Background: Recent studies of arthroscopic rotator cuff repairs have shown high failure. The different suture configurations were mostly tested in non degenerative animal tendon specimen. We used instead fresh-frozen degenerative human cadaver rotator cuffs. The goal of this study was to determine the biomechanical properties of commonly used arthroscopic stitches in ruptured human cuffs in comparison to intact rotator cuffs. Method: 36 human rotator cuff tendons were harvested, documented according to size, thickness and location of rupture, and divided into a ruptured and non ruptured specimen group. We found 12 ruptured and 24 intact cuffs. Three stitch configurations (simple, horizontal, and massive cuff stitch) with a Fiber Wire 2 (Arthrex) were randomized and biomechanically tested in each set of tendon specimen. The specimen were mounted on a uniaxial load machine (ZM200, Fa Shokoohi) and loaded to failure under displacement control at a rate of 0.6 mm/sec. Ultimate tensile load, and type of failure were recorded. Results: Ultimate tensile load was significantly higher (p < 0.05) for the massive cuff stitch (186 ± 12 N) than it was for either the simple stitch (102 ± 9 N) or the horizontal stitch (138 ± 10 N) in the intact cuff cohort. In the ruptured cuff group ultimate tensile load was significantly lower (p < 0.05) for the massive cuff stitch (115 ± 12 N), the simple stitch (77 ± 9 N), and the horizontal stitch (103 ± 10 N) in comparison to the intact cuff group. The simple and horizontal stitches failed by tissue pull-out in both groups, whereas the massive cuff failed by pull-out and once by suture breakage in the group of intact cuffs. Conclusion: Ruptured rotator cuffs showed significant less biomechanical strength concerning all three stitches in comparison to the intact cuff group. Overall the massive cuff stitch showed superior ultimate tensile load

Rotator cuff tears are the most common cause of shoulder disability, affecting 10% of the population under 60 and 40% of those aged 70 and above. Massive irreparable rotator cuff tears account for 30% of all tears and their management continues to be an orthopaedic challenge. Traditional surgical techniques, that is, tendon transfers are performed to restore shoulder motion, however, they result in varying outcomes of stability and complications. Superior capsular reconstruction (SCR) is a novel technique that has shown promise in restoring shoulder function, albeit in limited studies. To date, there has been no biomechanical comparison between these techniques. This study aims to compare three surgical techniques (SCR, latissimus dorsi tendon transfer and lower trapezius tendon transfer) for irreparable rotator cuff tears with respect to intact cuff control using a clinically relevant biomechanical outcome of rotational motion. Eight fresh-frozen shoulder specimens with intact rotator cuffs were tested. After dissection of subcutaneous tissue and muscles, each specimen was mounted on a custom shoulder testing apparatus and physiologic loads were applied using a pulley setup. Under 2.2 Nm torque loading maximum internal and external rotation was measured at 0 and 60 degrees of glenohumeral abduction. Repeat testing was conducted after the creation of the cuff tear and subsequent to the three repair techniques. Repeated measures analysis with paired t-test comparisons using Sidak correction was performed to compare the rotational range of motion following each repair technique with respect to each specimen's intact control. P-values of 0.05 were considered significant. At 0° abduction, internal rotation increased after the tear (intact: 39.6 ± 13.6° vs. tear: 80.5 ± 47.7°, p=0.019). Internal rotation was higher following SCR (52.7 ± 12.9°, intact - SCR 95% CI: −25.28°,-0.95°, p=0.034), trapezius transfer (74.2 ± 25.3°, intact – trapezius transfer: 95% CI: −71.1°, 1.81°, p=0.064), and latissimus transfer (83.5 ± 52.1°, intact – latissimus transfer: 95% CI: −118.3°, 30.5°, p=0.400) than in intact controls. However, internal rotation post SCR yielded the narrowest estimate range close to intact controls. At 60° abduction, internal rotation increased after the tear (intact: 38.7 ± 14.4° vs. tear: 49.5 ± 13°, p=0.005). Internal rotation post SCR did not differ significantly from intact controls (SCR: 49.3 ± 10.1°, intact – SCR: 95% CI: −28°, 6.91°, p=0.38). Trapezius transfer showed a trend toward significantly higher internal rotation (65.7 ± 21.1°, intact – trapezius transfer: 95% CI: −55.7°, 1.7°, p=0.067), while latissimus transfer yielded widely variable rotation angle (65.7 ± 38°, intact – latissimus transfer: 95% CI: −85.9°, 31.9°, p=0.68). There were no significant differences in external rotation for any technique at 0° or 60° abduction. Preliminary evaluation in this cadaveric biomechanical study provides positive evidence in support of use of SCR as a less morbid surgical option than tendon transfers. The cadaveric nature of this study limits the understanding of the motion to post-operative timepoint and the results herein are relevant for otherwise normal shoulders only. Further clinical evaluation is warranted to understand the long-term outcomes related to shoulder function and stability post SCR

The purpose of this diagnostic, cross-sectional study, was to determine the predictive value of clinical examination versus ultrasonographic evaluation in rheumatoid arthritis patients, suspected of having rotator cuff disease. The left and right shoulders of fifty consecutive patients from the rheumatoid clinic were subjected to clinical examination by a senior registrar in the department. Impingement was evaluated using the Neer, Hawkins and posterior impingement tests. The supra-spinatus tendon insertion (Jobe test), infraspinatusteres minor tendon insertions (resisted external rotation) and subscapularis tendon insertion (Gerber lift-off and push-off tests) into the rotator cuff were evaluated for a possible tear. A Professional Sport Sonographer, located in a separate examination room then performed an ultrasonographic evaluation on all of the patients. The clinical results were compared to the ultrasound results, hoping to find a method that will improve our current screening of rheumatoid patients for rotator cuff disease and planning of possible surgical treatment. A significant difference was found between the clinical and sonographic evaluation of the rotator cuffs. Impingement tests showed a false positive result of 85–89%, while the tests for cuff tears had a false negative value of 87–91% compared to ultrasound evaluation. A total disagreement of 45.8–60% and total agreement of 39.5–54.1% could be explained by the fact the synovitis is the hallmark of rheumatoid disease, which could cause pain without tears or impingement. The authors conclude that clinical examination of the rotator cuff in patients with rheumatoid disease is unreliable, and that ultrasound examination should form a routine part of the evaluation of all rheumatoid shoulders

Two dimensional ultrasound of the shoulder joint has become a well established diagnostic tool. Difficult interpretation of ultrasonographic findings, however, suggests that ultrasound appears not to be an always reliable method, especially in partial thickness tears. The present study was performed to determine whether the use of three dimensional (3D) sonography further increases the diagnostic yield of ultrasound. On a total of 22 externally intact appearing rotator cuffs of cadaveric shoulder joints 7 full thickness and 15 partial thickness incisions were carried out on the M. supraspinatus, subscapularis and infraspinatus tendon. The specimens included the humeral head, the glenoid, the joint capsule and periarticular tendons. Ultrasound was performed on the shoulder specimens in a water basin with a 8.5 MHz curved array transducer (Combison 530D, Kretztechnik, Zipf, Austria). With three dimensional ultrasound rotator cuff lesions were more often correctly diagnosed (sensitivity of 77 %) than with conventional 2D sonography (sensitivity of 64 %). Specificity was 85 % and 69 %, respectively. In partial thickness tears in particular, 3D imaging was the superior method reaching a sensitivity and specifity of 73% and 77%, respectively compared to 53% and 61%, respectively with 2D ultrasound. The use of three dimensional ultrasound appears to have a higher diagnostic yield in partial thickness tears. One advantage is that the examiner must not move the transducer to obtain other planes. Changes in echogenicity can be observed in the complete volume and in any plane. In the diagnosis of partial tears these changes enabled the examiner to distinguish intact from ruptured tissue

