The posterior triangle of the neck is an area of the body frequently visited by regional anesthesiologists, acute and chronic pain physicians, surgeons of all disciplines, and diagnosticians. It houses the entire brachial plexus from the roots to the divisions, the scalene muscles, the cervical sympathetic ganglions, the major blood vessels to and from the brain, the neuroforamina and various other structures of more or less importance to these physicians. Ultrasound (US) offers a handy visual tool for these structures to be viewed in real time and, therefore, its popularity and the need to understand it. We will discuss pertinent clinical anatomy of the neck and offer a basic visual explanation of the often-difficult two-dimensional (2-D) images seen with US.

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Surgeons are often reluctant to support regional anesthesia for shoulder surgery and other orthopaedic surgery. This is because the sometimes true, but usually perceived "slowing down" of operating room turnover times, and the perceived potential for added morbidity. The former (time issue) can only be solved by proper management, while the potential for added morbidity can be minimized by doing appropriate blocks for appropriate surgery at the correct times, when really indicated, with the correct equipment and techniques, and avoiding situations that are prone to causing morbidity. This article discusses in detail when it is appropriate to do blocks for shoulder surgery, but more important, when is it not appropriate to do blocks, and how to carefully calculate a risk-benefit ratio and avoid added morbidity.

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Platelet-rich plasma (PRP) has been extensively used in maxillofacial and oral surgery with predictable clinical outcomes. PRP has been used for hard and soft tissue regeneration. Anecdotal data indicate that PRP enhances the early wound-healing cascade by the interactions of activated platelet-released growth factors with the extra cellular matrix with potential potent anabolic affects. The processing of autologous PRP is highly variable and the types of propriety kits, centrifuges and vials available are numerous. Regarding facial rejuvenation and PRP, initial results are short-lived, inconsistent and further maintenance treatment is needed regarding facial wrinkle amelioration, as is the case with other fillers. It is not clear if "neocollagenesis" occurs after PRP rejuvenation therapy. Drawbacks of activated PRP, if used in the facial area, include the potential to micro-thrombosis in the region of the anterior facial vein, closed compartment syndrome and release of pro-inflammatory proteolytic activators from leucocytes. Compared to conventional culture mediums, unrefined and undiluted PRP may not be biologically suitable as a cell transport medium (i.e., for fibroblasts, keratinocytes and neural cells). Our ex vivo studies confirm potent TC mitogenic stimulation of human fibroblasts, keratinocytes, chondrocytes, neural tissue and myoblasts. There are no clinical reports of the application of PRP for repair of complex shoulder rotator cuff lesions. The authors describe the biology of platelet-rich plasma, potential application in dermal regeneration and rotator cuff surgery as an adjunct to conventional surgery for large or previous failed surgery, tissue physiological response to PRP and the molecular biology of PRP relevant to the shoulder surgeon.

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Purpose: To describe the technique and short-term results of arthroscopic repair of irreparable rotator cuff tears using a GraftJacket® allograft. Although current rotator cuff repair techniques offer excellent results in most cases, there are still many instances where tendon repair is not possible. Allograft substitutes offer the advantages of saving bone stock, while maintaining anatomic integrity within the shoulder. Materials and Methods: Between March 2003 and February 2004, 16 patients with massive, contracted immobile rotator cuff tears were treated with arthroscopic placement of a GraftJacket® allograft by a single surgeon. Patients were followed for 1-2 years. All were evaluated preoperatively and postoperatively using the modified University of California Los Angeles (UCLA) scoring system, Constant score and Simple Shoulder Test. MRI was performed postoperatively at 3 months and 1 year. Results: At mean follow-up time of 26.8 months (range, 12-38 months), 15 of 16 patients were satisfied with the procedure. The mean UCLA score increased from 18.4 preoperatively to 30.4 postoperatively ( P = 0.0001). The Constant score increased from 53.8 to 84.0 ( P = 0.0001). Statistically significant improvements were seen in pain, forward flexion and external rotation strength. Thirteen displayed full incorporation of the graft into the native tissue, as documented on magnetic resonance imaging. There were no complications in this cohort of patients. Conclusions: Our study supports GraftJacket® allograft as a viable solution for surgical salvage in select cases of massive irreparable rotator cuff pathology.

