Acromioplasty for impingement with an intact rotator cuff

This is a retrospective review of 108 patients who underwent decompressive anterior acromioplasty for chronic impingement in the absence of a full thickness rotator cuff tear. Before operation, all the patients had had shoulder pain for at least one year despite conservative treatment. At operation, the rotator cuff tendons were explored and were intact. Anterior acromioplasty, followed by rehabilitation was successful in 87% of patients. The operation was less successful in women, in those who had diminished movement before operation, who were involved in worker's compensation claims, and whose pain followed direct trauma. Appropriate selection of patients is considered the key to success.     

Open versus arthroscopic treatment of chronic rotator cuff impingement

We report the results of 238 consecutive patients who underwent in total 261 acromioplasties because of chronic rotator cuff impingement. The procedure was performed either in conventional open technique (80) or arthroscopically (181). Two years (1–10) after the operation 68% of the patients treated with the open technique had an excellent or good result compared 82% of the patients treated arthroscopically by an experienced arthroscopic surgeon. Compared to the open technique, the arthroscopic procedure had a statistically significant superior result concerning outcome, operating time and hospital stay. Arthroscopic procedures performed by less experienced surgeons had inferior results. Received: 3 July 2000     

肩关节脱位合并肩袖与Bankart损伤的诊治

目的 探讨关节镜下修复肩关节前脱位合并肩袖与Bankart损伤的疗效.方法 1999年9月至2007年7月收治16例肩关节脱位合并肩袖与Bankart损伤患者,男14例,女2例;左肩6例,右肩10例.交通伤8例,运动伤4例,牵拉伤4例.受伤至手术时间平均4.5个月(1.5～11.0个月).肩关节x线片显示肩盂撕脱骨折3例.16例患者肩关节核磁共振造影显示肩袖与Bankart损伤.关节镜探查发现肩袖于肱骨大结节处撕脱伴肩袖挛缩12例.采用关节镜下松解、缝合锚钉和骨锚钉同定缝合9例;因肩袖挛缩明显,进行关节镜与小切口辅助下肩袖缝合固定术3例;肩衲组织因牵拉松弛抬肩无力,采用等离子刀皱缩和肩袖缝合紧缩术4例.Bankart损伤采用关节镜下可吸收Bankart钉固定3例,钛合金缝合锚钉固定3例,关节镜下直接缝合修补盂唇3例,骨锚钉加会属锚钉固定7例.结果 16例患者术后获平均16.5个月(7～34个月)随访.肩关节稳定,肩外展和上举功能恢复正常12例,术后肩关节外展、抬举活动轻度受限2例,前伸活动疼痛2例.金属锚钉拔出再手术2例.采用美国加州洛杉矶大学UCLA肩关节功能评分:术前平均(21.5±5.5)分;术后平均(32.4±5.6)分,优12例,良4例.结论 肩关节脱位合并肩袖与Bankart损伤核磁共振造影有助于诊断;肩袖挛缩者应进行充分松解,无张力缝合固定有利于肩袖愈合;异体骨锚钉修复肩袖与Bankart损伤,生物固定、费用低廉,具有重要的价值.     

Postoperative subcoracoid impingement syndrome in patients with rotator cuff tear

Impingement of the tendinous rotator cuff on the coracoid process (subcoracoid impingement syndrome) has rarely been reported as a cause of pain after surgery for rotator cuff tear. We evaluated clinical features, surgical results, and histopathology findings of resected coracoid processes in patients with subcoracoid impingement syndrome after anterior acromioplasty and management of rotator cuff tear. Pain at the anterior aspect of the shoulder, localized tenderness of the coracoid process, anterior shoulder pain on horizontal adduction testing, and positive subcoracoid block suggest subcoracoid impingement syndrome. Postoperative subcoracoid impingement syndrome was investigated in 11 of 216 cases with rotator cuff surgery. The average patient age at the time of surgery was 61.2 y (range, 28-78 y). Coracoplasty (partial resection of the posterolateral side of the coracoid process) was performed in 9 shoulders that had not responded to a 6-month regimen of conservative treatment. Complete pain relief was achieved in all cases. Histopathologic findings revealed hypertrophic changes of the fibrocartilage layer at the posterior aspect of the resected coracoid process. We concluded that subcoracoid impingement syndrome was an important factor in unsuccessful rotator cuff surgery and recommend that coracoplasty be performed on patients with symptoms of subcoracoid impingement syndrome after management of the rotator cuff tear.     

