Endoscopic-Assisted Transaxillary Approach for First-Rib Resection and Neurolysis in Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a complex disorder with signs and symptoms resulting from compression of the brachial plexus and subclavian vessels. Although transaxillary first-rib resection is a well-established surgical treatment for patients with symptomatic TOS, this approach sometimes does not allow adequate exposure of the insertion point of the middle scalene muscle to the posterior part of the first rib and neurovascular bundle. The objective of this Technical Note is to describe an endoscopic-assisted transaxillary approach for first-rib resection and neurolysis. An endoscopic-assisted transaxillary approach for first-rib resection in TOS can provide excellent magnified visualization and safely allow sufficient decompression of the neurovascular bundle

Recovery of sensory disturbance after arthroscopic decompression of the suprascapular nerve

Background: Recently, the existence of sensory branches of the suprascapular nerve (SSN) has been reported, and sensory disturbance at the lateral and posterior aspect of the shoulder has been focused on as a symptom of SSN palsy. We have performed arthroscopic release of SSN at the suprascapular notch in patients with the sensory disturbance since 2006. The purposes of this study were to introduce the arthroscopic surgical technique and to investigate postoperative recovery of sensory disturbance. Methods: Twenty-five shoulders (11 men and 14 women, average age: 63.9 years (range, 41-77)) followed for more than 1 year were included in this study. Arthroscopic decompression of SSN was performed using a suprascapular nerve portal (SN portal) as a landmark for approaching the suprascapular notch. Sensory disturbance of the shoulder was evaluated pre- and postoperatively. The follow-up period was 12-30 months (avg. 18.5). Results: The arthroscopic procedures was able to be performed safely. The preoperative sensory disturbance fully recovered postoperatively in all shoulders. Conclusion: Arthroscopic release of SSN is considered to be a useful procedure for the entrapment of SSN at the suprascapular notch. The sensory disturbance at the lateral and posterior aspect of the shoulder can be used as one of the criteria of diagnosing SSN palsy especially in shoulders with massive rotator cuff tear, which usually have difficulty in diagnosing and assessing the treatment results of associated SSN palsy

Trapeziectomy with Ligament Reconstruction and Interposition Arthroplasty Using the Palmaris Longus Tendon : An Average 5-Year Follow-up

Background: Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of trapeziometacarpal osteoarthritis. We modified the LRTI, using the palmaris longus (PL) tendon instead of the FCR tendon. The aim of this retrospective study was to evaluate the clinical outcomes of trapeziectomy with our modified LRTI procedure at a mean follow-up of 5 years. Methods: Fourteen thumbs in 13 patients (12 women) with a mean age of 64 years (range, 50 to 77 years) were available for assessment for a mean duration of 62 months (range, 41 to 97 months). The patients were evaluated subjectively and objectively. Results: The modified LRTI procedure provided good pain relief, motion, strength, and stability without any severe complications related to the PL tendon harvesting. Radiography showed that compared to the preoperative status, the trapezial space decreased by about 40% at the final follow- up. Conclusions: The modified LRTI procedure provided significant subjective and objective improvements without severe complications particularly related to the harvesting of the PL tendon. This procedure is a valuable surgical option for trapeziometacarpal osteoarthritis and could be a useful salvage modality if the FCR tendon ruptures during the conventional LRTI procedure

Glenoid Stress Distribution in Baseball Players Using Computed Tomography Osteoabsorptiometry: A Pilot Study

Background: It is important to understand the loading conditions when considering the pathology of shoulder disorders in overhead athletes. However, because throwing is a complicated motion, direct measurement of the stress distribution across the glenohumeral joint is difficult. Subchondral bone density reportedly reflects the cumulative stress acting on a joint surface under actual loading conditions. Questions/Purposes: To assess alterations in stress distribution across the glenoid cavity caused by pitching, we investigated the distribution of subchondral bone density in nonathletic volunteers and asymptomatic baseball players, including fielders and pitchers. Methods: We collected computed tomography (CT) imaging data from the dominant-side shoulder of 10 nonathletic volunteers (controls), 10 fielders, and 10 pitchers in a competitive college baseball league (all men aged 19-24 years, mean 20.7 years). We measured the distribution of subchondral bone density of the glenoid cavity using CT osteoabsorptiometry. The obtained stress distribution map was divided into four segments: anterosuperior, anteroinferior, posteroinferior, and posterosuperior regions. The location and percentages of high-density regions on the articular surface were analyzed quantitatively. Results: The percentages of high-density regions, including the anteroinferior, and posterior segments, were greater in pitchers and fielders than in controls. The percentages of high-density regions did not differ significantly between pitchers and fielders. Conclusions: The bicentric density patterns indicate that the cumulative force of pitching activity affected the long-term stress distribution across the glenoid cavity. Clinical Relevance: The current results provide useful information for analyzing pitching activity and clarifying the pathology of shoulder disorders associated with throwing

Correction in Malrotation of the Scapula and Muscle Transfer for the Management of Severe Sprengel Deformity: Static and Dynamic Evaluation Using 3-Dimensional Computed Tomography

