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PubMed1997

Magnetic resonance imaging assessment of the rotator cuff: is it really accurate?

Magnetic resonance imaging (MRI) is used increasingly for evaluating the rotator cuff. This study of 39 shoulders (38 patients) compared the accuracy of MRI interpretation of rotator cuff integrity by a group of community hospital radiologists (clinical community scenario, CCS) with that of a musculoskeletal radiologist (experienced specialist scenario, ESS), relative to arthroscopy. For the CCS subgroup, the sensitivity, specificity, positive predictive value (PV), negative PV, and accuracy for partial tears were: 0%, 68%, 0%, 82%, and 59%, respectively; for complete tears: 56%, 73%, 36%, 86%, and 69%, respectively; and for all tears combined: 85%, 52%, 50%, 87%, and 64%, respectively. For the ESS subgroup, the respective values for partial tears were: 20%, 88%, 20%, 88%, and 79%, respectively; for complete tears: 78%, 83%, 58%, 92%, and 82%, respectively; and for all tears: 71%, 71%, 59%, 81%, and 71%, respectively. We concluded that MRI assessment of the rotator cuff was not accurate relative to arthroscopy. MRI was most helpful if the result was negative, and MRI diagnosis of partial tear was of little value. Considering the high cost of shoulder MRI, this study has significant implications for the evaluation of patients with possible rotator cuff pathology.

Adult↗
PubMed2004

Arthroscopic repair of massive, contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results.

PURPOSE: The purpose of this study is to describe the technique and review the preliminary results of arthroscopic repair of massive, contracted, immobile rotator cuff tears using an interval slide technique. TYPE OF STUDY: Case series. METHODS: From January 1999 to December 2000, the senior author (S.S.B.) performed arthroscopic rotator cuff repair on 94 massive rotator cuff tears. Of these, 9 (9.6%) were massive, severely contracted rotator cuff tears and required repair using an interval slide technique. A single interval slide was used in 6 patients, and a double interval slide was used in 3 patients. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) scoring system. RESULTS: At a mean follow-up time of 17.9 months (range, 10-24 months), 8 of 9 patients were satisfied with the procedure. The mean UCLA score increased from 10.0 preoperatively to 28.3 postoperatively (P <.00001). All patients showed some improvement in active motion, strength, or function. Active forward flexion improved significantly, from a preoperative mean of 108 degrees to a postoperative mean of 146.1 degrees (P =.025). Active external rotation increased significantly from a preoperative mean of 24.4 degrees to a postoperative mean of 35.0 degrees (P =.04). A significant increase in strength grade (2.2 to 3.6; P <.005) and function (2.5 to 7.1; P <.0005) were also seen. We encountered no significant complications to the procedure. CONCLUSIONS: The interval slide technique provides a method of mobilization of massive, severely contracted, immobile rotator cuff tears allowing repair of previously irreparable tears. This technique, in conjunction with arthroscopic rotator cuff repair, may provide patients with improvements in pain, motion, strength, and overall shoulder function. LEVEL OF EVIDENCE: Level IV.

Aged↗
PubMed1998

[Rotator cuff rupture: definition, establishing the diagnosis and therapy].

The rotator cuff tear is an extremely common disorder in the general as well in the orthopaedic praxis. The etiology is multifactorial with intrinsic and extrinsic factors. Clinical assessment of the patient is important for an exact diagnosis and an individual treatment plan. The treatment options of full thickness tears include conservative as well as operative procedures. Over the last years, modified techniques have improved the results of rotator cuff reconstruction.

Diagnosis, Differential↗
PubMed2004

Multivariate analysis of biochemical markers in synovial fluid from the shoulder joint for diagnosis of rotator cuff tears.

Multivariate discriminant analysis allowed definition of cytokine, matrix metalloproteinases (MMP), and tissue inhibitors of metalloproteinases (TIMP) levels in synovial fluid (SF) of patients with rotator cuff tears and other shoulder lesions. We analyzed SF aspirated from the glenohumeral joints of 17 patients with rotator cuff tears; SF from nine patients with other shoulder lesions was used to characterize a non-rotator-cuff-tear (NRCT) group. Discriminant analysis demonstrated statistically significant differences in (1) the determination of whether rotator cuff tear patients are separable from the NRCT group using the influential functions, the most influential of which were interleukin 1-beta, MMP-2, and MMP-13, and (2) the assessment of whether full-thickness rotator cuff tears are distinguishable from partial tears using identical influential functions. The most influential function in the latter analysis was MMP-13. Both interleukin 1-beta and MMP-13 might be biochemical markers of impending rotator cuff tears.

