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The complex anatomy of the shoulder often impedes the orthopedic surgeon's evaluation and understanding of injuries to the shoulder joint, particularly the rotator cuff muscle-tendon complex. Arthroscopy, MRI, and digital data analysis are several techniques now at the surgeon's disposal. This article reviews the application of these techniques in the evaluation of rotator cuff injuries.
STUDY DESIGN: Case report. BACKGROUND: Patients with hyperflexion/hyperabduction injury to the glenohumeral joint are at risk for isolated greater tuberosity fractures, which are often undiagnosed or misdiagnosed. In this case report, we describe the clinical decision-making process that led to the diagnosis of an isolated greater tuberosity fracture and subsequent rotator cuff tear. CASE DESCRIPTION: The patient was a 45-year-old male who sustained a shoulder injury as the result of a fall while skiing. After the initiation of physical therapy, he was diagnosed with an isolated greater tuberosity fracture. Little is known regarding the optimal management and overall prognosis of this type of fracture. Conservative nonoperative management and postoperative physical therapy management are discussed. OUTCOMES: With conservative nonoperative management, the patient was unable to regain high-level functional shoulder use. Suspicion of continued pathology of the greater tuberosity dictated further diagnostic imaging, which led to surgical intervention. Upon completion of postoperative rehabilitation, he was able to resume full recreational activities. DISCUSSION: It is recommended that sound clinical decision-making dictate the management and ongoing evaluation of traumatic shoulder injuries, especially when managing a patient with an injury for which optimal treatment and prognosis is not well established.
STUDY OBJECTIVE: To demonstrate the effect of preoperative and intraoperative, small-dose intravenous (IV) droperidol on postoperative pain relief in orthopedic patients given general anesthesia with morphine. DESIGN: Randomized, double-blind, prospective study. SETTING: University-affiliated hospital. PATIENTS: 84 ASA physical status I and II patients undergoing shoulder rotator-cuff repair with general anesthesia. INTERVENTIONS: Patients were randomly assigned to one of three groups: Group P (n = 27) wee given droperidol 10 microg/kg IV before skin incision; Group A (n = 30) received droperidol 10 microg/kg IV after skin incision; and Group C (n = 27) served as controls. General anesthesia consisted of sevoflurane and nitrous oxide in oxygen and IV morphine 0.2 mg/kg, which was given before skin incision. MEASUREMENTS: The degree of postoperative pain as assessed by postoperative pain scores and the number of supplemental analgesics given, and the frequency of postoperative nausea and vomiting, nightmares, and respiratory depression were compared among the three groups. A p-value < 0.05 was considered statistically significant. MAIN RESULTS: The postoperative pain score distribution was significantly greater in smaller values in Groups P and A than in Group C (p < 0.01). The number of supplemental analgesics given in the first 18 hours postoperatively was significantly smaller in Group P than in Groups A or C (p < 0.05). CONCLUSIONS: Preoperative IV droperidol resulted in improved postoperative pain relief inpatients undergoing shoulder rotator cuff surgery with general anesthesia using IV morphine.
Traumatic brain injury (TBI) is often accompanied by additional trauma that can be obscured by cognitive dysfunction or multiple injuries in the same region of the body. This report describes the case of an unhelmeted motorcycle rider who collided with a telephone pole. He sustained a diffuse subarachnoid hemorrhage, bilateral subdural hematomas (right frontal and left temporal), diffuse axonal injury in the subcortical and periventricular white matter, and a left tibial fracture. After medical and surgical stabilization, he was transferred to a subacute rehabilitation facility and then to a rehabilitation center. He was evaluated for pain and limited range of motion in his right shoulder, where both a rotator cuff tear and a brachial plexopathy were diagnosed. This report discusses concomitant injuries that occur with TBI, and the management of rotator cuff tears and brachial plexopathy.
BACKGROUND: Both general and nerve block anesthesia are effective for shoulder surgery. For outpatient surgery, it is important to determine which technique provides more efficient recovery. The authors' goal was to compare nerve block with general anesthesia with respect to recovery profile and patient satisfaction after rotator cuff surgery. METHODS: In this clinical trial, 50 consenting outpatients (aged 18-70 yr) were randomly assigned to receive either fast-track general anesthesia followed by bupivacaine (0.25%) wound infiltration or interscalene brachial plexus block (0.75% ropivacaine), each under standardized protocols. Blinded recovery room nurses assessed the need for pain treatment and rated patient eligibility for bypass of the phase 1 postanesthesia care unit and for discharge home. Patients were followed up for 2 weeks postoperatively. The primary outcome measures were postanesthesia care unit bypass and same-day discharge. Other same-day recovery outcomes included severity of and treatment for pain and time to ambulation. Postoperative outcomes at home included satisfaction with the anesthesia technique and absence of complications (at 2 weeks). RESULTS: Patients who received nerve block (vs. general anesthesia) bypassed the postanesthesia care unit more frequently (76 vs. 16%; P < 0.001), reported less pain, ambulated earlier, were ready for home discharge sooner (123 vs. 286 min; P < 0.001), had no unplanned hospital admissions (vs. 4 of 25 patients who underwent general anesthesia; P = 0.05), and were more satisfied with their care. No complications were reported in either treatment group. CONCLUSIONS: Nerve block anesthesia for outpatient rotator cuff surgery provides several same-day recovery advantages over general anesthesia.
