Rotator cuff tears are a common cause of shoulder pain and dysfunction. Therefore, the purpose of this in-vitro biomechanical study was conducted to determine the effects of simulated tears and subsequent repairs of the rotator cuff tendons on joint kinematics. Eight paired fresh-frozen cadaveric shoulder specimens (mean age: 66.0 ± 8.7 years) were tested using a custom loading apparatus designed to simulate unconstrained motion of the humerus. Cables were sutured to the rotator cuff tendons and the deltoid. Loads were applied to the cables based on variable ratios of electromyographic (EMG) data and average physiological cross-sectional area (pCSA) of the muscles. An electromagnetic tracking device (Flock of Birds, Ascension Technologies, VT) was used to provide real-time feedback of abduction angle, to which the loading ratio was varied correspondingly. 2 and 4cm tears were made starting at the rotator cuff interval and extending posteriorly. Specimens were randomised to receive either single or double suture anchor repair. In order to quantify repeatability, five successive tests on each of the intact, torn, and repaired cases were performed. Statistical significance was established using One- and Two-way Repeated Measured ANOVAs (p< 0.05). Rotator cuff tears caused alteration in glenohumeral kinematics. A 2cm tear caused the humerus to consistently move posterior through the arc of abduction; however, as the tear increased to 4cm the humerus moved anteriorly, returning towards the intact state. Double row suture anchor repairs more accurately reproduced the kinematics of the intact specimen compared to single row suture anchor repair. The initial posterior displacement in the plane of elevation with the sectioning of the supraspinatus is related to the diminished anterior moment on the glenohumeral joint. As the tear proceeds into the infraspinatus, the anterior and posterior forces become more balanced and a return to near normal intact kinematics was observed. This study demonstrates that double row suture anchor repair more accurately reproduces active shoulder kinematics of the intact shoulder specimens

Introduction. We aim to assess whether radiographic characteristics of the greater tuberosity fragment can predict rotator cuff tears inpatients with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity. Methods. A retrospective single-centre case series of 61 consecutive patients that presented with anterior shoulder dislocations combined with an isolated fracture of the greater tuberosity between January 2018 and July 2022. Inclusion criteria: patients with atraumatic anterior shoulder dislocation associated with an isolated fracture of the greater tuberosity with a minimum follow-up of 3-months. Exclusion criteria: patients with other fractures of the proximal humerus or glenoid. Rotator cuff tears were diagnosed using magnetic resonance or ultrasound imaging. Greater tuberosity fragment size and displacement was calculated on plain radiographs using validated methods. Results. The case series was composed of 22 men and 39 women with a mean age of 65 years (29 - 91 years). The mean follow-up was 15months and median follow up 8.5 months (3 – 60 months). A rotator cuff tear was diagnosed in 14 patients (16%) and involved the supraspinatus (13), infraspinatus (4) and subscapularis (2). Full-thickness tears occurred in 6 patients and partial-thickness tears in 8patients. The mean time from initial injury to rotator cuff tear diagnosis was 5 months (2 – 22 months). The mean greater tuberosity fragment length was 23.4 mm in rotator cuff tear patients versus 32.6 mm in those without a tear (p = 0.006, CI: -15 - -2). The mean greater tuberosity. fragment width was 11.1 mm in rotator cuff tear patients versus 17.8 mm in those without a tear (p = 0.0004, CI: -10 - -2). There was no significant difference in the super inferior and anteroposterior fragment displacement between the two groups. Conclusion. In patients with shoulder dislocations combined with an isolated fracture of the greater tuberosity, rotator cuff tears are associated with a smaller sized greater tuberosity fragment

Massive rotator cuff tears associated with glenohumeral arthritis are currently an unsolvable clinical entity. This study strictly defines the use of bipolar hemiarthroptasty for the entity of RCTA. Materials – Methods: We review our series of 14 patients with Rotator Cuff Tear Arthropathy (RCTA) who underwent a bipolar prosthesis of their shoulder. The average follow up was 27.8 months (range 24–48 months) and the average age was 71 years old (range 57–84 years old), of these 14 patients there were 9 male and 5 female. None of these patients had previous shoulder surgery and all patients underwent conservative treatment that failed to improve their symptoms or range of motion. Results: Preoperatively the average forward flexion was 300, external rotation 100 and the American Shoulder and Elbow Society (ASES) score was 25 points. Postoperativety the average forward flexion improved to 880, external rotation increased to 370 and the ASES score improved to 80 pts, 12 of the 14 patients stated that they had no pain with activities of daily living. Two patients persisted to have moderate pain in everyday activity. Conclusion: We believe that bipolar hemiarthroplasty is currently a good option for treatment of Rotator Cuff Tear Arthropathy, The results of bipolar hemiarthroplasty provided more reliable pain relief than that for hemiarthroplasty

Aims. Rotator cuff tear (RCT) is the leading cause of shoulder pain, primarily associated with age-related tendon degeneration. This study aimed to elucidate the potential differential gene expressions in tendons across different age groups, and to investigate their roles in tendon degeneration. Methods. Linear regression and differential expression (DE) analyses were performed on two transcriptome profiling datasets of torn supraspinatus tendons to identify age-related genes. Subsequent functional analyses were conducted on these candidate genes to explore their potential roles in tendon ageing. Additionally, a secondary DE analysis was performed on candidate genes by comparing their expressions between lesioned and normal tendons to explore their correlations with RCTs. Results. We identified 49 genes in torn supraspinatus tendons associated with advancing age. Among them, five age-related genes showed DE in lesioned tendons compared to normal tendons. Functional analyses and previous studies have highlighted their specific enrichments in biological functions, such as muscle development (e.g. myosin heavy chain 3 (MYH3)), transcription regulation (e.g. CCAAT enhancer binding brotein delta (CEBPD)), and metal ion homeostasis (e.g. metallothionein 1X (MT1X)). Conclusion. This study uncovered molecular aspects of tendon ageing and their potential links to RCT development, offering insights for targeted interventions. These findings enhance our understanding of the mechanisms of tendon degeneration, allowing potential strategies to be made for reducing the incidence of RCT. Cite this article: Bone Joint Res 2024;13(9):474–484

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 shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion. Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms. The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear. We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls. Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient. The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group. This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear

Glutamate regulates the expression of apoptosis-related genes and triggers the apoptosis of fibroblasts in rotator cuff tendons. Subacromial bursitis is always accompanied by symptomatic rotator cuff tear (RCT). However, no study has been reported on the presence of glutamate in subacromial bursa and on its involvement of shoulder pain in patients who had RCT. The purposes of this study were to determine whether the glutamate expression in subacromial bursa is associated with the presence of RCT and with the severity of shoulder pain accompanying RCT.

Subacromial bursal tissues were harvested from patients who underwent arthroscopic rotator cuff tendon repair or glenoid labral repair with intact rotator cuff tendon. Glutamate tissue concentrations were measured, using a glutamate assay kit. Expressions of glutamate and its receptors in subacromial bursae were histologically determined. The sizes of RCT were determined by arthroscopic findings, using the DeOrio and Cofield classification. The severity of shoulder pain was determined, using visual analog scale (VAS). Any associations between glutamate concentrations and the size of RCT were evaluated, using logistic regression analysis. The correlation between glutamate concentrations and the severity of pain was determined, using the Pearson correlation coefficient. Differences with a probability <0.05 were considered statistically significant.

Glutamate concentrations showed significant differences between the torn tendon group and the intact tendon group (P = 0.009). Concentrations of glutamate significantly increased according to increases in tear size (P < 0.001). In histological studies, the expressions of glutamate and of its ionotropic and metabotropic receptors have been confirmed in subacromial bursa. Glutamate concentrations were significantly correlated with pain on VAS (Rho=0.56 and P =0.01).

The expression of glutamate in subacromial bursa is significantly associated with the presence of RCT and significantly correlated with its accompanying shoulder pain.

Acknowledgements: This research was supported by the Basic Science Research Program, through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A3A01018955 and 2017R1D1A1B03035232).

Purpose of the Study: We evaluated the results of surgical treatment for rotator cuff tears accompanied by proximal humerus fractures. Materials and Methods: Between September 2005 and April 2009, among a total of 103 patients undergoing surgical treatment with internal fixation for humerus fracture, 7 patients (6 females, 1 male; mean age 72.4 years; range 56 to 84years) underwent surgical treatment for rotator cuff tears accompanied by proximal humerus fracture. The mean follow-up period was 14 months (range 5 to 24 months). Radiographically, all fractures were classified according to the AO/ASIF system. AO/ASIF system type 11A2 accompanied by 12C2 (n:1), 11B1 (n:2), 11B2 (n:2), 11C2 (n:2). MRI was not used in any of the cases. All rotator cuff tears were determinated during the operation. Rotator cuff tears were repaired by primary suture (n:2), suture anchor (n:5), using the deltoid split approach (after treatment of proximal humerus fracture with open reduction and internal fixation. All patients used shoulder-arm sling for 6 weeks. Standard fracture rehabilitation was performed. Functional and radiographic results were evaluated. Results: None of the patients developed nonunion, implant failure or avascular necrosis. In the final evaluation, the Constant shoulder score was 82.8 (50–100). All patients were satisfied with results. Conclusion: The presence of rotator cuff tears in fractures of the proximal humerus is a especially possible in the elderly. Simultaneous repair of the fracture and rotator cuff does not create a negative functional and radiologic effect and prevents a future functional loss. Therefore the investigation of rotator cuff tears in all proximal humerus fractures and when present, treatment in the same session will increase the success of functional results

Purpose of the study: Little work has been done to assess outcome of rotator cuff tear repair in young adults aged less than 40 years. The purpose of our study was to assess the clinical and anatomic outcomes in a continuous series of arthroscopic rotator cuff repairs performed in patients aged less than 40 years. Material and method: This was a retrospective analysis (2004–2007) of 15 young patients (age 18–39 years, mean 32.7 years) with rotator cuff tears confirmed on the arthroscan. All tears were repaired arthroscopically using the same reinsertion technique with anchors. Patients underwent bilateral assessment (SSV, Constant) at at least 12 months follow-up. A control imaging with injection (arthroscan or arthroMRI) was available in 12 of 15 patients. Results: The series included 7 female and 8 male patients, 13 right and 2 left shoulders; 14 of 15 shoulders were on the dominant side. The time from symptom onset to surgery was 26 months on average. Patients were reviewed at mean 31 months follow-up. Preoperative range of motion was preserved in all patients. The mean preoperative Constant score was 55.5 on the operated side and 91.4 on the other side. The preoperative arthroscan demonstrated partial deep tears of the supraspinatus or infraspinatus in 5 patients with a posterosuperior impingement. The ten other shoulders exhibited full thickness tears of the supraspinatus. At last follow-up, the mean Constant score was 77.2 (range 44–90) with significant improvement of all partial scores except force. Patients resumed their former occupational activities at mean 8 months (range 1–36); resumption of sports activities occurred during the 7th month. Subjective satisfaction rate was 81.7%. Postoperative imaging with injection showed a healed cuff in 83% of the shoulders reviewed (10/12). Discussion: Rotator cuff tears are exceptional in young subjects aged less than 40 years; there is considerable potential for worsening. Outcome after rotator cuff repair is very age dependent. It is important to diagnose these tears early to enable early repair; the anatomic results are good and persistent in younger patients

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position.

A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions.

Re-rupture rates after rotator cuff repair remain high because of inadequate biological healing at the tendon-bone interface. Single-growth factor therapies to augment healing at the enthesis have so far yielded inconsistent results. An emerging approach is to combine multiple growth factors over a spatiotemporal distribution that mimics normal healing. We propose a novel combination treatment of insulin-like growth factor 1 (IGF-1), transforming growth factor β1 (TGF-β1) and parathyroid hormone (PTH) incorporated into a controlled-release tyraminated poly-vinyl-alcohol hydrogel to improve healing after rotator cuff repair. We aimed to evaluate this growth factor treatment in a rat chronic rotator cuff tear model.

A total of 30 male Sprague-Dawley rats underwent unilateral supraspinatus tenotomy. Delayed rotator cuff repairs were then performed after 3 weeks, to allow tendon degeneration that resembles the human clinical scenario. Animals were randomly assigned to: [1] a control group with repair alone; or [2] a treatment group in which the hydrogel was applied at the repair site. All animals were euthanized 12 weeks after rotator cuff surgery and the explanted shoulders were analyzed for biomechanical strength and histological quality of healing at the repair site.

In the treatment group had significantly higher stress at failure (73% improvement, P=0.003) and Young's modulus (56% improvement, P=0.028) compared to the control group. Histological assessment revealed improved healing with significantly higher overall histological scores (10.1 of 15 vs 6.55 of 15, P=0.032), and lower inflammation and vascularity.

This novel combination growth factor treatment improved the quality of healing and strength of the repaired enthesis in a chronic rotator cuff tear model. Further optimization and tailoring of the growth factors hydrogel is required prior to consideration for clinical use in the treatment of rotator cuff tears. This novel treatment approach holds promise for improving biological healing of this clinically challenging problem.

Interstitial supraspinatus tears can cause persistent subacromial impingement symptoms despite non operative treatment. Autologous tendon cell injection (ATI) is a non-surgical treatment for tendinopathies and tear. We report a randomised controlled study of ATI compared to corticosteroid injection (CS) as treatment for interstitial supraspinatus tears and tendinopathy.

