Lesser tuberosity osteotomy for total shoulder arthroplasty. Surgical technique

BACKGROUND: Recent studies have suggested that tenotomy and repair of the subscapularis tendon carried out for anterior approaches to the shoulder can be followed by failure of the tendon repair and by changes resulting in permanent loss of subscapularis function. We hypothesized that release of the subscapularis with use of a superficial osteotomy of the lesser tuberosity followed by repair of the two opposing bone surfaces would lead to consistent bone-to-bone healing, which would be possible to monitor radiographically, and would lead to satisfactory clinical and structural outcomes. METHODS: Thirty-nine shoulders in thirty-six consecutive patients who, at an average age of fifty-seven years, had undergone total shoulder replacement through an anterior approach involving an osteotomy of the lesser tuberosity were evaluated at an average of thirty-nine months. Assessment included a standardized interview and physical examination, scoring according to the system described by Constant and Murley, and imaging with conventional radiography and computed tomography to assess healing of the osteotomy site and changes in the subscapularis. RESULTS: The osteotomized tuberosity fragment healed in an anatomical position in all shoulders, and no cuff tendon ruptures were observed. At the time of follow-up, thirty-three (89%) of thirty-seven shoulders evaluated with a belly-press test had a negative result and twenty-seven (75%) of thirty-six shoulders evaluated with a lift-off test had an unequivocally normal result. Fatty infiltration of the subscapularis muscle increased after the operation (p < 0.0001) and was at least stage two in eleven (32%) of thirty-four shoulders. The fatty infiltration had progressed by one stage in eight (24%) of the thirty-four shoulders, by two stages in five shoulders (15%), and by three stages in two shoulders (6%). CONCLUSIONS: Osteotomy of the lesser tuberosity provides an easy anterior approach for total shoulder replacement and is followed by consistent bone-to-bone healing, which can be monitored, and good subscapularis function. In the presence of documented anatomical healing of the osteotomy site, postoperative fatty infiltration of the subscapularis muscle remains unexplained and needs to be investigated further as it is associated with a poorer clinical outcome.

Acromioclavicular joint cyst: nine cases of a pseudotumor of the shoulder

OBJECTIVE: (1) To analyse the imaging appearances of nine patients with acromioclavicular joint cysts presenting as shoulder masses for tumor staging with operative, histopathological and joint aspiration findings.DESIGN AND PATIENTS: Retrospective review of imaging and correlation with clinical, operative and surgical notes. Images were reviewed by two musculoskeletal radiologists by consensus. Nine patients who presented clinically with a shoulder mass were evaluated by radiographs (n=9), ultrasound (n=1), conventional arthrography (n=3), MRI (n=6; with direct MR arthrography n=2, indirect MR arthrography n=4).RESULTS: All patients had a focal mass superior to the AC joint, with a size ranging from 1.5 cm to 6 cm and a mean of 3.27 cm. Correlation was available with surgery (n=7), histopathology (n=2) and cyst aspiration (n=2). Two patients were managed conservatively. Geyser sign was positive in all three arthrograms. All MRIs revealed extensive rotator cuff tears with a column of fluid extending from the glenohumeral joint through the rotator cuff tear into the acromioclavicular joint and acromioclavicular cyst. Chondrocalcinosis was seen in the acromioclavicular joint cyst (n=2) and in the glenohumeral joint (n=1). Aspirate in two patients contained calcium pyrophosphate dihydrate crystals.CONCLUSION: Acromioclavicular joint cysts may present as a tumor mass. They are associated with extensive rotator cuff tears and there is usually communication of the cyst with the joint space. This feature excludes a diagnosis of tumor. AC joint cysts may be associated with calcium pyrophosphate dihydrate deposition disease.

Pseudotumors of the shoulder invited review

This paper discusses the main types of MRI pseudotumors in and around the shoulder region. Some unusual types of pseudotumor will also be mentioned. Suggestions on how to improve awareness and diagnosis are also given.

EXPLORING CHANGES IN DETRITAL FLOCCULENT LAYER DYNAMICS DUE TO SHIFTS IN MACROPHYTE COMMUNITIES IN THE NORTHERN EVERGLADES

