The effect of rotator cuff tear size on shoulder strength and range of motion

STUDY DESIGN: Prospective cohort study. OBJECTIVES: To determine the effect of rotator cuff tear size on shoulder strength and range of motion. BACKGROUND: Patients with rotator cuff pathology typically present with weakness and motion loss in various motions. The extent to which the presence of a rotator cuff tear and the size of the tear affect strength and range of motion is not well understood. METHODS AND MEASURES: Sixty-one patients scheduled for surgery, with a diagnosis of a rotator cuff tear and/or subacromial impingement, underwent examination for shoulder pain, function, range of motion, and strength. The extent of rotator cuff pathology was documented during subsequent surgery (presence of tear, tear size, tear thickness). RESULTS: There were 10 massive tears, 15 large tears, 13 medium tears, 12 small tears, and 11 rotator cuffs without a tear. Patients had marked weakness in abduction strength at 90 degrees and 10 degrees of abduction, in external rotation strength at 90 degrees, and in the "full can test" (all, P<.0001). Marked range of motion losses in shoulder flexion and external rotation at 0 degrees and 90 degrees abduction (all, P<.001) were also observed. Abduction strength deficit at 10 degrees was affected by rotator cuff tear size (P<.0001). Twenty of 25 patients with large or massive tears had deficits greater than 50%, compared with only 1 of 11 patients with no tear, 2 of 12 patients with a small tear, and 5 of 13 patients with a medium tear (P<.0001). Other strength and range of motion deficits or indices of pain and function were unaffected by tear size. CONCLUSIONS: Weakness of greater than 50% relative to the contralateral side in shoulder abduction at 10 degrees of abduction was indicative of a large or massive rotator cuff tear.     

An assessment of the inter examiner reliability of clinical tests for subacromial impingement and rotator cuff integrity

Over 30 separate clinical signs for the shoulder have been described, most with little evidence to support their accuracy and reliability. The aim of our study was to evaluate the accuracy and reliability of some of the commonly used tests for rotator cuff disease. Two clinicians, a consultant with an established shoulder practice and a registrar with an interest in shoulder surgery, examined 63 patients with history suggestive of rotator cuff disease. A set of pre-determined clinical tests for impingement syndrome and rotator cuff tear were standardised and agreed upon before the study was commenced. The examination included eliciting a painful arc, the drop arm test, the Neer’s and the Hawkin’s sign for impingement syndrome. Integrity of the individual components of the rotator cuff was assessed by the strength of abduction initiation and at 90° abduction for supraspinatus tear (Jobe’s test), Speed’s and Yergason’s test for biceps pathology, strength of shoulder external rotation for infraspinatus tears and the Gerber lift-off test for subscapularis tears. Accuracy assessments were determined by comparing clinical findings against findings at arthroscopy in 50 of the 63 patients. The two observers did not differ significantly in their assessments. Un-weighted kappa values defining agreement between the two observers and the positive predictive values were evaluated. Our findings indicate that clinical signs can be relied upon for diagnosis of impingement but not for rotator cuff deficiency. Compared with other previously published studies, our study demonstrates that the inter observer agreement is better when the assessors have a special interest and understanding of shoulder disorders.     

