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PubMed1998

[Lifting osteotomy of the acromion as a new principle in treatment of impingement syndrome, especially in correlation with reconstruction of large rotator cuff lesions].

There are many different causes leading to impingement lesions of the shoulder (e.g., architecture of the acromion, arthritis of the acromioclavicular joint, bursitis subacromialis, chronic instability). There are also different ways of treating it. Neer described his technique of anterior acromioplasty in 1972. With this technique there is sometimes a limitation in the amount of resection possible because of the anatomical findings (i.e., very curved or small acromion). We developed a new technique: the lift-up osteotomy of the acromion (LOA). This technique allows us to gain as much subacromial space as needed (e.g., for large anterior deltoid flaps). Osteotomy of the acromion gives an excellent view of the rotator cuff. Even large lesions can easily be repaired. After the cuff repair is done, the acromion is refixed with two canulated screws. So far, we have used this LOA technique in more than 100 patients in impingement operations, cuff repairs and anterior deltoid flaps all with good results.

Acromion↗
PubMed1994

[Ultrasonographic diagnosis of the pathology of the rotator cuff and subacromial bursa: criteria].

Shoulder soft tissues echographic evaluation depends on the availability of well established echographic diagnostic criteria, which hasn't been fully accepted until nowadays, as results in that field have been controversial. The main purpose of the present study has been to determine the echographic criteria of the most frequent shoulder periarticular soft tissue pathology. A prospective study has been carried out, comparing the right to the left shoulder of 37 normals in order to determine the normal characteristics and limits of the selected echographic parameters (echogenicity, echostructure, dimensions in terms of width, rhythm of movement and rotator cuff competence ratio). Afterwards, the relative role of these variables in the identification of three different nosological groups determined through suitable gold standard diagnostic methods (36 suprasinatus tears, 20 supraspinatus tendinitis and 22 subacromial bursitis) has been determined. Lastly, the discriminant power of some echographic parameters association was tested, thus suggesting the echographic criteria to be selected. Results support the following criteria: 1) supraspinatus tears: cuff competence ratio less than 1, the difference value between the affected and the sound tendon thickness less than -1,8 mm associated with asymmetries of one of the remaining parameters (echogenicity, echostructure or rhythm); 2) supraspinatus tendinitis: the difference between the affected and the sound tendon thickness bigger than 1 mm associated with asymmetries of one of the remaining parameters (echogenicity, echostructure or rhythm); cuff competence ratio equal or above 1;3) subacromial bursitis: the difference between the affected and the sound bursa thickness bigger than 1 mm associated with asymmetries of one of the following parametres: echogenicity, echostruture or rhythm.

Acromioclavicular Joint↗
PubMed2006

The effect of cartilage-derived morphogenetic protein 2 on initial healing of a rotator cuff defect in a rat model.

This animal study evaluated the healing of supraspinatus tendon tears by use of a cartilage-derived morphogenetic protein 2 growth factor (CDMP-2) delivered to the repair. Forty-eight rats had bilateral, surgically created complete tears repaired by sutures with the growth factor introduced on one side. They were killed at 2, 3, 4, and 6 weeks, and the strength of the repairs was determined and histologic analysis performed. At 4 and 6 weeks, the CDMP-2-treated repairs were significantly stronger than the untreated repairs and histologic analysis showed more organized healing. The use of growth factors introduced at the time of rotator cuff repair might promote more rapid healing and subsequent, rapid patient rehabilitation.

Animals↗
PubMed2006

Engaging needles: a simple technique for arthroscopic side-to-side rotator cuff repair.

We present a simplified technique for the side-to-side arthroscopic rotator cuff repair. The instruments required for this technique are a 45 degrees Suture Lasso (SL; Arthrex, Naples, FL) and a 17F spinal needle (SN). With the arthroscope in the lateral portal, the SL is inserted through the posterior cannulas to grab healthy tissue at the posterior margin of the cuff. Through the anterior cannulas or through a skin puncture, the SN is inserted to catch healthy tissue at the anterior margin. Once both instruments are through the tissues, we manipulate them to make their tips converge. Because the SN diameter is small, it is very easy to engage its tip into the SL tip. Once engaged, a No. 1 PDS monofilament suture is easily passed through both instruments. When the suture comes out of the SL handle, both instruments can be pulled out, leaving the suture in place. Using a suture retriever clamp, the sutures are retrieved through a cannula for knot tying. This technique can be repeated as many times as necessary to place enough sutures in a side-to-side fashion to achieve the repair.

