Search

Fixation of clavicle fractures has now become a more popular option as it provides better outcome compared with conservative management. Wide-awake local anesthesia no tourniquet (WALANT) has been effectively used in plating of distal radius and olecranon fractures. This paper expands the usage of WALANT into the shoulder girdle, namely plating of the clavicle that has not been described. The operation is typically performed under general anesthesia. We report a case series of 16 patients who successfully underwent fixation of the clavicle under the wide-awake technique. The clavicle fractures were grouped under the AO Fracture Classification. The WALANT solution comprised 1% lidocaine, 1:100,000 epinephrine, and 10:1 sodium bicarbonate. A total of 40 mL was injected in each patient with 10 mL subcutaneously along the clavicle followed by 30 mL subperiosteally at multiple intervals and directions. The Numerical Pain Rating Score was 0 during WALANT injection and during surgery except for 2 patients with Numerical Pain Rating Scores of 1 and 2, respectively, during reduction. We conclude that clavicle plating under WALANT is a good alternative option of anesthesia. [ABSTRACT FROM AUTHOR]

Background: Controversy exists regarding the optimal technique of subscapularis mobilization during shoulder arthroplasty. The purpose of this study was to compare healing rates and subscapularis fatty infiltration in patients undergoing a lesser tuberosity osteotomy (LTO) versus subscapularis peel for exposure during shoulder arthroplasty. Materials and methods: Eighty-seven patients, with a mean age of 67.8 ± 10.9 years, undergoing shoulder arthroplasty, were randomized to receive either an LTO (n = 43) or peel (n = 44). Computed tomography scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included healing rates and subscapularis Goutallier fatty infiltration grade, as well as subscapularis strength and Western Ontario Osteoarthritis of the Shoulder Index and American Shoulder and Elbow Surgeons outcome scores. Results: Computed tomography imaging was available in 91% (n = 79) of the cohort. The healing rates for the peel (100%) and for the LTO (95%) did not differ significantly (P = .493). Preoperatively, the mean fatty infiltration grade for the peel (mean, 0.53) was not significantly different (P = .925) from the LTO (mean, 0.54). Postoperatively, the Goutallier mean fatty infiltration grade for the peel (mean, 0.95) did not differ significantly (P = .803) from the LTO (mean, 0.9). A significant increase in subscapularis fatty infiltration grade occurred postoperatively from the preoperative status (peel, P = .003; LTO, P = .0002). No statistically significant associations were observed between postoperative fatty infiltration grades and subscapularis strength, Western Ontario Osteoarthritis of the Shoulder Index scores, or American Shoulder and Elbow Surgeons scores. Discussion: No statistically significant differences were observed in the healing rates or subscapularis fatty infiltration grades between the peel and the LTO. This trial does not show any clear difference in radiologic and clinical outcomes of one subscapularis management technique over the other. [Copyright &y& Elsevier]

