These guidelines were developed jointly by the American Society of Health-System Pharmacists (ASHP), the Infectious Diseases Society of America (IDSA), the Surgical Infection Society (SIS), and the Society for Healthcare Epidemiology of America (SHEA). This work represents an update to the

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Clinical practice guidelines for antimicrobial prophylaxis in surgery

Background: Good functional results have been reported for arthroscopic repair of rotator cuff tears, but the rate of tendon-to-bone healing is still unknown. Our hypothesis was that arthroscopic repair of full-thickness supraspinatus tears achieves a rate of complete tendon healing equivalent to those reported in the literature with open or mini-open techniques.

Methods: Sixty-five consecutive shoulders with a chronic full-thickness supraspinatus tear were repaired arthroscopically in sixty-five patients with use of a tension-band suture technique. Patients ranged in age from twenty-nine to seventy-nine years. The average duration of follow-up was twenty-nine months. Fifty-one patients (fifty-one shoulders) had a computed tomographic arthrogram, and fourteen had a magnetic resonance imaging scan, performed between six months and three years after surgery. All patients were assessed with regard to function and the strength of the shoulder elevation.

Results: The rotator cuff was completely healed and watertight in forty-six (71%) of the sixty-five patients and was partially healed in three. Although the supraspinatus tendon did not heal to the tuberosity in sixteen shoulders, the size of the persistent defect was smaller than the initial tear in fifteen. Sixty-two of the sixty-five patients were satisfied with the result. The Constant score improved from an average (and standard deviation) of 51.6 ± 10.6 points preoperatively to 83.8 ± 10.3 points at the time of the last follow-up evaluation (p < 0.001), and the average University of California at Los Angeles score improved from 11.5 ± 1.1 to 32.3 ± 1.3 (p < 0.001). The average strength of the shoulder elevation was significantly better (p = 0.001) when the tendon had healed (7.3 ± 2.9 kg) than when it had not (4.7 ± 1.9 kg). Factors that were negatively associated with tendon healing were increasing age and associated delamination of the subscapularis or infraspinatus tendon. Only ten (43%) of twenty-three patients over the age of sixty-five years had completely healed tendons (p < 0.001).

Conclusions: Arthroscopic repair of an isolated supraspinatus detachment commonly leads to complete tendon healing. The absence of healing of the repaired rotator cuff is associated with inferior strength. Patients over the age of sixty-five years (p = 0.001) and patients with associated delamination of the subscapularis and/or the infraspinatus (p = 0.02) have significantly lower rates of healing.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Arthroscopic repair of full-thickness tears of the supraspinatus : does the tendon really heal?

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Clinical practice guidelines for antimicrobial prophylaxis in surgery.

Fractures are the most common large-organ, traumatic injuries to humans. The repair of bone fractures is a postnatal regenerative process that recapitulates many of the ontological events of embryonic skeletal development. Although fracture repair usually restores the damaged skeletal organ to its pre-injury cellular composition, structure and biomechanical function, about 10% of fractures will not heal normally. This article reviews the developmental progression of fracture healing at the tissue, cellular and molecular levels. Innate and adaptive immune processes are discussed as a component of the injury response, as are environmental factors, such as the extent of injury to the bone and surrounding tissue, fixation and the contribution of vascular tissues. We also present strategies for fracture treatment that have been tested in animal models and in clinical trials or case series. The biophysical and biological basis of the molecular actions of various therapeutic approaches, including recombinant human bone morphogenetic proteins and parathyroid hormone therapy, are also discussed.

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Fracture healing: mechanisms and interventions

Background: The Delta III reverse-ball-and-socket total shoulder implant is designed to restore overhead shoulder function in the presence of irreparable rotator cuff deficiency by using the intact deltoid muscle and the stability provided by the prosthetic design. Our purpose was to evaluate the clinical and radiographic results of this arthroplasty in a consecutive series of shoulders with painful pseudoparesis due to irreversible loss of rotator cuff function.