肩峰撞击征合并肩袖损伤的治疗

目的探讨对于肩峰撞击征合并肩袖损伤的治疗方法。方法2003年6月～2005年6月收治的肩峰撞击征患者25例,术前或术中诊断合并肩袖损伤者18例。对其中12例合并肩袖完全或不完全断裂的病例在进行肩峰成形的同时将断裂的冈上肌腱做紧缩缝合或做修复缝合锚钉止点重建术。术后指导患者系统功能康复,定期复查。按照ASES评分评价功能恢复情况。结果全部患者获得平均11个月随访。术前本组患者ASES评分平均为32.5分。术后:单纯肩峰成形患者ASES评分平均为92.5分,冈上肌腱做清创缝合的患者平均评分87.1分,冈上肌腱做止点重建患者平均评分85.9分。三种术式患者评分均较术前有显著性改善(P<0.01),而三种术式患者之间评分差异无显著性意义(P>0.05)。结论在对肩峰撞击征的治疗中要注意探查有无肩袖损伤,积极的肩袖修复治疗可获得满意的疗效。     

Internal impingement in the etiology of rotator cuff tendinosis revisited

Purpose: The theory of internal impingement holds that, in overhead athletes, repeated contact between the undersurface of the rotator cuff and the posterosuperior glenoid rim leads to articular-sided partial-thickness rotator cuff tears and superior labral lesions. However, we have noted this same constellation of lesions in our general patient population. These recreational athletic patients do not routinely assume the position of extreme abduction and external rotation, and thus are unlikely to experience significant internal impingement forces. The goal of this study was to document the prevalence of superior labral lesions in patients being treated for partial-thickness undersurface rotator cuff tears. Type of Study: Retrospective case series. Methods: We retrospectively reviewed the records of 75 shoulders arthroscopically treated for partial-thickness articular-sided rotator cuff tears. With the exception of one professional tennis player, no patients were playing sports at a professional or major college level. No professional or collegiate throwing athletes were included. The prevalence of these lesions and their association with recreational athletics was noted. Results: We found that 55 of 75 (73.3%) shoulders with articular-sided partial-thickness rotator cuff tears also had superior labral lesions. A statistically significant increased prevalence of superior labral lesions in the dominant shoulder was seen (P = .03). In addition, our patients who engaged in overhand throwing had significantly fewer superior labral lesions in the dominant shoulders than did nonthrowers (P = .017). Conclusions: The “kissing lesions” of undersurface rotator cuff tears and posterosuperior labral damage may be explained by mechanisms other than “internal impingement.”     

Correlation of acromial morphology with impingement syndrome and rotator cuff tears

Background and purpose Whether or not uncemented total hip arthroplasty (THA) can achieve durable fixation of implants to bone in patients on chronic hemodialysis is unknown. We analyzed the 2–13-year clinical outcomes of cementless THA in patients with end-stage renal diseases who were maintained on long-term hemodialysis.

Patients and methods We reviewed the outcome of 23 consecutive uncemented THAs undertaken between 1993 and 2004, in patients with chronic renal failure who had been on long-term hemodialysis (2–18 years). 1 patient died and 2 patients were lost to follow-up within 2 years, leaving 20 hips (20 patients, median age 66 (38–81) years at the time of THA, 11 females) that were reviewed at median 7 (2–13) years postoperatively.

Results Radiographic bone-ingrowth fixation of the components was found in 19 patients. 1 patient had aseptic loosening requiring revision surgery. The median d'Aubigne and Postel score was 10 (8–14) preoperatively and 15 (12–18) at final review. No prosthetic infections were found in any of the patients.

Interpretation Uncemented THA shows promising medium-term results in patients receiving long-term hemodialysis.     

Shoulder arthroscopy. Partial thickness tears of the rotator cuff

Partial tears are frequent in rotator cuff pathology. Articular-side lesions, bursal-side lesion and interstitial lesion inside the thickness of the tendon are described. Etiopathogeny is not clearly known. It seems a multifactory association with intrinsic tendinous factors (vascularity, normal ageing of the tendon), extrinsic mechanical factors (impingement syndrome) and trauma. Clinically, the complaint is a painful shoulder with full range of motion. The rotator cuff examination does not shown weakness but pain. The onset is traumatic or degenerative. It could be the consequence of overuse specially in case of overhead sport. Diagnosis is confirmed by arthro-CT or/and (arthro) MRI. It is useful for the treatment to determine the size of the rupture regarding the thickness of the tendon. Natural history shows that partial tears do not healed. Treatment of the partial tear of the cuff is still debatable particularly for intertstitial lesion (acromioplasty, debridment, repair). Isolated acromioplasty permit to obtain pain relief but do not prevent evolution to full-thickness tear when the lesion concern more than 50% of the thickness of the tendon. In this case, arthroscopic tendon repair gives good and reliable results.     

