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What's new in shoulder and elbow surgeryThis is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. What's New in Shoulder and Elbow Surgery
Matthew L. Ramsey, Charles L. Getz and Bradford O. Parsons J Bone Joint Surg Am. 2008;90:677-687. doi:10.2106/JBJS.G.01544 This information is current as of November 20, 2009
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article, or locate the article citation on Permissions] link. The Journal of Bone and Joint Surgery20 Pickering Street, Needham, MA 02492-3157 COPYRIGHT Ó 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED What's New in Shoulder and By Matthew L. Ramsey, MD, Charles L. Getz, MD, and Bradford O. Parsons, MD This annual update on shoulder and elbow surgery is a review of tine may have on rotator cuff healing following rotator cuff the most relevant studies from July 2006 through June 2007. It includes clinical and basic science articles from The Journal of Extracellular matrix scaffolds have been used during Bone and Joint Surgery (American Volume), The Journal of Bone rotator cuff surgery to augment deficient tissue and to close and Joint Surgery (British Volume), the Journal of Shoulder and small residual cuff tears. Interestingly, very few independent Elbow Surgery, and Arthroscopy: The Journal of Arthroscopic and data exist regarding the properties of commercially available Related Surgery. Relevant Level-I and Level-II studies from other extracellular matrix grafts. Derwin et al.2 investigated the medical journals are included where appropriate.
biomechanical, biochemical, and cellular properties of four The level of evidence is indicated at the end of each graft materials. Biomechanically, all four graft materials re- review when it is known. Particular attention should be paid to quired substantial stretch (10% to 30%) before they could the Level-I and Level-II studies as they represent randomized carry substantial load. DNA content, indicating residual native controlled studies. However, study design and analysis influ- cellular elements, was measurable in three of the four grafts but ences the quality of these studies. Additional Level-III and was significantly higher in one (TissueMend; Stryker Ortho- Level-IV studies representing important topics in shoulder and paedics, Mahwah, New Jersey). The poor biomechanical elbow surgery are also included in the review.
properties of these grafts suggest that the use of these graftsdoes not protect the rotator cuff repair through load sharing.
Additionally, measurable DNA content indicates that some cellular elements remain in the graft.
Rotator cuff healing following surgical repair continues The effect of nicotine on bone healing is well known. However, to be unpredictable. Blood flow to the tendon edge has been little is known about the effect of nicotine on tendon-to-bone viewed as evidence of the healing potential of the repair.
healing. Galatz et al.1 performed an eloquent experiment in Minimal d´ebridement of the tendon has been recommended which acute supraspinatus tendon repairs were performed in on the basis of studies that have demonstrated adequate blood rats. During the healing phase, some rats were exposed to flow to the torn tendon edge. However, Matthews et al.3 be- nicotine and others were exposed to saline solution as a con- lieved that cellular activity (as indicated by oxygen con- trol. There was a delay in tendon-to-bone healing in rats that sumption) in the torn rotator cuff is a more important had been exposed to nicotine. While the mechanical properties measure of the healing potential. Cellular oxygen consump- increased over time in both groups, the properties in the tion was measured in thirteen patients undergoing mini-open nicotine group lagged behind those in the control group.
repair of small, medium, large, and massive full-thickness This study demonstrated the detrimental effect that nico- tears. Control measurements were taken from three patientswith grossly normal tendons. All of the torn tendons hadlower cellular activity than did those in the control group.
Specialty Update has been developed in collaboration with the Council of Cellular activity was lower at the edge of the tear, with the Musculoskeletal Specialty Societies (COMSS) of the American Academy ofOrthopaedic Surgeons.
lowest activity occurring in larger tears. The authors believed Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor amember of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercialentity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, orother charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2008;90:677-87 d doi:10.2106/JBJS.G.01544 What's New in Shoulder and Elbow Surgery that the high rates of rerupture in patients with larger tears and independently influence outcome were patient age; the may be explained by diminished cellular activity at the tendon shape, retraction, and reducibility of the rotator cuff tear; fatty degeneration of the rotator cuff muscles; involvement of the The natural history of rotator cuff disease is poorly subscapularis; and the repair technique.
understood. Specifically, the demographic and morphologi-cal characteristics of asymptomatic and symptomatic rotator Partial-Thickness Tears cuff tears are not clearly established in the literature.
The operative treatment of articular-sided partial-thickness Yamaguchi et al.4 evaluated bilateral shoulder ultrasound rotator cuff tears remains controversial. Deutsch7 reported on studies for patients presenting with unilateral shoulder forty-one patients with articular-sided partial-thickness tears pain in an attempt to compare tear characteristics and the that were treated with completion of the tear and arthroscopic prevalence of asymptomatic and symptomatic rotator cuff repair of the full-thickness defect with use of a simple suture disease. Patient age correlated with both the presence or ab- technique. After short-term follow-up of three years, signifi- sence of a rotator cuff tear and the extent of the tear. The cant improvements were noted in terms of the American average age was 48.7 years for patients with no rotator cuff Shoulder and Elbow Surgeons (ASES) score, pain relief, and tear, 58.7 years for those with a unilateral tear, and 67.8 patient satisfaction. Forty (98%) of the forty-one patients were years for those with a bilateral tear. After the age of sixty- satisfied with the outcome.
six years, the likelihood of having a bilateral rotator cufftear was 50%. Overall, patients who presented with a full- Full-Thickness Tears thickness symptomatic tear had a 35.5% prevalence of a full- Cho et al.8 investigated postoperative pain management fol- thickness tear on the contralateral (asymptomatic) side. We lowing arthroscopic rotator cuff repair. In a randomized pro- can conclude from this study that bilateral rotator cuff dis- spective study, patients undergoing arthroscopic rotator cuff ease, either symptomatic or asymptomatic, is common in repair received patient-controlled analgesia by means of sub- patients who present with unilateral symptomatic disease.
