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This is an enhanced PDF from The Journal of Bone and Joint Surgery
89:220-230, 2007. doi:10.2106/JBJS.F.01417
J. Bone Joint Surg. Am.
Matthew L. Ramsey, Charles L. Getz and Bradford O. Parsons
What's New in Shoulder and Elbow Surgery
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Specialty Update
What's New in Shoulder
and Elbow Surgery
By Matthew L. Ramsey, MD, Charles L. Getz, MD, and Bradford O. Parsons, MD
This annual update on shoulder and elbow surgery is based on a
review of presentations at meetings of the Arthroscopy Associa-
tion of North America (Specialty Day, March 25, 2006, Chicago,
Illinois; Twenty-fifth Annual Meeting, May 18 to 21, 2006, Hol-
lywood, 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 Soci-
ety for Sports Medicine (Specialty Day, March 25, 2006, Chi-
cago, 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 configura-
tions. A "suture-bridging" technique utilizing medial anchors
with suture limbs traversing over the cuff to a lateral interfer-
ence screw attachment was compared with a double-row an-
chor repair. A four-limb suture bridge (two medial anchors
with four limbs over the cuff laterally) established a signifi-
cantly higher mean contact pressure area (72.3%) compared
with a two-limb suture bridge (57.3%) and a double-row re-
pair (35.1%) (p < 0.05). The authors concluded that increas-
ing footprint contact pressure may aid in rotator cuff healing.
Milano investigated the influence of acromioplasty on out-
come following arthroscopic rotator cuff repair. Eighty pa-
tients 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-adminis-
tered 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 deter-
mining the size of partial-thickness rotator cuff tears. The in-
tra-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 recom-
mendation 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 prospec-
tively 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 Shoul-
der 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 re-
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 prac-
tice, 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.
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What's New in Shoulder and Elbow Surgery
sults support completion of partial rotator cuff tears fol-
lowed 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 be-
tween the 7 and the 22-mm-passage repairs. The depth of su-
ture 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 at-
rophy on the outcome of arthroscopic repair of isolated su-
praspinatus tears in a study of thirty-two consecutive patients
with a minimum of twenty-four months of follow-up. Six pa-
tients (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 res-
onance imaging evaluation of the degree of atrophy and fatty
infiltration of the rotator cuff muscles has a significant influ-
ence 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 pos-
terosuperior part of the rotator cuff, and tears involving the
subscapularis were excluded from the study. The patients were
evaluated postoperatively with computed tomography or mag-
netic 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% (in-
cluding 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; how-
ever, pain scores did not correlate with tendon healing. Clinical
results and healing rates also were found to be strongly cor-
related 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 arthro-
scopic 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 pa-
tients 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 func-
tional scores showed less improvement. Given the recent
literature on healing rates of large and massive tears with at-
rophy 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 rota-
tor 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 classi-
fied 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 mi-
nor 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 infec-
tion 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 com-
mon 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
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What's New in Shoulder and Elbow Surgery
suggest that the eradication of deep infection following rota-
tor cuff repair is possible; however, substantial functional lim-
itations are not unusual.
Biceps Tendon
Costic compared two techniques for arthroscopic biceps teno-
desis in a fresh-frozen cadaveric shoulder model. The first tech-
nique (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 bi-
cipital groove via sutures that are passed through the tendon.
No significant difference was observed between the two tech-
niques. 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 ques-
tion 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 dis-
location in young patients was evaluated by Hovelius. The re-
sults 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 dis-
locations 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 stabiliza-
tion for the treatment of recurrent anterior instability. The
outcomes for twenty-four patients who had had open shoul-
der stabilization and sixty-nine patients who had had arthro-
scopic 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 dif-
ference between the groups with regard to the overall modi-
fied 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 mea-
sures are more appropriate, demonstrating equivalent results
between open and arthroscopic instability surgery.
The ability of contact athletes to return to sports ac-
tivity following arthroscopic anterior shoulder stabilization
was investigated by Williams. Twenty-four patients who had
undergone twenty-eight procedures were retrospectively re-
viewed. Patients were selected on the basis of a history of in-
volvement in contact sports, recurrent anterior instability, and
arthroscopic stabilization. Patients were excluded if they dem-
onstrated either glenoid or humeral bone loss or had had pre-
vious shoulder surgery. All patients had a minimum of two
years of follow-up. Twenty-one patients (88%) were able to re-
turn 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 West-
ern 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 shoul-
der stabilization for the treatment of recurrent anterior insta-
bility 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 popu-
lations 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 indepen-
dent examiner at an average of thirty-eight months after ar-
throscopic surgery. Of the ninety-nine shoulders, fifty-eight
were in high-demand patients participating in judo, karate,
boxing, gymnastics, wakeboarding, snowboarding, basket-
ball, handball, or rugby. In these fifty-eight high-demand pa-
tients, 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
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What's New in Shoulder and Elbow Surgery
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 pre-
dictors of outcome. Between 1999 and 2003, thirty-three con-
secutive patients with a mean age of twenty-five years who
underwent posterior arthroscopic shoulder stabilization with
suture anchors and/or suture capsulolabral plication were re-
viewed. 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 sur-
gery 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 consid-
ered in this group of patients.
