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PubMed2007

Shoulder arthroplasty versus hip and knee arthroplasties: a comparison of outcomes.

Although outcomes of shoulder, hip, and knee arthroplasties have been well-described, there have been no studies directly comparing the outcomes of these procedures as treatments for osteoarthritis. We compared the inpatient mortality, complications, length of stay, and total charges of patients who had shoulder arthroplasty for osteoarthritis with those of patients who had hip and knee arthroplasties for osteoarthritis. A review of the Maryland Health Services Cost Review Commission discharge database identified 994 shoulder arthroplasties, 15,414 hip arthroplasties, and 34,471 knee arthroplasties performed for osteoarthritis from 1994 to 2001. There were no in-hospital deaths after shoulder arthroplasty, whereas 27 (0.18%) and 54 (0.16%) deaths occurred after hip and knee arthroplasties, respectively. Compared with patients who had hip or knee arthroplasties, patients who had shoulder arthroplasties had, on average, a lower complication rate, a shorter length of stay, and fewer total charges. The latter had 1/2 as many in-hospital complications, were 1/6 as likely to have a length of stay 6 days or greater, and were 1/10 as likely to be charged more than $15,000. We believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties.

Aged↗

PubMed2006

Magnetic resonance imaging of the canine shoulder: an anatomic study.

OBJECTIVES: To describe the normal anatomy of the soft tissue stabilizing components of the canine shoulder identified by magnetic resonance imaging (MRI) and to evaluate specific acquisition sequences and planes for observing structures of diagnostic interest. STUDY DESIGN: Descriptive study. ANIMAL: Canine cadavers (n=3). METHODS: T1-weighted, proton density fat saturation (PD), and T2(*)-weighted gradient echo (GE) MRI sequences were obtained in the sagittal, transverse, and dorsal planes of the left shoulder of 3 canine cadavers. After imaging, each shoulder was embedded and thin sectioned. The corresponding right shoulder was frozen and thick sectioned. The anatomic structures on the histologic and frozen thick sections were visually correlated with the MR images. RESULTS: The sagittal plane provided a longitudinal view of the bicep, infraspinatus, and supraspinatus tendons. The biceps, supraspinatus, infraspinatus, and subscapularis tendons, and the medial and lateral glenohumeral ligaments were identified in the transverse and dorsal planes. The dorsal plane allowed for the bicep tendon to be evaluated transversely as it passed over the humeral head. The GE sequence was more useful in identifying tendons and ligaments. The PD sequence was more helpful in identifying fluid accumulations in the joint and around tendons. CONCLUSIONS: The tendinous and ligamentous structures that stabilize the canine shoulder joint can be readily identified with MRI. CLINICAL RELEVANCE: MRI has the potential to be a useful tool in the diagnosis of canine soft tissue shoulder injuries.

Animals↗

PubMed2004

Clinical factors predicting fractures associated with an anterior shoulder dislocation.

OBJECTIVES: To identify risk factors for fractures associated with an anterior shoulder dislocation treated in an emergency department (ED). METHODS: A retrospective case-control study over five years of patients with an anterior shoulder dislocation was accomplished in a university-affiliated ED. Chart review identified possible predictors of fractures. Comparing the profile of patients having a clinically important fracture associated with their shoulder dislocation (cases) with those sustaining a noncomplicated dislocation (controls) provided the outcome measure. RESULTS: A total of 334 patients were included in the study. Eighty-five (25.5%) had a clinically important fracture-dislocation, and the remaining 249 (74.5%) sustained a noncomplicated shoulder dislocation. Chi-square, logistic regression, and recursive partitioning analysis showed three significant factors for the presence of fracture-dislocation: 1) age 40 years or older, 2) a first episode of dislocation, and 3) mechanism of injury (i.e., a fall greater than one flight of stairs, a fight/assault episode, or a motor vehicle crash). A multiple logistic regression model estimated the significant adjusted odds ratios (and their 95% confidence intervals [95% CIs]) for each of the three factors: 5.18 (95% CI = 2.74 to 9.78), 4.23 (95% CI = 1.82 to 9.87), and 4.06 (95% CI = 1.95 to 8.48), respectively. A predictive model using any one of the three factors reached a sensitivity of 97.7% (95% CI = 91.8% to 99.4%), a specificity of 22.9% (95% CI = 18.1% to 28.5%), and a negative predictive value of 96.6% (95% CI = 88.3% to 99.6%). CONCLUSIONS: Three risk factors predict clinically important fractures that are associated with shoulder dislocation: age, first episode, and mechanism of dislocation. A prospective validation may lead to standardized use of prereduction radiographs of the shoulder in the ED.