acromial infusion with 0.5% bupivacaine (Group 1) or intra- The authors recommended surveillance at yearly intervals for venous injection with fentanyl and ketorolac tromethamine patients with known rotator cuff tears that are treated (Group 2). The immediate postoperative visual analog scale pain score was 7.6 for Group 1 and 7.4 for Group 2. At all ofthe time-points measured, no significant difference in post- Subacromial Decompression (Acromioplasty) operative visual analog scale pain scores was noted between the Barfield and Kuhn5 performed a systematic review of one groups. The authors concluded that subacromial infusion of Level-II and four Level-I randomized controlled prospective bupivacaine and intravenous injection of fentanyl and ketor- studies to determine whether the outcome of arthroscopic olac tromethamine were equally effective methods of postop- acromioplasty differs from that of open acromioplasty. With erative pain management following arthroscopic rotator cuff pain relief as the primary outcome, no differences were repair (Level II).
found between arthroscopic acromioplasty and open acro- There has been a rapid evolution in the arthroscopic mioplasty. Other outcomes that showed no difference included techniques for rotator cuff repair. When evaluating the liter- University of California at Los Angeles (UCLA) shoulder ature, the success or failure of arthroscopic techniques must be scores, range of motion, and strength. The data for the time judged against the results of established open techniques. In a required to perform surgery and the time to return to work study by Liem et al.9, the clinical outcomes and structural in- could not be used to recommend one approach over the other.
tegrity of arthroscopic and mini-open rotator cuff repairs were The authors concluded that, on the basis of the data available compared. Patients were matched according to age, gender, from the studies reviewed, they could not find appreciable and the duration of symptoms. Preoperative and postoperative differences between arthroscopic and open acromioplasty Constant scores and early postoperative range of motion were evaluated. Structural integrity of the rotator cuff was deter- Acromioplasty traditionally has been performed with mined with magnetic resonance imaging at the time of the rotator cuff repair. However, some surgeons currently are latest follow-up. The clinical outcome demonstrated no dif- performing arthroscopic rotator cuff repair without acromio- ferences between the two treatment groups. There was no plasty. In the randomized prospective study by Milano et al.6, difference in retear rates as demonstrated on postoperative patients undergoing arthroscopic rotator cuff repair with ac- magnetic resonance imaging between the arthroscopic repair romioplasty (Group 1) were compared with those undergoing group (six retears; 31.6%) and the mini-open group (seven arthroscopic rotator cuff repair without acromioplasty (Group retears; 36.8%). Smaller retears had no influence on the clin- 2). Acromioplasty did not significantly influence the outcome ical result, whereas more retracted retears correlated with as measured with the Constant score; the Disabilities of the lower abduction strength, regardless of the repair method. One Arm, Shoulder and Hand (DASH) score; and the Work-DASH can conclude that the arthroscopic repair of isolated supra- score (Level I). The variables that were shown to significantly spinatus tears produces excellent clinical results and equivalent What's New in Shoulder and Elbow Surgery tendon integrity as compared with mini-open repair (Level ward elevation above 90°. In two patients, postoperative electromyography demonstrated reinnervation potentials in Two studies summarized the results of arthroscopic the muscles supplied by the suprascapular nerve, with com- double-row rotator cuff repair10,11. Each of those studies cor- plete recovery occurring in one patient. The authors believed related function with the structural integrity of the repair. In that retraction of the rotator cuff (particularly the supraspi- the first study, Sugaya et al.10 reported on eighty-six patients natus) can create traction on the suprascapular nerve. Partial who underwent double-row rotator cuff repair. The repair repair may relieve some of this traction, allowing nerve re- technique varied slightly on the basis of the tear configuration covery and improved function.
but involved a medial and lateral row of suture anchors. Thetear sizes ranged from small to massive. The clinical outcome measures had all improved significantly at the time of the latest Infection following rotator cuff repair can be difficult to di- follow-up. The retear rate was 5% for small-to-medium tears agnose and treat and may have a profound effect on the and 40% for large and massive tears. Patients who had a function of the shoulder. Athwal et al.13 performed a retro- complete retear had a significantly poorer functional outcome spective review of the Mayo Clinic experience with infection compared with those who had a tear that partially or com- following rotator cuff repair in thirty-eight patients. Propion- pletely healed. Thus, arthroscopic double-row fixation results ibacterium acnes was the causative organism in 51% of the in improved healing for small to medium-sized tears. However, patients who were identified with a deep infection. At the the retear rate for shoulders with large and massive tears re- time of the most recent follow-up, the mean active elevation mains high. Huijsmans et al.11 performed ultrasound evalua- was 120° and the mean external rotation was 45°. In the tion of the shoulder to determine the integrity of the rotator group of patients who were available for follow-up, the cuff three weeks after arthroscopic double-row rotator cuff overall results, as measured with the ASES shoulder rating repair and at a minimum of one year postoperatively. Three and the Simple Shoulder Test, were excellent in seven weeks after surgery, ultrasound demonstrated an intact repair shoulders, satisfactory in nine, and unsatisfactory in eleven.
in 94% of the shoulders with a small tear, in 97% of those with The authors noted that Propionibacterium acnes can be dif- a medium tear, in 90% of those with a large tear, and in only ficult to identify and requires cultures to be monitored for at 66% of those with a massive tear. At the time of the latest least seven days.
follow-up, ultrasound demonstrated an intact repair in 88% ofthe shoulders with a small tear, in 93% of those with a medium Anterior Glenohumeral Instability/SLAP tear, in 78% of those with a large tear, and in 47% of those with The diagnosis of traumatic anterior instability is based on the a massive tear. The Constant score improved significantly in all clinical history, physical examination, and supporting radio- patients, but the improvement was significantly greater in graphic studies. However, the usefulness of various physical patients with a healed repair. Strength and active elevation examination tests in the diagnosis of anterior instability has increased significantly more in the group with an intact repair not been thoroughly investigated. Farber et al.14 evaluated than in the group with a failed repair; however, there was no patients with traumatic anterior shoulder instability that difference between the groups in terms of the pain score. Poor had been confirmed arthroscopically or documented radio- tissue quality was also associated with a higher failure rate than graphically after the trauma. The clinical usefulness of good tissue quality was. The authors concluded that a healed anterior apprehension, relocation, and anterior drawer rotator cuff can be expected in the majority of shoulders that tests was evaluated. All three tests for traumatic anterior are treated for a large, medium, or small tear, but massive tears shoulder instability were demonstrated to be specific but not continue to have a high failure rate. Furthermore, strength, sensitive. Apprehension is better than pain for use as a cri- range of motion, and functional recovery depend on rotator terion for a positive apprehension or relocation test. When cuff healing.
pain does not prevent it from being performed, the anterior While the results of rotator cuff surgery are linked to drawer test is helpful for diagnosing traumatic anterior in- tendon healing, other factors contribute to the overall results.
stability (Level I).