Hypothesis: The clavicle serves as a strut between the thorax and scapula, and lack of this function could affect shoulder mobility. We hypothesized that clavicular discontinuity changes shoulder kinematics, particularly affecting scapular motion. Materials and methods: The study used 14 cadaveric shoulders. Cadavers were stabilized in the sitting position. Manual elevation in the sagittal, scapular, and coronal planes was performed in the intact and clavicular discontinuity models. The thorax-scapula distance and 3-dimensional scapular motion during shoulder elevation were recorded using an electromagnetic tracking device. The differences between the 2 experimental models at each position were analyzed. Results: Clavicular discontinuity resulted in a decreased thorax-scapula distance and in reduced external rotation, upward rotation, and posterior tilting of the scapula. The kinematic changes were observed during elevations in all 3 planes but were greatest in the sagittal plane compared with the scapular and coronal planes. Conclusions: The findings of this study revealed that discontinuity of the clavicle affects shoulder kinematics. Because of its anatomic shape and position, the clavicle stabilizes the external, upward, and posterior rotation of the scapula during arm movement. This function of the clavicle may assist glenohumeral joint motion and help prevent subacromial impingement. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the biomechanical effects of latissimus dorsi transfer in a cadaveric model of massive posterosuperior rotator cuff tear. Methods: Eight cadaveric shoulders were tested at 0°, 30°, and 60° of abduction in the scapular plane with anatomically based muscle loading. Humeral rotational range of motion and the amount of humeral rotation due to muscle loading were measured. Glenohumeral kinematics and contact characteristics were measured throughout the range of motion. After testing in the intact condition, the supraspinatus and infraspinatus were resected. The cuff tear was then repaired by latissimus dorsi transfer. Two muscle loading conditions were applied after latissimus transfer to simulate increased tension that may occur due to limited muscle excursion. A repeated-measures analysis of variance was used for statistical analysis. Results: The amount of internal rotation due to muscle loading and maximum internal rotation increased with massive cuff tear and was restored with latissimus transfer (P < .05). At maximum internal rotation, the humeral head apex shifted anteriorly, superiorly, and laterally at 0° of abduction after massive cuff tear (P < .05); this abnormal shift was corrected with latissimus transfer (P < .05). However, at 30° and 60° of abduction, latissimus transfer significantly altered kinematics (P < .05) and latissimus transfer with increased muscle loading increased contact pressure, especially at 60° of abduction. Conclusion: Latissimus dorsi transfer is beneficial in restoring humeral internal/external rotational range of motion, the internal/external rotational balance of the humerus, and glenohumeral kinematics at 0° of abduction. However, latissimus dorsi transfer with simulated limited excursion may lead to an overcompensation that can further deteriorate normal biomechanics, especially at higher abduction angles. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine the effect of intraarticular pressure and the long head of biceps (LHB) tendon on passive translations of the glenohumeral (GH) joint. Tenotomy or tenodesis of the LHB are common procedures but the consequences on shoulder stability are unclear. Methods: A novel shoulder laxity testing rig permitting six degrees of freedom of motion was used to test passive translations in anterior, posterior, superior, and inferior directions in 10 cadaveric shoulders. Specimens were tested in neutral rotation with 0°, 30°, 60°, or 90° of GH abduction in the scapular plane. Translation loads up to 30N were applied, and displacements measured in an intact joint, vented joint and with the biceps tendon loaded (20N). Results: The GH joint was most lax at 30° GH abduction. Venting of the joint increased translations in all positions and directions (mean ± standard error of the mean), the greatest difference was 12.5 (3.9) mm in the anterior–posterior direction and 7.5 (3.9) mm in the SI direction. Loading the LHB tendon with 20N decreased translations in all directions. The largest difference was observed in the anterior direction, 13.9 (2.8) mm (P < .0005) and inferior direction, 12.0 (2.8) mm (P < .0005). Conclusion: Negative intraarticular pressure and the LHB contribute significantly to overall passive stability of the GH joint. Surgical division or transfer of the LHB tendon may impact on joint stability and function. [ABSTRACT FROM AUTHOR]

Background: The usual mechanism of anterior shoulder dislocation is widely believed to be a combination of glenohumeral joint abduction, extension, and external rotation forces, even though no published reports to date have investigated the arm position of anterior shoulder dislocation in detail. Understanding the exact position of anterior shoulder dislocations is important for the management of anterior shoulder instability. Materials and methods: The study included 40 shoulders of 38 patients (32 males, 6 females), aged 28.0 (range, 13-73) years with symptomatic post-traumatic recurrent anterior shoulder instability. While patients were under general anesthesia, but before shoulder-stabilizing surgery, we evaluated the angle of external rotation with 90° elevation in the scapular plane at which the humeral head showed anterior translations over the glenoid rim. Results: The center of anterior instability at 90° elevation in the scapular plane was at 25.9° of external rotation. Anterior translations were detected in the range of 3.4° of internal rotation to 55.1° of external rotation, and no shoulders (except one) showed anterior translation at maximal external rotation. Conclusions: Gross anterior translation was seen in the middle range of rotation at approximately 25° of external rotation, and anterior translation decreased close to the end of external and internal rotation. Shoulders with grade III translation showed anterior translation in a wider range of rotation, especially in external rotation. These data will help to further our understanding of the management and the prevention of anterior shoulder dislocations. [ABSTRACT FROM AUTHOR]

Background: Malposition of the glenoid component can result in premature component loosening or instability. This study was designed to test the ability of an experienced shoulder surgeon to position the glenoid component using standard preoperative planning and surgical bone preparation. Materials and methods: Thirteen patients having primary total shoulder arthroplasty were evaluated using 3-dimensional surgical simulator. Ideal version was considered to have version as close to perpendicular to the plane of the scapula, with complete contact of the back side of the component on glenoid bone and maintenance of the center peg of the component within bone. Results: The average retroversion angle was 13° (mean, standard deviation [SD] 12°), with a range of 1-42°. In 7 of these 13 cases, preoperative glenoid retroversion was greater or equal to 10°. In 3 cases, the component was malpositioned with greater than 10° of ideal version. In cases with less than 10° of preoperative retroversion, the glenoid component was placed within 10° of ideal version in all cases. Conclusion: Traditional methods to correct moderate to severe glenoid deformity and place the glenoid component within 5° of the ideal position are not consistent. Optimal glenoid component placement can be achieved when there is minimal bone deformity. Retroversion greater or equal to 20° makes it difficult to place a pegged glenoid component perpendicular to the plane of the scapula by asymmetric reaming without center peg perforation. [Copyright &y& Elsevier]