Accidental Falls↗

PubMed1999

Diagnostic classification of shoulder disorders: interobserver agreement and determinants of disagreement.

OBJECTIVES: To assess the interobserver agreement on the diagnostic classification of shoulder disorders, based on history taking and physical examination, and to identify the determinants of diagnostic disagreement. METHODS: Consecutive eligible patients with shoulder pain were recruited in various health care settings in the Netherlands. After history taking, two physiotherapists independently performed a physical examination and subsequently the shoulder complaints were classified into one of six diagnostic categories: capsular syndrome (for example, capsulitis, arthritis), acute bursitis, acromioclavicular syndrome, subacromial syndrome (for example, tendinitis, chronic bursitis), rest group (for example, unclear clinical picture, extrinsic causes) and mixed clinical picture. To quantify the interobserver agreement Cohen's kappa was calculated. Multivariate logistic regression analysis was applied to determine which clinical characteristics were determinants of diagnostic disagreement. RESULTS: The study population consisted of 201 patients with varying severity and duration of complaints. The kappa for the classification of shoulder disorders was 0.45 (95% confidence intervals (CI) 0.37, 0.54). Diagnostic disagreement was associated with bilateral involvement (odds ratio (OR) 1.9; 95% CI 1.0, 3.7), chronic complaints (OR 2.0; 95% CI 1.1, 3.7), and severe pain (OR 2.7; 95% CI 1.3, 5.3). CONCLUSIONS: Only moderate agreement was found on the classification of shoulder disorders, which implies that differentiation between the various categories of shoulder disorders is complicated. Especially patients with high pain severity, chronic complaints and bilateral involvement represent a diagnostic challenge for clinicians. As diagnostic classification is a guide for treatment decisions, unsatisfactory reproducibility might affect treatment outcome. To improve the reproducibility, more insight into the reproducibility of clinical findings and the value of additional diagnostic procedures is needed.

Acromioclavicular Joint↗

PubMedDate not supplied

Open repairs for the treatment of anterior shoulder instability.

Successful treatment of anterior instability of the shoulder requires a balance between restoring joint stability and minimizing loss of glenohumeral motion. The choice of treatment should be individualized on the basis of the patient's occupation and level of participation in sports, as well as on the degree of instability of the shoulder. Despite discussions to the contrary, there is no single "essential lesion," as proposed by Bankart, that is responsible for recurrent anterior shoulder instability, although the Bankart lesion is by far the most important. The choice of operative treatment must be tailored to correct the abnormality that is identified at the time of surgery. A variety of promising arthroscopic techniques have been developed for the treatment of anterior shoulder instability; however, open stabilization remains the standard, especially for severe instabilities, revision procedures, and for athletes who participate in contact sports. This article will review the open surgical techniques used for treatment of anterior instability of the shoulder. Both current and historical operations will be discussed. Regardless of which procedure is chosen by a surgeon, the treatment should follow the guidelines taught by Rowe: anatomic dissection at the time of surgery, identification and repair of the lesions responsible for the instability, returning tissues to their anatomic locations, and early postoperative range of motion. By following these guidelines, the results of treatment of anterior instability of the shoulder can be optimized.

Age Factors↗

PubMed2004

Nonoperative management for in-season athletes with anterior shoulder instability.