Suprascapular neuropathy has been associated with retracted Anterior instability is frequently associated with labral rotator cuff tears. Mallon et al.12 evaluated eight patients with detachment from the anteroinferior aspect of the glenoid.
massive, retracted rotator cuff tears with atrophy and fatty When the scapular periosteum does not rupture, an anterior replacement of the muscle. All patients had evidence of su- labroligamentous periosteal sleeve avulsion occurs. At times, prascapular neuropathy with denervation of the supraspina- the anterior labroligamentous periosteal sleeve avulsion will tus and/or infraspinatus muscles, and they were severely heal medially to the neck of the glenoid, effectively shortening limited preoperatively in forward elevation. Four patients the anterior band of the inferior glenohumeral ligament.
elected to undergo a rotator cuff d´ebridement with partial Theoretically, this will decrease passive external rotation in repair of the rotator cuff with use of a margin convergence abduction and external rotation. Deutsch et al.15 performed a technique. Following surgery, all four patients regained for- prospective study to test this hypothesis. External rotation at What's New in Shoulder and Elbow Surgery 90° of abduction was assessed in the affected and unaffected higher than those associated with open methods (Level II). A shoulders on examination with the patient under anesthesia.
randomized controlled study of arthroscopic and open stabi- Arthroscopy was used to identify patients who had a detached lization for the treatment of recurrent anterior instability18 Bankart lesion (Group 1) and patients who had a medially yielded a different result. Failure was defined as recurrent healed Bankart lesion (Group 2). Differences in external ro- subluxation, recurrent dislocation, or symptoms precluding tation at 90° of abduction between symptomatic and asymp- return to previous work or unrestricted active military duty.
tomatic shoulders were compared in both groups. Detachment There were three clinical failures (two after open stabilization of the labrum resulted in increased external rotation at 90° of and one after arthroscopic stabilization) according to the es- abduction, whereas a medially healed Bankart lesion resulted tablished criteria. There was significant improvement in the in decreased external rotation at 90° of abduction compared Single Assessment Numeric Evaluation. The mean loss of with the asymptomatic side. The authors concluded that loss motion (compared with the contralateral shoulder) was greater of ‡5° of external rotation at 90° of abduction in the affected in the shoulders treated with an open method. Subjective shoulder on examination with the patient under anesthesia evaluations were equal in both groups. This prospective ran- should create a high degree of suspicion for the presence of a domized trial indicates that open and arthroscopic surgery are medially healed Bankart lesion (Level II).
comparable for the treatment of recurrent anterior instability The long-term results of operative and nonoperative (Level I). These two studies alone do not clarify the questions treatment of first-time traumatic anterior dislocation were that have been raised with regard to arthroscopic and open studied by Jakobsen et al.16. The pathologic lesion was de- repairs. More work is required in order to define the technical fined arthroscopically as a capsular tear with no labral nuances that account for these differences.
injury, capsular tear and partial labral tear, or capsular As arthroscopic repairs for the treatment of anterior tear with labral detachment. The patients were randomized instability have been associated with a higher rate of redis- to an open repair group or a nonoperative treatment location than open repairs have, it is critical to understand the group. After a minimum duration of follow-up of two years, reasons for failure. Boileau et al.19 evaluated the outcomes of the rate of recurrence was 56% after nonoperative treatment arthroscopic Bankart repairs to identify risk factors for re- and 3% after open repair. The patients were evaluated after current instability. Labral repair combined with capsular re- ten years with use of the Oxford self-assessment score. Good tensioning was performed with use of absorbable suture or excellent results were obtained for 72% of the patients in anchors. Recurrent instability occurred in 15.3% of the pa- the operative treatment group, whereas 75% of the patients in tients. The risk of postoperative recurrence was related to the the nonoperative treatment group had an unsatisfactory re- presence of a compression defect or attritional bone loss on the sult because of recurrence, instability, and pain or stiffness.
glenoid, a large Hill-Sachs lesion, inferior and/or anterior The authors recommended considering primary repair for hyperlaxity, or the use of three or fewer suture anchors. Os- active patients to reduce the risk of recurrent dislocation seous Bankart lesions were not associated with a higher rate of recurrent instability. The combination of glenoid bone loss Open and arthroscopic techniques for anterior gleno- and inferior hyperlaxity led to a 75% recurrence rate. Unfor- humeral instability have been described. To date, most studies tunately, the authors did not report the extent of the tear over have indicated a higher redislocation rate in association with which the anchors were placed, but they recommended using arthroscopic repair as compared with open repair. Lenters four or more anchors in the repair and being cautious in pa- et al.17 performed a systematic review and meta-analysis of the tients with bone loss and hyperlaxity (Level IV).
literature to determine the effectiveness of arthroscopic repairsas compared with open repair for the treatment of recurrent Glenohumeral Arthritis anterior instability of the shoulder. Four randomized con- trolled trials, ten controlled clinical trials, and four other Glenoid component failure remains an area of interest related comparative studies were identified. The results were influ- to total shoulder arthroplasty as glenoid component longevity enced both by the quality of the study and by the arthroscopic has been linked to survivorship of the glenoid component.
technique. The meta-analysis revealed that, compared with Terrier et al.20 utilized a three-dimensional finite-element open repairs, arthroscopic repairs were associated with sig- model to study the effect of glenohumeral joint conformity nificantly higher risks of recurrent instability, recurrent dis- and glenoid version on glenoid stresses. Humeral and glenoid location, and reoperation. Arthroscopic approaches were also components were implanted in the model for two different less effective than open methods with regard to enabling pa- orientations of the glenoid component (0° and 15° of retro- tients to return to work and/or sports. On the other hand, version). Different degrees of radial mismatch (1 to 15 mm) analysis of the randomized clinical trials indicated that ar- between the humeral head and the glenoid were then tested. As throscopic repairs were associated with higher Rowe scores mismatch increased, glenohumeral contact pressure increased than open repairs were. Similarly, analysis of the arthroscopic significantly (threefold between 1 and 15 mm), and, as a result, suture-anchor techniques alone showed the Rowe scores to be stress within the polyethylene increased. Above 10 mm of What's New in Shoulder and Elbow Surgery mismatch, the stress exceeded the polyethylene yield strength.
eighteen. The result was excellent for eighteen shoulders, sat- Cement stress increased with progressively greater radial isfactory for thirteen, and unsatisfactory for five. Glenoid mismatch but was only severe for the retroversion case above erosion averaged 7.2 mm and appeared to stabilize at five years.