Background: The subscapularis is the strongest rotator cuff muscle. Bristow-Latarjet procedure may impair subscapularis function. The aim of the study is to describe the difference in isometric subscapularis (SSC) strength after L-shape tenotomy versus muscle split in patients who underwent to Bristow-Latarjet procedure. Materials and methods: From 2000 to 2006, we enrolled 376 patients for Bristow-Latarjet procedures. We identified 2 groups according to the subscapularis approach. Group A included 264 subjects with subscapularis L shape tenotomy; group B included 112 subjects with subscapularis muscle split. The subscapularis function was assessed with lift-off and belly-press tests. Isometric strength of rotator cuff muscle was assessed at an average follow-up of 45 months in group A and 42 months in group B, recording the maximum isometric peak torque (PT) (N), maximum isometric couple (Nm), relative strength index (N/Kg), strength, couple and external/internal rotator ratio. Constant and Rowe were used as scores. Results: Subscapularis assessment in the overall population showed 33 cases (8.8%) with a positive Lift-off test and 30 cases (8%) with a positive belly-press test. Rowe and Constant scores increased in both groups (P < .01). The mean PT in group A was lower of 24,8 Nw than group B (P < .01); similarly, the max PT values of group A were lower of 26.1 Nw than group B (P < .01). Conclusion: L-shaped tenotomy in Bristow-Latarjet procedure has a weakening effect on the subscapularis and for these reasons we strongly recommend the muscle split approach for an optimal subscapularis function recovery. [Copyright &y& Elsevier]

Background: Despite improved results with reverse shoulder arthroplasty (RSA), questions still remain regarding certain technical aspects of the operation. One particular area of question is the effect of subscapularis repair on complication rates, dislocation, pain, and overall range of motion. Some authors suggest that when a deltopectoral approach is used, not repairing the subscapularis leads to a higher complication rate, especially for dislocation. Materials and methods: From a reverse total shoulder arthroplasty database of 3 surgeons at 1 institution, we identified 55 patients who underwent RSA using the deltopectoral approach without subscapularis repair and 65 patients with subscapularis repair. Results: Complications were documented in 11 of 55 shoulders (20%) without subscapularis repair and in 13 of 65 shoulders (20%) with subscapularis repair. Dislocation occurred in 3 shoulders in the nonrepair group and in 2 shoulders in the repair group. These data indicate that nonrepair of the subscapularis did not have a significant effect on the risk of any complication, dislocation, infection, disassociation, or function. Conclusion: Repairing the subscapularis has no appreciable effect on complication rate, dislocation events, or range of motion gains and pain relief. [Copyright &y& Elsevier]

Background: Multiple biomechanical studies have analyzed the potential influence of inferior glenosphere tilt on scapular notching in reverse total shoulder arthroplasty (RTSA). The purpose of this study was to clinically determine the likelihood of scapular notching in a series of shoulders, with the glenospheres placed in neutral versus inferior tilt. Methods: From a database of all RTSA performed by the senior author, shoulders with a Delta III-type prosthesis and minimum 12-month follow-up (71 shoulders) were included. Notching in shoulders with neutrally placed glenosphere base plates (Group 1) was compared to notching with 10-15° inferiorly tilted base plates (Group 2). The prosthesis-scapular border angle (PSBA) was also defined and used to determine whether the radiographically quantified amount of inferior tilt was predictive of scapular notching independent of group assignment. Results: There were no significant differences in the grade of notching or incidence of notching between groups 1 and 2 after adjusting for length of follow-up and prosthesis selection. The PSBA was also not predictive of scapular notching. Conclusion: Despite previous biomechanical studies’ predictions that inferiorly tilting the glenosphere might reduce inferior scapular neck impingement and subsequent scapular notching, our data showed no difference at 1-year follow-up. [ABSTRACT FROM AUTHOR]

