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Background The etiology of instability following reverse total shoulder arthroplasty (RTSA) remains incompletely understood. The purpose of this study was to describe the shared characteristics, etiologies, and outcomes of early and late dislocations requiring operative revision. Methods We identified all patients at our institution who underwent operative revision of an RTSA for instability. Baseline demographic, clinical, and radiographic data were collected. Standardized outcome scores were collected preoperatively and at final follow-up. Characteristics of dislocations that occurred less than 3 months postoperatively (early) were compared with those that occurred more than 3 months postoperatively (late). Results Twenty-two patients met the criteria, and follow-up was obtained on 19 patients at 4.9 ± 2.5 years, with 14 early and 5 late dislocations. Most patients in both groups were men, were aged over 70 years, and had a history of shoulder surgery. On analysis of instability etiology, 68% had inadequate soft-tissue tensioning (10% due to partial axillary nerve injuries). The remaining patients had asymmetric liner wear, mechanical liner failure, or impinging heterotopic ossification. Asymmetric liner wear accounted for 60% of late dislocations. Recurrent instability after revision was present in 29% of early and 40% of late dislocators. Discussion No significant differences in outcomes or recurrence rates were found for early and late dislocations. Of the late dislocations, 80% had evidence of adduction impingement, via either heterotopic ossification or asymmetric polyethylene wear. Post-RTSA instability had 2 distinct etiologies: (1) instability due to inadequate soft-tissue tensioning and/or axillary nerve palsy and (2) instability due to impingement or liner failure.

Background The purpose of this manuscript is to describe what we believe to be the first series of patients surgically treated for idiopathic isolated teres minor atrophy and to present the results of surgical decompression of the nerve to the teres minor. Methods This is a retrospective cohort of 22 patients who underwent decompression of the nerve to the teres minor for isolated teres minor atrophy. Clinical data including duration of symptoms, additional diagnoses, concurrent procedures, preoperative physical examination findings, imaging data, and preoperative visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) scores were collected from the medical record. Postoperative patient-based clinical outcome measures including VAS, SST, and ASES scores were obtained during clinical examination or by telephone interview. Results Average length of follow-up was 26 months. Nine patients had concurrent procedures performed. Preoperatively, 12 of 14 (86%) had external rotation weakness in Hornblower's position. Postoperatively, pain scores decreased an average of 4 points; ASES scores increased 31.7 ± 20.2 points; SST scores increased 3.1 ± 2.3 points. No external rotation weakness was noted postoperatively in any tested patient. Two patients developed adhesive capsulitis. No other complications occurred. Conclusions Isolated compression of the nerve to the teres minor is a rare and novel clinical entity. In properly selected cases, open release of the fascial sling enveloping the nerve branches to the teres minor can provide relief of symptoms and clinical improvement.

Background: The purpose of this study was to examine the baseline function and results of arthroscopic cuff repair in shoulders with small and medium-sized full-thickness cuff tears with complete supraspinatus disruption compared with those with an intact anterior supraspinatus tendon. Methods: The study evaluated 112 subjects with small and medium-sized cuff tears. Subjects were grouped according to anterior supraspinatus integrity (83 shoulders intact, group 1; and 29 shoulders with anterior supraspinatus tendon disruption, group 2). Functional assessments included visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and Constant score. Repair integrity was assessed by ultrasound examination. Results: Group 2 shoulders had greater mean tear width, length, and area (P