Glenohumeral Arthritis
Basic Science
The biomechanical effect of inferior tuberosity displacement
during hemiarthroplasty for the treatment of a proximal hu-
meral 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) infe-
rior 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 tu-
berosities were placed 10 or 20 mm inferior to the anatomic
position, glenohumeral joint-reactive forces shifted signifi-
cantly superiorly, especially with abduction or elevation mo-
ments. The authors concluded that these alterations could
result in increased force required to raise the arm following
hemiarthroplasty with inferiorly positioned tuberosities, re-
sulting in poor functional outcome.
Craig and colleagues evaluated the glenoid compo-
nents that had been retrieved from sixty-five shoulders over
a twenty-six-year period. The original total shoulder replace-
ments had been performed for a variety of diagnoses, includ-
ing osteoarthritis, posttraumatic arthritis, inflammatory
arthritis, and osteonecrosis. The components had been re-
moved because of aseptic loosening in 81.5% of the cases and
septic loosening in 18.5%. The authors found several com-
mon 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 compo-
nents. The authors concluded that increased conformity be-
tween 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. Pre-
operative and postoperative functional evaluation was per-
formed 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 sig-
nificant 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 im-
proved 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 func-
tion 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 investi-
gated the failure characteristics of three subscapularis repair
techniques in a cadaver model. The subscapularis was circum-
ferentially isolated from the underlying capsule. The subscap-
ularis 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 shoul-
der 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. Af-
ter 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 tendon-
to-bone group. Complete failure occurred in four tendon-to-
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What's New in Shoulder and Elbow Surgery
bone specimens, one tendon-to-tendon specimen, and no
bone-to-bone specimen during the 150-N cyclic test. All spec-
imens that survived the 150-N cyclic test failed either com-
pletely or partially during the 300-N cyclic test. The tendon-
to-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 short-
ened 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 dur-
ing total shoulder replacement, fifteen cadaveric shoulders
were divided into three groups of five. The first group under-
went 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 ulti-
mate 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, re-
spectively). Clinically, 100 consecutive patients who had un-
dergone 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 re-
placement 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 mini-
mum 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 ar-
thritis. 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 re-
visions following reverse total shoulder arthroplasty. Five
centers participated in the study, in which 457 reverse total
shoulder arthroplasties were performed. A primary arthro-
plasty was performed in 297 patients, whereas a revision re-
verse 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 dislo-
cation, infection, and humeral fracture) than primary arthro-
plasty 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 ap-
proach (5.8% compared with 1.0%; p = 0.05). Whether this
higher rate of instability was due to a preponderance of del-
topectoral 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 intro-
duced 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 op-
erating 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 re-
verse 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 reimburse-
ment 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
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What's New in Shoulder and Elbow Surgery
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 up-
per extremity in six patients and the lower extremity in seven
patients. All upper extremity thromboses were on the opera-
tive 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 de-
termine 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 esti-
mate of preinjury functional capacity were obtained at the
time of presentation. All patients had a radiographic evalua-
tion at each visit to determine union and the maintenance of
fracture position. At subsequent follow-ups, patients were an-
alyzed 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, con-
trolled study comparing immediate operative treatment with
nonoperative treatment of displaced midshaft clavicular frac-
tures were reported by Hall and colleagues. Patients were ran-
domized 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). Complica-
tions in the nonoperative group included reflex sympathetic
dystrophy (one patient), symptomatic malunion (two pa-
tients), and nonunion requiring surgical treatment (six pa-
tients). 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 pa-
tients 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 reduc-
tion and internal fixation with a compression plate and fifteen
patients who had undergone delayed reconstruction with
open reduction and compression plate fixation for the treat-
ment 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 mus-
cle 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 frac-
ture 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 endur-
ance as well as a trend toward a decrease in outcome scores
(DASH and Constant scores).
Lo and associates described the anatomic landmarks for ar-
throscopic release of the transverse scapular ligament in a
study of six cadaveric shoulders. The authors described a step-
wise 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 in-
serted 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
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What's New in Shoulder and Elbow Surgery
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 anterolat-
eral portal. Clinically, they found that coplaning the inferior
aspect of the acromioclavicular joint and the use of a 70° ar-
throscope were valuable for improving arthroscopic visualiza-
tion. 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 la-
brum anterior-to-posterior) lesion repair aided by a trans-
tendinous portal. Each of these patients was found to have a
substantial tear of the rotator cuff in the area of the transtend-
inous 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 demon-
strated significant improvement. The mean ASES score im-
proved 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 modifi-
cation, medications, and physical therapy. Four patients un-
derwent humeral head resurfacing (one with additional
glenoid interposition), and two underwent hemiarthroplasty.
