Edward McFarland

One hundred twelve practicing members of the American Shoulder and Elbow Surgeons in the United States and Canada were surveyed regarding use of weighted views of the acromioclavicular joint. They were also asked about treatment for hypothetical patients seen in the emergency department or office with grade II or III acromioclavicular separations. One hundred five physicians (94%) responded to the survey. Eighty-five members (81 %) did not recommend obtaining weighted views in the emergency department. Sixty members (57%) did not use weighted views, and the majority commented that weighted views had no influence on their decision-making regarding treatment. Forty-five members (43%) used weighted views, but most did not use the results of this test to determine surgical intervention. Physicians recommending weighted views averaged 21 years of practice, compared with 16 years for those who did not obtain weighted views. Only nine physicians (9%) had changed treatment on the basis of weighted views. The patient's arm dominance, work, or athletic status did not influence most surgeons' decision to perform surgery when weighted views revealed a grade III separation. We found no correlation between obtaining weighted views and performing surgical reconstruction for patients with grade III acromioclavicular separations.

A shoulder injury that would cause an acromioclavicular (AC) separation in an adult generally causes a clavicle fracture in a young patient. As illustrated in a case report, the two injuries can look similar on a standard x-ray. Conservative treatment and prognosis for both clavicle fractures and AC separations are similar, but because some AC separations require surgical repair, accurate diagnosis is important. This can be done by obtaining x-rays at one-half of the standard exposure, including AP views with 10 degrees to 15 degrees of cephalic tilt. Spot or cone-down views and comparison views are also helpful.

Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty. We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adjusted for procedure, age, gender, race, marital status, comorbidity, diagnosis, insurance type, income, and hospital volume. For the 1868 discrete total shoulder arthroplasties and hemiarthroplasties done in the state of Maryland, the risk of at least one complication associated with the procedures done by the high-volume surgeon group was nearly half that associated with the procedures done by the low-volume surgeon group (adjusted odds ratio, 0.6; 95% confidence interval, 0.4 to 0.9). High-volume surgeons were three times more likely than were low-volume surgeons to have patients with a hospital stay of less than six days (odds ratio, 0.3; 95% confidence interval, 0.2 to 0.6). Although the average cost of hospitalization was $1000 less in the high-volume surgeon group compared with the low-volume surgeon group, this reduction did not reach significance after adjustment for multiple variables (odds ratio, 0.8; 95% confidence interval, 0.5 to 1.4). This study indicates that the patients of surgeons with higher average annual caseloads of total shoulder arthroplasties and hemiarthroplasties have decreased complication rates and hospital lengths of stay compared with the patients of surgeons who perform fewer of these procedures. These analyses of hospital discharge data are limited because of a lack of prospective data, operative details, and patient outcomes data. However, this study emphasizes the importance of continued education for orthopaedic surgeons who perform shoulder arthroplasty.

The advent of arthroscopy and the scientific study of the efficacy and accuracy of that examination have led to important advances in our understanding of the shoulder examination in the overhead and throwing athlete. In this review, we address current physical examination techniques and how to perform them, and explore their reported clinical efficacy, providing the practicing clinician with a better understanding of the proper application and interpretation of the shoulder examination in the overhead and throwing athlete.

Synovial cysts are most frequently found about the knee. Less commonly they have been described at the shoulder, elbow, ankle, and hip joints. Synovial cysts of the shoulder are associated with rheumatoid arthritis, osteoarthritis, chronic steroid use, Charcot joint disease, and long-standing rotator cuff tears. Although often asymptomatic, patients may present complaining of pain, loss of joint motion, or presence of an unexplained mass. The authors present the case of an elderly man with a very large synovial cyst presenting as an anterior chest wall mass.

LEARNING OBJECTIVES 1-To describe the normal imaging appearance of the reverse shoulder prosthesis. 2-To review the radiographic manifestations of the common complications associated with the reverse shoulder prosthesis. 3-To raise the awareness of this new device among radiologists. ABSTRACT A new generation of total shoulder prosthesis, known as the “reverse shoulder prosthesis” (RSP), has been introduced into the United States as of April, 2004. The RSP has a novel design which reverses the usual ball and socket arrangement of the shoulder, placing a ball in the glenoid fossa and a flat surface in the position of the humeral head. In patients with advanced rotator cuff arthropathy, failed hemiarthroplasty with rotator cuff disease or superior subluxation of the humerus due to rotator cuff disease, the RSP is advantageous as it resists glenohumeral subluxation and offers improved function. This exhibit will review the components of this prosthesis and its normal imaging appearance...

Arthroscopic repair of rotator cuff tears has been shown to be effective and safe. The use of suture anchors has increased the ability to perform rotator cuff repairs arthroscopically. However, the use of suture anchors for any surgery around the shoulder can result in complications if the devices are not used and inserted properly. Complications that have been reported with the use of suture anchors for rotator cuff surgery include prominent anchors in the tuberosities, dislodged anchors secondary to pull-out or improper insertion, and osteolysis around the anchors. We report a case of articular cartilage damage secondary to a suture anchor protruding through the humeral head because of improper anchor insertion. Our patient's case reminds surgeons not only to be careful of the depth of insertion of suture anchors when performing rotator cuff surgery but also to obtain radiographs to evaluate the anchor position if patients continue to have symptoms after rotator cuff repair us...