10 mm of mismatch. Retroversion increased all values by more Factors that were associated with unsatisfactory results were than twice and exceeded critical values above 10 mm of mis- the use of capsular tissue as the resurfacing material and in- match. This study confirmed all previous findings indicating fection. The authors currently recommend Achilles tendon that radial mismatch between the humerus and the glenoid allograft as the preferred resurfacing material (Level IV).
should not exceed 10 mm. Additionally, the detrimental effect The increase in the number of total shoulder replace- of retroversion on glenoid stresses was highlighted.
ments performed will undoubtedly result in an increase in the Concern about glenoid component survival has led number of revision procedures. Dines et al.24 investigated the some authors to attempt alternative treatments for glenohu- relationship between final outcome and the indication for meral arthritis. Lateral meniscal allografts have been used in revision surgery. Patients were divided into those with osse- conjunction with hemiarthroplasty for the treatment of gle- ous or component-related problems (Group 1), including nohumeral arthritis for patients in whom glenoid replacement revision of the glenoid component, conversion from hemi- is deemed undesirable. Creighton and colleagues21 investigated arthroplasty to total shoulder arthroplasty, revision of the the effect of a lateral meniscus allograft on the articular contact humeral stem, and periprosthetic fracture. The remainder of areas and pressures. The interposed lateral meniscus allograft the patients (Group 2) were those with soft-tissue deficiency, group showed a significant decrease in total force at both 220 including rotator cuff repair, failed tuberosity reconstruction, and 440 N as well as a decrease in contact area for the 220-N cuff tear arthropathy, instability, and infection. The final testing condition. No difference was noted in contact area at outcome was satisfactory in 50% of the shoulders and un- 440 N or in peak forces or peak contact areas for either 220 or satisfactory in 50%. The average scores for the shoulders in 440-N forces. Thus, from a biomechanical point of view, de- Group 1 were significantly better than those for the shoulders creased forces on the glenoid surface support biologic re- in Group 2. Component revisions, excluding humeral head surfacing with a lateral meniscus allograft of the glenohumeral revision for salvage, provide the best results, whereas soft- tissue reconstructions can be expected to yield poorer resultsoverall (Level II).
Outcomes of ArthroplastyHemiarthroplasty has been advocated by some for the treat- Reverse Total Shoulder Arthroplasty ment of osteoarthritis of the shoulder. Rispoli et al.22 evaluated There has been heightened interest in reverse total shoulder the results of hemiarthroplasty for the treatment of osteoar- arthroplasty in the United States since approval for these de- thritis. The forty-nine patients (fifty-one shoulders) in that vices was granted by the Food and Drug Administration in study were followed for a minimum of five years or until re- 2004. Increased interest, combined with the experience of our vision surgery. The patients demonstrated significant long- European colleagues, has resulted in a number of reports ap- term pain relief as well as improvement in abduction, internal pearing in the literature. The following studies document the rotation, and external rotation. However, moderate pain was early to intermediate-term experience with this device.
reported in nine shoulders and severe pain was reported in A multicenter study of the European experience was seven. Ten shoulders required revision surgery, which was performed by Guery et al.25 to determine the survival rate performed for the treatment of painful glenoid arthritis in nine based on the diagnosis leading to reverse total shoulder ar- cases. Radiographs demonstrated an increase in glenoid ero- throplasty. Eighty prostheses were implanted for the treatment sion at an average of 10.7 years postoperatively. A modification of cuff tear arthropathy, rheumatoid arthritis, or trauma or for of the Neer rating system was used to measure outcome. There revision following previous surgery. The survival rates with were ten excellent results, twenty satisfactory results, and prosthetic revision and glenoid loosening as the end points twenty-one unsatisfactory results. The authors concluded that were 91% and 84%, respectively, at 120 months. Shoulders that the clinical improvement demonstrated after hemiarthroplasty had cuff tear arthropathy demonstrated a significantly better for the treatment of osteoarthritis of the shoulder must be result than those that had been replaced for any other etiology.
viewed in the context of a high rate of unsatisfactory results On the other hand, the survival rate with an absolute Constant and a frequent need for revision surgery (Level IV).
score of <30 as an end point was 58% at 120 months, with no Another option for hemiarthroplasty in patients who are significant difference noted with respect to the reason for re- deemed to be inappropriate candidates for total shoulder ar- placement. The survival curves declined at two time-points.
throplasty is hemiarthroplasty with biologic resurfacing of the The first decline occurred at three years as a result of revision glenoid. Krishnan et al.23 reported their experience with this of the implant. This decline reflected early loosening of the procedure. A variety of tissues were used to resurface the glen- prosthesis. The second decline started at around six years and oid, including anterior capsule for seven shoulders, autoge- reflected progressive deterioration of the functional result. The nous fascia lata for eleven, and Achilles tendon allograft for authors concluded that this implant should be reserved for What's New in Shoulder and Elbow Surgery low-demand patients who are more than seventy years old.
infiltration of the teres minor muscle on the outcome of re- The best results are achieved in patients being managed for cuff verse total shoulder arthroplasty. Preoperative fatty infiltration tear arthropathy (Level IV).
