Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study

ObjectiveTo evaluate the feasibility, safety, and symptomatic efficacy of intra-articular Hylan G-F 20 in patients with shoulder osteoarthritis and an intact rotator cuff.MethodsOpen-label, prospective, multicenter study in patients with pain scores on a visual analog scale (VAS) between 40/100 and 90/100. An intra-articular injection of 2 ml of Hylan G-F 20 was given under fluoroscopic guidance. A second injection was given after 1, 2, or 3 months in the event of inadequate pain relief. The primary evaluation criterion was the VAS pain score 3 months after the first injection. Follow-up was 6 months.ResultsOf 39 included patients, 33 received a first injection and, among these, 16 received a second injection; 29 patients completed the study. No serious or severe treatment-related adverse events were recorded. There were 10 mild or moderate adverse events in eight patients. The mean VAS pain score decreased from 61.2 mm at baseline to 37.1 mm after 3 months (P < 0.001), and the decrease was larger in the subgroup that required a single injection.ConclusionThis prospective study shows that treatment with one or two intra-articular injections of Hylan GF 20 in patients who have shoulder osteoarthritis and an intact cuff is feasible, safe, and probably effective. Viscosupplementation using Hylan G-F 20 may constitute a helpful treatment option in patients who have shoulder osteoarthritis with an intact rotator cuff.     

Outcome analysis following open rotator cuff repair. Early effectiveness validated using four different shoulder assessment scales

Evaluation of upper extremity function after reconstructive surgery is increasingly important both to predict outcome and for the control of cost-effectiveness. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients with rotator cuff deficiency and correlated to the Constant-Murley Shoulder Score and a visual analogue scale for satisfaction. Seven women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 ± 10.5 years, r/l: 14/9, follow-up 57.8 ± 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons (ASES) Shoulder Index, the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). Additionally, a visual analogue scale for satisfaction was employed. All four scores and the visual analogue scale revealed improvement at a statistically significant level (P < 0.01) after surgery. All questionnaires showed a significant correlation with the Constant-Murley Shoulder Score (ASES: r = 0.871, P < 0.01; DASH: r = –0.758, P < 0.01, SST: r = 0.494, P < 0.05, Pearson’s correlation coefficient). Taken together, all questionnaires were easy to apply, and reliable evaluation of shoulder function was possible with significant correlation to the Constant-Murley Shoulder Score postoperatively. The SST was easy to apply, and compound outcome analysis was possible with the ASES Shoulder Index and DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination, which is advantageous but restricts the application to the office. For postoperative assessment without the patient having to return to the clinic, the ASES Shoulder Index is preferred because of its good correlation to the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762). Received: 4 October 1999     

Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective,randomized trial

BACKGROUND: Although both corticosteroid and hyaluronic acid injections are widely used to palliate the symptoms of knee osteoarthritis, little research involving a comparison of the two interventions has been done. We tested the hypothesis that there are no significant differences between Hylan G-F 20 (Synvisc) and the corticosteroid betamethasone sodium phosphate-betamethasone acetate (Celestone Soluspan) in terms of pain relief or improvement in function, as determined by validated scoring instruments. METHODS: One hundred patients with knee osteoarthritis were randomized to receive intra-articular injection of either Hylan G-F 20 or the corticosteroid, and they were followed for six months. The patients treated with Hylan G-F 20 received one course of three weekly injections. The patients treated with the corticosteroid received one injection at the time of enrollment in the study, and they could request one more injection any time during the study. An independent, blinded evaluator assessed the patients with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), a modification of the Knee Society rating system, and the visual analog pain scale. RESULTS: Both the group treated with the corticosteroid and the group treated with Hylan G-F 20 demonstrated improvements from baseline WOMAC scores (a median decrease from 55 to 40 points and from 54 to 44 points, respectively; p < 0.01 for both). The scores according to the Knee Society system did not significantly improve for the patients who received the corticosteroid (median, 58 to 70 points; p = 0.06) or for those who received Hylan G-F 20 (median, 58 to 68 points; p = 0.15). The scores on the visual analog scale improved for patients receiving Hylan G-F 20 (median, 70 to 52 mm; p < 0.01) but not for the patients who received the corticosteroid (median, 64 to 52 mm; p = 0.28). However, no significant differences between the two treatment groups were found with respect to the WOMAC, Knee Society system, or visual analog scale results. Women demonstrated a significant improvement in only one of the six possible outcome-treatment combinations (the WOMAC scale), whereas men demonstrated significant improvements in five of the six outcomes (all measures except the Knee Society rating system). CONCLUSIONS: No differences were detected between patients treated with intra-articular injections of Hylan G-F 20 and those treated with the corticosteroid with respect to pain relief or function at six months of follow-up. Women demonstrated significantly less response to treatment than men did for both treatments on all three outcome scales. Such significant gender-related differences warrant further investigation.     