A shift in plant communities of the Water Conservation Areas (WCAs) within the Everglades has been linked to changes in hydrology and high levels of nutrient loading from surrounding agicultural areas. This has resulted in the encroachment of dense cattail stands (Typha domingensis) into areas that had previously been a ridge and slough landscape populated primarily by native sawgrass (Cladium jamaicense). In order to study ecological management solutions in this area, WCA-2A was broken into study plots; several of which became open water areas through the application of herbicide and burning regimens. The open water areas allowed for Chara spp (a submersed algal species) to replace Typha domingensis as the dominant macrophyte. This study investigated the polymer and ionic profiles of Chara spp, Typha domingensis and Cladium jamaicense and their contributions to detrital flocculent (floc) in the study plots where they are the dominant macrophytes. Floc is not only an important food source for aquatic species; it also supports many algal, fungal and bacterial communities. Data gathered in this study indicated that the floc sample from a phosphorus enriched open water study plot (EO1) where Chara spp was the dominant macrophyte may contain cell wall polymers from sources other than Chara spp (most likely Typha domingensis), while the chemical and polymeric profile of the floc of the study plot where Typha domingensis is the dominant macrophyte (EC1) suggests that the floc layer has contributions from algal sources as well as Typha domingensis. Additionally, monoclonal antibodies to Arabinoglalactan protein (AGP) and (1,4)-β-D galactan were identified as possible biomarkers for distinguishing algal dominated floc layers from layers dominated by emergent vegetation. Calcium labeling could be a useful tool for this as well because of the high amount of Ca2+ associated with Chara spp cell walls. When looking into the soluble phosphorus content of the macrophytes and paired floc samples of WCA-2A, it was found that Chara spp may be contributing a greater amount of Ca-bound phosphorus to floc layers where it is the dominant macrophyte when compared to floc layers from study plots dominated by emergent macrophytes. Floc layers also appear to be acting as a nutrient sink for soluble phosphorus. The findings of this study support the overall hypothesis that the shift from native emergent macrophyte communities to submersed macrophyte communities in study sites of the northern Everglades is affecting the polymeric/chemical profile and ionic content of detrital floc layers. The effects of this shift may contribute to changes in complex flocculent community dynamics.

Reverse total shoulder arthroplasty

The radical changes in prosthetic design made in the mid 1980s transformed the historically poorly performing reverse ball-and-socket total shoulder prosthesis into a highly successful salvage implant for pseudoparalytic, severely rotator cuff-deficient shoulders. Moving the center of rotation more medial and distal as well as implanting a large glenoid hemisphere that articulates with a humeral cup in 155 degrees of valgus are the biomechanical keys to sometimes spectacular short- to mid-term results. Use of the reverse total shoulder arthroplasty device allows salvage of injuries that previously were beyond surgical treatment. However, this technique has a complication rate approximately three times that of conventional arthroplasty. Radiographic and clinical results appear to deteriorate over time. Proper patient selection and attention to technical details are needed to reduce the currently high complication rate.

Comfort of two shoulder actuation mechanisms for arm therapy exoskeletons: a comparative study in healthy subjects

Robotic exoskeletons can be used to study and treat patients with neurological impairments. They can guide and support the human limb over a large range of motion, which requires that the movement trajectory of the exoskeleton coincide with the one of the human arm. This is straightforward to achieve for rather simple joints like the elbow, but very challenging for complex joints like the human shoulder, which is comprised by several bones and can exhibit a movement with multiple rotational and translational degrees of freedom. Thus, several research groups have developed different shoulder actuation mechanism. However, there are no experimental studies that directly compare the comfort of two different shoulder actuation mechanisms. In this study, the comfort and the naturalness of the new shoulder actuation mechanism of the ARMin III exoskeleton are compared to a ball-and-socket-type shoulder actuation. The study was conducted in 20 healthy subjects using questionnaires and 3D-motion records to assess comfort and naturalness. The results indicate that the new shoulder actuation is slightly better than a ball-and-socket-type actuation. However, the differences are small, and under the tested conditions, the comfort and the naturalness of the two tested shoulder actuations do not differ a lot.

Paleo erosion rates and climate shifts recorded by Quaternary cut-and-fill sequences in the Pisco valley, central Peru

Fluvial cut-and-fill sequences have frequently been reported from various sites on Earth. Nevertheless, the information about the past erosional regime and hydrological conditions have not yet been adequately deciphered from these archives. The Quaternary terrace sequences in the Pisco valley, located at ca. 13°S, offer a manifestation of an orbitally-driven cyclicity in terrace construction where phases of sediment accumulation have been related to the Minchin (48–36 ka) and Tauca (26–15 ka) lake level highstands on the Altiplano. Here, we present a 10Be-based sediment budget for the cut-and-fill terrace sequences in this valley to quantify the orbitally forced changes in precipitation and erosion. We find that the Minchin period was characterized by an erosional pulse along the Pacific coast where denudation rates reached values as high as 600±80 mm/ka600±80 mm/ka for a relatively short time span lasting a few thousands of years. This contrasts to the younger pluvial periods and the modern situation when 10Be-based sediment budgets register nearly zero erosion at the Pacific coast. We relate these contrasts to different erosional conditions between the modern and the Minchin time. First, the sediment budget infers a precipitation pattern that matches with the modern climate ca. 1000 km farther north, where highly erratic and extreme El Niño-related precipitation results in fast erosion and flooding along the coast. Second, the formation of a thick terrace sequence requires sufficient material on catchment hillslopes to be stripped off by erosion. This was most likely the case immediately before the start of the Minchin period, because this erosional epoch was preceded by a >50 ka-long time span with poorly erosive climate conditions, allowing for sufficient regolith to build up on the hillslopes. Finally, this study suggests a strong control of orbitally and ice sheet forced latitudinal shifts of the ITCZ on the erosional gradients and sediment production on the western escarpment of the Peruvian Andes at 13° during the Minchin period.