Adolescent↗
PubMed2004

The interval slide in continuity: a method of mobilizing the anterosuperior rotator cuff without disrupting the tear margins.

Massive, contracted, immobile rotator cuff tears involving the subscapularis, supraspinatus, and infraspinatus tendons present difficult surgical challenges to the arthroscopic surgeon. We describe the interval slide in continuity, a release and resection of a portion of the coracohumeral ligament and rotator interval. This technique improves the mobility of the subscapularis and supraspinatus tendons but also maintains an important lateral bridge of tissue spanning the interval between the subscapularis anteriorly and the supraspinatus tendon superiorly. After repair of the subscapularis tendon, this lateral rotator interval tissue can greatly facilitate repair of the posterosuperior rotator cuff.

Arthroscopy↗
PubMed2003

Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients.

The importance of acromial morphology in the pathogenesis of rotator cuff tears remains controversial. Some surgeons place great emphasis on acromial morphology and others feel that acromial shape is a result of cuff tear pathology rather than the cause. The purpose of this study was to determine if there was an association between acromial morphology, age, and rotator cuff tears found by ultrasound in asymptomatic volunteer subjects with no past history of shoulder symptoms. One hundred eighteen outlet x-rays and ultrasound scans were performed in 59 asymptomatic patients in various age groups. Acromial morphology and the age of the patients were then correlated with the ultrasound findings. Older patients were noted to have a high incidence of type II and type III acromions (93% of those over 70). Full- and partial-thickness tears were more commonly seen in patients with type II or type III acromions compared with type I. Patients over 50 years had a high incidence of full-thickness tears (40%), but the incidence did not increase with increasing age past 50. These findings lend credence to the multifactorial etiology of rotator cuff tears. The patient's age (degeneration) and acromial morphology (impingement) are two of the factors involved in causing rotator cuff tears. The incidence of cuff tears and type III acromions was high in this group of entirely asymptomatic volunteer subjects. Surgeons should interpret radiologically hooked or curved acromions as well as rotator cuff tears diagnosed with ultrasound or other modalities with caution. It may well be that both of these findings should be regarded as part of the natural ageing process.

Acromion↗
PubMed2001

Arthroscopic treatment of massive rotator cuff tears.

In the past 10 years, arthroscopic surgeons have gone from being unable to repair any rotator cuff tears arthroscopically to being able to repair virtually all rotator cuff tears, even complex massive tears, arthroscopically. The factors responsible for this rapid evolution have been: (1) recognition of the mechanical principles responsible for a secure repair (margin convergence, knot security, loop security); (2) recognition of major tear patterns that require different techniques of repair; and (3) development of instrumentation and arthroscopic portals that predictably accomplish secure repair of the rotator cuff and direct access to the pathologic areas. In the current study, the author analyzes each factor, anatomic and mechanical, that influences the quality of the repair, and explains how to optimize the overall repair by optimizing each step in the repair. In the author's series of arthroscopic repair of rotator cuff tears, the results have been gratifying, with massive tears achieving final results equivalent to those of smaller tears.

Arthroscopy↗
PubMed1995

Rotator cuff insufficiency in the arthritic shoulder: treatment alternatives.

Shoulder arthroplasty can relieve the pain and improve the functional status of an arthritic shoulder. Because of the unique anatomic characteristics of the glenohumeral joint, the rotator cuff provides stability and control of shoulder motion. Thus, an intact, functioning rotator cuff is necessary for successful shoulder arthroplasty. There are clinical situations where the rotator cuff is torn, absent, or incompetent and an arthritic condition affects the shoulder. The patient must understand that, when confronted with rotator cuff insufficiency and shoulder arthritis, the goal of surgical treatment is limited to pain relief, with shoulder function often limited by the condition of the rotator cuff. We will discuss the incidence of rotator cuff disease associated with differing arthritic conditions, the treatment options available, and expected outcomes in these difficult and challenging clinical situations.

Arthritis↗
PubMed2006

Arthroscopic approach to massive rotator cuff tears.

The treatment of a patient with a painful massive rotator cuff tear can be challenging. Massive tears exceed 5 cm in length and involve partial or complete tearing of three tendons. The arthroscopic approach provides a minimally invasive technique to evaluate the tear, mobilize and repair tendons, and improve symptoms without disruption of the deltoid. The arthroscopic technique can create a low-tension repair. The reduction of postoperative motion provides the best environment for tendon-to-bone reattachment. Procedures that have reduced rates of adhesion formation allow for this protection with a minimal risk of stiffness. Reduction of the boutonniere effect of superior head migration leads to improved arm elevation. Strength deficits are common and relate to muscle and tendon deterioration that may not be reversible, even with successful closure of the tear. Weakness caused by suprascapular neuropathy may improve after the position and length of the posterosuperior cuff tendons are reestablished. Arthroscopic options include rotator cuff repair, partial cuff repairs, xenografts, decompression, débridement, biceps tenotomy, tenodesis, and use in autografting.