Die primäre inverse Frakturprothese

The treatment of comminuted three and four part fractures of the proximal humerus in elderly patients with degenerative rotator cuff tears is challenging. Primary reverse total shoulder arthroplasty (RSA) is an alternative; however, functional outcome is still unclear due to a lack of study results. The aim of this study was to examine the functional results of RSA and to compare them with the results after reconstruction and locking plate osteosynthesis 1 year after surgery. In this study 24 patients (mean age: 77.9±9.1 years) underwent RSA as primary treatment for three and four part fractures of the proximal humerus with either head split or rotator cuff tears >Bateman type II. The results obtained at 3, 6 and 12 months follow-up included shoulder range of motion (ROM), Constant score, age-adjusted and gender-adjusted Constant score and as a percentage when compared to the uninjured side. Data were compared to patients of matching age, gender and fracture pattern from a prospectively collected database of 526 patients treated by locking plate osteosynthesis. The mean shoulder ROM 1 year after surgery was 105±29° flexion, 99±31° abduction, 22±23° external rotation and 65±26° internal rotation. In 6 patients flexion-abduction was >130°. The mean Constant score (CS) 1 year postoperatively was 62.4±14, age and gender normalized CS was 79.2±20.5, CS compared to the uninjured side was 76.1% and there were no significant differences to matched individuals treated by open reduction and internal fixation using locking plates (p=0.360). There were no infections, dislocations, vascular or neural disorders and surgical revision was not necessary in any patient. RSA should be considered as an appropriate alternative for the primary treatment of comminuted three and four part fractures of the proximal humerus with head split or large rotator cuff tears in elderly patients. Although RSA can provide immediate shoulder stability for elderly patients with severe shoulder injuries, primary RSA needs investigation with regards to long-term outcome.     

Arthroscopic repair of massive,contracted, immobile rotator cuff tears using single and double interval slides: technique and preliminary results

Purpose: The purpose of this study is to describe the technique and review the preliminary results of arthroscopic repair of massive, contracted, immobile rotator cuff tears using an interval slide technique. Type of Study: Case series. Methods: From January 1999 to December 2000, the senior author (S.S.B.) performed arthroscopic rotator cuff repair on 94 massive rotator cuff tears. Of these, 9 (9.6%) were massive, severely contracted rotator cuff tears and required repair using an interval slide technique. A single interval slide was used in 6 patients, and a double interval slide was used in 3 patients. All patients were evaluated preoperatively and postoperatively using a modified University of California Los Angeles (UCLA) scoring system. Results: At a mean follow-up time of 17.9 months (range, 10–24 months), 8 of 9 patients were satisfied with the procedure. The mean UCLA score increased from 10.0 preoperatively to 28.3 postoperatively (P < .00001). All patients showed some improvement in active motion, strength, or function. Active forward flexion improved significantly, from a preoperative mean of 108° to a postoperative mean of 146.1° (P = .025). Active external rotation increased significantly from a preoperative mean of 24.4° to a postoperative mean of 35.0° (P = .04). A significant increase in strength grade (2.2 to 3.6; P < .005) and function (2.5 to 7.1; P < .0005) were also seen. We encountered no significant complications to the procedure. Conclusions: The interval slide technique provides a method of mobilization of massive, severely contracted, immobile rotator cuff tears allowing repair of previously irreparable tears. This technique, in conjunction with arthroscopic rotator cuff repair, may provide patients with improvements in pain, motion, strength, and overall shoulder function. Level of Evidence: Level IV.     

A larger critical shoulder angle requires more rotator cuff activity to preserve joint stability

Shoulders with rotator cuff tears (RCT) tears are associated with significantly larger critical shoulder angles (CSA) (RCT CSA = 38.2°) than shoulders without RCT (CSA = 32.9°). We hypothesized that larger CSAs increase the ratio of glenohumeral joint shear to joint compression forces, requiring substantially increased compensatory supraspinatus loads to stabilize the arm in abduction. A previously established three dimensional (3D) finite element (FE) model was used. Two acromion shapes mimicked the mean CSA of 38.2° found in patients with RCT and that of a normal CSA (32.9°). In a first step, the moment arms for each muscle segment were obtained for 21 different thoracohumeral abduction angles to simulate a quasi‐static abduction in the scapular plane. In a second step, the muscle forces were calculated by minimizing the range of muscle stresses able to compensate an external joint moment caused by the arm weight. If the joint became unstable, additional force was applied by the rotator cuff muscles to restore joint stability. The model showed a higher joint shear to joint compressive force for the RCT CSA (38.2°) for thoracohumeral abduction angles between 40° and 90° with a peak difference of 23% at 50° of abduction. To achieve stability in this case additional rotator cuff forces exceeding physiological values were required. Our results document that a higher CSA tends to destabilize the glenohumeral joint such that higher than normal supraspinatus forces are required to maintain modeled stability during active abduction. This lends strong support to the concept that a high CSA can induce supraspinatus (SSP) overload. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:961–968, 2016.     