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Among 83 arthroscopies performed from January 2005 to July 2006, seven patients (two female and five male) complained about chronic shoulder pain after an initial shoulder trauma without dislocation. The mean age was 31 years (range, 23-38). None of the patients suffered from stiffness. Only one patient was found with a true apprehension sign, but all the patients presented with pain during this test. The mean preoperative Constant score was 74.4/100 (range, 59-81); the mean pain score was 3.9/15 (range, 1.5-6); the mean activity level score was 9/20 (range, 6-12); the mean mobility score was 39.6/40 (range, 38-40); the mean strength score was 22/25 (range 10-25). Arthro-CT scans were performed in all cases and revealed a labral lesion. After an initial period of conservative treatment (mean 13.3 months, range 8-22 months), shoulder arthroscopy was scheduled. The gleno-humeral investigation showed one isolated anterior Bankart lesion with a Hill Sachs lesion and a glenoid bony Bankart lesion, two double anterior and posterior Bankart lesions, one triple anterior + posterior Bankart + type II SLAP lesion and three isolated type II SLAP lesions. Arthroscopic repair was undertaken if a labral lesion was confirmed during diagnostic arthroscopy. Our lack of follow-up did not allow us to draw early conclusions. But we were concerned about the delay before recovering a full range of motion. If conservative treatment fails, computerized tomography or magnetic resonance imaging using injected contrast seems to better detect these lesions. Moreover, diagnostic arthroscopy could be performed. Arthroscopic procedures such as Bankart repair with minimal capsular shift and type II SLAP repair with minimal tension may be considered if the lesions are confirmed.

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In this article, we document the history of the shoulder prosthesis in cases of gleno-humeral arthropathy with severely damaged peri-articular structures, in particular, the rotator cuff. Charles Neer was the first to search for a solution to this difficult problem and his work encouraged others including Paul Grammont to develop his revolutionary principles applied to the reverse shoulder prosthesis. Even now, newer versions of reverse prostheses continue to advance our understanding of how these difficult cases can be treated optimally.

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Arthroscopic repair of retracted adhesed rotator cuff tear is complicated by the fact that standard capsulotendinous releases seldom provide enough additional lateral excursion of the tendons for repair to bone. However, the stepwise incorporation of anterior interval slides, double interval slides, and interval slide in-continuity can dramatically increase the lateral excursion up to 5 cm., allowing for tension free repair to bone. This paper details the author's indications and techniques for performing these releases.

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The suprascapular nerve has three distinctive anatomical locations where it is most vulnerable to injury: at the suprascapular and spinoglenoid notch and along the supraspinatus fossa, where it is relatively fixed to the periosteum. The supraspinatus muscle has closest relation to all three and is also the most studied muscle of rotator cuff in conjunction with the mechanism of nerve neuropathy. Several anatomical studies try to mimic rotator cuff rupture and surgical reconstruction and thus describe effect on nerve when medial retraction or lateral advancement of the supraspinatus is present. Clinical series do not correlate with anatomical studies concerning safe amount of lateral traction of supraspinatus tendon. It is recommended to do a neurological evaluation of the suprascapular nerve in patients who are being considered for surgical repair of the rotator cuff tears and have a significant degree of muscle atrophy, as the accompanying neuropathy may prolong post-surgical recovery or result in a poor outcome. Recently new arthroscopic techniques have been described to release the suprascapular nerve at the suprascapular notch, and it is believed that this will have a beneficial effect on nerve recovery and resolution of pain in case of nerve entrapment.

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Ewing's sarcoma is a malignant non-osteogenic primary tumor of the bone. It is one of the most common primary malignant tumors of bone. Peak incidence is noticed in second decade of life with male preponderance of 1.6:1. It occurs most frequently in long bones and flat bones of pelvic girdles. In 30% cases, Ewing's sarcoma is multicentric in origin. In 14-50%, multiple metastases are present at the time of diagnosis. CNS spread is rare and isolated CNS involvement is not seen. Skull metastasis of Ewing's sarcoma is not rare compared to primary Ewing's sarcoma of the skull, but the actual frequency is unknown. We wish to report a case of "Primary Ewing's sarcoma of scapula with metastasis to Skull Vault in a Child resulting in sutural diastasis" diagnosed by clinicoradiological examination and confirmed by histopathology.

