The October 2024 Shoulder & Elbow Roundup360 looks at: Proximal humeral fractures with vascular compromise; Outcomes and challenges of revision arthroscopic rotator cuff repair: a systematic review; Evaluating treatment effectiveness for lateral elbow tendinopathy: a systematic review and network meta-analysis; Tendon transfer techniques for irreparable subscapularis tears: a comparative review; Impact of subscapularis repair in reverse shoulder arthroplasty; Isolated subscapularis tears strongly linked to shoulder pseudoparesis; Nexel and Coonrad-Morrey total elbow arthroplasties show comparable revision rates in New Zealand study; 3D MRI matches 3D CT in assessing bone loss and shoulder morphology in dislocation cases

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears. The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use. Cite this article: Bone Joint J 2024;106-B(9):970–977

Aims

Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients.

The December 2023 Shoulder & Elbow Roundup. 360. looks at: Clavicle fractures: is the evidence changing practice?; Humeral shaft fractures, and another meta-analysis…let’s wait for the trials now!; Hemiarthroplasty or total elbow arthroplasty for distal humeral fractures…what does the registry say?; What to do with a first-time shoulder dislocation?; Deprivation indices and minimal clinically important difference for patient-reported outcomes after arthroscopic rotator cuff repair; Prospective randomized clinical trial of arthroscopic repair versus debridement for partial subscapularis tears; Long-term follow-up following closed reduction and early movement for simple dislocation of the elbow; Sternoclavicular joint reconstruction for traumatic acute and chronic anterior and posterior instability

Aims

The outcomes following nonoperative management of minimally displaced greater tuberosity (GT) fractures, and the factors which influence patient experience, remain poorly defined. We assessed the early patient-derived outcomes following these injuries and examined the effect of a range of demographic- and injury-related variables on these outcomes.

Aims

The aim of this study was to compare the characteristics and outcomes of L-shaped and reverse L-shaped rotator cuff tears.

Aims

The purpose of this study was to identify the changes in untreated long head of the biceps brachii tendon (LHBT) after a rotator cuff tear and to evaluate the factors related to the changes.

Aims

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis.

Aims

The aim of this study was to assess hypertrophy of the extra-articular tendon of the long head of biceps (LHB) in patients with a rotator cuff tear.

We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention.

Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.

Cite this article: Bone Joint J 2014;96-B:75–81.

The June 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: whether reaching a diagnosis is more difficult than previously thought; adolescent and paediatric DDH; the A-frame orthosis and Legg-Calvé-Perthes’ disease; failure of hip surgery in patients with cerebral palsy; adolescent rotator cuff injuries; paediatric peripheral nerve injuries; predicting residual deformity following Ponseti treatment; and the Dunn procedure.

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001).

In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options.

Cite this article: Bone Joint J 2013;95-B:523–9.

This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001). It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign

PURPOSE. We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy. MATERIAL AND METHODS. 20 fresh cadaveric shoulders were dissected by wide delto-pectoral approach. After removal the deltoid and posterior rotator cuff, we removed humeral head on anatomical neck. So we obtained an articular view comparable to arthroscopical posterior portal view. We looked for a structure inserted on subscapularis tendon behind SGHL. By intra-articular view we removed SGHL and CHL from the medial edge of the bicipital groove, then subscapularis tendon from lesser tuberosity. We splitted the rotators interval above the superior edge of subscapularis tendon and observed the connections between subscapularis tendon, CHL and SGHL. RESULTS. 6 shoulders had massive cuff tears and were excluded. No ligamentous structure was visible between rotators interval and subscapularis tendon by simple intra and extra-articular examination. After removal of LGHS humeral insertion, no structure showed vertical attach on tendon yet. But after removal of subscapularis tendon from lesser tuberosity and medial traction we saw constantly a fibers bundle directly inserted onto supero-lateral edge of subscapularis tendon. DISCUSSION/CONCLUSION. Most authors agree about existence of CHL and SGHL and their bone insertions, whereas relations between themselves and subscapularis tendon aren't so well defined. We constantly found an effective link between subscapularis tendon and a fibers bundle mainly coming from LCH. It layed into supero-lateral edge of subscapularis tendon and could be seen only by medial traction of it. This ligamentous structure yields the « Comma Sign » in subscapularis tendon tears. This study confirms our clinical datas

Purpose of the study: Data concerning the teres minor in the context of rotator cuff tears is scarce despite the fact that this muscle plays a crucial role in the event of an infraspinaus tear. The purpose of this study was to analyse the computed tomography and magnetic resonance images of the teres minor muscle in rotator cuff tears. Material and method: The aspect of the teres minor muscle was studied in 1624 shoulders with rotator cuff tears. The axial and sagittal CT or MRI aspect was noted as normal, hypertrophic, atrophic or absent (Walch classification). We searched for correlations with the tendon torn, tear mechanism (trauma, degeneration, mixed), gender, dominance, time to imaging, age at imaging, and fatty infiltration of the supraspinatus, infraspinatus and subscapularis. Results: The teres minor was noted normal in 90.9% of the shoulder, hypertrophic in 5.2%, atrophic in 3.2% and absent in 0.2%. The type of cuff tear had a significant impact (p< 0.0005). Regarding the aspect of the teres minor muscle, the highest percentages were as follows: normal for isolated supraspinatus tears, hypertrophic for supraspinatus and subscapularis tears, atrophic for posterosuperior (supraspinatus, infraspinatus ± teres minor) tears and absent for massive tears involving the supraspinatus, the infraspinatus ± the subscapularis (p< 0.0005). The correlation was statistically significant between the aspect of the teres minor and the grade of fatty infiltration of the infraspinatus (p< 0.0005) and the subscapularis (p< 0.0005). Discussion: The aspect of an atrophic or absent teres minor, which correlates with the trumpet sign in massive tears, was only found in 3.5% of the tears. There would thus be few indications for latissimus dorsi transfer to restore active external rotation

