Sperling, John W.

Purpose Our purpose was to evaluate the distance from the bony edge of the glenoid to the visible (or macroscopic) demarcation at the junction of the labrum and the articular cartilage. Methods Ten fresh‐frozen cadaveric upper extremity specimens were dissected. The shoulder was disarticulated and periarticular structures were removed, leaving the glenoid with the labrum attached. The macroscopic edge of the glenoid was then marked with a drill at the 3‐, 4‐, 5‐, 6‐, 7, 8‐, and 9‐o'clock positions, as defined by a clock face (right) and a reverse clock face (left). Soft tissue and cartilage were then removed, and the distance from the outer edge of the drill hole to the bony rim was measured. Results The mean distance from the bony edge in hourly intervals starting at the 3‐o'clock position anteriorly and extending to the 9‐o'clock position posteriorly was 4.03 mm (range, 2.1 to 5.21 mm; SD, 0.96 mm), 4.2 mm (range, 2.1 to 5.31 mm; SD, 0.97 mm), 4.51 mm (range, 3.1 to 5.2 mm; SD, 0.91 mm), 5.14 mm (range, 3.1 to 7 mm; SD, 1.38 mm), 3.24 mm (range, 1.1 to 5.2 mm; SD, 1.4 mm), 3.78 mm (range, 1 to 6 mm; SD, 1.6 mm), and 4.28 mm (range, 2.1 to 7.3 mm; SD, 1.51 mm), respectively. A trend was noted for significant differences between locations, but this did not reach statistical significance (analysis of variance, P = .086). Conclusions The macroscopic edge of the labrum on the glenoid face does not correspond to the bony edge of the glenoid. The labrum overlaps onto the bony surface of the glenoid from a minimum of 1.6 mm to a maximum of 7.3 mm. Clinical Relevance Our findings provide anatomic data that enhances the arthroscopist's ability to anatomically reconstruct the glenoid labrum.

ABSTRACT We recently described a sonication technique for the diagnosis of prosthetic knee and hip infections. We compared periprosthetic tissue culture to implant sonication followed by sonicate fluid culture for the diagnosis of prosthetic shoulder infection. One hundred thirty-six patients undergoing arthroplasty revision or resection were studied; 33 had definite prosthetic shoulder infections and 2 had probable prosthetic shoulder infections. Sonicate fluid culture was more sensitive than periprosthetic tissue culture for the detection of definite prosthetic shoulder infection (66.7 and 54.5%, respectively; P = 0.046). The specificities were similar (98.0% and 95.1%, respectively; P = 0.26). Propionibacterium acnes was the commonest species detected among culture-positive definite prosthetic shoulder infection cases by periprosthetic tissue culture (38.9%) and sonicate fluid culture (40.9%). All subjects from whom P. acnes was isolated from sonicate fluid were male. We conclude that sonicate fluid culture is useful for the diagnosis of prosthetic shoulder infection.

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate.

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations.

Purpose There has been a significant increase in surgeon as well as patient interest in arthroscopic treatment of shoulder pathology. We hypothesize that patients have a strong preference for arthroscopic shoulder surgery. Currently, there are no data in the literature reporting on how people perceive open versus arthroscopic shoulder surgery. Methods Prospectively, a total of 202 patients were administered a questionnaire at the offices of 2 fellowship‐trained shoulder surgeons, 1 located at a tertiary referral center (center A) and 1 in private practice (center B). The questionnaire asked a series of questions about specific factors when choosing an orthopaedic surgeon and the preference for arthroscopic or open surgery. In addition, 7 short‐term and long‐term outcomes were listed, and the patient was asked to choose whether open or arthroscopic surgery would provide the best outcome or whether he or she felt that there was no difference. Results Among patients at center A, 88% would prefer arthroscopy if they were to have shoulder surgery, as would 96% of patients at center B. Among patients at center A, 14% would avoid shoulder surgery if the only option was open surgery, as would 25% at center B. The reputation of the surgeon and institution were the primary factors in choosing a surgeon. Recommendation of a former patient and years of surgeon experience were less important factors for patient selection of a shoulder surgeon. Conclusions The study shows that the vast majority of patients perceive multiple advantages of arthroscopic shoulder surgery despite a lack of published data to support many of these assumptions, particularly with regard to expected functional outcome of arthroscopic versus open shoulder surgery. Clinical Relevance Shoulder surgeons should be aware of these perceptions when discussing treatment options with patients. A continued effort should be made to emphasize known scientific data when considering the relative risks and benefits of arthroscopic and open shoulder surgery.