Kombinationsverletzungen von Labrum und Rotatorenmanschette

In the case of a shoulder dislocation, standard trauma series (AP / Y) are adequate ¶for radiological diagnosis. Degenerative changes or an excentric position of the humeral head are indicators for additional old or acute pathophysiological problems. If pain and weakness, especially during abduction and external rotation, persist for 2 or ¶3 weeks after repositioning, ultrasonography or MRI is indicated to exclude an accompanying tear of the rotator cuff. The incidence of accompanying rotator cuff tears in cases of anterior or inferior glenohumeral dislocation is in excess of 30% in patients over ¶40 years of age, and may exceed 80% in patients over 60 years of age. Following a first-time traumatic shoulder dislocation prompt operative repair of the acute rotator cuff tear generally leads to satisfactory results. For patients who have suffered a large number of recurrences both a superior and an anterior repair may be indicated, and this leads to better results than a rotator cuff repair alone. In the case of an irreparable rotator cuff defect in combination with a recurrent anterior shoulder dislocation a transfer of the pectoralis major can stabilize the shoulder and restore adequate function.     

Supraspinatus tendon load during abduction is dependent on the size of the critical shoulder angle: A biomechanical analysis

Shoulders with supraspinatus (SSP) tears are associated with significantly larger critical shoulder angles (CSA) compared to disease‐free shoulders. We hypothesized that larger CSAs increase the ratio of joint shear to joint compression forces (defined as “instability ratio”), requiring substantially increased compensatory supraspinatus loads. A shoulder simulator with simulated deltoid, supraspinatus, infraspinatus/teres minor, and subscapularis musculotendinous units was constructed. The model was configured to represent either a normal CSA of 33° or a CSA characteristic of shoulders with rotator cuff tears (38°), and the components of the joint forces were measured. The instability ratio increased for the 38° CSA compared with the control CSA (33°) for a range of motion between 6° to 61° of thoracohumeral abduction with the largest differences in instability observed between 33° and 37° of elevation. In this range, SSP force had to be increased by 13–33% (15–23 N) to stabilize the arm in space. Our results support the concept that a high CSA can induce SSP overload particularly at low degrees of active abduction. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 32:952–957, 2014.     

Modified load sharing rip-stop technique in patients with traumatic transtendinous rotator cuff tear: Surgical technique and clinical outcomes

BackgroundTranstendinous rotator cuff tear is likely to occur due to trauma in sports activities, with a frequency of <2% of total rotator cuff tears. These tears are difficult to treat because of limited tendon tissue in the proximal stump, and standard repair techniques are sometimes ineffective. Few studies have reported on the repair technique and clinical outcomes for transtendinous rotator cuff tear, and an appropriate repair technique has, therefore, not been established. The purpose of this study was to use our modified load sharing rip-stop technique to repair transtendinous rotator cuff tear and to clarify the clinical effectiveness of this technique.MethodsThis was a retrospective case series review of eight patients who underwent the modified load sharing rip-stop technique for repairing traumatic transtendinous rotator cuff tear between January 2013 and June 2017. The eight patients were followed up for at least 2 years (range: 24–41 months). Cuff integrity was evaluated using magnetic resonance imaging at 12 months after surgery using the Sugaya classification. We evaluated the pre- and postoperative ranges of motion, American Shoulder and Elbow Surgeons score, Constant Shoulder Score, and muscle strength at 90° abduction. Data were analyzed using the Mann–Whitney U test and Fisher's exact tests. P < .05 was considered to indicate statistical significance.ResultsSix patients were classified as Sugaya I and two as Sugaya II. ASES score (38.5–90.2, P = .0008), Constant shoulder score (36.5–79, P = .002), flexion (85°–158.1°, P = .002), abduction (85°–157.5°, P = .001), external rotation (38.8°–55°, P = .024), and muscle strength at 90° abduction (2.95–5.39 kg, P = .028) improved significantly. Six patients were able to return to their previous sports activity.ConclusionUsing our modified load sharing rip-stop technique for repair of transtendinous rotator cuff tear, patients obtained good clinical outcomes and could return to sports activities.     