Methods: Fifty-eight consecutive patients with moderate-to-severe shoulder pain and active anterior elevation of <90° due to an irreparable rotator cuff tear were treated with a Delta III total shoulder replacement at an average age of sixty-eight years. Seventeen of the procedures were the primary treatment for the shoulder, and forty-one were revisions. The patients were examined clinically and radiographically after an average duration of follow-up of thirty-eight months.

Results: On the average, the subjective shoulder value increased from 18% preoperatively to 56% postoperatively (p < 0.0001); the relative Constant score, from 29% to 64% (p < 0.0001); the Constant score for pain, from 5.2 to 10.5 points (p < 0.0001); active anterior elevation, from 42° to 100° (p < 0.0001); and active abduction, from 43° to 90° (p < 0.0001). The patients for whom the implantation of the Delta III prosthesis was the primary procedure and those who had had previous surgery showed similar amounts of improvement. The total complication rate, including all minor complications, was 50%, and the reoperation rate was 33%. Of the seventeen primary operations, 47% (eight) were associated with a complication and 18% (three) were followed by a reoperation. Of the forty-one revisions, 51% (twenty-one) were associated with a complication and 39% (sixteen) were followed by a reoperation. Subjective results and satisfaction rates were not influenced by complications or reoperations when the prosthesis had been retained.

Conclusions: Total shoulder arthroplasty with the Delta III prosthesis is a salvage procedure for severe shoulder dysfunction caused by an irreparable rotator cuff tear associated with other glenohumeral lesions. Complications were frequent following both primary and revision procedures, but they rarely affected the final outcome. The procedure has a substantial potential to improve the condition of patients with severe shoulder dysfunction, at least in the short term.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.

umeroscapular arthrodesis is a well-established operative procedure that involves fusion of the humeral head to the glenoid. In some procedures, the fusion also includes an acromiohumeral arthrodesis. Humeroscapular arthrodesis is commonly called “shoulder arthrodesis,” and we use that term in this paper for simplicity. Indications for this procedure early in the twentieth century included the treatment of residual glenohumeral destruction resulting from tuberculosis and the treatment of upper-extremity paralysis resulting from poliomyelitis. Additional historical indications included osteoarthritis, rheumatoid arthritis, irreparable injury of the rotator cuff, and severely comminuted fracture of the proximal aspect of the humerus. The advent of shoulder arthroplasty has resulted in a marked reduction in the number of shoulder arthrodeses performed, although there are instances when arthrodesis is favored over joint-replacement arthroplasty. This article reviews the indications for shoulder arthrodesis, the pertinent features of the preoperative evaluation, the controversial issue of the desirable position of the arthrodesis, the various techniques for shoulder arthrodesis, and the management of complications.

Current concepts review

Total shoulder arthroplasty, originally used by Pean in 1893 to treat tuberculous arthritis1 and subsequently modernized by Neer et al. in the 1950s for the treatment of three and four-part proximal humeral fractures2, has demonstrated clinical efficacy when used for the treatment of primary and secondary degenerative conditions of the shoulder. The overall number of shoulder replacements has increased in parallel to the total number of total joint arthroplasties. Approximately 7000 total shoulder replacements were performed annually in the United States from 1996 through 2002. This represents a 40% increase compared with the 5000 arthroplasties per year performed from 1990 through 19923-11. Despite the increase in the annual volume of shoulder arthroplasties, data have suggested that nearly three-fourths of the operations are performed by surgeons who do two or fewer procedures a year12,13. The favorability of the clinical outcomes of total shoulder arthroplasty as well as the decision to proceed with a total shoulder replacement instead of a hemiarthroplasty have been shown to depend on surgeon experience and hospital volume12-16. Patient readmission rates, complication rates, and lengths of hospital stays have all been shown to …

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Complications of total shoulder arthroplasty.

