Aims. Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients. Methods. This was a retrospective study involving 30 patients with an irreparable SSC tear and those with a SSC tear combined with a reparable supraspinatus tear, who underwent a latissimus dorsi tendon transfer. Clinical scores and active range of motion (aROM), SSC-specific physical examination and the rate of return to work were assessed. Radiological assessment included recording the acromiohumeral distance (AHD), the Hamada grade of cuff tear arthropathy and the integrity of the transferred tendon. Statistical analysis compared preoperative, short-term (two years), and final follow-up at a mean of 8.7 years (7 to 10). Results. There were significant improvements in clinical scores, in the range and strength of internal rotation and aROM compared with the preoperative values in the 26 patients (87%) who were available for long-term follow-up. These improvements were maintained between short- and long-term follow-ups. Although there was a decreased mean AHD of 7.3 mm (SD 1.5) and an increased mean Hamada grade of 1.7 (SD 0.5) at final follow-up, the rate of progression of cuff tear arthropathy remained low-grade. Comparison between the isolated SSC and combined SSC and reparable supraspinatus tear groups showed no significant differences. At final follow-up, one patient (3.8%) had undergone revision surgery to a reverse shoulder arthroplasty (RSA). No neurological complications were associated with the procedure. Conclusion. Latissimus dorsi transfer for an irreparable SSC tendon tear resulted in a significant clinical improvement, particularly in pain, range and strength of internal rotation and aROM, which were maintained over a mean of 8.7 years following surgery. Given that this was a long-term outcome study, there was a low-grade progression in the rate of cuff tear arthropathy. Thus, the long-term clinical efficacy of latissimus dorsi tendon transfer in patients with irreparable SSC was confirmed as a joint-preserving procedure for these patients, suggesting it as an effective alternative to RSA in young, active patients without degenerative changes of the glenohumeral joint. Cite this article: Bone Joint J 2024;106-B(9):957–963

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

16 to 34% of the population suffer from shoulder pain, the most common cause being rotator cuff tears. NICE guidance recommends using ultrasound scan (USS) or MRI to assess these patients, but does not specify which is preferable. This study assesses the accuracy of USS and MRI in rotator cuff tears in a DGH, to establish the most appropriate imaging modality. Patients who had at least two of shoulder ultrasound, MRI or arthroscopy within a seven month period (n=55) were included in this retrospective study. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated using arthroscopy as the true result, and kappa coefficients calculated for each pairing. 59 comparisons were made in total. Sensitivity for MRI in full supraspinatus tears was 0.83, and for USS 0.75. Specificity for MRI in these tears was 0.75, and for USS 0.83. Values were much lower in other tears, which occurred less frequently. USS and MRI completely agreed with each other 61.3% of the time. Both modalities were only completely accurate 50% of the time. Kappa coefficient between arthroscopy and MRI for supraspinatus tears was 0.658, and for USS was 0.615. There was no statistical difference between MRI and USS sensitivity or specificity (p=1), suggesting that one modality cannot be recommended over the other for full supraspinatus tears. They also do not tend to corroborate one another, suggesting that there is no benefit from doing both scans. Further research is needed to see how both modalities can be improved to increase their accuracy

Aims. Rotator cuff (RC) tears are common musculoskeletal injuries which often require surgical intervention. Noninvasive pulsed electromagnetic field (PEMF) devices have been approved for treatment of long-bone fracture nonunions and as an adjunct to lumbar and cervical spine fusion surgery. This study aimed to assess the effect of continuous PEMF on postoperative RC healing in a rat RC repair model. Methods. A total of 30 Wistar rats underwent acute bilateral supraspinatus tear and repair. A miniaturized electromagnetic device (MED) was implanted at the right shoulder and generated focused PEMF therapy. The animals’ left shoulders served as controls. Biomechanical, histological, and bone properties were assessed at three and six weeks. Results. Extension of the tendon from preload to the maximum load to failure was significantly better in the PEMF-treated shoulders at three weeks compared to controls (p = 0.038). The percentage strain was significantly higher in the PEMF group at both timepoints (p = 0.037). Collagen organization was significantly better (p = 0.034) as was tissue mineral density in the PEMF-treated group at three weeks (p = 0.028). Tendon immunohistochemistry revealed a prominent increase in type I collagen at the repair site at three weeks following continuous PEMF treatment compared with controls. None of the other tested parameters differed between the groups. Conclusion. MED-generated PEMF may enhance early postoperative tendon-to-bone healing in an acute rat supraspinatus detachment and repair model. Superior biomechanical elasticity parameters together with better collagen organization suggest improved RC healing. Cite this article: Bone Joint Res 2021;10(5):298–306

Background: It is commonly believed that rotator cuff tears do progress in size over time. Recent reports suggest that tear progression may not be necessarily true. It was the purpose of this study to review non-operatively treated isolated supraspinatus tears especially in terms of tear size progression. Methods: Inclusion criteria were non-operatively treated isolated full-thickness tears of the supraspinatus, MRI at time of diagnosis available, and patients willing to undergo an additional MRI after more than 2 years after diagnosis. Twenty-four patients (20 men, 4 women) with an average at time diagnosis of 51 years identified and reviewed with MRI and clinically based on the Constant score. Results: The average follow-up was 46 (27–87) months. The Constant score (not available at time of diagnosis) at follow-up averaged 75 points (relative Constant score 86%). Overall the average tear size did not change significantly over time (366mm2 at follow-up versus 393mm2 at time of diagnosis, p > 0.05). In 2 patients the tear was not detectable any longer on MRI suggesting that it was healed, in 7 patients the tear was smaller, in 10 patients it did not change over time and only in 5 patients it progressed. Discussion and Conclusion: Non-operatively treated isolated supraspinatus tears were unchanged, smaller or even healed in 79% of the patients after a follow-up period of more than 4 years. This suggests that supra-spinatus tears do not necessarily progress over time and even have a potential to heal

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

Surgical repair of posterosuperior rotator cuff tears has a poorer outcome and a higher rate of failure compared with repairs of supraspinatus tears. In this prospective cohort study 28 consecutive patients with an irreparable posterosuperior rotator cuff tear after failed conservative or surgical treatment underwent teres major tendon transfer. Their mean age was 60 years (48 to 71) and the mean follow-up was 25 months (12 to 80). The mean active abduction improved from 79° (0° to 150°) pre-operatively to 105° (20° to 180°) post-operatively (p = 0.011). The mean active external rotation in 90° abduction improved from 25° (0° to 70°) pre-operatively to 55° (0° to 90°) post-operatively (p < 0.001). The mean Constant score improved from 43 (18 to 78) pre-operatively to 65 (30 to 86) post-operatively (p < 0.001). The median post-operative VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to 5 (0 to 56) post-operatively (p < 0.001). In conclusion, teres major transfer effectively restores function and relieves pain in patients with irreparable posterosuperior rotator cuff tears and leads to an overall clinical improvement in a relatively young and active patient group with limited treatment options. Cite this article: Bone Joint J 2013;95-B:523–9

