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.
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
Aims.
The shoulder girdle is an extremely mobile joint.
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.
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.
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:
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. The creation of a posterosuperior massive rotator cuff tear resulted in significant superior translation of the humeral head relative to the intact cuff state (P=0.016). No significant differences were observed between each implant design and the intact cuff state as all implants decreased the superior migration of the humeral head that was observed in the cuff deficient state. On average, the 5mm low and high constraint implant models were most effective at restoring normal humeral head position to that of the intact cuff state (-1.3 ± 2.0mm, P=0.223; and −1.5 ± 2.3mm, P=0.928 respectively). No significant differences were observed across all test states for anterior-posterior translation of the humeral head. The cuff deficient on average resulted in posterior translation of the humeral head, however, this was not statistically significant (P=0.128). Both low and high constraint implant designs were found to be most effective at restoring humeral head position to that of the intact cuff state, on average resulting in a small anterior offset (5mm high constraint: 2.0 ± 4.7mm, P=1.000; 8mm high constraint: 1.6 ± 4.9mm, P=1.000). The 5mm high constraint implant was most effective in restoring normal humeral head position in both the superior-inferior and anterior-posterior directions. The results from this study suggest the implant may be an effective treatment for restoring normal glenohumeral kinematics and function in patients with massive irreparable rotator cuff tears. Future studies are needed to address the mechanical efficiency related to arm abduction which is a significant issue related to patient outcomes.Superior-Inferior Translation
Anterior-Posterior Translation
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.
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. Eighteen patients (11 women, 14 OA), mean age 70 years (range 57–80), performed 12 weeks of PSE with 1 weekly physiotherapist-supervised and 2 weekly home-based sessions. Feasibility was measured by drop-out rate, adverse events, pain and adherence to PSE. Patients completed Western Ontario Osteoarthritis of the Shoulder (WOOS) score and Disabilities of the Arm, Shoulder and Hand (DASH).Introduction and Objective
Materials and Methods
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.
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. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery.Background:
Methods:
The aim of this study was to compare the characteristics and outcomes of L-shaped and reverse L-shaped rotator cuff tears. A total of 82 shoulders (81 patients) after arthroscopic rotator cuff repair were retrospectively enrolled. The mean age of the patients was 62 years (SD 6), 33 shoulders (40.2%) were in male patients, and 57 shoulders (69.5%) were the right shoulder. Of these, 36 shoulders had an L-shaped tear (group L) and 46 had a reverse L-shaped tear (group RL). Both groups were compared regarding characteristics, pre- and postoperative pain, and functional outcomes. Muscle status was assessed by preoperative MRI, and re-tear rates by postoperative ultrasonography or MRI.Aims
Methods
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.
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. Thirty-eight patients with full-thickness rotator cuff tears have been enrolled after they had been informed about the use of PRP and the timing of its application postoperatively. Seventeen patients underwent arthroscopic rotator cuff repair and PRP injections (3 injections at 10 days each other), 21 underwent arthroscopic rotator cuff repair without PRP injections. Outcomes were assessed preoperatively, at 3, 6, 12, and minimum 16 months after surgery (average 17.7 +/− 1.7 months). Constant system, the University of California at Los Angeles (UCLA) system and a Visual Analogue Scale (VAS) scale were used; range of motion and strength in all planes were also assessed. The healing of the repair was assessed at magnetic resonance imaging at a minimum follow up of 6 months from surgery. All patients had the same rehabilitation protocol.Introduction
Patients & Methods
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.
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”. it was assumed that impaired vasal reaction to “hemodynamic stress” was a systemic condition. This phenomenon should therefore be not limited to the critical area of the tendon tear. Given this assumption post-ischemic vasodilation of brachial artery was studied through an echo-doppler (US) evaluation. 50 patients (mean 61 ± 4, range 50–65) all scheduled for surgical rotator cuff repair following a tendon tear, were enrolled. Three preoperative measurements of the brachial artery diameter before and after application of an ischemic band were collected. The size of the lesions was later assessed at the time of surgery. A statistical analysis was carried on to investigate the correlation between US assessment of brachial artery diameter and the corresponding size of the RC lesions. UCLA and ASES scores were also measured to assess clinical and functional outcomes.Introduction
Patients & Methods
To assess clinical outcome of massive rotator cuff tear repair using triceps myotendinous flap. This is a prospective cohort of 43 patients (24 male, 19 female) with average age of 62 years. The primary indication of surgery was pain. Patients with massive rotator cuff tear involving supraspinatus and infraspinatus, showing retraction and fatty infiltration in MRI were selected. Few (8/43) were with failed surgical treatment and rest had conservative treatment failed. They underwent rotator cuff repair during Feb 1999 to Jan 2004. The long head of the triceps was detached from the olecranon, rotated 180 degrees from its pivot point with its major vascular pedicle under the deltoid and acromion through the posterior capsule and attached to the greater tuberosity and any remnant of remaining cuff. All patients were assessed pre-operatively, at 3, 6 and 12 months post-operatively clinically and also using UCLA pain and functional score for shoulder. Shoulder range of motion was assessed before and after the surgery. 24 patients had minimum of 1 year and 19 had 2 year minimum follow-up.Aim
Method
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. We retrospectively reviewed 1,115 patients who underwent arthroscopic rotator cuff repair for full-thickness tears between October 2011 and May 2019. From this series, we identified 77 patients (28 male, 49 female) with a mean age of 64.1 years (50 to 80). Patients were classified into groups A (n = 47 incomplete) and B (n = 30 with biceps augmentation) according to the nature of their reconstruction. Clinical scores were checked preoperatively and at six months, one year, and two years postoperatively. In preoperative MRI, we measured the tear size, the degree of fatty infiltration, and muscle volume ratio of the supraspinatus. In postoperative MRI, the integrity of the repaired rotator cuff tendon was assessed using the Sugaya classification. Tendon thickness at the footprint was evaluated on T2-weighted oblique coronal view.Aims
Methods
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).