Complications associated with orthopaedic prostheses or implants account for approximately 5 per cent of the more than 3.5 million hospitalizations for musculoskeletal conditions82. This is important in light of the increasing number of patients who receive prostheses and the fact that the average age of patients who have a total shoulder arthroplasty is the lowest among those for all major joint replacements28,73. Like replacement procedures in other major joints, total shoulder arthroplasty is associated with numerous complications, including prosthetic loosening, glenohumeral instability, tears of the rotator cuff, periprosthetic fracture, infection, neural injury, and dysfunction of the deltoid.

In recent years, mirroring the increase in the number of total joint arthroplasties in general, the number of shoulder-replacement procedures has increased substantially28,71-73. However, despite this growth, fewer than 5000 total shoulder replacements were performed annually in the United States from 1990 through 1992, compared with 136,000 total hip and total knee arthroplasties28,71-73. Although the short-term (less than two-year) and mid-term (two to five-year) results of total shoulder arthroplasties have been encouraging, with some authors reporting good and excellent results in more than 90 per cent of shoulders, widespread experience and long-term evaluations approaching those for joint replacements in the lower extremities have not been published1,5,6,13,23,44,53,64,65,78.

Our review of forty-one series involving 1858 total shoulder arthroplasties reported from 1975 through 1995 revealed an average duration of follow-up of only 3.5 years3-6,12,13,15,16,19,25,26,32,34,38,40-42,44,48,53, …

Complications of total shoulder-replacement arthroplasty.

Early and mid-range followup studies of shoulder arthroplasty have been encouraging, showing good and excellent results in > 90% of shoulders. Despite this success, complications in shoulder replacement surgery are inevitable, with an incidence of approximately 14%. Numerous complications have been identified and include the following factors in order of decreasing frequency: instability, rotator cuff tear, ectopic ossification, glenoid component loosening, intraoperative fracture, nerve injury, infection, and humeral component loosening. Successful treatment of these difficulties requires careful identification and subsequent analysis of all factors contributing to the complication, knowing that the etiology is often multifactorial. Failed shoulder arthroplasty can be successfully managed with revision surgery, but the technically challenging surgery and the overall results are inferior compared with other diagnostic categories.

Complications of shoulder arthroplasty

Previous experimental studies of failure of rotator cuff repair have involved single pull to ultimate load. Such an experimental design does not represent the cyclic loading conditions experienced in vivo. We created 1 ×2 cm rotator cuff defects in 16 cadaver shoulders, repaired each defect with three MitekRC suture anchors (Mitek Surgical Products, Inc, Westwood, MA) using simple sutures of No. 2 Ethibond, and cyclically loaded the repairs by a servohydraulic materials test system actuator at physiological rates and loads (rate of 33 mm/s, load 180 N). A progressive gap was noted in each specimen, for a 100% rate of failure of the repairs. The central suture always failed first and by the largest magnitude, confirming tension overload centrally. One specimen exhibited combined bone and tendon failure, but the other 15 specimens failed through the tendon. Overall, the repairs failed to 5 mm and 10 mm at an average of 61 cycles and 285 cycles, respectively. Half the specimens were less than 45 years of age and had a 5-mm and 10-mm failure at an average of 107 and 478 cycles, respectively. The other half were over 45 years of age and failed to 5 mm and 10 mm at an average of 17 and 91 cycles, respectively, indicating more rapid failure of the rotator cuff tendons in the older group, and this was statistically significant ( P ≤ .02). Comparison of suture anchor fixation in this study with transosseous bone tunnel fixation in a previous cyclic loading study at this institution indicates that bone fixation by suture anchors is significantly less prone to failure than bone fixation through bone tunnels ( P = .0008). Changing the bone fixation from bone tunnels to suture anchors effectively transferred the weak link from bone to tendon.

Cyclic loading of anchor-based rotator cuff repairs: Confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation

Michael A. Wirth

Papers

Current concepts review

Complications of total shoulder arthroplasty.

Complications of total shoulder-replacement arthroplasty.

Complications of shoulder arthroplasty

Cyclic loading of anchor-based rotator cuff repairs: Confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation