Primary anterior shoulder dislocation and rotator cuff tears.

In a prospective controlled study 167 patients with 167 primary traumatic anterior shoulder dislocations underwent early ultrasonograpic evaluation for rotator cuff tears. We found 53 (31.7%) full-thickness cuff tears in this group. Compared with a group of 93 healthy volunteers, we found with statistical significance more cuff tears in the patients aged < 60 years. Women ruptured the cuff more often than men. If the patient is not able to elevate the affected arm more than 90 degrees in the scapular plane 2 weeks after the dislocation, there should be a high suspicion of rotator cuff tear (76.7%). For early detection of relevant rotator cuff lesions, we recommend shoulder ultrasonographic examination and measurement of active elevation after each traumatic shoulder dislocation in the above mentioned age group.     

Reversed arthroscopic subacromial decompression for massive rotator cuff tears

This prospective study evaluates the results of a procedure for massive rotator cuff tears that we term reversed arthroscopic subacromial decompression (ASD). The procedure includes an arthroscopic debridement of the subacromial space and glenohumeral joint, an arthroscopic tuberoplasty, and depending on the pathologic condition of the long head of the biceps, a biceps tendon tenotomy. Reversed ASD avoids a classic acromioplasty in order to preserve the integrity of the coracoacromial arch. Twenty-three patients with a mean age of 69 years underwent this procedure. After a mean follow-up of 40 months, the age-adjusted Constant score increased significantly, from 65.9% to 90.6% (P <.001), with 14 excellent, 5 good, 2 satisfactory, and 1 poor result. Preexisting osteoarthritic changes increased significantly but had no impact on the final clinical results. The acromiohumeral distance decreased from 5.1 to 4.5 mm (P =.004). There were no complications directly related to the surgical procedure. When compared with classic ASD studies for massive rotator cuff tears, we obtained similar midterm results with regard to pain relief, functional recovery, and patient satisfaction. We, therefore, conclude that reversed ASD with tenotomy of the long head of the biceps tendon offers a less invasive treatment strategy for massive rotator cuff tears while preserving the integrity of the coracoacromial arch.     

Subacromial decompression. Treatment for small- and medium-sized tears of the rotator cuff

We report the results of arthroscopic subacromial decompression and debridement of the rotator cuff for chronic small- and medium-sized tears in 114 patients (118 shoulders) between two and five years after surgery. The mean Constant score was improved to 69.8, and 88 shoulders (74.6%) had a satisfactory outcome. Of patients under the age of 60 years the outcome was satisfactory in 59.3%, and in those over 60 years, in 87.5% (p < 0.001). An unsatisfactory outcome was related to manual work (p < 0.001) and a duration of symptoms of more than 12 months (p < 0.05). The outcome was not related to the size of the tear, the muscles involved or biceps pathology. Further surgery was required in 25 patients after a mean of 13.7 months (3 to 35); ten tears had progressed in size, but none became irreparable. There was no relationship between the increase in the size of the tear and its initial size, the muscles involved or the presence of biceps pathology. No tear became smaller with time.     

Management of rotator cuff tears: A comparison of arthroscopic debridement and surgical repair

In a prospective study, 87 consecutive patients with 88 chronic, full-thickness tears of the rotator cuff were randomly assigned to either open surgical tendon repair and anterior acromioplasty (50 shoulders) or arthroscopic debridement and subacromial decompression (38 shoulders). All patients were reexamined 2 to 5 years after the operation with the University of California at Los Angeles 35-Point Scale for Pain and Function of the Shoulder. The average ratings were 30.5 (rotator cuff repair) and 25.1 (arthoscopic debridement/decompression) for each group. The open surgical repair group faired significantly better than the arthroscopic debridement group (p = .0028). Thirteen required subsequent procedures, four with tendon repair and nine with decompression. Five in the decompression group experienced cuff tear arthropathy. Surgical repair of full-thickness rotator cuff tears provided results superior to those of arthroscopic debridement and subacromial decompression.     

Arthroscopic debridement of massive rotator cuff tears: negative prognostic factors

Introduction The purpose of this study was to identify the factors that may lead to poor outcomes after arthroscopic debridement in massive rotator cuff tears.Materials and methods Thirty-three patients (10 women and 23 men) with massive, irreparable rotator cuff tears underwent arthroscopy by a single surgeon. The preoperative diagnosis was based on the clinical examination and MRI. Their mean age was 69 years (range 62–79 years), and the average follow-up was 31 months (range 24–46 months). If indicated, the performed arthroscopic debridement included acromioplasty, debridement of the cuff, resection of the distal part of the clavicle or tenotomy of the long head of the biceps. In 28 cases (85%) acromioplasties and in 6 cases (18%) biceps tenotomies were performed, 2 of which were a single tenotomy without any associated acromioplasty. One patient had been managed with concomitant resection of the distal part of the clavicle.Results The Constant and Murley Score improved by a mean of 30 points, from a mean of 37 points (range 21–52) preoperatively to a mean of 67 points (range 31–82) at the time of follow-up. Some 82% of the patients were satisfied with the procedure. The result was considered unsatisfactory because of inadequate pain relief in 4 shoulders, because of limited active abduction in 1 and because of limited external rotation in 1. A poor outcome was associated with a complete tear of the subscapularis tendon in 6 patients. The radiological study showed no significant narrowing of the subacromial space.Conclusion Our early results suggest that arthroscopic debridement is an excellent treatment for elderly patients with modest functional demands. However, its long-term consequences remain to be evaluated by studies with lengthy follow-up. Prognostic factors that may lead to a negative outcome are preoperative superior migration of the humeral head, presence of subscapularis tear, presence of glenohumeral arthritis and decreased range of motion.     