Purpose: Short-term results of surgical repair of subscapularis tears are well known. The purpose of this study was to assess long-term outcome after surgical repair of 21 full-thickness tears of the subscapularis. Material and methods: Inclusion criteria were subscapularis tear (n=21) which were isolated (n=9) or associated with a supraspinatus tear (n=11) without intraspinatus tears. The subscapularis was reinserted by transosseous fixation in fifteen cases and with a trapezeal flap in six. The supraspinatus was repaired by transosseous suture. Function (Constant score) was assessed preoperatively, at one and three years, and at last follow-up (nine years, range six to fifteen years). We also noted radiographic changes (subacromial height, osteoarthritis using the Samilson classification, anterior dislocation of the humeral head). Fatty degeneration (FD) of the cuff was assessed on pre-operative scans and at last follow-up. Arthroscan, performed at one year and ultrasonography performed at last follow-up were used to assess cuff continuity. Results: The rough Constant score was 45.2 (12–93.5) preoperatively, 67.5 (20–95) at one and three years and 59.45 (20–95) at last follow-up. At last follow-up, the Constant score was significantly better than preoperatively (improved pain score). There was only one case of repeated tear (repaired supraspinatus). At last follow-up we noted six anterior dislocations. The subacromial space remained unchanged (9.5 mm). Glenohumeral osteoarthritis developed in fourteen cases (2 Samilson class 3) including eight de novo degenerations. FD of repaired subscapularis tendons was 0.8 (0–4) preoperatively and 1.64 (1–4) at last follow-up. FD of unrepaired subscapularis tendons treated with a trapezeal flap worsened (2.2 to 2.7). FD of the supraspinatus and infraspinatus (0.5 preoperatively) worsened one stage. At last follow-up, the Constant score was lower in the presence of anterior dislocation of the humeral head (p=0.013). Development of anterior dislocation of the humeral head was correlated with major preoperative FD of the subscapularis (cut-off between 1.5 and 2, p=0.01). There was a correlation between more FD of the infraspinatus and the presence of anterior dislocation of the humeral head. Among the trapezeal flaps, there were only two good results (Constant scores 74 and 75) in patients with FD of the subscapularis scored 1.5 preoperatively. Conclusion: Functional and radiographic outcome after cuff repair or palliation with a trapezeal flap for subscapularis tears associated or not with supraspinatus tears is not satisfactory unless the fatty degeneration of the subscapularis is low preoperatively (δ 1.5)

Eighty-eight consecutive patients with symptomatic rotator cuff tears were entered in to a prospect study with a novel technique of open double row repair using a ‘Capstan’ screw technique. The medial row has standard anchors, but the lateral suture row is a 35mm × 6.5mm ‘Capstan' screw. This allows up to 28 suture bridges to be taken from the medial row to the lateral row compressing the footprint and spreading the load. This creates a very robust repair or ‘bulletproof repair’. This was used for medium to large isolated supraspinatus tears. Each patient had a pre and post operative Oxford Shoulder Score (OSS), American Shoulder and Elbow Score (ASES Score). The mean pre-operative OSS was 22 (maximum 48) and the mean post-operative OSS was 45, (p < 0.0001). Flexion improved from a mean of 117° to 172° (p < 0.0001). The clinical re-tear rate was 3.4%. 95% were satisfied with the procedure. There were no deep infections. 18% had transient stiffness, 6% stiffness at one year but none severe enough to warrant release. There were no instances of deltoid dysfunction. This demonstrates excellent results in terms of OSS, patient satisfaction and function. Clinical re-tear rate is markedly reduced in comparison to previous literature

Critical shoulder angle (CSA), lateral acromial angle (LAA), and acromion index (AI) are common radiologic parameters used to distinguish between patients with rotator cuff tears (RCT) and those with an intact rotator cuff. This study aims to assess the predictive power of these parameters in degenerative RCT. This retrospective study included data from 92 patients who were divided into two groups: the RCT group, which included 47 patients with degenerative full-thickness supraspinatus tendon tears, and a control group of 45 subjects without tears. CSA, AI, and LAA measurements from standardized true anteroposterior radiographs were independently derived and analyzed by two orthopedic surgeons. Receiver operating characteristic (ROC) analyses were performed to determine the cutoff values. No significant differences were found between patients in the RCT and control groups in age (p = 0.079), gender (p = 0.804), or injury side (p = 0.552). Excellent inter-observer reliability was seen for CSA, LAA, and AI values. Mean CSA (38.1°) and AI (0.72) values were significantly larger in the RCT group than in the control group (34.56° and 0.67°, respectively, p < 0.001) with no significant difference between groups for LAA (RCT, 77.99° vs. control, 79.82°; p = 0.056). ROC analysis yielded an area under the curve (AUC) of 0.815 for CSA with a cutoff value of 37.95°, and CSA was found to be the strongest predictor of the presence of a RCT, followed by AI with an AUC of 0.783 and a cutoff value of 0.705. We conclude that CSA and AI may be useful predictive factors for degenerative RCT in the Turkish population