Pain relief following the arthroplasty procedures was consis-
tent, but function was highly variable. The majority of the
cases were thought to be related to intraarticular use of ther-
mal 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 chon-
drolysis. Twelve shoulders in ten patients who underwent ar-
throscopic 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 un-
known, the authors believed there is a significant risk associ-
ated 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 anes-
thetics 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 tech-
nique, 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 ulti-
mate 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 collat-
eral ligament reconstruction with the docking procedure in a
study of 100 consecutive overhead athletes who had been fol-
lowed for an average of two years after the procedure. At the
time of surgery, all patients had routine arthroscopic assess-
ment. Arthroscopy revealed that 45% of the patients had asso-
ciated pathologic findings, which were addressed prior to the
reconstruction. Ninety of the 100 athletes were able to com-
pete 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 re-
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What's New in Shoulder and Elbow Surgery
construction 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 arthro-
scopic or open procedures for the treatment of lateral epi-
condylitis. 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 nor-
mal findings. Synovitis was found in 25% of the elbows that
were evaluated arthroscopically, and one loose body was re-
moved. 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 satisfac-
tory after 86% of the arthroscopic releases and 85% of the
open releases. Open and arthroscopic release appear to pro-
duce similar clinical results.
Fractures and Dislocations
Humerus (Distal)
The results of a multicenter, prospective, randomized, con-
trolled 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 re-
ported by McKee. Twenty-one patients who were sixty-five
years of age and older and had a type-C3 distal humeral frac-
ture were randomized into the two treatment groups. However,
because of the crossover from open reduction and internal fix-
ation 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 ar-
throplasty. Outcomes were measured with use of the Mayo El-
bow Performance Score (MEPS) and the DASH score. At all
time-points that were measured, patients in the total elbow ar-
throplasty group had significantly higher Mayo Elbow Perfor-
mance 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 ap-
pear 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 sta-
bility and vascularity to the capitellar fragments. If greater vi-
sualization 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 pa-
tient 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 Josefs-
son. 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 man-
aged nonoperatively with immediate mobilization (seven-
teen 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 com-
plaints whereas three described occasional pain, pain pre-
dominantly 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 osteoar-
thritis, but more degenerative changes were noted in the in-
jured 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 frac-
tures 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 per-
formed 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 addition-
ally at rest. Flexion in the injured elbows was limited com-
pared 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 signifi-
cantly more cysts, sclerosis, and osteophytes than did the un-
injured elbows (p < 0.001). On the basis of that study, we can
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What's New in Shoulder and Elbow Surgery
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 reduc-
tion and internal fixation of slightly displaced, but stable, par-
tial 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 aver-
age 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 re-
ported 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 ten-
sile 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 pa-
tients under the age of forty years underwent primary elbow
replacement between 1982 and 2003. Six patients had a bilat-
eral 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 deter-
mined 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 trau-
matic 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 ar-
throplasty in young patients can be effective.
Mallon and colleagues retrospectively reviewed forty
patients with forty-one semiconstrained total elbow replace-
ments who had at least ten years of follow-up. The preop-
erative diagnoses were posttraumatic arthritis (twenty-four
patients), inflammatory arthritis (twelve patients), osteoar-
thritis (four patients), and post-tumor resection (one patient).
Patient selection was limited to those willing to adopt a seden-
tary lifestyle. The average MEPS improved from 36 preopera-
tively to 90 postoperatively. The patients had a high (100%)
self-reported rate of satisfaction, despite a 34% rate of compli-
cations. 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.
Evidence-Based Orthopaedics
The editorial staff of The Journal reviewed a large number of
recently published research studies related to the musculoskel-
etal 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 arti-
cles 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.
Matthew L. Ramsey, MD
Charles L. Getz, MD
Penn Orthopaedic Institute, Penn Presbyterian Medical Center, One
Cupp Pavilion, 39th and Market Streets, Philadelphia, PA 19104. E-mail
address for M. L. Ramsey: email@example.com
Bradford O. Parsons, MD
The Leni and Peter W. May Department of Orthopaedics, Mount Sinai
School of Medicine, One Gustave L. Levy Place, New York, NY 10029
Evidence-Based Articles
Related to the Shoulder and Elbow
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
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What's New in Shoulder and Elbow Surgery
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 preopera-
tively 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 pa-
tients in the nonabsorbable suture anchor group and three patients in the ab-
sorbable 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 su-
ture materials were used. One hundred patients with tears of the rotator cuff
were prospectively randomized into two groups. Group 1 underwent transos-
seous repair with number-3 Ethibond with use of modified Mason-Allen su-
tures, 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 Con-
stant 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 signifi-
cantly 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 diag-
nosis 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 identifi-
cation 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 mag-
netic 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 pa-
tients 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 arthro-
plasty. 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
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 feed-
back group). In the navigation group, the calcium deposit was localized with
use of a radiographically guided, three-dimensional, computer-assisted de-
vice. 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 an-
alog 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 feed-
back group one deposit disappeared and twelve were altered. No severe com-
plications 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 ex-
tensor 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 treat-
ment (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 ob-
served 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 injec-
tion. 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
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What's New in Shoulder and Elbow Surgery
Pettrone FA, McCall BR. Extracorporeal shock wave therapy without local anes-
thesia for chronic lateral epicondylitis. J Bone Joint Surg Am. 2005;87:1297-304.