Hypothesis: We hypothesized that posterior capsule thickness (PCT) would be greater on the dominant arm compared to the non-dominant arm. We also hypothesized that PCT would negatively correlate with glenohumeral internal rotation and scapular upward rotation. In addition, PCT would positively correlate with glenohumeral external rotation. However, currently PCT has not been measured nor have correlations been identified to exist with glenohumeral and scapular motion. Therefore, the purpose of the study was to determine if the posterior capsule was hypertrophied on the dominant arm and to identify if relationships exist with glenohumeral internal rotation (IR), external rotation (ER), and scapular upward rotation (SUR). Materials and methods: PCT was measured using a 10-MHz transducer. Glenohumeral IR and ER was measured supine using a digital inclinometer. SUR was measure at 0°, 60°, 90°, and 120° of glenohumeral abduction using a modified digital inclinometer. Results: PCT was greater on the dominant compared with the nondominant arm (P = .001). A negative correlation was found between PCT and IR (–0.498, P = .0001). A positive correlation was found between PCT and ER (0.450, P = .002) and between PCT and SUR at 60°, 90°, and 120° of glenohumeral abduction (0.388, P = .006; 0.327, P = .023; 0.304, P = .036, respectively). Discussion: This in vivo study demonstrated a hypertrophied posterior capsule and its association with GIRD, ER, and SUR. These observations suggest that PCT does occur on the throwing arm of baseball players and is linked with glenohumeral and scapular alterations. Conclusions: This methodology could be used as a noninvasive screening evaluation for overhead athletes to identify those who may be at risk for shoulder injuries due to excessive capsular thickening. [ABSTRACT FROM AUTHOR]

Background: Alterations in scapular motion frequently are seen in association with various shoulder disorders. It is common clinically to compare the pathological shoulder with the contralateral shoulder, in spite of arm dominance, to characterize the disorder. However, there have been few articles that test the underlying assumption that dominant and nondominant shoulders exhibit comparable dynamic kinematics. The purpose of this study was to compare the 3-dimensional (3-D) scapular kinematics of dominant and nondominant shoulders during dynamic scapular plane elevation using 3-D–2-D (2-dimensional) registration techniques. Materials and methods: Twelve healthy males with a mean age of 32 years (range, 27–36) were enrolled in this study. Bilateral fluoroscopic images during scapular plane elevation and lowering were taken, and CT-derived 3-D bone models were matched with the silhouette of the bones in the fluoroscopic images using 3-D–2-D registration techniques. Angular values of the scapula and scapulohumeral rhythm were compared between dominant and nondominant shoulders with statistical analysis. Results: There was a significant difference in upward rotation angles between paired shoulders (P < .001), while significant differences were not found in the other angular values and scapulohumeral rhythm. The dominant scapulae were 10° more downwardly rotated at rest and 4° more upwardly rotated during elevation compared to the nondominant scapulae. Discussion/Conclusion: Scapular motion was not the same between dominant and nondominant arms in healthy subjects. The dominant scapula was rotated further downward at rest and reached greater upward rotation with abduction. These differences should be considered in clinical assessment of shoulder pathology. [ABSTRACT FROM AUTHOR]

Hypothesis: Reverse shoulder arthroplasty is growing in popularity for patients with deficient rotator cuffs; however, the phenomenon of scapular notching continues to be a concern. This study examined the effects of humeral component version in the Aequalis Reversed Shoulder Prosthesis (Tornier, Edina, MN) on impingement of the humeral prosthesis against the scapula to test the hypothesis that the mechanical contact of the humeral component with the scapular neck is influenced by the version of the humeral component. Materials and methods: Seven shoulders from deceased donors were tested after the Aequalis Reversed Shoulder was implanted. The deltoid, pectoralis major, and latissimus dorsi were loaded based on physiologic cross-sectional area. The degree of internal and external rotation when impingement, subluxation, or dislocation occurred was measured at 0°, 30°, and 60° glenohumeral abduction in the scapular plane. Testing was performed with the humeral component placed in 20° of anteversion, neutral version, 20° of retroversion, and 40° of retroversion. Results: Maximum external rotation at 0° abduction was –1° ± 4° at 20° anteversion, 15° ± 3° at neutral, 28° ± 4° at 20° retroversion, and 44° ± 5° at 40° retroversion (P < .05). Maximum internal rotation at 0° abduction was 128° ± 9° at 20° anteversion, 112° ± 9° at neutral, 99° ± 8° at 20° retroversion, and 83° ± 8° at 40° retroversion (P < .05). Maximum external rotation at 30° abduction was 70° ± 6° at 20° anteversion, 84° ± 7° at neutral, 97° ± 6° at 20° retroversion, and 110° ± 5° at 40° retroversion (P < .05). There was no limitation to internal rotation at 30° abduction. No impingement occurred at 60° abduction. Discussion: Version of the humeral component plays a role in range of motion and impingement in reverse total shoulder arthroplasty. Anteversion can significantly decrease the amount of external rotation achievable after reverse total shoulder surgery. Conclusion: Placing the Aequalis Reversed Shoulder humeral component at between 20° and 40° of retroversion more closely restores a functional arc of motion without impingement. [Copyright &y& Elsevier]