of the teres minor was assessed according to the method of Boileau et al.26 analyzed the intermediate-term results Goutallier et al. The patients with stage-0, 1, or 2 fatty infil- and complications of reverse total shoulder arthroplasty in tration of the teres minor (Group 1) had a significantly better forty-five patients. The procedure was performed for cuff tear ultimate Constant score, a significantly better subjective arthropathy, the sequela of fracture, and failure of a previous shoulder value, and significantly greater preoperative-to- arthroplasty (revision). Fourteen complications (including postoperative improvement than did the patients with stage-3 three dislocations, three deep infections, one case of aseptic or 4 fatty infiltration (Group 2). Group 1 had a net gain of 9° of humeral loosening, two periprosthetic humeral fractures, one external rotation with the arm at the side, whereas Group 2 had intraoperative glenoid fracture, one wound hematoma, two an average net loss of 7°. The authors concluded that stage-3 or late acromial fractures, and one axillary nerve palsy) occurred 4 fatty infiltration of the teres minor compromises the clinical in eleven patients. Complications were more frequent when outcome of reverse total shoulder arthroplasty in the treatment the reverse total shoulder arthroplasty was performed for re- of cuff tear arthropathy (Level II).
vision than when it was performed for the treatment of cufftear arthropathy (prevalence, 47% compared with 5%). All three groups showed a significant increase in active elevation Proximal Humeral Fractures and the Constant score but no significant change in active Nonoperative treatment of proximal humeral fractures re- external rotation or internal rotation. The outcome scores were quires that protected rehabilitation begin at some point.
all significantly higher in the cuff tear arthropathy group than Hodgson et al.29 performed a randomized prospective con- in the revision group. Scapular notching was seen in twenty-six trolled trial of minimally displaced proximal humeral fractures (68%) of the thirty-eight cases in which radiographic analysis that were treated with immediate physical therapy or with was possible. No glenoid loosening was observed at the time of physical therapy after three weeks of immobilization to de- follow-up, even when the notch extended beyond the inferior termine the effect of immobilization on disability. Disability screw. The authors concluded that the Grammont reverse total related to the fracture was measured at one and two years with shoulder arthroplasty can improve function and restore active use of the Croft shoulder disability questionnaire. A significant elevation. However, active rotation is usually unchanged be- difference in disability was demonstrated one year after the cause of the absence of anterior and posterior rotator cuff fracture between patients who had been managed with im- tissue. Results are less predictable and complication and revi- mediate physical therapy (prevalence of disability, 42.8%) and sion rates are higher in patients undergoing revision surgery those who had been managed with three weeks of immobili- than in those with cuff tear arthropathy.
zation (prevalence of disability, 72.5%). By two years, the The clinical finding of inferior scapular notching fol- prevalence of shoulder disability remained unchanged (43.2%) lowing reverse total shoulder arthroplasty has raised concerns in the immediate therapy group but had improved (59.5%) in about eventual glenoid loosening. Reverse total shoulder ar- patients who had been managed with three weeks of immo- throplasty with the Delta III prosthesis has been associated bilization. However, the difference between the immediate with inferior scapular notching. Simovitch et al.27 investigated therapy and immobilization groups at two years was not sig- the predictors of scapular notching in a series of seventy-seven nificant. Immediate rehabilitation after a minimally displaced arthroplasties. All sixty-three shoulders that had development proximal humeral fracture results in faster recovery, with of scapular notching did so in the first fourteen months maximum functional benefit being achieved at one year, postoperatively. Thirty-four (44%) of the seventy-seven whereas delaying rehabilitation with three weeks of shoulder shoulders had inferior scapular notching, twenty-three (30%) immobilization produces a slower recovery, which continues had posterior notching, and six (8%) had anterior notching.
for at least two years after the time of injury.
The angle between the glenosphere and the scapular neck aswell as the superior-inferior position of the glenosphere was Clavicular Fractures highly correlated with inferior notching. The height of im- Clavicular fractures historically have been treated non- plantation of the glenosphere had an approximately eight operatively. However, a growing body of literature supports the times greater effect on inferior notching than did the pros- surgical treatment of displaced clavicular fractures. The Ca- thesis-scapular neck angle. The authors provided recommen- nadian Orthopaedic Trauma Society30 performed a multicenter dations for ideal glenoid component positioning (Level II).
prospective randomized trial comparing the outcome of Studies have demonstrated functional improvement nonoperative treatment and plate fixation of displaced mid- following reverse total shoulder arthroplasty. However, reports shaft clavicular fractures. The average time to radiographic have indicated continued functional limitations in external union was significantly shorter in the operative group as rotation as a result of posterior rotator cuff deficiency or compared with the nonoperative group (16.4 compared with dysfunction. Simovitch et al.28 investigated the impact of fatty 28.4 weeks). There were two nonunions and no malunions in What's New in Shoulder and Elbow Surgery the operative group, compared with seven nonunions and nine thirteen pooled analyses were performed. Many of the benefits symptomatic malunions in the nonoperative group. Constant that were demonstrated in the individual studies were lost scores and DASH scores were significantly improved in the when the data were pooled. No significant benefit of extra- operative group at all time-points measured. This study sup- corporeal shock wave therapy over placebo was demonstrated ports primary plate fixation of completely displaced midshaft in eleven of the thirteen pooled analyses. Two pooled results clavicular fractures in active adult patients (Level I).
favored extracorporeal shock wave therapy. However, this Fractures of the distal part of the clavicle are classified on finding was not supported by the results of four other trials the basis of the integrity of the coracoclavicular ligaments. In that were unable to be pooled. Minimal adverse effects of ex- type-II distal clavicular fractures, the coracoclavicular liga- tracorporeal shock wave therapy were reported. On the basis of ments are incompetent, rendering the medial fragment un- a systematic review of the nine placebo-controlled trials, there stable. Haidar et al.31 reported the results for patients in whom is strong evidence that extracorporeal shock wave therapy type-II distal clavicular fractures had been treated with hook- provides little or no benefit in terms of pain and function in plate fixation. One patient failed to achieve union of the patients with lateral elbow pain. There is some evidence, based fracture. One patient had a delayed fibrous union that ulti- on one trial, that steroid injection may be more effective than mately healed 5.5 months following plate removal. Four extracorporeal shock wave therapy (Level II).
complications were encountered, including fixation failure in A prospective, placebo-controlled, double-blinded trial two patients, skin breakdown over the plate in one patient, and was performed by Placzek et al.34 to evaluate the efficacy of a a new clavicular fracture at the medial aspect of the plate in one single injection of botulinum toxin A in the treatment of lateral patient. None of these complications had an effect on fracture- epicondylitis. Follow-up evaluation was performed at two, six, healing. Plate removal was a planned part of treatment and was twelve, and eighteen weeks with use of a novel clinical pain performed in all but one patient, who refused. Nineteen pa- score and with a visual analog pain scale. The strength of the tients were satisfied with the final outcome. This study sup- third finger and wrist extension were evaluated, as was grip ports hook-plate fixation as an acceptable method for the strength. The clinical findings and subjective general assess- treatment of type-II fractures of the distal part of the clavicle.
ment significantly improved for the botulinum toxin A groupas compared with the placebo group. No significant difference between the groups was noted in terms of grip strength Lateral Epicondylitis measures. The results of this study demonstrate the short-term Effective treatments for lateral epicondylitis are not well es- beneficial effect of botulinum toxin A for the treatment of tablished in the literature. Very little evidence-based research lateral epicondylitis. However, this study does not answer the has proved one treatment method to be superior to another.
question of the long-term efficacy of this treatment (Level I).