Aim: Revision of shoulder replacements in patients with irreparably damaged rotator cuffs and disintegrated coracoacromial arch are typical indications for the Delta-III-prosthesis. The aim of this study was to evaluate the results of one-stage exchange procedures with and without reconstruction of the glenoid (n =21) and compare them with the preoperative status. Methods: Eighty-four patients who had undergone one-stage prosthesis exchange were included in the prospective analysis. Pain and functional results were recorded using our own specifically compiled follow-up questionnaire and evaluated according to the Constant/Murley Shoulder Score. The indications for exchange surgery were impingement and pain due to cranial dislocation of the prosthesis head in fifty-four cases, cranio-ventral dislocation in nineteen, periprosthetic infection in six, aseptic loosening in four, and postoperative ankylosis of the shoulder with heterotopic ossifications in one case. Results: The mean age of the patients was 68.1 years (49–82). Prior to our exchange surgery sixteen patients had already undergone one and five patients two exchange procedures with implantation of a standard prosthesis. Thirty-eight patients had had several non-arthroplasty revision operations. After exchange for a Delta prosthesis eighty-three of the patients were pain-free or experienced tolerable pain only when the joint was subjected to a longer period of strain. The Constant/Murley Shoulder Score improved from a mean preoperative value of 27 to 58 points within 36–48 months. The overall complication rate was 13.1%. Bony reconstruction of the glenoid did not appear to have any significant influence on the outcome of the exchange procedure. Conclusion: Patients’ satisfaction with the result of one-stage exchange of shoulder replacements using inverse implants is high due to the reliable and fast alleviation of pain, the satisfactory function of the joint and the fact that the need for nursing care can be avoided. The almost maximum functional result is already achieved after three months and with continued physiotherapy further gradual improvement is possible up to one year after surgery due to an increase in muscle strength. The outcome may be impaired by impingement at the lower glenoid rim leading to erosion and possible loosening of the component

Purpose of the study: The aim of this biomechanical study was to assess the performance of the deltoid muscle in the absence of a rotator cuff using different models for shoulder prosthesis. Material and methods: A computer model reproducing the three dimensions of the glenohumeral joint was use to analyze the force of the deltoid muscle during abduction movements in shoulders devoid of a rotator cuff. The three heads of the deltoid were analyzed in order to determine the most effective level of muscle tension. The lever arm of the deltoid was measured from 0–90° abduction. Using this 3D model, we simulated implantation of six different models of reversed prostheses in order to assess the biomechanical situation which would be the most favorable for the deltoid. Performance of the normal deltoid was compared with the performance of the deltoid after implantation of an anatomic prosthesis and after implantation of an reversed prosthesis. Several variables were studied: medial offset of the center of rotation, lateral offset of the humerus, lengthening of the deltoid muscle. Results: Optimal deltoid performance (especially from 60–90° abduction) was observed if the center of rotation was offset medially and the humerus was offset laterally and lowered. A 10% increase in the length of the muscle fibres increased muscle performance 18%. Exaggerated lateral offest of the humerus increased deltoid performance between 30 and 60° abduction but lost its beneficial effect at 90° abduction. From 15° abduction, a scapular notch appeared when the humerus was off set medially. This could be avoided if the humerus was offset laterally with a less medial center of rotation. Beyond 150° abduction, superior impingement appeared irrespective of the type of prosthesis. Discussion and conclusion: This biomechanical study proved the superiority of reversed prostheses compared with anatomic prostheses for massive rotator cuff tears. Medial offset of the center of rotation reduced shear forces on the glenoid. Lateral offset of the humerus increase via a pulley effect the lowering force of the deltoid. Lowering the humerus pulled on the muscle fibers of the deltoid and increased their performance. Dosing these three variables with an appropriate («ideal») design for the reversed prosthesis would optimize deltoid performance in patients with deficient rotator cuffs