Background Many studies have attempted to correlate radiographic acromial characteristics with rotator cuff tears, but the results have not been conclusive. Therefore, the purpose of this study was to determine the relationship between rotator cuff disease and the development of symptoms with different radiographic acromial characteristics, including shape, index, and presence of a spur. Materials and methods The records of 216 patients enrolled in an ongoing prospective, longitudinal study investigating asymptomatic rotator cuff tears were reviewed. All patients underwent standardized radiographic evaluation, clinical evaluation, and shoulder ultrasonography at regularly scheduled surveillance visits. Three blinded observers reviewed all radiographs to determine the acromial morphology, presence, and size of an acromial spur, as well as the acromial index. These findings were analyzed to determine an association with the presence of a full-thickness rotator cuff tear. Results The 3 observers demonstrated poor agreement for acromial morphology (κ = 0.41), substantial agreement for the presence of an acromial spur (κ = 0.65), and excellent agreement for the acromial index (κ = 0.86). The presence of an acromial spur was highly associated with the presence of a full-thickness rotator cuff tear ( P = .003), even after adjusting for age. No association was found between the acromial index and rotator cuff disease ( P = .92). Conclusion The presence of an acromial spur is highly associated with the presence of a full-thickness rotator cuff tear in symptomatic and asymptomatic patients. The acromial morphology classification system is an unreliable method to assess the acromion. The acromial index shows no association with the presence of rotator cuff disease.

The purpose of this study is to characterize the demographic features and physical function of subjects with asymptomatic rotator cuff tears and to compare their shoulder function with control subjects with an intact rotator cuff.This study enrolled 196 subjects with an asymptomatic rotator cuff tear and 54 subjects with an intact rotator cuff presenting with a painful rotator cuff tear in the contralateral shoulder. Various demographic features, shoulder function (American Shoulder and Elbow Surgeons score and Simple Shoulder Test score), range of motion, and strength were compared.The demographic features of the study and control groups were similar. Hand dominance was associated with the presence of shoulder pain (P.05). Subjects with an intact rotator cuff had greater but clinically insignificant American Shoulder and Elbow Surgeons (P.05) and Simple Shoulder Test (P.05) scores than those with an asymptomatic tear. No differences in functional scores, range of motion, or strength were seen between partial-thickness tears (n = 61) and full-thickness tears (n = 135). Of the full-thickness tears, 36 (27%) were classified as small, 85 (63%) as medium, and 14 (10%) as large. No differences were seen in functional scores among full-thickness tears of various sizes.When asymptomatic, a rotator cuff tear is associated with a clinically insignificant loss of shoulder function compared with an intact rotator cuff. Therefore a clinically detectable decline in shoulder function may indicate an "at-risk" asymptomatic tear. The presence of pain is important in cuff-deficient shoulders for creating a measurable loss of shoulder function. Hand dominance appears to be an important risk factor for pain.

Hypothesis Triceps tendon anatomy is important for surgical approaches to the elbow and tendon repair. The purpose of this study is to describe both the qualitative and quantitative anatomy of the triceps brachii tendon insertion. Materials and methods Thirty-six elbows were dissected from twenty-three cadavers. Dimensions of the triceps tendon proper, lateral triceps expansion, and tendon insertion were measured. The central triceps tendon morphology was described. Results All specimens showed a distinct lateral tendon expansion continuous with the anconeus fascia (mean width, 16.8 mm). The mean width of the proper triceps tendon was 23.7 mm. The mean maximum olecranon width was 26.9 mm. The ratio of the triceps tendon width to the olecranon width averaged 0.88. The mean thickness of the central tendon insertion was 6.8 mm. The medial triceps tendon showed a distinct, rolled medial edge and an insertion consistently confluent with the central tendon. The triceps footprint insertion was dome shaped. The mean insertional width and length of the tendon proper were 20.9 mm and 13.4 mm, respectively. The mean distance from the olecranon tip to the tendon was 14.8 mm. The tendon width, thickness, and insertional dimensions correlated with the olecranon width. Conclusions The lateral triceps expansion is a consistent anatomic finding with a width that is approximately 70% of the width of the central tendon. The triceps insertion has a broad width and narrow thickness that expands distally and correlates with the size of the olecranon. Knowledge of this anatomy will help the surgeon optimize surgical approaches and triceps repair techniques.