One hundred and fourteen patients with a minimum six-month his-
tory of lateral epicondylitis that had been unresponsive to conventional ther-
apy 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 signifi-
cant 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 seven-
teen of the fifty-eight subjects in the placebo group. This improvement per-
sisted 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 clini-
cally and electromyographically proven cubital tunnel syndrome were pro-
spectively 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 postop-
eratively. 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.
on January 9, 2007 www.ejbjs.orgDownloaded from


text:
Central Neuropathy
Here's a taste of what TheBody.com has to offer on this topic:
Ask the Experts
peripheral neuropathy?????I was diagnosed with hiv 4 years ago. My t-cell when first diagnosed was 300 put got on meds and numbers jumped up to 750. I have stayed on meds and numbers have stayed betwwen 700 - 800. I am on atripla at the moment and have never had any side...
Response from Keith Henry, M.D.
University of Minnesota, School of Medicine...Atripla overall has a low rate of peripheral neuropathy. The foot pain you describe (acute and short in duration first in one foot and then the other) does't sound much like either Read more »
Neuropathy in HeadWhat can you tell me about neuropathy which may be causing dizziness and headaches? Don't really... Read more »
mysterious neuropathy of legsFor the past three years I have had a mysterious neurological condition of my legs which has... Read more »
Understanding and Managing Peripheral Neuropathy...AIDS-defining illness or antiretroviral use, the association was no longer statistically significant. Alejandro Arenas-Pinto of the Centre for Sexual Health & HIV Research in London and colleagues reported on data from the Delta trial, a... Read more »
Peripheral Neuropathy...means beyond the main part while neuro means nerves and pathy means disease . Since your brain and spinal cord are the center for your nervous system, PN is found in other parts of your body. Normally, PN affects the toes, feet and legs... Read more »
Peripheral Neuropathy... What Is Peripheral Neuropathy? What Causes PN? How Is PN Diagnosed? How Is It Treated? Other Resources The Bottom Line What Is Peripheral Read more »
Peripheral Neuropathy and HIV/AIDS... Table of Contents What Is Peripheral Neuropathy? What Causes PN? Who Is at Risk of Developing PN? How Do You Know if You Have PN? PN Treatments Finding Support Read more »
Connect With Others
Posted by ScotCharles, 7 Replies...I have developed very bad neuropathy in my left foot that makes it difficult to walk without a cane. Several times recently, I have lost all strength on the left Read more »
chili pepper good for neuropathy
Posted by Anonymous, 1 Reply...I read that peppers are good for neuropathy, are there any other things that help with it, it is bad in my heels of my feet and legs. Read more »
What is neuropathy pain?
Posted by bura, 3 Replies...Can someone describe what is neuropathy pain? Read more »
chili pepper good for neuropathy
Posted by Anonymous...I read that peppers are good for neuropathy, are there any other things that help with it, it is bad in my heels of my feet and legs. Read more »
Resource Centers
Guides for People With HIV

subset: commoncrawl


text:
Australian Open 2014: Andy Murray upset by 'double bounce' call as Roger Federer halts comeback
British number one proud despite being knocked out in quarter-final
Paul Newman
Paul Newman is Tennis Correspondent for The Independent.
Melbourne Park
Wednesday 22 January 2014
Andy Murray's disappointment at going out of the Australian Open was compounded by a sense of injustice over a point that proved to be one of the key moments in his 6-3, 6-4, 6-7, 6-3 quarter-final defeat to Roger Federer.
Murray, playing only his second comeback tournament following back surgery, looked a spent force after three hours and 20 minutes on court and felt aggrieved that a misjudgement by the umpire, Pascal Maria, might have contributed to the length of the match.
The moment of controversy came at 4-4 in the third set, when Federer broke Murray's serve. The 32-year-old Swiss played a winning lob but television replays, which were shown on the big screen on court, suggested he might have made contact with the ball after it bounced twice.
Federer went on to break serve and although Murray broke back immediately and won the subsequent tie-break, the Scot was unhappy that the set might have taken longer than necessary.
"Roger asked for them to stop showing it on the video because I think he knew it bounced twice as well," Murray said. "I was disappointed because I got broken in that game and ended up breaking in the next game.
"Every point at that stage is crucial because I was pushing hard to try and get back into the match and fighting extremely hard," he added.
"Rather than spending an extra 30 minutes on that set, I potentially could have been serving a little bit fresher at the beginning of the fourth set, so it was disappointing."
Murray acknowledged that there was no provision to use video replays to review such issues but added: "Roger asked them not to show it on video because it looks controversial and doesn't look great, but it's fine for them to show videos of me every time I get annoyed on the court or whatever. It's up there the whole bloody match."
Federer did not think the ball had bounced twice. "It looked good," he said. "I just told the umpire: 'How can they show this and create this controversial moment potentially?' It's not really what you want to do. I hope it was played the right way. If it wasn't, I'm sorry. But it's an umpire's call."
