Metastatic breast carcinoma of the coracoid process: two case reports

<p>Abstract</p> <p>Background</p> <p>The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one report of metastatic disease to the coracoid.</p> <p>Methods and Results</p> <p>In this case report, we present two cases with metastatic breast carcinoma of the coracoid process, one of which presented with a pathologic fracture of the coracoid.</p> <p>Conclusions</p> <p>An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as they may be the first medical provider to encounter evidence of malignant disease.</p

Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT

Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Members of the Science of Variation Group--fully trained practicing orthopaedic and trauma surgeons from around the world--were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (&kappa;) measure. Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from &quot;slight&quot; to &quot;fair.&quot; A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (&kappa; = 0.35 compared with 0.30, p &lt; 0.001) and on the AO classification (&kappa; = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that was observed for selection of the treatment for proximal humeral fractures. The lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports

Outcomes after hemiarthroplasty for proximal humerus fracture are significantly affected by hand dominance

© 2015 Wolters Kluwer Health, Inc. Objectives: Hand dominance has been reported to be an important factor affecting outcomes after upper extremity trauma but remains unstudied after hemiarthroplasty for fracture. This study determined whether dominance affected outcomes after hemiarthroplasty for proximal humerus fractures. Design: Retrospective cohort study. Setting: Tertiary care referral center. Patients: Sixty-one patients, after hemiarthroplasty for proximal humerus fracture, returned for comprehensive assessment and were divided into 2 groups: dominant (DOM) shoulder affected (n 25) and non-dominant (non-DOM) shoulder affected (n 36). Intervention: Fracture-specific proximal humeral hemiarthroplasty for displaced proximal humerus fractures. Main Outcome Measures: Patients were assessed with self-reported outcomes (visual analog scale pain, American Shoulder and Elbow Surgeons shoulder score, disability of the arm, shoulder, and hand questionnaire, simple shoulder test, and short form 12) and objective (range-of-motion and hand-held dynamometer strength) testing. Results: At 49 months of mean follow-up, there were no significant differences between groups for gender, age, follow-up time, or visual analog scale pain (P \u3e 0.256). The DOM-affected group had significantly worse scores for American Shoulder and Elbow Surgeons shoulder score (P 0.043), disability of the arm, shoulder, and hand questionnaire (P 0.039), and simple shoulder test (P 0.021). The DOM-affected group also had consistently higher correlations between self-reported and objective outcomes than the non-DOM group. Conclusions: Patients who underwent hemiarthroplasty for fracture on their DOM shoulders had significantly poorer outcomes than patients with non-DOM-sided injuries. Although positive outcomes can be expected after hemiarthroplasty, patients should be instructed that they may have less satisfactory function and strength if their injury was on the DOM side. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence

Prevalence of symptoms of depression, anxiety, and posttraumatic stress disorder in workers with upper extremity complaints

Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy®. Fisheye STUDY DESIGN: Cross-sectional cohort study. Fisheye BACKGROUND: Symptoms of depression, panic disorder (PD), and posttraumatic stress disorder (PTSD) have been associated with musculoskeletal complaints and could represent barriers to recovery in injured workers. Fisheye OBJECTIVES: To determine the prevalence of symptoms of depression, PD, and PTSD utilizing the Patient Health Questionnaire (PHQ) in a cohort of patients presenting to an upper extremity injured-worker clinic; secondarily, to identify any relationships between patients screening positive and patient-reported outcome measures. Fisheye METHODS: In 2010, 418 patients completed the PHQ during their initial evaluation. Patients with PHQ scores exceeding threshold values for symptoms of depression, PD, or PTSD were compared based on patient-reported outcome scores, including the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The prevalence of symptoms, and their relationship with presenting complaints and patient-reported outcomes, were calculated. Fisheye RESULTS: Thirty-one percent of patients scored above thresholds for symptoms of at least 1 mental health disorder. Of those who screened positive, 67% screened positive for depression, 44% for PTSD, and 50% for PD, with 43% of patients positive for multiple symptoms. Patients experiencing neck pain had significantly higher screening rates of depressive symptoms (62.5% versus 20.1%, P = .004) and PD (37.5% versus 12.9%, P = .044) compared with other presenting complaints. Similarly, patients with chronic pain had higher rates of depression (54.5% versus 20.1%, P = .006), PD (63.6% versus 12%, P\u3e.001), and PTSD (36.4% versus 14.8%, P = .05) compared with other presenting complaints. Patients endorsing depressive symptoms had significantly lower SF-36 mental component summary scores (26.3 ± 10.7 versus 37.6 ± 9.9, P\u3c.001) and higher shortened-version DASH (72.3 ± 16.7 versus 61.5 ± 11.1, P = .003) and DASH work scores (86.5 ± 19.2 versus 82.1 ± 20.1, P = .007) compared to patients endorsing other items on the PHQ. Fisheye CONCLUSION: In this prospective cohort study of injured workers, we identified a relatively high prevalence of symptoms of psychological disorders utilizing the PHQ, with one third of injured workers screening positive for symptoms of depression, PD, or PTSD. Further longitudinal follow-up is necessary to determine the impact on treatment outcomes. Fisheye LEVEL OF EVIDENCE: Symptom prevalence, level 1b

Radial head fractures treated with modular metallic radial head replacement

© 2016 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED. Background: Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. Methods: The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. Results: At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p \u3c 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eightyear follow-up (p = 0.012), with no loss of motion or strength (p \u3e 0.05). Conclusions: The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up

Does bony increased-offset reverse shoulder arthroplasty decrease scapular notching?

