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The authors discuss the indication and various methods of repair of the rotator cuff tear. The results in 24 patients are evaluated with respect to postoperative pain and function.
PURPOSE OF THE STUDY: A series of 13 patients with an excentered osteoarthritis of the glenoid who underwent bipolar shoulder arthroplasty is reported. MATERIAL AND METHODS: The series included 13 patients treated in two centers between 1995 and 1998. Mean age was 70 years (58-88). Constant's absolute score and Swanson's score were used for clinical assessment. The Hamada and Fukuda classification was used for the radiographic assessment. The follow-up radiography series included an AP view in the three rotation positions, an AP view in maximum abduction to assess intraprosthetic mobility, a lateral view (Lamy) and measurements of both humeri. Several measurements were made to assess humerus lateralization and glenoid wear: deltoid lever arm, lateral humeral displacement, distance between the lateral border of the coracoid and the center of the glenoid and the subacromial space. Mean preoperative Constant score was 23 points: pain 3 pts, activity 5 pts, motion 13 pts, force 2 pts. Mean preoperative Swanson score was 11. Active anteflexion was 78 degrees, active abduction 68 degrees and passive external rotation 17 degrees. The Hamada and Fukuda classification was 9 grade 4 and 4 grade 5. All patients had a full thickness unrepairable rotator cuff tear: three with 2 tendon tears, and 10 with 3 tendon tears. All patients were reviewed clinically and had a complete radiography series at last follow-up (mean 28 months, range 7 - 56 months). RESULTS: At last follow-up, the mean absolute Constant score was 37 points: pain 10 pts, activity 9 pts, motion 14 pts, force 4 pts. Mean Swanson score at last follow-up was 19 points. Mean active anteflexion was 69 degrees, active abduction was 63 degrees and passive external rotation was 29 degrees. A satisfactory deltoid lever arm had been achieved compensating the glenoid wear by a greater lateral displacement of the humerus. At last follow-up, there were no cases of humeral loosening but three cases with important glenoid wear were observed after two years. Comparing the results obtained using small cups (40 and 44) with arthroplasties using large cups (48 and 52) showed a trend favoring small cups: Constant score 43 vs 32 points, Swanson score 21 versus 17 points, anteflexion 72 degrees versus 66 degrees and passive external rotation 34 degrees versus 26 degrees. DISCUSSION: Our results confirmed the efficacy of bipolar arthroplasty for pain relief, but the mobility outcome was less than satisfactory, excepting passive external rotation. It would appear to be preferable to use small cups. Comparing our results with data in the literature, particularly the better results for mobility using simple humeral prostheses, suggests that the principles of shoulder and hip arthroplasty concern different mechanisms: a sufficient deltoid lever arm must be achieved, but without overstretching the periarticular soft tissue (capsule, subcapsule, teres minor), and using a cup size close to the size of the healthy humeral head. Glenoid reaming should not be reserved only for asymmetrical glenoid wear in the horizontal plane. CONCLUSION: Our results suggest that bipolar arthroplasty for excentered osteoarthritis of the glenoid cavity is indicated for: stiffness in external rotation, major concentric wear in patients under 65 years of age, or asymmetric glenoid wear.
For any physician expecting a successful outcome of a treatment regimen a thorough understanding of the underlying pathogenetic mechanism and the pathology of the disease process is an absolute prerequisite. In addition, the surgeon, obviously wishing to obtain a positive outcome of the procedure, must know the reaction of the body to his or her surgical actions. In particular, he or she must be familiar with the factors guaranteeing an uneventful healing process. For example, with rotator cuff disease it is important to realize that the site of degeneration leading eventually to tearing does not lie in the tendon itself but at its insertion into bone. Moreover, the cells and vessels needed for healing after surgical repair do not originate from the torn tendinous stumps. An important source of cells and vessels is the subacromial bursa overlying the site of tearing. Consequently, the bursa must be preserved at all cost. The subchondral bone trough into which the medial tendon stump is usually anchored during repair represents the other source of healing tissue. Whereas surgeons understandably concentrate their attention on the site of tearing, the fate of the muscle in the torn bone-tendon-muscle unit must not be neglected. In experimental studies we were able to measure muscle atrophy and fat accumulation and could quantify their evolution over time. Finding no reversal of these two parameters after successful repair was disturbing. Shoulder surgeons will benefit from this comprehensive review of updated concepts.