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Neurogenic thoracic outlet syndrome (NTOS) is an oft-overlooked and obscure cause of shoulder pain, which regularly presents to the office of shoulder surgeons and pain specialist. With this paper we present an otherwise healthy young female patient with typical NTOS. She first received repeated conservative treatments with 60 units of botulinium toxin injected into the anterior scalene muscle at three-month intervals, which providing excellent results of symptom-free periods. Later a trans-axillary first rib resection provided semi-permanent relief. The patient was followed for 10 years after which time the symptoms reappeared. We review the literature and elaborate on the anatomy, sonoanatomy, etiology and characteristics, symptoms, diagnostic criteria and treatment modalities of NTOS. Patients with NTOS often get operated upon - even if just a diagnostic arthroscopy, and an interscalene or other brachial plexus block may be performed. This might put the patient in jeopardy of permanent nerve injury, and the purpose of this review is to minimize or prevent this.

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The process of autologous cell regeneration (ACR) is a facet of cell therapy and regenerative medicine. It is initiated when activated autologous platelet rich plasma alone (PRP), containing cytokines or growth factors, is injected into the dermis or other structure in order to initiate a regenerative or antiaging process. The recipients resident cells at the target zone are activated by biologically active growth factors, derived from the activated platelets in the PRP through a paracrine effect. The platelet gel that contains the fibrin and clumped platelets, releases growth factors that influences activation of macrophages and stem cells in the recipient site. Tissue regeneration is facilitated by stem cell proliferation and differentiation. The PRP that has sealant and wound healing properties, may shift the wound healing cascade to the left, thereby speeding up tissue regeneration and remodelling by the use of the recipients own plasma. Both the fibroblast and myofibroblast play key roles in the wound healing cascade. The fibroblast, of mesenchymal origin, plays a pivotal role in the formation of the extracellular matrix and deposition of collagen. A failure of organised fibroblast function results in important and disabling disease processes and conditions such as chronic ischaemic heart disease and remodelling of the heart, lung fibrosis, fibromatosis, solar aged-face, keloids, hypertrophic scar formation, nodular fasciitis, inguinal hernia, Dupuytren's disease and scleroderma. More recent additions include frozen shoulder and the captured shoulder. In aesthetic medicine, one of the prime functions of fractional photothermolysis with lasers, intense pulsed light and radiofrequency devices, is to stimulate dermal fibroblast proliferation, by thermal energy thereby increasing collagen deposition which enhances facial rejuvenation. Platelet -rich plasma (REGENLAB PRP, REGENLAB-ACR) possesses unique growth factors that stimulate, fibroblast, keratinocyte and myoblasts ex vivo in tissue culture, allowing three-dimensional cell proliferation within the fibrin gel. PRP can be used as a cell carrier (i.e., keratinocytes, fibroblasts), may enhance cell retention at the point of treatment. REGENKIT is authorized for human use, ISO and CE marked. In this overview fibroblast morphology, tissue culture and cell biology relevant to the shoulder surgeon is reviewed.

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We have developed an arthroscopic technique to reinforce the torn inferior glenohumeral ligament and the elongated strained capsule, with no need for hardware implants: the arthroscopic capsuloplasty. We have assessed early results of arthroscopic capsuloplasty on seven active athletes, observed for a painful unstable shoulder. All cases presented with anterior inferior capsular distension and a strained or ruptured IGHL; these are indications for this technique, independent of the presence of a Bankart lesion. Cases where a Bankart lesion was also repaired were not considered in these preliminary results. As with an open standard Neer capsular shift, an arthroscopic capsular re-tightening is performed, by means of a shift of the anteroinferior capsule incised one centimeter from the glenoid rim. Results with an average follow-up of 12 months were appraised following the Walch-Duplay score. The global result was bad for one patient with a retractile capsulitis after 6 months and good for another at 13 months after surgery. The remaining five patients had excellent global results and have resumed sports at the same level as before. The authors consider this technique to be an alternative to thermal capsular shifts and open procedures, although the series is limited and follow-up short, yet with quite encouraging results. Level of evidence : Case Series (level IV).

