Prolonged survival in patients with advanced melanoma treated with neoadjuvant chemotherapy followed by resection

We conducted this cadaveric study to define a biomechanical rationale for rotator cuff function in several deficiency states. A dynamic shoulder testing apparatus was used to examine change in middle deltoid muscle force and humeral translation associated with simulated rotator cuff tendon paralyses and various sizes of rotator cuff tears. Supraspinatus paralysis resulted in a significant increase (101%) in the middle deltoid force required to initiate abduction. This increase diminished to only 12% for full glenohumeral abduction. The glenohumeral joint maintained ball-and-socket kinematics during glenohumeral abduction in the scapular plane with an intact rotator cuff. No significant alterations in humeral translation occurred with a simulated supraspinatus paralysis, nor with 1-, 3-, and 5-cm rotator cuff tears, provided the infraspinatus tendon was functional. Global tears resulted in an inability to elevate beyond 25 degrees of glenohumeral abduction despite a threefold increase in middle deltoid force. These results validated the importance of the supraspinatus tendon during the initiation of abduction. Glenohumeral joint motion was not affected when the "transverse force couple" (subscapularis, infraspinatus, and teres minor tendons) remained intact. Significant changes in glenohumeral joint motion occurred only if paralysis or anatomic deficiency violated this force couple. Finally, this model confirmed that rotator cuff disease treatment must address function in addition to anatomy.     

Antitumor effect of DT-5461, a lipid A derivative, against human tumor xenografts is mediated by intratumoral production of tumor necrosis factor and affected by host immunosuppressive factors in nude mice

PURPOSE OF THE STUDY: The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results. METHODS: Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months). RESULTS: When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p < 0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p < 0.01), the forward elevation (p < 0.01), external rotation with elbow along side (p < 0.05) and overall mobility (p < 0.05) were worse; moreover, humeral head superior migration was greater (p < 0.01). DISCUSSION: Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps. CONCLUSION: During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.     

Temperature-controlled release property of phospholipid vesicles bearing a thermo-sensitive polymer

The supraspinatus, infraspinatus, teres minor and subscapu?aris muscles form a musculotendinous rotator cuff that provides dynamic stability to the shoulder joint. Symptoms of rotator cuff injury include limitation of motion, weakness and pain that often radiates down the upper arm and is present at night. Examination may reveal deltoid and rotator cuff atrophy, tenderness, limited passive range of motion and weakness on abduction and external rotation. Radiographs may show degenerative changes of the acromion or acromioclavicular joint, cysts, sclerosis and spurs of the greater tuberosity, and calcific deposits within the supraspinatus tendon. In most patients with subacromial impingement, conservative management, including physical therapy, nonsteroidal anti-inflammatory drugs and subacromial injections, is successful. Failure of conservative therapy after six to 12 weeks merits further evaluation with magnetic resonance imaging or arthrography, and consideration of surgery.     

Endoscopic mucosal resection of gastric tumors located in the lesser curvature of the upper third of the stomach

Between July 1991 and February 1995, 33 patients underwent bipolar shoulder arthroplasty for painful rotator cuff arthropathy of the shoulder. Twenty-two of these patients have been followed for an average of 28 months (range 24 to 48 months) and comprised the study group. All patients had massive, irreparable rotator cuff tears and presented with preserved passive motion, good deltoid function, and obliterated glenohumeral joint surfaces. Function and comfort were dramatically improved in all patients, with an average increase in active forward elevation of 29 degrees and a gain in active external rotation of 39 degrees. There was one complication requiring reoperation at 4 years. Utilizing the UCLA and Swanson scoring systems, all patients were rated fair or better.     

Arthroscopic treatment of rotator cuff disorders

The past 2 decades have seen rapid advancement in the field of shoulder arthroscopy in general and of rotator cuff disorders in particular. Arthroscopy allows superior visualization of pathologic conditions with less soft-tissue trauma than open exposures. Arthroscopic surgical techniques also are being applied to the actual treatment of many forms of rotator cuff disorders with clinical results similar to more traditional, open procedures. Although these techniques and their indications continue to evolve, it remains clear that, in carefully selected patients, arthroscopy has become a highly useful and effective tool in the diagnosis, evaluation, and surgical management of common disorders of the rotator cuff.     

Diagnosis of idiopathic myositis: value of 99mtechnetium pyrophosphate muscle scintigraphy and magnetic resonance imaging in targeted muscle biopsy

The widespread use and dramatic success of prosthetic joint implant surgery (arthroplasty) has greatly improved the quality of life for many individuals suffering from degenerative, arthritic, or injured joints. However, in a number of cases, recipients experience discomfort at the arthroplasty site that can signal biomechanical failure, or periprosthetic infection of the joint, or both. In fact, infection remains a devastating obstacle, preventing arthroplasty from being an almost perfect medical procedure. Existing tests for the diagnosis of infection in orthopedics are disappointing because of the relatively high frequency of false negative results. To overcome this shortcoming, and to reduce the number of infected revision arthroplasties, a methodology based on molecular biology has been established. The method allows the rapid, sensitive and accurate diagnosis of orthopedic infections, and should aid the clinician with treatment regimens, surgical decisions, and overall patient management in the growing arthroplasty population.     

