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PubMed1977

Status of total shoulder arthroplasty.

Some patients with degenerative, rheumatoid, and traumatic diseases of the glenohumeral joint require treatment primarily to relieve pain. In the absence of complete knowledge of basic mechanical requirements, clinical trials with both constrained and resurfacing prosthesis were initiated. Three types of constrained prostheses were placed in 23 patients. Pain relief was satisfactory, but six reoperations were necessary and motion greater than 90 degrees was rarely achieved. Twenty-five prostheses that were used to replace the glenohumeral articulation, but were not stable by virtue of design, were implanted. Again, pain relief was excellent; mechanical problems were not present, and motion was almost always greater than 90 degrees. Achieving stability by capsular-muscle cuff repair has not been as great a problem as anticipated. These results suggest that more emphasis should be placed on repair of the glenohumeral stabilizing structures than on their replacement.

Adult↗
PubMed2004

Does this patient have an instability of the shoulder or a labrum lesion?

CONTEXT: History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP). OBJECTIVE: To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP. DATA SOURCES: Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles. STUDY SELECTION: Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected. DATA EXTRACTION: Data were extracted on study population, clinical tests, reference tests, and outcome. The studies' methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist. DATA SYNTHESIS: Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care. CONCLUSIONS: Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.

Cartilage, Articular↗
PubMed1987

Magnetic resonance imaging of glenohumeral joint diseases.

Through the application of oblique planes and flexible surface coil techniques, magnetic resonance imaging (MRI) promises to be of great clinical value in the evaluation of a variety of pathologic conditions affecting the shoulder. In patients with joint effusions, the tendinous portion of the rotator cuff, glenoid labrum, and bicipital tendon can be readily visualized. This capability has particular relevance in patients with inflammatory disease and traumatic conditions. Rotator cuff atrophy and impingement of the coracoacromial arc upon the supraspinatus muscle and tendon can also be demonstrated. MRI is also useful in the evaluation of shoulder instability.

Humans↗
PubMed1988

Rotator cuff tear--relationship between clinical and anatomopathological findings.

Rotator cuff tears (RCT) are frequent and increase with age. Why do only a relatively small percentage cause a permanent severe handicap justifying surgery? Is there a relationship between size and site of the tear and the clinical symptoms? How do they influence the postoperative result? These questions were answered in a prospective study of 76 operated patients. We adopted D. Patte's classification of the RCT into four groups according to the site and size of the lesion. Our figures were compared with those obtained by Patte in an analogous study of 256 cases. Of the tears in our series, 56.5% belonged to groups I and II, which means that only the supraspinatous and occasionally also the subscapular muscles were involved. In 100% of the cases in group I we found only pain, whereas a pure symptomatology with pain alone was presented in only 51% of group II, in 48% of group III, and in 0% of group IV. Groups III (35.5%) and IV (8%) represent more extensive tears, involving not only the anterior part of the rotator cuff, e.g., the supraspinatous tendon, but also to a more or less severe extent, the infraspinatous and sometimes even the teres minor. In group IV the extensive tear is combined with osteoarthritic changes. In both groups a mixed symptomatology (pain and pseudoparalysis) is the rule. The result of operative treatment is satisfactory in all groups as far as pain relief is concerned. The improvement of active ROM is not as evident and seems, as expected, to be related to the severity of the lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

The Bankart lesion of the shoulder: a biomechanical analysis following repair.

The Bankart lesion of the shoulder has long been associated with anterior instability. Our laboratory has developed a biomechanical model of the human shoulder which was used to determine the effects of creating a Bankart lesion on cadaveric specimens and then to compare the effects of two repair techniques. The model simulates the abducted, externally rotated position of the glenohumeral joint and uses pneumatic cylinders to simulate the rotator cuff forces. Specimens were tested intact following a partial Bankart lesion, following a complete Bankart lesion, and after performing a Bankart repair using three Mitek suture anchors. Finally, both the traditional and Mitek repairs were tested until failure. Strain in the inferior glenohumeral ligament (IGHL) and torque resistance was measured as an indication of instability of the joint. Strain was noted to decrease with increasing depth of lesion of the IGHL. Torsional rigidity of the shoulder decreased with increasing depth of lesion as well. Repairing the shoulder restores the strain and rigidity to control conditions. The mean load until failure was greater with the traditional repair than with the suture anchor technique. This study quantitates the effects of a Bankart lesion of the shoulder, and demonstrates that repairing the lesion with a suture anchor technique restores the biomechanics of the shoulder.

Biomechanical Phenomena↗
PubMed1996

MRI examination of the glenohumeral joint after traumatic primary anterior dislocation. A descriptive evaluation of the acute lesion and at 6-month follow-up.