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.     

The effect of rotator cuff tears on reaction forces at the glenohumeral joint.

The rotator cuff muscles maintain glenohumeral stability by compressing the humeral head into the glenoid. Disruption of the rotator cuff compromises concavity compression and can directly affect the loads on the glenohumeral joint. The purpose of this study was to quantify the effect of rotator cuff tears on the magnitude and direction of glenohumeral joint reaction forces during active shoulder abduction in the scapular plane using nine cadaveric upper extremities. Motion of the full upper extremity was simulated using a dynamic shoulder testing apparatus. Glenohumeral joint reaction forces were measured by a universal force-moment sensor. Five conditions of rotator cuff tears were tested: Intact, Incomplete Supraspinatus Tear, Complete Supraspinatus Tear, Supraspinatus/Infraspinatus Tear, and Global Tear. Reaction forces at the glenohumeral joint were found to steadily increase throughout abduction and peaked at maximum abduction for all conditions tested. There were no significant differences in reaction force magnitude for the intact condition (337 +/- 88 N) or those involving an isolated incomplete tear (296 +/- 83 N) or complete tear (300 +/- 85 N) of the supraspinatus tendon. Extension of tears beyond the supraspinatus tendon into the anterior and posterior aspect of the rotator cuff led to a significant decrease in the magnitude of joint reaction force (126 +/- 31 N). Similarly, such tears resulted in a significant change in the direction of the reaction force at the glenohumeral joint. These results suggest that joint reaction forces are significantly affected by the integrity of the rotator cuff, specifically, by the transverse force couple formed by the anterior and posterior aspects of the cuff. The quantitative data obtained in this study on the effect of rotator cuff tears on magnitude and direction of the reaction force at the glenohumeral joint helps clarify the relationship between joint motion, joint compression and stability.     

反式全肩关节假体置换治疗巨大不可修复肩袖撕裂

目的探讨反式全肩关节置换术（reverse total shoulder arthroplasty,RTSA）治疗巨大不可修复肩袖撕裂的临床治疗效果。 方法对南京中医药大学附属医院2018年5月至2020年1月收治的采取RTSA治疗的13例巨大不可修复肩袖撕裂患者的临床资料进行回顾性分析。记录术前及最后一次随访时患者的肩关节前屈、外展、外旋活动,美国肩肘外科协会评分（American shoulder and elbow surgeons score,ASES）及美国加州大学洛杉矶分校（University of California at Los Angeles,UCLA）评分评估患者肩关节功能。并记录患者发生并发症的情况及影像学检查结果。术前行MR确定肩袖脂肪浸润程度,CT评价肩胛盂骨质情况及有无缺损,术后使用X线评估假体情况。 结果13例患者均随访至少12个月以上。统计术前与术后12个月数据之间的关系,术后12个月肩关节前屈、外展、外旋活动,ASES评分和UCLA评分较术前明显提高,差异具有统计学意义（P<0.01）。随访期内13例患者中有1例患者因局部血肿在术后1周行切开血肿清除引流术,所有患者功能恢复良好。 结论RTSA治疗巨大不可修复肩袖撕裂临床效果良好。     

