Faculty Bibliography

Treatment of patients with complex multifactorial diseases can be clarified by the development of clear, evidence-based treatment guidelines or algorithms. This article presents a detailed algorithm for the management of patients who present with persistent shoulder pain secondary to rotator cuff disorder, adhesive capsulitis, or glenohumeral osteoarthritis. The algorithm includes both nonpharmacologic and pharmacologic interventions and provides a stepwise approach for managing patients' care. While 'treatment pathways' are set forth for these specific disorders, the algorithm also provides a common nonoperative protocol for general shoulder conditions that should help simplify patient management and guide clinicians to alternative therapies

Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (<6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection

Preoperative evaluation for a total shoulder arthroplasty includes 2-dimensional analysis of the glenoid through either standard radiographs or computed tomography (CT) images. Recent evidence suggests that these 2-dimensional images may actually misrepresent the 3-dimensional (3D) anatomy of the glenoid. Because 3D reconstructions of CT images allow 3D visualization and analysis of the scapula as a free body, we hypothesized that they can reflect the true anatomy of the glenoid more accurately. To test this hypothesis, we obtained various glenoid morphometric measurements from excised cadaveric scapulae as well as their respective 3D CT images. On average, the glenoid version angles measured from the 3D CT images were within 1.0 degrees +/- 0.7 degrees (mean +/- SD) of those from the actual specimen (95% confidence limit, <2.2 degrees for all observers). These measurements from the 3D CT images showed high interobserver and intraobserver reliability (interobserver and intraobserver correlation coefficients, 0.983 and 0.978, respectively). Similarly, measured glenoid surface width and length from the 3D CT images were within 1.8 +/- 1.2 mm and 1.4 +/- 1.1 mm, respectively, of those from the actual specimen. In addition, we were able to estimate the glenoid surface area as well as the glenoid vault volume from the 3D CT images. These values were 8.67 +/- 2.73 cm2 and 11.86 +/- 5.06 cm3, respectively. The mean glenoid vault volume with respect to its surface area was 1.35 +/- 0.24 cm3/cm2 (range, 1.06-1.91 cm3/cm2). These data suggest that 3D CT images can accurately reflect the true anatomy of the glenoid and that they can provide valuable information regarding the glenoid surface and vault. As such, 3D CT images may prove to be a useful tool during the preoperative evaluation for a total shoulder arthroplasty, particularly in patients with significant glenoid bone loss

Humeral head replacement has been widely used for the treatment of complex proximal humeral fractures. The procedure is associated with a high rate of patient satisfaction as well as reliable relief of pain. The functional outcomes, however, have been variable. Reported complications include infection, neurologic injury, intraoperative fracture, instability, tuberosity malunion and nonunion, rotator cuff tear, heterotopic ossification, glenoid erosion, and stiffness. When technical factors such as tuberosity malunion or component malpositioning are considered as postoperative complications, the incidence of complications is relatively high. This high rate of complications, in turn, may be related to the wide range of reported functional outcomes

After its initial description by Neer and associates, humeral head replacement has been widely used to treat complex fractures of the proximal humerus. Many studies have confirmed that the treatment of proximal humeral fractures with humeral head replacement is associated with reliable pain relief as well as good patient satisfaction. A limited number of studies have also suggested that the prostheses have reasonable longevity, with the rate of prosthesis survival at 83% to 94% at 10 years. The functional outcome after the procedure, however, has not been as predictable. Using various outcomes scoring instruments, multiple studies have reported a wide range of results. Some authors have reported mostly disappointing outcomes, whereas others have reported generally satisfactory results. The most critical factor influencing the long-term outcome appears to be the position of the greater tuberosity. Other factors that are also associated with a good outcome include younger age, minimal delay between the traumatic event and the surgical procedure, and the absence of any neurologic deficit. For young patients with a complex proximal humeral fracture, humeral head replacement still remains a viable treatment option. However, whenever possible, most authors favor open reduction and internal fixation because of the issues affecting the longevity of the prosthesis. By understanding and minimizing the risk factors leading to a poor result, a reasonable functional outcome, reliable pain relief and a high rate of patient satisfaction can be expected after treatment of proximal humeral fractures with humeral head replacement

A variety of pathological conditions affect the acromioclavicular joint and the surrounding structures. For each of these, different procedures have been described with varying degrees of success. This article focuses on contemporary procedures. The acromioclavicular joint can be reapproximated using one of three stabilization techniques: (1) primary fixation across the acromioclavicular joint, (2) secondary stabilization of the joint by recreating the anatomic linkage between the distal clavicle and the coracoid process, or (3) dynamic stabilization of the joint by creating an inferiorly directed force on the distal clavicle. These methods are not mutually exclusive and may be combined in a single operative setting to produce a final construct with superior mechanical stability