BACKGROUND: Acute or recurrent anterior shoulder instability is a frequent injury for in-season athletes. Treatment options for this injury include shoulder immobilization, rehabilitation, and shoulder stabilization surgery. PURPOSE: To determine if in-season athletes can be returned to their sports quickly and effectively after nonoperative treatment for an anterior instability episode. METHODS: Over a 2-year period, 30 athletes matched the inclusion criteria for this study. Nineteen athletes had experienced anterior dislocations, and 11 had experienced subluxations. All were treated with physical therapy and fitted, if appropriate, with a brace. These athletes were followed for the number of recurrent instability episodes, additional injuries, subjective ability to compete, and ability to complete their season or seasons of choice. RESULTS: Twenty-six of 30 athletes were able to return to their sports for the complete season at an average time missed of 10.2 days (range, 0-30 years). Ten athletes suffered sport-related recurrent instability episodes (range, 0-8 years). An average of 1.4 recurrent instability episodes per season per athlete occurred. There were no further injuries attributable to the shoulder instability. Sixteen athletes underwent surgical stabilization for their shoulders during the subsequent off-season. CONCLUSIONS: Most of the athletes were able to return to their sport and complete their seasons after an episode of anterior shoulder instability, although 37% experienced at least 1 additional episode of instability during the season.

Adolescent↗

PubMedDate not supplied

The shoulder in competitive swimming.

Shoulder pain is the most common orthopaedic problem in competitive swimming. In a group of 137 of this country's best swimmers, 58 had had symptoms of "swimmer's shoulder." Population characteristics of this group indicated that symptoms increased with the caliber of the athlete, were slightly more common in men, and were related to sprint rather than distance swimming. The use of hand-paddle training exacerbated symptoms, which were more common during the early and middle season. Consideration of shoulder mechanics in swimming reveals that freestyle, butterfly, and backstroke require similar motions; a swimmer using any of these strokes is susceptible to developing shoulder pain. Swimmer's shoulder represents chronic irritation of the humeral head and rotator cuff on the coracoacromial arch during abduction of the shoulder, the so-called impingement syndrome. Treatment included stretching, rest, ice therapy, oral antiinflammatory agents, judicious use of injectable steroids, and surgery as a last resort.

Adolescent↗

PubMedDate not supplied

Rehabilitation of the pitching shoulder.

Shoulder pain is a common complaint among baseball pitchers. Frequently, the nature of shoulder pathology can be traced to lack of flexibility and muscular imbalance. This paper describes: the normal biomechanics of a properly functioning shoulder during a baseball pitch, pathomechanics of shoulder problems, flexibility requirements of the throwing shoulder, and the muscular balance necessary for an effective throwing shoulder. Appropriate examination procedures are described along with remedial exercises which ensure normal glenohumeral motion and integrated muscle action.

Athletic Injuries↗

PubMedDate not supplied

Cineradiographic studies with shoulder instabilities.

Thirty patients with shoulder disorders were examined with fluoroscopy under general anesthesia. Prior to this cineradiography, 20 shoulders had diagnoses of instability and 10 had diagnoses of other stable-shoulder disorders. Three patients (10%) had changes in their shoulder diagnoses after imaging: 1) One patient with an impingement syndrome also had an unstable shoulder; 2) One patient suspected of having anterior subluxations prior to imaging, demonstrated posterior subluxations instead with imaging; and 3) One patient with recurrent posterior dislocations demonstrated a multidirectional instability pattern with imaging. Fluoroscopic examination or the shoulder under anesthesia provides useful diagnostic information. Its use is recommended for documentation, especially when there is uncertainty about a diagnosis, or to confirm the proper placement of metal after reconstructive surgery.

Cineradiography↗

PubMedDate not supplied

Comparative functional analysis of the Bristow, Magnuson-Stack, and Putti-Platt procedures for recurrent dislocation of the shoulder.

