How to treat stiffness after proximal humeral fractures?

Shoulder stiffness is a frequent complication after proximal humeral fractures treated with or without surgery. Shoulder stiffness is associated with high rates of absence from work and a significant financial burden for the healthcare system. Secondary stiffness is characterized by additional extracapsular adhesions, including subacromial, subcoracoid, and subdeltoid spaces, usually derived from post-fracture or post-surgical extraarticular hematomas. Several secondary causes may coexist with capsular and extracapsular adhesions decreasing the shoulder motion, such as malunion, nonunion, metalwork failure, infection, and osteoarthritis, among others. Conservative treatment, usually prescribed for primary shoulder stiffness, has shown unfavorable results in secondary stiffness, and surgical intervention may be required. Surgical interventions need to be patient-specific. Usually, open or arthroscopic fibro-arthrolysis and subacromial release are performed, together with plate removal and biceps tenotomy/tenodesis. In severe osteoarthritis, shoulder replacement may be indicated. Ruling out infection is recommended in every case

Current concepts in chronic traumatic anterior shoulder instability.

Chronic traumatic anterior shoulder instability can be defined as recurrent trauma-associated shoulder instability requiring the assessment of three anatomic lesions: a capsuloligamentous and/or labral lesion; anterior glenoid bone loss and a Hill-Sachs lesion. Surgical treatment is generally indicated. It remains controversial how risk factors should be evaluated to decide between a soft-tissue, free bone-block or Latarjet-type procedure. Patient risk factors for recurrence are age; hyperlaxity; competitive, contact and overhead sports. Trauma-related factors are soft tissue lesions and most importantly bone loss with implications for treatment. Different treatment options are discussed and compared for complications, return to sports parameters, short- and long-term outcomes and osteoarthritis. Arthroscopic Bankart and open Latarjet procedures have a serious learning curve. Osteoarthritis is associated with the number of previous dislocations as well as surgical techniques. Latarjet-type procedures have the lowest rate of dislocation recurrence and if performed correctly, do not seem to increase the risk of osteoarthritis

Device for lengthening of a musculotendinous unit by direct continuous traction in the sheep

Background Retraction, atrophy and fatty infiltration are signs subsequent to chronic rotator cuff tendon tears. They are associated with an increased pennation angle and a shortening of the muscle fibers in series. These deleterious changes of the muscular architecture are not reversible with current repair techniques and are the main factors for failed rotator cuff tendon repair. Whereas fast stretching of the retracted musculotendinous unit results in proliferation of non-contractile fibrous tissue, slow stretching may lead to muscle regeneration in terms of sarcomerogenesis. To slowly stretch the retracted musculotendinous unit in a sheep model, two here described tensioning devices have been developed and mounted on the scapular spine of the sheep using an expandable threaded rod, which has been interposed between the retracted tendon end and the original insertion site at the humeral head. Traction is transmitted in line with the musculotendinous unit by sutures knotted on the expandable threaded rod. The threaded rod of the tensioner is driven within the body through a rotating axis, which enters the body on the opposite side. The tendon end, which was previously released (16 weeks prior) from its insertion site with a bone chip, was elongated with a velocity of 1 mm/day. Results After several steps of technical improvements, the tensioner proved to be capable of actively stretching the retracted and degenerated muscle back to the original length and to withstand the external forces acting on it. Conclusion This technical report describes the experimental technique for continuous elongation of the musculotendinous unit and reversion of the length of chronically shortened muscle

Deep-Learning-Based Segmentation of the Shoulder from MRI with Inference Accuracy Prediction