This study evaluated the effect of the gastrocnemius and soleus muscles on dynamic knee stability by studying the effect of passive calf muscle loading on anterior tibial translation in normal and anterior cruciate ligament (ACL) deficient knees. Anterior tibial translation was measured bilaterally in 12 anesthetized patients with unilateral ACL-deficient knees using a KT-1000 arthrometer. An ankle-foot orthosis was used to passively dorsiflex the ankle and generate tension in the calf muscles. As the ankle flexion angle was progressively changed from 30 degrees plantar flexion to 10 degrees dorsiflexion, anterior tibial translation decreased 43% and 37% with manual maximum force in normal and ACL-deficient knees, respectively (P < .0001). These findings suggest that the calf muscles may function as dynamic knee stabilizers. Anterior tibial translation also was measured in four cadaver knees. Significant decreases were seen in anterior tibial translation with progressive ankle do...

A specific and early diagnosis must be made in the injured skeletally immature throwing athlete. A well-outlined program of rest, rehabilitation, and proper throwing techniques should be implemented and continued. Overuse injuries are preventable when biomechanics are sound and pitch counts are done with the limits enforced. Guidelines for inning limits, number of pitches, rest intervals, and throwing programs should be followed for adolescent pitchers because adolescents differ from adults. Information is included for specifications of the ball and helmet, as well as chest protective equipment. The goal should be for the Little League players to have fun and be injury free as they are competing, which gives them the best experience and allows continuation of athletic activities for a lifetime.

Saphenous neuritis is a painful condition caused by either irritation or compression at the adductor canal or elsewhere along the course of the saphenous nerve. The condition also may be associated with surgical or nonsurgical trauma to the nerve, especially at the medial or anterior aspect of the knee. Saphenous neuritis can imitate other pathology around the knee, particularly a medial meniscal tear or osteoarthritis. Unrecognized saphenous neuritis can confuse the patient's clinical picture, complicate treatment, and compromise results. As an isolated entity, saphenous neuritis may appear in conjunction with other common problems, such as osteoarthritis and patellofemoral pain syndrome, and it can have an indolent and protracted course. Its clinical appearance is characterized by allodynia along the course of the saphenous nerve. The diagnosis is confirmed by relief of symptoms after injection of the affected area with local anesthetic. Initial treatment can include non-surgi...

Periarticular synovial chondromatosis associated with osteoarthrosis is a rare condition that is more frequently seen in the lower extremity than in the upper extremity. In patients who have synovial chondromatosis of the joints of the lower extremity and are symptomatic, the traditional method of treatment has included open or arthroscopic synovectomy and removal of loose bodies. In cases involving the upper extremity, especially in the shoulder, patients have variable disability and may be treated successfully without surgery. Two patients who presented to our practice with shoulder symptoms due to synovial chondromatosis were treated successfully without surgery. In both patients nonoperative treatment consisting of activity modification, nonsteroidal anti-inflammatory medication, and cryotherapy as needed led to a good result without surgical intervention.

The Ehlers-Danlos syndrome (EDS) is a rare, hereditary, connective-tissue disorder that results in increased laxity and poor soft-tissue healing. Surgical results and complications in these patients are not well documented in the literature. The goal of the present study was to survey patients with EDS who had surgery to the musculoskeletal system and document the results of surgery and complications. Forty-four patients with EDS were surveyed regarding the complications and results of surgical procedures to the shoulder, the elbow, the knee, or the ankle. Surgical procedures were performed for pain, instability, poor range of motion, or a combination of these, totaling 214 procedures. The population surveyed in the present study demonstrates that problems of surgical procedures in EDS may be high relative to other populations without connective-tissue disorders. More study is warranted in this patient population to validate the results in a larger cohort.

A case of myotonia congenita in an adolescent athlete was presented. Although this is a rare condition unknown to many treating physicians, the key to diagnosis was provocation of the patient's symptoms of muscle "tightening" and "cramping" during sustained exercise. The diagnosis would have been missed in routine office examinations with the patient at rest. The stereotypic generalized myotonic signs and symptoms were provoked after the patient was asked to play 20 minutes of basketball during one of his office evaluations. The provocative or postexercise examination was critical to the diagnosis as the resting office examination was completely normal. The diagnosis was subsequently confirmed by EMG and genetic testing. Myotonia congenita should be considered in the differential diagnosis of athletes with exercise-induced muscle "stiffness" or "cramping," particularly if the course is protracted and initial examinations are unremarkable. ...