Arthroscopy↗
PubMed2003

Association of shoulder sonographic findings with subsequent surgical treatment for rotator cuff injury.

OBJECTIVE: To identify any clinical and radiologic findings of rotator cuff injury that predict whether patients will undergo shoulder surgery. METHODS: We retrospectively studied all shoulder sonograms obtained at a single institution over 12 months. Possible predictors of surgical treatment were documented, including patient age and sex, duration and types of symptoms, and the location and severity of tendon damage on sonography. One hundred twenty-eight patients underwent shoulder sonography; 34 patients eventually underwent shoulder surgery. Multivariate logistic regression was performed to identify clinical and sonographic factors associated with the use of surgical therapy. RESULTS: The only statistically significant predictor of surgical intervention was the finding of full-thickness tears (with or without tendon retraction) on sonography (P = .03). Patients with full-thickness tears were 4.3 times more likely to undergo surgery than those with no tears (odds ratio, 4.3). CONCLUSIONS: The sonographic diagnosis of full-thickness rotator cuff tears is the only finding statistically associated with the use of surgical treatment. No single clinical variable was consistently associated with subsequent surgery. Partial-thickness tears on sonography also do not show any statistical association with the eventual use of surgery for rotator cuff symptoms.

Female↗
PubMed2000

Rotator cuff pathology and subacromial impingement.

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.

Adult↗
PubMedDate not supplied

Biomechanical evaluation of rotator cuff fixation methods.

Initial fixation strength and failure mode for various rotator cuff reattachment techniques (variations of the McLaughlin technique) were evaluated. Repair methods included standard suture (control), reinforced suture [expanded polytetrafluoroethylene (PTFE) patch and polydioxanone (PDS) tape augmentation] and stapling (nonarthroscopic and arthroscopic soft-tissue staples). The average strength of intact rotator cuff tissue (supraspinatus tendon) was also determined. The different rotator cuff repairs, including at least one control, were performed on fresh-frozen human cadaver shoulder pairs. Repairs were tested to failure in pure tension with the shoulder fixed in 60 degrees of abduction. Load and displacement data were normalized to controls, grouped according to failure modes, and statistically analyzed. The two basic failure modes observed were 1) bone failure, or suture tearing through the bone (indicating weak bone stock) and 2) tendon failure, or suture tearing of the rotator cuff. Gross comparisons between intact and repaired tendons indicated that the intact tendon was two to three times stronger than the repaired tendon. Based on the mode of failure and lack of increased strength after repair, the use of staples for cuff attachment is discouraged. PDS tape suture reinforcement did not increase fixation strength. In contrast, PTFE patch suture augmentation demonstrated statistically higher initial failure loads than did the control and was of specific benefit for shoulders with weak bone stock.

Adult↗
PubMedDate not supplied

Massive rotator cuff tears. Screening by routine radiographs.

To clarify their usefulness in screening massive rotator cuff tear, routine radiographs of the shoulder were compared in three groups: (1) shoulders with a massive rotator cuff tear (MRCT), (2) shoulders with a small full-thickness rotator cuff tear (SRCT), and (3) normal control shoulders. Two different statistical methods were employed to assess the gradation (order) of correlation in 83 shoulders (22 were MRCTs, 31 with SRCTs, and 30 controls). Superior migration of the humerus and deformity of the greater tuberosity showed by far the more significant contribution to MRCT than did other abnormalities. When the shoulders were screened for these two abnormalities, the sensitivity was 78% (21/27) and specificity was 98% (55/56).

Acromioclavicular Joint↗
PubMed2007

Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations.

