Specialty Update   |    
What's New in Shoulder and Elbow Surgery
Matthew L. Ramsey, MD1; Charles L. Getz, MD1; Bradford O. Parsons, MD2
1 Penn Orthopaedic Institute, Penn Presbyterian Medical Center, One Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104. E-mail address for M. L. Ramsey: Matthew.Ramsey@UPHS.upenn.edu
2 The Leni and Peter W. May Department of Orthopaedics, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Jan 01;89(1):220-230. doi: 10.2106/JBJS.F.01417
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This annual update on shoulder and elbow surgery is based on a review of presentations at meetings of the Arthroscopy Association of North America (Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-fifth Annual Meeting, May 18 to 21, 2006, Hollywood, Florida), the American Shoulder and Elbow Surgeons (Twenty-second Open Meeting, Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-third Closed Meeting, September 13 to 15, 2006, Chicago, Illinois), The American Orthopaedic Society for Sports Medicine (Specialty Day, March 25, 2006, Chicago, Illinois), the American Academy of Orthopaedic Surgeons (Seventy-third Annual Meeting, March 22 to 25, 2006, Chicago, Illinois), and the Orthopaedic Research Society (Fifty-second Annual Meeting, March 19 to 22, 2006, Chicago, Illinois).

Rotator Cuff

Basic Science

Park proposed a transosseous equivalent rotator cuff repair technique and performed a biomechanical study to evaluate footprint contact pressure in a variety of repair configurations. A "suture-bridging" technique utilizing medial anchors with suture limbs traversing over the cuff to a lateral interference screw attachment was compared with a double-row anchor repair. A four-limb suture bridge (two medial anchors with four limbs over the cuff laterally) established a significantly higher mean contact pressure area (72.3%) compared with a two-limb suture bridge (57.3%) and a double-row repair (35.1%) (p < 0.05). The authors concluded that increasing footprint contact pressure may aid in rotator cuff healing.


Milano investigated the influence of acromioplasty on outcome following arthroscopic rotator cuff repair. Eighty patients were prospectively randomized into two groups, with half undergoing rotator cuff repair with acromioplasty and half undergoing rotator cuff repair without acromioplasty. The outcome measures that were evaluated were the Constant score and the Quick-DASH and Work-DASH self-administered questionnaires. Comparison between the two groups failed to demonstrate a significant difference at two years of follow-up. The authors concluded that acromioplasty does not affect the outcome of arthroscopic rotator cuff repair.

Partial-Thickness Tears

Lo used a cadaver model to assess the accuracy and utility of an intra-articular depth gauge in comparison with those of quantification of the exposed rotator cuff footprint for determining the size of partial-thickness rotator cuff tears. The intra-articular depth gauge was found to be more accurate than measuring the amount of exposed footprint for determining the depth of partial rotator cuff tears. In a clinical study of the intra-articular depth gauge, treatment was altered 18% of the time (one patient was switched to repair and three were switched to débridement only) on the basis of Weber's recommendation of repair for tears in excess of 50%, and, thus, the depth gauge can be useful for directing the intraoperative treatment of partial-thickness rotator cuff tears.
The healing rate of partial-thickness rotator cuff tears following arthroscopic takedown and repair was evaluated by Yamaguchi. Forty-three patients were followed prospectively to evaluate healing following arthroscopic takedown (completion) and repair of the tears. Healing of the rotator cuff was assessed with ultrasound six months after surgery. The repair was intact in thirty-eight (88%) of the forty-three patients and was retorn in five. The average American Shoulder and Elbow Surgeons (ASES) score improved from 46.1 to 79.7, and the overall rate of patient satisfaction was 93%. The authors did not note the depth and size of the tears prior to completion. However, the healing rate for these patients exceeds that for patients with full-thickness tears. These results support completion of partial rotator cuff tears followed by repair.

Full-Thickness Tears

Deutsch evaluated the restoration of the rotator cuff footprint with use of a single lateral row of suture anchors after altering the depth of suture passage in a fresh-frozen cadaver model. The depths of suture passage that were tested were 7, 15, and 22 mm. Additionally, the strength of repair was compared between the 7 and the 22-mm-passage repairs. The depth of suture passage correlated with the restoration of the footprint. A suture-passage depth of 22 mm restored the footprint to 67% of native coverage, compared with 35% for the 7-mm depth and 47% for 15-mm depth (p < 0.001). The load to failure was significantly greater for the 22-mm-depth repairs than for the 7-mm-depth repairs (233 compared with 113 N; p < 0.05).
Liem evaluated the influence of fatty infiltration and atrophy on the outcome of arthroscopic repair of isolated supraspinatus tears in a study of thirty-two consecutive patients with a minimum of twenty-four months of follow-up. Six patients (18.8%) were found to have a retear on postoperative magnetic resonance imaging. The supraspinatus atrophy was significantly greater preoperatively (at least grade 2) in the re-tear group as compared with the healed group. The presence of atrophy decreased the clinical outcomes in patients with a healed rotator cuff as compared with patients who had a healed rotator cuff in the absence of atrophy. The degree of fatty infiltration of the supraspinatus and infraspinatus was significantly higher in the retear group as compared with the healed group. In addition, fatty infiltration appeared to progress in the retear group and remained static in the healed group. The authors concluded that preoperative magnetic resonance imaging evaluation of the degree of atrophy and fatty infiltration of the rotator cuff muscles has a significant influence on clinical outcome.
Members of the French Arthroscopy Society conducted a multicenter retrospective review of 576 arthroscopically repaired rotator cuff tears. All were isolated tears of the posterosuperior part of the rotator cuff, and tears involving the subscapularis were excluded from the study. The patients were evaluated postoperatively with computed tomography or magnetic resonance imaging arthrography and were rated with use of the Constant score. Overall, recurrent tears were found in 25.2% of the shoulders, with a complication rate of 3.1% (including a 2.7% rate of reflex sympathetic dystrophy, a 0.2% rate of infection, and a 0.2% rate of anchor migration). The overall Constant score and its subcategory scores for strength, mobility, and activity were found to have a highly significant correlation with the integrity of the rotator cuff repair; however, pain scores did not correlate with tendon healing. Clinical results and healing rates also were found to be strongly correlated with preoperative tear size, retraction, intrasubstance tears, fatty degeneration, and the age of the patient. Work-related injuries were correlated with poor clinical results.