The histologic characteristics of the deltoid muscle attachment to nine cadaveric acromia were studied using light microscopy. The deltoid muscle attaches to the anterior and lateral acromion primarily by direct tendinous attachment. The muscle attaches to the dorsal side of the acromion by periosteal fiber attachment. In the specimens studied, a hypothetical acromioplasty of 4 mm would release, on average, 41% of the direct fiber attachment, and a 6-mm acromioplasty would release 69% for all zones examined histologically. The functional and clinical effects of these findings are not known, but the deltoid muscle would be released by arthroscopic acromioplasty in areas where bone is removed.

Shoulder arthroscopy can be a safe and effective tool to perform a variety of diagnostic and therapeutic procedures about the shoulder. Careful attention to positioning, fluid management, use of traction, and appreciation of shoulder anatomy to select portal placement will help decrease the common complications associated with shoulder arthroscopy. The awareness of uncommon complications, such as deep venous thrombosis, pneumothorax, and iatrogenic rotator cuff tears will help the orthopedic surgeon to promptly diagnose and treat these problems.

Currently a myriad of devices are available for immobilization of the injured or postsurgical upper extremity. Some of these devices are straightforward and easily used, but some are more complicated and require more familiarity for their successful application. However, even simple devices have the potential for misapplication and thus prevent their benefit to the patient. This article is the first in a 3-part series. The goals of the series are (1) to present and review several devices on the market used by shoulder surgeons to immobilize the upper extremity, and (2) to discuss proper application and precautions of their use. It is intended that this series will benefit nurses, therapists, and trainers involved in the use of these devices.

An understanding of the anatomy and biomechanical features of the glenohumeral joint is necessary when understanding the concept of shoulder laxity. Glenohumeral laxity is a normal feature of shoulder motion, but only when that laxity becomes excessive does instability occur. The clinician must use the history and physical examination to distinguish normal from pathological laxity. Several examination techniques are commonly used to evaluate anterior, posterior, inferior, and multidirectional shoulder laxity. It has become appreciated the subluxation of the shoulder is clinically or symptomatically unstable. This paper reviews the current techniques to evaluate shoulder laxity and discusses the interpretation of these examinations as they relate to normal and pathological laxities.

Ligaments, including the anterior cruciate ligament (ACL), have a limited biological response to injury. The same healing process affects graft tissues used to reconstruct the ACL. These biological processes interact with mechanical forces to transform the grafts into tissues, which are expected to functionally replace the ACL. Although these grafts may undergo "ligamentization," they may not undergo "ACL-ization." Further study of the important relationship between these biological and biomechanical interactions is warranted.

Synovial cysts are most frequently found about the knee. Less commonly they have been described at the shoulder, elbow, ankle, and hip joints. Synovial cysts of the shoulder are associated with rheumatoid arthritis, osteoarthritis, chronic steroid use, Charcot joint disease, and long-standing rotator cuff tears. Although often asymptomatic, patients may present complaining of pain, loss of joint motion, or presence of an unexplained mass. The authors present the case of an elderly man with a very large synovial cyst presenting as an anterior chest wall mass.

Osteitis condensans of the clavicle is a benign, often painful disorder of unknown etiology manifested by bony sclerosis of the clavicular head with an uninvolved sternoclavicular joint. The case presented demonstrates the characteristic scintigraphic findings of osteitis condensans of the clavicle. A review of the published pathologically proven cases reveals this disorder to have distinctive clinical and radiological features that allow differentiation from infection, neoplasia, and arthritides in most instances. The frequent observation, as in this case, of devitalized bone and marrow fibrosis with remodeling of cancellous bone suggests that osteonecrosis may play an important role in the pathogenesis of this disorder.

Previous studies have demonstrated that a high surgical volume for certain surgical procedures reduces morbidity and improves economic outcome; however, to our knowledge, no study has demonstrated a similar relationship between volume and outcome for total shoulder arthroplasty and hemiarthroplasty. The objective of this study was to determine whether increased surgeon experience was associated with improved clinical and economic outcomes for patients undergoing total shoulder arthroplasty or hemiarthroplasty. We analyzed discharge data on patients treated between 1994 and 2000 from the Maryland Health Services Cost Review Commission, which has a statewide hospital discharge database of all patients in the state of Maryland. The database included all patients undergoing total shoulder arthroplasty and hemiarthroplasty. We assessed the relationship between surgeon volume (low, medium, and high) and the risk of complications, length of stay, and total charges. The statistics were adju...

Rotator cuff tears are reported as the most frequent cause of shoulder disability in the general population. Repair failure rates of 20-70% have been reported, and the inability to obtain a high healing rate has led clinicians and basic science researchers to investigate strategies that can augment the repair by biologically and mechanically reinforcing it with other tissues or materials. Our goal was to provide a systematic review of the current basic science and clinical understanding of commonly used rotator cuff grafts. Although many types of grafting materials have been used (autografts, allografts, xenografts, and dermal grafts), the ideal grafting material has not been found. It will require the continued effort of researchers and clinicians to develop and validate scaffold technology as a safe and effective treatment for improving the healing and outcomes of rotator cuff repairs. Additional studies are needed to support the routine use of augmentation in rotator cuff repairs.