Despite his disappointment, Murray was justifiably upbeat about his performances here, given that he had arrived at the tournament with only two competitive matches under his belt after undergoing back surgery four months ago. "I was proud of the way I fought," he said.
Murray saved 13 of the 17 break points that Federer created. The Scot, who had reached the semi-finals or better on his last four appearances here, had much more trouble creating inroads into Federer's service games, converting one of only two break points which he had forced.
Federer, who goes on to meet his old foe Rafael Nadal in the semi-finals after the Spaniard beat Grigor Dimitrov 3-6, 7-6, 7-6, 6-2, has looked in excellent shape ever since he arrived here just over a fortnight ago. Recruiting Stefan Edberg to his coaching entourage and using a new racket appear to have had a positive influence on him.
The former world No 1, who is through to his 11th successive Melbourne semi-final, took the first two sets with single breaks as Murray struggled to return serve.
The Scot, upping the tempo and hitting some big shots, finally broke when Federer served for the match at 5-4 in the third set. From 6-4 down in the subsequent tie-break Murray played four superb points, full of controlled aggression, to win it 8-6.
Both men were playing well at this stage and in the second game of the fourth set, which lasted 19 minutes, Federer failed to take six break points. But at 3-4 Murray looked a spent force physically and the Swiss made the final break of serve. He went on complete victory with an ace.
"It's basically been four months since I was lying on my back not being able to move or walk," Murray said. "I put in a lot of hard work for this long period. Then time goes into getting yourself ready. You want to give yourself the best chance to win. A lot of work went into this Slam compared with other ones where you have a few weeks to prepare. This time I had a long time to prepare, maybe just not enough matches."
Murray said he had felt okay physically and that his back had not been a problem. "Obviously that's the highest level I've played at in a long time," he said. "My serve slowed down a bit in the fourth set, especially the first couple of points when I was getting up after the change of ends, but I hung in well, pushed through it and almost got myself back in the match.
"I've come a long way in four months. Right now I'm obviously very disappointed. There are maybe some things I would possibly have done a bit differently if I was ever to have surgery again. But it's the first time I ever went through something like that. I thought I did a good job getting myself in good shape to be competitive at this level. I wasn't too far away in the end."
He added: "I don't know how many players have come back from surgery and won the first Grand Slam back in their second tournament. It's very unlikely to happen. I guess I just need to use this as a stepping stone to getting better and be happy that I've got through five matches."
Sport blogs
- 1 Germanwings crash: Captain of doomed plane was only 'on board because he changed job to spend more time with his children'
- 2 Ohio Democrat Teresa Fedor speaks out during abortion debate to reveal she has been raped – and is interrupted by laughter from Republicans
- 3 Gamers confess the worst things they've done in The Sims
- 4 Germanwings crash: 'Andreas Lubitz planned to marry pregnant girlfriend', claims German report
- 5 Germanwings plane crash: Transcript reveals passengers 'screamed for over five minutes' before plane crashed into mountain
Ukip supporters are 55 or older, white and socially conservative, finds British Social Attitudes Report
Street preacher quoting from the Bible fined for calling homosexuality an 'abomination'
Jeremy Clarkson sacked live: Alan Yentob 'wouldn't rule out' ex Top Gear host's BBC return
Woman filmed launching racist tirade against men on the Tube for speaking in 'own lingo'
The West has it totally wrong on Lee Kuan Yew
David Cameron calls Labour 'hopeless, sneering socialists' while announcing 7-day NHS plans
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How researchers are set to leave their marks on solving crime
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Visitor Information
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Next Exhibition
Guess What?
Hardcore Contemporary Art's Truly a World Treasure:
Selected Works from the YAGEO Foundation Collection
[ opens March 31, 2015 ]
Collection Gallery
The Collection Gallery exhibits selected works of nihonga (Japanese-style painting), yōga (Western-style painting), prints, sculpture, crafts (ceramics, textiles, metalworks, wood and bamboo works, lacquers and jewelry) and photography from the museum collection. Also shown are outstanding and monumental works of modern art in Japan, as well as modern and contemporary European and American art.
NOTE: Japanese names are generally represented in the traditional fashion, with the family name first, followed by the given name or the "artist name." (Exceptions are made for artists who are/were long-term residents of foreign countries, e.g., Tsuguharu Léonard Foujita, and for contemporary artists in accordance with the artist's [perceived] preference.)


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White Denim
Coo Coo Birds
The Independent
628 Divisadero St
San Francisco, CA, 94117
Doors 8:30 PM / Show 9:00 PM
This event is 21 and over
When a band's first album is unpredictable enough to invoke comparisons with artists as wildly diverse as hardcore innovators the Minutemen and professorial idiosyncrasy of Randy Newman, then you can reasonably assume its been made by people who care about music. Lots of it. Jazz, punk, funk, country, acid rock, even piano ballads -- all these labels have been used, accurately, to describe White Denim. Their second record is more problematic though. It has to sound like them.
