Glenohumeral arthritis in young individuals seems to be increasingly diagnosed and offered surgical treatment. As we've posted before these young individuals have different types of arthritis than their older counterparts - many are associated with failed prior surgeries, including chondrolysis, anchor problems in labral repairs, infection, and capsulorrhaphy arthropathy. Other causes of arthritis in young folks include avascular necrosis, inflammatory arthropathy, and glenoid dysplasia. Finally, young individuals may present with earlier stages of arthritis because of their inability to perform at their desired level. Thus there are at least three reasons why the management of arthritis in younger individuals is more demanding: (1) higher patient expectations, (2) increased longevity, (3) more complex pathology and (4) earlier presentation.
This is a review of many of the surgical options for the management of shoulder arthritis in the young person. It is apparent that thoughtful discussion of these options is warranted with each young patient considering shoulder arthroplasty. Longer term followup of these patients stratified by diagnosis will be of great interest.
The authors make a point about the ream and run procedure, "Whereas the described technique does not ream completely through subchondral bone, there is some concern that excessive reaming into the subchondral bone will lead to progressive glenoid erosion and medialization of the glenohumeral joint. It is unclear how this will affect long-term outcome, but it might make subsequent placement
of a glenoid prosthesis difficult if not impossible."
In this regard it is important to emphasize (as shown in the figure below), our technique for the ream and run procedure removes only enough bone to achieve a single glenoid concavity, it removes less bone than what is necessary to insert a standard polyethylene glenoid component, a stepped polyethylene glenoid component, or a metal-backed glenoid component.
Orthopedics — December 2014 Acromial Stress Fractures: Correlation With Acromioclavicular Osteoarthritis and Acromiohumeral Distance— by Samuel Dubrow, MD; et al Fractures around the acromion are a known complication of reverse total shoulder arthroplasty. The goal of this study was to report clinical outcomes in patients with acromial fractures after nonoperatively treated reverse total shoulder arthroplasty. Read more
The purpose of this study is to evaluate the muscle activity with surface electromyography (EMG) and the clinical outcome of the latissimus dorsi transfer. It remains unclear whether the clinical results of the latissimus dorsi transfer for massive posterosuperior rotator cuff tears are achieved either by active muscle contractions or by a passive tenodesis effect of the transfer.
METHODS:
Eight patients were evaluated preoperatively and at 1 year (SD, 0.1) after the latissimus dorsi transfer. Clinical evaluation of outcomes included active range of motion, Constant score, and visual analog scale (VAS) for pain and activities of daily living (ADL). Muscle activity was recorded with EMG during directional isometric abduction and adduction tasks.
RESULTS:
The external rotation in adduction improved from 23° to 51° (P = .03). The external rotation in abduction improved from 10° to 70° (P = .02). The mean Constant score improved from 39 to 62 postoperatively (P = .01). The VAS for pain at rest improved from 3.3 preoperatively to 0.1 (P = .02). The VAS for ADL improved from 4.9 to 2.3 (P = .05). The transferred latissimus dorsi remained active in all cases, as reflected by increased latissimus dorsi EMG activity during abduction tasks. In addition, the latissimus dorsi EMG activity shifted from preoperative antagonistic co-activation in adduction to synergistic activation in abduction.
CONCLUSION:
The latissimus dorsi has synergistic muscle activity after transfer. Apart from a tenodesis effect, directional muscle activity seems relevant for improved clinical outcome and pain relief. A specific gain was observed for external rotation in elevated arm positions, a motion essential for ADL tasks.
Trasposición del dorsal ancho en roturas del manguito
Cuando la rotura del manguito rotador abarca no solo el supraespinoso sino también al infraespinoso y el dolor resultante y las limitaciones funcionales causan más restricciones durante la vida diaria, la reparación quirúrgica es más compleja y el pronóstico es pobre. Para restaurar la abducción y la rotación externa, se puede realizar una trasposición del tendón del dorsal ancho o del redondo mayor a la parte lateral de la inserción del supraespinoso.
Este estudio utilizó EMG de superficie para determinar los niveles de activación pre y postoperatorios y calcular la ratio de activación (indicando una función en una dirección específica) para el deltoides, dorsal ancho y redondo mayor durante tareas isométricas en sujetos que recibieron trasposición quirúrgica del dorsal ancho.