Literature on anterior shoulder instability deals most often with elimination of recurrence following reconstruction. We analyzed the subjective function, loss of motion and shoulder strength of three operative procedures: Magnuson-Stack, Bristow, and Putti-Platt. A retrospective review of 27 patients, 9 in each surgical group, with no postoperative dislocations or on-going pain was performed. All patients were male, right hand dominant with the right shoulder affected. Average time of followup was 6.75 years (range, 4.2 to 10.3 years). All patients completed a questionnaire and had their range of motion measured by a hand-held goniometer and their shoulder strength tested on the Cybex II Dynomometer. Peak torque as a percent of body weight and side-to-side differences were calculated for six arm positions and compared to nine right hand dominant controls of similar age and recreational activity. Sixty percent returned to throwing sport. One Magnuson-Stack and Bristow patient felt full functional return to preinjury level. Three patients in each of these two groups returned to unmodified throwing sport whereas no Putti-Platt patient attained this level. Deficit of external rotation at shoulder neutral measured 4.7 degrees, Magnuson-Stack; 12.2 degrees, Bristow; and 21.8 degrees, Putti-Platt. At 90 degrees shoulder abduction, similar deficits in external rotation measured 6.4 degrees, 11.6 degrees, and 28.8 degrees respectively. These values were statistically significant employing analysis of variance. We compared the operative groups as a whole to the controls and compared the operative groups to each other.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

A survey of interfering shoulder pain in United States competitive swimmers.

The prevalence of shoulder pain in United States competitive swimmers has not been extensively surveyed but is perceived as common. To evaluate this concern, a questionnaire survey was conducted on 1262 United States swimmers: 993 age group, 198 senior development, and 71 national team athletes. We sought to identify the incidence of interfering shoulder pain in this population and how it is influenced by various training tasks. The prevalence of current shoulder pain in these groups varied between 10% (age group) to 26% (national team) and increased with time in the sport. In those athletes with a painful shoulder, weight training, use of hand paddles, kickboard use, stretching, and various resistance activities aggravated the painful shoulder. This survey has identified that interfering shoulder pain is present in a substantial number of competitive swimmers.

Adolescent↗

PubMed2006

Costs of shoulder pain in primary care consulters: a prospective cohort study in The Netherlands.

BACKGROUND: Shoulder pain is common in primary care, and has an unfavourable outcome in many patients. Information on the costs associated with health care use and loss of productivity in patients with shoulder pain is very scarce. The objective of this study was to determine shoulder pain related costs during the 6 months after first consultation in general practice METHODS: A prospective cohort study consisting of 587 patients with a new episode of shoulder pain was conducted with a follow-up period of 6 months. Data on costs were collected by means of a cost diary during 6 months. RESULTS: 84% of the patients completed all cost diaries. The mean consumption of direct health care and non-health related care was low. During 6 months after first consultation for shoulder pain, the mean total costs a patient generated were 689 euro. Almost 50% of this total concerned indirect costs, caused by sick leave from paid work. A small proportion (12%) of the population generated 74% of the total costs. CONCLUSION: The total costs in the 6 months after first consultation for shoulder pain in primary care, mostly generated by a small part of the population, are not alarmingly high.

Activities of Daily Living↗

PubMed2005

The effect of humeral component anteversion on shoulder stability with glenoid component retroversion.

BACKGROUND: Posterior glenoid bone loss is often seen in association with glenohumeral osteoarthritis. This posterior asymmetric wear can lead to retroversion of the glenoid component and posterior instability after total shoulder arthroplasty. Options for the treatment of this asymmetric wear include eccentric reaming of the so-called high side, bone-grafting, and/or anteverting the humeral component. Although anteverting the humeral component has been advocated by many, it has not been substantiated on the basis of biomechanical data. The purpose of the present study was to determine whether anteverting the humeral component increases the stability of a total shoulder replacement with a retroverted glenoid component. METHODS: A total shoulder arthroplasty was performed in eight human cadaveric shoulders. The glenoid component was placed in 15 degrees of retroversion. Two humeral versions were tested for each specimen: anatomic version and 15 degrees of anteversion relative to anatomic version. The specimens were mounted supine in a custom fixture on a servohydraulic testing system. The humerus was translated posteriorly by one-half of the width of the glenoid. Three positions of humeral rotation were tested for each position of humeral version. Both the energy and the peak load were analyzed as measures of joint stability. RESULTS: There was no significant difference in either energy or peak load between the tests performed with the humeral component in 15 degrees of anteversion and those performed with the component in anatomic version in any of the three rotational positions (p > 0.05). CONCLUSIONS: Although anteverting the humeral component during total shoulder arthroplasty to compensate for glenoid retroversion has been advocated, these data suggest that compensatory anteversion of the humeral component does not increase the stability of a shoulder replacement with a retroverted glenoid component.