Mid-term clinical outcome following rotator cuff repair using all-suture anchors

BackgroundSymptomatic rotator cuff tears can cause significant pain and functional disturbance, with associated financial ramifications. Non-surgical management should always be considered initially, however if recalcitrant to these measures surgical intervention may involve open, arthroscopic-assisted mini-open or arthroscopic rotator cuff repairs. The use of trans-osseous sutures and suture anchors has been reported with good results, with no significant differences if the repair remains intact or recurrent tears occur. The role of traditional suture anchors has been assessed clinically and biomechanically, however there have been reports of pull out, anchor material found within joint and concerns with the amount of bone loss. The all suture anchor (ASA) is proposed to address these concerns with encouraging cadaveric, biomechanical results to date.MethodsThe two senior authors performed 31 arthroscopic rotator cuff repairs using ASA with a double row technique at the two study centres’. The patients were reviewed in clinic at one month, three months, 6 months and a year postoperatively. The patients were assessed with the Constant score and clinical range of motion of the shoulder in abduction, forward flexion, external rotation and internal rotation. The surgical technique and rehabilitation was the same for both surgeons.ResultsAt a mean follow up of 10.2 months (range 3–12 months) the mean constant score was 77.1 (range 35–90), with a mean abduction of 139.6° (range 30–180°), external rotation of 43.4° (range 20–80°), and internal rotation to lumbar vertebrae 3–4 (range buttock to lumbar vertebra 1). There has been one re-rupture to date.ConclusionsThe functional and clinical results in our study are comparable to those reported in literature using standard anchors.     

The entire rotator cuff contributes to elevation of the arm

The function of the infraspinatus, teres minor, and subscapularis during elevation of the arm remains poorly defined. These muscles may generate moments that contribute to abduction of the arm, although they frequently are classified as humeral depressors. The purposes of this study were to measure the contributions to abduction made by the more inferiorly positioned rotator cuff muscles relative to the contributions of the supraspinatus and to determine the range of motion at which the muscles are most effective. Five fresh cadaveric shoulder girdles were mounted in an apparatus designed to simulate contraction of the deltoid and rotator cuff while maintaining the normal relationship between glenohumeral and scapulothoracic motions. The deltoid force required for elevation was measured without simulated contraction of the rotator cuff and with simulated contraction of the entire rotator cuff, of the supraspinatus only, and of the infraspinatus-teres minor and subscapularis only. A significant reduction in deltoid force when other muscle activity was added indicated that the additions contributed significantly to abduction. The deltoid force required with concurrent contraction of the entire rotator cuff averaged 41% less than with the deltoid alone but was not significantly different than with the deltoid and supraspinatus or with the deltoid, infraspinatus-teres minor, and subscapularis. Concurrent application of forces to the supraspinatus or the infraspinatusteres minro and subscapularis significantly reduced the required deltoid force over the range of motion studied by an average of 28 and 36%, respectively. The contributions of the rotator cuff muscles to abduction of the arm were greatest at low abduction angles (30 and 60°) and were insignificant by 120°. The infraspinatus-teres minor and subscapularis contribute significantly to abduction: their contibution was equal to that of the supraspinatus and, like the supraspinatus, they are most effective during the first 90° of abduction.     

Effect of reverse total shoulder arthroplasty humeral inclination on glenohumeral range of motion,deltoid force,and glenoid strain: a biomechanical study