Hypothesis: Elevation of the arm during a dynamic scaption exercise will result in a progressive narrowing of the acromiohumeral interval (AHI); however, the addition of a load will not significantly affect the AHI in healthy baseball players. Materials and methods: Thirteen healthy baseball players performed a seated scaption exercise from 0° to 90°, with and without a normalized additional load. Dynamic AHI intervals were measured using digital fluoroscopic videos with the arm at the side, and at 30°, 45°, 60°, and 75° of humeral elevation. Results: The mean AHI for unloaded and loaded scaption decreased significantly (P < .001) from the arm at the side (12.7 mm) until 45° (4.9 mm), further changes in the mean AHI between 45°, 60°, and 75° were not significantly different. Generally, loaded scaption resulted in smaller AHI values at 45°, 60°, and 75°; however, only the differences at 60° (P = .005) and 75° (P = .003) were significant. Discussion: Narrowing of the AHI during dynamic motion was similar to previous reports of static AHI, with the exception of the trend towards widening of the AHI seen at 75° during both conditions. The additional AHI narrowing observed at 60° and 75° during the loaded exercise may indicate that scapular positioning is more influential in this range. Conclusion: An additional AHI narrowing of 11% during loaded scaption, did not result in any clinical impingement during the exercise, but may have more serious implications in other healthy and pathologic populations. [Copyright &y& Elsevier]

Hypothesis: Our hypothesis was that tightening of the posterior capsule would lead to increased subacromial pressure and increased superior translation during active abduction in the scapular plane. Background: Subacromial impingement syndrome is a painful condition that occurs during overhead activities as the rotator cuff is compressed in the subacromial space. Unrecognized secondary causes of subacromial impingement may lead to treatment failure. Posterior capsular tightness, believed to alter glenohumeral joint kinematics, is often cited as a secondary cause of SI; however, scientific evidence is lacking. The primary objective of this study was to evaluate the effect of posterior capsular tightening on peak subacromial pressure during abduction in the scapular plane. Materials and methods: Ten fresh frozen shoulder specimens from deceased donors were mounted on a custom shoulder simulator. With the scapula fixed, the deltoid and rotator cuff muscles were loaded in discrete static steps with a constant ratio to elevate the humerus in the scapular plane. The treatment order (no tightening, 1-cm, and 2-cm tightening of the posterior capsule) was randomly assigned to each specimen. Peak subacromial contact pressure and glenohumeral kinematics at the peak pressure position were compared using a repeated measures analysis of variance. Results: Peak subacromial pressures (mean ± standard deviation) were similar between treatment groups: 345 ± 152, 410 ± 213, and 330 ± 164 kPa for no tightening, 1-cm, and 2-cm tightening of the posterior capsule respectively (P > .05). No significant differences were found for superior or anterior translations at the peak pressure position (P > .05). Discussion: Posterior capsular tightening, as a sole variable, did not contribute to a significant increase in peak subacromial pressure during abduction in the scapular plane. A similar study simulating active forward flexion is necessary to fully characterize the contribution of posterior capsular tightness to subacromial impingement. Conclusion: Tightening of the posterior capsule did not increase subacromial pressure, or increase superior or anterior translation during abduction in the scapular plane. [Copyright &y& Elsevier]

Hypothesis: The purpose of this study was to investigate the 3-dimensional (3-D) orientation of the glenoid and scapular planes. Different definitions of the glenoid plane were used and different planes measured, and we hypothesed that the 3-D plane with the least variation would be best to define the most reliable glenoid plane. Methods: We studied 150 CT scans from nonpathological shoulders from patients between 18 and 80. The scapular plane and 5 different glenoid planes were determined: inferior, anterior, posterior, superior, and neutral. All plane versions and inclination angles were measured. Because all examinations were done in a standardized position to the coronal, sagittal, and transverse planes of the body, the scapular plane could be defined versus the coronal, sagittal, and transverse planes of the body. Results: The version (mean, 3.76) of the inferior glenoid plane showed a significantly lower standard deviation than the version of the anterior (P < .001), posterior (P =.001), and superior (P =.001) glenoid plane (ANOVA). For inclination all planes have a similar variance. The scapular plane was different between gender (P =.022) and correlated with age. Conclusion: This study showed that the retroversion of the inferior glenoid is reasonably constant. The osseous anthropometry of the inferior glenoid can offer a reproducible point of reference to be used in prosthetic surgery of the shoulder. [Copyright &y& Elsevier]