Purpose: Determine the ideal form of subacromial decompression. Method: Six cadaveric shoulders with intact rotator cuffs (RTC) underwent “smooth & move (SM),” limited acromioplasty with coracoacromial ligament (CAL) preservation, and CAL resection. Glenohumeral translation was measured in four directions utilizing electromagnetic spatial sensors. Peak RTC pressure was measured during arm abduction utilizing pressure film sensors. Results: Anterosuperior translation was unchanged after SM or acromioplasty, but increased from 2mm at baseline to 4mm following CAL resection with the arm at 300 abduction (p=0.03). There were no significant changes in other directions of translation following any procedure. In neutral humeral rotation RTC pressure was unchanged after SM (p=1.00). Pressure decreased 64% after a limited acromioplasty (p=0.04), and 72% after CAL resection (p=0.03). There was a trend towards increased abduction at which peak pressure occurred following CAL resection (760 compared to 620;p=0.11) In external rotation, RTC pressure decreased 26% following SM, 52% after limited acromioplasty, and 64% after CAL resection, but values were not statistically changed (p=0.52, p=0.08, and p=0.06). Similarly, abduction angle at which peak pressure was reached increased but was statistically insignificant after SM (720; p=0.75), limited acromioplasty (750; p=0.11), and CAL resection (790; p=0.08). In internal rotation, RTC pressure decreased 32% following the SM, 59% following the limited acromioplasty, and 58% following CAL resection, but none reached statistical significance (p=0.52, p=0.26, p=0.17). Abduction angle of peak pressure was unchanged after SM (670; p=0.63) and limited acromioplasty (670; p=0.63), but increased following CAL resection (620 vs. 790; p=0.04). Conclusion: A CAL resection leads to increased anterosuperior instability. “Smooth and move” or acromioplasty can safely be performed without increasing translation. Rotator cuff pressure did not significantly decrease after SM. Rotator cuff pressure was significantly decreased to a similar degree following a limited acromioplasty or a CAL resection. A limited acromioplasty with preservation of the CAL may offer the greatest decrease in cuff pressures without the undesirable effect of increased translation. However, statistical significance was affected by high anatomic variability. Therefore, the choice between “smooth & move” and acromioplasty to decrease contact pressure is likely best to be individualized based on acromial morphology

Purpose of the study: The aim of this study was to evaluate the anatomical and technical limits of endoscopic rotator cuff repair. Anatomical results were also compared with functional assessment of the shoulder. Material and methods: A multicentric serie of 87 patients presenting a full thickness rotator cuff tear repaired endoscopically was retrospectively reviewed at 25.4 months (mean) post surgery. Limits of the surgical technique were studied in correlation with functional results and anatomic radiographic evaluation (arthroscans in 93 p. 100). Results: Anatomical repair (normal thickness and no contrast in the subacromial space on arthroscan) was achieved in 83 p. 100 of the rotator cuffs with limited damage to the frontal part of the supra spinatus tendon. This percentage fell to 57.8 p. 100 in case of posterior extension of the tear to the supra spinatus tendon and further dropped to 40.8 p. 100 in case of retraction to the apex of the humeral head. Functional outcome evaluated with the Constant score was strongly related to the radiographic cuff condition (p < 0.05). For distal and anterior tears of the supra spinatus tendon, the Constant score at revision was 89.8 points in cases with anatomic repair at revision. This score fell to 75 when the rotator cuff tear was evidenced radiographically (p < 0.0001). For tears involving the entire supra spinatus tendon repaired by arthroscopy, the functional difference at revision was 8 points on the Constant scale. Objective and subjective analysis of the surgical procedure identified significant peroperative elements predictive of clinical and anatomical outcome (difficult reduction, p < 0.05; subjective degree of solidity, p < 0.0001; anatomical aspect of the repaired cuff, p < 0.05). Discussion: A comparison of our findings with data on equivalent lesions reported in the literature suggests that endoscopic surgery for rotator cuff tears offers both functional and anatomic results equivalent to those achieved with conventional open surgery. This assumes that the surgical procedure is carried out by surgeons experienced in shoulder arthroscopy who can precisely gauge the posterior/anterior extension of the tears and the limits of the surgical technique