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We present four cases of shoulder lipomas in two females and two males in their fourth to fifth decades of life. All four lipomas were big. Three were subcutaneous and one was intermuscular. None of them were associated with any functional limitation of the affected shoulder. Subcutaneous or intermuscular lipomas around the shoulder do not appear to affect shoulder functions. Complete surgical excision is rewarding and was achieved under local anesthesia in all our patients with no incidence of recurrence.

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Background: Numerous exercises are used to strengthen muscles around the shoulder joint including the push-up and the push-up plus. An important consideration is the addition of surface instability in the form of swiss ball for rehabilitation and strength. The justification for the use of the swiss ball is based on its potential for increasing muscular demand required to maintain postural stability and for improving joint proprioception. Evidence for this is lacking in literature. Purpose of the Study: To compare the myoelectric amplitude of shoulder muscles during push-ups on labile and stable surface. Study Design: Same subject experimental study. Materials and Methods: Thirty healthy male subjects in the age group 20-30 years with a mean height of 173.65 cm (± SD 2.56) and a mean weight of 69.9 kg (±SD 0.2) were taken. Surface electromyogram was recorded from triceps, pectoralis major, serratus anterior and upper trapezius while performing push-up and push-up plus exercises, both on labile and stable surface. Results: Significant increase in muscle activity was observed in pectoralis major and triceps muscle (only during eccentric phase of elbow pushups), while serratus anterior and upper trapezius showed no change in activation level on swiss ball. Conclusion: The addition of a swiss ball is capable of influencing shoulder muscle activity during push-up variations, although the effect is task and muscle dependent.

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Subscapularis dysfunction after open instability repair has recently received increasing attention. Various clinical studies indicate that surgical approaches using partial or complete subscapularis tendon takedown techniques might impair subscapularis recovery and can negatively influence the final clinical outcome. This review article will focus on the potential pathogenesis, diagnosis, and clinical impact of the unrecognized condition and summarizes the currently available literature.

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Acromioclavicular joint dislocations are common injuries, which typically occur with trauma in young men. Treatment recommendations for these injuries are highly variable and controversial. There are greater than 100 surgical techniques described for operative treatment of this injury. One of the most widely recommended methods of surgical reconstruction for acromioclavicular joint dislocations is to utilize the coracoacromial ligament for stabilization of the distal clavicle. Several modifications of this procedure have been described which have involved adjunct coracoclavicular fixation or fixation across acromioclavicular joint. Although the literature is replete with descriptive papers, there is paucity of studies evaluating the surgical outcome of this procedure. We systematically reviewed the English language published literature in peer reviewed journals (Medline, EMBASE, SCOPUS) and assigned a level of evidence for available studies. We critically reviewed each paper for the flaws and biases and then evaluated the comparable clinical outcomes for various procedures and their modifications. The published literature consists entirely of case series (Level IV evidence) with variability in surgical technique and outcome measures. On review there is low level evidence to support the use of coracoacromial ligament for acromioclavicular dislocation but it has been associated with high rate of deformity recurrence. Adjunct fixation does not improve clinical results when compared to isolated coracoacromial ligament transfer. This is in part because of the high incidence of fixation related complications. Similar results are reported with coracoacromial ligament reconstruction for acute and chronic cases. The development of secondary acromioclavicular joint symptoms with distal clavicle retention is poorly reported with the incidence rate varying from 12% to 32%. Despite this, the retention or excision of distal clavicle did not affect overall clinical results except in the patients with pre existing acromioclavicular joint osteoarthritis who have inferior results with retention of distal end of clavicle. Further well designed clinical trials with validated outcome measures are required to fully evaluate the clinical results of this procedure.