Massive and Irreparable Tears

Weber investigated the role of rotator cuff débridement as a treatment for massive irreparable rotator cuff tears. Eighty patients were retrospectively evaluated following arthroscopic débridement of large and massive rotator cuff tears demonstrating preoperative atrophy (Thomazeau class 2 or 3) and fatty infiltration (Goutallier class 2, 3, or 4). All patients had attempted closure of the rotator cuff defect. However, mobilization techniques were avoided. Good to excellent results were obtained in 88% of the patients on the basis of the University of California at Los Angeles (UCLA) score. Pain was most significantly decreased, whereas functional scores showed less improvement. Given the recent literature on healing rates of large and massive tears with atrophy and fatty infiltration, débridement may play a role in the management of these patients.
Gerber and associates investigated whether the integrity of the teres minor musculotendinous unit was predictive of outcome following latissimus dorsi tendon transfer. Twenty-two patients who underwent latissimus dorsi tendon transfer for the treatment of massive, irreparable posterosuperior rotator cuff tears were retrospectively reviewed. Sixteen men and six women with a mean age of fifty-eight years (range, forty to sixty-eight years) were analyzed after an average duration of follow-up of thirty-four months (range, twenty-four to fifty-seven months). Fatty infiltration of the teres minor was classified as Goutallier stage 0 in five patients, stage 1 in six patients, stage 2 in four patients, stage 3 in six patients, and stage 4 in one patient. Eleven patients had a partial tear of the teres minor tendon, and two patients had a complete tear. Increased fatty infiltration of the teres minor that was classified as greater than stage 2 was associated with worse postoperative Constant scores (p = 0.015), age-adjusted Constant scores (p = 0.012), active external rotation (p = 0.016), and active elevation (p = 0.012). Simply the presence or absence of a tear of the tendon had no significant effect on the outcome.


Athwal and colleagues reviewed the Mayo Clinic experience with the prevalence, treatment, and outcomes of deep infection following rotator cuff repair. Thirty-nine cases of deep infection following rotator cuff repair were identified between 1975 and 2003. After a mean duration of follow-up of 8.2 years, seven patients had died and two patients had been lost to follow-up, leaving thirty patients available for outcome evaluation. The prevalence of deep infection after rotator cuff repairs that were performed at that institution was 0.43% (twenty-one of 4886). Propionibacterium was the most common organism, being isolated in 51% of the cases. A mean of 3.3 surgical débridements were necessary for the eradication of infection. At the time of the final follow-up, the mean active abduction was 121° and the mean external rotation was 44°. The ASES score averaged 67 points, and the Simple Shoulder Test (SST) score averaged 7.3 points. The data from that study suggest that the eradication of deep infection following rotator cuff repair is possible; however, substantial functional limitations are not unusual.

Biceps Tendon

Costic compared two techniques for arthroscopic biceps tenodesis in a fresh-frozen cadaveric shoulder model. The first technique (the so-called PITT technique) is a soft-tissue technique in which sutures are passed through the biceps tendon and are tied to the transverse humeral ligament. The other technique is one in which suture anchors fix the biceps tendon in the bicipital groove via sutures that are passed through the tendon. No significant difference was observed between the two techniques. Failure was observed predominantly in association with pullout of the suture through the biceps tendon rather than in association with failure of the anchor or failure at the transverse humeral ligament. The authors concluded that the quality of the biceps tendon may be the most important factor in choosing the repair technique. That study brings into question the initial strength of any repair technique that involves passing nongrasping sutures through the biceps tendon.

Glenohumeral Instability

Anterior Instability

The long-term prognosis of first-time anterior shoulder dislocation in young patients was evaluated by Hovelius. The results at twenty-five years of follow-up demonstrated that 115 (50%) of 229 shoulders had zero or one recurrence. Thirty-five shoulders with a history of two or more dislocations did not demonstrate any recurrence in the last ten years and were considered to have become stabilized over time. Recurrent dislocations were experienced in 7.4% of the patients. Surgical stabilization was performed in 27% of the patients. When stratified by age at the time of the first dislocation, 37% of the twelve to twenty-two-year-old patients, 28% of the twenty-three to twenty-nine-year-old patients, and 13% of the thirty to forty-year-old patients underwent surgical stabilization. Surgical failure occurred in 29% of the patients. The authors evaluated the glenohumeral joint for evidence of arthropathy. Normal findings were observed in 44% of the shoulders, mild arthropathy was noted in 29%, moderate arthropathy was noted in 9%, and severe arthropathy was noted in 17%. The authors concluded that the data did not support immediate stabilization after a first-time dislocation. However, they stressed that the natural history of a first-time dislocation is bound to arthropathy.
Tjoumakaris investigated the functional outcomes for patients who had undergone arthroscopic or open stabilization for the treatment of recurrent anterior instability. The outcomes for twenty-four patients who had had open shoulder stabilization and sixty-nine patients who had had arthroscopic shoulder stabilization were compared by means of a modified ASES score. The patients had a minimum of two years of follow-up, with the repair method chosen by surgeon preference. There was a single recurrence of instability in both the open group and the arthroscopic group. There was no difference between the groups with regard to the overall modified ASES scores or the subscores for pain, satisfaction, and function. The authors stated that recurrent instability may not be the most appropriate parameter with which to measure success. Instead, they believed that functional outcome measures are more appropriate, demonstrating equivalent results between open and arthroscopic instability surgery.
The ability of contact athletes to return to sports activity following arthroscopic anterior shoulder stabilization was investigated by Williams. Twenty-four patients who had undergone twenty-eight procedures were retrospectively reviewed. Patients were selected on the basis of a history of involvement in contact sports, recurrent anterior instability, and arthroscopic stabilization. Patients were excluded if they demonstrated either glenoid or humeral bone loss or had had previous shoulder surgery. All patients had a minimum of two years of follow-up. Twenty-one patients (88%) were able to return to contact sports at the same level. Seven patients did not return to contact sports, with only one of these seven patients not returning to sports because of continued problems with the shoulder. Two patients had recurrent instability, with one requiring revision surgery. Functional outcomes as measured with use of the ASES score, the L'Insalata score, and the Western Ontario Shoulder Instability Index (WOSI) were excellent both in patients who returned to contact sports and in those who did not. The authors concluded that arthroscopic shoulder stabilization for the treatment of recurrent anterior instability in selected patients provides an excellent functional outcome and can successfully return contact athletes to play.
In a prospective study, Mochizuki et al. compared arthroscopic Bankart repairs involving the use of suture anchors in high-demand and lower-demand patient populations with traumatic anterior glenohumeral instability. Ninety-nine shoulders in ninety-nine patients with traumatic unilateral anterior shoulder instability were evaluated on the basis of the Rowe score, the rate of recurrence, the return to activity, and the range of motion as measured by an independent examiner at an average of thirty-eight months after arthroscopic surgery. Of the ninety-nine shoulders, fifty-eight were in high-demand patients participating in judo, karate, boxing, gymnastics, wakeboarding, snowboarding, basketball, handball, or rugby. In these fifty-eight high-demand patients, the average Rowe score improved from 30.2 to 92.4 points. This finding was not different from that in the group of lower-demand patients, in whom the score improved from 31.5 to 90.6 points. The high-demand patients lost a mean of 4° of external rotation in adduction. This finding also was not different from that in the group of lower-demand patients, who lost a mean of 3° of external rotation in adduction. The recurrence rate in the group of high-demand patients (3.4%, two of fifty-eight) was lower than that in the group of lower-demand patients (4.9%, two of forty-one). All patients were able to return to their sports at the same level or a higher level following surgery.