Rotator cuff pathology is the main cause of shoulder pain and dysfunction in older adults. When a rotator cuff tear involves the subscapularis tendon, the symptoms are usually more severe and the prognosis after surgery must be guarded. Isolated subscapularis tears represent 18% of all rotator cuff tears and arthroscopic repair is a good alternative primary treatment. However, when the tendon is deemed irreparable, tendon transfers are the only option for younger or high-functioning patients. The aim of this review is to describe the indications, biomechanical principles, and outcomes which have been reported for tendon transfers, which are available for the treatment of irreparable subscapularis tears.

The best tendon to be transferred remains controversial. Pectoralis major transfer was described more than 30 years ago to treat patients with failed surgery for instability of the shoulder. It has subsequently been used extensively to manage irreparable subscapularis tendon tears in many clinical settings. Although pectoralis major reproduces the position and orientation of the subscapularis in the coronal plane, its position in the axial plane – anterior to the rib cage – is clearly different and does not allow it to function as an ideal transfer. Consistent relief of pain and moderate recovery of strength and function have been reported following the use of this transfer. In an attempt to improve on these results, latissimus dorsi tendon transfer was proposed as an alternative and the technique has evolved from an open to an arthroscopic procedure. Satisfactory relief of pain and improvements in functional shoulder scores have recently been reported following its use. Both pectoralis minor and upper trapezius transfers have also been used in these patients, but the outcomes that have been reported do not support their widespread use.

Cite this article: Bone Joint J 2024;106-B(9):970–977.

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

Rotator cuff repair is performed to treat shoulder pain and disability. Failure of the tendon repair site is common; one strategy to improve healing is to enforce a period of post-operative immobilisation. Immobilisation may have unintended effects on tendon healing. Tenocytes under uniaxial strain form more organised collagen and up regulate expression of proliferative genes. Vitamin C (ascorbic acid), an anti-oxidant that is a co-factor for collagen synthesis, has also been reported to enhance collagen deposition and organisation. The purpose of this study was to compare human tenocyte cultures exposed to uniaxial cyclical strain with or without slow-release ascorbic acid (ascorbyl-2 phosphate) to determine their individual and combined effects on tissue remodelling and expression of tissue repair genes. Rotator cuff tissues were collected from degenerative supraspinatus tears from eight patients. Tenocytes were incorporated into 3D type I collagen culture matrices. Cultures were divided into four groups: 1) ascorbic acid (0.6mMol/L) + strain (1%–20% uniaxial cyclic strain at 0.1 Hz), 2) ascorbic acid unstrained, 3) strain + vehicle 4) unstrained + vehicle. Samples were fixed in paraffin, stained with picrosirius red and analysed with circular polarising light. A second set of cultures were divided into three groups: 1) 0.5mM ascorbic acid, 2) 1mM ascorbic acid, 3) vehicle cultured for 24, 72, 120 and 168 hours. Cell-free collagen matrix was used as a control. Tenocyte proliferation was assessed using the water soluble tetrazolium-1 (WST1) assay and f tissue repair gene expression (TGFB1, COL1A1, FN1, COLIII, IGF2, MMP1, and MMP13), were analysed by qPCR. The data were analysed using a Split model ANOVA with contrast and bonferroni correction and a one-way ANOVAs and Tukey's test (p<0.05 was significant). Our results indicated that unstrained cultures with or without exposure to slow release ascorbic acid exhibited greater picrosirius red birifringency and an increase in collagen fiber deposition in a longitudinal orientation compared to strained tenocytes. We found that slow release ascorbic acid promoted significant dose and culture-time dependent increases in tenocyte proliferation (p<0.05) but no obvious enhancement in collagen deposition was evident over cultures without ascorbic acid supplementation. Based on these data, applying strain to tenocytes may result in less organised formation of collagen fibers, suggestive of fibrotic tissue, rather than tendon remodelling. This may indicate that a short period of immobilisation post-rotator cuff repair is beneficial for the healing of tendons. Exposure to slow release ascorbic acid enhanced tenocyte proliferation, suggesting that supplementation with Vitamin C may improve tendon repair post-injury or repair. Future studies will assess levels of tissue repair-associated proteins as well as comparing traumatic and degenerative rotator cuff tears to healthy uninjured rotator cuff tissue

