What's new in shoulder and elbow surgery
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What's New in Shoulder and Elbow Surgery
Matthew L. Ramsey, Charles L. Getz and Bradford O. Parsons J Bone Joint Surg Am.
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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
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-
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
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
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
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
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-
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
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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.
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rotator cuff repair with and without subacromial decompression: a prospective
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randomized study. Arthroscopy. 2007;23:81-8.
to ten years. J Bone Joint Surg Am. 2006;88:1742-7.
7. Deutsch A. Arthroscopic repair of partial-thickness tears of the rotator cuff.
26. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverse
J Shoulder Elbow Surg. 2007;16:193-201.
shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revisionarthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.
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.
ular notching in patients managed with the Delta III reverse total shoulder re-placement. J Bone Joint Surg Am. 2007;89:588-600.
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.
magnetic resonance imaging-controlled matched-pair analysis. Arthroscopy.
J Bone Joint Surg Am. 2007;89:934-9.
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.
clinical trial. J Bone Joint Surg Am. 2007;89:1-10.
31. Haidar SG, Krishnan KM, Deshmukh SC. Hook plate fixation for type II
12. Mallon WJ, Wilson RJ, Basamania CJ. The association of suprascapular neu-
fractures of the lateral end of the clavicle. J Shoulder Elbow Surg. 2006;15:
ropathy with massive rotator cuff tears: a preliminary report. J Shoulder Elbow Surg.
32. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with
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movement and exercise, corticosteroid injection, or wait and see for tennis elbow:
cuff repair. J Shoulder Elbow Surg. 2007;16:306-11.
randomised trial. BMJ. 2006;333:939.
14. Farber AJ, Castillo R, Clough M, Bahk M, McFarland EG. Clinical assessment of
33. Buchbinder R, Green SE, Youd JM, Assendelft WJ, Barnsley L, Smidt N. Sys-
three common tests for traumatic anterior shoulder instability. J Bone Joint Surg
tematic review of the efficacy and safety of shock wave therapy for lateral elbow
pain. J Rheumatol. 2006;33:1351-63.
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.
of chronic radial epicondylitis with botulinum toxin A. A double-blind, placebo-
controlled, randomized multicenter study. J Bone Joint Surg Am. 2007;89:255-60.
16. Jakobsen BW, Johannsen HV, Suder P, Søjbjerg JO. Primary repair versusconservative treatment of first-time traumatic anterior dislocation of the shoulder: a
35. Eames MH, Bain GI, Fogg QA, van Riet RP. Distal biceps tendon anatomy: a
randomized study with 10-year follow-up. Arthroscopy. 2007;23:118-23.
cadaveric study. J Bone Joint Surg Am. 2007;89:1044-9.
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.
J Bone Joint Surg Am. 2006;88:1795-801.
18. Bottoni CR, Smith EL, Berkowitz MJ, Towle RB, Moore JH. Arthroscopic versus
37. Sanchez-Sotelo J, Torchia ME, O'Driscoll SW. Complex distal humeral frac-
open shoulder stabilization for recurrent anterior instability: a prospective ran-
tures: internal fixation with a principle-based parallel-plate technique. J Bone Joint
domized clinical trial. Am J Sports Med. 2006;34:1730-7.
Surg Am. 2007;89:961-9.
19. Boileau P, Villalba M, H´
ery JY, Balg F, Ahrens P, Neyton L. Risk factors for
38. Akesson T, Herbertsson P, Josefsson PO, Hasserius R, Besjakov J, Karlsson
recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint
MK. Primary nonoperative treatment of moderately displaced two-part fractures of
Surg Am. 2006;88:1755-63.
the radial head. J Bone Joint Surg Am. 2006;88:1909-14.
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.
15 april 2010 #16 www.erasmusmagazine.nl OP DE ARBEIDSMARKT Ontbijten met Wat nou 24/7 10 ‘Hypotheekrenteaftrek is pervers' Begin deze maand gaf ik een nieuwe collega een rondlei- ding op campus Woudestein. Hij komt uit Leiden, dus dan duik je als Rotterdammer toch wat in de excuusmodus als je zo langs onze grauwe gebouwen loopt. Weinig
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