Posterior Instability

Posterior shoulder instability is a diagnostic and arthroscopic surgical challenge. Provencher and colleagues presented a study of arthroscopic posterior shoulder stabilization and evaluated preoperative and intraoperative variables as predictors of outcome. Between 1999 and 2003, thirty-three consecutive patients with a mean age of twenty-five years who underwent posterior arthroscopic shoulder stabilization with suture anchors and/or suture capsulolabral plication were reviewed. Functional outcomes were determined on the basis of the ASES score, the WOSI, the Subjective Patient Shoulder Evaluation, and the Single Assessment Numeric Evaluation (SANE). The average duration of follow-up was 39.1 months (range, twenty-two to sixty months). There were a total of seven failures, four of which were due to recurrent instability and three of which were due to pain. Overall, the mean ASES score was 94.6, the mean Subjective Shoulder Rating was 20.0, the mean WOSI value was 389.4 (81.5% of normal), and the mean SANE value was 87.5. Preoperative predictors of a poor result were voluntary instability (p = 0.025) and previous surgery on the shoulder (p = 0.02). The arthroscopic treatment of posterior shoulder instability is an effective means of treating symptoms associated with recurrent posterior subluxation of the shoulder. Patients with voluntary instability and previous surgery had worse outcomes than did those with a traumatic etiology, suggesting that surgery should be carefully considered in this group of patients.

Glenohumeral Arthritis

Basic Science

The biomechanical effect of inferior tuberosity displacement during hemiarthroplasty for the treatment of a proximal humeral fracture was evaluated by Huffman and colleagues in a study of eight fresh-frozen cadavers. Three test conditions were studied: (1) anatomic tuberosity reconstruction, (2) inferior tuberosity displacement of 10 mm, and (3) inferior tuber-osity displacement of 20 mm. The specimens were mounted in a custom testing jig, and muscle loads were applied. When tuberosities were placed 10 or 20 mm inferior to the anatomic position, glenohumeral joint-reactive forces shifted significantly superiorly, especially with abduction or elevation moments. The authors concluded that these alterations could result in increased force required to raise the arm following hemiarthroplasty with inferiorly positioned tuberosities, resulting in poor functional outcome.
Craig and colleagues evaluated the glenoid components that had been retrieved from sixty-five shoulders over a twenty-six-year period. The original total shoulder replacements had been performed for a variety of diagnoses, including osteoarthritis, posttraumatic arthritis, inflammatory arthritis, and osteonecrosis. The components had been removed because of aseptic loosening in 81.5% of the cases and septic loosening in 18.5%. The authors found several common patterns of glenoid wear. Scratching and pitting of the glenoid were found most commonly on the inferior portion of the component and represented the most common form of wear. Edge deformation was found in thirty-one (47.7%) of the specimens. Abrasions on the component were found most frequently on the anterior portion of the component. The components were then characterized as conforming or non-conforming on the basis of the radius of curvature mismatch between the glenoid and the humeral head. Edge deformation and radiolucent lines were found to occur with significantly greater frequency in association with the conforming components. The authors concluded that increased conformity between the humeral head and the glenoid leads to edge wear and glenoid loosening.


Blaine and colleagues performed a prospective multicenter study of 210 patients who were managed with total shoulder arthroplasty for the treatment of primary osteoarthritis. Preoperative and postoperative functional evaluation was performed with use of the SST, ASES score, a visual analog pain scale, and a physical examination. A minimum of two years of follow-up was available for 102 patients. Patients had significant improvement in the SST score (from 3.66 to 9.71, p < 0.0001), the ASES score (from 31.28 to 75.19, p < 0.0001), and the visual analog pain score (from 7.10 to 2.54, p < 0.0001). Active range of motion also improved significantly in all planes. Elevation improved from 105° to 154°, external rotation improved from 33° to 69°, and internal rotation improved from S1 to L1 (p < 0.0001 for all). That study demonstrated that total shoulder arthroplasty reliably relieves pain and improves function in patients with osteoarthritis of the glenohumeral joint.

Techniques of Conventional Prosthetic Arthroplasty

Total shoulder arthroplasty is a successful procedure that is associated with good long-term results. One complication is failure of the subscapularis repair, leading to weakness in internal rotation and anterior instability. Hoenecke investigated the failure characteristics of three subscapularis repair techniques in a cadaver model. The subscapularis was circumferentially isolated from the underlying capsule. The subscapularis tendon was released from the tuberosity to allow for one of three repair techniques: tendon-to-tendon, tendon-to-bone, or bone-to-bone with use of a buttress plate. The shoulder was mounted on a fatigue-testing machine, and the medial end of the subscapularis tendon was attached to a soft-tissue clamp. Each specimen initially was tested for fatigue at 150 N for 500 cycles and then was tested at 300 N for 2500 cycles. After repair, the length of the subscapularis tendon was reduced by 15% in the tendon-to-tendon group and by 12% in the bone-to-bone group and was increased by 7% in the tendonto-bone group. Complete failure occurred in four tendon-to-bone specimens, one tendon-to-tendon specimen, and no bone-to-bone specimen during the 150-N cyclic test. All specimens that survived the 150-N cyclic test failed either completely or partially during the 300-N cyclic test. The tendonto-bone repair group had the greatest number of failures. The bone-to-bone and tendon-to-tendon repairs performed the best; however, tendon-to-tendon repair significantly shortened the length of the tendon, thus potentially limiting the range of external rotation postoperatively. The bone-to-bone repair offered the best combination of biomechanical strength and restoration of subscapularis length.
In a biomechanical and clinical study examining various techniques for takedown and repair of the subscapularis during total shoulder replacement, fifteen cadaveric shoulders were divided into three groups of five. The first group underwent lesser tuberosity osteotomy with single-row repair, the second group underwent lesser tuberosity osteotomy with double-row repair, and the final group underwent tenotomy and repair. The repairs were cyclically stressed at 180 N for 400 cycles and then were loaded to failure. On the basis of the ultimate strength, the osteotomized specimens with single and double-row repair had a significantly higher load to failure than the tenotomy specimens did (430, 466, and 252 N, respectively). Clinically, 100 consecutive patients who had undergone total shoulder replacement with lesser tuberosity osteotomy with a double-row repair were evaluated at twelve to twenty-four months of follow-up. The belly-press test was normal in eighty-six patients, the lift-off test was normal in seventy-nine patients, and eighty-two patients could tuck in their shirt. The authors concluded that osteotomy of the lesser tuberosity with a double-row repair improves subscapularis function after total shoulder replacement.

