviewed. Eleven consecutive patients, whose average age was 34 years, had a duration of preoperative symptoms ranging from 12 to 60 months. Ten patients had electromyograms documenting a long thoracic nerve injury. Using an inferior axillary incision, the tendon of the sternal head of the pectoralis major is mobilized and transferred to the inferior angle of the scapula. The tendon transfer is reinforced with autogenous fascia lata. After surgery, a scapulothoracic orthosis is worn for 6 weeks, and restriction of vigorous activities is recommended for 6 months. At an average followup of 41 months, 10 of 11 (91%) patients had satisfactory results with significant improvement in function and reduction of pain. Each of these 10 patients had improved scapular tracking with no scapular winging or mild, dynamic winging at latest followup. One patient had an unsatisfactory result with a full recurrence of scapular winging secondary to noncompliance with the postoperative physical therapy regimen. The split pectoralis major tendon transfer provides a reasonable substitute for a paralyzed serratus anterior muscle in scapular stabilization. Strict adherence to technical principles and postoperative rehabilitation reliably leads to satisfactory clinical results.

Adult↗
PubMed1996

Biochemical markers in synovial fluid identify early osteoarthritis of the glenohumeral joint.

The objective of this study on the glenohumeral joint was to assess the (1) accuracy of clinical diagnosis of osteoarthritis compared with arthroscopic diagnosis, and (2) the ability of biochemical markers in synovial fluid to detect osteoarthritis. Patients (96) were examined clinically and the preoperative diagnosis of osteoarthritis was recorded. At surgery (arthroscopy or arthroplasty), the glenohumeral joint was inspected for signs of osteoarthritis, and the joint osteoarthritis grade (I-IV) was recorded. At surgery, synovial fluid lavage was obtained from the joint, and later analyzed to determine levels of aggrecan components: total sulfated glycosaminoglycan and keratan sulfate epitope, link protein and the chondroitin sulfate epitope recognized by antibody 3B3 (3B3(-)). Compared with arthroscopic diagnosis of osteoarthritis, the results showed that the clinical diagnosis did not wrongly identify joints without osteoarthritis, and was always able to identify joints with advanced (Grade IV) osteoarthritis. Grade II osteoarthritis was rarely identified (10% of the time), and Grade III osteoarthritis was identified 50% of the time. Biochemical assessment of the synovial fluid showed that the catabolic markers (sulfated glycosaminoglycan, keratan sulfate and link protein) were elevated in fluids from joints with moderate (Grade III) and advanced osteoarthritis (Grade IV), and the 3B3(-) epitope was elevated in Grades II, III, and IV. These results show that arthroscopic diagnosis for osteoarthritis, of the glenohumeral joint is particularly useful for early and moderate osteoarthritis, where clinical (nonarthroscopic) diagnosis is poor, and that biochemical analysis of the synovial fluids corresponds well to arthroscopic diagnosis of shoulder osteoarthritis.

Arthroscopy↗
PubMed1996

Glenohumeral stability. Biomechanical properties of passive and active stabilizers.

The shoulder is characterized foremost by its mobility and large range of motion. The glenohumeral joint is notable for its relative lack of bony constraint, relying heavily on the congruent articulating surfaces and surrounding soft tissue envelope for static and dynamic stability. Effective function in the articulation is achieved by a complex interaction between the various articular and soft tissue restraints. The rotator cuff muscles center the humeral head in the congruent glenoid fossa through the midrange of motion, when the capsuloligamentous structures are lax. However, incongruent joints, especially in positions of loading asymmetry (in external rotation), have larger translations that occur at the extremes of motion. Excessive translations are then effectively restricted by the mechanical properties of the inferior glenohumeral ligament. When the capsule is tightened anteriorly it results in an anterior tether and causes an associated posterior shift in contact on the glenoid. The posterior migration of the humeral head center and glenohumeral contact are again more pronounced in shoulders with reduced congruence. Additional studies of normal motion in different planes, the effects of rotator cuff pathology and dysfunction on the kinematics of the joint, proprioception of the capsule, and biomechanical tests of the inferior glenohumeral ligament and other components of the joint capsule at strain rates associated with injury, need to be conducted to understand the specifics of normal shoulder function and the pathophysiologic processes that occur during shoulder degeneration.

Biomechanical Phenomena↗
PubMed1995

Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability.

Thirty-five shoulders in thirty-four patients were treated with a superior shift of the posteroinferior aspect of the capsule because of recurrent posterior glenohumeral subluxation and dislocation. The physical examination revealed three types of posterior instability in these patients preoperatively: unidirectional (six shoulders), bidirectional (posterior and inferior) (seven shoulders), and multidirectional (posterior and inferior dislocation with anterior subluxation) (twenty-two shoulders). Eleven shoulders had had previous operative procedures. At the time of the index operation, the most common abnormal findings in these shoulders were capsular redundancy and excessive volume of the glenohumeral joint. Complete detachment of the posterior aspect of the labrum was found in only four shoulders. There was no excessive glenoid retroversion in these patients. All thirty-four patients were available for follow-up at an average of five years (range, two to twelve and a half years) postoperatively. Over-all, the result for seventeen of the thirty-five shoulders was rated as excellent; eleven, as good; one, as fair; and six, as poor. Four shoulders became unstable again. Six of the seven unsatisfactory results were in shoulders that had had previous attempts at stabilization. A successful result was achieved in twenty-three of the twenty-four shoulders in which the superior shift of the posteroinferior aspect of the capsule was the initial repair.

Adolescent↗
PubMed1995

Prosthetic design considerations in total shoulder arthroplasty.