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We describe 14 patients who underwent transfer of latissimus dorsi using a new technique through a single-incision. Their mean age was 61 years (47 to 76) and the mean follow-up was 32 months (19 to 42). The mean Constant score improved from 46.5 to 74.6 points. The mean active flexion increased from 119 degrees to 170 degrees , mean abduction from 118 degrees to 169 degrees and mean external rotation from 19 degrees to 33 degrees . The Hornblower sign remained positive in three patients (23%) as did the external rotation lag sign also in three patients (23%). No patient had a positive drop-arm sign at follow-up. No significant difference was noted between the mean pre- and postoperative acromiohumeral distance as seen on radiographs. An increased grade of osteoarthritis was found in three patients (23%). Electromyographic analysis showed activity of the transferred muscle in all patients.
OBJECTIVE: To present a case of shoulder impingement syndrome managed with a conservative multimodal treatment approach. CLINICAL FEATURES: A patient had anterior shoulder pain and a diffuse ache in the right upper arm, with tenderness in the shoulder region on palpation. Shoulder range of motion was limited with pain and catching, coupled with limited and painful cervical motion. After physical and orthopedic examination, a clinical diagnosis of shoulder impingement syndrome was made. INTERVENTIONS AND OUTCOME: The patient underwent a multimodal treatment protocol including soft tissue therapy, phonophoresis, diversified manipulation; and rotator cuff and shoulder girdle muscle exercises. Outcomes included pain measurement; range of motion of the shoulder, and return to normal daily, work, and sporting activities. At the end of the treatment protocol the patient was symptom free with all outcome measures normal. The patient was followed up at 4 and 12 weeks and continued to be symptom free with full range of motion and complete return to normal daily and pre-treatment activities. CONCLUSION: This case report shows the potential benefit of a multimodal chiropractic protocol in resolving symptoms associated with shoulder impingement syndrome.
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OBJECTIVES: Calcified tendinitis of the shoulder joint is a common painful condition. Resorption of the calcium deposits is one of the key events in the pathogenesis of this disease. The aim of this study was to examine whether the multinucleated giant cells that appear in this condition have osteoclast phenotypes. METHODS: Immunohistochemical and RNA in situ hybridization analysis of cathepsin K, a marker for osteoclasts, was performed in human surgical samples. RESULTS: The multinucleated cells located near the calcium deposits were positive for cathepsin K protein and mRNA. Reverse transcription-polymerase chain reaction using human cathepsin K-specific oligonucleotide primers confirmed that synthesis of cathepsin K mRNA occurs in the tissues of calcified rotator cuffs. CONCLUSION: The multinucleated giant cells which appear in the resorption area of calcium deposits in calcified tendinitis have the osteoclast phenotype.
This article describes the symptomatology of three patients following electrical accidents. The flow of the current was from hand to hand, voltage was 220/380 V, and duration was at least a few seconds for all patients. The development of symptoms was the same, and may be explained as a thermal effect of electricity on the tissue. Initially the patients experienced transient confusion, followed by stiff muscles after 1 to 3 days, and then pain in the muscle attachments and joints close to path of the current. This pain increased slowly during the first two weeks. Recovery was gradual, but often incomplete. The case notes showed that electrical accidents may be followed by chronic rotator cuff tendinitis. The clinical examination also revealed a hearing loss at about 2,000 Hz and above 4,000 Hz. The neuropsychological testing indicated a diffuse impaired function in only one patient.
STUDY DESIGN: Single-session, posttest only, descriptive analysis of range of motion (ROM) and strength. OBJECTIVES: To measure ROM and strength approximately 12 weeks following arthroscopic anterior stabilization of the glenohumeral joint with thermal capsulorraphy. BACKGROUND: Treatment of the patient with anterior, unidirectional glenohumeral joint instability often includes surgical stabilization. Current methods focus on arthroscopic stabilization and early ROM and strengthening to restore normal function to the upper extremity. METHODS AND MEASURES: Twenty patients diagnosed with unidirectional shoulder instability (mean age 24.5 years, SD = 8.48) underwent a postoperative rehabilitation program following unilateral arthroscopic shoulder stabilization with thermal capsulorraphy. Objective testing including ROM and isokinetic internal rotation (IR) and external rotation (ER) strength at 90, 210, and 300 degrees/s was performed 12 weeks postoperatively. RESULTS: Ten patients had a complete return of shoulder flexion ROM at 12 weeks. There were deficits compared to the noninjured extremity in postoperative glenohumeral joint mean abduction (9.8 +/- 12.7 degrees), IR (8.4 +/- 15.0 degrees), and ER (13.1 +/- 14.4 degrees). Isokinetic testing showed a complete return of ER strength on the postoperative extremity compared to the uninjured extremity for 12 patients with a 4% (+/- 21.1%) mean deficit measured in IR strength at the slowest testing velocity. No significant difference was found between extremities in the external/internal rotation ratios. CONCLUSION: Postoperative rehabilitation emphasizing progressive ROM and rotator cuff and scapular strengthening has produced favorable results in patients 12 weeks postoperatively with respect to glenohumeral joint ROM and IR and ER strength. Further research and follow-up is required to obtain long-term outcomes with respect to patient satisfaction and stability of the glenohumeral joint following this arthroscopic procedure.