Outcomes of Arthroplasty

Rispoli presented the results of a minimum five-year follow-up study of the Mayo Clinic experience with humeral head replacement for the treatment of isolated osteoarthritis of the shoulder in a series of sixty patients. Patients with any other pathologic diagnosis were excluded from the study. Fifty-one of the sixty patients were available for clinical review at a minimum of five years. Nine shoulders were not available for review because the patient had died (seven shoulders) or had been lost to follow-up (two shoulders) but were included in the survival analysis. There was significant improvement in terms of long-term pain relief (p < 0.0001), active abduction (p < 0.0001), internal rotation (p < 0.0242), and external rotation (p < 0.0001). The clinical results were measured according to the modified Neer rating system. The results were excellent in 20% of the shoulders, satisfactory in 39%, and unsatisfactory in 41%. Ten shoulders underwent revision surgery, with nine of the revisions being performed because of painful glenoid arthritis. Thirty-nine shoulders were available for radiographic review. Glenoid erosion was present in 95% of these shoulders. Biconcavity of the glenoid did not affect the survival rate or the final outcome. Hemiarthroplasty of the shoulder carries a high rate of unsatisfactory results and demonstrates a high rate of radiographic evidence of glenoid erosion.

Constrained Prosthetic Arthroplasty

Walsh presented a multicenter study of complications and revisions following reverse total shoulder arthroplasty. Five centers participated in the study, in which 457 reverse total shoulder arthroplasties were performed. A primary arthroplasty was performed in 297 patients, whereas a revision reverse total shoulder arthroplasty was performed in 164 patients. The authors reported an overall complication rate of 25.6%. Revision reverse total shoulder arthroplasty was associated with higher rates of complications (including dislocation, infection, and humeral fracture) than primary arthroplasty was, both intraoperatively (30.9% compared with 2.7%, p < 0.001) and postoperatively (33.6% compared with 12.6%, p < 0.001). The deltopectoral approach was found to have a higher rate of instability compared with a superolateral approach (5.8% compared with 1.0%; p = 0.05). Whether this higher rate of instability was due to a preponderance of deltopectoral approaches in the revision arthroplasty group was not noted by the authors. That study highlights the difficulties that a surgeon can expect in association with reverse total shoulder arthroplasty.
The introduction of reverse total shoulder arthroplasty has provided us with another option for the treatment of shoulder pathology. However, the cost of this newly introduced technology is unknown to many. Collins performed a comparison of charges, costs, and hospital reimbursements for a consecutive series of twenty-eight reverse total shoulder arthroplasty procedures and a randomly selected group of twenty-eight standard total shoulder arthroplasties that were performed during the same time interval. The cumulative operating room charges for reverse total shoulder arthroplasty exceeded those for conventional total shoulder arthroplasty by $226,947.00. The average length of stay was 2.8 days for reverse total shoulder arthroplasty, compared with 2.0 days for total shoulder arthroplasty. The implant costs were $14,837.00 for reverse total shoulder arthroplasty, compared with $9327.00 for total shoulder arthroplasty. Actual reimbursement was $7479.00 for reverse total shoulder arthroplasty, compared with $7861.00 for total shoulder arthroplasty. With all costs considered, there was a net loss to the hospital of $7358.00 for reverse total shoulder arthroplasty as compared with $1466.00 for total shoulder arthroplasty. The authors concluded that although reverse total shoulder arthroplasty offers potentially excellent solutions to patients with rotator cuff-deficient arthritic shoulders, there is no profit margin and, with higher complication rates, the widespread use of this implant should be carefully considered.

Complications and Revisions

The prevalence of deep-vein thrombosis following shoulder arthroplasty is unknown. Willis et al. performed a prospective surveillance of 100 consecutive patients undergoing shoulder arthroplasty at a single center. Patients who were managed with anticoagulation therapy preoperatively were excluded from the study. Four-limb cold-flow Doppler ultrasonography was performed two days (100 patients) and twelve weeks (fifty patients) after surgery to document the presence or absence of deep-vein thrombosis. The overall prevalence of deep-vein thrombosis was 13%. Deep-vein thrombosis involved the upper extremity in six patients and the lower extremity in seven patients. All upper extremity thromboses were on the operative side, with five involving the subclavian/axillary vein and one involving the axillary/brachial vein. Lower extremity deep-vein thromboses involved the ipsilateral lower extremity in five patients and the contralateral lower extremity in two patients. Two patients had a symptomatic nonfatal pulmonary embolism, while one patient had a fatal pulmonary embolism. Thus, thromboembolic events following shoulder arthroplasty may occur more commonly than previously thought, in both the acute and subacute postoperative periods. The authors suggested that additional studies should be performed to determine the role of routine chemoprophylaxis following shoulder arthroplasty.


Proximal Humeral Fractures

Tejwani reported on sixty-seven patients who had a diagnosis of a one-part proximal humeral fracture. The average age of the patients was 64.8 years (range, twenty-five to ninety years). All patients were managed with early range of motion and strengthening. Demographic characteristics and an estimate of preinjury functional capacity were obtained at the time of presentation. All patients had a radiographic evaluation at each visit to determine union and the maintenance of fracture position. At subsequent follow-ups, patients were analyzed on the basis of physical examination (range of motion), radiographic examination, the ASES score, and the Short Form Musculoskeletal Assessment (SF-36). By three months, all patients had achieved radiographic and clinical union. At one year, the ASES score was worse than the preinjury value (p < 0.0001). The range of shoulder motion on the affected side was diminished compared with that on the unaffected side in terms of internal rotation (p < 0.005) and external rotation (p < 0.001), but not forward flexion. The authors concluded that patients with minimally displaced proximal humeral fractures that were treated nonoperatively failed to return to preoperative functional status at the time of the one-year follow-up.