Bisset et al.32 conducted a randomized clinical trial to evaluatethe efficacy of physical therapy as compared with expectant management or corticosteroid injection. The results were as- The functional anatomy of the distal biceps tendon and apo- sessed at the initiation of treatment, at six weeks, and at fifty- neurosis is not well understood. Eames et al.35 performed two weeks. The corticosteroid treatment group showed sig- dissections of the distal biceps tendon and aponeurosis in ca- nificantly better results at six weeks as compared with the davers. In most specimens, the distal biceps tendon was made physical therapy group but had a high recurrence rate and up of two distinct parts, each a continuation of the long and significantly poorer outcomes at fifty-two weeks. Physical short heads of the muscle. In the other specimens, there was therapy was better than expectant management at six weeks interconnection of the short and long heads of the muscle. The but was no different at fifty-two weeks, when most patients in tendon insertion on the tuberosity was investigated as an in- both groups reported a successful outcome. The significant dication of its function. The short head inserted distal to the short-term benefits of corticosteroid injection do not last be- radial tuberosity, where it acted more as a flexor of the elbow, yond six weeks and appear to have a detrimental effect in the whereas the long head inserted on the tuberosity away from the long term. Physical therapy provides short-term benefit but no axis of rotation of the forearm, where it acted more as a su- long-term benefit greater than that of expectant management pinator. The bicipital aponeurosis consisted of three layers that completely encircled the ulnar forearm flexor muscles. This A systematic review of randomized controlled trials with study highlights the potential independent function of each use of Cochrane Collaboration methodology was performed portion of the biceps muscle and raises the question of their by Buchbinder et al.33 to establish the efficacy of extracorporeal separate function at the elbow.
shock wave therapy in the treatment of lateral epicondylitis.
Nine placebo-controlled trials and one trial in which extra- Fractures and Dislocations corporeal shock wave therapy was compared with steroid Distal Part of the Humerus injection were included in the review. The nine placebo- Complex fractures of the distal part of the humerus can be controlled trials had conflicting results. With the data available, difficult to characterize on the basis of conventional radio- What's New in Shoulder and Elbow Surgery graphic techniques. Doornberg et al.36 evaluated the use of factory primary result. Forty of the forty-nine patients had no three-dimensional computed tomography reconstructions to subjective complaints, eight were slightly impaired as the result improve fracture characterization, classification, and treatment of occasional elbow pain, and one had daily pain. Flexion, decisions in comparison with plain radiographs and two- extension, and pronation were slightly impaired in the injured dimensional computed tomography. Plain radiographs and elbow as compared with the uninjured elbow. Degenerative two-dimensional computed tomography scans were initially changes were noted in 82% of the injured elbows, compared evaluated. Two weeks later, a second evaluation was performed with 21% of the uninjured elbows. The authors concluded that with use of three-dimensional computed tomography recon- the results of nonoperative treatment were generally satisfac- structions. Five fracture characteristics were evaluated with tory, especially if a delayed radial head excision is performed in each assessment: the presence of a fracture line in the coronal the few cases in which the early outcome is unsatisfactory plane; articular comminution; metaphyseal comminution; the presence of separate, entirely articular fragments; and impac-tion of the articular surface. Fractures were also classified ac- Complex Instability cording to the AO/ASIF Comprehensive Classification of The results of fixation of comminuted radial head fractures Fractures and the classification system of Mehne and Matta.
with associated injuries have been disappointing. Grewal Intraobserver and interobserver reliability of both classifica- et al.39 presented the short-term outcomes for a group of pa- tion systems was improved with the use of three-dimensional tients who were managed with modular metallic radial head computed tomography reconstructions. Additionally, the level replacement for the treatment of comminuted radial head of intraobserver agreement for all fracture characteristics was fractures. Associated injuries included isolated dislocation or improved from moderate to substantial. The authors con- dislocation associated with a fracture of the coronoid process.
cluded that three-dimensional computed tomography recon- The patients demonstrated significant decreases in impair- structions were a helpful tool for preoperative planning in ments over time, with the majority of the recovery occurring cases of distal humeral fractures.
by six months. There were slight-to-moderate deficits in range The surgical treatment of complex distal humeral of motion and strength on the affected side as compared with fractures can be complicated by severe comminution, bone the unaffected side. The level of patient satisfaction was high at loss, and osteopenia. Anatomic plate designs, a better un- three months and remained high at two years. All elbow joints derstanding of the biomechanics of these injuries, and the remained stable, and no implant-related issues requiring re- adoption of a principle-based surgical technique have im- vision occurred. Mild osteoarthritis was seen in five (19%) of proved the treatment of these injuries. Sanchez-Sotelo et al.37 the twenty-six patients, and the authors concluded that evaluated a group of patients with complex distal humeral modular metallic radial head replacement for comminuted fractures that were fixed with parallel plates. The technical radial head fractures with associated injuries is an effective goals of surgery were (1) to maximize fixation in the distal treatment option (Level IV).
fragments and (2) to gain stability at the supracondylar levelthrough screw fixation in the distal segment. Applying this principle-based approach, the authors were able to obtain The long-term results of Monteggia fractures are not well union of all but one of the fractures after the initial operation.
documented in the literature. Konrad et al.40 performed a One patient required bone-grafting to achieve union. Post- retrospective review after an average duration of follow-up of operative stiffness requiring contracture release occurred in 8.7 years in order to correlate the Bado and Jupiter classifica- five patients. Functional range of motion was achieved in tions with long-term results after operative treatment. Satis- most patients, and the final outcome was satisfactory in factory results were achieved in thirty-four of forty-seven twenty-seven of thirty-four patients. This study demonstrates patients. The factors that were correlated with a poor clinical the ability to achieve predictable results with use of the outcome were posterior Monteggia fracture-dislocations principle-based surgical technique (Level IV).