Total shoulder endoprosthesis design St. Georg

Experiences with shoulder replacement in 40 cases since 1966 and the development of a nonblocked total prosthesis are described. The replacement of both joint surfaces according to the principles of low friction arthroplasty ist needed to obtain relief of pain. The nonblocked system corresponds in a high degree to physiologic conditions. The shape of the implant and the meticulous reconstruction of the inner and outer rotator cuffs reduce the danger of dislocation considerably. Only small bone resection is necessary. In cases of dislocated compound fractures and of painful posttraumatic and rheumatic arthrosis, total replacement could be an alternative to resection of the humeral head as well as to shoulder arthrodesis.     

Arthroscintigraphy in suspected rotator cuff rupture

AIM: In order to evaluate the diagnostic efficiency of arthroscintigraphy in suspected rotator cuff ruptures this new imaging procedure was performed 20 times in 17 patients with clinical signs of a rotator cuff lesion. The scintigraphic results were compared with sonography (n = 20), contrast arthrography (n = 20) and arthroscopy (n = 10) of the shoulder joint. METHODS: After performing a standard bone scintigraphy with intravenous application of 300 MBq 99m-Tc-methylene diphosphonate (MDP) for landmarking of the shoulder region arthroscintigraphy was performed after an intraarticular injection of 99m-Tc microcolloid (ALBU-RES 400 MicroCi/5 ml). The application was performed either in direct combination with contrast arthrography (n = 10) or ultrasound conducted mixed with a local anesthetic (n = 10). Findings at arthroscopical surgery (n = 10) were used as the gold standard. RESULTS: In case of complete rotator cuff rupture (n = 5), arthroscintigraphy and radiographic arthrography were identical in 5/5. In one patient with advanced degenerative alterations of the shoulder joint radiographic arthrography incorrectly showed a complete rupture which was not seen by arthroscintigraphy and endoscopy. In 3 patients with incomplete rupture, 2/3 results were consistent. A difference was seen in one patient with a rotator cuff, that has been already revised in the past and that suffered of capsulitis and calcification. CONCLUSION: Arthroscintigraphy is a sensitive technique for detection of rotator cuff ruptures. Because of the lower viscosity of the active compound, small ruptures can be easily detected, offering additional value over radiographic arthrography and ultrasound, especially for evaluation of incomplete cuff ruptures.     

The chaperonin containing TCP-1 (CCT) displays a single-ring mediated disassembly and reassembly cycle

A prospective study of 40 shoulder arthroplasties in patients with rheumatoid arthritis was performed to evaluate the results of rotator cuff repair at the time of arthroplasty. A large cuff tear was present in 21 shoulders, and good repair of the cuff was performed in 9. In the other shoulders the repair was considered insufficient. All patients were clinically evaluated using the Hospital for Special Surgery 100-point scoring system. The minimum follow-up period for inclusion in this study was 2 years. The quality of the repair of the ruptured cuff at the time of surgery had a significant influence on the postoperative clinical score (linear regression model, P = .002). The clinical score of the shoulders with good repair of the rotator cuff improved considerably and continued to improve even after the first-year follow-up examination. Meticulous repair of the ruptured cuff at the time of arthroplasty is recommended.     

Historical development of shoulder care

The development over the last century and a half of treatment for dislocation of the shoulder, fractures, acromioclavicular dislocation, arthroplasty, and rupture of the rotator cuff is outlined.     

Protection from carcinogenic agents in work environments: considerations on Title VII of Legislative Decree 626/94

A variety of techniques are available for reconstruction of the wrist. The efficacy of wrist arthroplasty, however, is met with narrowed indications and does not enjoy the success that total joint replacement in other joints, such as the hip and knee, has enjoyed. With design improvements during the last decade, good short-term results from total wrist arthroplasty can be expected in the low-demand patient with rheumatoid arthritis. Wrist arthrodesis, either pancarpal or limited, is considered the primary surgical alternative in patients with most arthritic conditions of the wrist. The pancarpal arthrodesis is a predictable, durable alternative to a variety of post-traumatic, degenerative, or neoplastic conditions of the wrist; however, some authors report that complications may be prevalent. This procedure also may be modified and applied to the destroyed rheumatoid wrist. Overall, selection of fixation mode depends on bone quality. In an attempt to preserve motion, various limited arthrodeses of the carpus have been described. Although technically demanding, successful results may be expected, especially in conditions of carpal instability. With the current wide array of surgical alternatives, the surgeon must consider each case carefully and select the procedure that best applies to each particular situation. Furthermore, it is extremely important that the surgeon educate the patient on the limitations of each procedure.     