Fits; the title is both a knowingly bad pun and a reference to the odd tantrum endured in its creation- manages just that. Anyone familiar with the ferocious drive of the Texan trio's renowned live shows, where songs merge into each other and the playing guides the direction of the performance, will recognize their approach. Recorded and produced by the band in their infamous studio/trailer, Fits is more coherent than debut Workout Holiday, yet sacrifices none of its imagination. Though there's barely a pause between tracks the set ebbs and flows, ranging from the soft-hearted to the ferocious.
The band describes it, with only light sarcasm, as The Friendship Record. 'We were congratulating each other for having good ideas," says singer/guitarist James Petralli of the sessions, "We went through a lot of positive and negative things and came out of it a lot closer."
For all the contemplation, Fits is effortlessly fun. There are more elements of jazz and soul than previously. Vocals sit in the mix rather than on top, effectively another instrument. The playing is, again, deft without being showy, and there are melodic hooks to spare. So what's the secret? "We set the tempos high and set off," says Petralli. It's that simple. And it works. In spades.
Coo Coo Birds
"Hold Onto Your Girlfriends, the Coo Coo Birds Have Arrived. The Coo Coo Birds embody timeless rock 'n' roll attitude, with their era-spanning sound drawing from garage, psychedelic, and 50′s rock, all created in the old convent in San Francisco where the band resides. Band Name: Coo Coo Birds Hometown: San Francisco Born Date: Jan 2012 Sounds Like: Boiler Pot Rock n' Roll at its best. The 1950′s got a new skate board, then fell off when 1967 tripped him. Then 1977 came along and beat them both up for it, and all three were arrested by Officer 2012. Fun Fact: The band lives in an ex-Convent turned artist community, and derives much of their inspiration from this unique SF scene. " — Katie Kopacz, Sf Station
Who's Going
Upcoming Events
The Independent
Tue, March 31
Wed, April 1
Kitty, Daisy and Lewis
Thu, April 2
Fri, April 3
Bob Marley's "Exodus"
Sat, April 4
Bob Marley's "Exodus"
Sun, April 5
Bob Marley's "Exodus"
Tue, April 7
The Preatures
Thu, April 9
Knox Hamilton
Fri, April 10
Bright Light Bright Light
Sat, April 11
The Soul Rebels
White Denim with Coo Coo Birds
Saturday, July 6 · Doors 8:30 PM / Show 9:00 PM at The Independent


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ACE Fit Share
Add some diversity to your fitness program with these butt and hip exercises from the American Council on Exercise. We'll help you tone up those glutes and get that butt into shape. Choose from a wide variety of hip flexibility and strengthening exercises including glute bridges, BOSU lateral jumps and more. These exercises come with detailed instructions, step-by-step guidance and tutorials on proper equipment use. For full workout routines featuring butt and hip exercises, be sure to visit our Workouts section.
Fit Life Articles
Are you ready for Sunday's Super Bowl kick-off? Typically one of the most indulgent days of the year, it is possible to stay on track with your fitness plan. ACE Exercise Physiologist Jacque Ratliff created a super-fun game-time workout that will help you keep moving...
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Gary Gensler, chairman of the Commodity Futures Trading Commission, said the agency is trying to bolster competition in the derivatives market. However, Gensler acknowledged that it will take some time to implement the Dodd-Frank Act. "I think Congress' intent was to open it up. We'll see how successful. You'll get to judge that in a few years," Gensler said.
View Full Article in:ForexYard
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Did Administration Threaten Benghazi Whistleblowers?
Their lawyer says the O admin did
(Fox News) At least four career officials at the State Department and the Central Intelligence Agency have retained lawyers or are in the process of doing so, as they prepare to provide sensitive information about the Benghazi attacks to Congress, Fox News has learned.
Victoria Toensing, a former Justice Department official and Republican counsel to the Senate Intelligence Committee, is now representing one of the State Department employees. She told Fox News her client and some of the others, who consider themselves whistle-blowers, have been threatened by unnamed Obama administration officials.
"I'm not talking generally, I'm talking specifically about Benghazi — that people have been threatened," Toensing said in an interview Monday. "And not just the State Department. People have been threatened at the CIA."
Ms. Toensing has refused to identify her client, but has stated that the person has knowledge on what happened in the months before the 9/11 attack, during the attack, and after the attack. She has further stated that the threats are about the ending of careers if people testify, a clear violation of federal law.
It's been over 7 months, and we still do not fully know what happened, particularly before and during the attack. The O administration has been stonewalling and stalling, refusing to provide the full information. Of course, let's admit that Republicans made a huge mistake in focusing on the talking points surrounding the video that supposedly started the attack.
And you have a special forces operator stating that forces could have gotten to Benghazi by at least the 2nd attack, and that the special forces community feels betrayed.
It should be very interesting when these folks sit down and testify in front of Congress. Of course, liberals have already wrote the deaths of Americans, including our ambassador, as a "big nothing burger." These are the same people who whined about the August 6th PDB and the "Downing Street Memo" for over half a decade (some still are), yet want no details of Benghazi.
Crossed at Pirate's Cove. Follow me on Twitter @WilliamTeach.
Also see...