One hundred two type II SLAP lesions without associated anterior instability, Bankart lesion, or anterior inferior labral pathology were surgically treated under arthroscopic control. There were three distinct type II SLAP lesions based on anatomic location: anterior (37%), posterior (31%), and combined anterior and posterior (31%). Preoperatively, the Speed and O'Brien tests were useful in predicting anterior lesions, whereas the Jobe relocation test was useful in predicting posterior lesions. Rotator cuff tears were present in 31% of patients and were found to be lesion-location specific. In posterior and combined anterior-posterior lesions, a drive-through sign was always present (despite absence of anterior-inferior labral pathology or a Bankart lesion) and was eliminated by repair of the posterior component of the SLAP lesion. We conclude that SLAP lesions with a posterior component develop posterior-superior instability that manifests itself by a secondary anterior-inferior pseudolaxity (drive-through sign), and that chronic superior instability leads to secondary lesion-location-specific rotator cuff tears that begin as partial thickness tears from inside the joint.
Skeletal muscles is an uncommon site for metastatic spreading of malignancies such as carcinoma of the lung. Thus, to date, there have been only a small number of reports of carcinoma of the lung spreading to the skeletal muscles. This case study reports the rare combination of a rotator cuff lesion of the shoulder with the late occurrence of the metastasis of a squamous cell carcinoma of the lung in the ipsilateral deltoid muscle. The problems that result from this combination concerning diagnosis and therapy are discussed.
On the basis of their clinical and surgical experience of 480 shoulders operated upon for rotator cuff pathology, together with a review of the literature, the authors undertake a critical analysis of the Neer impingement syndrome. Since this syndrome cannot explain all lesions and above all cover all rotator cuff pathology, they suggest an anatomical classification based upon a description of lesions. They describe their indications for surgery on the basis of their results and of those from the literature.
Fifty-two patients, 17 acute and 35 chronic, underwent US of the shoulder. The first class of patients had clinical history of blunt trauma occurred 2 to 30 days before examination. The second class of patients included 15 patients with history of trauma occurred 3 months (or more) before examination and 20 patients affected with impingement syndrome. As to the US signs of rotator cuff tear reported in the literature, the results of the study, supported by arthrographic (21 cases), MR (2 cases) and surgical (24 cases) findings, indicate that their presence and significance differ in the acute and in the chronic patient and that: 1) Focal discontinuity, appearing as a hypoechoic area, is demonstrable only in the acute patient. The sign is due to a tear filled with blood and/or bursal liquid and holds high diagnostic accuracy. It is rare that an acute lesion appears as a hyperechoic linear density--which has doubtful diagnostic accuracy. 2) Non-visualization of the cuff is observable in both the acute and the chronic patient and indicates rupture in both of them. This sign has high diagnostic accuracy. 3) Thinning of the cuff is also observable both in the acute and in the chronic patient. Nevertheless, while in the former the sign can be regarded with confidence as indicating a tear in almost all cases, in the latter it may be due either to a tear or to degeneration. Arthrography or MR Imaging are therefore advisable in this group of patients, especially if surgical treatment is considered.
Outcome evaluation is becoming increasingly important for reconstructive surgery in musculoskeletal diseases. In addition to established shoulder-scores, new outcome-scores are being developed to cover all effects caused by a disease or intervention. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients suffering from rotator cuff deficiency. These were correlated to the Constant-Murley Shoulder Score and to a visual analogue scale for satisfaction. 7 women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 +/- 10.5, r/l: 14/9, FU 57.8 +/- 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons Shoulder Index (ASES), the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). In addition, a visual analogue scale for satisfaction was employed. All four scores as well as the visual analogue scale revealed improvement at a statistically significant level (paired, two-tailed t-test, P < 0.01) after surgery. All questionnaires had a significant correlation with the Constant-Murley Shoulder Score (Pearson's correlation coefficient: ASES: r = 0.871, P < 0.01; DASH: r = -0.758, P = < 0.01; SST: r = 0.494, P < 0.05). All were easy to apply and provided a reliable, postoperative evaluation of shoulder function. The SST was easy to apply, however compound outcome analysis was only possible with the ASES Shoulder Index and the DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination which is advantageous but must be carried out in the clinic. For postoperative assessment, without the patient having to return to the clinic, the ASES Shoulder Index is preferred as it correlates well with the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).