Inclusion criteria were patients with symptom duration > 6 months, MRI confirmed intrasubstance supraspinatus tear, and prior treatment with physiotherapy and ≥ one CS or PRP injection. Participants were randomised to receive ATI to the interstitial tear or corticosteroid injection to the subacromial bursa in a 2:1 ratio, under ultrasound guidance. Assessments of pain (VAS) and function (ASES) were performed at baseline, and 1, 3, 6 and 12 months post treatment.

30 participants (19 randomised to ATI) with a mean age of 50.5 years (10 females) and a mean duration of symptoms of 23.5 months. Baseline VAS pain and ASES scores were comparable between groups. While mean VAS pain scores improved in both groups at 3 months after treatment, pain scores were superior with ATI at 6 months (p=0.01). Mean ASES scores in the ATI group were superior to the CS group at 3 months (p=0.026) and 6 months (p=0.012). Seven participants in the CS group withdrew prior to 12 months due to lack of improvement. At 12 months, mean VAS pain in the ATI group was 1.6 ± 1.3. The improvements in mean ASES scores in the ATI group at 6 and 12 months were greater than the MCID (12.0 points). At 12 months, 95% of ATI participants had an ASES score > the PASS (patient acceptable symptom state).

This is the first level one study using ATI to treat interstitial supraspinatus tear. ATI results in a significant reduction in pain and improvement in shoulder function.

Introduction and Objective

Only few studies have investigated the outcome of exercises in patients with glenohumeral osteoarthritis (OA) or rotator cuff tear arthropathy (CTA), and furthermore often excluded patients with a severe degree of OA. Several studies including a Cochrane review have suggested the need for trials comparing shoulder arthroplasty to non-surgical treatments. Before initiation of such a trial, the feasibility of progressive shoulder exercises (PSE) in patients, who are eligible for shoulder arthroplasty should be investigated. The aim was to investigate whether 12 weeks of PSE is feasible in patients with OA or CTA eligible for shoulder arthroplasty. Moreover, to report changes in shoulder function and range of motion (ROM) following the exercise program.

Patients over 70 years old have subclinical or impending rotator cuff dysfunction, raising concern about TSA in this population. The purpose of this study is to examine whether reverse total shoulder arthroplasty (RTSA) should be considered for the treatment of glenohumeral osteoarthritis in the presence of an intact rotator cuff (GHOA+IRC in patients older than 70 years of age.

Twenty-five elderly (>70 years) patients at least one year status-post RTSA for GHOA+IRC were matched via age, sex, body mass index, smoking status, and whether the procedure involved the dominant extremity with 25 GHOA+IRC patients who received anatomic total shoulder arthroplasty (TSA). Standardised outcome measures, range of motion, and treatment costs were compared between the two groups. Treatment cost was assessed using implant and physical therapy costs as well as reimbursement.

Patients who received RTSA for GHO+IRC had significantly lower pre-operative active forward elevation (AFE, 69° vs. 98°, p <0.001) and experienced a greater change in AFE (p=0.01), but had equivalent AFE at final follow-up (140° vs. 142°, p=0.71). Outcomes were otherwise equivalent between groups with no differences. In both those patients who underwent TSA and those that underwent RTSA, significant improvements between pre-operative and final follow-up were seen in all standardised outcome measures and in AFE (p<0.001 in all cases). RTSA provided these outcomes at a cost savings of $2,025 in Medicare reimbursement due to decreased physical therapy costs.

In patients over the age of 70 with GHOA+IRC, RTSA provides similar improvement in clinical outcomes to TSA at a reduced cost while avoiding issues related to the potential for subclinical or impending rotator cuff dysfunction.

The management of patients with massive irreparable rotator cuff tears (RCT) has traditionally proved challenging. This prospective study was undertaken with the aim to assess the overall functional outcome following the use of human dermal allograft in the reconstruction of massive irreparable RCT.

15 patients were included in the study, having a median age of 63 years. All patients underwent open reconstruction of massive irreparable RCT. None of the selected patients had evidence of significant gleno-humeral arthritis. All patients were evaluated pre- and post- operatively by the treating surgeon, and followed up for 12 months. The same physiotherapy protocol was prescribed for all patients. Initial and follow-up assessments were done at regular intervals using the Oxford and quick-DASH scoring systems.

A very high patient satisfaction rate, with substantial improvement in pain and function was noted. There was substantial improvement in Oxford shoulder score from a mean of 23.3 to 8.7 (p<0.01), and a similar improvement in mean quick-DASH score from 50.3 to 23.0 (p<0.01)

Of the 15 patients, 11 had an improvement of >10 in Oxford score, with these reporting a score of <10 after 12 months. None of the patients had any significant complications because of the surgery, and none had a deterioration in Oxford score from their pre-operative status.

We found that Human dermal allograft is a very effective tool in the repair of massive irreparable RCT, with excellent follow-up results after one year.

Anatomy of the rotator cuff tendons, their relationship to the greater tuberosity, and the tensile and compressive properties of the cuff tendons have been extensively studied recently. From these anatomical and biomechanical studies, it has been clarified that stress concentration at the anterior portion of the supraspinatus tendon, shearing force, and mechanical friction as well as the degenerative weakness of the cuff tendons can all play a role in the occurrence of a tear. Strength of initial repair is limited, and thus the arm after repair should be positioned such that undue tension at the repair site is eliminated.

Background:

Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up.

Aims

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

Disuse osteoporosis of the greater tuberosity is a consequence of rotator cuff tear. This is a significant problem as the tendon is implanted into a trough within the greater tuberosity during repair. Failure of the repair is a common complication (up to 50%). We hypothesized that failure in re-implantation is due to deficient bone cell response to mechanical stimulation in the tuberosity. In order to establish whether these cells are capable of responding appropriately to mechanical stimuli, the response of bone cells derived from the tuberosity was compared with that of cells derived from the acromion. This was measured in terms of strain related increases in alkaline phosphatase (ALP) activity, nitric oxide (NO) and prostaglandin (PG) production (which are recognised markers of osteoblast differentiation and their response to mechanical strain).

Primary osteoblasts were cultured from samples of acromion and greater tuberosity taken during routine rotator cuff repair (n=5 pairs). The derived cells were placed under cyclic strain at a physiological magnitude for 10 min at 1Hz using well established controls. Samples of media were analysed for changes in NO and PG production and the cells were reacted for ALP. Cells were stimulated with dexamethasone, ascorbic acid and beta-glycerophosphate (established mediators of osteoblast differentiation) then reacted for ALP.

Preliminary results suggest that cells derived from the acromion exhibit significant increases in cellular NO release and in ALP activity, whereas cells derived from the humeral greater tuberosity fail to exhibit any such increases. In marked contrast cells derived from both sites exhibit increases in ALP activity in response to dexamethasone, ascorbic acid and beta-glycerophosphate treatment.

The results suggest that whilst cells derived from the tuberosity after rotator cuff tear respond appropriately to chemical and hormonal stimuli, they are compromised in their ability to respond to mechanical stimulation. It is tempting to speculate that such relationships are also evident in vivo and that they underpin reimplantation failures.

In 1990, after many years of experience with 150 repairs, an arthroscopic transhumeral rotator cuff reconstruction technique was developed and used by the authors to treat all sizes of rotator cuff tears. This technique allowed the same type of repair to be performed as with the open procedure, thus providing the possibility to achieve the same success rate as an open repair with the advantages of minimally invasive surgery.

We reviewed a total of 307 arthroscopic rotator cuff repair procedures performed on 304 patients between December 1990 and March 1994. There were 150 cases with arthroscopic transhumeral fixation and 157 with tendon end-to-end. Of the 150 transhumeral repair cases studied, 18 cases were traumatic, 124 were Impingement III tears, and eight were defects after calcium removal. The tears were classified as 42 – small, 66 – medium, and 42 – large. Average age was 56 years.

An anterior acromioplasty and an arthroscopic tendon to bone repair using the bone cutting giant needle was performed in all of the cases. An AC joint plasty was done in 20 cases and a tendon transposition in five cases. Postoperatively, the patients started full passive motion a day after surgery and active motion six weeks later.

Of the 150 cases with arthroscopic transhumeral repair cases, it was possible to evaluate 132 patients having 133 procedures. Mean follow-up was five years. The results were evaluated according to the classification of Neer. There were 64% classified as excellent, 34% as satisfactory, and 2% as unsatisfactory. The UCLA average score improved from 15.8 preoperatively to 31.5 postoperatively. Full reconstruction was done in all cases except three.

Arthroscopic transhumeral reconstruction of rotator cuff tear reduces morbidity without having to perform open surgery. This procedure can be performed in an outpatient setting. After the learning curve, repairs are easier than the open method and have fewer complications.

Introduction

Rotator cuff healing after an arthroscopic repair is discussible because of the high incidence of failures. Among biologic augmentations currently used, platelet-rich plasma (PRP) is one of the most applied, supposed to enhance and accelerate the healing process in different musculoskeletal disorders. However, the evidence supporting its successful administration is still lacking, especially in the field of the rotator cuff repair. Our purpose is to clarify if the recovery is accelerated and the integrity of repaired construct is increased in patients undergoing PRP injections after arthroscopic repair of the rotator cuff.

Disturbed muscular architecture, fatty infiltration and muscular atrophy remain irreversible in chronic rotator cuff tears (RCT) even after repair. Poly-[ADP-ribose]-polymerase 1 (PARP-1), a nuclear factor involved in DNA damage repair, has shown to be a key element in the up-regulation of early muscle inflammation, atrophy and fat deposition. We therefore hypothesized that the absence of PARP-1 would lead to a reduction in muscular architectural damage, early inflammation, atrophy and fatty infiltration subsequent to combined tenotomy and neurectomy in a PARP-1 knock-out mouse model.

PARP-1 knock-out (KO group) and standard wild type C57BL/6 (WT group) mice were randomly allocated into three different time points (1, 6 and 12 weeks, total n=72). In all mice the supraspinatus (SSP) and infraspinatus (ISP) tendons of the left shoulder were detached and the SSP muscle was denervated according to a recently established model. Macroscopic muscle weight analysis, retraction documentation using macroscopic suture, magnetic resonance imaging, immunohistochemistry gene expression analysis using real time qPCR (RTqPCR) and histology were used to assess the differences in muscle architecture, early inflammation, fatty infiltration and atrophy between knock out and wild type mice in the supraspinatus muscle.

The SSP did retract in both groups, however; the KO muscles and tendons retracted less than the WT muscles (2.1±21mm vs 3.4±0.41mm; p=0.02). Further assessment of muscle architecture demonstrated that the pennation angle was significantly higher in the KO groups at 6 and 12 weeks (28±5 vs 36±5 and 29±4 vs 34±3; p<0.0001). Combined Tenotomy and neurectomy resulted in a significant loss of muscle mass in both groups compared to the contralateral unoperated side (KO group 62±11% and WT group 52±11%, p=0.04) at 6 weeks. But at 12 weeks postoperatively, there was a significant increase in muscle mass to near normal levels in KO group compared to the WT group (14±6% and 42±7% lower muscle mass respectively; p<0.0001) and less fatty infiltration (12.5 ± 1.82% and 19.6 ± 1.96%, p=0.027). Immunohistochemistry revealed a significant decrease in the expression of inflammatory, apoptotic, adipogenic and muscular atrophy genes at both the 1 week and 6 weeks time points, but not at 12 weeks in the KO group compared to the WT group. This was confirmed by histology.

Our study is the first to show that knocking out PARP-1 leads to decreased loss of muscle architecture, early inflammation, fatty infiltration and atrophy after combined tenotomy and neurectomy of the rotator cuff muscle. Although the macroscopic muscles reaction to injury is similar in the first 6 weeks, its ability to regenerate is much greater in the PARP-1 group leading to a near normalization of the muscle substance and muscle weight, less retraction, and less fatty infiltration after 12 weeks.

Introduction

recent studies recognised metabolic abnormalities as additional factors in the development of rotator cuff (RC) tendinopathy. It has been hypothesised that the insertional area of this tendon is susceptible to degenerative changes due to intrinsic hypovascularization. The mechanisms underlying this process are not yet clear. In this study we attempted to confirm if larger lesions of the RC are related to impaired vasodilatatory response of the local circulation in conditions of “hemodynamic stress”.

Aim

To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap.

Aims

This study compared patients who underwent arthroscopic repair of large to massive rotator cuff tears (LMRCTs) with isolated incomplete repair of the tear and patients with incomplete repair with biceps tendon augmentation. We aimed to evaluate the additional benefit on clinical outcomes and the capacity to lower the re-tear rate.

Hemiarthroplasty has been accepted as a viable alternative in the treatment of painful arthritis due to massive rotator cuff failure in patients with well-preserved functional active forward elevation of the shoulder. Unfortunatley, the early clinical results and long-term durability of hemiarthroplasty for rotator cuff tear arthropathy (RCTA) have been inferior to those seen in other disorders, most notably concentric osteoarthritis. Concern regarding the potential need for revision to a reverse shoulder arthroplasty has given rise to the notion of a resurfacing prosthesis as a primary procedure rather than a traditional stemmed-hemiarthroplasty in the hopes of reducing procedural and postoperative complications.

Eleven resurfacing humeral arthroplasties (Global CAP, Depuy) were performed for RCTA as a primary arthroplasty. There were six males and five females, average age of 74.7 years. 36% had undergone previous surgery on the affected side. All had failed a minimum of one year of non-operative treatment prior to surgery. Follow-up averaged eight months (range 4–12).

Prospective mean data analysis showed an improvement in all scales from preoperative baseline levels inclusive of the SST (3.5–6), ASES assessment form (8–17.5), Constant score (49–79) and the DASH (50–27). Mean active forward elevation remained relatively unchanged (one hundred and nine to one hundred degrees), while mean active external rotation improved (thirty-three to fifty-four degrees). Mean computerised muscle testing showed improvement in both elevation (5.1–7.7 N/m) and external rotation strength (2.6–5 N/m). Radiographic analysis has not shown any evidence of implant loosening to date.

Resurfacing humeral arthroplasty seems to demonstrate early favorable clinical results in this group of patients with RCTA. This may serve as an alternative to a stemmed-hemiarthroplasty in these patients and possibly result in a less complicated revision to a reverse prosthesis in the future should this be deemed necessary. Given these results are early, ongoing clincal followup will be necessary to define the longer-term durability of this procedure.

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff.

Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically.

At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch.

Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment.

Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005).

Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff.

Rotator cuff pathologies are related with higher incidence of morbidity in the modern society in young patients. Although it is well known that rotator cuff is sandwiched between the acromion and humeral head during various movements of the shoulder joint, only few studies have investigated this looking at the humeral head as a culprit for the rotator cuff pathology.

We carried out the cadaveric study of 15 shoulder joints to find out the influence of the humeral head anatomy on the rotator cuff pathology. We dissected 15 shoulder joints and looked at the rotator cuff tears. All the specimens were examined and photographed digitally from the superior aspect of shoulder joint. All these images were entered into a computer and using special software, we carried out 3D reconstruction of these images. With this software, the outermost point of intersection of humerus head with acromion decided. We calculated the area of the humeral head in an outside the acromion and correlated with the rotator cuff tear.

We found that the area of the humeral head outside the acromion is variable, ranging from 18% to 50% of diameter of humeral head (mean 34%, median 33%, mode 20%, 33%, 45%). When the area of humerus head outside the acromion is less than 32% of the diameter of head (i.e. humerus head was more under the acromion and less outside the outer most point of acromion), those specimens had either incomplete or complete rotator cuff tear.

We conclude that when the area of humeral head, covered under the acromion is more than 68% of the diameter of the head, they have more chances of developing rotator cuff pathology as compare to other individual.

Prevalence of rotator cuff tears increases with advancing age (Ellman et al). In spite of proximal humeral fractures being common in the elderly, the influence of a coexistent rotator cuff tear on outcome has, to our knowledge, not been previously investigated. This study prospectively assessed whether the presence of a rotator cuff tear in association with a proximal humeral fracture influences functional prognosis.

85 patients treated conservatively for proximal humeral fractures were evaluated prospectively with Ultrasonography to determine the status of the rotator cuff. Every patient was managed by immobilisation of the arm in a sling for two weeks followed by a course of physiotherapy based on the Neer regime. Functional outcome was measured using the Constant shoulder score and the Oxford shoulder score, at 3-months and 12-months post injury.

Sixty-six of the 85 patients were female. The fractures were equally distributed for hand dominance. There were 27 patients with an undisplaced fracture, 34 patients with Neer's Type II fracture and 24 patients with Neer's Type III and IV fracture. There were 43 patients with full thickness cuff tears and 42 patients with no cuff tear or a partial thickness tear. Full thickness cuff tears were much more frequent in the over 60 year age group, which is consistent with the known increased incidence of cuff tears with increasing age.

The outcome scores at 3 and 12 months showed no statistically significant difference for either the Constant score or the Oxford score with regards to cuff integrity. Analysis of these scores showed no correlation between presence or absence of a full thickness cuff tear and shoulder function

The results of this study indicate that rotator cuff integrity is not a predictor of shoulder function at 12 months following proximal humeral fracture, as measured by outcome scores. This suggests that there is therefore no clinical indication for routine imaging of the rotator cuff in patients for whom conservative management is the preferred treatment option.

Purpose: A major issue in the Canadian health care system are the extensive wait times for consultation with an orthopaedic surgeon. We identified that a high percentage of patients referred to shoulder surgery sub-specialists for chronic full thickness rotator cuff tears had not undergone appropriate non-operative treatment prior to being referred, and ultimately did not require surgery. In an effort to improve the referral process and to optimize patient care, we sought to identify clinical predictors for outcome of non-operative treatment of chronic full-thickness rotator cuff tears. This would allow general practitioners to clearly identify patients who are most likely to fail non-operative treatment and actually require surgical consultation. The primary purpose of this study was to determine if the outcome of non-operative treatment in chronic, symptomatic, full-thickness rotator cuff tears could be predicted based upon presenting clinical characteristics, including: age, dominant extremity involvement, gender, duration of symptoms, onset (acute or chronic), forward elevation range of motion, external rotation strength, size of tear, smoking status, and the Rotator Cuff Quality of Life Questionnaire score (RCQOL).

Method: Fifty patients, between the ages of 40 and 85 years, with a documented full-thickness tear on ultrasound or magnetic resonance imaging (MRI), were recruited prospectively. They underwent a three month home-based program of non-operative treatment under the supervision of an experienced physiotherapist and sport medicine physician. At the conclusion of the three month program, patients were evaluated by an orthopaedic surgeon and were defined as having been successful or as having failed non-operative treatment. Successful patients declined surgical treatment after consulting with the surgeon, whereas failed patients elected to undergo surgery, or, if avoiding surgery for other health or “life” reasons, had not experienced adequate improvement with the non-operative program to have been considered successful. The patient’s baseline clinical characteristics were analyzed using logistic regression to determine which characteristics were predictive of outcome.

Results: Thirty-eight of 50 (76%) of patients were successful with the non-operative program. Univariate analysis showed that a patient’s Rotator Cuff Quality of Life questionnaire score was a significant predictor of outcome of non-operative treatment (p = 0.017). Patients who were successful with non-operative treatment had a mean baseline RCQOL score of 49/100, whereas patients who failed non-operative treatment had a mean baseline RCQOL score of 31/100. The two factors of patient age and dominant extremity involvement also trended toward significance.

Conclusion: Baseline RCQOL score can predict which patients will be successful with non-operative treatment and which patients will fail non-operative treatment for a chronic, full-thickness rotator cuff tear.

Due to an arthroscopic’s surgery progress, almost all type of rotator cuff lesions including massive tears can be repaired. Correct preoperative surgical planning needs combination of dates coming from clinical history, diagnostic imaging and the demand of patient.

Purpose: the goal of this study is to report on the arthroscopic repair of massive rotator cuff tear: surgical techniques used, outcome.

Type of study: retrospective study in 2 Orthopedic Center in Rome (Italy).

Methods: Between 2000 and 2007, 457 patients underwent arthroscopic repair of rotator cuff tear: 93 of these were complete massive cuff tear. The pre-op and postoperative outcomes were analyzed using the Costant Score (CS), Simple Shoulder Test (SST), a single question reflecting satisfaction. The patients were divided in 2 group: massive antero-superior and massive postero-superior cuff tear. The average age of patients was: 55–74 yrs; the average time from onset of symptoms to surgery was 16,7 months.

Results: the CS score improved from 0–3 pre-op to 7–10 post op; the SST score from 18–32 pre-op to 68–90. The patient satisfaction rate was > 90%.

Conclusion: The arthroscopic repair of massive rotator cuff tear is an effective procedure for decresing pain and improving function of the shoulder. The patient satisfaction rate is very high. The right indication to surgery, the correct surgical procedure and the appropriate physical terapy are the keys of success.

The goal of this retrospective study was to evaluate the result of this technique proposed as initial treatment (group 1: 17 cases) or after a failure of repairing cuff (group 2: 7 cases).

Materials and Methods: Eleven females and thirteen males with an average age of fifty six years were available for this study. Initial rupture was always massive (2 tendons, retracted to the glenoid level), superior and posterior(20 cases) with superior lesion of the subscapularis in 4 cases. An ascension of the humeral head was found in 18 cases. Degree of fatty degeneration evaluated with CT arthrogram was 3.45 for the supra spinatus and 3.25 for the infra spinatus. The latissimus dorsi was harvested with axillary approach and released from the angle of the scapula to be able to cover the humeral head. Coraco acromial arch was preserved. Abduction splint was maintained 6 weeks.

Results: The average follow up was 21 months(12/48). For the 24 patients Constant score was improved from 34,6 to 55,6(+21): a significant improvement of forward active elevation from 98° to 153 (+55°) but a little improvement of external rotation from 23 to 33 (+10°). The best results were obtained in group 1: constant score progressed from 34 to 58 (+24) with an increasing of 66° (98 to 164°) of forward active elevation and 13°(22 to 35°) of external rotation. Results of group 2 are less: Constant score progressed from 36 to 51(+15), forward elvevation 33°(96 to 129°) and 3° (27 to 30°) of active external rotation. 2 failures caused by a rupture of the transfer. Painrelief was obtained in 90% but any improvement of strength.

Discussion and Conclusion: Ours results indicate that latissimus dorsi transfer improves range of motion, pain, function and patient satisfaction with irreparable rotator cuff tear. We recommend to use it for pseudoparalytic and painfull shoulder, with a persistent acriomo humeral space, after failure of rehabilatation, for young patient. A stable humeral head with a good subscapularis without previous operation are good pronostic factors.

Aims

Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided.

Our study aimed to determine the presence of rotator cuff tears in asymptomatic shoulders of patients with symptomatic tears in the contralateral shoulder.

We asked 50 patients between the ages 40 and 83 years to complete a questionnaire. A single radiologist carried out ultrasonographic evaluation of both shoulders. Impingement signs were graded according to Neer’s classification and tears were graded according to Wiener and Seitz’s classification.

In 53% of asymptomatic shoulders there were tears that did not greatly differ from those on the symptomatic side. The only difference between asymptomatic and symptomatic tears was subacromial bursitis and biceps tendinopathy.

The high incidence of asymptomatic rotator cuff tears suggests that initial treatment of rotator cuff tears should be conservative and based on clinical judgment rather than on imaging modalities.

The purpose of this study was to investigate the role that genetics play in the aetiology and symptomatology of full thickness tears of the rotator cuff.

From a retrospective, cohort study of 205 patients diagnosed with full thickness rotator cuff tears, we determined, using ultrasound, the prevalence of full thickness tears in their 129 siblings. Using 150 spouses as controls, the relative risk of full thickness rotator cuff tear in siblings v controls was 2.42 (p< 0.0001, 95 % CI 1.77 to 3.31). The relative risk of symptomatic full thickness rotator cuff tear in siblings v controls was 4.65 (p< 0.0001, 95 % CI 2.42 to 8.63).

The significantly increased risk for tears in siblings implies that genetic factors play a major role in the development of full thickness tears of the rotator cuff.

Introduction and purpose: The functional result of the functional repair of the rotator cuff is multifactorial. The purpose of this study was to assess the influence of supraspinatus and infraspinatus fatty degeneration prior to surgery on the functional result of open rotator cuff repair surgeries.

Materials and methods: The study comprised 32 patients (19 females and 13 males) operated on for a rotator cuff tear by means of open surgery. Mean age: 58.16. The right arm was involved in 20 cases, whereas the left one was involved in the remaining 12. The acromion was type II in 28 cases and type III in 4. In all cases a previous MRi was available. The analysis of fatty degeneration was made on the basis of Goutallier’s criteria. The assessment of the functional result was made according to Constant’s score. Minimum follow-up: 1 year.

Results: Mean Constant score: preop 51.41 (range: 30–69); postop (at the end of follow-up) 83 (range: 77–100). Fatty degeneration of the supraspinatus was deg. I in 32.25% of cases and deg. II in 45.16%. As regards the infraespinatus, 38,7% of cases had no fatty degeneration and 41.93% had deg. I. No significant differences were found regarding the post Constant score between patients with deg. 0-I supraspinatus fatty degeneration and patients with 0-I infraspinatus fatty degeneration (p 0.604) or between patients with deg. II-III-IV supraspinatus fatty degeneration and those with deg. 0-I infraspinatus fatty degeneration (p.654).

Conclusions: (1) Surgical repairs of rotator cuff tears lead to a satisfactory final functional result. (2) Considering the size of our sample, there do not seem to exist significant differences with respect to functional result between patients with supraspinatus (degrees 0–4) and patients with infraspinatus fatty degeneration (limited to deg. 0–1).

Purpose: With this retrospective study, the results of rotator cuff repairs in patients of 60 years and older were compared to patients younger 60.

Methods: 76 patients with an average age of 65 years (60–78 years, group A) and 167 patients younger 60 years (group B) were clinical (Constant – score) and sonographical examined after follow-up of 2 years after reconstruction of the rotator cuff.

Results: In group A, 24 one-, 37 two-, 11 three- and 4 four-tendon tears were treated and the average age and gender adjusted Constant-score was 90,4% (13–126%). 29% showed sonographical signs of a re-defect. In group B, 56 one-, 69 two-, 33 three-, and 9 four-tendon tears were treated and the average age and gender adjusted Constant-score was 81,1% (15–116%). 32% showed sonographical signs of a re-defect.

Conclusion: Both groups did not show significant differences regarding clinical results in the Constant-score size of the rotator cuff defect or occurrence of re-tears. The results in patients older 60 were even better than in younger patients, therefore the older age of the patient should not be primary reason for not repairing a symptomatic rotator cuff tear.

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.

The assessment of the arthroscopic findings in patients suffering from impingement syndrome and partial tear of the supraspinatus tendon, staged as type 1& 2 under Ellman, Gartsman, Snyder, that were treated by acromioplasty, debridment and repair of the supraspinatus tear.

Thirty four patients,(20 male, 14 female), with a median age of 52 years, (48–64 years old), underwent shoulder joint arthroscopy. All were evaluated by two physicians and subjected to plain films (AP& Y views) as well as to MRI.

Clinically, the differencies in the evaluation of patients with type 1& 2a lesion were insignificant. Type 2b had a better outcome, but in comparison to type 1, that were subjected only to acromioplasty, variations involving range of motion, pain and scoring (Constant & Oxford scores), were observed, from the first stages of rehabilitation, with no further improvement. The comparative method in relation to the clinical trials was in favor of those patients treated with repair of the tear.

After a 29 m follow up, we suggest only acromioplasty, in stages 1& 2a, although the daily activities of each patient can change the approach. In type 2b lesions, irrespective of age, we suggest the repair of the tear

Aim: To compare results of hemi arthroplasty (Aequalis) and reverse arthroplasty (Delta) in treatment of arthropathy with massive cuff tear.

Methods: This was a multicentric study included 142 shoulder arthroplasties (80 reverse and 62 hemiarthroplasties). The pre-op. status was similar in two population according to Constant score, active anterior elevation (AAE) and active external rotation (AER).

Results: The patients were evaluated with a mean follow-up of 44 months. There were 7 failures needed 5 revisions (2 in hemi group and 3 in reverse one). The Constant score was significantly better (p< 0,01) in reverse group (65.6) than in hemi group (46.2). AAE was significantly better (p< 0,01) in reverse group (138°) than in hemi group (96°). AER was significantly better (p< 0,05) in hemi group (22°) than in reverse group (11°) but external rotation in elevated position and internal rotation were not different. These results stay similar even with a follow up over 5 years. In reverse group, partial glenoid unscrewing was observed in 3 patients, and a notch in pillar of scapula in 50 cases. In hemi group, upward migration was observed in 32 cases.

Conclusions: We found significantly better results for reverse prostheses. The inherent risk of hemiarthroplasties is upward migration wearing the coraco acromialarch. The inherent risk of reverse prosthesis is the notch in scapula, and the strain on glenoid fixation, but the results over 5 years stay satisfactory.

Purpose: The goal of this retrospective study was to analyze the results of each kind of reoperation used in rotator cuff retear.

Materials and Methods: 38 rotator cuff retear were reoperated. 18 female and 20 male with a mean age was 57(range 40 to 73 years). Initial tear were repaired by open surgery with a procedure of trans osseous reinsertion in 26 cases. Arthro CT Scan, confirmed the recurrent tear and evaluated the size, number of tendon involved and the global fatty degeneration index (GFDI) of the muscle.The size of the retear was smaller in 9 patients, same in 5 and bigger in 23 with always a decreasing of the GFDI from 0.83 to 1.60. The mean time of reoperation was 29 months(range 1 to 120). We performed 14 trans osseous reinsertion, 6 latero lateral tendinous suture, 3 resection reinsertion, 5 deltoid flap, 3 latissimus dorsi flap, 4 reversed prosthesis, one arthrodesis, one subscapularis flap and one debridment for acute infection. A biceps tenodesis were performed in 20 cases.

Results: Results were evaluated with a mean follow-up of 33 months (range 5 to 145). The constant’s score improved from 46(22 to 68) preoperatively to 67(40–95) post operatively with a decreasing of the GFDI in 0.83 to 1.60. The best results were obtained with a trans osseous reinsertion (Constant’s score 70; gain 40%) and latero lateral tendinous suture(Constant’s score 78; gain 37%). However, the gain higher was obtained with the reversed prosthesis(Constant’s score 57;gain 88%).

Discussion and Conclusion: Arthro CT Scan is a good way to diagnose a recurrent rotator cuff tear and to choose the type of new operation when shoulder still painfull. The final result is higher if it is possible to do a transosseous reinsertion for a small retear with a good trophicity of the muscle (GFDI lower). However for pseudo paralytic shoulder, reversed prosthesis can improved the constant’s score from 34 to 64 with a restoration of a good elevation. Latissimus dorsi flap (deltoid and subscapularis flap) are usefull for painrelief but the improvement of motion is less.

Aim of Study: To evaluate the efficacy of pulsed radio-frequency ablation to the suprascapular nerve in patients with chronic shoulder pain secondary to cuff tear arthropathy.

Methods: Twelve patients with chronic shoulder pain secondary to cuff tear arthropathy were recruited following ethics approval. Mean age 68 yrs (60–83 yrs). The suprascapular notch was identified under image intensifier and the suprascapular nerve lesioned with pulsed radiofrequency ablation for 120 seconds. Patients were assessed with the Oxford and Constant Shoulder scores, Visual Analogue pain score and sleep score pre, 3 and 6 months post procedure. Statistical analysis was undertaken using the Friedman test (non parametric analysis of variance).

Results: Ten patients had an improvement in the visual analogue pain score and Constant score, 11 in the Oxford score and all an improvement in sleep pattern.

Conclusions: Shoulder pain was reduced in 10 out 12 patients up to 6 months post procedure. This procedure may be a useful adjunct in elderly patients with painful cuff tear arthropathy who are not suitable for surgery.

Synovitis in the subacromial bursa (SAB) and the gle-nohumeral joint (GHJ) is often seen in rotator cuff diseases. In order to clarify its significance, following studies were conducted. The mRNA expression levels of IL-1B, sIL-1ra and icIL-1ra and the amount of substance P in the SAB synovium were correlated with the degree of shoulder pain. The cytokine-mRNAs in the GHJ synovium expressed more significantly in full-thickness tears (perforating tears) than in non-perforating tears. Biochemical markers (MMP-1, MMP-3) in the GHJ fluid were significantly higher in massive cuff tears than in smaller tears. These findings suggest the possibility that SAB and GHJ synovitis in rotator cuff diseases are associated with shoulder pain and the development of glenohumeral arthropathy, respectively.

Aims

The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff.

Background: Prevalence of rotator cuff tears increases with advancing age (Ellman et al). In spite of proximal humeral fractures being common in the elderly, the influence of a coexistent rotator cuff tear on outcome has, to our knowledge, not been previously investigated.

Aim: This study assess whether the presence of a rotator cuff tear in association with a proximal humeral fracture influences prognosis.

Methods: 85 patients treated conservatively for proximal humeral fractures were evaluated prospectively with Ultrasonography to determine the status of the rotator cuff. Every patient was managed by immobilisation of the arm in a sling for three weeks followed by a course of physiotherapy based on the Neer regime. Functional outcome was measured using the Constant shoulder score and the Oxford shoulder score, at 3-months and 12-months post injury.

Results: Sixty-Six of the 85 patients were female. The fractures were equally distributed for hand dominance. There were 27 patients with an undisplaced fracture, 34 patients with Neer’s Type II fracture and 24 patients with Neer’s Type III and IV fracture. There were 43 patients with full thickness cuff tears and 42 patients with no cuff tear or a partial thickness tear. Full thickness cuff tears were much more frequent in the over 60 year age group, which is consistent with the known increased incidence of cuff tears with increasing age.

The outcome scores at 3 and 12 months showed no statistically significant difference for either the Constant score or the Oxford score with regards to cuff integrity. Analysis of these scores showed no correlation between presence or absence of a full thickness cuff tear and shoulder function

Conclusion: The results of this study indicate that rotator cuff integrity is not a predictor of shoulder function at 12 months following proximal humeral fracture, as measured by outcome scores. This suggests that there is therefore no clinical indication for routine imaging of the rotator cuff in patients for whom conservative management is the preferred treatment option.

Aim: The prevalence of rotator cuff tears increases with advancing age. Proximal humeral fracture are also common in the elderly, but the influence of a coexistent rotator cuff tear on clinical outcome following fracture has not been previously investigated.

Method: In this study 85 patients treated conservatively for proximal humeral fractures were evaluated with ultrasonography to determine the status of the rotator cuff. Outcome was evaluated using the Constant shoulder score and Oxford shoulder score, and recorded at 3 months and 12 months follow up. The null hypothesis is that there is no correlation between the presence of absence of cuff tear following fracture and clinical outcome.

The data was analysed to determine if the presence of a full thickness rotator cuff tear influenced functional outcome in these patients.

The null hypothesis has not been disproved. There is no statistically significant difference in outcome with presence of an associated full thickness rotator cuff tear with proximal humeral fractures.

Conclusion: At present this study suggests that there is no indication for routine ultrasonography evaluation of the rotator cuff following proximal humerus fracture.

Introduction

We performed humeral head replacement (HHR) with smaller head for closing the cuff defect in patients of cuff tear arthropathy (CTA). And also, if the cuff defect could not close by decreasing the head size, we add muscle tendon transfer such as latissimus dorsi transfer for posterosuperior defect and pectoralis major transfer for anterosuperior defect.

Introduction

In recently, Reverse shoulder arthroplasty (RSA) in patients with irreparable rotator cuff tear has been worldwidely performed. Many studies on RSA reported a good improvement in flexion of the sholulder, however, no improvement in external rotation (ER)and internal rotation motion (IR). Additionally, RSA has some risks to perform especially in younger patients, because high rates of complications such as deltoid stretching and loosening, infection, neurologic injury, dislocation, acromial fracture, and breakage of the prosthesis after long-term use were reported. Favard et al noted a 72% survival with a Constant-Murley score of <30 at 10 years with a marked break occurring at 8 years. Boileau et al noted caution is required, as such patients are often younger, and informed consent must obviously cover the high complication rate in this group, as well as the unknown longer-term outcome. Its use should be limited to elderly patients, arguably those aged over 70 years, with poor function and severe pain related to cuff deficiency. We developed a novel strategy in 2001, in which we used the humeral head to close the cuff defect and move the center of rotation medially and distally to increase the lever arm of the deltoid muscle.

Surgical repair of rotator cuff tendon is one of the most common orthopaedic procedures performed in the United States. This prospective single-surgeon study reports the long-term results of chronic rotator cuff repair. Vigorous statistical analysis was carried out to detect any association of various outcome parameters with the exact surgical pathology.

105 consecutive shoulders (97 patients) undergoing open repair of chronic (> 3 months) rotator cuff tear between 1975 to 1983 by the senior author were recruited to the study. Pain unresponsive to nonoperative treatment was the indication for surgery. The details of patient’s medical records, radiographic data, and the operative findings were prospectively reviewed. There were 67 males and 30 females with a mean age of 58 years (range, 38 to 75). Follow-up averaged 11 years with no patients lost to follow-up. There were 16 small, 40 medium, 38 large and 11 massive tears.

Surgical repair relieved pain in 92% of patients (p< 0.0001). There was also a significant improvement in range of motion (p< 0.0001) and strength of abduction and external rotation following surgery (p< 0.0001). Return of movement and strength decreased with increasing tear size. At the latest follow-up results were rated as excellent in 68 shoulders, satisfactory in 12, and unsatisfactory in 25. 8 out of the 11 massive tears had unsatisfactory outcome. There were eight reoperations for traumatic retears.

Standard tendon repair techniques combined with adequate postoperative protection and monitored physical therapy produced consistently satisfactory results. Introduction of experimental repair methods should be confined to those patients with massive tendon tears and only then with the hope of increasing function, as pain relief is satisfactory with usual treatment methods.

Introduction: Shoulder pain, caused by subacromial impingement or rotator cuff tear, is common for the middle-aged and elderly people. It can cause diminished ability to work and prolonged sick-leaves. The purpose of this study was to evaluate the effect of the operative treatment of this pain (arthroscopic subacromial decompression, rotator cuff repair) when the patients returned home the same day (outpatient) from the day-surgery unit or stayed 1–3 nights at the ward (hospitalized).

Methods: Ninety-three patients were included in this prospective, comparative study. The inclusion criteria were:

1) shoulder pain more than 6 months with no response for conservative treatment,

The minimum of the follow-up was 2 years (range 24 to 32 months), and 76 patients (82%) participated to the evaluation at this point. In the outpatient group were 37 patients (24 subacromial impingements, 13 rotator cuff tears), and in the hospitalized group 39 patients (23 subacromial impingements, 16 rotator cuff tears). Evaluation methods were clinical examination, radiographic evaluation, isometric elevation strength measurements, as well as the University of California Los Angeles (UCLA) and Constant shoulder scores. All operations were done by one experienced orthopaedic surgeon, and all evaluations at the follow-up by one independent examiner.

Results: At the follow-up, both shoulder scores (UCLA, Constant) were significantly better than the preoperative scores in every patient group (p< 0.001). In the patients with subacromial impingement, muscle strengths of the operated shoulders improved to the level of non-operated, contralateral shoulders, while in the patients with rotator cuff tear, the strength was still diminished (the mean difference in elevation strengths when comparing to the contralateral side was 1.8 kg). However, no significant differences in the shoulder scores or muscle strengths were found when the outpatient group and hospitalized group were compared.

Conclusions: Operative treatment of subacromial impingement and rotator cuff tear after failed conservative treatment led to good results at 2-year follow-up. The patients in the outpatient-group had similar results than the patients in the hospitalized patient-group. However, because the hospitalization is more expensive, the outpatient surgery is recommended.

Arthroscopic management has been recommended for some SLAP lesions, but no studies have focused on patients over 50 with rotator cuff tear and Type II SLAP lesion. Our hypothesis was that there was no difference in clinical outcome between repairing of the Type II SLAP lesion and tenotomy of the long head of the biceps tendon after having repaired the rotator cuff tear. This was a randomized controlled clinical trial.

We recruited 63 patients. In 31 patients, we repaired the rotator cuff and the Type II SLAP lesion (Group 1). In the other 32 patients, we repaired the rotator cuff and tenomized the long head of the biceps (Group 2). 7 patients (2 in the group 1 and 5 in the group 2) were lost to final follow up.

At the 5.2 year follow-up, statistically significant differences were seen with respect to the UCLA score and ROM values. In Group 1 (SLAP repair and rotator cuff repair), the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.4 (range 6 to 14) to an average of 27.9 (24–35) postoperatively (P< 0.001). In Group 2 (biceps tenotomy and rotator cuff repair) the UCLA showed a statistically significant improvement from a pre-operative average rating of 10.1 (range 5 to 14) to an average of 32.1 (range 30 to 35) post-operatively (P< 0.001) There was statistically significant difference in total post-operative UCLA scores and ROM when comparing the two groups post-operatively (P< 0.05).

There are no advantages in repairing a Type II SLAP lesion when associated with a rotator cuff tear in patients over 50. Rotator cuff repair alone is sufficient to produce a good post-operative outcome, allowing to avoid post-operative stiffness of the shoulder.

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

Failure of healing is a well-known problem after repair of the rotator cuff. This study aimed to investigate if early repair of trauma-related full-thickness rotator cuff tears (FTRCTs) could prevent this failure.

Aims

A trial-based comparison of the use of resources, costs and quality of life outcomes of arthroscopic and open surgical management for rotator cuff tears in the United Kingdom NHS was performed using data from the United Kingdom Rotator Cuff Study (UKUFF) randomised controlled trial.

Aims

The aim of this study was to analyse human muscle tissue before and after rotator cuff repair to look for evidence of regeneration, and to characterise the changes seen in the type of muscle fibre.

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears. Cite this article: Bone Joint J 2024;106-B(9):978–985

Rotator cuff tears are common, with failure rates of up to 94% for large and massive tears. 1. For such tears, reattachment of the musculotendinous unit back to bone is problematic, and any possible tendon-bone repair heals through scar tissue rather than the specially adapted native enthesis. We aim to develop and characterise a novel soft-hard tissue connector device, specific to repairing/bridging the tendon-bone injury in significant rotator cuff tears, employing decellularised animal bone partially demineralised at one end for soft tissue continuation. Optimisation samples of 15×10×5mm. 3. , trialled as separate cancellous and cortical bone samples, were cut from porcine femoral condyles and shafts, respectively. Samples underwent 1-week progressive stepwise decellularisation and a partial demineralisation process of half wax embedding and acid bathing. Characterisations were performed histologically for the presence/absence of cellular staining in both peripheral and central tissue areas (n=3 for each cortical/cancellous, test/PBS control and peripheral/central group), and with BioDent reference point indentation (RPI) for pre- and post-processing mechanical properties. Histology revealed absent cellular staining in peripheral and central cancellous samples, whilst reduced in cortical samples compared to controls. Cancellous samples decreased in wet mass after decellularisation by 45.3% (p<0.001). RPI measurements associated with toughness (total indentation depth, indentation depth increase) and elasticity (1st cycle unloading slope) showed no consistent changes after decellularisation. X-rays confirmed half wax embedding provided predictable control of the mineralised-demineralised interface position. Initial optimisation trials show proof-of-concept of a soft-hard hybrid scaffold as an immune compatible xenograft for irreparable rotator cuff tears. Decellularisation did not appreciably affect mechanical properties, and further biological, structural and chemical characterisations are underway to assess validity before in vivo animal trials and potential clinical translation

Objectives . Rotator cuff tears are among the most common and debilitating upper extremity injuries. Chronic cuff tears result in atrophy and an infiltration of fat into the muscle, a condition commonly referred to as ‘fatty degeneration’. While stem cell therapies hold promise for the treatment of cuff tears, a suitable immunodeficient animal model that could be used to study human or other xenograft-based therapies for the treatment of rotator cuff injuries had not previously been identified. Methods . A full-thickness, massive supraspinatus and infraspinatus tear was induced in adult T-cell deficient rats. We hypothesised that, compared with controls, 28 days after inducing a tear we would observe a decrease in muscle force production, an accumulation of type IIB fibres, and an upregulation in the expression of genes involved with muscle atrophy, fibrosis and inflammation. Results . Chronic cuff tears in nude rats resulted in a 30% to 40% decrease in muscle mass, a 23% reduction in production of muscle force, and an induction of genes that regulate atrophy, fibrosis, lipid accumulation, inflammation and macrophage recruitment. Marked large lipid droplet accumulation was also present. Conclusions . The extent of degenerative changes in nude rats was similar to what was observed in T-cell competent rats. T cells may not play an important role in regulating muscle degeneration following chronic muscle unloading. The general similarities between nude and T-cell competent rats suggest the nude rat is likely an appropriate preclinical model for the study of xenografts that have the potential to enhance the treatment of chronically torn rotator cuff muscles. Cite this article: Bone Joint Res 2014;3:262–72

The June 2012 Shoulder & Elbow Roundup. 360. 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.

The aim of this study was to observe the macroscopic and microscopic appearance of the Coracoacromial ligament and Subacromial bursa during Subacromial decompression and correlate it with the outcome at 3 months. Twenty patients with Subacromial Impingement without Rotator Cuff tear and five patients with large/massive irreparable Rotator Cuff tears who underwent a Subacromial Decompression. Patients with other shoulder pathology were excluded. Patients completed an Oxford Shoulder Score pre-operatively and their injection history was noted. At operation the shape of the acromion was noted. The macroscopic appearance of the CA ligament and the Subacromial bursa was classified as normal, mild/moderate and severe. Biopsies of the Subacromial bursa and CA ligament were taken and were analysed using histological and contempory immunocytochemical techniques. A histological analysis was performed using Mayer’s Haemotoxylin and Eosin, Toluidine Blue and Congo Red. Sections were stained with primary antibodies against PCNA (Proliferating cell nuclear antigen), Mast Cell Tryptase, CD3 (T-cell), CD20 (B cell), CD 34 (QBEnd 10), CD45 (Leucocyte Common Antigen), CD68 and D2–40 (Lymphatic Endothelial Marker). Post operatively the patients completed an Oxford Shoulder Score at 3 months. All the patients demonstrated an improvement in their Oxford Shoulder Score. The histological analysis demonstrated thickening of the synovial membrane and increased vascularity within the bursa and ligament. Increased numbers of inflammatory cells were present within the ligament and bursa of patients with impingement compared with massive rotator cuff tears. There was a relationship between outcome and the appearance of the bursa and ligament

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.

Our aim was to determine the most repeatable three-dimensional measurement of glenoid orientation and to compare it between shoulders with intact and torn rotator cuffs. Our null hypothesis was that glenoid orientation in the scapulae of shoulders with a full-thickness tear of the rotator cuff was the same as that in shoulders with an intact rotator cuff. We studied 24 shoulders in cadavers, 12 with an intact rotator cuff and 12 with a full-thickness tear. Two different observers used a three-dimensional digitising system to measure glenoid orientation in the scapular plane (ie glenoid inclination) using six different techniques. Glenoid version was also measured. The overall precision of the measurements revealed an error of less than 0.6°. Intraobserver reliability (correlation coefficients of 0.990 and 0.984 for each observer) and interobserver reliability (correlation coefficient of 0.985) were highest for measurement of glenoid inclination based on the angle obtained from a line connecting the superior and inferior points of the glenoid and that connecting the most superior point of the glenoid and the most superior point on the body of the scapula. There were no differences in glenoid inclination (p = 0.34) or glenoid version (p = 0.12) in scapulae from shoulders with an intact rotator cuff and those with a full-thickness tear. Abnormal glenoid orientation was not present in shoulders with a torn rotator cuff

Intra-synovial tendon injuries affect compressed tendon within a synovial environment (eg Rotator cuff tears of the shoulder) and frequently demonstrate ‘failed healing'. Current therapeutic methods for tendon tears (intra-synovial corticosteroid medication and surgical debridement) offer poor outcomes and new strategies for enhancing repair are needed. We have therefore evaluated two different approaches involving the use of mesenchymal stem cells and scaffolds. Bone marrow- and synovial-derived stem cells were capable of adhering to cut surfaces of tendon in vitro and modulating the release of extracellular matrix into the media. However, when administered in vivo into the digital flexor tendon sheath in naturally-occurring deep digital flexor tendon tears in horses and in an experimental model in sheep, neither cell type was capable of healing the tendon defect. Superparamagnetic iron oxide particle labelling of the implanted cells imaged using MRI and histologically revealed that cells only engraft into the synovium. In contrast a non-cellularised bilayered electrospun and woven polydioxanone scaffold, when used in the same experimental sheep model via a modified open approach and sutured over the created defect resulted in no local or systemic signs of excessive inflammation 3 months after implantation. All the tendon lesions healed with only a mild local inflammatory reaction and minimal-to-mild adhesion formation. Significant proliferative fibroblast infiltration was observed within and immediately adjacent to the implanted scaffold. The cellular infiltrate was accompanied by an extensive network of new blood vessel formation within the new tissue. In conclusion, the use of a scaffold to cover the defect appears to be a more successful strategy to repair intra-synovial tendon defects than intra-synovially injected mesenchymal stem cells. It remains to be tested whether the combination of the two techniques might offer an even better healing response

Aims. The aim of this study was to analyze the results of reverse shoulder arthroplasty (RSA) in patients with type 1 sequelae of a fracture of the proximal humerus in association with rotator cuff deficiency or severe stiffness of the shoulder. Patients and Methods. A total of 38 patients were included: 28 women and ten men. Their mean age at the time of arthroplasty was 73 years (54 to 91). Before the RSA, 18 patients had been treated with open reduction and internal fixation following a fracture. A total of 22 patients had a rotator cuff tear and 11 had severe stiffness of the shoulder with < 0° of external rotation. The mean follow-up was 4.3 years (1.5 to 10). The Constant score and the range of movement of the shoulder were recorded preoperatively and at final follow-up. Preoperatively, radiographs in two planes were performed, as well as CT or arthro-CT scans; radiographs were also performed at final follow-up. Results. The mean Constant score improved from 25 points (5 to 47) preoperatively to 57 points (15 to 81) postoperatively. The mean forward elevation of the shoulder increased from 73° (10° to 130°) preoperatively to 117° (15° to 170°) postoperatively. Previous surgery did not influence the outcome. Patients with rotator cuff tears had lower Constant scores than patients without (p = 0.037). Those with preoperative stiffness of the shoulder had lower postoperative external rotation compared with patients without stiffness (p = 0.046). There was no radiographic evidence of loosening. Three complications occurred, leading to revision surgery in two patients. In all, 17 patients rated their result as very good (45%), another 17 as good (45%), two as satisfactory (5%), and two as unsatisfactory (5%). Discussion. RSA is an effective form of treatment for patients with type 1 sequelae of a fracture of the proximal humerus associated with rotator cuff deficiency or stiffness of the shoulder, with high rates of satisfaction. Rotator cuff tears and stiffness of the shoulder had an adverse effect on the clinical outcome. Cite this article: Bone Joint J 2018;100-B:318–23

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.