Background: The clinical results of surgical procedures for severe Sprengel's deformity have been uncertain. To obtain improved elevation, we consider that it is necessary to realign the lateral border of the scapula for upward rotation. The purposes of the current study were to evaluate the clinical results and range of motion of the scapula after such realignment. Methods: Seven cases of Sprengel's deformity of Cavendish grade 3 or 4 were treated surgically and then clinically evaluated and examined using three-dimensional computed tomography (3D CT). (Two boys and five girls aged 50.9 ± 15.4 months, mean ± standard deviation at the time of operation.) The mean follow-up was 53.1 months (range, 12 to 92 months). After the omovertebral bone and the superomedial side of the scapula were removed, the levator scapulae and rhomboids were reattached to wrap around the scapula at maximum upward rotation to assist in maintaining this position. Cavendish and Rigault grades were used for evaluation of postoperative appearance. The superior displacement and rotation of the scapula were measured on the trunk posterior view using 3D CT. The relationship between improvement in the range of motion and radiologic change were analyzed statistically. Results: The postoperative flexion (97.9° ± 12.9° to 160° ± 11.5°) and abduction (99.3° ± 13.0° to 161.4° ± 15.7°) were significantly improved compared with the mean preoperative values (P < .0001). 3D CT revealed that in all patients the malrotation of the scapula was improved postoperatively. The current study shows that successful realignment of the scapula led to these improved clinical results. Conclusions: Our procedure has advantages not only for recovery of the range of motion but also for reducing the characteristic lump in the web of the neck. However, our procedure has an inherent limitation related to asymmetrical shoulder level and width. 3D CT may be useful for preoperative planning and postoperative evaluation

Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes

Background: Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. Methods: From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. Results: Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112° ± 17° preoperatively to 128° ± 12° postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 ± 23 points preoperatively to 191 ± 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. Conclusions: The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions

Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes : Surgical Technique

BACKGROUND: Although autologous osteochondral mosaicplasty is widely used as a procedure for osteochondritis dissecans lesions, the effectiveness of this procedure in elbow lesions remains unclear. Our aim was to clarify the surgical efficacy of mosaicplasty for teenage athletes with advanced lesions of capitellar osteochondritis dissecans. METHODS: From 2001 to 2006, nineteen teenage male patients who were competitive athletes and had advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. The mean age of the patients was 14.2 years. The surgical technique involved obtaining small-sized cylindrical osteochondral grafts with a mean diameter of 3.5 mm from the lateral periphery of the femoral condyle at the level of the patellofemoral joint and transplanting the grafts (mean, 3.3 grafts) to prepared osteochondral defects. The patients were evaluated clinically and radiographically at a mean of forty-five months after surgery. RESULTS: Eighteen patients were free from elbow pain, and one had mild pain occasionally. The mean total arc of elbow motion and standard deviation increased significantly from 112° ± 17° preoperatively to 128° ± 12° postoperatively (p < 0.005). The mean clinical score described by Timmerman and Andrews (with a maximum of 200 points) improved significantly from 131 ± 23 points preoperatively to 191 ± 15 points postoperatively (p < 0.0001). All patients except one had an excellent or good clinical result. All donor knees were graded as excellent on the basis of the Lysholm knee scoring system. All patients except two returned to a competitive level of the sport they had previously played. Neither loose-body formation nor secondary osteoarthritic changes were found in any patient. CONCLUSIONS: The current midterm results indicate that mosaicplasty can provide satisfactory clinical outcomes for teenage athletes with advanced capitellar osteochondritis dissecans lesions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: "Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes" (2009;91:2359-66)

In Vivo Visualization of Vascular Patterns of Rotator Cuff Tears Using Contrast-Enhanced Ultrasound

Background: Hypoxia and decreased blood supply have been proposed as risks for tendon rupture. Visualization of the vascularity of intact and torn rotator cuffs would be useful for improving treatments for rotator cuff tear. Purpose: To assess vascularity inside a tendon or an adjacent rotator cuff insertion point in patients differing in age and extent of damage to the tendon. Study Design: Cross-sectional study. Methods: Ten volunteers (all men) and 15 patients (10 men, 5 women) consented to participate in the study. Contrast agent for enhanced ultrasound was injected intravenously. Enhanced ultrasound images of the torn cuff and the contralateral shoulder were recorded for 1 minute. Four small regions of interest, the articular and bursal sides of the tendon and the medial and lateral sides of the bursa, were studied on all shoulders. Results: There was a significant decrease in blood flow in the intratendinous region in elderly subjects compared with young subjects but age had no effect on blood flow in bursal tissue. Blood flow in ruptured rotator cuffs did not differ from that in intact rotator cuffs. The intraclass correlation coefficient for intraobserver reproducibility was 0.82 (95% confidence interval, 0.77 to 0.86). Conclusions: The findings of this investigation were the hypovascular pattern in intratendinous tissue compared with the subacromial bursa, the age-related decrease in intratendinous vascularity, and the hypovascular pattern in the tendon, regardless of rupture of the tendon. Clinical Relevance: Clarification of vascular patterns inside or around the torn ends of a rotator cuff will assist in the development of successful treatments for torn rotator cuffs