Después de la trasposición tendinosa, el dorsal ancho se activaba todavía durante las tareas isométricas, pero se alteró la dirección: se había convertido en un músculo importante en la abducción y rotación externa. El redondo mayor, como se esperaba, no cambió la función direccional, pero su función como adductor proporcionando coactivación durante la abducción se incrementó.
> De: Henseler et al., J Shoulder Elbow Surg 23 (2014) 553-560. Todos los derechos reservados: Journal of Shoulder and Elbow Surgery Board of Trustees. Pincha aquí para acceder al resumen de Pubmed.. Traducido por Francisco Jimeno Serrano
Panel discusses use of reverse total shoulder arthroplasty for proximal humeral fractures
Orthopedics Today, April 2014
William N. Levine
Panel discusses use of reverse total shoulder arthroplasty for proximal humeral fractures Management of displaced three- and four-part proximal humeral fractures continues to challenge surgeons. In this Orthopedics Today Round Table, surgeons discuss reverse total shoulder replacement as an option for elderly patients with complex displaced four-part proximal humeral fractures. Read more
Orthopedics — December 2014 Human Dermal Allograft for Massive Rotator Cuff Tears— by Zinon T. Kokkalis, MD; et al Previously published studies reported variable results using various suture techniques and reconstruction options for massive rotator cuff tears. The authors retrospectively studied shoulders with massive rotator cuff tears treated with a human dermal allograft through a mini-open approach.Read more
Clavos percutáneos de fracturas de tres o cuatro partes del húmero proximal en pacientes ancianos en mal estado general: MIROS® frente a la fijación tradicional.
Int Orthop. 2012 Jun;36(6):1267-73. doi: 10.1007/s00264-011-1474-5. Epub 2012 Jan 18.
Percutaneous pinning of three- or four-part fractures of the proximal humerus in elderly patients in poor general condition: MIROS® versus traditional pinning.
Elderly subjects often have fractures of the proximal humerus, which may be difficult to manage in patients in poor general condition. The MIROS is a new percutaneous pinning device allowing correction of angular displacement and stable fixation of fracture fragments. We evaluated the results of percutaneous fixation of three- or four-part fractures of the proximal humerus of patients in the American Society of Anesthesiologists physical status three or four treated either with MIROS or traditional percutaneous pinning (TPP).
METHODS:
A total of 31 patients treated with MIROS and 27 undergoing TPP were enrolled in the study. Pre-operatively anteroposterior and transthoracic or axillary radiographs were obtained in all cases and computed tomography scans in patients with the most complex fractures. Follow-up evaluations were carried out at three, six, 12 and 16 weeks, and six months, one year and two years postoperatively, using the Constant Score (CS) and subjective shoulder value (SSV) methods.
RESULTS:
Of the 58 patients, 52 could be evaluated at all follow-ups. In both three- or four-part fractures there were significantly higher CS and SSV scores in the MIROS compared to the TPP group at all the late follow-ups. Lower rates of deep infection, pin tract infection and pin mobilisation were found in the MIROS group (p < 0.001). In both groups there was a significant association between the final result (CS) and either the type of fracture or complications (p < 0.001).
CONCLUSIONS:
The MIROS resulted in better clinical results and less complications than TPP in elderly patients. This method, however, may not be indicated for younger patients in good general condition.
Resumen PROPÓSITO: Los sujetos ancianos a menudo tienen fracturas del húmero proximal, que puede serdifícil de manejar en pacientes en mal estado general. El MIROS es un nuevo dispositivo de clavos percutáneos permitiendo la corrección de desplazamiento angular y una fijación estable de fragmentos de la fractura. Se evaluaron los resultados de la fijaciónpercutánea de tres o cuatro partes fracturas del húmero proximal de los pacientes en la Sociedad Americana de Anestesiólogos de estado físico tres o cuatro tratados ya sea con MIROS o clavos percutáneos tradicional (TPP). MÉTODOS: Un total de 31 pacientes tratados con MIROS y 27 que experimenta TPP se inscribieron en el estudio. Anteroposterior y transtorácica o axilares radiografías antes de la cirugía se obtuvieron en todos los casos y la tomografía computarizada en pacientes con las fracturas más complejas. Las evaluaciones de seguimiento se realizaron a los tres, seis,12 y 16 semanas, y seis meses, un año y dos años más después de la operación,mediante la puntuación de Constant (CS) y el valor del hombro subjetiva (SSV) métodos. RESULTADOS: De los 58 pacientes, 52 pudieron ser evaluados en todos los seguimientos. En ambos de tres o cuatro partes fracturas no fueron significativamente más altos puntajes CS y SSVen el MIROS comparación con el grupo TPP en todos los finales de los seguimientos. Se encontraron menores tasas de infección profunda, infección del tracto pin pin y movilización en el grupo MIROS (p <0,001). En ambos grupos hubo una asociación significativa entre el resultado final (CS) y, o bien el tipo de fractura o complicaciones (p<0,001). CONCLUSIONES: El MIROS dio lugar a mejores resultados clínicos y menos complicaciones que TPP en pacientes de edad avanzada. Este método, sin embargo, puede no estar indicada para pacientes más jóvenes en buen estado general.
A young gymnast presents with a history of recurrent elbow pain, swelling, and locking and catching. She has failed conservative treatment. When an unstable OCD lesion of the capitellum is diagnosed, the authors recommend elbow arthroscopy, removal of a loose body, and microfracture of the OCD lesion.
Edward S. Chang, MD, and Christopher C. Dodson, MD
Disclosures
The authors have no disclosures relevant to this article.
Background
Osteochondritis dissecans (OCD) of the capitellum is a rare disorder generally seen in the immature athlete. The exact etiology is unclear, however there is an association between this condition and athletes that sustain repetitive trauma to the radiocapitellar joint (ie, overhead athletes, gymnasts).
The typical presentation is in a young athlete with lateral elbow pain and swelling that is worse with activity and improves with rest. A detailed history and physical examination, along with advanced imaging modalities, can lead to early diagnosis.
Treatment of OCD lesions depends on the size, grade, and location:
Stable, low-grade lesions can be treated with rest and activity modification, with gradual return to sports.
Operative treatment is generally indicated for:
Unstable lesions
Presence of loose bodies
Mechanical symptoms
Failure of non-operative treatment
Surgical techniques range from debridement to fragment fixation to osteochondral autograft transplantation surgery (OATS). Clinical outcomes and return to sport vary by surgical technique, and long-term results are still needed to assess its efficacy.
The following case illustrates a classic presentation of a young gymnast with OCD of the capitellum who underwent successful treatment via arthroscopic repair.
In these two articles the authors examine in nine patients the concept that resection of the distal 1 cm of a torn rotator cuff tendon would enhance its healing properties.
They hypothesized that the expression of proapoptotic and antiapoptotic molecules and cytokines is dependent on the distance from the torn supraspinatus tendon edge and this expression may influence its potential for healing.
They found that in moving from the distal to the proximal parts of the tendon edge, the expression of proapoptotic caspases 9, 8 and 3; Bax; and TNF-α significantly decreased and the the expression of antiapoptotic Bcl-2 and IL-10 expression was increased.
They also found that expression of type I collagen, pro-proliferative IL-4, and IL-13 significantly increased and that of pro-inflammatory IL-1β and anti-proliferative IFN-γ decreased from the distal to the proximal parts of the tendon edge.
On these bases they suggest that resection of 10 mm from the edge of the torn supraspinatus tendon may enhance the healing process.
However, they point out that the number of patients that could be included in this study was limited because of the increased risk of tension in the repaired tendon when its distal centimeter was resected.
Comment: This is interesting work. Basically the authors found that the tendon edge is less metabolically enabled that the tendon a bit more proximal. What we don't know is how these metabolic characteristics are changed by the repair process - it is possible that surgery changes the environment from what became evident from these biopsies taken before the repair was carried out. At rotator cuff repair surgery, avoiding excessive tension is a priority - thus there is a concern that resection of 10 mm of tendon will increase the tension. Finally, there is the question of whether the majority of the healing activity takes place from the tendon edge or from the bone to which it is repaired.