Objectives. Rotator cuff tears are among the most frequent upper extremity injuries. Current treatment strategies do not address the poor quality of the muscle and tendon following chronic rotator cuff tears. Hypoxia-inducible factor-1 alpha (HIF-1α) is a transcription factor that activates many genes that are important in skeletal muscle regeneration. HIF-1α is inhibited under normal physiological conditions by the HIF prolyl 4-hydroxylases (PHDs). In this study, we used a pharmacological PHD inhibitor, GSK1120360A, to enhance the activity of HIF-1α following the repair of a chronic cuff tear, and measured muscle fibre contractility, fibrosis, gene expression, and enthesis mechanics. Methods. Chronic supraspinatus tears were induced in adult rats, and repaired 28 days later. Rats received 0 mg/kg, 3 mg/kg, or 10 mg/kg GSK1120360A daily. Collagen content, contractility, fibre type distribution and size, the expression of genes involved in fibrosis, lipid accumulation, atrophy and inflammation, and the mechanical properties of the enthesis were then assessed two weeks following surgical repair. Results. At two weeks following repair, treatment groups showed increased muscle mass but there was a 15% decrease in force production in the 10 mg/kg group from controls, and no difference between the 0 mg/kg and the 3 mg/kg groups. There was a decrease in the expression of several gene transcripts related to matrix accumulation and fibrosis, and a 50% decrease in collagen content in both treated groups compared with controls. Additionally, the expression of inflammatory genes was reduced in the treated groups compared with controls. Finally, PHD inhibition improved the maximum stress and displacement to failure in repaired tendons. Conclusions. GSK1120360A resulted in improved enthesis mechanics with variable effects on muscle function. PHD inhibition may be beneficial for connective tissue injuries in which muscle atrophy has not occurred. Cite this article: J. P. Gumucio, M. D. Flood, A. Bedi, H. F. Kramer, A. J. Russell, C. L. Mendias. Inhibition of prolyl 4-hydroxylase decreases muscle fibrosis following chronic rotator cuff tear. Bone Joint Res 2017;6:57–65. DOI: 10.1302/2046-3758.61.BJR-2016-0232.R1

Reverse shoulder arthroplasty (RSA) was released into the United States market in 2004 for the indication of Rotator Cuff Tear Arthropathy. Since that time the indications have widened and now include massive rotator cuff tears that are not deemed to be surgically repairable. This diagnosis includes patients that are considered young in terms of shoulder replacement surgery. These patients do not have the radiographic changes of arthropathy, but most have undergone multiple surgical procedures in the past to attempt to repair the rotator cuff deficiency. These younger patients have a different post-op expectation than the patient with advanced arthropathy over the age of 70. The complication rate seen in this younger patient population is higher than seen in the older population undergoing RSA. The post-operative survey for satisfaction is also considerably lower in the younger population group. RSA for massive rotator cuff tears in a younger population under the age of 65 years gives a lower patient satisfaction result and a higher complication rate than age-matched patients older than 65 years. Although this is still the best procedure available for this difficult diagnosis, patients younger than 65 years should be consulted as to what their expectations are post-operatively. Pain relief is still the main reason to undergo an RSA

Trauma is often involved in the history given at presentation but the main underlying problem in patients with Rotator Cuff tearing is degenerative change. There has been a transition in techniques for repair of tendon tears from majority open repairs in the 1970–80s to minideltoid repairs in the 1980–90s. In the last 10–15 years there has been a strong drive to evolve the repair to an all arthroscopic technique. With this evolution has come new equipment, implants and steep learning curves for surgeons at significant increase in cost to the health system with no clear improvement in long term outcome. The ability to obtain repair of a degenerate tendon to bone remains the challenge and poses a difficult problem for all orthopaedic surgeons

Aims

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.

Aims

Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE.

Aims

The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system.

Introduction. Rotator cuff tears remain a problem, with massive tears having a failure rate of repair reported of up to 60%, despite advances in surgical techniques. Tissue engineering techniques offers the possibility of regenerating damaged tendon tissue to a pre-injury state. We explore these techniques by implanting two novel tendon augmentation grafts with use of platelet rich plasma (PRP) in sheep. Methods. A total of 24 sheep were operated on, with the infraspinatus being surgically cut from its attachment to the humeral head. Each tendon was repaired using suture anchors and an interpositional implant according to 4 groups: (1) Empty control, (2) Novel collagen fibre implant with PRP (3) A novel collagen sponge implant (4) and the collagen sponge with PRP. The sheep were killed at 12 weeks and the implant site harvested and its histology evaluated. Results. Our findings showed that these novel grafts were well integrated into the tissue, with minimal inflammatory response. However, as expected, the material had not yet completely broken down. Our initial findings suggest that the combination of PRP with the collagen sponge best enhanced the repair of the tendon. Conclusion. Tissue engineered collagen graft hold great potential for the repair of tendons

The management of shoulder instability has changed a great deal in the last five years due to a better understanding of the biomechanics of the shoulder and the use of arthroscopic surgery. It is essential to understand the anatomy of the labrum and bony structures of the shoulder joint, as well as the contribution of these structures as well as the Rotator Cuff to stability in the different positions of the arm. The history and examination still remains the most important diagnostic tool and a thorough history and examination cannot be over-emphasised. MR Arthrography is the investigation of choice in confirming the diagnosis of instability while a CT scan may be required if there is significant bony damage. The most controversial topic is that of the first time dislocator. If there is a significant labral tear then the options of an arthroscopic labral repair or external rotation brace need to be considered. In the absence of a labral tear then physiotherapy is the treatment of choice. For recurrent dislocators, the results of arthroscopic labral repairs with capsular plication techniques are approaching those of the gold standard open stabilisation. If, however, there is significant bony damage to the glenoid or humeral head then a bone block procedure may be the treatment of choice. Rotator Cuff tears need to be excluded in older patients with instability and often in such cases an arthroscopic procedure to deal with the Rotator Cuff and Labrum can be done simultaneously

INTRODUCTION. Rotator cuff tears are common injuries which often require surgical repair. Unfortunately, repairs often fail [1] and improved repair strength is essential. P2 Porous titanium (DJO Surgical, Austin TX) has been shown to promote osseointegration [2,3] and subdermal integration [4]. However, the ability of P2Porous titanium to aid in supraspinatus tendon-to-bone repair has not been evaluated. Therefore, the purpose of this study was to investigate P2 implants used to augment supraspinatus tendon-to-bone repair in a rat model [5]. We hypothesized that supraspinatus tendon-to-bone repairs with P2 implants would allow for ingrowth and increased repair strength when compared to standard repair alone. METHODS. Thirty-four adult male Sprague-Dawley rats were used (IACUC approved). Rats received bilateral supraspinatus detachment and repair with one limb receiving P2 implant. Animals were sacrificed at time 0 (n=3), 2 weeks (n=8), 4 weeks (n=9) and 12 weeks (n=14). Limbs were either dissected for histological and SEM analysis or mechanical testing as described previously [5]. Specimens for histology and SEM were embedded in PMMA for tissue-implant interface analysis. Specimens were first viewed in SEM under BSE to detect bony ingrowth, then stained with Sanderson's Rapid Bone Stain and viewed under transmitted and polarized light for tissue ingrowth. Comparisons were made using Student's t-tests with significance at p≤0.05. RESULTS. No differences in cross-sectional area were detected at any time point (Fig 1A). Percent relaxation was significantly increased in the P2 group at 2 weeks, but not at 4 and 12 weeks (Fig 1B). Maximum load was significantly increased in the P2 group at 2 weeks, but not at 4 weeks (Fig 1C – maximum load not reported due to failure at grip at 12 weeks). Modulus was significantly increased in the P2 group at 4 weeks, but not at 2 or 12 weeks (Fig 1D). No differences were detected in stiffness at any time point (data not shown). BSE analysis demonstrated bone ingrowth (Fig 2) and histological analysis showed soft tissue integration (Fig 3). DISCUSSION. Results indicate superior mechanical properties in the P2 group at 2 and 4 weeks, and tissue ingrowth at all time points. Importantly, at 2 weeks, the P2group had 76% increased maximum load compared to standard repair. As supraspinatus tendon re-tears are extremely common early [1] and occur at the tendon-to-bone interface, this finding supports the reduction of re-tear risk with the P2 implant. Although no differences were detected in maximum load at 4 weeks, the increase at 2 weeks denotes that P2 implants improved early tendon-to-bone healing. Additionally, at 4 weeks, the P2 implant group had significantly increased elastic modulus, further supporting increased mechanical properties due to the P2 implant. Clinically, improved early healing might allow faster rehabilitation and associated recovery. This study demonstrates that the P2 implant improves tendon-to-bone healing up to 4 weeks (with no detrimental effects at longer time points), suggesting that P2 porous titanium may be of benefit for use in clinical rotator cuff repairs

Among 41 adult haemophiliacs 15 suffered from shoulder symptoms. We examined 12 patients by radiography and ultrasound. Four had bilateral symptoms making a total of 16 symptomatic shoulders. Of these, 10 had abnormal ultrasound scans with eight having evidence of rotator cuff tears. Evidence of bicipital tendonitis was found in two. Pain with loss of range of movement and a positive impingement sign was the most reliable clinical indicator of a cuff tear. Joint incongruity and superior migration of the humeral head were the best radiographic indicators. Rotator cuff tears are a common component of haemophilic arthropathy of the shoulder

Aims

The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature.

Background: Rotator cuff tears involving the subscapularis are less common than those involving the posterior superior rotator cuff. The purpose of this study is to report the results of repair of isolated tears of the subscapularis. Methods: Eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age at surgery was 53.2 years. The mean interval from onset of symptoms to surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative in etiology. Twenty-three of the tears involved the superior third of the subscapularis tendon, forty-one involved the superior two thirds, and twenty were complete tears. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, while ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis; thirteen shoulders underwent concomitant biceps tenotomy; and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean fortyfive month follow-up (range 24 to 132 months). Results: The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively (p< 0.001). Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four patients had mild glenohumeral arthritis. Postoperatively, twenty-five patients had mild glenohumeral arthritis and two patients had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results independent of the preoperative condition of the biceps tendon

The early diagnosis of the suprascapular nerve (SSN) entrapment in overhead athletes with simultaneous shoulder injuries and its arthroscopic release plays an important role for their appropriate treatment and recovery. SSN release at suprascapular and spinoglenoid notches, seems very helpful for increasing their performance. 21 Elite overhead athletes were treated from Jan 2005–May 2009. From 16 to 34 years old, mean 26 years, 4 Javelin throwers (Olympic and National level thrower), 4 Weightlifters (International level), 8 Volleyball Players, 3 Kick Boxer, 2 Water Polo Players. Extreme ROM of arm creates large torques about the shoulder cycle of repetitive microtrauma to the SSN, Direct trauma: fracture, dislocation, blunt trauma traction injury, Sling effect with hyper-abduction injury at the SS Notch, Correlation ROM with SSN entrapment in volley ball players, Eccentric contraction of the ISP (spinoglenoid notch), Internal impingement, Rotator cuff tears, Biceps lesions, Instability, SLAP lesion, Bankart lesion, Mainly infraspinatus muscle atrophy. X-rays, Nerve conduction studies, EMG studies, MRI. All of them had complete pain relief, especially at the posterior shoulder, regained full ROM of the operated shoulder, 19 fully recovered at the pre-injury level, 2 at the postoperative phase, Muscle atrophy improved. Advanced SSN entrapment provoke significant muscle wasting, often irreversible. This underscores the importance of a quick and accurate diagnosis to appropriate intervention. The overhead athletes with increased ROM of their shoulder predispose in SSN entrapment and shoulder injuries and vice-versa. An arthroscopic shoulder procedure for repairing the glenohumeral pathology with a simultaneous arthroscopic SSN release seems to be the appropriate treatment regarding to our resu

This study evaluated the impact of surgical wait-list times on the functional status and productivity of patients with rotator cuff tear. Two hundred and five patients were evaluated by a blind evaluator and by self report when referred for surgical management of cuff tear (confirmed by ultrasound or MRI). Patients were assessed on a monthly basis prior to surgery (two year limit). ROM and strength were assessed by an independent evaluator; patient’s self-reported comorbidity, functional status (WORC, SST), work limitations (WLQ-26) and work lost-time. Changes in health status were assessed using repeated measures ANOVA and GLM. The mean age of the population used was 56+/−11 years in which 74% were males and 26% females. Tear size was distributed amongst this population as small (0–1 cm {45%), moderate (1–3cm 27%), large (3–5cm 23.2%) and massive (5+cm 15%). Patients had symptoms or an average of fourteen months prior to referral. Despite this, decline in strength (p mental demands) (output demands > time management demands). Loss in productivity exceeded 15%. Rotator cuff tear causes substantial at work-limitation and work lost time. Patients lost strength and declined in functional status while waiting for surgical repair of a torn rotator cuff. The burden of illness, while waiting for cuff repair its substantial

Background. Rotator cuff tears pose a huge socioeconomic burden. Our study uses Fourier transform infrared spectroscopy (FTIR) as it is a quick, non-manipulative and non-destructive test, which can identify a wide range of chemical targets from small intraoperatively obtained specimens. The aim of this study was (i) to characterise the chemical and structural composition of rotator cuff tendons and (ii) to identify structural differences between anatomically distinct tear sizes. Such information may help to identify specific biomarkers of rotator cuff tear pathologies, which in turn could allow early identification and monitoring of disease progression. FTIR may provide insight into the different healing rates of different tear sizes. Methods. The infrared spectra of 81 torn rotator cuff tendons were measured using a FTIR spectrometer. The rotator cuff tear sizes were classified as partial, small, medium, large and massive, and compared to 14 normal controls. All spectra were classified using standard multivariate analysis; principal component analysis, partial least square and discriminant function analysis. Results. FTIR readily differentiated between normal and torn tendons, and different tear sizes. We identified the key discriminating molecules and spectra altered in torn tendons as: (i) carbohydrates/phospholipids (1030-1200 cm. -1. ), (ii) collagen (1300-1700, 3000-3350 cm. -1. ) and (iii) lipids (2800-3000 cm. -1. ). Partial tears were chemically distinct from normal and small tears, and primarily involved a reduction in collagen type II. Conclusion. This study has demonstrated that FTIR can identify different sizes of rotator cuff tear based upon distinguishable chemical and structural features. The onset of rotator cuff tear pathology is mainly due to alterations of the collagen structural arrangements, with associated changes in lipids and carbohydrates. The approach described is rapid and has the potential to be used intraoperatively to determine the quality of the tendon and extent of disease, thus guiding surgical repairs or for monitoring of treatments