Aged↗

PubMed1994

Vacuum phenomenon: a potential pitfall in the interpretation of gradient-recalled-echo MR images of the shoulder.

OBJECTIVE: Axial gradient-recalled-echo (GRE) MR images of the shoulder obtained with the arm in external rotation may show a curvilinear or circular low-signal-intensity focus in the superior portion of the glenohumeral joint space that is thought to represent gas within the joint (vacuum phenomenon). This study was performed to determine the prevalence of this finding on GRE MR images of the shoulder to confirm that it represents gas in the joint, and to establish criteria to distinguish it from a true abnormality. SUBJECTS AND METHODS: We reviewed all external-rotation GRE images of 45 consecutive patients and 10 volunteers for the presence of low-signal-intensity foci and joint effusion. These findings were correlated with findings on corresponding spin-echo and GRE images of the shoulder with the arm in neutral position. MR findings also were correlated with findings on plain radiographs (37 patients) and shoulder CT scans (three patients and five volunteers) and with results of arthroscopy (19 patients). RESULTS: In nine (20%) of 44 patients and in five (50%) of 10 volunteers, axial external-rotation GRE images showed curvilinear or circular low-signal-intensity foci interposed between the opposing glenohumeral articular surfaces at the superior aspect of the glenohumeral joint that were not seen on MR images obtained with the arm in neutral position. In two of three patients and in all five volunteer subjects, CT scans of the shoulder showed a small focus of gas within the joint, corresponding in location to the intraarticular low-signal-intensity focus seen on MR images. Joint effusions were seen on MR images of 15 patients, and none of these images showed intraarticular gas. CONCLUSION: Circular or linear areas of low signal intensity are frequently seen on GRE MR images of the shoulder obtained with external rotation of the arm and represent small foci of intraarticular gas (vacuum phenomenon). Awareness of this potential pitfall and an understanding of the characteristic appearance and location of this collection of intraarticular gas may help prevent misdiagnosis of intraarticular loose bodies or chondrocalcinosis.

Adult↗

PubMed2006

Painless reduction of acute anterior shoulder dislocations without anesthesia.

In 1938, Dr Henry Milch described a maneuver for the reduction of acute anterior shoulder dislocations consisting of shoulder abduction and external rotation with "pulsion" of the humeral head. Although many methods may be used to reduce the dislocated glenohumeral joint, the Milch technique is unique because of its gentle, effective, and relatively painless nature. This article studied the effectiveness of this technique on 76 consecutive acute anterior shoulder dislocations in 75 patients seen in our institution's two campuses over an 18-month period. Twelve shoulders had concomitant fractures of the greater tuberosity. All 76 shoulders were reduced on the first attempt. No anesthesia was used, and no complications were reported from the reduction maneuver. The Milch method is an ideal first line treatment for all acute anterior shoulder dislocations including those associated with fracture of the greater tuberosity.

Adult↗

PubMed1999

Alternative and effective treatment of shoulder ganglion cyst: ultrasonographically guided aspiration.