In this retrospective study postoperative subscapularis (SSC) function was measured with an electronic force measurement plate (FMP) and clinical scores and correlated with SSC-muscle cross sectional area on defined MRI-sequences. 82 patients with subscapularis tears (34 isolated SSC tears and 48 combined SSC/SSP tears) were followed up at a mean of 38 (24–72) months after tendon reconstruction with the Constant score (CS) and clinical SSC-tests (Napoleon test, Lift off test). SSC-muscle function was assessed in the belly-press- and the lift off position using a custom made electronic FMP (force in Newton). SSC muscle strength values were compared with the contra-lateral side. SSC-muscle atrophy (muscle cross sectional area in mm. 2. ) was measured on standardised sagittal MRI-planes and compared with a healthy matched control group (CG) (Mann-Whitney-U-Test). The mean CS improved from 51p to 81p in isolated tears (group 1) and from an average 47 p to 78 p in combined tears (group 2) (each p< 0.01). Overall 85% of the patients rated their result as good or excellent. Positive and intermediate postop. Napoleon tests were still present in 30% in group 1 and in 25% in group 2. Mean postoperative SSC-muscle strength in the belly-press position averaged 64 N (contralatera sidel-CL: 86 N) in group 1 and 81 N (CL: 91 N) in group 2. Lift-off test strength averaged 36 N (CL: 69 N) in group 1 and 50 N (CL: 63 N) in group 2 (each p< 0.05). Postoperative MRI revealed a significant reduced SSC muscle cross sectional area for the operated side compared with the CG (group 1: SSC: 1974 mm. 2. ; CG 2980 mm. 2. p< 0,05; group 2: SSC: 1829 mm. 2. ; CG 2406 mm. 2. − SSP: 570 mm. 2. ; CG 812 mm. 2. each p< 0,05). Despite good clinical results after reconstruction of isolated and combined subscapularis tears a marked subscapularis strength deficit remains that is not reflected in the Constant Score, but can be detected with the new measurement device. Additionally a subscapularis muscle atrophy remains in the postoperative course that cannot be reversed by surgery

This study examined the role of vitamin D as a factor accounting for fatty degeneration and muscle function in the rotator cuff. There were 366 patients with disorders of the shoulder. A total of 228 patients had a full-thickness tear (group 1) and 138 patients had no tear (group 2). All underwent magnetic resonance arthrography and an isokinetic muscle performance test. The serum concentrations of vitamin D (25(OH)D₃) were measured.

In general, a lower serum level of vitamin D was related to higher fatty degeneration in the muscles of the cuff. Spearman’s correlation coefficients were 0.173 (p = 0.001), −0.181 (p = 0.001), and −0.117 (p = 0.026) for supraspinatus, infraspinatus and subscapularis, respectively. In group 1, multivariate linear regression analysis revealed that the serum level of vitamin D was an independent variable for fatty degeneration of the supraspinatus and infraspinatus.

The serum vitamin D level has a significant negative correlation with the fatty degeneration of the cuff muscle and a positive correlation with isokinetic muscle torque.

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis. At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively. Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head

The purpose of this study is to report the 1 to 5 year results of arthroscopic Rotator Cuff repairs. Between November 2001 to May 2003, 115 consecutive patients were operated (73 males and 42 females) with arthroscopic repair. 13 patients were lost to follow up, leaving 102 patients available for follow up. Patients were evaluated using the Constant score, satisfaction levels and ultrasound scan to evaluate cuff integrity. Failures were defined as dissatisfied patients and those who had had a re-operation. Re-tear rate was recorded. The mean follow up time was 23.8 months (range 12–61). Mean age was 57.3 years (range 23–78). 47% had a history of trauma. There were 107 patients (95.5%) with full thickness tears and 5 (4.5%) had partial thickness tears. Of the full thickness tears, 8 (7.6%) were massive in size, 36 (34%) large, 44 (41.5%) medium and 18(17%) small. Isolated Supraspinatus (SSP) tear was recorded in 83.5% and subscapularis tear in 7 %. A combination of SSP tear with infraspinatus and teres minor was found in 9.6%. 86% had Acromioplasty (ASD) with or without an AC joint excision arthroplasty. Two patients had Bankart repairs in addition at the time of cuff repair. The mean pre op Constant score was 40.9 points (95% CI 37.3 to 44.5), which had improved to 84.8 (CI 82.2 to 86.9) at last follow-up. 78% returned to same work and 82% returned to pre injury leisure activity. There were 20 re-tears (19.6%). eight of the 102 patients were not satisfied. Five of these patients had revision operation. Arthroscopic cuff repair shows high satisfaction rate (92%) and good functional results with 20% re-tear rate, while offering all the advantages of arthroscopic surgery