Loss of motion of the elbow joint has several etiologies, with trauma to the elbow being most common. Restricted elbow motion can lead directly to functional decline and interfere with activities of daily living. Most patients can regain a functional arc of motion with a combination of physical therapy and a splinting regimen. However, some patients will maintain persistent elbow stiffness. Traditionally, open techniques have been used successfully to release the elbow joint capsule and regain a functional arc of motion. Early results of arthroscopic elbow capsule release were concerning for peripheral nerve injury. Technical advances and modifications have allowed arthroscopic capsular release of the elbow to emerge as a safe and reliable, though technically demanding, and method to restore elbow motion.

Background Surgical treatments have been selected to treat advanced osteochondritis dissecans (OCD) of the humeral capitellum. Purpose To evaluate the clinical results of surgical treatments for advanced capitellar OCD lesion and to clarify problems of poor clinical results. Methods Cases were reviewed for 27 patients with advanced OCD lesions treated operatively. All patients were male baseball players, with a mean of 13.3 years at the time of surgery. Drilling only was performed for 3 patients, fragment fixation for 13 patients, and removal of the detached fragment with drilling for four patients. Since 2004, reconstruction of the articular surface with use of osteochondral autograft from the rib has been performed for 7 patients with osteochondral defect. Mean follow-up was 37.4 months. Follow-up assessment included modified elbow rating system, evaluation of radiographs, and return to sports. Results Mean subjective score improved significantly from 70 to 96 postoperatively. Mean objective score improved significantly 71 to 81 postoperatively. A postoperative return to baseball was achieved by 25 patients. On the final radiographs, 4 patients showed flattening of >70% of the capitellum or degenerative changes, including insufficient remodeling of the lateral margin of the capitellum. Although patients could return to baseball, postoperative total arc of the elbow was decreased compared with the preoperative total arc. Conclusion Surgical treatments were useful to restore advanced OCD lesions. Our results suggest that reconstruction of the lateral margin of the capitellum is important for achieving good clinical results. Level of evidence Level 4.

The purpose of this study was to examine patterns of rotator cuff tear size progression in degenerative rotator cuff tears and to compare tear progression risks for tears with and without anterior supraspinatus tendon disruption.Asymptomatic full-thickness rotator cuff tears with minimum 2-year follow-up were examined with annual shoulder ultrasound examinations. Integrity of the anterior 3 mm of the supraspinatus tendon determined classification of cable-intact vs. cable-disrupted tears. Tear enlargement was defined as an increase of 5 mm or more in width. Tear propagation direction was calculated from measured changes in tear width in reference to the biceps tendon on serial ultrasound examinations.The cohort included 139 full-thickness tears with a mean subject age of 63.3 years and follow-up duration of 6.0 years. Ninety-six (69.1%) of the tears were considered cable intact. Cable-disrupted tears were larger at baseline (median, 19.0 mm vs. 10.0 mm; P.0001) than cable-intact tears. There was no difference in the risk of enlargement (52.1% vs. 67.4%; P = .09) or time to enlargement (3.2 vs. 2.2 years; P = .37) for cable-intact compared with cable-disrupted tears. There was no difference in the magnitude of enlargement for cable-intact and cable-disrupted tears (median, 7.0 mm vs.9.0 mm; P = .18). Cable-intact tears propagated a median of 5 mm anteriorly and 4 mm posteriorly, whereas cable-disrupted tears propagated posteriorly.The majority of degenerative rotator cuff tears spare the anterior supraspinatus tendon. Although tears classified as cable disrupted are larger at baseline than cable-intact tears, tear enlargement risks are similar for each tear type.