Aim: To assess the outcome of arthroscopic subacromial decompression on rotator cuff muscles. Material: 44 patients with impingement syndrome and intact rotator cuffs were recruited 3 years ago. All were followed up 6 months after surgery and 17 were selected randomly to attended after 3 years. Methods: All patients prior to surgery underwent:. Clinical examination. Constant Scoring. Cybex testing of the rotator cuff muscles. MRI scans. Arthroscopic examination followed by arthroscopic SAD. Standard post-op rehab. Tests were repeated at 6 months, and in 17 patients again 3 years after surgery. Results: 1– 41patients (93.18%) improved subjectively at 6 months, and 12 (out of 17) were still satisfied after3 years. 3- Impingement signs disappeared in 41 patients at 6 months and in 13 out of 17 at three years. 4- Average increase in Constant score was 18 points at 6 months and 4 points at 3 years. Pain ADL Pos. ROM Power Total Pre-op mean 5.71 5.23 5.23 25.45 8.76 50.38 Post-op mean 11.67 8.04 8.14 38.05 20.9 86.8 3 years mean 10.91 8.02 7.83 42.78 16.6 86.14 5-Dynamometer (Cybex) Muscle testing: Average power in Watts Abduct Adduct Int. Rot. Ext. Rot. Int. Rot. Ext. Rotation at side at side at 90abduct at 90abduct Pre-op 40.01 61.3 38.2 23.12 32.56 27.78 6/12 postop 54.78 76.6 51.93 36.34 40.74 39.19 3 years p.o. 52.65 69.98 52.77 38.55 40.78 36.21. Conclusions. SAD still provides good pain relief. Muscle power increases post-operative but tends to plateau or slightly decrease after 3 years. Dynamic muscle power measurement is recommended for accurate assessment. Other Cybex measurements (Torque) had little relation to clinical outcome. Constant score does not accurately assess changes in muscle power

Purpose: There is still debate on classification, pathogenesis, and treatment of partial non-full thickness tears of the rotator cuff. We assessed mid-term outcome after arthroscopic repair. Material and methods: Between 1990 and 1998, 208 partial tears of the rotator cuffs were treated in our unit. Eighty patients were reviewed by an examiner different and independent from the surgery team. The review included a physical examination, Constant score and radiography. The series included 42 men and 38 women, mean age 52 years (23–73) who were seen at a mean follow-up of 59 months (17–118). We identified four groups: group 1 included lesions of the deep articular aspect of the supraspinatus: 34 cases; group 2 included tears of the superficial aspect: 27 cases; group 3 included tears involving both the deep and superficial aspect without full-thickness tear on the preoperative arthrogram; and group 4 included lesions involving a partial tear of the supraspinatus associated with another articular lesion. Acromioplasty was performed in all cases associated with section of the acromiocoracoid ligament. Results: Absolute Constant score progressed from 53 points preoperatively to 80 points at last follow-up. Mean Constant score of the contralateral shoulder was 87 points. There was a significant difference between outcome in the first three groups where the mean age was 50 years and the fourth group (trauma context) where the mean age was 36 years. Constant score was 84.7, 92, 92, and 73 for groups 1, 2, 3 and 4 respectively. There was no statistically significant improvement compared with the preoperative Constant score (67 points). Radiographically, there was no change in the subacromial space. Superficial lesions were more frequently associated with type 3 acromial impingement. Discussion: Globally, we observed a deterioration of outcome with time compared with the first review, with 76% satisfactory results at five years. The same outcome was obtained with superficial and deep lesions. We are in agreement with others that it is necessary to identify a subgroup of patients under 40 years of age with a partial tear of the rotator cuff in a trauma context. For these patients, arthroscopic acromioplasty is not a satisfactory therapeutic approach. The causal lesion (posterosuperior impingement, rim injury or instability) should be treated