The aim of this study was to evaluate the effects of repeated steroid injections into the subacromial space. Thirty rats were injected either 3 or 5 times with triamcinolone in a dosage equivalent to that given to human beings or 3 or 5 times with saline into the subacromial space. One rat received no injection. The supraspinatus and infraspinatus tendons were evaluated macroscopically and microscopically. Two different staining methods were used on each sample including hematoxylin eosin and Miller's elastin/van Gieson's solution. After 5 steroid injections, we found focal inflammation, necrosis, and fragmentation of collagen bundles in the tendon in 4 of 7 rats. The tendons of the controls showed a normal structure (P < .05). There were no pathologic changes among the rats that were injected with triamcinolone 3 times. These results show that repeated subacromial injections of triamcinolone may cause damage to the rotator cuff of the rat. This finding may indicate cautious use of subacromial steroid injections in human beings.
Biomechanical models of the shoulder mechanism require estimates of muscle moment arm magnitude. Some shoulder models have estimated muscle moment arms by assuming an idealized minimum distance path from the origin to insertion that passes around the bony geometry. Alternatively, the principle of virtual work can be used to estimate moment arms from tendon excursion and joint-angle data. The purpose of this study was to determine if these two methods give different estimates of abduction moment arms for the supraspinatus, infraspinatus, and subscapularis muscles. Muscle moment arms were estimated for these muscles on ten fresh frozen cadaver specimens. The results showed a significant difference between the two estimation methods. Average differences were 3.1 mm (10.6%), 3.9 mm (43.9%), and 7.2 mm (70.3%) for the supraspinatus, subscapularis, and infraspinatus muscles, respectively. These results suggest that shoulder models based on the origin-insertion method may give higher rotator cuff muscle force estimates than methods using the slope of the tendon excursion vs joint angle relationship.
A total of 191 patients from 29 orthopedic practices are analyzed in this report. All had full-thickness tears documented by imaging tests and/or surgical observation; 190 had tears of the supraspinatus, 54 had tears of the infraspinatus, and 13 had tears of the subscapularis. The greatest functional deficits were in the ability to place 8 pounds on a shelf at the level of the head (93% unable), the ability to throw overhand (93% unable), and the ability to sleep on the affected side (86% unable). The SF-36 physical role function and comfort scores were 27% and 48%, respectively, of those of age- and sex-matched controls. Of the variables suggested by a review of the literature, only female sex, involvement of the infraspinatus in the cuff tear, and workers' compensation claims were significantly correlated with lower shoulder function in this series of patients.
Double-contrast arthrotomography of the shoulder appears extremely valuable; we have verified its accuracy in measurements of complete rotator cuff tears. The first 31 patients so investigated and explored surgically have been retrospectively evaluated. Accurate measurements were found in 85% of the coronal diameters and in 69% of the sagittal ones.
The purpose of this study was to compare 2 different training modes in improving shoulder cuff muscular performance. Thirty-nine participants were randomly assigned into 3 groups: the isolated group exercised using 2-kg dumbbells; the complex group used a protocol with complex exercises; and the control group had no training. All participants trained for 6 weeks (3 times per week) and were evaluated isokinetically before (pretest) and after the training period (posttest). Results showed that the complex group significantly improved their muscular performance, but the isolated group did not, indicating that isolated exercises are only effective when the training goal is to strengthen the weaker muscle group, but they must be replaced by more complex and closed-kinetic exercises in order to obtain considerable improvement of the rotator cuff strength. The authors propose that a strengthening program should start with isolated movements for better stimulation of the weaker muscles and continue with complex exercise for more impressive strengthening.