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We are reporting an interesting case of glenoid fracture in a 46-year-old male which was fixed with the help of arthroscopy. At present, anterior or posterior glenoid rim fractures and some greater tuberosity fractures are widely treated arthroscopically. We report the arthroscopically assisted fixation of a transverse articular glenoid fracture. Arthroscopic reduction and percutaneous fixation of glenoid fractures not only allows anatomic reduction with minimal surgical trauma but provides a valid diagnostic and treatment alternative for associated capsular, ligamentous, labral or tendon injuries as well as joint irrigation. The principle portals are discussed. We suggest fixation with cannulated screws for better stability of fracture fragments and advise K-wires for fractures that are comminuted and not amenable to cannulated screw fixation. However, arthroscopic fixation of shoulder fractures is associated with a learning curve depending on surgeon's experience in shoulder arthroscopy.

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Surgeons and patients are often reluctant to support regional anesthesia (RA) for shoulder and other orthopedic surgeries. This is because of the sometimes true but usually incorrectly perceived "slowing down" of operating room turnover time and the perceived potential for added morbidity. Recently, severe devastating and permanent nerve injury complications have surfaced, and this article attempts to clarify the modern place of RA for shoulder surgery and the prevention of these complications. A philosophical approach to anesthesiology and regional anesthesiology is offered, while a fresh appreciation for the well-described and often forgotten microanatomy of the brachial plexus is revisited to explain and avoid some of the devastating complications of RA for shoulder surgery.

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Purpose: The purpose of the present study was to analyze the effect of aging on activation capacity of shoulder muscles, between individuals of young and older age groups, during dynamic activities of pulling, pushing, elevation and throwing activities. Materials and Methods: Nine young male adults of 20-29 year age group and eight old male individuals of 50-59 year age group, without any shoulder problems, were studied. Signals were recorded by surface electromyography as "percentage maximum voluntary isometric contraction" from middle deltoid, posterior deltoid, supraspinatus, and infraspinatus muscles of the shoulder. The results obtained from the muscles of younger age group were compared with those of older age group. Unpaired 't' - test was used for purpose of statistical analysis. Results: Significant increase in muscle activity was observed in elderly group as compared to younger group in activities involving pull, push, elevation and throw. Posterior deltoid (P <0.036) and infraspinatus (P <0.026) exhibited greater activity during pulling. Greater activity was observed in middle deltoid (P <0.015), supraspinatus (P <0.02) and infraspinatus (P <0.012) during pushing. During elevation posterior deltoid (P <0.02) and infraspinatus (P <0.05) were found to be more active. During throwing greater activity was observed in middle deltoid (P <0.034), posterior deltoid (P <0.05) and infraspinatus (P <0.05). Conslusion: Greater recruitment of the selected shoulder muscles occurs, with aging, during the dynamic activity. With aging, the percentage of muscle fibers decrease, resulting in the decrease of muscle strength. This may imply that, as a compensatory mechanism, elderly individuals require greater recruitment of muscle fibers to perform an activity than younger individuals. Clinical Relevance: Difference in recruitment pattern in the muscles of stability and mobility, between old and young individuals may be regarded as a potential factor for development of shoulder instability syndrome in elderly individuals.

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Objective: To present the Computed Tomography (CT)-Arthrography appearance of the most common types of anterior labral lesion and to assess the diagnostic value of this technique in the detection and classification of the antero-inferior labral tears in glenohumeral joint instability. Materials and Methods: The pre-operative CT-Arthrography records of 43 patients, who underwent surgery for anterior shoulder instability, were retrospectively evaluated independently by two radiologists. The data were compared with arthroscopic results and the diagnostic accuracy of CT-Arthrography was calculated to detect the labral lesion and the agreement between the CT-Arthrography lesions classification and the arthroscopy classification. Results: The CT-Arthrography sensitivity, specificity and accuracy were: 92% / 89% (reader 1/reader 2), 86% / 86% and 91% / 88% respectively. The CT-Arthrography classification was correct in 86% of cases. Conclusions: CT-Arthrography appears to be an accurate means for identification and classification of the anterior labral tears and, identifying the labral degeneration, this technique can be very helpful in the selection of patient for arthroscopic stabilization of the shoulder.