The purpose of this study was to document the subscapularis healing rate by use of postoperative ultrasound and correlate healing to physical examination findings. We included 23 patients (30 shoulders), who underwent total shoulder arthroplasty in the study. The evaluation included a standard history and physical examination, ultrasound evaluation, and outcome questionnaires. The postoperative examination included careful documentation of an abdominal-compression test to evaluate subscapularis function. All patients had an improvement in functional outcome scores and shoulder range of motion. Of 30 shoulders, 26 (87%) had an intact subscapularis as determined by ultrasound. By use of ultrasound as the gold standard, the abdominal-compression test had 7 false-positive results, 3 false-negative results, 19 true-negative results, and 1 true-positive result. The sensitivity of the abdominal-compression test was 25%, and the specificity was 73%. The negative predictive value was 86%, and the positive predictive value was 13%. The abdominal-compression test demonstrated a low sensitivity, specificity, and positive predictive value in this study for the assessment of subscapularis function after total shoulder arthroplasty. If a subscapularis tear is suspected in a patient after total shoulder arthroplasty, the abdominal-compression test is unreliable in predicting a subscapularis defect.

The purpose of this study was to evaluate range of motion and patient-reported outcome after complete arthroscopic release of post-traumatic elbow contracture. Fourteen consecutive patients who underwent elbow arthroscopy and capsular release were reviewed retrospectively at a minimum follow-up of 1 year. Pain and range of motion were measured. Patient outcome was assessed with the American Shoulder and Elbow Surgeons Elbow Assessment Form. Mean self-reported satisfaction on a visual analog scale was 8.4 out of 10. Only 6 patients continued to have pain, with a mean maximum pain score of 4.6 out of 10. Flexion increased from a mean of 117.5 degrees to 133 degrees, and extension improved from a mean of 35.4 degrees to 9.3 degrees. In those patients with a preoperative arc of motion less than 100 degrees (10 patients), the mean arc of motion improved from 69 degrees to 119 degrees. All patients had improved function after the procedure, with a mean self-reported functional ability score of 28.3 out of 30. There were no neurovascular complications. The improvement in range of motion and functional outcome compares favorably with open-release procedures. Combined with the potential benefits of improved joint visualization and low surgical morbidity, arthroscopic release of post-traumatic elbow contracture appears to be a reasonable alternative to open techniques.

Background Patient-derived self-assessment potentially minimizes loss of valuable outcomes data, conserves medical resources, and benefits patients by saving valuable time out of work and travel expenses. The purpose of this study was to determine the physician-patient correlation of a patient-derived outcomes questionnaire that assesses range of motion (ROM) and strength after shoulder arthroplasty. Methods One hundred twenty consecutive patients completed a home-based questionnaire before their 1-year postoperative visit after shoulder arthroplasty. The questionnaire contained demographic information such as age, gender, type of surgery, education level, and income. Diagram-based questions, in which patients were asked to identify the image representing their own active shoulder ROM in various planes, were included. Patients were asked to perform a strength examination using premeasured zip-lock bags filled with water that correspond to predetermined weights up to 2.72 kg. The κ statistics were used to assess the degree of agreement between the patient's self-assessment and the clinician's measures. Results The κ statistics indicated moderate clinician-patient agreement (0.5-0.59) on items related to ROM and substantial to almost perfect agreement (0.62-0.92) on items related to strength (forward flexion and abduction). A majority of patients (>88%) correctly estimated their ROM within 1 grade of the clinician's measurement. Patients tended to err toward overestimating their ROM. Conclusions This patient-derived questionnaire provides a moderate to high level of agreement with clinician assessment. This assessment questionnaire may be an important tool in facilitating both clinical and research follow-up of patient outcomes after shoulder arthroplasty.