Clavicular Fractures

The results of a multicenter, prospective, randomized, controlled study comparing immediate operative treatment with nonoperative treatment of displaced midshaft clavicular fractures were reported by Hall and colleagues. Patients were randomized into a nonoperative group that was treated with sling immobilization or an operative group that was treated with plate-and-screw fixation. The Constant Shoulder Score (CSS), the Disabilities of the Arm, Shoulder and Hand (DASH) score and SF-36 scores were collected at six weeks and at three, six, and twelve months. Seventy-two patients with at least one year of follow-up were available for review. The CSS and DASH scores were better in the operative group at all time-points measured (p = 0.001 and p = 0.021, respectively). Complications in the nonoperative group included reflex sympathetic dystrophy (one patient), symptomatic malunion (two patients), and nonunion requiring surgical treatment (six patients). Complications in the operative group included local plate-site irritation (two patients) and late wound dehiscence (one patient). The authors concluded that operative fixation of displaced midshaft clavicular fractures provided significant improvement in functional outcome as compared with sling treatment at one year of follow-up.
Potter and colleagues performed a review of thirty patients to determine if delay in the repair of displaced, midshaft clavicular fractures negatively affected shoulder strength or outcome. All patients had sustained a completely displaced, closed, midshaft clavicular fracture. Included in the review were fifteen patients who had undergone acute open reduction and internal fixation with a compression plate and fifteen patients who had undergone delayed reconstruction with open reduction and compression plate fixation for the treatment of nonunion or malunion at a mean of fifty-eight months after the injury. Functional assessment was performed with use of the DASH and Constant scores as well as objective muscle strength and endurance testing. There were no significant differences between the acute fixation group and the delayed reconstruction group with regard to range of motion. In a subset of each group that was tested for endurance, delayed fixation led to a significant decrease in muscle endurance with regard to shoulder flexion (p = 0.007). Late reconstruction of nonunion or malunion following a displaced midshaft fracture of the clavicle resulted in restoration of objective muscle strength similar to that seen in association with immediate fixation; however, there was a significant loss in muscle endurance as well as a trend toward a decrease in outcome scores (DASH and Constant scores).


Lo and associates described the anatomic landmarks for arthroscopic release of the transverse scapular ligament in a study of six cadaveric shoulders. The authors described a stepwise progression that was used to find the transverse scapular ligament safely by finding the distal part of the clavicle and then moving medially to the trapezoid ligament, which inserted on the clavicle 1.7 ± 0.1 cm from the distal part of the clavicle. The medial extent of the coracoclavicular ligaments were then found 1.9 ± 0.3 cm medial to their lateral border. The medial conoid ligament was then dissected inferiorly 1.5 ± 0.1 cm to the base of the coracoid. The authors found the transverse scapular ligament at the coracoid insertion of the conoid ligament and were able to safely incise the ligament with dissecting scissors that were placed through an anterolateral portal. Clinically, they found that coplaning the inferior aspect of the acromioclavicular joint and the use of a 70° arthroscope were valuable for improving arthroscopic visualization. The authors concluded that this procedure was feasible and safe.
Mair reported on a case series of six patients who had previously undergone an arthroscopic SLAP (superior labrum anterior-to-posterior) lesion repair aided by a transtendinous portal. Each of these patients was found to have a substantial tear of the rotator cuff in the area of the transtendinous portal. The average age of the patients was 34.4 years. Five patients were noted to have a normal rotator cuff at the time of the index SLAP repair. The other patient was noted to have a mild partial supraspinatus tear. Five of the six patients reported that the symptoms were worse following the index SLAP repair. All patients underwent repeat shoulder arthros-copy at an average of fifteen months following the original SLAP repair. All patients were noted to have a full-thickness rotator cuff tear associated with the previous transtendinous portal. Following rotator cuff repair, the patients demonstrated significant improvement. The mean ASES score improved from 45.4 (range, 34 to 60) preoperatively to 90.5 (range, 77 to 100) at a mean of sixteen months of follow-up. The authors stressed placement of the portal medial to the muscle-tendon junction to avoid this complication.
Chondrolysis is a rare but devastating complication of shoulder arthroscopy. Larsen and associates reported on six cases of severe chondrolysis following arthroscopy in a group of patients between fifteen and thirty-two years of age. Four of the six patients had previously been managed with thermal capsulorrhaphy, and all patients had had previous labral or instability surgery. The presenting complaint was severe pain and loss of motion that were not responsive to activity modification, medications, and physical therapy. Four patients underwent humeral head resurfacing (one with additional glenoid interposition), and two underwent hemiarthroplasty. Pain relief following the arthroplasty procedures was consistent, but function was highly variable. The majority of the cases were thought to be related to intraarticular use of thermal tissue ablators. However, some patients had development of chondrolysis with minimal or no use of thermal devices in the shoulder. The authors recommended the judicious use of thermal energy within the joint and noted that care should be taken not to allow the fluid temperature to rise during use of these devices.
Hansen reported on 152 patients who underwent 177 shoulder arthroscopies between January 2003 and December 2005 for the treatment of postarthroscopic evidence of chondrolysis. Twelve shoulders in ten patients who underwent arthroscopic stabilization had development of chondrolysis. All of these patients had been managed postoperatively with an intra-articular pain pump catheter infusing Marcaine (0.25%) with epinephrine at a concentration of 1:200,000. Seven other patients who were managed with an intraarticular pain pump catheter did not have development of chondrolysis. No other patients had development of chondrolysis in this group. No other common factors were identified. The authors pointed out that the pH of marcaine with epinephrine is between 3.5 and 5.5. All cases of chondrolysis occurred after the beginning of the use of a larger pain pump that infused this medication at a rate of 4.16 mL/hour over two or three days. Although the exact etiology and mechanism of chondrolysis are still unknown, the authors believed there is a significant risk associated with the use of intraarticular pain pump catheters and bupivicaine with epinephrine. These pumps should be used with caution until the safety of constantly infusing local anesthetics intra-articularly is better defined.