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Purpose: Accuracy and efficacy of an intra-articular infiltration of corticosteroid and local anesthetic in the symptomatic acromioclavicular joint were studied in 44 patients. Methods: Accuracy of the infiltration was studied using a blind technique with a dynamic fluoroscopic control. Results: Accuracy of the blind infiltration technique was only 50% and the dynamic fluoroscopic technique remains our preferred technique in the clinical setting. On average patients reported a 65% decrease in the intensity of the pain following the injection. At an average follow-up of forty-two months, 59% had undergone surgery, 14% of patients reported more than three months of symptoms relief. Conclusions: Despite the poor long-term results of injecting the acromioclavicular joint, it remains a valuable technique. It has a low cost, minor risks of complications and has high diagnostic value. All but one patients reporting short-term pain relief. Level of Evidence: Level III, case control study.

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Separation of the acromioclavicular joint in conjunction with a coracoid fracture is a rare injury. Treatment decisions are traditionally based on the level of the fracture, the status of the coracoclavicular ligament and the activity level of the patient. We present a novel coracoid fracture pattern treated nonoperatively in a young, active patient and a thorough review of the literature regarding this topic.

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High-resolution ultrasound has gained increasing popularity as an aid in the diagnosis of rotator cuff pathology. With the advent of portable machines, ultrasound has become accessible to clinicians. Aim: This study was conducted to evaluate the accuracy and reliability of ultrasound in diagnosing rotator cuff tears by a shoulder surgeon and comparing their ability to that of a musculoskeletal radiologist. Materials and Methods: Seventy patients undergoing shoulder arthroscopy for rotator cuff pathology underwent preoperative ultrasonography (US). All patients were of similar demographics and pathology. The surgeon used a Sonosite Micromax portable ultrasound machine with a 10-MHz high frequency linear array transducer and the radiologist used a 9-12 MHz linear array probe on a Siemens Antares machine. Arthroscopic diagnosis was the reference standard to which ultrasound findings were compared. Results: The sensitivity in detecting full thickness tears was similar for both the surgeon (92%) and the radiologist (94%). The radiologist had 100% sensitivity in diagnosing partial thickness tears, compared to 85.7% for the surgeon. The specificity for the surgeon was 94% and 85% for the radiologist. Discussion: Our study shows that the surgeons are capable of diagnosing rotator cuff tears with the use of high-resolution portable ultrasound in the outpatient setting. Conclusion: Office ultrasound, by a trained clinician, is a powerful diagnostic tool in diagnosing rotator cuff tears and can be used effectively in running one-stop shoulder clinics.

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Purpose: To evaluate the results of early arthroscopic release in the patients of stiff shoulder Methods: Twenty patients of stiff shoulder, who had symptoms for at least three months and failed to improve with steroid injections and physical therapy of 6 weeks duration, underwent arthroscopic release. The average time between onset of symptoms and the time of surgery was 4 months and 2 weeks. The functional outcome was evaluated using ASES and Constant and Murley scoring systems. Results: All the patients showed significant improvement in the range of motion and relief of pain by end of three months following the procedure. At 12 months, mean improvement in ASES score is 38 points and Constant and Murley score is 4O.5 points. All patients returned to work by 3-5 months (average -4.5 months). Conclusion: Early arthroscopic release showed promising results with reliable increase in range of motion, early relief of symptoms and consequent early return to work. So it is highly recommended in properly selected patients. Level of evidence: Level IV

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Ultrasound (US) use has rapidly entered the field of acute pain medicine and regional anesthesia and interventional pain medicine over the last decade, and it may even become the standard of practice. The advantages of US guidance over conventional techniques include the ability to both view the targeted structure and visualize, in real time, the distribution of the injected medication, and the capacity to control its distribution by readjusting the needle position, if needed. US guidance should plausibly improve the success rate of the procedures, their safety and speed. This article provides basic information on musculoskeletal US techniques, with an emphasis on the principles and practical aspects. We stress that for the best use of US, one should venture beyond the "pattern recognition" mode to the more advanced systematic approach and use US as a tool to visualize structures beyond the skin (sonoanatomy mode). We discuss the sonographic appearance of different tissues, introduce the reader to commonly used US-related terminology, cover basic machine "knobology" and fundamentals of US probe selection and manipulation. At the end, we discuss US-guided needle advancement. We only briefly touch on topics dealing with physics, artifacts, or sonopathology, which are available elsewhere in the medical literature.

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