It took a lot of guts to do what this young man did. They also offered him 20k in hush money. Fabulous. The proof in my opinion here is that...Read More
William Teach
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Worried about a government shutdown? Don't be. It won't affect you much. But that isn't what the left and the
Obama's Overtime Decree
Virtually every domestic policy enacted by Obama has had the effect of maintaining or exacerbating high unemployment. A coming decree
Lord Monckton Warns of Obama's Copenhagen Threat
Lord Christopher Monckton is one of the last true Britons, a countermoonbat who has been eviscerating the global warming hoax


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Alexandria second at AGC
Although the Alexandria girls' golf team did not have one of its best days at the Alexandria Golf Club on Wednesday afternoon, the team's overall feelings from the meet were still positive.
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You will need your subscription account number and phone number. Not sure if you have an account? Email us at email@example.com and we can help you.


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Too Scared To Get Tested After Sharing A Shower
Here's a taste of what TheBody.com has to offer on this topic:
Ask the Experts
Im so scared (CASUAL CONTACT, 2010)I am 29 years old with 3 children and a husband. I just found out today that my father who has been living with me for 2 months has HIV. I need to know what kind of precautions should I take with my kids and the family being around him?
Response from Robert J. Frascino, M.D.
The Robert James Frascino AIDS Foundation...chapped lips form the cold along with a little cold sore from the cold too.I am so in distress I have been avoiding my family for fear of passing along this virus. My husband is now thinking other things about me because I will not get intimate... Read more »
Young and scaredI know many people donate to this site when asking a question, but I am very young and dont have a... Read more »
MY LIFE IS IN DANGER!First of all, I would like to thank you for all the marvellous advice and solutions you have given... Read more »
HIV Transmission...health care provider and obstetrician if you are HIV positive If you protect yourself in these ways, you do not need to be afraid of getting or passing HIV by casual contact. Remember, HIV is not transmitted by: Hugs Dancing Sharing food... Read more »
What Are the Symptoms of HIV and AIDS?...can happen for any number of reasons, including guilt, stress or obsessive-compulsiveness. The key is to realize when your fears about HIV are legitimate and when they're not. Keep in mind that, if you're worried that something you did put you... Read more »
Did You Just Test HIV Positive?...and don't feel that you have to tell everyone right away (see The Well Project's info sheet on disclosure ). But don't let fear of being judged cause you to isolate yourself and not talk to anyone. If it is hard to tell family and friends at... Read more »
HIV Testing...official will ask for the names, addresses, e-mails and/or phone numbers of other people (contacts) with whom you have had sex or shared needles. The health department will then try to locate each contact to tell them that they have been exposed... Read more »
Connect With Others
Please Help, Confused and scared...
Posted by jrob123, 2 Replies...condom on. She then had one with her and puts it on me. We then had intercouse with the condom no lube. I was very nervous and scared. It was breif. Soon after we were done I quickly went to throw out the comdom which I dont think broke. and took... Read more »
Sexual Relations With A Virgin- Advice needed!
Posted by scared_elf, 3 Replies...little scenarios which I need clarification on: 1. He lives in a college/university residence whereby showers, bathrooms etc are shared. What if someone masturbated in the shower prior to him using it and there was semen in the shower? 2. He does... Read more »
Not sure what I'm feeling ...
Posted by guyinwa77, 8 Replies...the treatments out there I will outlive them - so I would rather just keep this to myself in that regard. I guess too I am scared as hell. I'm a 31yo males in Washington. I want to fall in love - but now I feel like I won't be wanted. I'm... Read more »
Any one from India, Pakistan, Dubai, Qatar, Saudi
Posted by salma, 3 Replies...share mutual thoughts with my fellow men from Dubai, India, Pakistan, Qatar, Saudi Arabia, Oman, Bahrain, its very lonely & scared sometimes, if anyone feels the same, please drop in a line..many thanks in advance.. Read more »
Resource Centers
Guides for People With HIV


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Science: Order and Design focuses on life science for 7th grade. Students are introduced to the scientific method, and encouraged to apply it through the text as they investigate botany, anatomy, zoology, microbiology, and ecology. Discovering the thoughts of the Creator through the structure and function of His creation is encouraged.
Chapters feature colorful photography and art which helps to illustrate important concepts and spark student interest. Bolded terms help students know where to focus their studying attention, and charts and diagrams clarify difficult concepts. "Check it Out" hands-on activities are included, along with "A closer look" pages and post-chapter section reviews with "Thought Provoker" question.
480 pages. Designed for a full year; includes health.
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The eurocrisis fully exposes the folly of deficit mania in a time of recession. So why are the GOP candidates still oblivious?
Attacks on church-state separation by Romney, Gingrich and Santorum reflect the growing power in the party of religious extremists.
Why does 76 percent of the civil libertarian's Super PAC money come from billionaire Peter Thiel, whose Palantir Technologies helps the government spy on citizens?
Finally, after years of persistent effort by courageous women activists, one of the world's most brutal dictators has been indicted.
The GOP panders to racists, and liberals are blamed for a "neurotic" obsession with race.
