ResearchPad - shoulder Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Radiographic parameters and a novel fluoroscopic control view for posterior screw fixation of coracoid base fractures]]> Introduction: Coracoid fractures have the potential to lead to inadequate shoulder function. Most coracoid base fractures occur with scapular fractures and the posterior approaches would be utilized for surgical treatment. We investigated the possibility of fixing the coracoid through the same approach without an additional anterior approach. Materials and methods: Multi-slice CT scans of 30 shoulders were examined and the following measurements were performed by an independent specialized radiologist: posterior coracoid screw entry point measured form infraglenoid tubercle, screw trajectory in coronal plane in relation to scapular spine and lateral scapular border, screw trajectory in sagittal plane in relation to glenoid face bisector line and screw length. We used the results from the CT study to guide postero-anterior coracoid screw insertion under fluoroscopic guidance on two fresh frozen cadaveric specimens to assess the reproducibility of accurate screw placement based on these parameters. We also developed a novel fluoroscopic projection, the anteroposterior (AP) coracoid view, to guide screw placement in the para-coronal plane. Results: The mean distance between entry point and the infraglenoid tubercle was 10.8 mm (range: 9.2–13.9, SD 1.36). The mean screw length was 52 mm (range: 46.7–58.5, SD 3.3). The mean sagittal inclination angle between was 44.7 degrees (range: 25–59, SD 5.8). The mean angle between screw line and lateral scapular border was 47.9 degrees (range: 34–58, SD 4.3). The mean angle between screw line and scapular spine was 86.2 degrees (range: 75–95, SD 4.9). It was easy to reproduce the screw trajectory in the para-coronal plane; however, multiple attempts were needed to reach the correct angle in the parasagittal plane, requiring several C-arm corrections. Conclusion: This study facilitates posterior fixation of coracoid process fractures and will inform the “virtual visualization” of coracoid process orientation.

<![CDATA[Why does radial head arthroplasty fail today? A systematic review of recent literature]]>

  • Since the introduction of the radial head prosthesis (RHP) in 1941, many designs have been introduced. It is not clear whether prosthesis design parameters are related to early failure. The aim of this systematic review is to report on failure modes and to explore the association between implant design and early failure.

  • A search was conducted to identify studies reporting on failed primary RHP. The results are clustered per type of RHP based on: material, fixation technique, modularity, and polarity. Chi-square tests are used to compare reasons for failure between the groups.

  • Thirty-four articles are included involving 152 failed radial head arthroplasties (RHAs) in 152 patients. Eighteen different types of RHPs have been used.

  • The most frequent reasons for revision surgery after RHA are (aseptic) loosening (30%), elbow stiffness (20%) and/or persisting pain (17%). Failure occurs after an average of 34 months (range, 0–348 months; median, 14 months).

  • Press-fit prostheses fail at a higher ratio because of symptomatic loosening than intentionally loose-fit prostheses and prostheses that are fixed with an expandable stem (p < 0.01).

  • Because of the many different types of RHP used to date and the limited numbers and evidence on early failure of RHA, the current data provide no evidence for a specific RHP design.

Cite this article: EFORT Open Rev 2019;4:659-667. DOI: 10.1302/2058-5241.4.180099




To evaluate the health-related quality of life (HRQoL) of patients who have undergone reverse shoulder arthroplasty (RSA) for rotator cuff arthropathy (RCA).


A retrospective study with 35 patients who underwent RSA from August 2007 to July 2015. We collected clinical data and applied the 36-item Short Form Health Survey (SF-36).


Of the 35 patients, 29 (82.9%) were female, and mean age was 75.71 years, ranging from 50 to 89 years. The dominant side was frequently affected (68.6%), and most of the cases were Hamada type 3 (57.1%). The Mackenzie approach was used in 30 patients (85.7%). Physical and mental HRQoL was not associated with severity of RCA before RSA. Lower scores for Physical Functioning, Role Physical, Bodily Pain, and Physical Component Summary (PCS) were associated with other orthopedic comorbidities. Vitality, Role Emotional, Mental Health, and Mental Component Summary (MCS) were significantly higher in patients without depression. Orthopedic comorbidity and depression predicted lower PCS and longer follow-up time predicted better PCS scores. Depression was also a predictor of the MCS.