Shoulder arthrography for determination of size of rotator cuff tear

One hundred eight shoulder arthrograms were performed in 105 patients who subsequently underwent surgical repair of a rotator cuff tear. Eighty-seven were single-contrast arthrograms and 21 were double-contrast studies; three or more views were used for all shoulders. Four readers independently evaluated the arthrograms (two orthopaedic surgeons and two radiologists). The size of the rotator cuff tear could be categorized into one of four groups with accuracy in only 56% of the cases; however, the fear size was identified with accuracy or within one size category in 96% of the shoulders studied.     

开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤

目的 探讨开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤的疗效.方法 2004年3月至2007年8月,对收治的20例术前明确诊断为肩峰撞击征合并肩袖损伤的患者采用开放性肩峰成形术治疗,同时修复肩袖,对肩袖全层撕裂患者以锚钉固定的方法行止点重建.术后进行系统功能康复.按照ASES评分评价功能恢复情况.结果 18例患者术后获6～13个月(平均11个月)随访.患者ASES评分术前平均为36.5分,术后为90.5分,差异有统计学意义(t=13.865,P<0.01).4例行因上肌腱直接修复患者术前ASES评分平均为53.4分,术后平均为93.2分,差异有统计学意义(t=1.387,P<0.05).14例行止点重建锚钉固定术患者术前ASES评分平均为33.4分,术后为86.2分,差异有统计学意义(t=2.962,P<0.05).结论 开放性肩峰成形术治疗肩峰撞击征合并肩袖损伤可获得满意的疗效,易于在基层医院开展.     

Shoulder scoring scales for the evaluation of rotator cuff repair

Various assessment tools have been proposed for evaluation of shoulder function. Analyses of comparability, validity, and reliability among shoulder assessment tools are lacking. The purpose of our investigation was to compare the results of three commonly used shoulder assessment tools in the evaluation of a specific shoulder condition. Seventy-two full-thickness rotator cuff tears were treated with an open rotator cuff repair from 1986-1993. The average age of the patients at surgery was 58 years (range, 24-92 years). The median duration of followup at the time of evaluation for this study was 55 months (range, 24-102 months; standard deviation, 22 months). Correlation among the results of the UCLA, Constant-Murley, and the Simple Shoulder Test scales was fair (range, 0.66-0.76). More importantly, the three systems were evaluated for their ability to accurately predict improved motion, strength, and patient satisfaction. The Simple Shoulder Test and the Constant-Murley scales showed the highest positive predictive values. The Simple Shoulder Test is a patient-based self-assessment device that easily can be incorporated into a busy clinical practice, providing outcome data comparable with complex evaluation systems when evaluating the results of rotator cuff repair.     

Arthroscopic treatment of rotator cuff disease

The goal of this article is to summarize the current concepts on rotator cuff disease with an emphasis on arthroscopic treatment. Most rotator cuff tears are the result of an ongoing attritional process. Once present, a tear is likely to gradually increase in size. Partial-thickness and subscapularis tears can both be successfully treated arthroscopically if conservative management fails. Partial tears involving greater than 50% of tendon thickness should be repaired. Articular-sided partial tears involving less than 50% of the rotator cuff can reliably be treated with debridement. A more aggressive approach should be considered for low-grade tears (<50%) if they occur on the bursal side. Biomechanical and anatomic studies have shown clear superiority with dual-row fixation compared with single-row techniques. However, current studies have yet to show clear clinical advantage with dual-row over single-row repairs. Biceps tenotomy or tenodesis can reliably provide symptomatic improvement in patients with irreparable massive tears. True pseudoparalysis of the shoulder is a contraindication to this procedure alone and other alternatives should be considered.     

Shoulder impingement

Understanding the pathophysiology and treatment of rotator cuff disorders is the key to understanding all other aspects of shoulder rehabilitation. Impingement rehabilitation focuses on strengthening the humeral head depressors, while ignoring the deltoid and supraspinatus muscles. Later treatment includes specific retraining of scapular balancing muscles. The final phase of treatment includes strengthening the prime humeral movers in positions that avoid further stress to the injured rotator cuff tendons and, last of all, specifically strengthening the supraspinatus muscle.