In less than two years, Athens has changed from a reasonably prosperous capital to a broken city.
Costly technologies have opened up new sources in the Western Hemisphere—but they pose immense environmental dangers.
Why was Baby Doc able to return after decades of exile and evade justice, despite his crimes?
The NBA point-guard phenom has sparked a national discussion about racism against Asian-Americans.
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24/7 Customer Support
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Genuine Bosch part. Bosch brands include Bosch, Thermador, Gaggenau, and others.
Check your model number or use our Cross Reference Tool to determine if this part will work with your appliance.
Where can I find my model number?
Part Diagram
Part Number 00368282 (AP2827386) replaces 1047076, 14-38-637, 14-38-637-01, 368282, AH3454960, EA3454960, PS3454960.
Baffle, Convection 27 In., Welded Assembly


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Book your room at Hotel Sortale
Hotel with a restaurant, in Orosei (Gulf of Orosei)
This hotel is located in Orosei (Gulf of Orosei), close to the beach, Museo Comunale, Marina di Orosei Beach, and Su Petrosu Beach. Area attractions also include Osalla Beach and Cala Cartoe Beach.
Hotel Features
In addition to a restaurant, Hotel Sortale features a bar/lounge. Other amenities include complimentary wireless Internet access and a rooftop terrace.
Room Amenities
Televisions come with satellite channels. Guestrooms also feature complimentary wireless Internet access, air conditioning, and climate control.Information missing or incorrect? Tell us!
Hotel Amenities
Hotel Amenities
Dining options at the hotel include a restaurant and a snack bar/deli. A bar/lounge is on site where guests can unwind with a drink. A complimentary breakfast is offered. A computer station is located on site and high-speed wireless Internet access is complimentary.
This Orosei hotel also offers a rooftop terrace, a library, and a terrace. For a surcharge, a roundtrip airport shuttle (available on request) is offered to guests. Onsite self parking is complimentary.
- Babysitting or childcare (surcharge)
- Airport transportation (surcharge)
- Total number of rooms - 22
- Number of floors - 2
- Free newspapers in lobby
- Free breakfast
- Express check-in
- Express check-out
- Front desk (limited hours)
- Tours/ticket assistance
- Free WiFi
- Computer station
- Rooftop terrace
- Bar/lounge
- Gift shops or newsstand
- Library
- Garden
- Terrace
- Luggage storage
- Restaurant
- Safe-deposit box at front desk
- Year Built 1992
- Snack bar/deli
- Free self parking
- Number of buildings/towers - 1
- Television in lobby
- Multilingual staff
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Free self parking
Room Amenities
- Air conditioning
- Private bathroom
- Free toiletries
- Hair dryer
- Shower only
- Television
- Satellite TV service
- Rollaway/extra beds available
- Free WiFi
- Climate control
- Room service (limited hours)
- Cribs/infant beds (surcharge)
- Connecting/adjoining rooms available
Where to Eat
Guests are offered a complimentary buffet breakfast.
Onsite venue - This restaurant specializes in local cuisine and serves dinner only. Guests can order drinks at the bar and enjoy alfresco dining (weather permitting). A children's menu is available.
Room service (during limited hours) is available.
Nearby Things to Do
The recreational activities listed below are available either on site or nearby; fees may apply.
- Kayaking nearby
- Bicycle rentals nearby
- Hiking/biking trails nearby
- Scuba diving on site
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible path of travel
- In-room accessibility
Hotel Policies
Check-in time starts at 10 AM
Check-in time ends at 11 PM
Check-out time is 10 AM
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Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
No elevators
No pets or service animals allowed
- Airport shuttle fee: EUR 120 per person (roundtrip)
- Crib (infant bed) fee: EUR 15.00 per night
We should mention
Cash transactions at this property cannot exceed EUR 999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation. Only registered guests are allowed in the guestrooms. The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation. No pets and no service animals are allowed at this property.


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Pfister Sedona Dual Funtion Hand Shower
Special Offer:
24 Issues of Better Homes and Gardens
Included with your purchase - a $10 value (Subscription and Rebate Info)
Pfister Sedona Dual Funtion Hand Shower
Additional Documents
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|Product Type: Hand shower
|Shower Head Type: Handheld shower head
|Style: Modern
|Finish: 1: Brushed Nickel
|Finish: 2: Chrome
|Adjustable Spray: Yes
|Hand Shower Included: Yes
|Rough-In Valve Included: No
|Body Jets: Yes
|Faucet Handle Included: No
|Country of Manufacture: China
|Installation Required: Yes
About the Manufacturer
Since 1910, Pfister has led the industry with many first to market products, from the first single control shower lever to the first full product line using ceramic disc valves. Explore their rich history of innovation and discover how Pfister became one of the most trusted names in the industry today.
Pfister Sedona Dual Funtion Hand Shower
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OUR SKU # PPR2288Sedona Dual Funtion Hand Shower is also sometimes listed under the following manufacturer numbers: 016-LT0C, 016-LT0K, 016-LT0Y