Abstract A common method of treating PASTA (partial articular surface tendon avulsion) lesions involves completing the tear followed by arthroscopic repair. Frequently, the boundaries of the tear are difficult to determine from the bursal side with the use of a single marking stitch. Therefore, we describe a simple technique that allows the surgeon to reproducibly define the boundaries of the partial tear. Following a standard arthroscopic examination of the articular portion of the shoulder joint, the PASTA lesion is identified. A spinal needle is introduced and the most anterior and posterior aspects of the tear are marked by passing 2 sutures. Following a bursectomy, the 2 sutures that clearly define the boundaries of the tear are identified. The tear is then completed by “connecting the dots” outlined by the sutures and an arthroscopic repair is performed in the standard manner.

Background The triceps tendon has been described as a single unit with contribution from each of the 3 heads of the muscle. An observation at the time of surgical repair of a triceps tendon injury led to an anatomical study to further define the anatomy of this tendon as it inserts on the olecranon. Hypothesis The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads. Study Design Descriptive laboratory study and case report. Methods Eight cadaveric elbows were dissected to examine the triceps tendon. None of the specimens had any evidence of prior injury or surgery to the elbow. All specimens were fresh-frozen and stored at–4°C until they were thawed for use. Skin and subcutaneous tissue were removed, and the tendon of each head of the triceps was explored from the muscle to its bony insertion. Results In all 8 specimens, on gross inspection, the medial head had a separate insertion deep to the common insertion of the lateral and long heads. The muscle of the medial head extended further distally than did the long and lateral heads. The medial head was muscular to its deep insertion, with a small amount of tendon blended with the muscle distally. Histologic analysis demonstrated that the tendon of the medial head and that of the other 2 heads are confluent distally at their olecranon insertion. Conclusion The medial head of the triceps has a tendon that is distinct from, and deep to, the common tendon of the long and lateral heads on gross inspection. Histologic studies show the insertion of these 2 tendons is confluent. Clinical Relevance This anatomy has important implications for surgical repair of these tendon injuries. Rupture of the deep triceps insertion alone can occur and lead to weakness of elbow extension with the elbow flexed beyond 90°. Triceps strength should be tested with the elbow fully flexed when injury to the tendinous insertion is suspected.

Purpose Currently, there is little information available concerning the results of shoulder synovectomy in patients with rheumatoid arthritis. Furthermore, it remains difficult to assess the success of shoulder synovectomy because of a high association of rotator cuff tears in rheumatoid patients. We hypothesized that synovectomy in patients with a functionally intact rotator cuff would provide durable pain relief. Type of Study Case series. Methods Sixteen shoulders in 13 patients with rheumatoid arthritis were treated with arthroscopic shoulder synovectomy from 1988 to 2002 with a mean follow‐up of 5.5 years. Patients with full‐thickness rotator cuff tears or partial tears that required repair were excluded. Two of the 13 patients had been diagnosed with juvenile rheumatoid arthritis and 11 had adult‐onset disease. The medical records of the patients were reviewed and patients were assessed clinically and by questionnaire to assess pain, satisfaction, range of motion, radiographic outcomes, and occurrence of complications. Results There was an improvement in pain at long‐term follow‐up in 13 of 16 patients ( P < .001). Active shoulder elevation improved from a median of 145° to 160° but was not significant ( P = .14). External rotation improved significantly ( P = .01) from a median of 45° (range, 0° to 90°) to 60° (range, 0° to 100°). According to the Neer rating system, there were 5 excellent, 8 satisfactory, and 3 unsatisfactory results. Seven of 8 shoulders followed‐up radiographically for more than 1 year showed radiographic progression of disease. All 3 patients reporting pain that was no better or worse than before surgery had radiographic arthrosis at last follow‐up with advancing periarticular erosions and reduction of glenoid articular space. Conclusions Arthroscopic synovectomy of the shoulder in patients with rheumatoid arthritis with an intact rotator cuff offers a reliable decrease in pain with less predictable improvements in range of motion. Limitations in predicting final results based on preoperative radiographs should be discussed with patients; those with more advanced radiographic changes may not benefit from the procedure. Level of Evidence Level IV, therapeutic study, case series, no control group.

Abstract Synovial chondromatosis of the shoulder has been treated in the past with an open arthrotomy, removal of loose bodies, and synovectomy. Several authors have described arthroscopy as a means of treating this rare disorder because of the excellent visualization of the glenohumeral joint, decreased morbidity, and early rehabilitation potential. This article offers a technique in which a large‐bore cannula and high pressure and flow are used to facilitate the removal of loose bodies from the joint.