(Bado type II), fractures involving the olecranon and coronoid(Jupiter type IIa), fractures of the radial head, coronoid frac- tures, and complications requiring further surgery.
Displaced two-part fractures of the radial head are increasinglytreated with open reduction and internal fixation. The natural history of nonoperative treatment of displaced two-part frac- The intermediate-term results following open contracture tures has been poorly understood. Recently, Akesson et al.38 release for the treatment of posttraumatic stiffness of the evaluated the results of nonoperative treatment of forty-nine of elbow were reported by Sharma and Rymaszewski41. Surgery these fractures at an average of nineteen years. Initial nonop- involved release of the contracted capsule, removal of any erative treatment included either early mobilization or cast impinging osseous abnormalities (coronoid and olecranon immobilization for an average of two weeks. Six patients re- tip osteophytes and osteophytes in the radial and olecranon quired a delayed radial head excision because of an unsatis- fossae), and release of intra-articular adhesions as necessary.
What's New in Shoulder and Elbow Surgery In a series of twenty-five patients, the average arc of motion revision methods. Nineteen complications occurred in four- improved from 55° to 105° at one year after surgery. This teen patients. Risk factors for component fracture include improvement was maintained over the follow-up period component notching, component design, and high stresses (mean, 7.8 years). Pain, function, and patient satisfaction due to bone deficiency (Level IV).
were improved in twenty-three of twenty-five patients. The The presence of an olecranon fracture or nonunion can authors demonstrated that the results of open release for create technical challenges during total elbow arthroplasty.
posttraumatic stiffness of the elbow are durable at least Marra et al.45 reported their experience with these cases. The through the intermediate term.
goal of treatment was to maintain the integrity of the triceps The functional outcomes following arthroscopic cap- mechanism. During arthroplasty, the olecranon was fixed sular release of the stiff elbow in twenty-two patients were with a tension band in sixteen elbows, was excised in four, reported by Nguyen et al.42. Capsular release and gutter d´e- and was sutured in two. A stable fibrous union was present in bridement were performed, but the posterior bundle of the three patients and was not disrupted at the time of surgery.
medial collateral ligament was not addressed. The average end Union was achieved in nine of eighteen patients in whom points of extension and flexion significantly improved to 19° fixation of the olecranon fragment was attempted. A stable and 141°, respectively. The average improvement in the arc of fibrous union did not appear to affect the final outcome.
motion was 38°. All patients had improved elbow function, After an average duration of follow-up of 5.5 years, twenty-one and most were satisfied with the results of the procedure. The of twenty-five patients had a satisfactory result. There was a authors believed that the results of arthroscopic d´ebridement significant improvement in the Mayo Elbow Performance and capsulectomy of the stiff elbow are comparable with those Score, from 42 points preoperatively to 86 points described in previous reports on open and arthroscopic treatment (Level IV).
Upcoming Meetings and Events There are several upcoming courses sponsored by the AAOS or jointly between the AAOS and ASES.
Nonoperative treatment of the arthritic elbow should be at- 1. Sixth Biennial Combined AAOS/ASES Shoulder and tempted before operative treatment is considered. Viscosup- Elbow: Current Techniques and Controversies (Course plementation has been utilized to treat arthritic conditions of #3215); April 3 through 6, 2008; Orlando, Florida.
the knee. However, its effectiveness in the elbow has not been 2. AAOS/ASES Arthroscopic Management of Rotator Cuff established. Van Brakel and Eygendaal43 performed a series of Disease and Instability (Course #3206); July 18 and 19, three injections of sodium hyaluronate within a four-week 2008; Rosemont, Illinois.
period for the treatment of posttraumatic osteoarthritis of the 3. AAOS/ASES Management of the Unstable Shoulder: elbow in eighteen patients. Patients were evaluated with regard Arthroscopic and Open Repairs (Course #3208); October to pain and function before the initial injection and at three 3 and 4, 2008; Rosemont, Illinois.
and six months after injection. Viscosupplementation resulted 4. AAOS/ASES Shoulder Arthroplasty: Surgical Indications in slight, short-term pain relief and a very limited decrease in and Techniques (Course #3236); November 21 and 22, activity impairment at evaluation after three months. After six 2008; Rosemont, Illinois.
months, no beneficial effects were noted. On the basis of the 5. AAOS Elbow Reconstruction: Arthroscopy, Instability results of this nonrandomized study, the authors did not rec- and Arthroplasty (Course #3213); December 12 and 13, ommend viscosupplementation for the treatment of post- 2008; Rosemont, Illinois.
traumatic osteoarthritis of the elbow (Level IV).
In addition, the ASES Annual Open Meeting will be held Total Elbow Arthroplasty on Specialty Day at the Annual Meeting of the AAOS (March 8, Component fracture following total elbow arthroplasty is an 2008), in San Francisco, California.
uncommon complication but is difficult to treat. Athwal andMorrey44 reviewed the Mayo Clinic experience with this Shoulder and Elbow Fellowships complication. When the bone-cement interface was intact, the Fellowships in shoulder and elbow surgery continue to gain in implant was cemented into the preserved cement mantle.
popularity. There are currently nineteen shoulder and elbow However, when the bone-cement interface was loose, the im- fellowships available. There is now a formalized match process plant was recemented into the bone after it was prepared with that includes the majority of the fellowships. The match pro- traditional techniques. The Mayo Elbow Performance Score cess allows the fellowship applicants to interview at a number (MEPS) was satisfactory for thirteen of twenty-one patients at of programs without being pressured to make a choice prior to an average of 5.1 years. Outcomes were generally better for completing the interview process. Hopefully, all programs can patients who were managed with a cement-in-cement revision be encouraged to participate in the match process moving as compared with those who were managed with traditional What's New in Shoulder and Elbow Surgery Matthew L. Ramsey, MD Bradford O. Parsons, MD Charles L. Getz, MD The Leni and Peter W. May Department of Orthopaedics, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107. E-mail Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, address for M.L. Ramsey: [email protected] 1. Galatz LM, Silva MJ, Rothermich SY, Zaegel MA, Havlioglu N, Thomopoulos S.