Subcoracoid transfer of the pectoralis major has recently been described as a reconstruction for subscapularis insufficiency. The purpose of this study was to examine the surgically relevant anatomy of this transfer. The importance of understanding this anatomy was recently highlighted to us following our encounter with musculocutaneous neuropraxia in 2 patients after transfer of the entire pectoralis major, one deep to the musculocutaneous nerve. Dissections were performed on 20 fresh, whole human cadavers in which the entire pectoralis major muscle, medial and lateral pectoral nerves, and musculocutaneous nerve were explored and quantified. The relationship between the pectoralis major and the conjoined tendon was studied in situ and after simulated transfers. The medial and lateral pectoral nerves were located far medial to the pectoralis major tendon insertion and appeared to be safe from injury as long as surgical dissection remained lateral to the pectoris minor and less than 8.5 cm from the humeral insertion. Transfer of the pectoralis major superficial to the musculocutaneous nerve created less tension than transfer deep to the musculocutaneous nerve. Because proximal innervation of the coracobrachialis and short head of the biceps is not an uncommon occurrence, a split pectoralis major transfer, release of the proximal musculocutaneous branches, or debulking of the pectoralis major muscle belly may be required in some instances to prevent tension on the nerve. Because of the variability and location of the musculocutaneous nerve, it should always be visualized operatively. Transfer of the pectoralis major tendon lateral to the biceps tendon appeared to best restore the muscle length-tension relationship. (J Shoulder Elbow Surg 2001;10:453-9.)

The purpose of this study was to examine longitudinally the natural history of asymptomatic rotator cuff tears over a 5-year period and to assess the risk for development of symptoms and tear progression. Since 1985 through the present, bilateral sonograms were done on all patients. A review of consecutive sonograms done from 1989 to 1994 revealed 58 potential patients with unilateral symptoms who had contralateral asymptomatic rotator cuff tears. Of these 58 patients, 45 (22 men, 23 women) responded to a comprehensive questionnaire and 23 additionally returned for examination and repeat sonographic evaluation. The questionnaire was based on the American Shoulder and Elbow Surgeons score and included several outcome-based questions. A physical examination was performed in a standardized fashion along American Shoulder and Elbow Surgeons guidelines. Repeat high-resolution sonograms were performed by a single experienced radiologist. Primary and repeat sonograms were then reassessed for tear size and location by two independent experienced radiologists blinded to the clinical data results. Twenty-three (51%) of the previously asymptomatic patients became symptomatic over a mean of 2.8 years. The average Activities of Daily Living score for those remaining asymptomatic was 28.5 of 30 and for those becoming newly symptomatic, 22.9 of 30 (P

Background Advanced-stage osteochondritis dissecans of the capitellum affecting the lateral wall may result in osteoarthritis, and suitable treatment is needed to avoid permanent deformation and impaired function. We aimed to assess postoperative outcomes of costal osteochondral autograft for treatment of this condition. Methods We included 22 young overhead athletes (mean age, 13.9 years) with advanced osteochondritis dissecans of the humeral capitellum who underwent costal osteochondral autograft. All patients had elbow pain and wide-range articular cartilage lesions. We evaluated clinical and radiographic outcomes at a mean follow-up of 27 months (range, 12-77 months). Results All patients achieved rapid functional improvement and returned to their former sports activity levels. The baseball players were able to play catch within 62 to 164 days (mean, 107 days) and returned to full pitching activity within 123 to 339 days (mean, 226 days). We assessed mean elbow function by the clinical rating system of Timmerman and Andrews and the Japanese Orthopaedic Association sports score; the scores improved from 121.5 and 53.7 points preoperatively to 169.2 points and 86.1 points, respectively, at the time of follow-up. Four patients required additional minor surgical procedures, including screw removal, loose body removal, and shaving off of spur formation. No patient showed obvious radiographic changes of osteoarthritis. All patients were satisfied with the final outcomes and had good functional recovery. Conclusion Costal osteochondral autograft gave satisfactory results for advanced osteochondritis dissecans of the humeral capitellum with extensive lesions affecting the lateral wall.