BackgroundReverse total shoulder arthroplasty (RSA) primarily varies between 2 implant design options: a 135 humeral stem inclination that closely resembles anatomic orientation, versus the Grammont-style 155 humeral stem inclination that further medializes and distalizes the center of rotation (COR). The purpose of this study was to compare deltoid force, glenoid strain, and simulated glenohumeral range of motion (ROM) between RSA 135 and RSA 155 designs, with a series of standardized permutations of glenosphere offset and rotator cuff pathology.MethodsTwelve fresh-frozen cadaveric shoulder specimens were studied using a shoulder simulator. Native shoulder motion profiles for reproducible abduction range of motion were established using a customized testing device. Optical 3-dimensional tracking and pressure sensors were used to accurately record glenohumeral range of motion (ROM), deltoid force, and glenoid strain for RSA 135 and RSA 155 designs. For each cohort, all combinations of glenosphere offsets and rotator cuff tendon involvement were evaluated.ResultsThere was no significant difference in the overall abduction ROM between the 155 and the 135 humeral stem implants (P = .75). Resting abduction angle and maximum abduction angle were significantly greater with a 155 + STD (standard offset) construct than with a 135 + STD construct (P < .001 and P = .01, respectively). Both stem inclinations decreased combined deltoid force requirements as compared the native shoulder with a massive cuff tear. Effective glenoid strain did not vary significantly between 135 + STD and 155 + STD constructs (P = .66).ConclusionOverall, range of motion between the 135 and the 155 humeral stem inclinations was not significantly different. The cumulative deltoid force was lower in RSA shoulders when compared to native shoulders with massive rotator cuff tears, highlighting the utility of both implant designs. The Grammont-style 155 stem coupled with a 2.5 mm inferior offset glenosphere required less deltoid force to reach maximum abduction than did the more anatomic, lateralized 135 stem coupled with a 4 mm lateral offset glenosphere.Level of EvidenceBasic Science, Biomechanics Controlled Laboratory Study     

Editorial Commentary: Classic Arthroscopic Anterolateral Acromioplasty Does Not Translate to Clinically Meaningful Differences in Lateral Acromial Overcoverage

Despite its time-honored tradition, the classic Neer acromioplasty has come under increased scrutiny in the recent literature, particularly when performed in the absence of rotator cuff repair. The American Medical Association Current Procedural Terminology Committee has transitioned the acromioplasty procedure, and definition of the related Current Procedural Terminology code 29827, to a procedure that is “added-on” to shoulder arthroscopy. Several authors have sought to investigate the true value of arthroscopic subacromial decompression for extrinsic sources of impingement. Common indications for acromioplasty include bursal-sided tears, prominent type III hooked acromial morphology, calcified coracoacromial ligament, and severe rotator cuff tendinopathy. However, the classic arthroscopic acromioplasty may not meaningfully address lateral outlet impingement and acromial overcoverage, as measured by an elevated critical shoulder angle or acromial index, thereby leading to persistent abduction impingement and mechanical abrasion. In these cases, lateral acromial resection of up 5 to 10 mm may be preferentially considered to decrease the pathologic critical shoulder angle (>35°) and reduce the risk of primary or secondary rotator cuff tendon failure.     

A new test of resistance in the diagnosis of postero-superior rotator cuff tears

The aim of this study was to assess the diagnostic accuracy of a new clinical test for the diagnosis of subacromial impingement and full thickness postero-superior rotator cuff tears. One hundred and twenty patients who underwent arthroscopic treatment for acromioplasty or cuff repair were previously submitted to a new test of resistance. The test is performed in the standing position with the involved arm in 90° abduction, 20°–30° anteposition and in external rotation (as for full-can test). Thus, the patient was invited to follow the way of a spiral drawn on a drawing sheet for 20 turns; 1 turn = from the centre to the end of the spiral and vice versa (spiral width = 20 cm). The test was considered positive when the patient was not able to conclude it due to strength decrease or to shoulder pain. Sensitivity, specificity, positive and negative predictive values as well as diagnostic accuracy were calculated for our test of resistance. The test resulted scarcely reliable as detector of subacromial impingement and not very reliable as detector of small tear. When the test is positive there is a high probability that a subacromial disease exists; instead, when it is negative there is a high probability that the patient has not a large or massive cuff tear. The resistance test (Gum-Turn test) adds to our armamentarium of physical examination signs in patients with painful shoulder and furnishes further information on possible dimensions of tendinous tear.     