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.
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.
Type of study: retrospective study in 2 Orthopedic Center in Rome (Italy).
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).
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. This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively.Aims
Methods
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.
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. Twenty-six patients were evaluated from October 2016 to December 2017. The participants were categorized into three groups based on their diagnoses: the rotator cuff tear group; normal rotator cuff group; and adhesive capsulitis group. After establishing a posterior standard viewing portal, intravenous administration of ICG at 0.2 mg/kg body weight was performed, and fluorescence images were recorded. The time from injection of the drug to the beginning of enhancement of the observed area was measured. The hypovascular area in the rotator cuff was evaluated, and the ratio of the hypovascular area to the anterolateral area of the rotator cuff tendon was calculated (hypovascular area ratio).Objectives
Methods
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
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.
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. PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.Aims
Materials and Methods
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 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.
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. The purpose of this study was to investigate clinical and functional outcomes of this procedure for CTA according to Hamada-Fukuda classification.Introduction
Aim
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. The aim of this study was to investigate clinical outcome of our strategy for younger patients with an irreparable rotator cuff tear.Introduction
Aim
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 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.
1) shoulder pain more than 6 months with no response for conservative treatment, 2) no previous shoulder surgery of the same shoulder or surgery of the contralateral shoulder, 3) clinically and radiologically diagnosed subacromial impingement or rotator cuff tear. 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.
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.
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. A cohort of 162 patients who underwent isolated supraspinatus with the preservation of LHBT was enrolled and evaluated. The cross-sectional area (CSA) of the LHBT on MRI was measured in the bicipital groove, and preoperative to postoperative difference was calculated at least 12 months postoperatively. Second, postoperative changes in the LHBT including intratendinous signal change, rupture, dislocation, or superior labral lesions were evaluated with seeking of factors that were correlated with the changes or newly developed lesions after rotator cuff repair.Aims
Methods
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. In this prospective trial, 62 consecutive patients (14 women (23%), 48 men (77%); median age 61 years (interquartile range (IQR) 54 to 65)) with trauma-related FTRCT underwent arthroscopic single-row repair within six weeks of trauma. Tendon integrity was assessed one year after surgery using the Sugaya score on MR images. Patients were followed up with Western Ontario Rotator Cuff (WORC) index, EuroQol visual analogue scale (EQ VAS), and the Constant–Murley score (CS) two years after repair.Aims
Patients and Methods
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. Using data from 273 patients, healthcare-related use of resources,
costs and quality-adjusted life years (QALYs) were estimated at
12 months and 24 months after surgery on an intention-to-treat basis
with adjustment for covariates. Uncertainty about the incremental
cost-effectiveness ratio for arthroscopic Aims
Patients and Methods
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. Patients were assessed pre-operatively and one year post-operatively
using the Oxford Shoulder Score (OSS) and MRI. The cross-sectional
area and distribution of the type of muscle fibre were assessed
on biopsies, which were taken at surgery and one year post-operatively.
Paired samples from eight patients were analysed. There were three
men and five women with a mean age of 63 years (50 to 73).Aims
Patients and Methods
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 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:
Objectives .
The June 2012 Shoulder &
Elbow Roundup. 360. looks at: reverse shoulder replacement;
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
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. Using the ClinicalTrials.gov (CTG) and the International Clinical Trials Registry Platform (ICTRP) databases, we comprehensively surveyed clinical trials of decellularized tissue use in orthopaedic surgeries registered before 1 September 2022. We evaluated the clinical results, tissue processing methods, and commercial availability of the identified products using academic literature databases and manufacturers’ websites.Aims
Methods
Our aim was to determine the most repeatable three-dimensional measurement of glenoid orientation and to compare it between shoulders with intact and
Intra-synovial tendon injuries affect compressed tendon within a synovial environment (eg
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.
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. In total, 101 patients (53 female, 48 male) with a mean age of 50.9 years (19 to 76) with minimally displaced GT fractures were recruited to a prospective observational cohort study. During the first year after injury, patients underwent experiential assessment using the Disabilities of the Arm, Shoulder and Hand (DASH) score and assessment of associated injuries using MRI performed within two weeks of injury. The primary outcome was the one-year DASH score. Multivariate analysis was used to assess the effect of patient demographic factors, complications, and associated injuries, on outcome.Aims
Methods
Objectives.
Reverse shoulder arthroplasty (RSA) was released into the United States market in 2004 for the indication of
Trauma is often involved in the history given at presentation but the main underlying problem in patients with
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. NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation.Aims
Methods
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. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates.Aims
Methods
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. We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217).Aims
Methods
Introduction.
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.
INTRODUCTION.
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.
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. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database.Aims
Methods
Background:
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,
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%.
Background.
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.
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
We assessed a new knotless anchor system (Opus AutoCuff, ArthroCare Sports Medicine), which was designed to repair
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
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.
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
Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a
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:
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.
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 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.
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:
Introduction:
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.
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.
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.