Without a clear understanding of the functional role of the biceps tendon, treatment recommendations have been a subject of controversy. An objective review of the available information would suggest that some humeral head stability may be imparted through the tendon. However, the magnitude of this function is likely to be small and possibly insignificant. In contrast, the symptomatic significance of the long head of the biceps is less controversial, and it has become increasingly recognized as an important source of persistent shoulder pain when not specifically addressed. When present, persistent pain from the long head of the biceps is likely to have more negative functional consequences than loss of the tendon itself. Given these concerns, evaluation and treatment of patients with long head of the biceps disorders should be individualized, based on the likelihood that biceps-related pain will resolve. Although not universally accepted, we recommend tenodesis of the long head of the biceps in those cases in which there are either chronic inflammatory or structural changes, which would make it unlikely that the pain would resolve. These clinical situations in which tenodesis would be required include greater than 25% partial thickness tearing of the tendon, chronic atrophic changes of the tendon, any luxation of the biceps tendon from the bicipital groove, any disruption of associated bony or ligamentous anatomy of the bicipital groove that would make autotenodesis likely (i.e., 4-part fracture), and any significant reduction or atrophy of the size of the tendon that is more than 25% of the normal tendon width. Relative indications for biceps tenodesis also include biceps disease in the context of a failed decompression for rotator cuff tendinitis. It should be emphasized that routine tenodesis is not recommended during operative treatment for the rotator cuff. Rather, we avoid tenodesis whenever it is believed that inflammatory changes to the biceps tendon are reversible. Because of this, tenodesis is not required in most cases.

Previous infection has been considered a strict contraindication to implantation or reimplantation of an elbow prosthesis. The purpose of this study was to investigate whether these patients can in fact be successfully treated with a prosthetic arthroplasty given previous treatment of the infection. Ten consecutive prosthetic arthroplasties performed in patients with documented infections in the elbow were retrospectively reviewed. Seven of the patients had infectious complications of total elbow arthroplasties that led to resection. Two patients had previous infections from septic joints and 1 from open reduction internal fixation. The median interval of time from infection treatment to final implant was 45 months (3.8 years). All arthroplasties were performed by the same surgeon with a modified Coonrad-Morrey, semiconstrained prosthesis. Patients were monitored for clinical signs of infection including radiographic and serologic studies and clinical evaluation based on the Mayo Elbow Performance Score. Mean surveillance was 4 years (range 2.8 to 5.4 years). Eight of the 10 cases have not shown signs of infection at the latest assessment. Two have had recurrent infections. The time interval from the original infection to latest implantation did not correlate with infection recurrence. Among those 8 without recurrent infection, 7 had excellent and 1 had satisfactory results according to the Mayo Elbow Performance Score. The recurrent infections were rated as failures. The average score was 32 before and 81 after surgery. The average pain score was 15 before surgery, and the average postoperative pain score was 40. Salvage of previously infected elbows with prosthetic arthroplasty can provide excellent results in a significant proportion of patients. Although the procedure offers superior functional outcomes compared with the alternative treatment options, it is technically demanding.

The purpose of this report was to investigate the vascular anatomy of the ulnar nerve at the elbow with a technique of combined India ink and latex injection followed by nondissection chemical debridement. Twenty-two fresh human cadaveric arms were injected with India ink to stain the intraneural microcirculation followed immediately by latex injection and chemical debridement for study of the extraneural vascularization. After clearing with a modified Spalteholtz technique, the intraneural blood supply was studied in 10 of the specimens. The findings demonstrated a consistent but segmental extraneural and intraneural vascular supply from the superior ulnar collateral, inferior ulnar collateral, and posterior ulnar recurrent arteries. No identifiable direct anastomosis was seen between the superior ulnar collateral and posterior ulnar recurrent arteries in 20 of 22 arms. The inferior ulnar collateral artery provided the only direct vascularization to the nerve in the region just proximal to the cubital tunnel. Although the clinical importance of maintaining specific arterial sources to the ulnar nerve has not been determined, these anatomic findings indicate that the arterial contribution from the inferior ulnar collateral artery may be more important than appreciated previously.