Arthroscopy↗
PubMed1993

Management of rotator cuff calcifications.

Although investigators do not agree on the etiology of calcification of the rotator cuff, it may be linked to hypoxia of the tissue. New evidence suggests that there may be a genetic predisposition linked to the HLA-A1 antigen. The initial phases of formation of the calcification are rarely symptomatic. The acute phase symptoms that debilitate the patient are usually associated with the resorptive phase, in which there is vascular invasion and influx of phagocytic cells, increasing the intratendinous pressure and exacerbating the symptoms. Conservative treatment including local injections of anesthetic, needling, and barbotage is frequently successful. Steroid injections are controversial and may slow the long-term resorption of calcium. A small group of patients remain symptomatic. For these patients and for the chronic subacute patient who fails to resolve with conservative treatment, excision of calcium offers reliable relief. Previous experience with open excision provided predictable results but with a surprisingly long time to recovery. Recent experiences with arthroscopic excision have decreased the morbidity, and several investigators have reported uniformly excellent results. The technique is demanding, but arthroscopy permits reliable removal of the calcification and resolution of pain. Acromioplasty with or without coracoacromial ligament resection should be performed only in patients in whom impingement has been demonstrated by physical examination or intraoperative arthroscopic examination.

Arthroscopy↗
PubMed2001

[Transdermal nitroglycerin versus corticosteroid infiltration for rotator cuff tendinitis].

AIMS: To compare transdermal nitroglycerin (NTG) and corticosteroid infiltration in patients with rotator cuff tendinitis (RCT). DESIGN: Experimental, randomized controlled study. SETTING: Semirural basic health area in the Garraf region of Barcelona province, Spain, with a population of public health service users of 12000. PATIENTS AND METHODS: Patients diagnosed as having RCT of less than 6 weeks' evolution who had not responded to treatment with oral nonsteroid antiinflammatory drugs. The patients were distributed randomly into two groups: a) group A, local infiltration via a posterior approach with a depot corticosteroid and local anesthesia, and b) group B, treated for 3 days with a 5-mg NTC patch. MAIN MEASURES: Age, sex, pain (measured with an analog visual scale) and adverse events. In patients who showed a partial response, treatment was repeated up to 3 times at 15-day intervals. Pain was tested after 7-10 days of treatment. Complete improvement was considered a reduction in pain of more than 5 points on the analog visual scale; partial improvement was considered a reduction of 3-5 points, and treatment failure was recorded when there was no improvement in pain or when there was a decrease of less than 3 points. RESULTS: A total of 48 patients were included; 33 (69%) were women and 15 (31%) were men. Mean age was 61 years. In group A, complete improvement was seen in 19 patients and partial improvement in 3; treatment failed in 2 patients. In group B complete improvement was seen in 5 patients, partial improvement in 5, and failure of treatment in 14. The difference between groups was statistically significant. Adverse events were mild pain at the injection site in 4 patients from group A, and headache in 15 patients from group B, 8 of whom abandoned treatment for this reason. CONCLUSION: Treatment with NTG is not a clear alternative to infiltration of corticosteroids in patients with RCT, because of its lack of effectiveness and because of the greater number of patients who had adverse events that lead them to abandon treatment.

Analgesics↗
PubMed2004

Adhesion of the subacromial bursa may cause subacromial impingement in patients with rotator cuff tears: pressure measurements in 18 patients.

In order to determine whether adhesion of the subacromial bursa leads to impingement, we measured the subacromial contact pressures before and after release of adhesion of this bursa. 18 shoulders with cuff tears and adhesion of the subacromial bursa were evaluated in 8 male and 10 female patients, of mean age 62 (53-71) years and who had no particular limitation of shoulder motion. We recorded subacromial pressures using a very sensitive film inserted under the acromion during surgery. In passive scapular plane elevation (scaption) at 100 degrees, the mean subacromial contact pressure and area declined from 1.43 (SD 0.23) MPa before release to 1.14 (SD 0.35) MPa after release (p < 0.001), and from 163 (SD 81) mm2 before release to 80 (SD 46) mm2 after release (p < 0.001), respectively. We suggest that adhesion of the subacromial bursa increases impingement between the acromion and the insertion of rotator cuff tendons.