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

Os acromiale, failure of fusion of the secondary centers of ossification of the acromion process, has been noted as a contributing factor in shoulder impingement syndrome and rotator cuff tears. Treatments for symptomatic os acromiale with or without rotator cuff tears have been reported in the literature and range from excision of small fragments to fusion of larger, fragments with internal fixation and bone grafting. Generally, rotator cuff repairs have been performed when possible. We report an acromion splitting approach through an existing os acromiale to gain exposure for the repair of a massive rotator cuff tear. Subsequent to this repair, the acromion was repaired with internal fixation. Good functional use of the patient's upper extremity was obtained and the patient expressed satisfaction with the surgical outcome. The acromion splitting approach is a viable approach in patients with an os acromiale and a coexistent rotator cuff tear.     

Surgical management of osteoarthritis

The surgical management of osteoarthritis has progressed greatly in the past 30 years and often is indicated when noninvasive measures can no longer provide sufficient pain relief and maintenance of function. Physicians can choose from a variety of surgical procedures, depending on patient age, the joint involved, functional expectations, patient activity demands, and degree of cartilaginous loss. Surgical procedures for arthritic joints can be classified in two broad categories: those that are cartilage-sparing, such as osteotomy, and those that are cartilage-sacrificing, such as arthroplasty. This article discusses those procedures most commonly used for the major weightbearing joints of the lower extremities (hip, knee, ankle) as well as the large joints of the upper extremity (shoulder, elbow).     

MR arthrography of the shoulder joint in a postoperative patient sample

Indications of MR arthrography were analyzed in this prospective study. The aim was to evaluate possible advantages over conventional MRI, establish diagnostic criteria and to analyze its meaning further for the therapeutic management of postoperative patients. MR arthrography was performed in eight patients who had undergone surgical repair of rotator cuff lesions (modified Neer acromioplasty) and in six patients who had undergone arthroscopic therapy of recurrent unidirectional dislocation of the shoulder by combined arthroscopic intra- and extracapsular repair. MR investigations were performed before and after application of a contrast solution (2 mmol Gd-DTPA). All patients suffered from chronic postoperative pain. In patients with rotator cuff lesions, a partial tear could be verified in one patient and excluded in all others. In patients after arthroscopic therapy by combined intra- and extracapsular repair, a radiologically patulous-appearing capsule correlated with clinically recurrent dislocations. In all other patients diagnostic criteria, such as distribution of the intra-articular contrast solution, proliferation of scar tissue, nodular appearance of the glenohumeral ligaments and capsule thickness, correlated with a regular postoperative status. MR arthrography of the shoulder represents a promising method in the evaluation of the postoperative shoulder. It might further improve the evaluation of reactive capsule alterations, scar tissue proliferation, and the labroligamentous complex, as well as the ability to differentiate partial and complete rerupture from degenerative changes of the rotator cuff.     

The unstable shoulder in young subjects. Surgical experience

The stability of the scapulo humeral joint depends on three anatomical factors: bony: surface and integrity of the glenoid cavity. ligamentous: joint capsula and labrum gleno?dale. muscular: coordination and condition of the components of the rotator cuff that maintains the humeral head in the center of the joint, whatever be the position of the arm. Clinically, the most frequent aspect is the anterior recurrent dislocation, occurring in young patients.... Other forms are possible: posterior, multi directional, associated with a lesion of the rotator cuff in elderly patients.... Lately a new aspect was described: the painful and unstable shoulder. It is observed in high level sportsmen, who practice throwing sports. The only treatment is surgical. Two kinds of techniques are currently used: preglenoid transfer of the coracoid process, and different kinds-of capsuloplasty. Arthroscopy allows a more precise diagnose, but is not yet a good therapeutic procedure. Surgical treatment avoids recurrence in more than 95% of cases, but clinical osteoarthritis of the gleno humeral joint is observed in about 10% of cases after a long follow up (more than 10 years).     