Basic Science

Chebli and associates presented the results of a biomechanical evaluation of a novel lateral collateral ligament reconstruction technique involving the use of split anconeus fascia. In this technique, a strip of anconeus fascia is released from its origin and is split down to its insertion on the ulna. One segment is passed under the anular ligament to reconstruct the radial collateral ligament proper, and the inferior strip is used to reconstruct the lateral ulnar collateral ligament with use of a docking technique. Ten fresh-frozen cadaveric elbows had resection of the lateral collateral ligament followed by reconstruction with use of the split anconeus fascia. A pivot-shift test was performed, and ultimate load to failure was recorded and compared with that in ten intact elbows. The ultimate load to failure was 110.5 N in the reconstruction group, compared with 99.7 N in the control group. There was no significant difference between these two groups. This novel technique appears to have biomechanical support for its clinical use.


Altchek retrospectively reviewed the results of medial collateral ligament reconstruction with the docking procedure in a study of 100 consecutive overhead athletes who had been followed for an average of two years after the procedure. At the time of surgery, all patients had routine arthroscopic assessment. Arthroscopy revealed that 45% of the patients had associated pathologic findings, which were addressed prior to the reconstruction. Ninety of the 100 athletes were able to compete at the same or higher level for at least twelve months after the reconstruction. Seven patients returned to activities at a lower level for more than twelve months. Two patients had a fair result, and one had a poor result. Three patients required reoperation because of ulnar nerve symptoms (two patients) or elbow stiffness (one patient). The docking procedure for reconstruction of the medial collateral ligament in high-demand patients is associated with acceptable outcomes.

Lateral Epicondylitis

Kim and colleagues reported the results of a retrospective review of thirty-four patients who were managed with arthroscopic or open procedures for the treatment of lateral epicondylitis. All patients had had a failure of nonoperative treatment for one year prior to surgery. Fourteen patients had an open release, thirteen had an arthroscopic release, and seven underwent arthroscopic evaluation with open release. Arthroscopic evaluation of the extensor carpi radialis brevis demonstrated that 10% of the patients had a complete tear, 60% had fraying or a partial-thickness tear, and 30% had normal findings. Synovitis was found in 25% of the elbows that were evaluated arthroscopically, and one loose body was removed. The outcomes were measured at an average of sixteen months postoperatively with use of the Nirschl pain score and the Nirschl and Pettrone assessment. The results were satisfactory after 86% of the arthroscopic releases and 85% of the open releases. Open and arthroscopic release appear to produce similar clinical results.

Fractures and Dislocations

Humerus (Distal)

The results of a multicenter, prospective, randomized, controlled trial in which open reduction and internal fixation was compared with total elbow arthroplasty for the treatment of displaced intra-articular fractures in elderly patients was reported by McKee. Twenty-one patients who were sixty-five years of age and older and had a type-C3 distal humeral fracture were randomized into the two treatment groups. However, because of the crossover from open reduction and internal fixation to total elbow arthroplasty in five patients and the death of two patients, fifteen patients underwent open reduction and internal fixation and twenty-five underwent total elbow arthroplasty. Outcomes were measured with use of the Mayo Elbow Performance Score (MEPS) and the DASH score. At all time-points that were measured, patients in the total elbow arthroplasty group had significantly higher Mayo Elbow Performance Scores. DASH scores were significantly lower (better) for the total elbow arthroplasty group as compared with the open reduction and internal fixation group at three and six months and remained slightly lower for as long as two years. Patients in the total elbow arthroplasty group also had a larger arc of motion (107° compared with 95°), but this difference was not significant. Elderly patients with severe distal humeral fractures who are managed with total elbow replacement appear to have better short-term outcomes than do those who are managed with open reduction and internal fixation.

Humerus (Capitellum)

Mighell reported the clinical results for fifteen patients who had a capitellar fracture of the humerus. Seven patients had a type-I fracture, two had a type-III fracture, and six had a type-IV fracture. Surgery was performed through an extended Kocher approach. Dissection was carried out anterior to the lateral ulnar collateral ligament in an attempt to maintain stability and vascularity to the capitellar fragments. If greater visualization was required, this ligament was released from the lateral epicondyle and was repaired at the conclusion of the procedure. The clinical result was measured with use of the Broberg-Morrey scale. All patients had a good-to-excellent functional result. The average arc of motion was 124°. No cases of osteonecrosis or nonunion were reported, and no patient required a second operation.

Radial Head

The long-term outcome following an isolated Mason type-I fracture that was displaced 1 or 2 mm was reported by Josefsson. Twenty women and twelve men with an average age of forty-six years at the time of the injury were reexamined at an average of twenty-one years after the injury. All were managed nonoperatively with immediate mobilization (seventeen patients) or with plaster immobilization (fifteen patients) for an average of two weeks. The follow-up included subjective, objective, and radiographic evaluation, and the uninjured elbow served as a control in each case. At the time of follow-up, twenty-nine individuals had no subjective complaints whereas three described occasional pain, pain predominantly when loading the elbow and nondaily pain, or pain at rest. There was no impairment of range of motion, no reduced strength, and no radiographic evidence of osteoarthritis, but more degenerative changes were noted in the injured elbows as compared with the uninjured elbows (85% compared with 4%, p < 0.001). The long-term outcome of nonoperative treatment of these displaced Mason type-I fractures of the radial head or neck was good or excellent in all cases. The data strongly suggested that these fractures should be treated nonoperatively.
The goal of the study by Herbertsson was to evaluate the long-term outcome of conservatively treated Mason type-II fractures of the radial head. Fifty-three patients with an average age of forty-seven years at the time of the injury were reevaluated at an average of nineteen years after the injury. The primary treatment included immediate mobilization in nine patients and plaster immobilization for an average of two weeks in forty-four. A delayed radial head excision was performed in eight patients. Forty-one patients (77%) had no subjective complaints at the time of follow-up, ten (19%) had occasional elbow pain, and two (4%) had pain additionally at rest. Flexion in the injured elbows was limited compared with that in the uninjured elbows (137° ± 6° compared with 139° ± 7°), as was extension (-4° ± 11° compared with 1° ± 5°) and supination (85° ± 8° compared with 88° ± 4°) (p < 0.01 for all). The formerly injured elbows had significantly more cysts, sclerosis, and osteophytes than did the un-injured elbows (p < 0.001). On the basis of that study, we can conclude that most individuals with a Mason type-II fracture of the radial head have a good long-term outcome following conservative treatment.
Ring investigated the long-term results of open reduction and internal fixation of slightly displaced, but stable, partial articular (Mason type-II) fractures of the radial head. Sixteen patients were evaluated at an average of twenty-two years. Eleven patients were managed with screw fixation, whereas the remaining five underwent fixation with a small T-plate. Complications occurred in five patients and included two deep infections, two cases in which hardware restricted motion, and one posterior interosseous nerve palsy. The average flexion-extension arc at the time of the latest follow-up was 129°. Results were mixed, with thirteen of sixteen patients having a good or excellent result according to the MEPS. The authors concluded that the results were no better than the reported results of nonoperative treatment for these minimally displaced, uncomplicated fractures.