We evaluated the morphology of the ulnar nerve and cubital tunnel with noninvasive magnetic resonance imaging (MRI). We used fresh human cadavers with the elbow in full extension, 90 degrees of flexion, and full flexion. For each elbow, 1-mm slices were imaged interpolated, and reconstructed into 3-dimensional data volumes, and then manually segmented before they were examined with sequential transverse sections, curved sections, and 3-dimensional images. The ulnar nerve follows a tortuous course in full extension, becomes progressively linear with incremental elbow flexion, shifts anteriorly in the cubital tunnel, and flattens against the medial epicondyle. The proximal and midportions of the cubital tunnel also change with flexion from round to elliptical. In addition, successive increases occur in the cross-sectional diameter of the mediolateral plane. The nerve is surrounded by fat throughout the cubital tunnel except adjacent to the medial epicondyle. These observations suggest that the ulnar nerve progressively stretch over the medial epicondyle occurs when the normal elbow is flexed. Direct compression areas of the ulnar nerve were not seen in our study of normal human elbows.

Background The purpose of this study was to describe the complex anatomy surrounding the teres minor muscle. Methods Thirty-one cadaveric human shoulders were dissected. Qualitative fascial and neurovascular anatomy were described. Location of motor nerves to teres minor were measured in reference to local anatomy. Results Fascial anatomy of the posterior shoulder had 2 distinct and equally common variants, 1 of which demonstrated a stout, inflexible fascial compartment enveloping the teres minor muscle. The other had a continuous fascia enveloping both the infraspinatus and teres minor muscles. In both variants, the primary nerve to teres minor traveled around a fascial sling, becoming sub-fascial at an average of 44 mm (range, 25-68) medial to the teres minor's insertion. The nerve took its most angulated course as it entered the fascial sling. Smaller accessory innervation of teres minor began, on average, 30 mm (range, 15-48) medial to the muscle's lateral insertion. None of the accessory motor nerves coursed deep to the fascial sling nor to the distinct teres minor fascial compartment. Conclusion A stout fascial sling may be the potential site of greatest compression and tethering of the primary motor nerve to teres minor. Additional lateral accessory motor nerves to teres minor remained extra-fascial and took a less angulated path. Half of the shoulders demonstrated a separate teres minor fascial compartment. An improved understanding of the fascial anatomy and innervation pattern of the teres minor muscle may help clinicians who treat patients with symptomatic isolated teres minor muscle atrophy.

The use of shoulder ultrasound as an imaging modality has recently gained widespread attention; however, the ability of ultrasound to diagnose long head of the biceps tendon pathology accurately still remains unclear. The biceps tendons in 71 patients were prospectively evaluated by comparison of standard ultrasonographic and arthroscopic examinations. Arthroscopic examination was used as the gold standard comparison. Ultrasound showed a 100% specificity and 96% sensitivity for subluxation or dislocation. Ultrasound detected all complete ruptures of the biceps tendon but detected none of the 23 partial-thickness tears. Overall, ultrasound diagnosed 35 of 36 normal biceps tendons (specificity, 97%) and 17 of 35 abnormal biceps tendons (sensitivity, 49%). Ultrasound can reliably diagnose complete rupture, subluxation, or dislocation of the biceps tendon. It is not reliable for detecting intraarticular partial-thickness tears.

The purpose of this study was to evaluate the outcome after subcoracoid pectoralis major transfer for anterior-superior shoulder instability in massive rotator cuff insufficiency. Fourteen patients underwent subcoracoid pectoralis major transfer for this debilitating surgical complication. At a mean 17.5-month follow-up, there were 11 satisfactory and 3 unsatisfactory results. Nine of the patients were satisfied with the procedure and would repeat the operation under similar circumstances. Pain scores, as measured on a visual analog scale, decreased from 6.9 to 3.2 postoperatively. Mean forward flexion increased from 24.4 degrees to 60.8 degrees. American Shoulder and Elbow Society functional outcome score increased from 27.2 preoperatively to 47.7 postoperatively. Thirteen of the fourteen patients had improved humeral head containment and improved ability to perform activities of daily living at waist level. A subcoracoid pectoralis major muscle transfer has a low complication rate and is a viable option in this difficult patient population, with better results than those previously reported.