Surgical repair of chronic rotator cuff tears. A prospective long-term study

BACKGROUND: Rotator cuff disease or injury is one of the most frequently seen orthopaedic conditions, and surgical repair of rotator cuff tears is a common procedure. A prospective analysis of the operation, with consistent assessment of patient characteristics, variables associated with the rotator cuff tear and repair techniques, and outcome factors, was performed. METHODS: One hundred and five shoulders with a chronic rotator cuff tear underwent open surgical repair and acromioplasty between 1975 and 1983. The patients were followed for an average of 13.4 years (range, two to twenty-two years). There were sixteen small tears, forty medium tears, thirty-eight large tears, and eleven massive tears. The tears were repaired directly (seventy-two tears), by V-Y plasty (twelve), by tendon transposition (twenty), or by reinforcement with a fascia lata graft (one). The long head of the biceps had been previously torn in eleven shoulders and was tenodesed in three other shoulders. In fifty-six shoulders, the distal part of the clavicle was excised for treatment of degenerative arthritic changes, often associated with osteophyte formation. RESULTS: Satisfactory pain relief was obtained in ninety-six shoulders (p < 0.0001). There was significant improvement in active abduction (p < 0.001) and external rotation (p < 0.007) as well as in strength in these directions of movement (p < 0.03 and p < 0.002, respectively). At the latest follow-up evaluation, the result was rated as excellent for sixty-eight shoulders, satisfactory for sixteen, and unsatisfactory for twenty-one. Tear size was the most important determinant of outcome with regard to active motion, strength, rating of the result, patient satisfaction, and need for a reoperation. Older age, less preoperative active motion, preoperative weakness, distal clavicular excision, and a transposition repair technique were all associated with larger tear size. There were eight reoperations; five were for rerepair of a persistent or recurrent rotator cuff tear. CONCLUSIONS: Standard tendon repair techniques combined with anterior acromioplasty, postoperative limb protection, and monitored physiotherapy can produce consistent and lasting pain relief and improvement in range of motion. Improving the results of this procedure will depend upon the development of new techniques to address the active motion and strength deficiencies following repair of massive rotator cuff tears.     

What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?

Background

Few studies define the clinical signs to evaluate the integrity of teres minor in patients with massive rotator cuff tears. CT and MRI, with or without an arthrogram, can be limited by image quality, soft tissue density, motion artifact, and interobserver reliability. Additionally, the ill-defined junction between the infraspinatus and teres minor and the larger muscle-to-tendon ratio of the teres minor can contribute to error. Therefore, we wished to determine the validity of clinical testing for teres minor tears.

Question/Purposes

The aim of this study was to determine the accuracy of commonly used clinical signs (external rotation lag sign, drop sign, and the Patte test) for diagnosing the teres minor’s integrity.

Methods

We performed a prospective evaluation of patients referred to our shoulder clinic for massive rotator cuff tears determined by CT arthrograms. The posterosuperior rotator cuff was examined clinically and correlated with CT arthrograms. We assessed interobserver reliability for CT assessment and used three different clinical tests of teres minor function (the external rotation lag sign, drop sign, and the Patte test). One hundred patients with a mean age of 68 years were available for the analysis.

Results

The most accurate test for teres minor dysfunction was an external rotation lag sign greater than 40°, which had a sensitivity of 100% (95% CI, 80%–100%) and a specificity of 92% (95% CI, 84%–96%). External rotation lag signs greater than 10° had a sensitivity of 100% (95% CI, 80%–100%) and a specificity of 51% (95% CI, 40%–61%). The Patte sign had a sensitivity of 93% (95% CI, 70%–99%) and a specificity of 72% (95% CI, 61%–80%). The drop sign had a sensitivity of 87% (95% CI, 62%–96%) and a specificity of 88% (95% CI, 80%–93%). An external rotation lag sign greater than 40° was more specific than an external rotation lag sign greater than 10° (p < 0.001), and a Patte sign (p < 0.001), but was not more specific than the drop sign (p < 0.47). There was poor correlation between involvement of the teres minor and loss of active external rotation.

Conclusions

Clinical signs can predict anatomic patterns of teres minor dysfunction with good accuracy in patients with massive rotator cuff tears. This study showed that the most accurate test for teres minor dysfunction is an external rotation lag sign and that most patients’ posterior rotator cuff tears do not lose active external rotation. Because imaging is not always accurate, examination for integrity of the teres minor is important because it may be one of the most important variables affecting the outcome of reverse shoulder arthroplasty for massive rotator cuff tears, and the functional effects of tears in this muscle on day to day activities can be significant. Additionally, teres minor integrity affects the outcomes of tendon transfers, therefore knowledge of its condition is important in planning repairs.

Level of Evidence

Level III, diagnostic study.     

The derotation sign for perioperative diagnosis of significant partial-thickness rotator cuff tears

Purpose: To describe and evaluate a simple perioperative test (the derotation sign) that differentiates significant (grade 3) partial-thickness and small full-thickness rotator cuff tears from insignificant (grades 1 and 2) partial-thickness rotator cuff tears and intact rotator cuffs. Type of Study: Sensitivity and specificity study. Methods: A study was conducted of 123 patients who underwent shoulder arthroscopy for chronic symptomatic rotator cuff disease, each of whom was subjected to a derotation test under general anesthesia. Specifically, the glenohumeral joint was rapidly distended with fluid just before arthroscopy. One of 3 possible observations was made: (1) the arm rotated internally only, (2) the arm initially rotated internally and then externally rotated (positive derotation sign), or (3) the arm did not rotate at all. Arthroscopic findings were then correlated with the derotation test. Results: Forty-one shoulders had no arm rotation on derotation testing; all had rotator cuff tears greater than 2 cm in size. Forty-two shoulders with impingement and no rotator cuff tears, as well as 23 shoulders with grade 1 or grade 2 partial-thickness rotator cuff tears showed internal rotation only. Seventeen shoulders had a positive derotation sign; all of these had either a grade 3 partial-thickness or a small full-thickness (<1 cm) rotator cuff tear. Conclusions: The derotation test is useful in the perioperative differentiation of functionally intact rotator cuffs from those with significant tears. The derotation sign is specific for the diagnosis of grade 3 partial-thickness and/or small (<1 cm) full-thickness rotator cuff tears.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 3 (March), 2002: pp 284–286     

关节镜下"三角布钉"结合改良Mason-Allen技术治疗巨大"L"或"U"型肩袖损伤

目的评估在关节镜下"三角布钉"结合改良Mason-Aallen技术在临床中治疗巨大"L"或"U"型肩袖损伤的疗效。 方法回顾性分析2015年1月至2019年1月，西安交通大学附属红会医院收治的86例巨大"L"或"U"型肩袖损伤患者临床资料，其中男56例、女30例；年龄40 ~ 65岁，平均（52.5±2.5）岁。根据DeOrio和Cofield分型巨大肩袖损伤，且为"L"或"U"型。应用关节镜下"三角布钉"结合改良Mason-Allen技术治疗，记录肩关节活动度及并发症，手术前后采用Constant评分及视觉模拟评分（visual analogue scale,VAS）评价肩关节功能。 结果术前症状持续时间1 ~ 23个月，平均（6.2±2.5）个月；86例患者均获24 ~ 72个月随访，平均（29.3±4.5）个月；均无感染等并发症；术后12个月随访时超声检查，75例肩袖完整，8例部分损伤，3例出现全层撕裂后再次行关节镜手术治疗；末次随访肩关节活动度：前屈（170.7±3.5）°，外展（155.8±3.8）°，外旋（39.4±3.4）°，内旋（40.5±3.3）°；Constant评分由术前（31.2±1.2）分提高至术后（82.5±3.2）分（P<0.05）；VAS由术前（7.8±3.2）分减少至术后（1.3±0.5）分（P<0.05）。 结论关节镜下"三角布钉"结合改良Mason-Allen技术治疗巨大肩袖损伤有效，便于操作，可以减轻疼痛，改善肩关节功能，对于治疗巨大"L"或"U"型肩袖损伤是一种新的选择方法，值得临床推广。