Introduction: Shoulder arthroplasty in rheumatoid patients gives satisfactory pain relief and some recovery of motion. Long term complications are however frequent, such as loosening of the glenoid and rotatorcuff insufficiency. Proximal migration (PM) might be related to both these conditions, and is assumed to lead to deterioration in function and recurrence of pain. Goal: Aim of this study was to evaluate the occurrence and identify risk factors for proximal migration after shoulder arthroplasty in a rheumatoid population. Methods and patients: Data of 102 patients (FU 5.8 yrs) treated with a shoulder arthroplasty for rheumatoid gleno-humeral disease was analysed. Requirements were at least 3 years of follow–up and 3 follow-up moments. At each visit clinical scores and standardised radiographs were performed prospectively. Rotator-cuff status was scored per-operatively. For quantification of PM a validated measurement technique - The Spina Humeral centre method- was used. A significant decrease of the subacromial space was defined as more than two times the standard deviation of the measurement accuracy (3.65 mm). Results: In 25 of 77 cases PM was present. PM commenced in two separate patterns, determined by the time-frame that passed before PM commenced. Early PM started directly during postoperative rehabilitation within the first two postoperative years, late PM after two years. This allowed group formation according to migration pattern; patients with no PM (PMnone), patients with late PM (PMlate) and those with early PM (PMearly). Age was higher in the PMearly group. Rotator cuff tears were more frequent and more severe in the PM groups. The ROM improved postoperatively in the PMnone and PMlate group, with deterioration of the latter in time. The HSS clinical outcome score improved in all groups. Quality of rotator cuff repair did not alter PM outcome. PM did not occur more frequently in hemi-artho-plasty compared to total shoulder arthroplasty. A more upward oriented glenoid was observed in the PMearly and PMlate groups

The diagnosis of chronic lesions of the rotator cuff is challenging. We have developed a new index to improve the sonographic diagnosis of chronic tears of the cuff. In a pilot study, we examined 50 asymptomatic healthy volunteers by ultrasound to establish the diameter of the rotator cuff in relation to the tendon of the long head of biceps. Subsequently, the index was calculated in 64 patients who had had shoulder pain for more than three months caused by clinically diagnosed lesions of the rotator cuff. The compensatory hypertrophy of the biceps tendon was quantified sonographically in relation to the diameter of the cuff. Comparison with the contralateral shoulder revealed a significantly higher biceps rotator-cuff ratio (p < 0.05) for patients with torn rotator cuffs. A ratio greater than 0.8 was considered pathological (index positive); the mean ratio in the control group was 0.43. The sensitivity of a positive index was 97.8%, the specificity 63.2%, the positive predictive value 86.3%, and the negative predictive value 92.4% in comparison with surgical findings. Use of the index improves sensitivity in the diagnosis of chronic tears of the cuff by ultrasound

We assessed a new knotless anchor system (Opus AutoCuff, ArthroCare Sports Medicine), which was designed to repair torn rotator cuffs. This knotless anchor winches cuff tissue into the bone with a mattress suture that is cinched into place without the need for knots. We reviewed patients who underwent arthroscopic repair with this technique with a minimum follow up of one year. This is prospective study of a consecutive series of the first one hundred patients who underwent arthroscopic cuff repair with the Autocuff system in 2005. Nine were lost to follow-up leaving ninety-one were available for review. All sizes of cuff tear were addressed and in all one hundred and eighty anchors were deployed. There were thirty seven men and sixty seven women with an average age of 69.4 years (range 36–85 years) Follow-up was by clinical assessment, cuff ultrasound and plain radiographs one year after surgery (12–20 months). Pain relief was described as good to excellent in 93% of patients and Constant scores improved by an average of 34 points with 48.5% being good to excellent, 39.4% fair and 12.1% poor. Nine anchors (5%) in eight patients had pulled out at one year, of which three were symptomatic. Suture repair poses varied points of weakness; loose knots, suture attrition and screw toggle all contribute to failure. We have shown that cuff repair by this method appears to be effective up to one year. It is important, however, to spread the tension of the repair with more than one anchor when treating larger tears

Introduction: The rotator cuff is subject to constant pressure from the head of the humerus. This tends to ‘wring out’ the blood supply resulting in a functionally avascular critical zone, although microvessels can be identified. This zone is the site of degeneration and tears. Damage repair under these conditions would be difficult. Myofibroblasts are characteristic of the contractile phase of wound healing. We have examined their distribution in both healthy resected and torn, degenerating rotator cuff tissue and correlated their presence with vascularity and hypoxia in the surrounding tissue. Methods: Rotator cuff tissue was obtained from ten patients undergoing surgical repair. The size of tear was 1–4.5cm, Immunohistochemical staining with commercial monoclonal antibodies to HIF-1α (Hypoxia inducible factor), vimentin, smooth muscle actin (SMA), CD31 and VEGF was performed on formalin fixed paraffin embedded tissues. Visualisation used standard DAB chromagen technique. Results: Focal myofibroblast positivity (SMA+/VIM+) was detected, areas of positivity were found at the interface between torn and degenerating tissues adjacent to the tear. Myofibroblasts were absent in degenerating tissue. The areas of myofibroblast positivity were well vascularized, with strong VEGF positivity. Nuclear HIF-1α positivity was identified in the adjacent endothelial cell population and sporadically in fibroblast population, although not in the myofibroblasts. Conclusion: Evidence of an ongoing wound healing response was found in tissue from torn rotator cuffs. However, it was patchy and infrequent

Introduction The accuracy of ultrasonography has been reported to be high in diagnosing full thickness rotator cuff tears if measurements are made in both in the coronal and sagital planes. The purpose of this study is to determine how well pre-operative shoulder ultrasound rotator tear measurements when performed only in the coronal plane, the common practice in Israel, predicts the intra-operative surgical findings. Materials and Methods Fifty consecutive patients who underwent open rotator cuff repairs were included in the study. All patients underwent a pre-operative ultrasound by the same experienced musculoskeletal ultrasoundist. Rotator cuff tears were measured in the coronal plane only. This was compared with the tear size measured intra-operatively. Regression analysis was done between the two variables. Results The mean size of rotator cuff tears as determined by ultrasonography was 15.56±8.07mm and the measure size of the tears intraoperatively was 27.94±9.8 mm. The result of the regression analysis of the two variables was R2= 0.268405 for the first 25 patients and R2= 0.310309 for the second 25 patients. Discussion Using ultrasound it is easy to visualize the extent of rotator tears in the coronal plane, but more time consuming to measure the extent in the sagital plane, where the tear may have its greatest extension. Ultrasound measurements tear measurements in this study, made only in the coronal plane correlated poorly with intraoperative findings and only minimally improved over the time course of the study. Conclusion Proper assessment of a possible candidate for a rotator cuff repair should include an ultrasound with the tear size measured specifically in both the coronal and sagital planes

Introduction and Objectives: Among the pathological conditions associated with the subacromial space is rupture of the rotator cuff. Patients affected by this injury have a poorer response to medical or rehabilitative treatment than do patients with subacromial injuries without concurrent tearing of the rotator cuff. For this reason, surgical treatment is more often needed. Surgical treatment includes the excision of subacromial osteophytes and repair of the affected tendon. Even though acromioplasty can be performed arthroscopically, cuff repair generally requires small incisions due to the technical complexity of the procedure. Materials and Methods: We have carried out a prospective study of 36 patients with torn rotator cuffs diagnosed by MRI who underwent acromioplasty performed with an incision of approximately 4cm when necessary and cuff repair either by direct suturing or reinforcement with rotator cuff plasty performed by the same surgeon. The rehabilitation protocol included early mobilisation at 24–48 hours, passive assisted mobilisation until the 4th week, and active mobilization after the 5th week. Follow-up time was a minimum of one year with pre- and postoperative Constant scale evaluations. We compared various results including previous duration of symptoms, the severity of cuff tearing, and the surgical technique that was used. Results: Favorable results were achieved in terms of pain relief and restoration of mobility compared to the preoperative period, even though strength was not equal to that of the contralateral shoulder. Discussion and Conclusions: Open surgery for rotator cuff tear repair continues to be the best surgical option if a small incision is made, good technique used, and early rehabilitation is performed

Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT). Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT. Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p> 0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p< 0.05) but this significance was not seen in the right shoulders (p> 0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force. Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear. Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score

Purpose of the study: The objective of this study was to identify clinical and anatomic factors which could affect the outcome of tendon healing after arthroscopic repair of rotator cuff tears. Material and methods: This prospective cohort study included 122 patients who underwent arthroscopic treatment between May 1999 and September 2002. One hundred twelve patients (114 shoulders) were reviewed (93.4%). Mean age at surgery was 61 years. An arthroscan (78% of patients) or magnetic resonance imaging (MRI) were performed six months postoperatively. Mean follow-up was 24 months (range 13–46 months). Results: Rotator cuff tears healed completely in 64% of the shoulders (n=73) and partially in 7% (n=8). No healing was observed in 29% (n=33). The Constant score was 49.8 preoperatively and 82.4 at last follow-up (p< 0.0001). Cuff healing improved clinical outcome with a Constant score of 85 points versus 77, particularly for force, 14.5 points versus 10 without healing. Four factors were statistically predictive of tendon healing: duration from symptom onset to operation (24 months for healed tears versus 37 months, p< 0.05); age at cuff repair (81% healed tears in patients aged less than 50 years versus 50% for patients aged over 65 years, p< 0.002); sagittal extension of the rotator interval or extension to the upper third of the infrascapularis (45% healed tears versus 79% without anterior extension, p< 0.0001); fatty degeneration (69% of healed tears for Goutallier grade 0 versus 38% for grade 1 and 2, p< 0.01). Conclusion: This study demonstrated that four factors can predict tendon healing: time to treatment, age at surgery, anterior extension of the tear, fatty degeneration

We retrospectively reviewed the results of 21 patients (22 shoulders) who had surgery for os acromiale. The mean age of the 6 men and 15 women was 52 years. The dominant side was involved in 10 patients. The duration of symptoms ranged from one month to 13 years. Ten patients had a history of recent trauma. All presented with tenderness over the site of the os and signs of impingement. In three patients, signs of weakness suggested a rotator cuff tear, and three patients had tenderness over the acromioclavicular joint. Rotator cuff tears, four partial and eight full thickness, were present in 12 cases. Surgery included excision of the os in nine cases and fixation in 13. Ancillary procedures included acro-mioclavicular joint excision (eight), rotator cuff repair (eight), cuff debridement (three) and biceps tenodesis (one). At follow-up, which ranged from 5 months to 6 years, Constant and American Shoulder and Elbow Surgeons’ scores were assessed. The presence of a deltoid defect was noted and deltoid strength was measured. The mean Constant score at follow-up was 77. Deltoid strength was notably reduced in abduction but not in forward flexion. There were no cases of sepsis. Five cases required further surgery. In three, this involved removal of metal, but persistent pain necessitated one subsequent rotator cuff repair and one arthroscopic debridement of the subacromial space. The outcome of both fixation and excision was satisfactory, but the reoperation rate was higher in patients who underwent fixation. We advise arthroscopic excision of meso-acromion in the absence of a full thickness rotator cuff tear

Rotator cuff tears are an increasingly recognizable and common problem amongst the elderly. We undertook this review to assess outcome from open surgical rotator cuff repair and acromioplasty in patients over the age of 70 years. A retrospective review of 61 patients with 64 full thickness rotator cuff tears treated with open repair and decompression acromioplasty between 1/1/92 and 30/6/04.To evaluate the current functional state and satisfaction (mean time from surgery 46.3 months) 50 patients were contacted and invited to attend for clinical evaluation using Constant and Murley’s functional score and/or answer a modified subjective 12 point Simple Shoulder Test. Eleven patients were not contactable despite attempts through post and phone. All grades of tears were reparable with 48 being good tendon to bone. All the patients underwent a six week supervised physiotherapy programme. Complications included 6 frozen shoulder and seven cases of re- rupture .One patient each developed pulmonary embolism and reflex sympathetic dystrophy. Based on the definitive scoring of Constant and Murley’s 31 were rated as excellent (80–100 points) 9 good (65–79), 2 fair (50–64) and 2 poor (less than 50). Out of the total 43 patients (44 shoulders) examined and scored 90% showed excellent and good results. Symptomatic rotator cuff tears in the elderly, active and healthy patients treated by a surgical repair results in good and early functional return, lasting pain relief and excellent patient satisfaction and should be actively considered as a definitive mode of treatment in this age group