Patients who had undergone RSA for RCA had good HRQoL. Longer follow-up time was associated with better HRQoL. Good results were maintained over the follow-up period. Level of evidence II, retrospective study.




To evaluate whether body mass index (BMI) 30 can be used as a cut-off point in decisions about whether or not to perform long head biceps (LHB) tenodesis, leading to a low rate of esthetic complaints, and to compare two tenodesis techniques.


Ninety-six patients underwent shoulder arthroscopy where tenotomy was performed separately in patients with a BMI ≥30 and was followed by tenodesis when BMI <30. The patients were assessed on the basis of their personal perception of the deformity and by 3 independent observers.


The patient's perception of esthetic deformity in the arm was 15.6%. In the tenotomy group (12.5%) and in the tenodesis group (17.9%) - (p = 0.476). Patients with rocambole-like tenodesis perceived the deformity in 13.2% of cases, while patients with anchor tenodesis noticed the deformity 27.8% (p = 0.263) of the time. There was no statistical difference in the perception of deformity among the independent examiners.


BMI 30 can be used as a cut-off point in decisions about whether or not to perform LHB tenodesis, leading to low rates of esthetic complaint by patients (12.5%). The rocambole-like tenodesis technique appears to be more able to avoid esthetic deformity of the arm after the LHB tenotomy according to the patients' observations. Level of evidence II, Prospective comparative study.

<![CDATA[Evidence-Based Review of Clinical Diagnostic Tests and Predictive Clinical Tests That Evaluate Response to Conservative Rehabilitation for Posterior Glenohumeral Instability: A Systematic Review]]>


Posterior glenohumeral instability is poorly understood and can be challenging to recognize and evaluate. Using evidence-based clinical and predictive tests can assist clinicians in appropriate assessment and management.


To review evidence-based clinical diagnostic tests for posterior glenohumeral instability and predictive tests that identify responders to conservative management.

Data Sources:

A comprehensive electronic bibliographic search was conducted using Embase, Ovid MEDLINE, PEDro, and CINAHL databases from their date of inception to February 2017.

Study Selection:

Studies were included for further review if they (1) reported on clinical diagnostic tests for posterior or posteroinferior instability of the glenohumeral joint, (2) assessed predictive clinical tests for posterior instability of the glenohumeral joint, and (3) were in English.

Study Design:

Systematic review.

Level of Evidence:

Level 4.

Data Extraction:

Data were extracted from the studies by 2 independent reviewers and included patient demographics and characteristics, index/reference test details (name and description of test), findings, and data available to calculate psychometric properties.


Five diagnostic and 2 predictive studies were selected for review. There was weak evidence for the use of the jerk test, Kim test, posterior impingement sign, and O’Brien test as stand-alone clinical tests for identifying posterior instability. Additionally, there was weak evidence to support the use of the painless jerk test and the hand squeeze sign as predictive tests for responders to conservative management. These findings are attributed to study design limitations, including small and/or nonrepresentative samples.


Clustering of thorough history and physical examination findings, including the aforementioned tests, may identify those with posterior glenohumeral instability and assist in developing management strategies.

<![CDATA[Arthroscopic double-row rotator cuff repair: a comprehensive review of the literature]]>

Rotator cuff repairs seek to achieve adequate tendon fixation and to secure the fixation during the process of biological healing. Currently, arthroscopic rotator cuff repair has become the gold standard. One of the earliest defined techniques is single-row repair but the inadequacy of single-row repair to precisely restore the anatomical footprint as well as the significant rates of retear especially in large tears have led surgeons to seek other techniques. Double-row repair techniques, which have been developed in response to these concerns, have various modifications like the number and placement of anchors and suture configurations.

