Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures

Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.

Long-term Outcome After Nonoperative Treatment for Rockwood I and II Acromioclavicular Joint Injuries

Background: Rockwood I and II acromioclavicular joint injuries are generally treated nonoperatively. The long-term outcome is considered to be good but has not yet been properly investigated. Purpose: To assess the long-term outcome after nonoperative therapy for Rockwood I and II acromioclavicular joint injuries regarding functional and radiologic outcome. Study Design: Cohort study; Level of evidence, 3. Methods: Eligible patients visited the emergency department between January 2003 and December 2015 and were ≥16 years old at the time of presentation. The main study parameters were the Constant score, the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. The Constant score was measured in the injured and contralateral shoulders. Radiologic outcomes in both shoulders included joint displacement, joint space, degenerative changes, osteolysis of the distal clavicle, and ossification of the ligaments. Results: A total of 75 patients were included for follow-up. After a median follow-up of 85 months (interquartile range [IQR], 68.0-100.0), the mean Constant score in the injured shoulder for the total sample was 88.6 (SD, 12.7) as compared with 93.3 (SD, 8.7) in the contralateral shoulder, with a significant difference of 4.7 points between shoulders. The median Disabilities of the Arm, Shoulder and Hand score was 4.2 (IQR, 0.0-10.8), and the median Simple Shoulder Test was 100 (IQR, 91.7-100.0). The median patient satisfaction for the injured shoulder was 83 (IQR, 70.0-95.0). Regarding radiologic outcomes, for the injured shoulder versus the contralateral shoulder, patients had similar rates of degeneration (44% vs 46%) but more frequent osteolysis of the distal clavicle (31% vs 0%), ossification of the ligaments (29% vs 7%), and deformity of the distal clavicle (19% vs 0%). Conclusion: Despite the frequent occurrence of radiographic changes, long-term functional outcome after Rockwood I and II acromioclavicular joint injuries is good, with only clinically nonrelevant functional differences between the injured and contralateral shoulders.

A Method of Shoulder Spica Cast Application In Shoulder Muscle Transfer Patients In Supine Position

Background Children with birth brachial plexus injury (BBPI) often require secondary surgery for the shoulder. The shoulder spica is necessary after shoulder muscle transfer surgery in babies with BBPI. However, its application can be difficult in the supine position under anesthesia. The authors describe a simple and cost-effective method of applying the shoulder spica cast without changing the supine position under anesthesia. Technique While still under anesthesia, the child is placed in a supine position and then elevated on the wooden bar. The POP roll is wrapped around in a cylindrical manner, starting from the level one inch above the anterior superior iliac spine. The contralateral shoulder is also incorporated into the cast. Conclusion The spica application technique described comprises commonly available materials, such as a wooden plank, pair of bolsters, plaster of Paris rolls, and dressing materials overcoming the need for customized apparatus or the operation table. The materials are easy to assemble and thereby applicable just about anywhere. The task also becomes less challenging for the anesthetic in the supine position. This technique is easily reproducible and cost-effective.

Single-center Experience in the Treatment of Extremely Medial Clavicle Fractures with Vertical Fixation of Double-plate

Background: Patients suffering from medial clavicle fractures combined with displacement need surgical intervention. This research reports the effect of double-plate fixation as an innovative procedure in the treatment of extremely medial clavicle fractures.Methods: Nine patients complaint of extremely medial clavicle fracture were enrolled in this research from Mar 2017 to March 2018. Patients were treated with an open reduction and internal fixation using the double-plate technique. Postoperative X-ray was taken regularly to observe the fracture healing at each visit, and the related complications were also recorded. The rating score systems of Constant Murley score of treated shoulder and contralateral shoulder, Rowe score as well as American Shoulder and Elbow Surgeons (ASES) were questionnaire to evaluate postoperative shoulder joint function.Results: All patients achieved postoperative fracture healing with no complications. Only one patient complained of slight restriction, two patients complained of pain during overhead work, and another patient occurred plate breakage. Meanwhile, the Constant Murley scores of treated and contralateral shoulder were 94.1 and 98.5 points, respectively, indicating the similar shoulder function. Furthermore, the Rowe and ASES scores of the involved shoulder were 96.7 and 96.3 points at average, respectively.Conclusions: It is the first time to introduce the surgical technique of vertical double-plate fixation for stable fixation of extremely medial clavicle fractures, which could provide the surgeons an alternative method for this type of fracture.

Arthroscopic Latarjet for Recurrent Shoulder Instability

Background and Objectives: The all-arthroscopic Latarjet (aL) procedure was introduced to manage recurrent shoulder instability. Our study aimed to report the outcomes of aL procedures with the Rowe, University of California-Los Angeles (UCLA), simple shoulder test (SST) scores, and range of motion (ROM) in external rotation at a minimum follow-up of 2 years. Material and Methods: A total of 44 patients presenting recurrent shoulder instability were managed with aL procedure. Clinical outcomes were assessed at a mean follow-up of 29.6 ± 6.9 months. The postoperative active ROM was measured and compared with the contralateral shoulder. The Rowe, UCLA, and SST scores were administered preoperatively and postoperatively. Results: No patients experienced infections or neuro-vascular injuries. Seven (15%) patients required revision surgery. After surgery, the external rotation was statistically lower compared to the contralateral shoulder, but it improved; clinical outcomes also improved in a statistically significant fashion. Conclusions: The aL produced good results in the management of recurrent shoulder instability, but the complication rate was still high even in the hands of expert arthroscopist.