Aim: To investigate the effect of Arthroscopic Subacromial Decompression and rehabilitation on rotator cuff muscle strength and function. Material: 24 patients with primary impingement syndrome and intact rotator cuffs were recruited. 8 further patients were excluded due to pathologies found at arthroscopy. Methods: All recruited patients prior to surgery underwent: 1- Through clinical examination. 2-Constant Scoring. 3- Detailed Cybex dynamometer testing of the rotator cuff muscles of both shoulders in six different positions with the same range and for power, speed and torque. 4- MRI scans. 5- Full arthroscopic examination followed by a routine arthroscopic SAD. 6-Standard post-op rehab programme. All tests were repeated at the minimum of 6 (average 6.3) months after the operation. Results:. CLINICAL. - 23 (95.83%) improved subjectively, and were back to their normal daily routines. - The average improvement in VAS scoring was an average of 3.5 (2–7)). - Impingement signs disappeared in 23 patients (95.83%). - Average increase in Constant score was 23 points, from 53.5 to 76.5.Average pain increased from 7.5 to 9, ADL from 5.5 to 6, hand position from 7 to 8, range of motion from 21.5 to 37 & power from 9 to 17. Dynamometer Muscle testing (All measurement of power was done in watts). A-Abduction power increased from an average of 14.5 to 32.9, Adduction from 17 to 42. b- At maximal adduction internal rotators increased from 25.5 to 34.55, external rotators from 20.25 to 30.85 and. c- At 90° abduction the internal rotators increased from 19.55 to 31.3, and the external rotators from 16.6 to 21.95. Conclusions:. -ASD provides good pain relief. -Most patients return to work before the end of 6 months period; however there seems to be a tendency for further improvement after the 6 months period. - Muscle power increases post-operative but with individual variation. -Dynamic Power assessment is preferable to the Constant Score method, as power is measured in Watts, and can test below 90° of elevation. -Power measurement is the only parameter directly related to the clinical outcome of ASD

Aims

Orthopaedic surgery requires grafts with sufficient mechanical strength. For this purpose, decellularized tissue is an available option that lacks the complications of autologous tissue. However, it is not widely used in orthopaedic surgeries. This study investigated clinical trials of the use of decellularized tissue grafts in orthopaedic surgery.

Aims

Rotator cuff disease (RCD) can considerably decrease quality of life. Here, we investigated whether health-related quality of life (HRQoL) influences the need for surgery in patients with RCD.

Aims

Rotator cuff muscle atrophy and fatty infiltration affect the clinical outcomes of rotator cuff tear patients. However, there is no effective treatment for fatty infiltration at this time. High-intensity interval training (HIIT) helps to activate beige adipose tissue. The goal of this study was to test the role of HIIT in improving muscle quality in a rotator cuff tear model via the β3 adrenergic receptor (β3AR).

Objectives

Indocyanine green (ICG) fluorescence angiography is an emerging technique that can provide detailed anatomical information during surgery. The purpose of this study is to determine whether ICG fluorescence angiography can be used to evaluate the blood flow of the rotator cuff tendon in the clinical setting.

Aims

Many biomechanical studies have shown that the weakest biomechanical point of a rotator cuff repair is the suture-tendon interface at the medial row. We developed a novel double rip-stop (DRS) technique to enhance the strength at the medial row for rotator cuff repair. The objective of this study was to evaluate the biomechanical properties of the DRS technique with the conventional suture-bridge (SB) technique and to evaluate the biomechanical performance of the DRS technique with medial row knots.

The April 2012 Shoulder & Elbow Roundup³⁶⁰ looks at katakori in Japan, frozen shoulder, if shoulder impingement actually exists, shoulder arthroscopy and suprascapular nerve blocks, why shoulder replacements fail, the infected elbow replacement, the four-part fracture, the acromion index, and arm transplantation

Objectives

To investigate the appropriate dose and interval for the administration of triamcinolone acetonide (TA) in treating tendinopathy to avoid adverse effects such as tendon degeneration and rupture.

The June 2012 Shoulder & Elbow Roundup³⁶⁰ looks at: reverse shoulder replacement; torn rotator cuffs and platelet-rich fibrin; rotator cuff repair; frozen shoulder; whether an arthroscopic rotator cuff repair actually heals; the torn rotator cuff’s effect on activities of daily living; subacromial impingement; how to improve the reliability of the Constant-Murley score; and failure of the Neer modification of an open Bankart procedure.