20. Terrier A, B¨ uchler P, Farron A. Influence of glenohumeral conformity on Nicotine delays tendon-to-bone healing in a rat shoulder model. J Bone Joint Surg glenoid stresses after total shoulder arthroplasty. J Shoulder Elbow Surg. 2006; 2. Derwin KA, Baker AR, Spragg RK, Leigh DR, Iannotti JP. Commercial extracel- 21. Creighton RA, Cole BJ, Nicholson GP, Romeo AA, Lorenz EP. Effect of lateral lular matrix scaffolds for rotator cuff tendon repair. Biomechanical, biochemical, meniscus allograft on shoulder articular contact areas and pressures. J Shoulder and cellular properties. J Bone Joint Surg Am. 2006;88:2665-72.
Elbow Surg. 2007;16:367-72.
3. Matthews TJ, Smith SR, Peach CA, Rees JL, Urban JP, Carr AJ. In vivo mea- 22. Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Humeral head surement of tissue metabolism in tendons of the rotator cuff: implications for replacement for the treatment of osteoarthritis. J Bone Joint Surg Am. 2006;88: surgical management. J Bone Joint Surg Br. 2007;89:633-8.
4. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The 23. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ. Humeral hemiarthro- demographic and morphological features of rotator cuff disease. A comparison plasty with biologic resurfacing of the glenoid for glenohumeral arthritis. Two to of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88: fifteen-year outcomes. J Bone Joint Surg Am. 2007;89:727-34.
24. Dines JS, Fealy S, Strauss EJ, Allen A, Craig EV, Warren RF, Dines DM. Out- 5. Barfield LC, Kuhn JE. Arthroscopic versus open acromioplasty: a systematic comes analysis of revision total shoulder replacement. J Bone Joint Surg Am.
review. Clin Orthop Relat Res. 2007;455:64-71.
6. Milano G, Grasso A, Salvatore M, Zarelli D, Deriu L, Fabbriciani C. Arthroscopic 25. Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total rotator cuff repair with and without subacromial decompression: a prospective shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five randomized study. Arthroscopy. 2007;23:81-8.
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8. Cho NS, Ha JH, Rhee YG. Patient-controlled analgesia after arthroscopic rotator 27. Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scap- cuff repair: subacromial catheter versus intravenous injection. Am J Sports Med.
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9. Liem D, Bartl C, Lichtenberg S, Magosch P, Habermeyer P. Clinical outcome and 28. Simovitch RW, Helmy N, Zumstein MA, Gerber C. Impact of fatty infiltration tendon integrity of arthroscopic versus mini-open supraspinatus tendon repair: a of the teres minor muscle on the outcome of reverse total shoulder arthroplasty.
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29. Hodgson SA, Mawson SJ, Saxton JM, Stanley D. Rehabilitation of two-part 10. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional fractures of the neck of the humerus (two-year follow-up). J Shoulder Elbow Surg.
outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89:953-60.
30. Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with 11. Huijsmans PE, Pritchard MP, Berghs BM, van Rooyen KS, Wallace AL, de Beer plate fixation of displaced midshaft clavicular fractures. A multicenter, randomized JF. Arthroscopic rotator cuff repair with double-row fixation. J Bone Joint Surg Am.
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32. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with 13. Athwal GS, Sperling JW, Rispoli DM, Cofield RH. Deep infection after rotator movement and exercise, corticosteroid injection, or wait and see for tennis elbow: cuff repair. J Shoulder Elbow Surg. 2007;16:306-11.
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15. Deutsch A, Ramsey ML, Williams GR Jr. Loss of passive external rotation at 90 34. Placzek R, Drescher W, Deuretzbacher G, Hempfing A, Meiss AL. Treatment degrees abduction is predictive of a medially healed Bankart lesion. Arthroscopy.
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17. Lenters TR, Franta AK, Wolf FM, Leopold SS, Matsen FA 3rd. Arthroscopic 36. Doornberg J, Lindenhovius A, Kloen P, van Dijk CN, Zurakowski D, Ring D. Two compared with open repairs for recurrent anterior shoulder instability. A and three-dimensional computed tomography for the classification and manage- systematic review and meta-analysis of the literature. J Bone Joint Surg Am. 2007; ment of distal humeral fractures. Evaluation of reliability and diagnostic accuracy.
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What's New in Shoulder and Elbow Surgery 39. Grewal R, MacDermid JC, Faber KJ, Drosdowech DS, King GJ. Comminuted 42. Nguyen D, Proper SI, MacDermid JC, King GJ, Faber KJ. Functional outcomes radial head fractures treated with a modular metallic radial head arthroplasty.
of arthroscopic capsular release of the elbow. Arthroscopy. 2006;22:842-9.
Study of outcomes. J Bone Joint Surg Am. 2006;88:2192-200.
43. van Brakel RW, Eygendaal D. Intra-articular injection of hyaluronic acid is noteffective for the treatment of post-traumatic osteoarthritis of the elbow. Arthros- 40. Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP. Monteggia fractures in adults: long-term results and prognostic factors. J Bone Joint Surg Br.
44. Athwal GS, Morrey BF. Revision total elbow arthroplasty for prosthetic frac-tures. J Bone Joint Surg Am. 2006;88:2017-26.
41. Sharma S, Rymaszewski LA. Open arthrolysis for post-traumatic stiffness of 45. Marra G, Morrey BF, Gallay SH, McKee MD, O'Driscoll S. Fracture and non- the elbow: results are durable over the medium term. J Bone Joint Surg Br.
union of the olecranon in total elbow arthroplasty. J Shoulder Elbow Surg.
Visit www.HyponatremiaCME.org for additional cases and activities Clinical Perspectives in As a physician scientist who has been studying and treating hyponatremic patients for the past 30 years, I am pleased to introduce this case-based continuing medical education publication and associated Web-based interactive learning program, Clinical Perspectives