Return To Sport Testing At 6 Months After Arthroscopic Shoulder Stabilization Demonstrates Residual Functional Deficits

Objectives: A good outcome after arthroscopic stabilization for recurrent shoulder instability is often characterized by a successful return to sport while minimizing complications. While many physicians use a minimum of 5 months as a time to return, there is currently no consensus regarding timing or objective criteria for return to sport. The objective of this study is to evaluate the ability of postoperative patients to meet expected goals of achieving appropriate strength and using standardized objective evaluations of strength and physical function. Methods: 33 consecutive patients who underwent arthroscopic shoulder stabilization surgery from 2012 until 2018 and completed their postoperative rehabilitation with the same institution were subjected to functional testing to evaluate their readiness for return to sport. Isometric unilateral external rotation to internal rotation (ER/IR) ratio was measured using a hand held dynamometer at 0 and 90 degrees of shoulder abduction. Posterior rotator cuff activation was evaluated using a repetition to failure technique with 5% body weight at 0 and 90 degrees of abduction. Prone trapezius activation was measured in repetitions to failure with a prone Y exercise. A subset of throwing athletes (N= 11) were evaluated for total arc of motion. Results: Isometric testing at revealed that 18% (6/33, mean ratio 71%) patients met the expected goal of 80% ER/IR strength at both 0 and 90 degrees of abduction, with mean ratios of 71% and 62%, respectively. 73% (24/33) and 42% (14/33) of patients met goal of 90% of the contralateral ER repetitions to failure in rotator cuff activation testing at 0 and 90 degress of abduction, respectively. 55% (18/33) of patients met goal of 90% of contralateral prone Y repetitions to failure on lower trapezius activation testing, with mean. Mean total arc of postoperative motion for the 11 throwers was 91.6% of the contralateral shoulder. Thirty-six percent (4/11) patients did not reach 90% of the total arc of motion of the uninvolved shoulder. Conclusion: A substantial number of athletes in our cohort do not meet the expected goals for their operative shoulder in achieving appropriate strength, particularly in ER, nor arc of motion compared to the contralateral shoulder.

Manipulation under anaesthesia for frozen shoulders: outdated technique or well-established quick fix?

Manipulation under anaesthesia (MUA) for frozen shoulder (FS) leads to a considerable increase in range of motion and Oxford shoulder score, a significant reduction in pain and around 85% satisfaction. A clearly defined indication for MUA in FS patients cannot be extracted from this review or the available literature. The associating criteria before proceeding to MUA vary widely. All but one study in this review lacked a control group without intervention. Therefore, firm conclusions about the role of MUA in the treatment of FS cannot be drawn from the current literature. An overall complication rate of 0.4% was found and a re-intervention rate of 14%, although most of the included papers were not designed to monitor complications. The following criteria before proceeding to MUA are proposed: a patient unable to cope with a stiff and painful shoulder; clinical signs of a stage 2 idiopathic FS; lessening pain in relation to stage 1; external rotation < 50% compared to contralateral shoulder joint; a minimal duration of symptoms of three months; and failure to respond to an intra-articular corticosteroid infiltration. Cite this article: EFORT Open Rev 2019;4:98-109. DOI: 10.1302/2058-5241.4.180044

Prognostic Factors for Functional Outcome After Rotator Cuff Repair: A Prospective Cohort Study With 2-Year Follow-up

Background: Although shoulder function is reported to be generally good after rotator cuff repair, limited knowledge exists regarding which prognostic factors predict functional outcomes. Purpose: To identify pre- and perioperative predictors of functional outcomes after arthroscopic rotator cuff repair. Study Design: Case-control study; Level of evidence, 3. Methods: A cohort of 733 consecutive patients treated with rotator cuff repair between 2010 and 2014 in a single orthopaedics unit was included. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariable linear regression analyses were used to predict shoulder function at 2-year follow-up, as measured by the Western Ontario Rotator Cuff Index (WORC). Results: In total, 647 (88%) patients were followed for 25 ± 5 months (mean ± SD; range, 17-66 months). In the multivariable regression model, the adjusted R2 was 0.360, indicating that 36% of the variation in the WORC at final follow-up could be explained by this statistical model. The multivariable linear regression analysis revealed that the strongest positive independent predictors of shoulder function at 2 years were preoperative WORC and Constant-Murley score in the contralateral shoulder. The model also indicated that activities of daily living, age, subacromial decompression, and biceps surgery had independent positive associations with better shoulder function at 2 years. In addition, previous surgery in the ipsilateral or contralateral shoulder, smoking, partial rotator cuff repair, preoperative pain, and atrophy in the infraspinatus were all independent factors negatively associated with shoulder function after 2 years. The overall healing rate of complete repairs per magnetic resonance imaging was 80%. Conclusion: The most important finding of the present study was that the strongest prognostic factors for better WORC at 2-year follow-up were better preoperative WORC and Constant-Murley score in the contralateral shoulder. Although not all the prognostic factors identified in this study are modifiable, they can still be useful for guiding patients in shared decision making with the surgeon. This cohort study shows that if selection of patients is performed properly, it is possible to obtain a successful outcome.