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Background Little information exists to guide the choice of exercise for regaining shoulder range of motion (ROM). The purpose of this study was to compare the maximal ROM reached, pain and difficulty associated with 4 commonly prescribed exercises. Methods Forty (9 females) patients with various shoulder disorders and a limited flexion ROM performed 4 exercises for regaining shoulder flexion ROM in a randomized order. Exercises included the self-assisted flexion, forward bow, table slide and rope-and-pulley. Participants were videotaped while performing all exercises and the maximal flexion angle reached during each exercise was recorded using Kinovea motion analysis freeware (Kinovea 0.8.15). Pain intensity and the perceived level of difficulty associated with each exercise were also recorded. Results The forward bow and table slide generated significantly greater ROM compared with the self-assisted flexion and rope-and-pulley (P ≤ 0.005). The self-assisted flexion was associated with a greater pain intensity compared with the table slide and rope-and-pulley (P = 0.002) and a greater perceived level of difficulty compared with the table slide (P = 0.006). Conclusions Due to the greater ROM allowed, and similar or even lower level of pain or difficulty, clinicians may wish to initially recommend the forward bow and table slide for regaining shoulder flexion ROM.

Aims Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. Methods A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals’ left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. Results Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. Conclusion MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298–306.

Background The delivery of orthopaedic care via telemedicine services has the potential to promote accessibility and decrease medical care expenses, while facilitating the control of infectious disease spreading. The purpose of this study was to assess agreement regarding diagnosis, recommended course of management and the perceived need for additional diagnostic testing between a video examination (VE) and a face to face (FTF) assessment of patients with shoulder disorders. Methods Forty-seven (18 females) patients presenting to a shoulder surgery clinic were assessed consecutively by VE and a FTF examination. All assessments were conducted by a shoulder specialist. Agreement regarding the established diagnosis, the recommended course of management and the need for additional diagnostic tests was assessed using percent agreement and kappa (95% CI) coefficient. Differences in the content, duration and satisfaction between the two examination modes were also assessed. Results Percent agreement and kappa (95% CI) coefficient for agreement regarding diagnosis were 85.1% and 0.82 (0.69–0.94), respectively. Percent agreement and kappa (95% CI) coefficient regarding the recommended course of management and the need for additional diagnostic testing were 61.7% and 0.43 (0.22–0.63), and 74.5% and 0.49 (0.25–0.74), respectively. The VE resulted in collection of less physical examination information, took longer to complete and was associated with less satisfaction by both patient and examiner. Conclusions Video examination of patients with shoulder disorders may present a valid alternative to FTF examination. Nevertheless, the content of the video-based physical examination may need to be modified to facilitate a clearer detection of indications for specific interventions or diagnostic tests.

Background: this pilot study aimed at determining whether the application of a novel new method of generating pulsed electromagnetic field (PEMF), the Fracture Healing Patch (FHP), accelerates the healing of acute distal radius fractures (DRF) when compared to a sham treatment. Methods: 41 patients with DRFs treated with cast immobilization were included. Patients were allocated to a PEMF group (n = 20) or a control (sham) group (n = 21). All patients were assessed with regard to functional and radiological outcomes (X-rays and CT scans) at 2, 4, 6 and 12 weeks. Results: fractures treated with active PEMF demonstrated significantly higher extent of union at 4 weeks as assessed by CT (76% vs. 58%, p = 0.02). SF12 mean physical score was significantly higher in PEMF treated group (47 vs. 36, p = 0.005). Time to cast removal was significantly shorter in PEMF treated patients, 33 ± 5.9 days in PEMF vs. 39.8 ± 7.4 days in sham group (p = 0.002). Conclusion: early addition of PEMF treatment may accelerate bone healing which could lead to a shorter cast immobilization, thus allowing an earlier return to daily life activities and work. There were no complications related to the PEMF device (FHP).