Total shoulder replacements should, as far as possible, be designed after normal anatomy. A small mismatch in curvature between the humeral head and glenoid surfaces may reduce edge loading when the humerus translates on the glenoid, but may increase contact stresses caused by point loading. Modularity increases sizing options but decreases head size for a given soft-tissue space and introduces the risk of component dissociation. Releases and soft-tissue balancing at surgery, and rehabilitation afterwards, are more important than the type of glenohumeral prosthesis implanted.

Humans↗
PubMed1995

Arthroscopic evaluation and treatment of the rotator cuff.

Arthroscopy has improved our diagnostic assessment of rotator cuff disease, especially in understanding patterns of articular surface partial-thickness tears. Arthroscopic subacromial decompression is a proven and reliable alternative to open acromioplasty. Despite continued controversy, most partial-thickness rotator cuff tears may be satisfactorily treated by arthroscopic debridement and decompression. The role for debridement and decompression without repair for full-thickness rotator cuff tears seems less than initially suggested, as several recent independent studies have documented results inferior to open repair. Arthroscopically assisted mini-open repair of small, full-thickness rotator cuff tears is a reliable procedure. Arthroscopic repair appears promising, but is not yet well enough documented to be considered a standard treatment.

Arthroscopy↗
PubMed1995

Management of multidirectional instability.

Since 1980, several authors have reported successful treatment of multidirectional instability with use of the inferior capsular shift. Neer's initial report in a series of 32 patients noted only one unsatisfactory result. One decade later he reported that ¿more than 100 additional inferior capsular shifts have been done with similar satisfactory results.¿ The authors have reported preliminary results following 75 inferior capsular shifts performed in young athletes. Eighty-nine percent were able to return to their major sport while seventy-three percent maintained the same level of competitiveness. Seven patients (9.3%) reported a single episode of probable subluxation that was not followed by recurrent instability and did not affect the final result, whereas two patients (2.7%) dislocated postoperatively. Both of these cases were associated with a traumatic episode. The average loss of external rotation was 7 deg. Altchek and Warren reported their results following a T-plasty modification of the Bankart procedure for multidirectional instability in 42 shoulders. The patient population differed somewhat because 38 of the 42 cases had a Bankart lesion or detachment of the labrum and glenohumeral ligament complex. Patient satisfaction was rated excellent for 40 (95%) of the shoulders. The average loss of external rotation was 5 deg. Altchek and Warren noted that throwing athletes were unable to throw a ball with as much speed as before the operation. Additionally, 7 of 42 shoulders (16%) demonstrated 2+ or greater posterior instability postoperatively. There were four cases of symptomatic recurrent instability, one anterior and three posterior, while one patient required a posterior stabilization 2 years postoperatively. Recently Cooper and Brems' reviewed their series of 43 shoulders in 38 patients with a minimum 2-year follow-up after inferior capsular shift. Thirty-nine of 43 shoulders (91%) were rated by the patient as satisfactory with no recurrent instability. Postoperatively recurrent symptomatic instability developed in four patients (11%). Two of these patients required subsequent revision inferior capsular shifts and one of those went on to a humeral head replacement for arthritis of dislocation. The latter patient had received a prior Bristow procedure. Cooper and Brems concluded that the inferior capsular shift procedure provided satisfactory objective and subjective results. Failures and recurrences of symptomatic instability generally occurred in the early postoperative period less than 2 years following surgery. Their findings did not demonstrate a deterioration of the results, with a follow-up of 6 years. The authors recently reported the results after inferior capsular shift from classic multidirectional instability in 52 shoulders. Thirty-six shoulders were approached from the anterior side and 16 from posterior. All were completely immobilized in a brace for 6 weeks postoperatively. Forty-nine shoulders were observed over 2 to 11 years (average: 5 years). Satisfactory results were achieved in 94% of cases. Turkel and coworkers demonstrated that anterior glenohumeral stability is provided by varying regions of the capsule depending on arm position. Similarly, Warner and coworkers have recently demonstrated that inferior humeral translation is restrained by the anterosuperior capsule and ligaments with the arm at the side, and by the inferior capsule and ligaments with the arm in abduction. This is consistent with the clinical findings of Neer and Foster, who described inferior humeral translation with the arm at the side and with the arm in abduction in patients with multidirectional instability, and emphasized reducing redundant capsular volume on all sides at the time of surgical reconstruction. The capsular shift procedure eliminates laxity in the rotator interval, anterosuperior capsule, and anteroinferior capsule.(ABSTRACT TRUNCATED)

Arm Injuries↗
PubMed1994

The use of arthroscopy in the treatment of resistant frozen shoulder.

Arthroscopy serves as a useful adjunct to manipulation under anesthesia in the treatment of resistant frozen shoulder. In this technique the shoulder is manipulated under interscalene brachial plexus block anesthesia, followed by arthroscopic examination and debridement of the glenohumeral joint and the subacromial space. The addition of arthroscopy allows the identification and treatment of associated pathology, such as impingement lesions and secondary subacromial space inflammation, calcific deposits, and acromioclavicular arthritis. Range of motion can also be increased by arthroscopically guided sectioning of the coracohumeral ligament. This treatment regimen has yielded overall satisfactory results in 25 (83%) of 30 shoulders in this series. The subgroup with diabetes mellitus fared less well than the other groups, with only 64% satisfactory results. While most patients with frozen shoulder will respond to nonoperative treatment, the technique of manipulation under anesthesia followed by arthroscopy offers a safe and reliable treatment for the resistant frozen shoulder.

Adult↗