JAAOS, Volume 26, No. 5

Understanding the Importance of the Teres Minor for Shoulder Function: Functional Anatomy

Although the teres minor is often overlooked in a normal shoulder, it becomes a key component in maintaining shoulder function when other rotator cuff tendons fail. The teres minor maintains a balanced glenohumeral joint and changes from an insignificant to the most significant external rotator in the presence of major rotator cuff pathology. The presence or absence of the teres minor provides prognostic information on the outcomes of reverse total shoulder arthroplasty and tendon transfers. Clinical tests include the Patte test, the Neer dropping sign, the external rotation lag sign, and the Hertel drop sign. Advanced imaging of the teres minor can be used for classification using the Walch system. Understanding the function and pathology surrounding the teres minor is paramount in comprehensive management of the patient with shoulder pathology. Appropriate clinical examination and imaging of the teres minor are important for preoperative stratification and postoperative expectations.

      • Subspecialty:
      • Shoulder

    Motocross Injuries in Pediatric and Adolescent Patients

    Motocross is a popular sport in which participants ride a two-wheeled, motorized vehicle on an uneven 2-km track with natural or human-made obstacles. Participants compete at high rates of speed, and children as young as age 4 years compete in age-appropriate groups. Motocross is recognized as a strenuous sport with a high accident rate. Most injuries are musculoskeletal in nature. The most commonly injured areas are the forearm, clavicle, femur, and tibia. Many injuries require surgical treatment. Some patients sustain head trauma with loss of consciousness. Children should have age-appropriate training before participation is allowed. Adult supervision should occur at all times. Appropriate helmet fitting with assistance from an expert is associated with a decreased risk of concussion symptoms. Parents and coaches need to weigh the benefits of participation with the frequency of injuries, missed academic time, and the cost of medical treatment.

        • Subspecialty:
        • Trauma

        • Pediatric Orthopaedics

      Internal Fixation of Osteoporotic Bone

      Osteoporosis is one of the costliest conditions managed by orthopaedic surgeons. This condition, which is characterized by decreased bone density and thinning of cortical bone, is strongly influenced by complex signaling in both the hormonal and mechanical environments. Osteoporosis cannot be cured; instead, it can only be managed to decrease patient morbidity. Current pharmacologic treatments are aimed at minimizing bone turnover and have substantial side effects. Therefore, much work remains to find safer and more effective agents to restore bone density. In addition to the high incidence of fracture in elderly patients, many of the traditional fixation constructs used for repair of these fractures are not suitable for use in osteoporotic bone. Increased use of fixed-angle locking plates, intramedullary devices, and bone substitutes has greatly improved outcomes in these patients.

          • Subspecialty:
          • Osteoporosis

        Psychological Factors Affecting Outcomes After Elective Shoulder Surgery

        To optimize outcomes following elective shoulder surgery, it is important to address not only the injury or pathology itself, but also the cognitive and emotional factors that may influence a patient’s recovery. Depression, anxiety, catastrophic thinking, distress, somatization, and decreased self-efficacy are among the most common psychological factors associated with adverse perioperative events and poor postoperative outcomes. Such factors may manifest at any point during recovery. Validated questionnaires can be used to measure psychological factors preoperatively, thereby enabling earlier intervention that may mitigate any potential negative effect of these factors on the patient’s overall outcome. Orthopaedic surgeons must be sensitive to the influence of stress, distress, and limited coping strategies on patients and should learn how best to mitigate the detrimental effects of these factors on outcomes after elective shoulder surgery.

            • Subspecialty:
            • Shoulder and Elbow

            • Shoulder

          Effect of Facility Ownership on Utilization of Arthroscopic Shoulder Surgery

          Introduction: We examined practice patterns and surgical indications in the management of common shoulder procedures by surgeons practicing at physician-owned facilities.

          Methods: This study was a retrospective analysis of 501 patients who underwent arthroscopic shoulder procedures performed by five surgeons in our practice at one of five facilities during an 18-month period. Two of the facilities were physician-owned, and three of the five surgeons were shareholders. Demographics, insurance status, symptom duration, time from injury/symptom onset to the decision to perform surgery (at which time surgical consent is obtained), and time to schedule surgery were studied to determine the influence of facility type and physician shareholder status.