When the literature is reviewed, it is possible to say that double-row repairs demonstrate superior biomechanical properties. In regard to retear rates, both double row and transosseous equivalent (TOE) techniques have also yielded more favorable outcomes compared to single-row repair. But the clinical results are conflicting and more studies have to be conducted. However, it is more probable that superior structural integrity will yield better structural and functional results in the long run. TOE repair technique is regarded as promising in terms of better biomechanics and healing since it provides better footprint contact. Knotless TOE structures are believed to reduce impingement on the medial side of tendons and thus aid in tendon nutrition; however, there are not enough studies about its effectiveness.

It is important to optimize the costs without endangering the treatment of the patients. We believe that the arthroscopic TOE repair technique will yield superior results in regard to both repair integrity and functionality, especially with tears larger than 3 cm. Although defining the pattern of the tear is one of the most important guiding steps when selecting the repair technique, the surgeon should not forget to evaluate every patient individually for tendon healing capacity and functional expectations.

<![CDATA[Acute postoperative pain after arthroscopic rotator cuff surgery: A review of methods of pain assessment]]>

Introduction: Pain can be severe during the first days after arthroscopic surgery, and acute pain is an important outcome in clinical trials of surgical technique or anaesthetic strategy. A standardized, validated method of assessing acute postoperative pain would improve the quality of clinical studies, and facilitate systematic reviews and meta-analyses. A step on the way towards this standard is to investigate the methods most commonly used in recent literature.

Methods: PubMed and CINAHL databases were searched, including studies of arthroscopic rotator cuff surgery with a primary pain-related outcome during the first postoperative week, published in English from 2012 to 2017.

Results: A total of 47 studies were included, all measuring pain intensity using a pain rating scale. Most frequently used was the visual analogue scale using the anchors “no pain” and “worst pain imaginable”, with recordings at 1, 2, 4, 6, 8, 12, and 24 hours postoperatively. A total of 34 studies recorded analgesic consumption, usually as average cumulated consumption in mg. Time to first analgesic request or first pain were recorded in 11 studies, and 4 different starting points were used.

Discussion: This review describes the currently most common methods of assessing acute postoperative pain in clinical trials of arthroscopic shoulder surgery involving rotator cuff repair, and the large variety of methods applied. Based on this study and international guidelines, several recommendations on how to measure and report postoperative pain outcomes in future trials are proposed.

<![CDATA[An Epidemiological Comparison of Elbow Injuries Among United States High School Baseball and Softball Players, 2005-2006 Through 2014-2015]]>


Pitching is a common mechanism of injury in baseball, with known risk factors for elbow injuries among adolescent pitchers.


Elbow injury rates and mechanisms will differ between high school baseball and softball players.

Study Design:

Descriptive epidemiology study.

Level of Evidence:

Level 3.


Baseball- and softball-related injury data from the 2005-2006 through 2014-2015 academic years were collected from the High School Reporting Information Online (RIO) Internet-based data collection tool. Athlete-exposure (AE) and injury data were collected by certified athletic trainers. Rate ratios (RRs) were calculated comparing injury rates in the 2 populations. Injury proportion ratios (IPRs) comparing elbow injuries in pitchers and nonpitchers were calculated as the proportion of all elbow injuries in pitchers divided by the proportion of all elbow injuries in nonpitchers.


A total of 214 elbow injuries in male baseball players occurred over 2,327,774 AEs, for an overall elbow injury rate of 0.92 per 10,000 AEs. A total of 75 elbow injuries were reported in female softball players over 1,731,644 AEs, for an overall rate of 0.43 per 10,000 AEs. The rate of elbow injury was significantly higher for baseball than softball (RR, 2.12; 95% CI, 1.64-2.77). A significantly greater proportion of elbow injuries in baseball were pitching-related compared with those from softball, with 50.2% occurring while pitching in baseball versus 11.0% in softball (IPR, 4.58; 95% CI, 2.35-8.93). If all injuries occurring during pitching were removed from both sports, the difference in elbow injury rate for baseball and softball would no longer be significant (RR, 1.19; 95% CI, 0.88-1.62).