Operative treatment of malunion of a fracture of the proximal aspect of the humerus

We retrospectively reviewed the medical records, operative reports, and preoperative and postoperative radiographs of thirty-nine patients who had been managed operatively for malunion of a fracture of the proximal aspect of the humerus. The malunions were categorized according to the presence of osseous abnormalities, including malposition of the greater or lesser tuberosity (type I; twenty-eight patients), incongruity of the articular surface (type II; twenty-six patients), and malalignment of the articular segment (type III; sixteen patients). Soft-tissue abnormalities, such as soft-tissue contracture, a tear of the rotator cuff, and impingement, were also recorded. At an average of forty-four months (range, twelve to fifty-three months) postoperatively, the patients were assessed for pain relief, the range of motion of the shoulder, and the ability to perform activities of daily living. The result was satisfactory for twenty-seven patients (69 per cent) and unsatisfactory for the remaining twelve (31 per cent) at the latest follow-up evaluation. Of the twenty-seven patients who had a satisfactory result, twenty-six (96 per cent) had had complete operative correction of all osseous and soft-tissue abnormalities. Of the twelve patients who had an unsatisfactory result, four had had complete operative correction of these abnormalities (p < 0.0001). Twenty-six patients (67 per cent) had incongruity of the glenohumeral joint at the time of presentation. Twenty-three of these patients had the incongruity corrected with prosthetic arthroplasty (twenty-two) or arthrodesis of the glenohumeral joint (one); the result was satisfactory for seventeen (74 per cent). In contrast, the result was unsatisfactory for all three patients in whom the incongruity had not been corrected at the time of the operation (p = 0.01). Eleven patients had malposition of the greater or lesser tuberosity but a congruent joint surface preoperatively. Ten patients in this group were managed with either osteotomy of the tuberosity or acromioplasty, and nine of them had a satisfactory result at the latest follow-up evaluation. The result was unsatisfactory for one patient who was managed with only correction of a soft-tissue contracture (that is, no treatment of the malposition) (p = 0.05). Both osseous and soft-tissue abnormalities were identified as the cause of pain and stiffness in patients who had malunion of a fracture of the proximal aspect of the humerus. We concluded that operative management of these patients is successful only if all osseous and soft-tissue abnormalities are corrected at the time of the operation.     

Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach

Calcific deposits located within the tendons of the rotator cuff are frequently seen in patients presenting with shoulder pain. The pathogenesis of calcific tendinitis and the optimum management of patients presenting with acute symptoms are unclear. This paper reviews the incidence, proposed etiologies, and a unique treatment approach of rotator cuff calcific tendinitis. A case report of a patient with acute calcific tendinitis and subsequent shoulder motion and strength deficits is presented. A rational evaluation and treatment plan is outlined, which includes management and posttreatment changes, and radiographic findings are discussed. A team-management approach by physical therapy and orthopaedics services is emphasized.     

Histopathological findings in the proprioception of the shoulder joint

Purpose of this study was the evaluation of distribution and morphology of mechanoreceptors in the glenohumeral joint capsule and rotator cuff in comparison to the coracoacromial ligament by means of specific immunfluorescence microscopy. The complemente joint capsules, rotator cuffs and coracoacromial ligaments of three fresh cadaver shoulder were harvesed. Serial cryostate sections were taken and alternately incubated with antiserum against neurofilament, lamin or myelin of peripheral nerves. The antibody-reaction was visualized with fluorescin lg-G. The nerve endings were photographed and computer-aided 3-dimensional reconstructions were performed. Three types of corpuscular and free nerve endings of different morphology were found in different distributions: whereas the Ruffini corpuscles were much more frequent in the coracoacromial ligament and rotator cuff, Pacini endings were predominantly found in the joint capsule. Generally corpuscular nerve endings were more frequent in the coracoacromial ligament and the rotator cuff than in the antero-inferior capsule and the number of corpuscles increased from medial to lateral within the anterior and inferior parts of the capsule. The dense ligamentous tissue was almost aneural whereas the periarticular fatty or loose connective tissue contained nerve fibres and nerve endings. In view of the results of other experimental and clinical studies the high frequency of Ruffini and Pacini endings in the rotator cuff and coracoacromial ligament suggest, that both are involved in the neurosensory control of glenohumeral stability and subacromial impingement. In contrast our findings in the joint capsule do not clearly prove, that those joint receptors predominantly maintain joint stability.     

Pathokinesiology and total joint arthroplasty

Gait analysis data relating to total joint arthroplasty were reviewed to assess their impact on the evolution of prosthetic design. Although joint replacement designs have led to clinical improvement, they do not yet permit the restoration of normal gait. Normal function may be difficult to attain in patients with arthritic destruction, because of a proprioceptive defect. Arthroplasty improves gait by relieving pain, but other factors (previous gait patterns, prosthetic design, muscle weakness, balance, and proprioception) seem to prevent most patients from regaining normal gait.     

Total wrist arthroplasty

Although arthroplasty is a well-established procedure for many joints, its use in the wrist is less common, and the indications are less well defined. The standard procedure for the painful arthritic wrist remains radiocarpal arthrodesis. However, as technology and surgical procedures improve, wrist arthroplasty is being used more frequently. The authors provide a brief history of total wrist arthroplasty and review the arthroplasties most commonly used in the United States. Results with total wrist implants, the complications related to arthroplasty, technical aspects of the procedure, and salvage options are also discussed.