© 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Background: The purpose of this cohort study was to compare scapular notching rates, range of motion, and functional outcomes between patients who underwent a standard Grammont-style reverse shoulder arthroplasty (RSA) and patients who underwent bony increased-offset reverse shoulder arthroplasty (BIO-RSA) at a minimum of 2years\u27 follow-up. We hypothesized that the BIO-RSA cohort would have lower notching rates and improved rotational range of motion; however, validated outcome scores between cohorts would be no different. Methods: A comparative cohort study was designed after a sample size calculation. A total of 40 patients were studied with 20 in each cohort (RSA vs BIO-RSA). All patients underwent an interview and physical examination. Outcomes included range of motion; shoulder strength; Disabilities of the Arm, Shoulder and Hand (DASH) score; American Shoulder and Elbow Surgeons score; Simple Shoulder Test score; Constant score; and Global Rating of Change scale score. Radiographs were obtained for all patients and examined for scapular notching. Results: When we compared demographic characteristics between the standard RSA and BIO-RSA cohorts, including age, sex, and follow-up duration, there were no significant differences between groups (. P\u3e.05). In addition, there were no significant differences between cohorts when we compared forward elevation (. P=.418); external rotation (. P=.999); internal rotation (. P=.071); strength (. P\u3e.376); Disabilities of the Arm, Shoulder and Hand score (. P=.229); American Shoulder and Elbow Surgeons score (. P=.579); Simple Shoulder Test score (. P=.522); Constant score (. P=.917); or Global Rating of Change scale score (. P=.167). The frequency of scapular notching, however, was significantly higher (. P=.022) in the RSA cohort than in the BIO-RSA cohort: 75% versus 40%. Conclusions: Although the scapular notching rate was significantly higher in the standard RSA group, no other outcome measures were statistically different, including range of motion, strength, and validated outcome scores

IGF2 expression and β-catenin levels are increased in Frozen Shoulder Syndrome

Purpose: Frozen Shoulder Syndrome is a fibrosis of the shoulder joint capsule that is clinically associated with Dupuytren’s disease, a fibrosis of the palmar fascia. Little is known about any commonalities in the pathophysiology of these connective tissue fibroses. β-catenin, a protein that transactivates gene expression, and levels of IGF2 mRNA, encoding insulin-like growth factor-II, are elevated in Dupuytren’s disease. The aim of this study was to determine if correlating changes in β-catenin levels and IGF2 expression are evident in Frozen Shoulder Syndrome. Methods: Tissue from patients with Frozen Shoulder Syndrome and rotator cuff tear were obtained during shoulder arthroscopies. Total protein extracts were prepared from tissue aliquots and β-catenin immunoreactivity was assessed by Western immunoblotting. In parallel, primary fibroblasts were derived from these tissues and assessed for IGF2 expression by quantitative PCR. Results: β-catenin levels were significantly increased in Frozen Shoulder Syndrome relative to rotator cuff tear when assessed by Western immunoblotting analyses. IGF2 mRNA levels were significantly increased in primary fibroblasts derived from frozen shoulder syndrome tissues relative to fibroblasts derived from rotator cuff tissues. Conclusions: As in Dupuytren’s disease, β-catenin levels and IGF2 expression are elevated in Frozen Shoulder Syndrome. These findings support the hypothesis that these connective tissue fibroses share a common pathophysiology

Effect of Concomitant Elbow Injuries on the Outcomes of Radial Head Arthroplasty: A Cohort Comparison

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Objectives: To compare physical impairments and patient-reported outcomes in patients after simple and complex elbow injuries who were treated with radial head arthroplasty. Design: Prospective. Setting: Quaternary upper extremity referral hospital. Patients/Participants: 148 patients with isolated elbow trauma and no previous injury to the elbow were prospectively enrolled after radial head arthroplasty for an acute unreconstructable fracture. Injury patterns were classified as simple or complex based on the presence or absence of associated elbow fractures and/or dislocation. Intervention: Radial head arthroplasty. Main Outcome Measurements: Patient-Rated Elbow Evaluation (PREE), Disability of the Arm, Shoulder, and Hand, range of motion (ROM), and Biodex measurements. Results: At a minimum 1-year follow-up PREE and Disability of the Arm, Shoulder, and Hand, and ROM and strength values were similar. Forty-four patients evaluated at a mean of 7 years demonstrated no effect of injury pattern on clinical outcomes at any time point. Continued statistical improvements in PREE, supination ROM, and flexion ROM at medium term compared with earlier follow-up were observed. Eight patients required secondary surgery, 2 in the simple injury group and 6 complex injury patients. Conclusions: Concomitant elbow injuries do not affect the longer term outcomes of patients with unreconstructable radial head fractures requiring radial head arthroplasty. Patient outcomes continued to improve beyond 2 years of follow-up. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence