Delta Reverse Polarity Shoulder Replacement: Single Surgeon Experience with a Minimum 2-Year Follow-up

Background

The delta reverse shoulder replacement system was developed for the treatment of rotator cuff arthropathy so that the deltoid can substitute for the deficient rotator cuff. To evaluate the results of delta reverse shoulder replacement for functional improvement and complications in a consecutive series by a single surgeon over a period of six years with a minimum follow-up of 2 years.

Methods

The data were collected retrospectively from electronic theatre records. Over a period of 6 years (2006-2012), 46 cases that fulfilled the inclusion criteria were identified. There were 34 females and 12 males. The average age of patients was 76.2 years (range, 58 to 87 years). A single surgeon performed all procedures using the anterosuperior approach. The mean follow-up time was 49 months (range, 24 to 91 months). All cases had preoperative and postoperative Constant scores. We collected the data on indications, hospital stay, and change in the Constant score, complications, and reoperation rates.

Results

The main indication for surgery was rotator cuff arthropathy (52.2%), followed by massive rotator cuff tear (28.3%), osteoarthritis (8.7%), fractures (6.5%), and rheumatoid arthritis (4.3%). Also, 65.2% of the cases were referred by general practitioners, 26% of the cases were referred by other consultants, and 8.8% of the cases were already under the care of a shoulder surgeon. The average preoperative Constant score was 23.5 (range, 8 to 59). The average Constant score at the final follow-up was 56 (range, 22 to 83). On average, there was an improvement of 33 points in the Constant score. The improvement in the Constant score was significant (p < 0.001). We observed complications in four patients (8.6%). Three of four patients (6.5%) needed reoperation. The first complication was pulmonary embolism in the early postoperative period. The other complications included dissociation of the glenosphere from the metaglene, deltoid detachment, and stitch abscess.

Conclusions

This is a single-surgeon, single-approach series of 46 cases with a minimum follow-up of 2 years. At this stage, the results are encouraging with no cases of loosening, dislocation, or nerve injury.     

Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy

Introduction:

Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers.

Materials and Methods:

Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients).

Results:

Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft).

Conclusion:

Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.     

Magnetic Resonance Imaging of Shoulder Arthroplasty

Background

Magnetic resonance (MR) imaging evaluation of the painful failed shoulder arthroplasty is a useful imaging modality due to advancements in metal artifact reduction techniques, which allow assessment of the integrity of the supporting soft-tissue envelope and the implant.

Questions/Purposes

The focus of this pictorial review is to illustrate the benefits of MR imaging, whether used alone or as an adjunct to other imaging modalities, in aiding the clinician in the complex decision making process.

Methods

A PubMed (MEDLINE) search focusing on the complications and imaging assessment of shoulder arthroplasty was performed. Articles were selected for review based on their pertinence to the aforementioned topics.

Results

We discuss the ability of MR imaging to identify why a patient’s arthroplasty may have failed. Specific causes including component loosening and implant failure, rotator cuff and deltoid integrity, infection, subtle fractures, and nerve pathology are reviewed, with illustrative sample images.

Conclusion

MRI is a valuable tool in the assessment for pathology in the shoulder following arthroplasty.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9399-3) contains supplementary material, which is available to authorized users.     

Effectiveness of Subacromial Anti-Adhesive Agent Injection after Arthroscopic Rotator Cuff Repair: Prospective Randomized Comparison Study

Background

Arthroscopic rotator cuff repair generally has a good clinical outcome but shoulder stiffness after surgery due to subacromial adhesion is one of the most common and clinically important complications. Sodium hyaluronate (HA) has been reported to be an anti-adhesive agent in a range of surgical procedures. However, there are few reports of the outcomes of arthroscopic rotator cuff repair of the shoulder. This study examined whether a subacromial injection of HA/carboxymethylated cellulose (CMC) affected the postoperative shoulder stiffness and healing of rotator cuff repair, as well as the safety of an injection.

Methods

Between January 2008 and May 2008, 80 consecutive patients with arthroscopic rotator cuff repair were enrolled. The patients were assigned randomly to the HA/CMC injection group (n = 40) or control group (n = 40). All patients were evaluated using the visual analog scale (VAS) for pain, passive range of motion at 2, 6 weeks, 3, 6, 12 months after surgery, and the functional scores at 6, 12 months postoperatively. Cuff healing was also evaluated using CT arthrography or ultrasonography at 6 or 12 months after surgery.

Results

The HA/CMC injection group showed faster recovery of forward flexion at 2 weeks postoperatively than the control group but the difference was not statistically significant (p = 0.09). There were no significant difference in pain VAS, internal rotation, external rotation and functional scores between two groups at each follow-up period. The functional scores improved 6 months after surgery in both groups but there were no differences between the two groups. The incidence of unhealed rotator cuff was similar in the two groups. There were no complications related to an injection of anti-adhesive agents including wound problems or infections.

Conclusions

A subacromial injection of an anti-adhesive agent after arthroscopic rotator cuff repair tended to produce faster recovery in forward flexion with no adverse effects on cuff healing. However, its anti-adhesive effects after rotator cuff repair should be considered carefully with further studies.     

Correlation between Rotator Cuff Tears and Repeated Subacromial Steroid Injections: A Case-Controlled Study

INTRODUCTION

Concern exists regarding potential damage to the rotator cuff from repeated corticosteroid injections into the subacromial space.

PATIENTS AND METHODS

In this retrospective, case-controlled study, 230 consecutive patients presenting to three orthopaedic units with subacromial impingement and investigated as an end-point with magnetic resonance imaging (MRI) of the shoulder were divided into groups having received less than three or three or more subacromial injections of corticosteroids.

RESULTS

With no significant difference in age and sex distribution, analysis by MRI showed no significant difference between the two groups in the incidence of rotator cuff tear (P < 1.0).

CONCLUSIONS

This suggests that corticosteroid use in patients with subacromial impingement should not be considered a causative factor in rotator cuff tears.     

Prevalence of associated injuries after anterior shoulder dislocation: a prospective study

Purpose

Anterior shoulder dislocation can be associated with many lesions such as Bankart lesions, rotator cuff tears (RCT), Hill-Sachs lesions or greater tuberosity fractures. It has been documented that early management of the associated injury affords better recovery of shoulder function. The aim of this study was to highlight the incidence of associated injuries after anterior shoulder dislocation.

Methods

A total of 240 patients with traumatic anterior glenohumeral dislocations were subjected to complete history taking, neurovascular assessment and pre-reduction plain X-ray. An X-ray was taken immediately after reduction. Ultrasonography (US) and magnetic resonance imaging (MRI) were done within one week after reduction in all patients. Nerve conduction studies were ordered for any patient with suspected nerve injury.

Results

Associated lesions were reported in 144 (60 %) patients. RCT was the most common injury (67 cases). It was isolated in 34 patients (14.15 %), while it was combined with other lesions in 33 cases (13.75 %). Axillary nerve injury was encountered in 38 patients, of them 8 (3.33 %) were isolated and 30 (12.5 %) were combined. Greater tuberosity fracture was found in 37 patients, of them 15 (6.25 %) were combined with axillary nerve injury, and in the other 22 patients (9.17 %) the fracture was isolated. All cases with Hill-Sachs and Bankart lesion were combined lesions with no isolated cases. There was a significant relation between the incidence of associated injuries and age, mechanism of injury and the affected side.

Conclusions

Lesions associated with traumatic anterior glenohumeral dislocations are more frequent than expected. Thorough clinical examination and detailed imaging including US and MRI are mandatory to avoid a missed diagnosis.

     

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability

Purpose

Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients.

Methods

Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48–82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented.

Results

Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery.

Conclusions

Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.     

Complications and Outcomes of Minimally Invasive Percutaneous Plating for Proximal Humeral Fractures

Background

The minimally invasive plate osteosynthesis (MIPO) technique using periarticular locking plates may be a good option for the repair of displaced proximal humeral fractures. However, axillary nerve complications related to this technique may be underestimated. The purpose of this study is to evaluate the outcomes of the minimally invasive plating, focusing on the complications.