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

Aim:. To assess the long term MRI pathoanatomical changes of unrepaired, isolated full thickness supraspinatus tears in a population of patients that had acromioplasty done for symptomatic impingement syndrome. Background:. To date there are no studies assessing the effect of acromioplasty on rotator cuff tear progression in impingement syndrome. The natural evolution of unrepaired tears suggests that small isolated tears may heal, and not all tears progress onto significant fatty change and atrophy. Which tears heal and which tears progress and the effect of acromioplasty on tear progression is still not known. Results:. There were 17 shoulders examined. Average age of our patients was 65 years at time of surgery and 73 years at follow up. The patients were divided into three groups depending on the size of the tear at the time of surgery: C1 tears (< 1cm) n = 5, C2 tears (1–2 cm) n = 8, C3 tears (2–3 cm) n = 4. The C1 tear group did the best clinically with a Constant score mean 86, 4(range 83–96) and mean Oxford score of 47 (range 46–48). The MRI findings in this group showed only one patient (20%) with significant fatty infiltration and atrophy. The C2 group had mean Constant scores of 72(range 65–98), mean Oxford score 45(range 42–48). On MRI evaluation there were 2 patients (11.8%) that had tears that had regressed in size (CI 1.4‐36.4). In the C3 group the mean Constant score was 75(range 65–85) and Oxford score 45(range 42–48). MRI evaluation revealed that all (100%) the rotator cuff tears went on to significant degeneration and atrophy in this group. No statistical difference was found between these groups when assessing Oxford score (p=0.75) and Constant scores(p=0.69). Significant associations were found between tear size and fatty infiltration (p=0.028), and tear size and atrophy (p=0.054. Conclusion:. Acromioplasty in the management of impingement syndrome may be protective when small isolated tears are noted during surgery as two tears regressed in size. Large tears all progress onto fatty infiltration and atrophy, but all three groups despite tear size had good clinical and functional outcomes. More research is needed to further understand the evolution of tears in impingement syndrome

Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years (2001-2004). The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal/ partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery. We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears

1. The end-results of conservative treatment of supraspinatus tears have been studied in a series of 109 patients graded on a clinical basis, and in a further series of twenty-seven patients assessed initially by procaine infiltration. 2. In 87 per cent. of patients with mild lesions, full function was regained in an average period of five and a half weeks. In more than 50 per cent. of patients with apparently severe lesions, there was full functional recovery in eleven to thirteen weeks. 3. Clinical assessment, other than as mild or apparently severe, is unreliable in the early stages. 4. Procaine infiltration of recent tears, by abolishing pain and spasm, allows more accurate assessment of supraspinatus function and gives a more clear indication as to the advisability of conservative or early operative treatment. If such infiltration of the torn segment of tendon fails to restore voluntary abduction power, early operative repair is indicated. 5. Six patients with negative procaine tests, in whom the shoulder cuff was subsequently explored, all showed extensive tears