Three-dimensional (3D)-image-based anatomical analysis of rotator cuff tear patients has been proposed as a way to improve repair prognosis analysis to reduce the incidence of postoperative retear. However, for application in clinics, an efficient and robust method for the segmentation of anatomy from MRI is required. We present the use of a deep learning network for automatic segmentation of the humerus, scapula, and rotator cuff muscles with integrated automatic result verification. Trained on N = 111 and tested on N = 60 diagnostic T1-weighted MRI of 76 rotator cuff tear patients acquired from 19 centers, a nnU-Net segmented the anatomy with an average Dice coefficient of 0.91 ± 0.06. For the automatic identification of inaccurate segmentations during the inference procedure, the nnU-Net framework was adapted to allow for the estimation of label-specific network uncertainty directly from its subnetworks. The average Dice coefficient of segmentation results from the subnetworks identified labels requiring segmentation correction with an average sensitivity of 1.0 and a specificity of 0.94. The presented automatic methods facilitate the use of 3D diagnosis in clinical routine by eliminating the need for time-consuming manual segmentation and slice-by-slice segmentation verification

A biomechanical study comparing the mean load to failure of two different osteosynthesis techniques for step-cut olecranon osteotomy

Background Olecranon osteotomies are frequently used to expose distal humeral intraarticular fractures. The step-cut olecranon osteotomy (SCOOT) is an augmented version of the oblique olecranon osteotomy, which has recently been evaluated biomechanically with tension band wiring (TBW) fixation. However, complications with TBW are common. In this study, we, therefore, compared the mean load to failure of TBW with compression screws for SCOOT fixation. We hypothesized a higher load to failure for the compression screw group. Methods We performed a SCOOT on 36 Sawbones. Eighteen were fixed with TBW, and another 18 with two compression screws. The humeroulnar joint was simulated using an established test setup, which allows the application of triceps traction force through a tendon model to the ulna, while the humeroulnar joint is in a fixed position. Eight models of each fixation group were tested at 20°, and eight at 70° of flexion by isometrical loading until failure, which was defined as either a complete fracture or gap formation of more than 2 mm at the osteotomy site. Results At 20° of flexion, mean load to failure was similar between the TBW group (1360 ± 238 N) and the compression screw group (1401 ± 261 N) (P = .88). Also, at 70° of flexion, the mean load to failure was similar between the TBW group (1398 ± 215 N) and the compression screw group (1614 ± 427 N) (P = .28). Conclusions SCOOTs fixed with TBW and compression screws showed similar loads to failure. A SCOOT fixed with compression screws might be a valuable alternative for surgeons when treating intraarticular distal humeral fractures. However, future in vivo studies are necessary to confirm our results in a clinical setting

Surgical Management of Massive Irreparable Cuff Tears: Latissimus Dorsi Transfer for Posterosuperior Tears.

PURPOSE OF REVIEW This review aims to describe the role of the latissimus dorsi transfer (LDT) for patients with irreparable posterosuperior rotator cuff tears (RCTs). RECENT FINDINGS Historically, the LDT has been performed as an open (double-incision) procedure for neurologically intact, relatively young patients with irreparable posterosuperior RCTs with disabling loss of active external rotation with or without impaired active elevation. The transferred tendon reconstitutes the posterior rotator cuff and force couple, respectively and thus has the potential to function effectively as an external rotator and humeral head depressor. Long-term results of the open technique have demonstrated in the majority of patients substantial and durable improvements in shoulder function and pain relief at the 10-year benchmark. With the advancements of arthroscopic surgery, the LDT was expanded to an arthroscopically assisted procedure with promising short-term results. In addition to adequate technical performance, the success of the procedure depends on preoperative factors, such as exclusion of glenohumeral osteoarthritis and acromial acetabularization; intact or reparable subscapularis tendon; intact (or hypertrophic) teres minor muscle; adequate preoperative activity of the latissimus dorsi; and normal or mild impairment of overhead function. The LDT (open or arthroscopically assisted) is a reliable treatment option for patients with massive, irreparable posterosuperior RCTs with disabling loss of active external rotation, with or without diminished overhead function and without advanced glenohumeral osteoarthritis. Precise patient selection is of tremendous importance in the success of the LDT