Complex Instability

Ring described his experience with a newly described injury pattern in the elbow. Varus posteromedial rotational injuries include a fracture of the medial facet of the coronoid with tensile failure of the lateral collateral ligament complex. Sixteen patients with these injuries were identified. All sixteen patients had an anteromedial coronoid facet fracture, and thirteen of the sixteen had a lateral ulnar collateral ligament tear. Three patients without a lateral ulnar collateral ligament injury had an associated fracture. The initial treatment was surgical for fourteen patients. In twelve of these fourteen patients, the coronoid fragment was plated along the medial side of the ulna. Four of the sixteen patients who had coronoid facet malalignment and residual subluxation had development of arthrosis and had a fair or poor result. All twelve patients with anatomic restoration had a good or excellent result and had an average arc of motion of 120°. That study highlights the need to recognize this fracture pattern and to fix it anatomically. Failure to do so may result in accelerated arthrosis of the joint.


The effectiveness of total elbow arthroplasty in patients under the age of forty years was investigated by Celli. Forty-nine patients under the age of forty years underwent primary elbow replacement between 1982 and 2003. Six patients had a bilateral procedure. The mean age of the patients was thirty-two years. The average duration of clinical and radiographic follow-up was ninety-one months. The objective outcome was determined with use of the MEPS in 41 elbows. The outcome was rated as excellent for thirty-six elbows, good for one, fair for three, and poor for one. Thirty-five of the thirty-six elbows with inflammatory disease were considered to be satisfactory at 7.3 years, and sixteen of the nineteen elbows with traumatic conditions were considered to be satisfactory at 8.1 years. Overall, total elbow arthroplasty in these young patients revealed a final success rate of 93% at ninety-one months, with an overall survival rate free of revision of 80%. That study indicates that, in a selected population, total elbow arthroplasty in young patients can be effective.
Mallon and colleagues retrospectively reviewed forty patients with forty-one semiconstrained total elbow replacements who had at least ten years of follow-up. The preoperative diagnoses were posttraumatic arthritis (twenty-four patients), inflammatory arthritis (twelve patients), osteoarthritis (four patients), and post-tumor resection (one patient). Patient selection was limited to those willing to adopt a sedentary lifestyle. The average MEPS improved from 36 preoperatively to 90 postoperatively. The patients had a high (100%) self-reported rate of satisfaction, despite a 34% rate of complications. Thirteen elbows required revision, which resulted in an average duration of survival of eighteen years for the elbow replacement. On the basis of those findings, we can conclude that the adoption of a sedentary lifestyle results in long-term component survival for semiconstrained elbow replacements.
The editorial staff of The Journal reviewed a large number of recently published research studies related to the musculoskeletal system that received a Level of Evidence grade of I. Over 100 medical journals were reviewed to identify these articles, which all have high-quality study design. In addition to articles cited already in this Update, nine level-I articles were identified that were relevant to shoulder and elbow surgery. A list of those titles is appended to this review. We have provided a brief commentary about each of the articles to help to guide your further reading, in an evidence-based fashion, in this subspecialty area.


Tan CK, Guisasola I, Machani B, Kemp G, Sinopidis C, Brownson P, Frostick S. Arthroscopic stabilization of the shoulder: a prospective randomized study of absorbable versus nonabsorbable suture anchors. Arthroscopy. 2006;22:716-20.
This study prospectively evaluated patients undergoing arthroscopic Bankart repair who were randomized to either a nonabsorbable suture anchor group or an absorbable suture anchor group. One hundred and thirty patients with recurrent traumatic anterior instability of the shoulder were included in the study. Six patients were lost to follow-up. Patients were assessed preoperatively and postoperatively on the basis of the Oxford Instability Score, a visual analog scale for pain and instability (VAS Pain and VAS Instability), and a quality-of-life questionnaire (SF-12). The average duration of follow-up was 2.6 years. No differences between the groups were noted in terms of the rate of recurrence or any of the scores. Recurrent dislocation occurred in four patients in the nonabsorbable suture anchor group and three patients in the absorbable suture anchor group, for an overall redislocation rate of 6% in the whole series. No differences in the outcome of arthroscopic Bankart repair were seen between the two groups.
Boehm TD, Werner A, Radtke S, Mueller T, Kirschner S, Gohlke F. The effect of suture materials and techniques on the outcome of repair of the rotator cuff: a prospective, randomised study. J Bone Joint Surg Br. 2005;87:819-23.
This prospective, randomized study on the repair of rotator cuff tears compared the clinical results of two suture techniques for which different suture materials were used. One hundred patients with tears of the rotator cuff were prospectively randomized into two groups. Group 1 underwent transosseous repair with number-3 Ethibond with use of modified Mason-Allen sutures, and Group 2 underwent transosseous repair with 1.0-mm polydioxanone cord with use of modified Kessler sutures. After twenty-four to thirty months, the patients were evaluated clinically on the basis of the Constant score and with use of ultrasonography. Ninety-two patients completed the study. No significant difference was seen between the two groups in terms of the Constant score (91% compared with 92%), the rate of further tearing (18% compared with 22%), or the rate of revision (4% compared with 4%). In cases of further tearing, the outcome in Group 2 did not differ from that for the intact repairs (91% compared with 91%), but in Group 1 it was significantly worse (94% compared with 77%; p = 0.005).
Iannotti JP, Ciccone J, Buss DD, Visotsky JL, Mascha E, Cotman K, Rawool NM. Accuracy of office-based ultrasonography of the shoulder for the diagnosis of rotator cuff tears. J Bone Joint Surg Am. 2005;87:1305-11.
Ninety-eight patients (ninety-nine shoulders) with a diagnosis of a rotator-cuff-related problem underwent office-based ultrasonography of the shoulder. The results of the ultrasonographic studies were compared with the results of magnetic resonance imaging and the operative findings. Office-based ultrasonography led to the correct diagnosis for thirty-seven (88%) of forty-two shoulders with a full-thickness rotator cuff tear, twenty-six (70%) of thirty-seven shoulders with a partial-thickness rotator cuff tear, and sixteen (80%) of twenty shoulders with normal tendons. In no case was the surgical approach altered by the operative findings, but the operative finding of a full-thickness tear resulted in an arthroscopic rotator cuff repair in four shoulders. There were no significant differences between magnetic resonance imaging and ultrasonography with regard to the correct identification of a full-thickness tear or its size. The sensitivity of ultrasonography for detecting the anteroposterior tear size was 86%, and that of magnetic resonance imaging was 93% (p = 0.26). The sensitivity of ultrasonography for detecting the mediolateral tear dimension was 83%, and that of magnetic resonance imaging was 88% (p = 0.41). A well-trained office staff and an experienced orthopaedic surgeon can effectively utilize ultrasonography, in conjunction with clinical examination, to accurately diagnose the extent of rotator cuff tears.
Lo IK, Litchfield RB, Griffin S, Faber K, Patterson SD, Kirkley A. Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis. A prospective, randomized trial. J Bone Joint Surg Am. 2005;87:2178-85.
Forty-two patients with a diagnosis of osteoarthritis of the shoulder were randomized to receive a hemiarthroplasty or a total shoulder arthroplasty. The patients were evaluated preoperatively and postoperatively with a disease-specific quality-of-life measurement tool (the Western Ontario Osteoarthritis of the Shoulder [WOOS] index), general shoulder-rating scales (the University of California at Los Angeles [UCLA] shoulder scale, the Constant score, and the American Shoulder and Elbow Surgeons [ASES] evaluation form), general pain scales (the McGill pain score and visual analog scale), and a global health measure (the Short Form-36 [SF-36]). Significant improvements in disease-specific quality of life were seen two years after both total shoulder arthroplasty and hemiarthroplasty. There were no significant differences in quality of life (WOOS score) between the group managed with total shoulder arthroplasty and that managed with hemiarthroplasty (p = 0.18). Both total shoulder arthroplasty and hemiarthroplasty improved disease-specific and general quality-of-life measurements.
Sabeti-Aschraf M, Dorotka R, Goll A, Trieb K. Extracorporeal shock wave therapy in the treatment of calcific tendinitis of the rotator cuff. Am J Sports Med. 2005;33:1365-8.
A prospective, randomized study of fifty patients was performed. The population was divided into two groups (the navigation group and the feedback group). In the navigation group, the calcium deposit was localized with use of a radiographically guided, three-dimensional, computer-assisted device. The feedback group was treated after the point of maximum tenderness was located through palpation by the therapist with use of feedback from the patient. A total of three sessions of constant low-energy focused shock wave therapy was administered in weekly intervals in both groups. Both groups had significant improvements in the Constant and Murley score and the visual analog pain scale after twelve weeks. The results in the navigation group were significantly better than those in the feedback group. In the navigation group six calcium deposits disappeared and nine were altered, whereas in the feedback group one deposit disappeared and twelve were altered. No severe complications occurred. Three-dimensional, computer-assisted navigation yields significantly better results and is therefore recommended when extracorpo-real shock wave therapy is used for the treatment of calcific tendinitis of the rotator cuff.