Purpose: To report the technique and outcome of subscapularis (SSC) lengthening in shoulder arthroplasty. Procedure: When external rotation measures less than 20°, a coronal subscapularis lengthening is performed. This utilizes the interval between the anterior shoulder capsule and subscapularis to titrate the correct amount of anatomic length. Results: Average preoperative passive ER was -2°. Average postoperative ER was 48°. Belly press was graded as normal in 13 pts, mild in 12 pts, and poor in 2 pts. Conclusion: Subscapularis tendon lengthening provides a large surface area for tendon healing and allows anatomic length to be restored. Subscapularis lengthening may preserve a better length-tension relationship of the SSC muscle in shoulders with significant IR contracture undergoing shoulder arthroplasty. [Copyright &y& Elsevier]

Hypothesis: The external rotation lag sign (ERLS) is a test designed to assess the integrity of the supraspinatus (SSP) and infraspinatus tendons. This study intends to determine the electromyographic pattern of shoulder girdle muscles during a series of ERLS tasks conducted at full adduction and 20° of elevation to figure out the better way to perform the test. The second aim is to assess the final contribution of the SSP to the ERLS by measuring the amount of lag after an SSP block induced by botulinum toxin. Materials and methods: Ten subjects with healthy shoulders were examined by a series of five ERLS trials at full adduction and 20° of elevation in the scapular plane. Surface and intramuscular electromyographic activity of the shoulder girdle muscles was recorded and normalized against either the mean activity of all the muscles or the peak activity. The lag was simultaneously measured by an infrared optoelectronic system before and after the selective block of the SSP muscle. Results: The SSP contributed 20% of the electrical activities during the ERLS, which was found to be significantly greater than the contributions of the other shoulder girdle muscles, except for the infraspinatus. The selective block of the SSP caused a lag of 4° in all 10 shoulders at 20° but no increase in lag at 0° of elevation. Conclusions: The ERLS is potentially able to detect an isolated SSP tear if the test is performed correctly (20° of abduction). The deltoid and biceps muscles are almost silent during the test, limiting confounding factors. [Copyright &y& Elsevier]

Hypothesis: The scapulothoracic (ST) joint affects glenohumeral (GH) joint function. We observed 3-dimensional scapular motions during arm elevation and lowering to identify the scapulohumeral rhythm in healthy subjects and to compare it between the dominant and nondominant arms. Materials and methods: Twenty-one healthy subjects participated in this study. Participants randomly elevated and lowered the arms in the scapular plane, and data were recorded by a computerized 3-dimensional motion analyzer at each 10° increment. Results: Of the 42 shoulders, 21 showed a greater ratio of GH motion relative to ST motion whereas the other 21 showed a smaller ratio of GH motion relative to ST motion. The angle of upward rotation of the scapula showed a statistically significant difference between both types. The mean maximum angles of upward rotation, posterior tilting, and internal rotation were 36.2° ± 7.0°, 38.7° ± 5.7°, and 36.8° ± 12.2°, respectively. No significant difference was found in angles of 3 scapular rotations between the dominant and nondominant arms. Discussion: These results indicate that there are 2 distinctly different scapulohumeral rhythms in healthy subjects but without a significant difference between dominant and nondominant arms. These findings should be referred to when one is interpreting kinematics in a variety of shoulder disorders. [Copyright &y& Elsevier]

Background: The contribution of scapulothoracic and glenohumeral motion to overall shoulder motion remains difficult to determine. We sought to determine the exact ratio between these two motion components in order to better understand overall shoulder kinematics in asymptomatic individuals in unconstrained reaching. Materials and methods: This study assessed shoulder motion using bone-fixed sensors to quantify scapulohumeral motion during unconstrained raising and lowering of the arm. Electromagnetic tracking devices rigidly fixed to bone pins recorded active scapular and humeral motion. Results: We found a significant difference in the ratio of glenohumeral elevation to scapular upward rotation during arm raising (2.3) and lowering (2.7). Each degree of glenohumeral elevation yielded scapular upward rotation of 0.43° (raising) compared with downward rotation of 0.37° (lowering), across the motion arc. Until 125° of glenohumeral elevation, the scapula internally rotated and then externally rotated with further elevation. Scapular upward rotation and posterior tilting progressively increased until maximal elevation. Scapulohumeral rhythm was greatest in the first increment of raising the arm and higher overall when lowering the arm. Discussion: Understanding these data allows improved evaluation of potential motion abnormalities in patients with shoulder pathology and may improve treatment for restoration of normal shoulder motion. [Copyright &y& Elsevier]