The effect of various configurations of placement of transosseous sutures on the immediate strength of fixation was studied in forty-five fresh-frozen humeri from cadavera of older individuals (mean age at the time of death, sixty-three years). The ultimate strength (the strength to failure) was significantly greater (p < 0.05) when the sutures were placed at sites more distal to the tip of the greater tuberosity or when the sutures were tied over a wider bone bridge. Cortical augmentation with use of a plastic button through which the transosseous sutures were tied increased the ultimate strength approximately 1.9-fold. The increase in the ultimate strength of the transosseous repair corresponded significantly with the increasing mean thickness of the cortical bone as the sutures were placed more distally along the lateral aspect of the humerus. We concluded that the strength of the fixation of a rotator cuff repair can be increased by placing the transosseous sutures at least ten millimeters distal to the tip of the greater tuberosity and by tying them over a bone bridge that is at least ten millimeters wide. When bone is very osteoporotic, cortical augmentation with a readily available plastic button strengthens the repair.
Out of 78 patients identified who underwent mini-open cuff repair, 64 were interviewed and returned a detailed questionnaire and 47 returned for a physical examination. Their average age was 64 years (31 to 85 years); and the average follow-up was 29.2 months (range, 12 to 65 months). The average tear size was 8 cm2. Preoperatively, all patients complained of pain and weakness. Ninety-six percent of patients displayed positive impingement signs preoperatively compared with 16% postoperatively. Active elevation increased significantly (P < .05) from 129 degrees to 166 degrees. At the time of follow-up there was no significant difference between active elevation in the operative and contralateral shoulders (P > .05). Weakness was detectable by physical examination in 83% of patients initially, and in 22% at the time of the final examination. The average pain and function scores improved significantly. Eighty-nine percent were satisfied with the results of their surgery. Three patients required further surgery on their shoulder. We found no correlation between cuff tear size and final Hospital for Special Surgery shoulder score.
BACKGROUND: Long-term follow-up studies are necessary to critically evaluate the outcome of a treatment intervention for a specific disorder. However, patients may cease participating in a long-term study and become lost to follow-up; thus, their current condition is unknown. The underlying characteristics that predispose a patient to become lost to follow-up are difficult to identify and control. Patients who are lost to follow-up may be contacted by telephone; however, the effect of administering a functional assessment questionnaire by telephone compared with that of mailing a questionnaire is unknown. The purpose of this study was to compare patients who continued to respond to requests for follow-up with those who did not. A second purpose was to compare responses obtained by mail with those obtained by telephone interview. METHODS: Two hundred and twenty-four patients with a rotator cuff tear were enrolled in an ongoing study of shoulder function and general health. Self-assessment questionnaires were mailed to every patient at six-month intervals. Sixty-seven patients (30 percent) regularly responded to mailings (identified as responders in this study), fifty-five patients (25 percent) responded occasionally (these patients were not included in the analysis), and 102 patients (46 percent) ceased to respond and became lost to follow-up (identified as nonresponders in this study). This investigation was performed to determine: (1) the characteristics of nonresponders compared with those of responders, (2) the functional status of nonresponders as assessed with a questionnaire over the telephone, and (3) the effect of administering a self-assessment functional questionnaire by telephone compared with that of sending the same questionnaire by mail. RESULTS: Nonresponders tended to have lower initial scores for the mental health summary (p = 0.03) and for social function (p = 0.01), were less likely to have had surgery (p = 0.009), and were less likely to consume alcohol (p = 0.03). At the last known time when they completed the mailed questionnaire, nonresponders reported significantly worse shoulder function than responders (p = 0.0001). However, on telephone questioning the mean number of shoulder functions that the nonresponders indicated that they could perform was greater than the mean number documented on their last mailed questionnaire (p < 0.0001). In a random subgroup of responders, the mean number of functions that the patients indicated that they could perform when interviewed by telephone was significantly greater than the number indicated on their most recent mailed questionnaire (p < 0.01). The results obtained by telephone from this random subgroup of responders were similar to those obtained by telephone from the nonresponders. CONCLUSIONS: There are differences between patients who continue to participate in a study and those who become lost to follow-up. Functional assessment questionnaires administered by telephone yield different results than the same questionnaires sent by mail. These considerations are relevant to the design, implementation, and interpretation of clinical studies in which functional questionnaires are used.