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Shoulder Terrible Triad (STT) Is a Traumatic Anterior Thirty Consecutive Patients with Acute STT Were Included at = 0.035)

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Shoulder Terrible Triad (STT) Is a Traumatic Anterior Thirty Consecutive Patients with Acute STT Were Included at = 0.035) Research Article Shoulder Terrible Triad: Classification, Functional Results, and Prognostic Factors Abstract Michael Marsalli, MD Introduction: The shoulder terrible triad (STT) is a traumatic anterior 05/12/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkA4yilPh4ZDsrpoocajAiJdtOaDhCDQISXqFQVTejGI4w== by https://journals.lww.com/jaaos from Downloaded Oscar Sepúlveda, MD shoulder dislocation, associated with rotator cuff (RC) tear and nerve injury from the brachial plexus. This study aimed to describe the Downloaded Nicolás Morán, MD functional results and prognostic factors of surgery in patients with Juan Manuel Breyer, MD from STT. https://journals.lww.com/jaaos Methods: Thirty consecutive patients with acute STT were included at the same institution. All patients were examined with x-rays, MRI, and electromyography. Surgical treatment in the acute setting was indicated to address an RC injury or a displaced greater tuberosity by fracture. Variables registered on the day of surgery were preoperative BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3fgGGXf0fUkA4yilPh4ZDsrpoocajAiJdtOaDhCDQISXqFQVTejGI4w== Constant and Western Ontario Rotator Cuff (WORC) scores and injury pattern. At final discharge, Constant, American Shoulder and Elbow Surgeons (ASES), WORC, and subjective shoulder value scores were recorded by an independent evaluator. From the Orthopaedic Department, Results: Twenty-seven patients underwent a complete follow-up. Hospital del Trabajador and Clínica Universidad de los Andes The dominant arm was affected in 50% of cases. The mean follow-up (Dr. Marsalli), Orthopaedic was 27 (12 to 43) months. The mean WORC and Constant scores Department, Hospital del Trabajador improved from 1,543 to 1,093 (P = 0.015) and 31 to 54 (P = 0.003), (Dr. Sepúlveda and Dr. Morán), and Orthopaedic Department, Hospital del respectively. The ASES and subjective shoulder value scores at the Trabajador and Clínica Alemana end of the follow-up were 60 and 56 points, respectively. RC tears (Dr. Breyer), Santiago, Chile. and nerve injuries that did not involve the axillary or suprascapular Correspondence to Dr. Marsalli: nerves were associated to better results than greater tuberosity [email protected] fractures and injuries to the axillary or suprascapular nerves, None of the following authors or any respectively, in WORC (P = 0.028), Constant (P = 0.024), and ASES immediate family member has received anything of value from or has stock or scores (P = 0.035). Preoperative WORC and Constant scores were stock options held in a commercial independent prognostic factors. company or institution related directly or Conclusions: The most frequent patterns include complete RC tears, indirectly to the subject of this article: Dr. Marsalli, Dr. Sepúlveda, Dr. Morán, anterior capsular injuries, and an axillary nerve injury. Patients had and Dr. Breyer. improved functional scores at the end of follow-up after surgery. Better Supplemental digital content is functional results were correlated to RC tears, injuries to nerves with on 05/12/2020 available for this article. Direct URL innervation distal to the shoulder, and higher preoperative Constant citation appears in the printed text and is provided in the HTML and PDF and WORC scores. versions of this article on the journal’s Web site (www.jaaos.org). J Am Acad Orthop Surg 2020;28: he “shoulder terrible triad” (STT) tional structures of the shoulder. In 200-207 Tis defined as a traumatic shoulder 1991, it was described for the first 2 DOI: 10.5435/JAAOS-D-19-00492 dislocation associated with a rotator time by Gonzalez et al from two cuff(RC)tearandaninjurytothe cases. Then, in 1994, Güven et al3 Copyright 2020 by the American 1 Academy of Orthopaedic Surgeons. brachial plexus branches. It is a triple reported one case and named it the injury that compromises all func- “unhappy triad of the shoulder.” The 200 Journal of the American Academy of Orthopaedic Surgeons Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Michael Marsalli, MD, et al term “shoulder terrible triad” was (4) Minimum follow-up of 1 year All patients underwent at least a sec- first used by Groh and Rockwood1 in for functional assessment. ond EMG during the follow-up. 1995. It has been described briefly in We excluded patients with irrepa- On the day of surgery, a Western literature as case reports.1-6 However, rable RC tears who required another Ontario Rotator Cuff (WORC) and a the patterns of injury have not been type of reconstructive surgery and Constant score were assigned to all characterized, and surgical