Ultrasonography for rotator cuff disease is a cheap and non-invasive investigation. Our study investigates the tendon specific pathologies leading to misinterpretation of ultrasound findings and their implication for the surgical management. On hundred and five consecutive patients who had an ultrasound scan by a single musculoskeletal radiologist and then underwent shoulder arthroscopy by a single shoulder surgeon for rotator cuff pathologies were included. Surpraspinatus Tendon (SST): There was a sensitivity of 90%. The relatively low positive predictive value (76%) and specificity (42.5%) were influenced by a high number of false positives. This was a mixed group of 23 cases, in which ultrasonography had described either a full-thickness (FTT) or partial-thickness (PTT) tear when arthroscopy did not show any evidence for a cuff tear. Seven of these cases were described as FTT with dimensions less than 1 cm and in ten cases the radiologist described a “possible sub-centimetre tear”. Subscapularis Tendon (SSC): There was a specificity of 100%. The poor negative predictive value (78%) and sensitivity (26%) were caused by a high number of false negatives. Further analysis of the 20 “false negative” patients showed four FTT and sixteen PTT. All partial thickness tears involved the superior fibres of the subscapularis tendon. Our results confirm that USG is a reliable investigation in larger full thickness tears, particularly of the superior rotator cuff (SST). The reliability is significantly reduced in sub-centimetre tears and partial thickness tears, particularly of the subscapularis tendon. Associated tendon pathologies like intra-tendinous calcifications and intra-substance tears make an accurate diagnosis even more difficult and add to the tendency to ‘over-diagnose’ tears of the rotator cuff with use of ultrasonography. The shoulder surgeon should be aware of the potential misinterpretation of ultrasonography findings and be prepared to adjust the surgical procedure accordingly

The aim of our biomechanical study was to find out whether the prosthetic design, especially of the metaphyseal part, and the type of tuberosity fixation influences the primary stability in shoulder arthroplasty. Materials and Methods: 16 fresh frozen human cadaveric humeri were dissected until only the rotator cuff remained. A four-part fracture was simulated by osteotomy. In a first step two types of shoulder prosthesis (open stem versus closed stem) were used. The Tornier Aequalis prosthesis (open stem) using suture fixation and the Mathys Affinis fracture prosthesis (closed stem) using cable fixation were implanted according to standard techniques. The specimens were then loaded into a servo-pneumatic testing device in 25° of abduction. In 20 consecutive cycles traction of 40 Newton was alternating exerted on the subscapularis and infraspinatus tendon, while a continuous force of 40 Newton was exerted on the greater tuberosity to simulate the pull of the m. supraspinatus. The motion of the fragments was recorded by 2 high speed cameras. The following parameters were investigated : Failure of osteosynthesis, intertuberosity motion, motion lesser tuberosity-shaft, motion greater tuberosity-shaft, motion metaphysis-shaft. After completing the first series the cable fixation exposed to be more stable. In a second series we compared cable versus suture fixation in the Affinis fracture prosthesis to find out whether the stability was depending on the prosthesis design. Results:. Series 1: The intertuberosity motion was significantly lower in the cable prosthesis. The tuberosity-shaft motion was significantly lower in the cable group for greater and lesser tuberosity. The metaphysis - shaft motion did not significantly differ in both groups. Series 2: The intertuberosity motion was significant lower when the tuberosities were fixed by cable. The tuberosity-shaft motion was significantly lower when cable fixation was used. The metaphysis-shaft motion was not significantly diverse. Conclusion: Highest primary stability of tuberosity fixation in trauma-arthroplasty of the shoulder was measured in cable fixation and closed stem. We proved that the kind of fixation was the most important factor determing the stability. Metaphyseal design was less important