Primary traumatic anterior dislocation of the shoulder in young patients has a high recurrency rate. There are varying opinions on the pathology behind the recurrences. The aim of this study was to describe the MRI characteristics of the acute lesion, and at 6-month follow-up. Thirty patients aged 18-30 years with primary traumatic anterior dislocation of the shoulder were randomized into two groups. One group was treated with acute arthroscopic lavage within 10 days. The control group was treated with traditional non-operative therapy. All patients underwent acute MRI within 10 days and before the arthroscopic lavage, and again at the 6-month follow-up, for evaluation of the lesions. The acute MRI verified Hill-Sachs lesions in all patients. At the 6-month follow-up MRI, there was no change in the size of the Hill-Sachs lesion. This was also the case with the six patients in the control group with recurrent dislocations during the first 6 months. Twenty-nine patients (97%) had joint effusion at the acute MRI, which was very useful for evaluation of the soft tissue pathology. The glenohumeral ligaments were detached in 20/30 patients (66%), and the labrum in 22/30 patients (70%). A capsulolabral detachment classified as a Baker 3 lesion was seen in 16/30 (53%) of the patients, including all six patients with recurrent dislocation. At the 6-month control only 3/30 (10%) of the patients had joint effusion for adequate evaluation of the labrum and ligamentous pathology. A Hill-Sachs lesion was found in 100% of the patients after primary dislocation, and recurrent dislocations did not change the size of the lesion. The study supports the opinion that this lesion is overlooked in the clinical situation. The joint effusion at the acute MRI was of utmost importance for evaluation of the soft tissue pathology. The 6-month MRI control was therefore considered inconclusive when evaluating capsulolabral lesions, due to lack of effusion. MRI arthrography with contrast administration would have been very helpful at the 6-month examination.

Adolescent↗
PubMed1993

Posttraumatic arteriovenous fistula and subclavian vein thrombosis: treatment by percutaneous arterial embolization and vein angioplasty.

A 71-year-old woman had edema and venous dilatation of her upper right limb that caused painful functional disability following a shoulder injury. Arteriograms demonstrated an arteriovenous fistula between the subclavian artery and vein associated with thrombosis of the vein at the same level. The arteriovenous fistula was found to have multiple arteriovenous communications. Because of associated distal venous thrombosis, venous drainage was retrograde through the brachial vein. The inflow arteries of the fistula were embolized and then the subclavian vein thrombosis was recanalized, dilated, and an endoluminal stent inserted. Clinical signs completely resolved.

Aged↗
PubMed2006

[Arthroscopic Bankart operation using absorbable suture anchors].

OBJECTIVE: Arthroscopic refixation of the labrum-ligament complex at the glenoid. INDICATIONS: Posttraumatic anterior or anterior-inferior shoulder instability with Bankart or ALPSA lesion (anterior labral periosteal sleeve avulsion). CONTRAINDICATIONS: Atraumatic shoulder instability. Instabilities due to blunted or frayed degeneration of the labrum-ligament complex. HAGL lesion (humeral avulsion of the glenohumeral ligaments) with humeral detachment of the glenohumeral ligaments. Larger bony glenoid defects. SURGICAL TECHNIQUE: Mobilization of the labrum-ligament complex from the neck of the glenoid, superior tightening and refixation at the glenoid rim with the aid of absorbable suture anchors. POSTOPERATIVE MANAGEMENT: Immobilization of the affected arm for 4 weeks in an immobilization bandage with abduction pillows. Daily pendulum exercises. Active flexion up to 70 degrees and abduction up to 40 degrees, all in neutral or internal rotation. Avoidance of external rotation for a total of 6 weeks. RESULTS: From January 1999 to December 2001, 58 patients with a Bankart or ALPSA lesion were treated with arthroscopic shoulder stabilization using absorbable suture anchors and slowly absorbable braided sutures. 56 patients underwent a follow-up clinical examination after, on average, 31 months (24-48 months). None of these patients had suffered more than five shoulder dislocations before the operation (average 2.8). Of the intraoperative lesions, a plain Bankart lesion was present in twelve patients (21.4%), 44 patients had an ALPSA lesion (78.6%), of which one in two were combined with an SLAP 2 or SLAP 3 lesion (superior labrum from anterior to posterior). In the evaluation using the Rowe Score, there was an excellent result for 40 patients (71.4%), and a good result for twelve (21.4%). Four patients suffered a repeat dislocation and were therefore classified as poor results (7.2%).

Absorbable Implants↗
PubMed1997

[Arthroscopic surgical measures in the shoulder joint].

Arthroscopic and open surgery have to be combined for successful surgical therapy of the shoulder joint. A surgeon performing open surgery alone or just using arthroscopic measures cannot cover the full spectrum of modern shoulder surgery. Isolated diagnostic arthroscopy is rarely indicated. Far more common, diagnostic arthroscopy is combined with an operative procedure both to confirm preoperative assessment of pathology and to uncover associated lesions. The results of arthroscopic stabilization of chronic anterior post-traumatic dislocations fail to compare with the high success rates of open procedures. Better patient selection will probably be the key to improving results. In cases of acute traumatic first-time dislocation in young, highly athletic people, arthroscopic repair of the isolated Bankart-Perthes lesion offers the attractive advantage of anatomic reconstruction with minimal soft-tissue dissection. Further indications for arthroscopic measurements of pathologies of the glenohumeral joint are synovectomy in rheumatoid arthritis, capsulotomy in frozen shoulder and tenodesis for lesions of the long head of the biceps. Arthroscopic subacromial decompression according to Ellman is the procedure performed most often and most successfully in the shoulder joint and has overcome the classic Neer open acromioplasty. For smaller tears of the supraspinatus tendon, arthroscopic acromioplasty can be combined with an all arthroscopic suture repair or with mini-open repair. Larger tears of the rotator cuff are still the domain for open reconstructive procedures. In associated or isolated AC joint arthritis, an arthroscopic Mumford procedure can be performed. For chronic calcific tendinitis, isolated arthroscopic excision of the calcium deposit is of great value. Additionally, acromioplasty is needed for true mechanical obstruction of the subacromial space.