Acromion↗
PubMed2005

[MR imaging of tendon diseases. Exemplified using the examples of rotator cuff, epicondylitis and achillodynia].

Diseases of tendons have recently increased in importance. This may be due to the increasing popularity of free time sport, but also to the increasing number of treatment possibilities. The origin of damage to the tendons can be explained by a series of mechanisms, of which reduced tissue perfusion and mechanical irritation with microtrauma, which lead to degeneration, can be considered as the most important. Imaging diagnostics plays a significant role in the diagnosis and planning of the therapy of such illnesses. In addition to the conventional x-ray to determine the position of the joint and bony structures, ultrasound can be used to examine the tendons, bursae and tissue.MRI is an excellent method for examining the pathology of tendons due to its exceptional qualities for imaging tissue and joints as well as its high specificity. Using MRI, it is possible to determine the degree of morphological change, make reproducible examinations, as well as determining comorbidity factors or the reasons for the changes early in the illness. It therefore influences surgical decisions and can play a key role in the planning of operations. MRI arthography can-depending on the question-increase the diagnostic power in cases of alterations in the rotator cuff.

Achilles Tendon↗
PubMedDate not supplied

Influence of rotator cuff tearing on glenohumeral stability.

This study hypothesizes that full-thickness tearing of the rotator cuff can lead to joint instability and that the degree of instability depends on the size and location of the tear. Twelve cadaveric shoulder specimens were divided into two groups: group 1 had a circular tear centered at the critical area, and group 2 had a circular tear centered at the rotator interval. Each group was tested at 2.5 cm and 5 cm tear sizes. Unloaded, and with the arm in 90 degrees flexion and full internal rotation, the humeral head shifted posteriorly. With loading, a large and more anteriorly located defect had the most influence on stability. The tear size had the greatest effect on stability in the inferior direction for group 1 and on the anterior direction for group 2. The tear location had the most significant effect on stability in the inferior and anterior directions for the smaller tear and on the anterior direction for a larger tear.

Aged↗
PubMedDate not supplied

The relationship among strength and mobility measures and self-report outcome scores in persons after rotator cuff repair surgery: impairment measures are not enough.

In the past, measures of active range of motion and strength testing were deemed sufficient to "prove" the efficacy of treatment interventions. In the current outcomes milieu, however, the focus has shifted to patient-centered assessment (ie, patients' ability to perform activities that are personally relevant). We report results from a study with patients in the private practice of a shoulder surgeon. In this study we evaluated the relationship between impairment measures and scores from several shoulder outcome scales. In addition, we examined transcripts of interviews with shoulder patients regarding the impact of shoulder problems on their lives. One hundred eight persons participated in a randomized trial of home exercise instruction after arthroscopic repair of rotator cuff tears. Two impairment measures were used-strength estimates obtained by use of a Nicholas electronic dynamometer and range of motion in the standing position. Self- reported outcomes were measured by use of the Shoulder Pain and Disability Index (SPADI) and the University of Pennsylvania (UPenn) Shoulder Scale. Pearson correlation coefficients were calculated to estimate the associations between scores on impairment measures and self-report measures. R 2 values were calculated to estimate the proportion of variance shared by impairment and self-report scores. We found that the linear relationship between impairment scores and patient-reported outcomes was quite low, explaining as little as 8% of the total variance. Qualitative analysis of patient interviews suggests that patients distinguish between their impairment and their status on personally relevant outcomes. Future research should evaluate the nature of patient judgments of shoulder health outcomes.

Exercise Therapy↗
PubMed2001

[Total inverted shoulder prosthesis and rotator cuff insufficiency: evaluation and determination of anatomical parameters predictive of good functional outcome in 21 shoulders].

OBJECTIVE: Evaluation of the functional results of the Delta 3 inverted shoulder prosthesis and determination of a radio-anatomical index predictive of best functional outcome. PATIENTS AND METHODS: Retrospective analysis of 19 patients (21 shoulders). Clinical (pain, satisfaction, amplitudes, Constant index) and radiological (acromio-epiphyseal distance) evaluation at a mean follow up of 13.6 months. RESULTS: Outcomes concerning pain, quality of life and Constant index were good and similar to other series. Few complications were observed. An increase of the acromio-epiphyseal distance of 33 to 50% compared to the non operated side is associated with a good functional result. CONCLUSION: Our results confirm those of other series and show that Delta 3 inverted prosthesis is an efficient therapeutic alternative in arthropathy with rotator cuff tears. Rehabilitation is fairly short and easy. The increase of the acromio-epiphyseal distance determines the tension of the deltoid muscle and could predict a favorable outcome.