Eighteen people (10 men, 8 women) were examined on a 0.3-T (low-field) imager with T1-weighted axial and coronal images and either axial or coronal T2-weighted images. Thirty-two people (22 men, 10 women) were examined on a 1.5-T (high-field) imager with axial T1-weighted images and coronal, sagittal dual-echo images. Rotator cuff lesions were diagnosed by the following findings: abnormal signal in the tendon, irregularity or discontinuity at the musculo-tendinous junction, or muscle abnormality. Glenoid labrum tears were considered if one or more of the following criteria were present: labral deformity of unusual size, focal defect, amputation or displacement with fluid, or capsular stripping. Comparison between the high-field and low-field MR images in the evaluation of rotator cuff lesions suggests that the high-field imager is better than the low-field imager in the differentiation of tendinitis from tears, in the confirmation of bursitis and in detection of subscapularis lesions. A higher contrast-to-noise ratio (CNR), less time consumption, and more section planes (especially, sagittal sections) appear to be the main reasons for this. As far as labral lesions are concerned, the performances of the high-field imagers and low-field imagers were almost equal. The artifact of greater chemical shift with a high-field imager would more or less, we assume, degrade the better CNR achievable in the diagnosis of labral lesions.
PURPOSE: The purpose of this work was to establish the optimal means of evaluation of the rotator cuff interval (RCI) and rotator interval capsule and demonstrate normal anatomy of the RCI using MR imaging and MR arthrography. METHOD: MR arthrography was performed in 32 cadaveric shoulders. In 20 cases, MR imaging was completed prior to arthrography. Pre- and postarthrography studies included standard imaging planes. Images were evaluated by the consensus of two musculoskeletal radiologists with attention to the RCI, rotator interval capsule (measurements on postarthrographic studies), and crossing structures. In five cases, specialized imaging planes were performed after arthrography. RESULTS: The RCI, rotator interval capsule, and crossing structures were best evaluated by MR arthrography. The anteroposterior dimension of the rotator interval capsule could be best depicted on postarthrogram images. CONCLUSION: MR arthrography, with both standard and specialized imaging planes, is a useful way to evaluate the RCI, the rotator interval capsule, and its crossing structures.
The patient is placed in the lateral position, and an arthroscopic cuff repair is performed according to standard techniques. The line of repair is usually in the shape of a "T" or an "L." The repair is viewed through the lateral portal, with fluid inflow through the scope. Mattress sutures are placed in the anterior and posterior portions of the cuff, with respect to the line of repair, just medial to the most medial point of the tear. The sutures are placed in accordance with margin convergence suture passing methods. Next, 2 double-stranded suture anchors are placed into the lateral aspect of the greater tuberosity, which can be used to secure the anterior and posterior portions of the rotator cuff as well as the patch. The cuff sutures are tied first; then, the patch is addressed. The graft is sized by placement of a ruled probe or similar device into the subacromial space. The length of each side of the "rectangle" is measured to obtain the dimensions of the patch. The patch is then cut to fit the measurements. If the patch material is elastic, a slightly smaller than measured graft is cut to provide tension on the repair. The arthroscope is then moved to the posterior portal, and a large (8 mm) cannula, with a dam, is placed into the lateral portal. All sutures are brought out of the lateral cannula, and corresponding ends of each suture are held together in a clamp. The sutures are placed in their respective orientations once outside the cannula (e.g., anterior-medial, anterior-lateral), covering all 4 quadrants. Care is taken to ensure that the sutures have no twists and are not wrapped around one another. The sutures are passed through the graft, in mattress fashion, with a free needle, in their respective corners and clamped again. The graft is then grasped with a small locking grasper on its medial edge and is passed through the cannula into the subacromial space. The clamps holding the sutures are then gently pulled to remove the slack. A smaller (5 mm) cannula is placed through 1 of the anchor incisions into the subacromial space. The medial 2 sutures are retrieved, a pair at a time, through the small cannula and are tied according to standard arthroscopic techniques; then, the lateral 2 sutures are retrieved from the anchor. The graft should cover the area of repair completely and should be under slight tension. Additional sutures may be placed to further secure or tension the graft as necessary, with the use of standard suture passing techniques, similar to those used when margin convergence is performed. Passive shoulder motion, pendulum exercises, and active elbow and wrist motion begin 2 days after surgery when the dressing is removed. Active assisted motion and active motion begin at 6 weeks, with integrated periscapular stabilization exercises. Formal cuff strengthening begins no sooner than 12 weeks after surgery for large and massive tears.