Faes M, van den Akker B, de Lint JA, Kooloos JG, Hopman MT. Dynamic extensor brace for lateral epicondylitis. Clin Orthop Relat Res. 2006;442:149-57.
The effect of a new dynamic extensor brace on the symptoms of lateral epicondylitis was assessed. Sixty-three patients were randomly assigned to twelve weeks of brace treatment (Group 1, thirty patients) or no brace treatment (Group 2, thirty-three patients). Outcome measures included pain (as assessed with a visual analog scale), pain-free grip strength, maximum grip strength, and functionality of the arm. Brace treatment resulted in significant pain reduction, improved functionality of the arm, and improvement in pain-free grip strength. The beneficial effects of the dynamic extensor brace observed after twelve weeks were significantly different from the effects in the group that received no brace. The beneficial effects of the brace were sustained for another twelve weeks. No correlation between the duration of symptoms and treatment effects of the brace was revealed.
Buchbinder R, Green SE, Youd JM, Assendelft WJJ, Barnsley L, Smidt N. Shock wave therapy for lateral elbow pain. Cochrane Database of Systematic Reviews. 2005;4.
This review included nine trials that randomized 1006 patients to extracorporeal shock wave therapy or placebo and one trial that randomized ninety-three patients to extracorporeal shock wave therapy or steroid injection. The quality of the study methodology was determined, and the data were assessed. When possible, pooled analysis was performed. If there was too much heterogeneity of the data, no pooling was performed. On the basis of the review of the placebo-controlled trials involving 1006 patients, there was a "platinum" level of evidence suggesting that extracorporeal shock wave therapy provides little or no relief of pain or improvement in function as compared with placebo. There was also a "silver" level of evidence that steroid injection may be more effective than extracorporeal shock wave therapy.
Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anesthesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005;87:1297-304.
One hundred and fourteen patients with a minimum six-month history of lateral epicondylitis that had been unresponsive to conventional therapy were randomized into active treatment and placebo groups. The protocol consisted of three weekly treatments of either low-dose shock wave therapy or a sham treatment. Sixty-one patients completed one year of follow-up, whereas thirty-four patients crossed over to receive active treatment. A significant difference in pain reduction was observed at twelve weeks in the intent-to-treat cohort (p = 0.001), with an improvement in the pain score of at least 50% being seen in thirty-four of the fifty-six patients in the active treatment group who were managed according to protocol as compared with only seventeen of the fifty-eight subjects in the placebo group. This improvement persisted in those who were followed to one year. Functional activity scores, activity-specific evaluation, and the overall impression of the disease state all showed significant improvement as well (p < 0.05). Crossover patients also showed significant improvement after twelve weeks of active treatment, with 56% (nineteen) of thirty-four achieving at least a 50% improvement in the pain score (p < 0.0001).
Nabhan A, Ahlhelm F, Kelm J, Reith W, Schwerdtfeger K, Steudel WI. Simple decompression or subcutaneous anterior transposition of the ulnar nerve for cubital tunnel syndrome. J Hand Surg [Br]. 2005;30:521-4.
Sixty-six patients with pain and/or neurological deficits with clinically and electromyographically proven cubital tunnel syndrome were prospectively randomized into two treatment groups. Thirty-two patients underwent ulnar nerve decompression without transposition, and thirty-four underwent anterior subcutaneous transposition of the nerve. Follow-up examinations evaluating pain, motor and sensory deficits, and motor nerve-conduction velocities were performed three and nine months postoperatively. There were no significant differences between the two groups with regard to the outcome at either postoperative follow-up examination. Thus, the authors recommended simple decompression of the nerve for patients without deformity of the elbow.

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