Ultrasonography of rotator cuff tears.

This is a prospective study of ultrasonography of the rotator cuff mechanism as an alternative to arthrography for screening rotator cuff tears. Seventy-two patients (40 men and 32 women) with possible rotator cuff tears were referred for shoulder arthrography. Before arthrography, bilateral shoulder sonography was performed by a technician under the direction of a radiologist. Arthrograms and sonograms were read separately, and a decision as to the absence or presence of a rotator cuff tear was made without knowledge of the results of the other examination. The results showed 90% sensitivity and 91% specificity, with a positive accuracy of 87%, and a negative accuracy of 93%. Ultrasonography of the rotator cuff is a noninvasive, painless, and cost-effective screening method for patients with a suspected rotator cuff tear.     

Arthroscopic subacromial decompression in the treatment of full-thickness rotator cuff tears

Arthroscopic subacromial decompression has become an accepted treatment for patients with impingement syndrome; however, its use for full-thickness rotator cuff tears is controversial. We observed 25 patients with full-thickness rotator cuff tears treated by arthroscopic subacromial decompression and cuff debridement alone with a minimum of 1 year follow-up observation. Based on the University of California at Los Angeles shoulder rating, 84% of the cases were rated as excellent or good. There was significant improvement in pain, function, motion, and strength. Eighty-eight percent of the patients were satisfied with the procedure. Although all tear sizes improved significantly, smaller tears fared better than larger tears. The preliminary results of arthroscopic subacromial decompression with cuff debridement compare favorably to open techniques of rotator cuff repair with or without acromioplasty and should be considered in selected patients with full-thickness rotator cuff tears.     

Glenoid version and rotator cuff tears.

The purpose of this study was to determine the relationship between rotator cuff (RC) tear and the orientation of the glenoid. Ninety-six shoulders (94 patients) that underwent open RC repair were grouped according to the type of tear. We measured on MRI the acromio-glenoid angle (AG) and the supraspinatus fossa glenoid angle on the anterior-posterior (SGAP) and axial (SGAX) views. RC patients had a smaller AG angle (76+/-7 degrees vs. 86+/-10 degrees ) and a larger SGAP angle (112+/-6 degrees vs. 102+/-7 degrees ) compared to controls (p<0.001). We also found a highly significant difference (p<0.001) in glenoid version measured by SGAX between anterior cuff tears (-5+/-4 degrees ) and posterior cuff tears (3+/-3 degrees ). Furthermore, we identified an association between RC tear and the orientation of the glenoid relative to the axis of the supraspinatus fossa. Greater retroversion is predictive of an anterior cuff injury and greater anteversion is predictive of a posterior cuff injury.     

Superior capsular reconstruction for irreparable rotator cuff tears: A literature review and specialist practice report

BackgroundRecent evidence continues to confirm the effectiveness of arthroscopic superior capsular reconstruction (SCR) in relieving pain and improving function in an irreparable cuff deficient shoulder. This paper presents an up-to-date literature review on SCRand a tertiary referral unit experience in the United Kingdom.MethodsData was prospectively collected on patients undergoing SCR for irreparable rotator cuff tears using a dermal allograft. Patients with already established arthritis were excluded. The first 49 consecutive cases performed by 3 surgeons over 3 years (including their learning curve) with average follow-up of 19 months (range 3–37 months) were analysed. The outcomes assessed were re-operation rates, patient satisfaction and complications. The study group was analysed to identify the factors predicting outcomes.ResultsThe average age of the cohort was 56 years. The re-operation rate in this group was 12.2% with each of these 6 patients subsequently undergoing a reverse total shoulder arthroplasty. Forty (82%) patients were satisfied with the outcome of the procedure with 35 (72%) of them showing complete pain relief, 5 (10%) having dull aches and clicks and the remaining 9 (18%) unsatisfied due to pain. There was no difference in satisfaction rates between different age groups (p > 0.05). The pre-operative factors associated with poor outcomes included patients with multiple previous surgeries on the same shoulder (p = 0.02) and teres minor atrophy or tear (p = 0.03). The other factors that showed a trend towards inferior outcomes (but not statistically significant) included patients with degenerative tears, symptoms of longer duration (>24 months) and subscapularis tear/atrophy. No serious adverse effects such as graft rejection, infection or neuro-vascular injury were observed.ConclusionEarly results of superior capsular reconstruction are promising and may offer an answer to a challenging group of patients with symptomatic irreparable rotator cuff tears. It is likely that the relatively low re-operation rates can be further improved by considering the negative prognostic factors in defining indications for surgery.     