The rate of elbow injuries is significantly higher in baseball than softball. This is attributable to differences in rates of pitching-related injuries between these 2 groups.

Clinical Relevance:

These results demonstrate that overhand pitching increases risk of elbow injury in high school athletes.

<![CDATA[Post-traumatic stiff elbow]]>

  • Post-traumatic and post-operative stiffness of the elbow joint is relatively common and may in pronounced cases markedly interfere with normal upper extremity function.

  • Soft-tissue contractures and heterotopic bone formation are two major causes of limited movement.

  • Extensive recent research has elucidated many of the pathways contributing to these conditions, but the exact mechanisms are still unknown.

  • In the early phase of soft-tissue contractures conservative treatment may be valuable, but in longstanding cases operative treatment is often necessary.

  • Several different options are available depending on the severity of the condition and the underlying offending structures. Surgical treatment may allow significant gains in movement but rarely complete restoration, and complications are not uncommon.

  • The following presentation reviews the recent literature on pathomechanisms and treatment alternatives.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170062

<![CDATA[Current concepts in the primary management of irreparable posterosuperior rotator cuff tears without arthritis]]>

  • Various procedures exist for patients with irreparable posterosuperior rotator cuff tears (IRCT). At present, no single surgical option has demonstrated clinical superiority.

  • There is no panacea for treatment and patients must be aware, in cases of palliative or non-prosthetic options, of an alarming rate of structural failure (around 50%) in the short term.

  • The current review does not support the initial use of complex and expensive techniques in the management of posterosuperior IRCT.

  • Further prospective and comparative studies with large cohort populations and long-term follow-up are necessary to establish effectiveness of expensive or complicated procedures such as superior capsular reconstruction (SCR), subacromial spacers or biological augmentation as reliable and useful alternative treatments for IRCT.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180002




To determine the relationship between the functional outcome achieved following Oberlin transfer, the cognitive level of the patient, and the time elapsed between the trauma event and surgery.


Eighteen patients with a traumatic injury to the brachial plexus (C5-C6 and C5-C7) were evaluated. Seventeen (94.4%) patients were males and one (5.6%) was female, with a mean age of 29.5 years (range 17-46 years). We evaluated the active range of motion, elbow flexion strength, and Disabilities of the Arm, Shoulder and Hand (DASH) and determined the correlation between the procedural outcome and the patient's cognitive level, as assessed by the Mini-Mental State Exam (MMSE).


We found statistically significant correlations between the MMSE scale and strength recovery (84.4%, p<0.001), which was classified as excellent, and between the MMSE and British Medical Research Council (BMRC) scales (78.4%, p>0.001), which classified cognitive level as good.


We found a positive correlation between cognitive capacity and functional outcome of patients submitted to Oberlin surgery. The time elapsed between trauma and the surgical procedure showed an inversely proportional correlation with the strength of recovery. Level of Evidence II, Retrospective Study.

<![CDATA[Association between alcohol consumption and rotator cuff tear]]>

Background and purpose — Long-term alcohol intake is associated with various negative effects on capillary microcirculation and tissue perfusion. We hypothesized that alcohol consumption might be a risk factor for both the occurrence and the severity of rotator cuff tears (RCTs).

Patients and methods — A case-control study was performed. We studied 249 consecutive patients (139 men and 110 women; mean age 64 (54–78) years) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group had 356 subjects (186 men and 170 women; mean age 66 (58–82) years) with no RCT. All participants were questioned about their alcohol intake. Participants were divided into: (1) non-drinkers if they consumed less than 0.01 g of ethanol per day, and (2) moderate drinkers and (3) excessive drinkers if women (men) consumed > 24 g (36 g) per day for at least 2 years.

Results — Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR = 1.7, 95% CI: 1.2–3.9; women: OR = 1.9, 95% CI: 0.94–4.1). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions.