The therapeutic effect of ultrasonographically guided aspiration of a ganglion cyst of the shoulder is evaluated. Fifteen patients (nine male, six female) with chronic shoulder pain were enrolled in this study. Each patient was referred to rule out rotator cuff lesion. The ultrasonographic examination showed an anechoic cystic lesion in the shoulder region in every patient and abnormality of the rotator cuff in only four patients. Under ultrasonographic guidance, an 18 gauge needle was inserted into the cyst to aspirate the fluid. Initial sonographic imaging showed the cyst, which appeared as a localized fluid accumulation and was located between the deltoid muscle and the subscapularis tendon in seven patients, between the deltoid muscle and the biceps tendon in one patient, below the coracoacromial ligament in five patients, and over suprascapular notch area in one patient. The ganglion cysts ranged in size from 3.5 to 30 mm. The amount of aspirated fluid in each cyst varied from 0.4 to 12 ml (mean, 2.6 ml +/- 3.1) with a clear or light yellowish color and a jelly-like appearance. No major complications occurred during or after this procedure. The symptom (pain) was improved after sonographically guided aspiration in each patient. Follow-up study showed complete relief of pain in four patients, marked improvement in nine patients, and mild improvement but still persistent shoulder pain in two patients. Duration of follow-up study ranged from 2 to 24 months (mean, 6.4 months +/- 6.9). The success rate for sonographically guided aspiration was 86% on the basis of marked symptom improvement or relief. Ultrasonographically guided aspiration of shoulder ganglion cysts is an effective procedure in the management of shoulder pain caused by ganglion cysts.

Adult↗

PubMed2000

The effect of electroacupuncture on shoulder subluxation for stroke patients.

In this study, we evaluated the effect of electroacupuncture on shoulder subluxation for stroke patients. Twenty hemiplegic patients with shoulder subluxation were randomly and equally divided into two groups. The subjects in the control group received conventional therapy, and the subjects in the study group were treated with electroacupuncture and conventional therapy for four weeks. The visual analog scale (VAS) for shoulder pain, motor function status, anthropometry, and X-ray assessment were used to evaluate the status of shoulder subluxation before and after treatment. The results indicated that the pain scores decreased in the study groups significantly more than those in the control group. The degrees of shoulder reduction, including the measurement of anthropometry and X-ray assessment in the study group, were more than those of the control group. However, the motor function status showed no significant difference between two groups. It is concluded that electroacupuncture can be an effective adjuvant management in the treatment of shoulder subluxation for stroke patients.

Adolescent↗

PubMed2003

Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up.

BACKGROUND: The purpose of this study was to evaluate prospectively the surgical outcomes of arthroscopic repair of anterior capsulolabral lesions with use of suture anchors in a large series of patients who were followed for two to six years. METHODS: We evaluated the results of arthroscopic Bankart repair with use of suture anchors and nonabsorbable sutures in 167 patients with traumatic recurrent anterior instability of the shoulder. The mean age at the time of the operation was twenty-five years. Preoperatively and at the time of follow-up (at a mean of forty-four months), the patients were assessed with three objective outcome measurement tools (the Rowe score, the University of California at Los Angeles [UCLA] shoulder rating scale, and the American Shoulder and Elbow Surgeons [ASES] score) and two subjective measurement tools (pain and function visual analog scales). The recurrence rate, range of motion, and risk factors for postoperative recurrence were evaluated. RESULTS: All shoulder scores improved after surgery (p < 0.001). According to the Rowe scale, 130 patients (78%) had an excellent score; twenty-nine (17%), a good score; six (4%), a fair score; and two (1%), a poor score. Overall, the rate of postoperative recurrence of instability was 4% (one dislocation, two subluxations, and four positive results on the anterior apprehension test). Postoperative recurrence was related to an osseous defect of >30% of the entire glenoid circumference. In the patients with recurrent postoperative instability, the episodes were less frequent than they had been preoperatively and shoulder function was related to activity level. A revision arthroscopic Bankart repair stabilized three of the four shoulders in which it was performed. One hundred and fifty-two patients (91%) returned to >/=90% of their preinjury activity level. The mean loss of external rotation (and standard deviation) was 2.0 degrees +/- 4.0 degrees. CONCLUSIONS: We found that, in contrast to previous reports on the results of arthroscopic repair, arthroscopic capsulolabral repair with use of suture anchors can provide satisfactory outcomes in terms of recurrence rate, activity, and range of motion.

Activities of Daily Living↗