treatment those with nondisplaced GT fractures patients scheduled for an arthroscopic results have not been described in that did not need fixation. All study RC repair.6,7 At the end of the surgery, larger series. participants provided informed con- the following variables were recorded The main objective was to de- sent, and the study was authorized by in the surgical database: sex, age, type scribe the functional results after sur- the local scientific ethics committee. of abductor injury, and type of ante- gical treatment in patients with an rior glenoid injury according to the STT. The secondary objectives were to Surgical Intervention and arthroscopic findings. According to the International Society of Arthros- (1) characterize injury patterns in a Follow-up cohort of patients with an STT and (2) copy, Knee Surgery, and Orthopaedic describe prognostic factors of surgical All patients were initially admitted Sports Medicine consensus,8 RC in- treatment in patients with an STT. to the emergency department due juries were classified based on size to a working accident, covered under according to Snyder9 and retraction the local working accidents insurance according to Patte.10 Fatty degen- Methods law. Shoulder radiographs were taken eration was classified according to before and after shoulder reduction. Goutallier et al11 as Fuchs et al12 Patient Selection All patients had their shoulder re- demonstrated that a grading system duced under conscious sedation on the of fatty degeneration is reproducible A retrospective cohort study was de- same day of the initial trauma. After as well on CT scans as on MRI scans. signed. An STT was defined as shoulder this, all patients were referred to the Subscapular injuries were classified dislocation associated with a neuro- shoulder surgery specialists. according to Lafosse et al13 and GT logical injury involving the brachial Additional imaging studies included fractures according to Mutch et al.14 plexus (root, trunk, cord, or terminal shoulder magnetic resonance for sus- Nerve injuries were described and branch) and a complete RC tear or pected RC injuries and CT scans to classified according to Seddon15 based displaced greater tuberosity (GT) frac- evaluate GT fractures before surgery. on the initial EMG findings. ture. We decided to include displaced Neurological lesions were suspected All surgeries were done by a team GTfracturesassociatedtoananterior during physical examination if any of five shoulder surgeons at a single shoulder dislocation and a neurologi- sensory or motor deficits of the mus- trauma center. RC tears were repaired cal injury involving the brachial plexus culocutaneous, radial, medium, or arthroscopically with suture anchors. as a STT. Displaced GT fractures create ulnar nerves were observed. Sensory Suture anchor repair technique was a discontinuity of the load transfer examination of the terminal branch of decided by each surgeon; 70% of the between the RC and the proximal the axillary nerve was done to find RC repairs were done with a single row humerus, so they are a functionally changes that were suggestive of axil- technique and 30% with a double-row similar injury to a complete postero- lary nerve damage. Deltoid muscle transosseous equivalent repair. The superior RC tear in the setting of an strength was not initially considered average number of anchors used was STT. Therefore, RC injuries and dis- suggestive of axillary nerve damage as 2.7 (range, 1 to 5). Fifty-two percent placed GT compromise the proximal it may be difficult to test after a recent underwent an acromioplasty. No cap- humerus abductor complex and can be traumatic episode and a concomi- sulolabral or bony Bankart repair was considered different types of STT. tant GT fracture or RC tear.4 The done as an associated procedure. Split Patients from our surgical database STT was diagnosed by the shoulder GT fractures were fixed with plate from 2014 to 2016 were reviewed. specialist after clinical and imaging and screws, and avulsion fractures Inclusion criteria were as follows: evaluations and surgery were indi- werefixedwithopensurgeryand (1) A consecutive series of patients cated. All patients were examined suture anchors. Examples of RC re- with an STT. using electromyography (EMG) to pairs and GT fixations can be seen in (2) Admitted for an arthroscopic confirm the presence and extension of Supplemental Digital Content 1 (Fig- repair of a complete RC tear or a nerve injuries. For changes in EMG to ure 1, A, http://links.lww.com/JAAOS/ GT fracture fixation. manifest Wallerian degeneration, the A438); Supplemental Digital Content (3) First anterior shoulder dislo- EMG was done between the fourth 2 (Figure 1, B, http://links.lww.com/ cation episode before surgery. and sixth week after the initial injury.5 JAAOS/A439); Supplemental Digital March 1, 2020, Vol 28, No 5 201
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