Interpretation — Long-term alcohol intake is a significant risk factor for the occurrence and severity of rotator cuff tear in both sexes.

<![CDATA[Subscapularis tendon tears]]>

  • Tears of the subscapularis tendon have been under-recognised until recently. Therefore, a high index of suspicion is essential for diagnosis.

  • A directed physical examination, including the lift-off, belly-press and increased passive external rotation can help identify tears of the subscapularis.

  • All planes on MR imaging should be carefully evaluated to identify tears of the subscapularis, retraction, atrophy and biceps pathology.

  • Due to the tendency of the tendon to retract medially, acute and traumatic full-thickness tears should be repaired. Chronic tears without significant degeneration should be considered for repair if no contraindication exists.

  • Arthroscopic repair can be performed using a 30-degree arthroscope and a laterally-based single row repair; one anchor for full thickness tears ⩽ 50% of tendon length and two anchors for those ⩾ 50% of tendon length.

  • Biceps pathology, which is invariably present, should be addressed by tenotomy or tenodesis.

  • Timing of post-operative rehabilitation is dictated by the size of the repair and the security of the repair construct. The stages of rehabilitation typically involve a period of immobilisation followed by range of movement exercises, with a delay in active internal rotation (IR) and strengthening in IR.

Cite this article: EFORT Open Rev 2017;2:484–495. DOI: 10.1302/2058-5241.2.170015

<![CDATA[Arthroscopic remplissage]]>

  • Posterolateral humeral head defects can be large and engage on the anterior glenoid, and they usually contribute to anterior shoulder instability in 40% to 90% of cases.

  • The purpose of this study is to evaluate the results of the largest series of patients who underwent arthroscopic remplissage with Bankart repair for recurrent anterior shoulder instability due to associated Bankart lesions, with large and engaging (> 25% involvement) humeral Hill-Sachs defects (HSDs).

  • A total of 51 patients underwent arthroscopic Bankart repair with remplissage technique for the treatment of recurrent anterior glenohumeral instability with large and medial HSDs. Pre-operative imaging in all patients identified a Bankart lesion with an associated HSD that involved > 25% of the humeral head. The Rowe score was used to assess the patients clinically.

  • A total of 46 patients were male. The mean age of the patients was 28.7 years (18 to 43). The mean follow-up period was 31 months (20 to 39). At the final follow-up, three patients reported recurrence of instability (two dislocations and one subluxation). The mean Rowe score improved to 95.4 points (function, 45.5 of 50; stability, 26.4 of 30; motion, 8 of 10; pain, 8 of 10).

  • The arthroscopic remplissage technique with Bankart repair gave satisfactory results and is still considered to be an effective, safe and reliable procedure for treatment of glenohumeral instability in cases with large and medial HSDs.

Cite this article: EFORT Open Rev 2017;2:478–483. DOI: 10.1302/2058-5241.2.160070

<![CDATA[An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature]]>

Within orthopedics, the use of platelet-rich plasma (PRP) has been rapidly increasing in popularity, however, its true effectiveness has yet to be fully established. Several studies find that injecting PRP to the site of injury does not provide any significant benefit with respect to clinical outcomes; however, many others report the contrary. Due to the conflicting evidence and multiple meta-analyses conducted on the topic, a literature review of high-quality evidence on the use of PRP for common orthopaedic conditions was performed. Thus far, the evidence appears to suggest that PRP may provide some benefit in patients who present with knee osteoarthritis or lateral epicondylitis. On the other hand, evidence appears to be inconsistent or shows a minimal benefit for PRP usage in rotator cuff repair, patellar and Achilles tendinopathies, hamstring injuries, anterior cruciate ligament (ACL) repair, and medial epicondylitis. There is limited confidence in the conclusions from the published meta-analyses due to issues with statistical pooling, and limited subgroup analyses exploring the substantial heterogeneity across studies. Evidence-based clinicians considering the use of PRP in their patients with musculoskeletal injuries should be weary that the literature appears to be inconsistent and thus far, inconclusive.