Association of osteopenia of the humeral head with full-thickness rotator cuff tears

Rotator cuff tendon repair may fail for various reasons. Although the role of repair techniques and of the musculotendinous unit has been studied, there is little information on the quality of the bone to which the tendon is to be repaired. Therefore, 14 cadaveric humeral heads, 7 specimens without and 7 with a full-thickness rotator cuff tendon tear, were quantitatively assessed by use of high-resolution micro-computed tomography. Bone density is higher below the articular surface than in the greater tuberosity (40% vs 10%-20%), and tendon tears are associated with a reduction in cancellous bone density of greater than 50%, leading to a virtually hollow greater tuberosity, with intact cortical bone. The results found suggest that in long-standing rotator cuff tears, creating a deep trough should be avoided to achieve reliable tendon-to-bone contact. For optimal suture fixation to bone, sutures or anchors should be positioned subcortically or medially under the articular surface.     

Conservative treatment of rotator cuff tears.

Among 124 shoulders in 114 patients with complete rotator cuff tears who had been treated conservatively from 1980 until 1989, 62 shoulders in 54 patients were observed to identify the findings on initial examinations and correlate them with the final results. The follow-up period averaged 3.4 years. According to modified criteria of Wolfgang, 51 shoulders in 45 patients (82%) rates satisfactory (excellent or good). The overall scores of pain, motion, and function improved significantly. The results were less satisfactory in patients observed more than six years. The patients with satisfactory results (Group 1) and unsatisfactory results (Group 2) among those observed more than five years were compared. In Group 1, the scores of pain, motion, and strength improved significantly at follow-up examinations, whereas those of function did not. In Group 2, no improvement was recognized in any categories. The only significant differences in the initial findings between the two groups were the active abduction angle and the abduction strength: the patients in Group 1 retained a good range of motion and strength, whereas those with unsatisfactory results had a limited range and muscle weakness on first examinations. Conservative treatment affords satisfactory results when it is given to the patients with well-preserved motion and strength, although in some cases function may deteriorate with time.     

Massive rotator cuff tears: functional outcome after debridement or arthroscopic partial repair

Background  

The surgical treatment of massive rotator cuff tears (RCT) is still controversial and can be based on a variety of different surgical repair methods. This study investigated the effectiveness of arthroscopic debridement or arthroscopic partial repair in patients with massive RCT.     

Partial cuff debridement for irreparable defects of the rotator cuff

The treatment of massive rotator cuff tears can pose a difficult problem for the unprepared orthopaedic surgeon.There are many ways to treat massive rotator cuff tears, and one viable option is debridement with acromioplasty. For this form of treatment to be successful, the surgeon must choose his patient carefully. This report will focus on patient selection, biomechanics, and postoperative rehabilitation. A thorough understanding of rotator cuff tear biomechanics is needed when treating a massive tear; thorough physical and radiological examinations will help the orthopedist understand the biomechanic characteristic of the patient's tear. A tear that is balanced in both the transverse and coronal planes is stable and functional and will do well with debridement. Conversely, a tear that is unbalanced in either the transverse or coronal planes is unstable and nonfunctional and will not do well with simple debridement. Nonfunctional tears demand an attempt at rotator cuff tendon repair to restore balance to the cuff, making the tear functional. Debridement of a functional tear can be successfully performed with arthroscopic or open technique. Preservation or reconstruction of the coracoacromial (CA) arch is important because it adds anterosuperior stability to the shoulder with a massive rotator cuff tear. Postoperative rehabilitation is as important as the surgery itself and will also be emphasized. Many surgeons have had success with debridement of massive rotator cuff tears; however, as with any procedure, proper understanding of the pathology and proper patient selection is paramount to obtaining a successful result.     

Degenerative change and rotator cuff tears

Summary In order to determine the effects of friction and rubbing in the development of rotator cuff tear, we studied 160 shoulders of 80 cadavers (age at death 43–93 years, mean 69.3 years). Seventy-two cadavers were fixed with formalin and eight were fresh cadavers. The surface of the cuff and the undersurface of the acromion were observed macroscopically. Eight shoulders of fresh cadavers were examined by scanning electron microscopy. Ninety-eight specimens (61%) showed degenerative changes of the supraspinatus tendon. The number of tendons with degeneration and tear increased from the fifth to sixth decade of life, and the size of the tear increased with age. However, there was no sustained increase in the incidence with aging from the age of 60 to 90 years, and the percentage with degenerative changes of the cuff remained at approximately 60% in each decade. Ninety-six specimens (60%) showed degeneration of the subacromial surface. The percentage with degeneration of the undersurface of the acromion remained at approximately 60% from the sixth to ninth decade. There was a significant correlation between the severity of the changes in the rotator cuff and the subacromial surface. Scanning electron microscopy showed changes suggesting effects of friction and rubbing on the rotator cuff, such as regularly arranged wool-like spherical structures on the surface of the tendon and rounded ruptured ends of the tendon fibers. These results indicate that degenerative change of the rotator cuff is aggravated by a friction and rubbing mechanism with the undersurface of the acromion and leads to development of a complete tear.