PURPOSE: The purpose of this study was to evaluate arthroscopically the frequency and type of instability of the long head of the biceps (LHB) tendon in patients undergoing rotator cuff repair. METHODS: In 200 consecutive patients undergoing arthroscopic rotator cuff repair, LHB instability was assessed statically and dynamically in the anteroposterior direction. In addition, macroscopic lesions of the LHB, as well as lesions of the adjacent rotator cuff tendons, were documented. RESULTS: LHB instability (subluxation or dislocation) was found in 45% of patients, with isolated anterior instability in 16%, isolated posterior instability in 19%, and combined anteroposterior instability in 10%. Whereas LHB subluxations were observed in both directions, dislocations were only seen in anterior LHB instability. Anterior instability was more associated with a subscapularis lesion, whereas posterior instability was more associated with a supraspinatus tear. Lesions of the LHB tendon were strongly associated with LHB instability and the size of the rotator cuff tear. CONCLUSIONS: In 200 patients with rotator cuff tears LHB instability could be observed arthroscopically in 45%, with 16% being anterior, 19% being posterior, and 10% being anteroposterior. LHB instability was associated with LHB lesions, with 15% of the LHB tendons showing a normal appearance when unstable versus 70% when stable. Preoperative O'Brien and Speed tests did not correlate with intraoperative observed LHB pathology. The size of the rotator cuff tear could be correlated with the grade of LHB lesion, becoming more significant with augmenting tear size. On the basis of these observations, we created a new arthroscopic classification of LHB instability with respect to the direction and extent of LHB instability, lesions of the LHB, and status of the adjacent rotator cuff tendons. LEVEL OF EVIDENCE: Level IV, diagnostic study with poor reference standard.

Activities of Daily Living↗
PubMed1992

[Ultrasonography of the rotator cuff of the shoulder].

Clinical examination for rotator cuff (RC) tear is rarely conclusive. Arthrography has been considered the standard diagnostic procedure for detection of rotator cuff tears. Ultrasonography (US) is less time-consuming and less expensive than arthrography and is, in addition, noninvasive. During recent years, many reports concerning US evaluation of RC tears have been published, but with different results about the diagnostic value of the examination. Recently, some authors have pointed out the ability of US in visualizing degenerative changes in the RC and that it is difficult to differentiate between tears and degenerative changes. By review of the English literature, we conclude that the experienced examiner with proper equipment can confidently differentiate between normal and pathological RC an that in quite a number of cases it is possible to differentiate tears from degenerative changes. In case of doubt, the examination should be supplemented by shoulder arthrography. In the hands of an experienced examiner with proper equipment US seems to be suitable as the initial imaging modality for evaluation of RC.

Humans↗
PubMed1998

Electromyographic activities of the biceps during arm elevation in shoulders with rotator cuff tears.

We investigated electromyographic activities of the biceps in 40 shoulders with full-thickness tears of the rotator cuff and 40 asymptomatic shoulders, with a normal rotator cuff on MRI, to determine the role of the biceps in cuff-deficient shoulders. Using surface electrodes, biceps activities were recorded during arm elevation in the scapular plane with and without a 1-kg load. The percentages of integrated electromyograms to the maximum voluntary contraction (%MVC) were obtained at 30 degrees, 60 degrees, 90 degrees, and 120 degrees of elevation. In the normal shoulders, %MVC of the biceps was always less than 10% through the arc of elevation both with and without load. Among 40 shoulders with rotator cuff tears, 14 showed increased activities of the biceps more than 10% in %MVC (p < 0.0001), whereas the remaining 26 shoulders had activities similar to the normal shoulders. The biceps activities in these 14 shoulders increased with load application and at higher angles of elevation. The muscle strength tended to be weaker in shoulders with increased biceps activities than in those without. Our findings suggest a potential supplemental function of the biceps in shoulders with rotator cuff tears.

Adult↗
PubMed2005

Ultrasonography of the rotator cuff: a comparison with arthroscopy in one-hundred-and-ninety consecutive cases.

PURPOSE: To evaluate the accuracy of high-resolution ultrasonography compared to arthroscopy in the detection of rotator cuff tears. MATERIAL AND METHODS: Preoperative ultrasonography (US) with a 10-MHz commercially available linear-array transducer and a standardized study protocol was performed in 190 consecutive shoulders in 185 patients with a history of shoulder pain for more than 3 months. The findings at US were classified into intact cuff, partial-thickness, and full-thickness rotator cuff tears, and correlated with findings at shoulder arthroscopy. RESULTS: US correctly depicted 118 of 124 rotator cuff tears with sensitivity 95%, specificity 94%, PPV 97%, NPV 91% and accuracy 95%, all 94 full-thickness tears (sensitivity 100%, specificity 91%, PPV 91%, NPV 100%, and accuracy 95%), 24 of 30 partial-thickness tears (sensitivity 80%, specificity 98%, PPV 86%, NPV 96%, and accuracy 95%). CONCLUSION: US is a highly accurate diagnostic method for detecting full-thickness rotator cuff tears, but is less sensitive in detecting partial-thickness rotator cuff tears.

Adult↗