Hypothesis: This study investigated the feasibility of quantifying the coactivation levels in the evaluation of synergisms of the scapular stabilizing muscles during the elevation and lowering of the arms. This method, which quantifies the overlapping area of the normalized electromyographic (EMG) activity, could be applicable in assessing such muscular synergies. Materials and methods: Both shoulders of 10 healthy volunteers were assessed. The coactivation of 3 synergic muscular groups (upper, middle and lower trapezius; upper trapezius and serratus anterior; middle trapezius and serratus anterior) and the isolated electromyographic activity of each muscle were analyzed. Results: Analysis of variance revealed that the coactivation values between the synergic groups were different from the isolated levels of each respective muscle for both movements (24.42 < F < 40.12; df=6; p < 0.001). The coactivation values of all groups during elevation were different from those during the lowering of the arms (13.31

From 1981 to 2001, 91 shoulder resections were performed to treat shoulder girdle tumors (64 primary and 27 metastatic) in 90 patients (53 male and 37 female patients). The mean age was 34 years in patients with a primary tumor and 61 years in those with metastases. There were 7 partial scapulectomies, 13 total scapulectomies, 56 proximal humeral resections, 5 diaphyseal resections, 5 total shoulder girdle resections (Tikhoff-Linberg procedure), and 5 other procedures performed. Prosthesis implantation was carried out in 41 cases, autologous fibular transposition was done in 19, and massive homologous bone grafting was done in 4. Of the patients, 37 were clinically reviewed with a mean follow-up of 4.7 years (range, 1-20 years) by use of the recommendations of the Musculoskeletal Tumor Society for pain, function, position of hand, lifting ability, manual dexterity, and satisfaction. Nine patients were reviewed via a questionnaire and telephone interview. Twenty-six had died, and eighteen were lost to follow-up. The best results were achieved after partial scapulectomy and after humeral resection reconstructed with fibular transposition, when the function of the rotator cuff was preserved. After total scapulectomy and after humeral resection with the implantation of a tumor endoprosthesis, the function of the shoulder remained moderate because the rotator cuff was damaged. The overall satisfaction was generally good after all types of shoulder resections as a result of pain relief, preserved hand function, and improvement of psychological status. Patients can compensate extremely well by using the preserved joints and the contralateral upper limb; therefore, patient satisfaction does not rely on shoulder function alone. [Copyright &y& Elsevier]

The goal of this study was to measure 3-dimensional shoulder motion by use of a direct invasive technique during 4 different arm movements in healthy volunteers. Eight subjects with healthy shoulders were recruited. Optoelectronic marker carriers (ie, infrared light-emitting diodes) were mounted on bone pins, which were inserted into the lateral scapular spine. Subjects performed 4 different arm movements while the motion was being recorded by a precision optoelectronic camera. Joint angles were calculated in 3 dimensions. Intraclass correlation coefficients and root-mean-square differences were calculated as measures of reliability. During abduction, the scapula tipped posteriorly (44° ± 11°), rotated upward (49° ± 7°), and rotated externally (27° ± 11°). For reaching, the scapula consistently rotated upward (17° ± 3°) and rotated internally (18° ± 6°) whereas tipping was generally less than 10° (5° ± 2°). Overall, the range of scapular movement for the hand behind the back was small and variable, with most rotations not exceeding 15°. For horizontal adduction, the scapula tipped anteriorly (8° ± 3°), rotated upward (5° ± 2°), and rotated internally (27° ± 6°). These scapular rotations provide normative data that will be useful for diagnosing scapular dysfunction. [Copyright &y& Elsevier]

Fractures of the clavicle are common and most often occur in the middle third. The clavicle has several important functions, each of which may be affected after fracture and malunion. In this retrospective study, we reviewed 132 patients with united fractures of the middle third of the clavicle after conservative management. Residual symptoms and overall patient satisfaction after treatment were assessed through a questionnaire. Clavicular shortening after union was calculated on a standardized anteroposterior chest radiograph. Intraobserver variability and interobserver variability of measurements by use of this method are insignificant. The mean follow-up was 30 months (range, 12-43 months). The mean modified Constant score was 84 (range, 62-100). Of the patients, 34 (25.8%) were dissatisfied with the result of their management. Final clavicular shortening of more than 18 mm in male patients and of more than 14 mm in female patients was significantly associated with an unsatisfactory result. [Copyright &y& Elsevier]