Arthritis, Rheumatoid↗
PubMed2004

[Shoulder Arthroplasty. Surgical management].

Shoulder arthroplasty covers an extensive indication spectrum of degenerative, inflammatory to infectious, tumorous, instability-associated and neurogenic disease to acute trauma and posttraumatic joint destruction. Each of these indications requires its own regime and an appropriate implant. Osteoarthritis is the most frequent indication, and will be used as an example for surgical management, bringing the manufacturer-nonspecific general guidelines, joint mechanics and surgical technology into agreement. The fundamentals of the technique of implantation refer to the anatomical adaptability of the third generation of shoulder prostheses, which permits an accurate reconstruction of glenohumeralen joint centring. This article also describes far-reaching principles, which are generally applicable to all indications for shoulder arthroplasty.

Arthroplasty, Replacement↗
PubMed2001

[Severe complications of Staphylococcus aureus infection in the child].

Life threatening complications can be caused by staphylococcal infection, even if they appear as a simple pustulosis, via hamatogenous dissemination. On the other hand the bacteria is able to penetrate the skin without pre-existing skin lesions and reach the adjacent soft tissue, as was the case with a 9 year old boy who had a contusion of the left shoulder and a consecutive life threatening septicemia.

Abscess↗
PubMed2006

[MR imaging of the shoulder. Impingement and instability-related abnormalities].

In addition to the case history and the clinical examination, MR imaging has an important role in the diagnosis and differential diagnosis of numerous shoulder abnormalities and in the investigation of chronic shoulder pain. Important indications for MR imaging are any conditions or symptoms making assessment of the rotator cuff and the labrocapsular complex necessary. Assessment of the rotator cuff muscles, in particular, is crucial. The value of MR arthrography, which is still controversial, is discussed. The greatest potential benefit of MR arthrography is the accurate evaluation of subtle rotator cuff abnormalities and shoulder instability-related lesions, and the assessment of pathologic conditions of the long biceps tendon. This paper describes the most common pathologic findings of the shoulder joint and describes how the relevant findings are reported and quantified for the orthopaedic shoulder surgeon.

Humans↗
PubMed1998

[Arthroscopic extra-articular Bankart procedure].

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69.7% were classified as excellent, 10.9% as good, 9.7% fair and 9.7% poor. Postoperative complications: the recurrence rate was 9.7%, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3%) and a frozen shoulder in 6 cases 3.6%). 61% of the patients involved in overhead or contact sports returned to their preoperative sport activities.

Accidents↗
PubMed1998

[Posterior shoulder joint instability. Classification, pathomechanism,diagnosis, conservative and surgical management].

The posterior instability of the shoulder is a more difficult diagnostic and therapeutic challenge than the anterior instability. There are many etiologies and causes of posterior instability. Most studies in the literature are retrospective and yield a great variation in therapeutic recommendations. Generally it has to be separated in traumatic and atraumatic instabilities. Most of the traumatic dislocations are impaction fractures of the humeral head against the dorsal glenoid. Therapy is depending on the size of the humeral defect, the duration of dislocation and the functional demand of the patient. Therapeutic possibilities are closed reduction and fixation with a cast, open reduction and the transfer of the lower tubercule (McLaughlin's procedure), lifting of the defect and supporting with cancellous bone, subcapital rotational osteotomy or arthroplasty. The therapy of choice for atraumatic instability is a individualized rehabilitation program with strengthening and balancing of rotator cuff muscles and scapular stabilizers. Psychologic abnormalities and emotional problems have to be recognized prior to any operative procedure. These patients are no operative candidates. Operative treatment of choice is the posterior capsular shift addressing the causative redundancy or laxity of the postero-inferior capsule. Posterior bony procedures as glenoid osteotomy or bone block transfers are indicated, if the pathologic geometry of the glenoid is primarily responsible for posterior instability. It is strongly recommended to combine them with a capsular shift to address the secondary capsular redundancy.

Decision Making↗
PubMed2002

Anterior labroligamentous periosteal sleeve avulsion lesion at the superior glenoid labrum.

An unusual type of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion in the superior, instead of the usual inferior, part of the anterior glenoid labrum is presented in a 33-year-old man who sustained a traumatic dislocation of his left shoulder. Magnetic resonance imaging raised the possibility of an ALPSA lesion and later arthroscopy confirmed the diagnosis. Arthroscopic repair of the lesion was performed after the labral avulsion was lateralized.

Adult↗