          Results: Median duration of symptoms before surgery was significantly shorter in workers’ compensation patients than in non–workers’ compensation patients (47% less; P < 0.0001) and in men than in women (31% less; P < 0.001), but was not influenced by shareholder status or facility ownership (P > 0.05). Time between presentation and surgical consent was not influenced by facility ownership (P = 0.39) or shareholder status (P = 0.50). Time from consent to procedure was 13% faster in physician-owned facilities than in non–physician-owned facilities (P = 0.03) and 35% slower with shareholder physicians than with nonshareholder physicians (P < 0.0001).

          Discussion: The role of physician investment in private healthcare facilities has caused considerable debate in the orthopaedic surgery field. To our knowledge, this study is the first to examine the effects of shareholder status and facility ownership on surgeons’ practice patterns, surgical timing, and measures of nonsurgical treatment before shoulder surgery.

          Conclusions: Neither shareholder status nor facility ownership characteristics influenced the speed with which surgeons determined that shoulder surgery was indicated or surgeons’ use of preoperative nonsurgical treatment. After the need for surgery was determined, patients underwent surgery sooner at physician-owned facilities than at non–physician-owned facilities and with nonshareholder physicians than with shareholder physicians.

          Level of evidence: Level III

              • Subspecialty:
              • Shoulder and Elbow

            The Effect of Door Opening on Positive Pressure and Airflow in Operating Rooms

            Introduction: Door openings and increased foot traffic in operating rooms (ORs) during total joint arthroplasty are thought to increase the risk of surgical site infection.

            Methods: Digital manometers were used to collect pressure data during off-hours at the thresholds of both the outer door (ie, the door to the common OR hallway) and the inner substerile door, which opens to the substerile hallway, of six empty ORs used for total joint arthroplasty. Airflow patterns were visualized with smoke studies to determine whether outside air entered the ORs during single or multiple door openings. Data were analyzed using the Student t-test and one-way analysis of variance.

            Results: Positive pressure was not defeated during any door-opening event. The average time for recovery of the initial pressurization in the OR regardless of the door used was between 14 and 15 seconds (P = 0.462). No differences in the degree of room depressurization were noted between entry of personnel through the outer door, passing of a surgical tray through the outer door, and entry of personnel through the inner door (P = 0.312). Smoke studies confirmed that no contaminated outside air entered the OR with single door opening. Outside air entered the OR if two doors were open simultaneously.

            Conclusion: Single door opening does not defeat OR positive pressure, but simultaneous opening of two doors allows contaminated air to flow into the OR. OR traffic should continue to be limited during surgical procedures. OR personnel should be educated about the danger to the sterile field that can result from simultaneous door openings and should be discouraged from such activity.

                Clinical Outcomes After Reverse Shoulder Arthroplasty With and Without Subscapularis Repair: The Importance of Considering Glenosphere Lateralization

                Introduction: Recent biomechanical data suggests that repairing the subscapularis during reverse shoulder arthroplasty (RSA) can increase the force required by the posterior rotator cuff and deltoid to elevate the arm.

                Methods: We retrospectively studied patients who underwent primary RSA and had baseline and minimum 2-year postoperative American Shoulder and Elbow Surgeons (ASES) shoulder scores, stratified them according to subscapularis management, then subgrouped them according to lateralization of the glenosphere component.

                Results: Patients with subscapularis repair and a lateralized glenosphere had significantly less improvement in ASES scores than did those without lateralization (P = 0.016) and patients without subscapularis repair (P = 0.006). Individually, subscapularis management (P = 0.163) and glenosphere lateralization (P = 0.847) had no significant effect on the change in ASES score but in combination did have a significant effect on the change in ASES score (P = 0.002).

                Discussion: The combination of subscapularis repair and glenosphere implant lateralization in RSA translates to significantly less clinical improvement.

                Conclusions: Patients who underwent both subscapularis repair and glenosphere lateralization had significantly less improvement in ASES scores.

                Level of Evidence: Level III

                    • Subspecialty:
                    • Shoulder and Elbow