A TEX 86 lake record suggests simultaneous shifts in temperature in Central Europe and Greenland during the last deglaciation

High-resolution quantitative temperature records from continents covering glacial to interglacial transitions are scarce but important for understanding the climate system. We present the first decadal resolution record of continental temperatures in Central Europe during the last deglaciation (similar to 14,60010,600cal. yrB.P.) based on the organic geochemical palaeothermometer TEX86. The TEX86-inferred temperature record from Lake Lucerne (Vierwaldstattersee, Switzerland) reveals typical oscillations during the Late Glacial Interstadial, followed by an abrupt cooling of 2 degrees C at the onset of Younger Dryas and a rapid warming of 4 degrees C at the onset of the Holocene, within less than 350years. The remarkable resemblance with the Greenland and regional stable oxygen isotope records suggests that temperature changes in continental Europe were dominated by large-scale reorganizations in the northern hemispheric climate system.

ARMin III – arm therapy exoskeleton with an ergonomic shoulder actuation

Rehabilitation robots have become important tools in stroke rehabilitation. Compared to manual arm training, robot-supported training can be more intensive, of longer duration and more repetitive. Therefore, robots have the potential to improve the rehabilitation process in stroke patients. Whereas a majority of previous work in upper limb rehabilitation robotics has focused on end-effector-based robots, a shift towards exoskeleton robots is taking place because they offer a better guidance of the human arm, especially for movements with a large range of motion. However, the implementation of an exoskeleton device introduces the challenge of reproducing the motion of the human shoulder, which is one of the most complex joints of the body. Thus, this paper starts with describing a simplified model of the human shoulder. On the basis of that model, a new ergonomic shoulder actuation principle that provides motion of the humerus head is proposed, and its implementation in the ARMin III arm therapy robot is described. The focus lies on the mechanics and actuation principle. The ARMin III robot provides three actuated degrees of freedom for the shoulder and one for the elbow joint. An additional module provides actuated lower arm pro/supination and wrist flexion/extension. Five ARMin III devices have been manufactured and they are currently undergoing clinical evaluation in hospitals in Switzerland and in the United States.

Circum-Antarctic Coastal Environmental Shifts During the Late Quaternary Reflected by Emerged Marine Deposits

This review assesses the circumpolar occurrence of emerged marine macrofossils and sediments from Antarctic coastal areas in relation to Late Quaternary climate changes. Radiocarbon ages of the macrofossils, which are interpreted in view of the complexities of the Antarctic marine radiocarbon reservoir and resolution of this dating technique, show a bimodal distribution. The data indicate that marine species inhabited coastal environments from at least 35000 to 20000 yr sp, during Marine Isotope Stage 3 when extensive iceberg calving created a 'meltwater lid' over the Southern Ocean. The general absence of these marine species from 20000 to 8500 yr sp coincides with the subsequent advance of the Antarctic ice sheets during the Last Glacial Maximum. Synchronous re-appearance of the Antarctic marine fossils in emerged beaches around the continent, all of wh ich have Holocene marine-limit elevations an order of magnitude lower than those in the Arctic, reflect minimal isostatic rebound as relative sea-level rise decelerated. Antarctic coastal marine habitat changes around the continent also coincided with increasing sea-ice extent and outlet glacial advances during the mid-Holocene. in view of the diverse environmental changes that occurred around the Earth during this period, it is suggested that Antarctic coastal areas were responding to a mid-Holocene climatic shift associated with the hydrological cycle. This synthesis of Late Quaternary emerged marine deposits demonstrates the application of evaluating circum-Antarctic phenomena from the glacial-terrestrial-marine transition zone.

Risk adjustment in aging societies

Background In Switzerland, age is the predominant driver of solidarity transfers in risk adjustment (RA). Concerns have been voiced regarding growing imbalances in cost sharing between young and old insured due to demographic changes (larger fraction of elderly >65 years and rise in average age). Particularly young adults aged 19–25 with limited incomes have to shoulder increasing solidarity burdens. Between 1996 and 2011, monthly intergenerational solidarity payments for young adults have doubled from CHF 87 to CHF 182, which corresponds to the highest absolute transfer increase of all age groups. Results By constructing models for age-specific RA growth and for calculating the lifetime sum of RA transfers we investigated the causes and consequences of demographic changes on RA payments. The models suggest that the main driver for RA increases in the past was below average health care expenditure (HCE) growth in young adults, which was only half as high (average 2% per year) compared with older adults (average 4% per year). Shifts in age group distributions were only accountable for 2% of the CHF 95 rise in RA payments. Despite rising risk adjustment debts for young insured the balance of lifetime transfers remains positive as long as HCE growth rates are greater than the discount rate used in this model (3%). Moreover, the life-cycle model predicts that the lifetime rate of return on RA payments may even be further increased by demographic changes. Nevertheless, continued growth of RA contributions may overwhelm vulnerable age groups such as young adults. We therefore propose methods to limit the burden of social health insurance for specific age groups (e.g. young adults in Switzerland) by capping solidarity payments. Conclusions Taken together, our mathematical modelling framework helps to gain a better understanding of how demographic changes interact with risk adjustment and how redistribution of funds between age groups can be controlled without inducing further selection incentives. Those methods can help to construct more equitable systems of health financing in light of population aging.