The footprint medialization allows a tension free repair in severely retracted rotator cuff tears (RCT), thereby de-creasing the rate of retear. The purpose of the study was to evaluate the clinical and radiological results in a cohort of chronic RCT treated with medialized repair. Secondary purpose was to analyze the impact of medialization length on shoulder function and tendon healing.It was hypothesized that the medialization length would have an impact on clinical and radiological outcome.A consecutive series of thirty patients that underwent arthroscopic repair of a massive posterosuperior RCT at a single institution were retrospectively studied at mean follow-up 18.4months (SD 15.3; range 9-58). The medialization of the medial footprint was measured intraoperatively. Preoperative and postoperative examination included active range of motion, abduction strength, pain assessment, and functional scores. The postoperative rotator cuff integrity was evaluated according to the Sugaya's classification. Types IV-V were categorized as absence of healing.At final follow-up the clinical outcomes were significantly improved in all patients (p≤0.001) with the exception of external rotation that displayed no significant improvement (p=0.05). In group 1 (n=8) medialization length was≤10mm (mean 8, SD 1.9) and in group 2 (n=14)10mm (mean 12.6, SD 1.7). There were no significant differences regarding preoperative and postoperative clinical outcomes (p0.05) between two groups. Group 2 demonstrated moderate correlation between length of medialization and Sugaya stage of tendon healing (r=0.53, p=0.049). Absence of healing was noted in 4/22 patients, 1/8 in group 1 and 3/14 in group 2.Medialized repair is an effective technique for treating chronic, massive and retracted posterosuperior RCT. A medialization of the footprint less than or equal to 10mm is recommended, as it was associated with good clinical and radiological results. The rate of tendon healing decreases when medialization exceeds 10mm.III.

Reverse total shoulder arthroplasty (RSA) associated with modified L'Episcopo (isolated LD) or L'Episcopo (combined TM and LD) procedures had been confirmed to effectively overcome the expected external rotation deficit in patient with postero-superior massive cuff tear and teres minor deficiency. The objective of this study was to evaluate the radiological bony lesions of the lateral proximal humerus following RSA combined with tendon transfer, and to determine whether these bony lesions affect the clinical outcome.A retrospective review of 24 RSAs (mean age 68.71 years, range 52-83) associated with modified L'Episcopo procedure (9) and L'Episcopo procedure (15) was performed. X-rays were assessed for lateral cortex lesions and were categorized into either intact, irregular or complete lytic appearances. In addition, signs of stem loosening were assessed. Clinical outcome measures included range of motion, SSV, VAS, and Constant-Murley scores.With a mean follow-up of 44.71 months (12-97; SD 27.42), eight (33.3%) patients demonstrated intact lateral cortex, eight (33.3%) irregular and eight (33.3%) lytic lesions. 40% of cemented stems demonstrated a deformed cortex compared to 74% of cementless stems. Radiolucent lines were detected in one cemented stem (p=0.046). GT resorption (p=0.147), condensations lines (p=0.449) and spot weld (p=0.342), appeared exclusively in non-cemented stem. Postoperatively all patients (24) demonstrated significant improvements in all clinical and functional parameters. A comparison between patient with (Group 2, 16 patients) and without bony lesions (Group 1, 8 patients) revealed no significant differences in functional scores and range of motion: Constant (p=0,61), VAS (p=0,61), SSV (p=0,66) and external rotation (p=0,34).At short-term follow-up, RSA combined with L'Episcopo or modified l'Episcopo procedure resulted in high incidence (67%) of lateral proximal humerus lesions. Radiolucent lines were noted in cemented stems whereas, signs of stress shielding and GT resorption appeared in non-cemented stems. Yet, no case of humeral loosening was detected and these lesions did not seem to affect the clinical outcome. The use of cemented straight standard-length humeral stems should be positively considered in RSA associated with LD\TM tendon transfer.IV; retrospective study.

Introduction Proximal humerus nails (PHN) are commonly used for the treatment of simple proximal humerus fractures, and have a reported malunion rate of about 10%. The surgeons who used PHN in one medical institution have noticed a high rate of fracture re-displacement in the early post-operative period. This study's aim is to evaluate the rate of secondary displacement and malunion of patients treated for two part proximal humerus fractures with an angle-stable PHN (MultiLoc), and to assess possible risk factors for this secondary displacement. Methods A retrospective study comprised of 25 consecutive patients with 2 part surgical neck or metaphysis displaced proximal humerus fracture, treated with PHN between the years 2014–2017. Results assessed included radiographic measures (neck-shaft angle) and clinical data: range of motion (ROM) and functional scores (Constant, DASH, SSV). A univariate regression analysis was used to assess possible risk factors for secondary displacement. Results Mean age was 66.6 (range 17–93), and mean follow up was 20 months (range 6–40). Mean neck shaft angle (NSA) changed from 139.1° post operatively to 122.6° at last follow up, with 6 patients (24%) having a NSA change larger than 20°. Two patients (8%) ended up with NSA less than 90°, defined as malunion. The deltoid tuberosity index was found to correlate with the degree of displacement (−0.41, p = 0.04). Conclusions PHN for simple displaced proximal humerus fractures was associated with fair clinical results but an unacceptable rate secondary displacement. The deltoid tuberosity index was found to correlate with the degree of this secondary displacement.