Introduction: We have devised a new technique of lesser tuberosity osteotomy with double row fixation of the subscapularis using suture anchors. Aim: To evaluate the biomechanical properties of this novel technique against two established methods of subscapularis repair including tendon to tendon and transosseous repairs. Method: Matched pairs of human cadaveric shoulders were allocated into 3 groups. Group 1 consisted of the double row technique with incision of the subscapularis along the bicipital groove with a lesser tuberosity osteotomy. A double loaded suture anchor was placed along the medial border of the osteotomy site and sutures were passed through subscapularis medial to the bone island in a horizontal mattress manner. A second anchor was inserted along the lateral border of the osteotomy site and the two sutures were tied onto the subscapularis holding sutures. In group 2, the subscapularis was divided 1cm medial to the bicipital groove and repaired with tendon to tendon suturing. In group 3, the subscapularis was repaired to the cut humeral neck through transosseous tunnels. The cyclic elongation, load to failure, displacement and mode of failure were analysed. Results: All specimens in Group 1 and 40% of Group 2 and 3 passed the cyclic loading test. The ultimate tensile strength in Group 1 was found to be 2.8 times that of Group 2 and 2.4 times that of Group 3 (p< 0.05). Simple suturing failed by suture cutting out of soft tissue and tranosseous repair failed by a combination of the suture cutting out through bone and soft tissue. Conclusion: This novel technique is simple to perform and biomechanically stronger than established methods of repair. A stronger fixation may allow early mobilization without the risk of tendon rupture and is much less likely to loosen with gap formation and subsequent fibrous tissue interposition. Additional advantages include bone to bone healing without violation of the subscapularis tendon

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

The benefit of open stabilization for recurrent shoulder instability is well known, however there have been recent reports of postoperative dysfunction of the subscapularis tendon following open shoulder surgery (Habermeyer et al, Scheibel et al). We present our findings in patients who have undergone an open anterior stabilization using a subscapularis split approach. We reviewed 48 patients (49 shoulders), who were treated by the senior author (SB) from 2003–2005. They all underwent an open anterior stabilization of shoulder through a deltopectoral approach, with a subscapularis split technique, without any lateral tendon detachment. The minimum follow-up was 2 years, with average 34 months. Thirty-eight shoulders underwent an isolated anterior stabilization (1 bilateral) and 11 patients had additional procedures (8 bone grafts, 1 SLAP repair, 1 cuff repair, 1 anterior and posterior repair). There were 41 male and 7 female patients, and the mean age was 23.9 years (range 15–47 years). All patients were involved in sports and 45 had presented with recurrent dislocations. Patients were followed up using the Oxford instability score and the Rowe score questionnaires. All had a clinical examination for range of movement, stability, subscapularis muscle function, or signs of dysfunction. All had a MRI to assess the quality of the subscapularis muscle and tendon. Mean postoperative Oxford instability score was 22.5 and the Rowe score was 69.38. Two patients had redislocated following re-injury. There was no evidence clinically of subscapularis dysfunction and the muscle and tendon were normal on all MRI scans. External rotation was reduced by a mean of 15.6 degrees. There was no significant loss of flexion or abduction. 81% of patients returned to their previous level of sport. With a subscapularis split technique for anterior shoulder stabilization there is no significant postoperative dysfunction or damage to the subscapularis muscle, and most patients return to their previous level of sport