Introduction. Both anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty are the standard of care for various end-stage degenerative conditions of the glenohumeral joint. Osteoarthritis (OA) is the most common indication for aTSA while Rotator Cuff Tear Arthropathy (CTA) is the most common indication for rTSA. Worldwide, the usage of both aTSA and rTSA has increased significantly due in part, to the predictability of acceptable outcomes achieved with each prosthesis type. The aim of this study is to quantify outcomes using 5 different metrics and compare results achieved for each indication using one platform total shoulder arthroplasty system which utilizes the same humeral component and instrumentation to perform both aTSA or rTSA. Methods. 200 patients (70.9 ± 7.3 yrs) were treated by two orthopaedic surgeons using either aTSA or rTSA. 73 patients received aTSA (67.4 ± 8.0 yrs) for treatment of OA (PHF: 64 patients; YM: 9 patients) and 127 patients received a rTSA (72.9 ± 6.1 yrs) for treatment of CTA (PHF: 53 patients; YM: 74 patients). These patients were scored pre-operatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics; active abduction, forward flexion, and external rotation were also measured. The average follow-up for all patients was 31.4 ± 9.7 months (aTSA: 32.5 ± 12.1 months; rTSA: 30.8 ± 8.0 months). A Student's two-tailed, unpaired t-test was used to identify differences in pre-operative, post-operative, and pre-to-post-operative improvements in results, where p < 0.05 denoted a significant difference. Results. All patients demonstrated significant improvements in pain and function following treatment of OA with aTSA and of CTA with rTSA. No instances of instability or glenoid loosening were reported in either cohort; one instance of infection occurred in the rTSA cohort. The average pre- and post-operative outcome scores and range of motion measurements are presented in Figures 1 and 2, respectively. The average improvement in outcome scores and range of motion measurements are presented in Figure 3, respectively. Discussion and Conclusions. The results of this study demonstrate that CTA patients had significantly lower pre-operative scores as measured by 3 of the 5 metrics and significantly less active abduction and forward flexion than OA patients. While aTSA and rTSA were used to treat different indications; each treatment method provided a significant improvement in all 5 outcome score measurements and all 3 motion measurements for its respective indication at a similar mean follow-up. Interestingly, a few comparative differences were observed: aTSA was associated with significantly higher post-operative scores according to 2 of the 5 metrics, greater range of motion according to all 3 active motion measurements, and was demonstrated to be significantly more effective at improving active external rotation; whereas, rTSA was associated with significantly larger improvements in outcome scores according to 2 of the 5 metrics and was demonstrated to be significantly more effective at improving active forward flexion. Additional and longer term follow-up is required to confirm these findings

Rotator cuff repair failure may to some extent be attributed to tendon-bone gap formation at the repair sight caused by insufficient suture tightening. We measured the footprint contact properties over time of single row and trans-osseous equivalent repairs. We also investigated the effect of suture retightening on the repair. Rotator cuff tears (RCT) were created in the supra-spinatus tendon of 6 cadaveric shoulders. An electronic pressure sensor (Tekscan) was placed between the tendon and bone to measure the footprint pressure. The OPUS AutoCuff System was used to consecutively repair the RCT using a single row repair (SR-R) and two trans-osseous equivalent repair (TOE-R) techniques;. two parallel sutures (TOE-P) and. cross over suture pattern (TOE-C). Sutures were tightened, then retightened in each group. Peak initial contact force, were recorded on suture tightening (peak force) and equilibrium contact properties after 300 seconds relaxation (equilibrium force). Data were analysed using pairwise ANOVA. All techniques demonstrated a similar trend in the contact properties over the test period with an initial peak in contact force on tightening of the sutures, followed by a rapid drop in contact pressure immediately after suture tightening, and finally tending towards equilibrium contact force at 300 seconds. The TOE-C group demonstrated the highest mean ‘peak force’ and the highest ‘equilibrium force’ after 300 seconds relaxation. The TOE-P ‘peak force’ and ‘equilibrium force’ were −15% and −3% that of TOE-C, while the SRR was −45% and −25% that of TOE-C. Retightening the sutures a second time had little effect on the SSR contact properties, while retightening the TOE repairs increased the equilibrium contact force by 30% although this was not significant. Significant relaxation occurs especially within the first 30s, compromising the contact properties. TOE-R’s exhibit better contact properties than SRR. Retightening the TOE-R’s tended towards a higher final equilibrium contact force. SRR repair contact properties were unaffected by a second tightening. TOE-R’s should be re-tightened before the suture is locked

Purpose: Centred degeneration of the shoulder joint is defined as a degeneration of the glenohumeral surfaces without ascension of the humeral head. We investigated the influence of partial or full thickness rotator cuff tears and/or fatty degeneration of the supraspinatus on the results of total shoulder arthroplasty. Material and methods: During a multicentric review of 766 cases of centred degeneration of the shoulder joint treated with the Aequalis prosthesis, we identified 555 shoulders in 478 patients with an interpretable preoperative arthroscan. All patients were reviewed with a minimum follow-up of two years (mean 3.6 years). Constant score and radiological findings were recorded. We identified 41 shoulders with partial tears of the supraspinatus and 42 shoulders with full-thickness tears of the supraspinatus alone. Moderate fatty degeneration was observed in 90 shoulders (≤ 2) and severe fatty degeneration of the infraspinatus or the subscapularis (> 2) in 15. We analysed the Constant scores, subjective results, radiological results, and rate of complications in each of these populations. Results: Rotator cuff tears involving the supraspinatus alone did not have a destabilising effect, the head of the humerus did not influence the postoperative result assessed by the overall Constant score, motion in all planes, subjective result, radiological result, or rate of complications. There was no significant difference in complication rate. Presence or not of cuff repair did not influence these results. Inversely, fatty degeneration ≥ 2 involving the infrastpinatus or the subscapularis had a significant effect, decreasing the Constant score, active external rotation, active anterior elevation, and subjective result. On the contrary, it did not influence the radiological results or the rate of complications. Discusssion: This multicentric study confirms that the degenerated shoulder joint can remain centred with a solitary tear of the supraspinatus. This has no effect on the clinical result and does not require repair. Inversely, fatty degeneration is highly predictive of the quality of the final result

Introduction: Rotator cuff tears are a common injury which affects both the young athlete and the sedentary elderly alike. This condition is commonly treated with glucocorticoid injections as part of initial management. The effects, however, of these injections on the histology of collagen and the metabolism of tendon fibroblasts are still controversial. Materials and methods: In this study, samples from 19 patients with rotator cuff tears were taken during definitive surgery to manage these tears. There was a history of glucocorticoid injections in all of the patients. The samples were examined in terms of histopathology using light microscopy, in situ hybridization to detect the presence of glucocorticoid receptor mRNA and TUNEL assay to determine the incidence of apoptosis. Results: Light microscopy of hematoxylin-eosin stained samples from the study group showed marked cellularity although there were no signs of inflammation. The nuclei were noted to be rounded and a significant number showed pyknosis. Angiogenesis was also noted in the sections, consistent with previous finding of angio-fibroblastic hyperplasia as a characteristic of tendinosis. Collagen structure was noted to be abnormal, with longitudinal clefts and focal areas of marked disorganization of fibers. In situ hybridization showed a strong signal for glucocorticoid receptor mRNA in all of the samples. TUNEL assay also showed a strong signal for apoptosis of the tendon fibroblasts in the study group as compared to the control group which showed almost no signal. Conclusion: Our results suggest that although an overall picture of hypercellularity is seen in cases of tendinosis and tendon tears, a high percentage of these cells are undergoing apoptosis. This may reflect a natural high rate of turnover of cells during the process of repair or may be due to exogenous factors. Glucocorticoids almost certainly affect metabolism of tendon fibroblasts and subsequently collagen structure as seen by the abundant expression of the receptor mRNA. However, a causal relationship between glucocorticoids and apoptosis of tenocytes is yet to be established

Purpose: To review the results of simple arthroscopic subacromial decompression in patiens with impingement syndrome and rotator cuff tears without repairing the tears. Type of Study: prospective study. Material and Methods: From 1998 to 2003, 160 patients (168 shoulders) had arthroscopic subacromial decompression for impingement syndrome with a torn rotator cuff without repairing the tear of the cuff (120 males and 40 females). The average patient age was 64 years and the average follow up was 24 months. With increasing use of arthroscopy in the treatment of shoulder disorders, tears of the rotator cuff have been well described. Management of rotator cuff tears should include consideration of tear size, patient age and activity level, and tear etiology. Operative treatment of impingement syndrome in elderly less active lower demand patients with small and moderate tears involves decompression with and without repairing the cuff. We evaluated the clinical outcome of arthroscopic subacromial decompression and debridement in 160 patients ( 168 shoulders ) with impingement syndrome with small and moderate tears of the rotator cuff without repairing the cuff. Rotator cuff tears are graded arthroscopically as small (< 1 cm), moderate (> 1 cm < 3 cm ), large (> 3 cm < 5 cm ), and massive rotator cuff tears (> 5 cm ). Results: At follow up 96 patients (60%) were rated excellent or good , 56 patients (35%) were rated fair and 8 patients (5%) were rated poor. The average “Constant” score was 62 preoperative compared with 82 postoperative in the improved group (152 patients) . The 8 patients who showed no improvement had average postoperative “Constant” score of 64. Conclusions: Arthroscopic subacromial decompression without suture of the cuff in elderly less active lower demand patients with impingement syndrome with small and moderate tears of the cuff is a legitimate method of treatment for their shoulder pain and limitation of function. The main advantages were: immediate physiotherapy and return of function since there is no need for immobilization

Purpose: The purpose of this study was to analyse the factors affecting outcome after prosthesis implantation for osteonecrosis of the humerus in order to ascertain details concerning the indications for humerus or total prostheses in this condition. Material and methods: Forty-seven women and 27 men, mean age 57 years with osteonecrosis of the humerus underwent surgery for implantation of 80 shoulder prostheses. According to the Arlet and Ficat classification as modified by Cruess there were five grade II, fifteen grade III, 41 grade IV and fourteen grade V shoulders, with five unclassifiable shoulders. there were 14 supraspinatus tears and five infraspinatus tears. The 26 total shoulder prostheses and 54 humeral prostheses were reviewed at a mean 47 months follow-up. Pre-operative x-rays were available for 65 shoulders and postoperative x-rays for 58. Results: The subjective outcome was considered good irrespective of the grade (very satisfied 60%, satisfied 30%, dissatisfied 4%). The mean postoperative Constant score was 70 ± 15. The preoperative score was lower for more advanced disease but the difference was not significant at postoperative assessment. The total prosthesis provided better results in grade V shoulders and the hemiprosthesis in grade II and III shoulders. The result of the humeral prostheses depended on the grade of necrosis. The postoperative Constant score was lower for advanced necrosis with lower scores for motion, force and pain (which was not influenced by age). At last follow-up, 31% of the x-rays revealed a significant narrowing of the glenoid-head space. The clinical outcome was significantly less satisfactory for all Constant scores. Rotator cuff tears, preoperative stiffness favoured glenoid wear. Tears of both cuff tendons led to poor outcome. Bone collapse with impaction of the head into the glenoid and medialisation of the humerus was a significant factor predictive of less satisfactory outcome. Discussion: The grade of necrosis is a determining factor for indications for humerus or total shoulder arthroplasty for the treatment of osteonecrosis. Our objective results lead us to recommend a humeral prosthesis for grade II and III patients and a total shoulder arthroplasty for grade V patients. For grade IV patients, the choice depends on patient age, shoulder stiffness, the status of the cuff, and most importantly, collapsus of the head of the humerus with impaction-medialisation of the humerus

Purpose: Reports on the histological lesions observed in patients with degenerative disease of the shoulder have generally involved only a few cases. We conducted a prospective study in 662 shoulders operated on for impingement or rotator cuff tear. Material: The cases analysed included 402 subacromial impingements and 260 rotator cuff tears. Methods: Pathology specimens were obtained from the subacromiodeltoid bursa, the acromion, the acromio-coracoid ligament, the acromioclavicular joint, the borders of the rotator cuff tear, and the biceps tendon. There were 2573 pathology specimens. Results: The pathology examination revealed degenerative lesions (fibrosis, oedema, calcifications, fissuration, atrophy, delamination, fatty infiltration, necrosis, chondroid metaplasia, fragmentation), or inflammation. The subacromiodeltoid bursa presented fibrosis lesions in 3 out of 4 cases (74%). Signs of inflammation were found in 21% of the cases, oedema in 9%, and no lesion in 15%. The acromiocoracoid ligament showed oedema in 35%, fissuration in 35%, delamination in 25%, fragmentation in 11%, atrophy in 8%, fatty infiltration in 6%, necrosis in 4%, hypervascularisation in 2%, chondroid metaplasia in 1%, and no lesion in 27%. For the acromion, degenerative lesions were present in 88%, impingement in 83%, cuff tears in 92%. Lesions of the cuff in patients with tears showed degeneration in 86% (fissuration 46%, necrosis 35%, fragmentation 30%, vascular penetration with chondroid metaplasia 17%, delamination 10%, haemorrhagic remodelling 4%, adipose degeneration 3%, atrophy 2%, oedema 42%, calcifications 30%, fibrosis 26%, inflammation 7%, and no lesion 1 case). The biceps tendon showed degenerative lesions (90%), inflammation 2 cases, no lesion 3 cases. The acromioclavian joint (67 cases) showed degenerative lesions in all cases. Rotator cuff tears showed inflammatory lesions 30%, and subacromial impingement 16%. Discussion: The statistical analysis revealed a significant correlation between the presence of a normal subacromiodeltoid bursa and the type of pathology. There was a significant statistical relationship between the presence of inflammatory lesions and the type of pathology. There was no significant correlation with the pain score. There was a significant relationship between the presence of fibrosis of the acromiocoracoid ligament and the functional score at last follow-up. The presence of ligament fibrosis would be a sign of poor prognosis. This relationship was present irrespective of the pain, force and stability scores. Conclusion: The acromiocoracoid ligament was not found to be particularly involved suggesting that the idea of impingement should be revisited. For cases with a tear, the presence of a acromiocoracoid ligament with no histological lesion confirms that tears are not always associated with an impingement. Among cuff tear or impingement cases, there was a number of acromions with no bone lesion. Inflammatory lesions were not frequent. Unravelling the pathology of the degenerative shoulder is a complex process making interpretation and correlation with clinical signs and proposed therapeutic protocols difficult