Background: Humeral avulsion of the glenohumeral ligament (HAGL) is an uncommon condition but a major contributor to shoulder instability and functional decline. Purpose: To describe the pre- and postoperative HAGL lesion presentations of instability, pain, and functionality and the return-to-sports activities in patients managed arthroscopically for anterior and posterior HAGL lesions. Study Design: Case series; Level of evidence, 4. Methods: Data on patients with HAGL lesions treated with arthroscopic repair between 2009 and 2018 were retrospectively retrieved from medical charts, and the patients were interviewed to assess their level of postoperative functionality. The Rowe; Constant; University of California, Los Angeles; Oxford; and pain visual analog scale (VAS) scores were obtained for both pre- and postoperative status. Return-to-sports activities and level of activities after surgery were compared with the preinjury state, and complications, reoperations, and recurrent instability were recorded and evaluated. Results: There were 23 study patients (12 females and 11 males; mean age, 24 years). The mean follow-up duration was 24.4 months (range, 7-99 months; median, 17 months). In 7 (30.4%) of the patients, HAGL lesions were diagnosed only intraoperatively. A significant improvement was seen in all examined postoperative functional scores and VAS. At the last follow-up visit, 2 patients (8.7%) reported residual instability with no improvement in pain levels and declined any further treatment, and 3 others (13.0%) required revision surgeries for additional shoulder pathologies (reoperations were performed 18-36 months after the index procedure). The remaining 18 patients (78.3%) were free of pain and symptoms. There was a mean of 0.65 coexisting pathologies per patient, mostly superior labral anterior-posterior, Bankart, and rotator cuff lesions. Conclusion: HAGL lesions are often missed during routine workup in patients with symptoms of instability, and a high level of suspicion is essential during history acquisition, clinical examination, magnetic resonance imaging arthrogram interpretation, and arthroscopic evaluation. Arthroscopic repair yields good pain and stability results; however, some high-level athletes may not return to their preinjury level of activity.

Background The use of video examinations (VE) may improve patient care by offering them a low-cost and easy access to physicians, save traveling expenses and shorten waiting time. The aim of this study was to validate the use of Smartphones for distant assessment of shoulder function by comparing the Constant scores (CS) of patients obtained by both VE and conventional face-to-face (FTF) examination. Methods Fifty-one subjects (age 19–80 years; women:men 18:33) who presented to a shoulder clinic with a variety of complaints were prospectively recruited and underwent FTF and VE in alternating order. CS obtained by the two methods were compared. Four patients were unable to complete the VE due to technical problems or non-compliance. Results Forty-seven (92%) subjects successfully completed both examinations. The mean difference in CS was −0.53 points (95%CI: −2.6:1.6), with limits of agreement of −7.7:6 points. Agreement of correlation coefficient, accuracy and precision were 0.91 (95%CI: 0.86:0.96), 0.99 (95%CI: 0.92:1.00) and 0.91 (95%CI: 0.86:0.96), respectively. Conclusion VE can obtain a reliable estimate of shoulder function. The mean video CS was only −0.53 points from the mean frontal CS. Individual variations of CS did not exceed a 7-point distance from the “gold standard” estimate.

Background: This study compared the radiological outcomes of adult closed distal radius fractures (DRFs) reduction with and without fluoroscopy. We hypothesized that fluoroscopy-assisted reduction would not improve radiographic alignment or decrease the need for surgery. Methods: Hospital medical records and radiographic images of all patients who presented with DRFs between April to June 2009 and April to June 2013 were reviewed. All patients underwent closed reduction and immobilization with or without fluoroscopic assistance. Reduction attempts were noted and pre- and postreduction posteroanterior and lateral radiographs were reviewed for fracture stability. Results: Eighty-four patients underwent reduction without fluoroscopy (group 1), and 90 patients underwent reduction with the aid of fluoroscopy (group 2). According to accepted radiographic guidelines, nonsurgical treatment was indicated for 62% of patients in group 1 and 56% of patients in group 2 ( P = .44). In addition, no significant difference between the groups was observed in any postreduction radiographic parameters ( P > .53) or postreduction alignment of unstable fractures ( P = .47). Conclusions: Reduction without the use of fluoroscopy demonstrated noninferiority when compared with fluoroscopy-assisted reduction in the emergency department for closed adult DRFs.