Internal rotation contracture/tightness presents a functional problem for the patient and a technical challenge for the surgeon performing total shoulder arthroplasty most commonly occurring in cases of osteoarthritis. Internal rotation contractures result from a number of physiologic and biomechanical conditions. Osteophytes, which form around the head and neck of the humerus and glenoid provide a mechanical block to external rotation, which occurs over time. The inability to pass through a full excursion of external rotation tightens the anterior capsular structures over time and causes a contracture of the musculotendinous units (subscapularis and pectoralis major), responsible for internal rotation. The osteophytes themselves also change the vector of pull of the internal rotators and cause them to be “tented” anteriorly. Hence the issues causing an internal rotation contracture and inhibiting external rotation following total shoulder arthroplasty include a mechanical bone block, diminished tissue compliance and abnormal tendon excursion. Management of this problem has frequently been focused predominantly on fractional lengthening the subscapularis tendon, but all components must be addressed at the time of surgery to make sure that a functional range of motion in external rotation can be achieved following reconstruction. This video details the assessment of each of these components and their management. Surgical technique includes: resection of all obstructive osteophytes which block rotation and which cause abnormal tendon excursion; adequate head removal and shaping to provide restoration of an anatomical arc of curvature of the humeral head in continuity with the metaphyseal support base, adequate release of upper pectoralis major tendon tightness, release of capsular contractures and adhesions about the subscapularis muscle and tendon; and fractional lengthening of the subscapularis muscle-tendon itself to allow adequate healthy reattachment of the subscapularis tendon to the more superior aspects of the rotator cuff without allowing anterior instability to occur. Attention to the myotendinous junction rather than thinning the tendon itself has proven to be important in achieving a healthy tendon attachment without significant attenuation. Appropriate seating of the humeral head in anatomic version is also important to prevent unnatural distention of the anterior structures. These surgical techniques should help the surgeon provide an anatomic restoration of motion and function

Introduction: Latarjete operation for anterior shoulder instability, first described by Latarjete in 1954 consists of transfer of the coracoid process through the sub-scapularis tendon to the neck of the scapula. Many modifications were described in the English literature as described by Mc Murray in 1958, by Bonin in 1969 or May in 1970. In 1985, Braly and Tullos emphasized that the Bankart lesion, when present, should be corrected. Rockwood transplants the entire coracoid process onto the neck by “laying it flat” onto the neck of the scapula using two screws instead of one, which gives a larger base for the coracoid transplant. The disadvantages of this procedure, as described in the English literature, are relative shortening of the sub-scapularis tendon, thereby decreasing internal rotation power, limited external rotation and the possibility to damage the musculocutaneous nerve. Purpose of the Study: To demonstrate that transplantation of the coracoid process with its tendon attachments through a split in the subscapularis muscle and tendon without shifting the capsula gives better results then transplant of the coracoid process with capsule-labral repair. The goal of this report is to review the result of our series. Patients and Methods: Between January 2000 and June 2005, 26 Latarjete operations (Rockwood modification) were performed by the senior author. The indication for surgery was failed artroscopic Bankart repair or anterior shoulder instability associated with anterior inferior glenoid deficiencies (“inverted pear” deformity). Five cases were excluded having less than 6 months follow-up. In the first 5 cases in addition to the coracoid process transfer, labral repair with capsular shift was performed whereas in the next 21 cases only coracoid process transplant with excision of the damaged labrum/scar tissue and no capsular shift was performed. The postoperative rehabilitation program was the same for both groups. The patients age and sex was very close in both groups. The parameters for comparison between the two groups were: range of motion, stability after 6 months, return to work and sport activity, satisfaction, and complication rate. Results: 6 months after surgery all patients of both groups returned to full work and sport activity including contact sports. No recurrent dislocation was encountered during this short period of follow up. All patients who underwent this procedure, with or without capsule-labral repair, were satisfied with the procedure. In the small group that included capsulo-labral repair an average of 10 degrees decrease of external rotation was encountered compared to the opposite shoulder. In the second group no decrease in range of motion was found. Conclusion: Transfer of the coracoid process through the subscapularis tendon alone has better results then Latarjete operation complemented with capsulo-labral repair in regard of range of motion. The procedure is simple and of short duration giving the best solution for failed artroscopic procedures or for cases of shoulder instability having anterior inferior glenoid deficiencies. The authors are aware that longer follow up is mandatory