Changes in upper body posture, colloquially termed forward head posture (FHP), are considered to be an etiologic factor in the pathogenesis of subacromial impingement syndrome (SIS). The literature suggests that postural deviations associated with FHP follow distinct patterns involving an increase in the thoracic kyphosis angle and a downwardly rotated, anteriorly tilted, and protracted scapula, which in turn leads to increased compression in the subacromial space. These postural changes are thought to occur concurrently with an imbalance of the musculature, and conservative rehabilitation commonly involves addressing both posture and muscle imbalance. There is a paucity of evidence supporting the hypothesis that posture and muscle imbalance are involved in the etiology of SIS. The purpose of this study was to investigate whether FHP was associated with an increased thoracic kyphosis, an altered position of the scapula; and a reduction in glenohumeral elevation range. Selected sagittal and frontal plane postural measurements were made in 60 asymptomatic subjects and 60 subjects with SIS. The findings suggested that upper body posture does not follow the set patterns described in the literature, and further research is required to determine whether upper body and scapular posture and muscle imbalance are involved in the pathogenesis of SIS. [Copyright &y& Elsevier]

A modified technique of scapulothoracic fusion was used in 6 patients who did not have muscular dystrophy and who were later evaluated clinically. The cause of the painful winging of the scapula was traumatic disruption of the trapezius and the accessory nerve in 3 patients, injury to the brachial plexus in 2, and Sprengel’s deformity in 1. To obtain fusion, double wires were passed around each of 4 ribs. A Rush pin was then contoured to fit the curvature of the scapula, and the wires were passed through the scapula and tied over the Rush pin with bone graft. The mean age of the patients was 30 years (range, 22–39 years), with a mean follow-up of 49 months. The mean increase in elevation was 18° with significant pain relief. The medium-term results showed that this operation was successful in achieving stability of the scapula while improving pain and function in patients without facioscapulohumeral dystrophy. [Copyright &y& Elsevier]

Hypothesis We aimed to report our experience in treating congenital pseudarthrosis of the clavicle (CPC). Materials and methods A retrospective search of the archive of our institute was performed; 27 cases (12 male and 15 female patients) affected by CPC were recorded. Among these patients, 19 underwent surgical intervention for cosmetic appearance between 1960 and 2015. Of 19 patients, 18 were treated by pseudarthrosis resection and stabilization with a Kirschner wire, whereas in 1 case, the osteosynthesis was performed with a plate. Iliac crest bone autograft was used in 15 patients, whereas 4 patients were treated with a fibular allograft. Results The mean follow-up period was 36.3 ± 49.1 months. Bone healing was achieved in 14 of 19 operated cases (74%); none of the patients had complaints regarding cosmetic abnormalities or unesthetic appearance. All the operated patients were pain free, range of motion was complete, and no other subjective anomalies were found. No vascular or neurologic complications were observed. However, the use of allograft was associated with high rates of nonunion in this case series ( P = .037). Conclusion CPC can be satisfactorily treated by K-wire fixation and autologous iliac crest bone grafting, which showed better results in terms of functional and cosmetic outcome. [ABSTRACT FROM AUTHOR]

Background: Forequarter amputation (FQA) is reserved for large, multifocal, or recurrent tumors affecting the shoulder and upper extremity. Although it is performed less frequently with the advancement of limb salvage surgery, FQA remains an important treatment in select patients. The purpose of this study is to illustrate the surgical technique in a case series of 4 patients. Methods: Between 2010 and 2012, 4 patients (mean age, 61 years; range, 36-78 years) presented with malignant disease of the upper extremity that was not amenable to or had failed limb salvage. All patients had FQA by the illustrated anterior clavicular osteotomy technique. Patient data were retrospectively reviewed from preoperative workup until last follow-up or death. Results: All patients had tumors that involved major neurovascular structures of the upper extremity and shoulder girdle. One presented with neuroendocrine carcinoma and has achieved local control after FQA. Three presented with high-grade sarcoma. One of these had recurrence after prior limb salvage and neoadjuvant radiation and unfortunately succumbed to metastatic disease 6 months after FQA. An additional sarcoma patient who presented after shoulder arthroscopy for a “labral cyst” with recurrent and fulminant synovial sarcoma succumbed to her disease. The remaining sarcoma patient has had no recurrence and minimal phantom pain at last follow-up. Discussion: Obtaining vascular control early in the procedure is crucial to minimize blood loss. When it is indicated, FQA is a relatively safe and reliable procedure for dealing with otherwise challenging tumors of the shoulder girdle and upper extremity. [Copyright &y& Elsevier]