Seven patients with osteochondral defects of the humeral head were treated over a 3 year period (2002–2005). In six of the patients the diagnosis was made incidentally at time of arthroscopy with the seventh patient being diagnosed preoperatively. There were 5 males and 2 females with an average age of 48 years. Four patients had a history of trauma. The preoperative diagnosis was impingement in 5, supraspinatus partial thickness tear in one and an osteochondral defect in the seventh. Ultrasound revealed a supraspinatus partial thickness tear in one, fluid in the biceps grove in one, and was normal in the other 5. One patient had a MRI which showed a SLAP lesion. All patients had conservative treatment with subacromial injection with 2 patients having complete relief of pain, 2 having almost complete relief, and the other 4 having improvement but not complete relief of pain. Only 2 of the patients had a minor reduction in movement. At arthroscopy the osteochondral defect measured 1x 1 cm in four cases and 1 x 1,5 cm in the other 3. In all patients the osteochondral defect was debrided and the exposed bone abraded. Four patients had an acromioplasty, one had an acromioplasty and excision of the AC joint, one had a debridement only and the seventh patient had an acromioplasty, SLAP repair and debridement of a partial thickness supraspinatus tear. The follow-up averaged 24 months (6–58). The VAS improved from an average of 6,4 preoperatively to 1,2 postoperatively and the ASES improved from 47 preoperatively to 85 postoperatively. All patients were happy to have had the procedure. In conclusion, debridement and abrasion of osteochondral defect was an effective treatment in this series. Acromioplasty should be added when indicated

Ultrasound imaging has become an essential adjunct to clinical examination when assessing a patient with suspected rotator cuff pathology. With the new high-resolution portable machines it has become feasible for the shoulder surgeon to perform the scans himself in the clinic and save a great deal of time. This study was conducted to examine the accuracy of the ultrasound scans performed by a single surgeon over a period of four years. The ultrasound findings were uniformly documented and collected prospectively. Out of a total of 364 scanned patients we selected 143 who ultimately received an operation and we compared the surgical findings with the ultrasound reports. The intra-operative findings included 77 full thickness supraspinatus tears, 24 partial thickness tears and 42 normal cuffs. Three full thickness tears were missed on ultrasound and reported as normal / partially torn. Four normal/ partially torn cuffs were thought to have a full thickness tear. This presents 96.3% sensitivity and 94.3% specificity for full thickness tears. Three partial thickness tears were reported normal on ultrasound and eight normal cuffs were thought to have partial thickness tears. This presents 89% sensitivity and 93.7% specificity for partial thickness tears. The size estimation of full thickness tears was more accurate for large/massive tears (96%) than moderate (82%) and small/pinhole tears (75%). The tear sizes were more often underestimated which may partly reflect disease progression during the unavoidable time lag between scan and surgery. We conclude that shoulder ultrasound performed by a sufficiently trained orthopaedic surgeon is a safe and reliable practice to identify rotator cuff tears

Purpose of the study: When repairing rotator cuff tears, injury to the infraspinatus is generally a posterior extension of a supraspinatus tear. The description of isolated tears of the infraspinatus has not been to our knowledge reported in the literature. We report a series of 13 cases with more than one year follow-up. Material and methods: Thirteen patients underwent surgery for an isolated tear of the infraspinatus between 1995 and 2004. There were ten men and three women. Mean age at surgery was 47 years (range 34–62). The right shoulder was involved in seven of the thirteen cases, and the dominant shoulder in eight. A progressive onset was observed in eleven patients and nine had a history of treated calcified tendinopathy. Clinically, pain was the predominant symptom. The Jobe test was deficient in all patients as was external rotation (except one patient). The preoperative Constant score was 70 (range 62–87). X-rays revealed type C posterior calcification in nine patients. A full-thickness tear was observed in seven cases, a partial deep tear in three, and a partial superficial tear in three. Isolated fatty degeneration of the infraspinatus noted Goutallier grade 2 or greater was observed in seven patients. Open surgical repair was preformed in all patients. Results: Mean time to revision was 29 months (range 12–82). Subjectively, six patients were very satisfied, six were satisfied, and one was disappointed (failure by secondary tear). Two shoulder-hand syndromes were noted in the postoperative period. At last follow-up, the Constant score was 83.5 (range 64–97). All patients except one were satisfied with pain relief but the lack of force was significant. Discussion and conclusion: Isolated tears of the infra-spinatus are rare, but there is a notable relationship with calcifying tendinopathy of the same tendon. Repair should be undertaken before the development of fatty degeneration in order to improve the chances of force recovery