Excessive apoptosis has been found in torn supraspinatus tendon1 and mechanically loaded tendon cells2. Following oxidative and other forms of stress, one family of proteins that is often unregulated are Heat Shock Proteins (HSPs). The purpose of this study was to determine if HSPs were unregulated in human and rat models of tendinopathy and to determine if this was associated with increased expression of regulators of apoptosis (cFLIP, Caspases 3& 8). A running rat supraspinatus tendinopathy overuse model 3 was used with custom microarrays consisting of 5760 rat oligonucleotides in duplicate. Seventeen torn supraspinatus tendon and matched intact subscapularis tendon samples were collected from patients undergoing arthroscopic shoulder surgery. Control samples of subscapularis tendon were collected from ten patients undergoing arthroscopic stabilisation surgery and evaluated using semiquantative RT-PCR and immunohistochemistry. Rat Microarray: Upregulation of HSP 27 (×3.4) & 70 (×2.5) and cFLIP (×2.2) receptor was noted in degenerative rat supraspinatus tendon subjected to daily treadmill running for 14 days compared to tendons of animals subject to cage activity only. Histological analysis: All torn human supraspinatus tendons exhibited changes consistent with marked tendinopathy. Matched subscapularis tendon showed appearances of moderate-advanced degenerative change. Apoptosis mRNA expression: The expression levels of caspase 3 & 8 and HSPs 27 & 70 were significantly higher in the torn edges of supraspinatus when compared to matched subscapularis tendon and control tendon (p< 0.01). cFLIP showed significantly greater (p< 0.001) expression in matched subscapularis compared to supraspinatus and control tendon. Immunohistochemical analysis: cFLIP, Caspase 3 & 8 and HSP 27 and 70 was confirmed in all samples of torn supraspinatus tendon. Significantly increased immunoactivity of Caspase 3& 8 and HSP 27 & 70 were found in torn supraspinatus (p< 0.001) compared to matched and normal subscapularis. The proteins were localized to tendon cells. The finding of significantly increased levels of Heat Shock Proteins in human and rat models of tendinopathy with the co-expression of other regulators of apoptosis suggests that Heat Shock Proteins play a role in the cascade of stress activated-programmed cell death and degeneration in tendinopathy

Purpose: The purpose of this study was to assess long-term functional outcome after arthroscopic acromioplasty for full-thickness rotator cuff tears, to evaluate the efficacy of complementary procedures (biceps tenotomy, extended acromioclavicular resection), and to examine the course of anatomic lesions. Material and methods: From 1988 to 1994, 141 full-thickness rotator cuff tears were treated by arthroscopic acromioplasty. Ninety-eight patients, mean age 60 years, were reviewed clinically, radiographically, and sonographically at more than eight years. The mean preoperative Constant score was 48.5 points. The tear involved the supraspinatus in 18 cases, the supraspinatus and infraspinatus in 40, the supraspinatus and the subscapularis in ten, and all three tendons in 20. Coronal extension showed a distal tear in four, an intermediate tear in 52, and a retracted stump in 32. Systemic acromioplasty was associated in 36 patients with tenotomy of the long head of the brachial biceps and in 44 with acromioclavicular extension. Results: At mean follow-up of 10.7 years (8–13.5), the mean Constant score was 60 points. The clinical outcome was excellent or good in 39.7%, fair in 45.5%, and poor in 14.8. 62.5% of the patients were satisfied or very satisfied. The height of the subacromial space was 5.19 mm at last follow-up compared with 4.3 mm preoperatively. The antalgesic effect of biceps tenotomy was significant when the initial acromiohumeral space was less than 5 mm. This procedure did not produce any significant change in the subacromial height or development of osteoarthritis at last follow-up. Sonography showed stability of the size of the tear in 83.8% of the cases. The results were significantly less satisfactory when the initial tear involved the subscapularis or all three tendons. Conclusion: The clinical results of arthroscopic acropmioplasty for full-thickness tears show long-term stability. Biceps tenotomy improves the antalgesic effect significantly, particularly if the subachromial space measures less than 5 mm preoperatively, without causing significant radiological degradation. Extension to the acromioclavicular level should be systematic in patients with acromioclavicular pain preoperatively and/or radiological anomalies

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor. Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid. All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001). Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery. A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy. Cite this article: 2015;97-B:1090–5