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.

Aims

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.