Acromion↗
PubMed2003

Reconstruction of a defect of the rotator cuff with polytetrafluoroethylene felt graft. Recovery of tensile strength and histocompatibility in an animal model.

We reconstructed defects in the infraspinatus tendon u sing polytetrafluoroethylene (PTFE) felt grafts in 31 beagle dogs and examined the mechanical responses and histocompatibility. Except for one infected specimen, all the reconstructed infraspinatus tendons healed. We examined eight specimens each immediately after surgery and at six and 12 weeks. The ultimate tensile strength of the reconstructed tendons was 60.84 N, 172.88 N, and 306.51 N immediately after surgery and at six and 12 weeks, respectively. The stiffness of the specimens at the PTFE felt-bone interface was 9.61 kN/m, 64.67 kN/m, and 135.09 kN/m immediately after surgery and at six and 12 weeks, respectively. Six tendons were examined histologically at three, six, 12 and 24 weeks. Histological analysis showed that there was ingrowth of fibrous tissue between the PTFE fibres. Foreign-body reactionswere found at the margin of the PTFE-bone interface between 12 and 24 weeks. The mechanical recovery and tissue affinity of PTFE felt to bone and to tendon support its use for reconstruction of the rotator cuff. The possible development of a foreign-body reaction should be borne in mind.

Animals↗
PubMedDate not supplied

An anatomic study of the effects on the suprascapular nerve due to retraction of the supraspinatus muscle after a rotator cuff tear.

The purpose of this anatomic study was to assess the risk to the suprascapular nerve by measuring the tension on the nerve and the angle between the nerve and its motor branch at the scapular notch with medial supraspinatus tendon retraction. Twelve shoulders in six cadavers were dissected to evaluate the branching point of the first motor branch of the suprascapular nerve, the change in angle between the nerve and its first motor branch at the scapular notch with retraction of the supraspinatus tendon, and the resulting tension on the nerve. The first motor branch originated at the notch in 9 cadavers, just proximal in 1, and just distal in 2. With the supraspinatus muscle in its anatomic position, the suprascapular nerve and its first motor branch angle measured 142.6 degrees at the scapular notch. After retraction of the supraspinatus, the angle markedly decreased to 98.7 degrees and 34.6 degrees with 1 cm and 5 cm of medial retraction, respectively. The motor branch was taut in all specimens at 2 to 3 cm of retraction. Medial retraction of the supraspinatus tendon drastically changes the course of the suprascapular nerve through the scapular notch, creating increased tension on the nerve. The degree of rotator cuff muscle atrophy frequently observed after a massive tear may be explained by increased tension on the nerve due to muscle retraction.

Humans↗
PubMedDate not supplied

Structural changes of the rotator cuff caused by experimental subacromial impingement in the rat.

Subacromial impingement of the infraspinatus tendon was experimentally created in 28 young adult rats by thickening the undersurface of the acromion with either one or two platelike bony transplants of the ipsilateral scapular spine. Nine nonoperated and eight shoulders that had undergone a sham operation served as control groups. The rats were killed after 2 days and after 1, 2, 4, 8, 16, and 32 weeks for histologic evaluation. All rats with experimental subacromial impingement showed an infraspinatus tear on the bursal side of the tendon. An isolated tear on the articular side or within the tendon was not seen. Two plates caused larger tears than one (P = .04), and more long-standing impingement was associated with larger lesions (P = .002). Multiple chondrocytes were observed within the tendon adjacent to the bony transplants. No calcium deposits were found. In the subacromial space rapid thickening of the bursa was observed. The undersurfaces of the bony transplants showed no evidence of abrasion or remodeling caused by the tendon. The shoulders of the control groups were found intact without any alteration. Experimental subacromial impingement in the rat caused bursal side rotator cuff tears. The type of partial tears that are most frequently observed in clinical practice, that is, intratendinous and articular side tears, were not seen in this experimental model.

Acromioclavicular Joint↗