In many studies, short-term and midterm results of debridement seem to show satisfactory results. However, the three long-term studies currently available all report that these initial results deteriorate significantly with time and are not acceptable. If debridement is considered, careful preoperative and intraoperative evaluation as discussed by Burkhart should be followed. We believe an adequate understanding of the anatomic subtleties, pathologic changes, biomechanical forces, and advanced reconstructive techniques allows repair to be performed in most, if not all, rotator cuff tears of the shoulder. The findings of the study described herein indicate that repair of these tears is the treatment of choice.
A study of 5 fresh cadaveric shoulders demonstrated that an oblique-sagittal plane which crosses the scapula through the medial border of the coracoid process offers a view of the supraspinatus fossa mostly limited by bone. This view could easily be reproduced by MRI and we called it the Y-shaped view. It allowed a reliable measurement of supraspinatus muscle atrophy by the calculation of the occupation ratio (R) which is the ratio between the surface of the cross-section of the muscle belly and that of the fossa. This ratio was calculated in a prospective study based on 55 shoulders divided into 3 groups with different rotator cuff status: group I, 15 controls; group II, 10 degenerative cuffs, without tears; group III, 30 operated tears. There was no difference between groups I (mean ratio 0.7) and II (mean ratio 0.62), but the ratio was decreased in group III (mean ratio 0.44), in which the extent of the tear in both the sagittal and coronal planes aggravated the muscle atrophy. We propose a three-stage classification to improve indications for rotator cuff tear treatment.
An 80-year-old woman with repeated hemarthrosis of the right shoulder was examined and treated arthroscopically. Plain radiographs indicated narrowing of the acromiohumeral interval (3 mm) with large acromial spur. Under fluoroscopic visualization, the impingement between the humeral head and the medial edge of the acromion was seen at 50 degrees abduction. The area of impingement of the humeral head seemed to be just medial to the greater tuberosity. Arthroscopically, a crater formation was seen at this site. Active bleeding was seen at the center of the crater, which was interpreted as the principal cause of intra-articular hemorrhaging. The undersurface of the acromion was irregular because of the presence of osteophyte. At 50 degrees abduction, the crater impinged with the medial edge of the acromion. We assume that both the presence of osteophyte and the instability caused by the massive rotator cuff tear might contribute to the attrition of the humeral head. In this patient, intra-articular hemorrhaging was successfully treated arthroscopically by coagulation of the bleeding point with minimal abrasion of the undersurface of the acromion. We believe that the arthroscopy facilitated the clinical management of the repeated hemarthrosis with massive rotator cuff tear.
We studied the relationship between fatty degeneration in the supraspinatus muscle after rotator cuff tear and muscle atrophy and tendon retraction in 41 cadaveric shoulders. Eighteen shoulders had a supraspinatus tendon tear. Transverse sections of the supraspinatus muscle were made at the proximal end of the scapular notch. The tendon fiber areas were stained red and the muscle fiber areas were stained yellow by the van Gieson method. Areas of fatty degeneration were stained orange-red by the Sudan three method. These areas were measured with a computer color image analysis system. There were many areas of the fatty degenerative change in the supraspinatus muscles associated with a cuff tear, mainly around the tendon fibers and the vessels. The fatty degeneration in the supraspinatus muscle after cuff tear was found to have a strong association with the degree of retraction of the tendon fibers rather than the reduction of muscle volume.
This study prospectively evaluated the clinical outcome of 41 patients who underwent arthroscopic repair of a significant (>50% thickness) partial-thickness supraspinatus tear. Tears were converted to full-thickness lesions and repaired with suture anchors and simple sutures. Of the tears, 80% (33/41) involved the articular surface. The mean age of the patients was 49 years (range, 23-70 years), and the mean follow-up was 38 months (range, 24-50 months). All patients had improvements in range of motion and strength. Postoperative isometric strength measurements revealed no significant difference between the operative and asymptomatic shoulder. Significant improvements were demonstrated for American Shoulder and Elbow Surgeons scores (from 42 to 93 points, P < .001), pain relief (from 6.5 to 0.8 points, P < .001), and satisfaction (from 3.0 to 9.2 points, P < .001). Of the 41 patients, 40 (98%) were satisfied with their outcome. This study documented the successful clinical outcome of arthroscopic repair of significant partial-thickness rotator cuff tears.