Methods

The records of 21 consecutive patients treated for proximal humerus fractures using the MIPO technique with locking plates were retrospectively reviewed. These patients were treated between March 2009 and March 2011 with a minimum one-year follow-up. The clinical function, complications, and radiological bony union were evaluated.

Results

All of the patients, with one exception, showed at least 90 degrees of flexion and abduction at the shoulder joint six months postoperatively. The average Constant scores at three months, six months, and one year follow-ups were 74.0 (range, 62 to 90), 79.4 (range, 64 to 91), and 82.7 (range, 66 to 92), respectively. All of the patients achieved bony union within the average of 3.2 months (range, 2 to 6 months). There was one case of delayed union, one case of intra-articular screw penetration, and one case of axillary nerve paresis (incomplete injury), which did not completely recover during the one year of follow-up.

Conclusions

The MIPO technique using periarticular locking plates is a useful option for the treatment of selected cases of displaced proximal humeral fractures. However, nerve complications such as axillary nerve paresis should be considered along with implant-related complications when choosing patients for minimally invasive plating.     

Rotator Cuff Tear and Glenohumeral Instability

Background

The rotator cuff plays a significant role in the static and dynamic stability of the glenohumeral joint. Rotator cuff tears may occur after shoulder dislocations, whether in younger athletes or older patients with age-related tendon degeneration. Untreated tears may cause persistent pain, dysfunction, instability, and degenerative changes. A thorough understanding of when to look for rotator cuff tears after shoulder dislocations and how best to manage them may decrease patients’ pain and improve function.

Questions/purposes

We systematically reviewed the available literature to better understand (1) when a rotator cuff tear should be suspected after a dislocation, (2) whether surgical or nonsurgical approaches result in better scores for pain and satisfaction in patients with rotator cuff tears resulting from shoulder dislocations, and (3) whether intraarticular lesions, rotator cuff tears, or both should be addressed when surgery is performed.

Methods

We systematically searched MEDLINE^®, CINAHL, and EMBASE for studies published from 1950 to 2012. We included studies reporting outcomes after treatment in patients with rotator cuff tears and shoulder dislocations. We excluded case reports, studies without any treatment, and studies about patients treated with arthroplasty. Five Level III and six Level IV studies were ultimately selected for review.

Results

Patients with persistent pain or dysfunction after a shoulder dislocation often had a concomitant rotator cuff tear. Surgical repair resulted in improved pain relief and patient satisfaction compared to nonoperative management. Repair of the rotator cuff, along with concomitant capsulolabral lesions, helped restore shoulder stability. While these findings are based on Level III and IV evidence, better long-term studies with larger cohorts are needed to strengthen evidence-based recommendations.

Conclusions

Persistent pain and dysfunction after a shoulder dislocation should prompt evaluation of the rotator cuff, especially in contact or overhead athletes, patients older than 40 years, or those with nerve injury. Surgery should be considered in the appropriately active patient with a rotator cuff tear after dislocation. While the current literature suggests improved stability and function after surgical repair of the rotator cuff, higher-quality prospective studies are necessary to make definitive conclusions.     

Gender Affects Early Postoperative Outcomes of Rotator Cuff Repair

Background

The literature does not provide consistent information on the impact of patients'' gender on recovery after rotator cuff repair. The purpose of this study was to determine whether gender affects pain and functional recovery in the early postoperative period after rotator cuff repair.

Methods

Eighty patients (40 men and 40 women) were prospectively enrolled. Pain intensity and functional recovery were evaluated, using visual analog scale (VAS) pain score and range of motion on each of the first 5 postoperative days, at 2 and 6 weeks and at 3, 6, and 12 months after surgery. Perioperative medication-related adverse effects and postoperative complications were also assessed.

Results

The mean VAS pain score was significantly higher for women than men at 2 weeks after surgery (p = 0.035). For all other periods, there was no significant difference between men and women in VAS pain scores, although women had higher scores than men. Mean forward flexion in women was significantly lower than men at 6 weeks after surgery (p = 0.033) and the mean degree of external rotation in women was significantly lower than men at 6 weeks (p = 0.007) and at 3 months (p = 0.017) after surgery. There was no significant difference in medication-related adverse effects or postoperative complications.

Conclusions

Women had more pain and slower recovery of shoulder motion than men during the first 3 months after rotator cuff repair. These findings can serve as guidelines for pain management and rehabilitation after surgery and can help explain postoperative recovery patterns to patients with scheduled rotator cuff repair.     

Vascular and Nerve Injury After Knee Dislocation: A Systematic Review

Background

Vascular injury is a devastating complication of acute knee dislocation. However, there are wide discrepancies in the reported frequency of vascular injury after knee dislocations, as well as important differences among approaches for diagnosis of this potentially limb-threatening problem.

Questions/purposes

We determined (1) the frequency of vascular and neurologic injury after knee dislocation and whether it varied by the type of knee dislocation, (2) the frequency with which surgical intervention was performed for vascular injury in this setting, and (3) the frequency with which each imaging modality was used to detect vascular injury.

Methods

We searched the MEDLINE^® literature database for studies in English that examined the clinical sequelae and diagnostic evaluation after knee dislocation. Vascular and nerve injury incidence after knee dislocation, surgical repair rate within vascular injury, and amputation rate after vascular injury were used to perform a meta-analysis. Other measures such as diagnostic modality used and the vessel injured after knee dislocation were also evaluated.

Results

We identified 862 patients with knee dislocations, of whom 171 sustained vascular injury, yielding a weighted frequency of 18%. The frequency of nerve injuries after knee dislocation was 25% (75 of 272). We found that 80% (134 of 160) of vascular injuries underwent repair, and 12% (22 of 134) of vascular injuries resulted in amputation. The Schenck and Kennedy knee dislocation classifications with the highest vascular injury prevalence were observed in knees that involved the ACL, PCL, and medial collateral liagment (KDIIIL) (32%) and posterior dislocation (25%), respectively. Selective angiography was the most frequently used diagnostic modality (61%, 14 of 23), followed by nonselective angiography and duplex ultrasonography (22%, five of 23), ankle-brachial index (17%, four of 23), and MR angiography (9%, two of 23).

Conclusions

This review enhances our understanding of the frequency of vascular injury and repair, amputation, and nerve injuries after knee dislocation. It also illustrates the lack of consensus among practitioners regarding the diagnostic and treatment algorithm for vascular injury. After pooling existing data on this topic, no outcomes-driven conclusions could be drawn regarding the ideal diagnostic modality or indications for surgical repair. In light of these findings and the morbidity associated with a missed diagnosis, clinicians should err on the side of caution in ruling out arterial injury.     

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps,part II: a report of 7 cases

PURPOSE: This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps. METHODS: Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo). RESULTS: All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed. CONCLUSIONS: This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.     

Latissimus-dorsi-Transfer bei nichtrekonstruierbarem Rotatorenmanschettendefekt

Objective

Improvement of glenohumeral dynamic centering and active external rotation by a transfer of the latissimus dorsi tendon to the greater tuberosity or the lateral proximal humerus.

Indications

Irreparable posterosuperior rotator cuff tears.

Contraindications

Cuff tear arthropathy, subscapularis tendon tear, deltoid insufficiency, palsy of the axillary nerve.

Surgical technique

Diagnostic arthroscopy in lateral decubitus position. Placement of suture through the biceps tendon and supragleonidal tenotomy. Posterior approach. Preparation and mobilization of a pedicled latissimus dorsi flap. Second anterior incision with delta split. Debridement of the torn rotator cuff. Insertion of suture anchors in the greater tuberosity. Passing of the muscle flap inferior to the posterior deltoid and fixation with suture anchors to the greater tuberosity (where applicable suturing with remaining rotator cuff tissue).

Postoperative management

Immobilization in a thorax abduction cast for 6?weeks. Passive exercises out of the cast (IR/ER 0-0-free and ABD/ADD free-45-0°). Active assistive exercises from week?4 postoperatively. Stepwise increase of passive range of motion from week?7. Unlimited active range of motion from week?10.

Results

After an average follow-up of 57.6 (SD?27.5) months 17?patients were examined clinically. The average age at time of surgery was 55.6 (SD?7.7) years. At follow-up the patients showed an average Constant score of 64.4?points (SD?17.4). The active external rotation in 0° abduction was 16° (SD?17). The 4?patients (23%) with a sonographically-detected retear of the latissimus flap presented worse clinical results.     

An in-vitro study of rotator cuff tear and repair kinematics using single- and double-row suture anchor fixation

Purpose:

Double-row suture anchor fixation of the rotator cuff was developed to reduce repair failure rates. The purpose of this study was to determine the effects of simulated rotator cuff tears and subsequent repairs using single- and double-row suture anchor fixation on three-dimensional shoulder kinematics. It was hypothesized that both single- and double-row repairs would be effective in restoring active intact kinematics of the shoulder.

Materials and Methods:

Sixteen fresh-frozen cadaveric shoulder specimens (eight matched pairs) were tested using a custom loading apparatus designed to simulate unconstrained motion of the shoulder. In each specimen, the rotator cuff was sectioned to create a medium-sized (2 cm) tear. Within each pair, one specimen was randomized to a single-row suture anchor repair, while the contralateral side underwent a double-row suture anchor repair. Joint kinematics were recorded for intact, torn, and repaired scenarios using an electromagnetic tracking device.

Results:

Active kinematics confirmed that a medium-sized rotator cuff tear affected glenohumeral kinematics when compared to the intact state. Single- and double-row suture anchor repairs restored the kinematics of the intact specimen.

Conclusions:

This study illustrates the effects of medium-sized rotator cuff tears and their repairs on active glenohumeral kinematics. No significant difference (P ≥ 0.10) was found between the kinematics of single- and double-row techniques in medium-sized rotator cuff repairs.

Clinical Relevance:

Determining the relative effects of single- and double-row suture anchor repairs of the rotator cuff will allow physicians to be better equipped to treat patients with rotator cuff disease.     

Anterior Shoulder Dislocation

INTRODUCTION

Anterior dislocation of the shoulder is commonly seen in accident and emergency (A&E) and trauma clinics. In this article, we review the existing literature on the injury and the recent trends in management.

MATERIALS AND METHODS

We have discussed this condition with our colleagues and performed a Medline search (‘anterior shoulder dislocation’) of the relevant papers. We also describe key historical publications and recent developments regarding immobilisation of the joint.

RESULTS

Management decisions regarding this condition continue to vary between units, especially for recurrent and posterior dislocation. This paper lays some emphasis on the choice of analgesic agent when attempting shoulder reduction in the A&E setting. A summary of the data from our own department has provided a graphical representation of the classical age and sex distribution for this condition.

CONCLUSIONS

Shoulder dislocation is a common injury. Delays in diagnosis remain the single biggest obstacle to optimum results in this group of patients. A significant proportion will require eventual surgery and up to a third of these patients will go on to develop long-term shoulder arthritis. Even patients who have experienced a single episode of dislocation may go on to develop long-term sequelae.     

A Comparison of Conventional Ultrasonography and Arthrosonography in the Assessment of Cuff Integrity after Rotator Cuff Repair

Background

This study was designed to perform conventional ultrasonography, magnetic resonance arthrography (MRA) and arthrosonography exams after rotator cuff repair to compare the results of conventional ultrasonography and arthrosonography with those of MRA as the gold standard.

Methods

We prospectively studied 42 consecutive patients (14 males, 28 females; average age, 59.4 years) who received arthroscopic rotator cuff repair due to full-thickness tears of the supraspinatus tendon from 2008 to 2010. The integrity assessment of the repaired rotator cuff was performed 6 months postoperatively using conventional ultrasonography, MRA, and arthrosonography.

Results

The diagnostic accuracy of the conventional ultrasonography compared to MRA was 78.6% and the McNemar test results were 0.016 in full-thickness tear and 0.077 in partial-thickness tear. The diagnostic accuracy of arthrosonography compared to MRA was 92.9% and the McNemar test results were 0.998 in full-thickness tear and 0.875 in partial-thickness tear.

Conclusions

It was found that the integrity assessment of the repaired rotator cuff by ultrasonography must be guarded against and that arthrosonography is an effective alternative method in the postoperative integrity assessment. Also, an arthrosonography seems to be a suitable modality to replace the conventional ultrasonography.     

Long-term outcome and structural integrity following open repair of massive rotator cuff tears

Background:

Surgical repair of massive rotator cuff tears is associated with less favorable clinical results and a higher retear rate than repair of smaller tears, which is attributed to irreversible degenerative changes of the musculotendinous unit.

Materials and Methods:

During the study period, 25 consecutive patients with a massive rotator cuff tear were enrolled in the study and the tears were repaired with an open suture anchor repair technique. Preoperative and postoperative clinical assessments were performed with the Constant score, the simple shoulder test (SST) and a pain visual analog scale (VAS). At the final follow-up, rotator cuff strength measurement was evaluated and assessment of tendon integrity, fatty degeneration and muscle atrophy was done using a standardized magnetic resonance imaging protocol.

Results:

The mean follow-up period was 70 months. The mean constant score improved significantly from 42.3 to 73.1 points at the final follow-up. Both the SST and the pain VAS improved significantly from 5.3 to 10.2 points and from 6.3 to 2.1, respectively. The overall retear rate was 44% after 6 years. Patients with an intact repair had better shoulder scores and rotator cuff strength than those with a failed repair, and also the retear group showed a significant clinical improvement (each P<0.05). Rotator cuff strength in all testing positions was significantly reduced for the operated compared to the contralateral shoulder. Muscle atrophy and fatty infiltration of the rotator cuff muscles did not recover in intact repairs, whereas both parameters progressed in retorn cuffs.

Conclusions:

Open repair of massive rotator tears achieved high patient satisfaction and a good clinical outcome at the long-term follow-up despite a high retear rate. Also, shoulders with retorn cuffs were significantly improved by the procedure. Muscle atrophy and fatty muscle degeneration could not be reversed after repair and rotator cuff strength still did not equal that of the contralateral shoulder after 6 years.

Level of evidence:

Level IV     

The Prevalence of Os Acromiale in Korean Patients Visiting Shoulder Clinic

Background

The prevalence of os acromiale has been documented to be between 1% and 15% and is known to be clinically associated with subacromial impingement or rotator cuff tear. However, the prevalence of os acromiale in Korea has not yet been determined. The purpose of this study is to evaluate the prevalence of os acromiale in Korean patients who visited shoulder clinics and to investigate the correlations with rotator cuff tear.

Methods

We retrospectively reviewed the X-rays of patients visiting a shoulder clinic at a tertiary hospital in Korea from January 2011 to January 2012 to determine the frequency of os acromiale. X-ray findings were confirmed with magnetic resonance imaging (MRI) for patients who had these images available. MRI was also used to assess the status of the rotator cuff. The correlation between the presence of os acromiale either with gender, hand dominance or rotator cuff tear was analyzed statistically.

Results

A total of 2,946 shoulders from 1,568 patients were analyzed with X-rays. Thirteen cases out of 1,568 patients had an os acromiale; and there were five and eight cases of pre-acromiale and meso-acromiale, respectively. Thus, the prevalence of os acromiale in this study population was found to be 0.7 (7 cases per 1,000 patients). Bilaterality was found in two cases. Os acromiale was not more frequent according to gender (five males versus eight females, p = 0.525) and hand dominance was not associated with frequency of os acromiale (seven dominant arms versus six non-dominant arms, p = 0.631). A sub-analysis of shoulders with available MRIs (1,074 shoulders) revealed that there were two rotator cuff tears (40%) out of five cases of os acromiale, whereas 607 rotator cuff tears were observed (57%) among 1069 cases without os acromiale. This difference was not statistically significant (p = 0.656).

Conclusions

The identified prevalence of os acromiale in Korean patients who visited shoulder clinics is 0.7%, which is much lower as compared with the prevalence of general population from other ethnic groups. No correlation was observed between rotator cuff tears and os acromiale in this study population.