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.     

Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years’ follow-up

Purpose: The purpose of this study was to compare the outcomes of arthroscopic repair of medium and large rotator cuff tears with the outcomes for mini-open repair of similar tears in which arthroscopic repair was technically unsuccessful. Type of Study: Retrospective case series. Methods: We evaluated 76 patients who were treated for full-thickness rotator cuff tears either by all-arthroscopic (42 patients) or mini-open salvage of technically unsuccessful arthroscopic repair (34 patients). Patients who had acromioclavicular arthritis, subscapularis tear, or instability were excluded. There were 39 men and 37 women, with a mean age of 56 years (range, 42 to 75 years). At a mean follow-up of 39 months (range, 24 to 64 months), the results of both groups were compared using the University of California Los Angeles and American Shoulder and Elbow Surgeons shoulder rating scales. Results: Shoulder scores improved in all ratings in both groups (P < .05). Overall, 66 patients showed excellent or good and 10 patients showed fair or poor scores by the University of California Los Angeles scale. Seventy-two patients satisfactorily returned to previous activity, and 4 showed unsatisfactory returns. The range of motion, strength, and patient satisfaction were improved postoperatively. No differences were seen in shoulder scores, pain, and activity return between the arthroscopic and mini-open salvage groups (P > .05). However, patients with larger tears showed lower shoulder scores and less predictable recovery of strength and function (P < .05). Postoperative pain was not different with respect to the size of the tear (P = .251). Conclusions: Arthroscopic repair of medium and large full-thickness rotator cuff tears had an equal outcome to technically unsuccessful arthroscopic repairs, which were salvaged by conversion to a mini-open repair technique. Surgical outcome depended on the size of the tear, rather than the method of repair.     

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.     

Degenerated coracoacromial ligament in shoulders with rotator cuff tears shows higher elastic modulus: measurement with scanning acoustic microscopy

Purpose  The purpose of this study was to determine the elasticity of the coracoacromial ligament in shoulders with and without rotator cuff tears. Methods  The coracoacromial ligaments from 20 cadaveric shoulders (average patient age 79.5 years; 8 men, 12 women) were divided into six portions — three portions (acromial, central, and coracoid) in two layers (superficial and deep). A total of 120 samples were studied. First, the samples were classified by the collagen fiber orientation into three degeneration patterns: wavy, straight, irregular. For each pattern, the tissue sound speed, which shows a positive correlation with elasticity, was measured with scanning acoustic microscopy. Next, the samples were divided into three groups: 60 samples from shoulders with rotator cuff tears (RCT group), 30 samples from shoulders with an intact rotator cuff and a subacromial spur (spur group), and 30 samples from shoulders with an intact rotator cuff without a subacromial spur (control group). All shoulders with rotator cuff tears had subacromial spurs. The tissue sound speed and the histological findings were compared among the groups. Results  The sound speeds in the wavy, straight, and irregular patterns were 1592 ± 17.2 m/s (mean ± SD), 1626 ± 28.0 m/s, and 1607 ± 29.8 m/s, respectively (P < 0.0001). The sound speed in the straight pattern was higher than that in the wavy pattern (P < 0.0001), and that in the irregular pattern was lower than that in the straight pattern (P = 0.0023). The RCT group and the spur group had more straight patterns (P = 0.0002) and fewer wavy patterns (P < 0.0001) than did the control group. Significant differences in the sound speed were observed between the groups (P < 0.0001): 1596 ± 19.1 m/s in the control group, 1630 ± 31.5 m/s in the spur group, 1612 ± 28.6 m/s in the RCT group. Conclusions  The coracoacromial ligament in shoulders with rotator cuff tears shows higher elastic modulus than in age-matched normal shoulders due to degeneration of the ligament.     

肩袖撕裂合并冻结肩行手法松解后的关节镜下表现及影响因素分析

目的 观察肩袖撕裂合并冻结肩行手法松解后的关节镜下表现,并分析其影响因素。方法 回顾性分析2017年9月至2019年9月收治的68例肩袖撕裂合并冻结肩病人的病例资料,其中,男35例,女33例,年龄为（52.68±6.54）岁,均行一期麻醉后手法松解联合关节镜检查并肩袖修复术,观察手法松解后的关节镜下表现,比较松解损伤病人和未损伤病人之间的性别、患侧、肩袖撕裂程度差异,分析患肩关节疼痛时间、肩关节活动受限病程和实施手法松解时间与手法松解损伤的相关性。收集病人的数字分级法（numerical rating scale, NRS）疼痛评分、美国肩肘外科医师学会（American Shoulder and Elbow Surgeons, ASES）评分、Constant-Murley评分及丹麦健康与医疗管理局（Danish Health and Medicine Authority）满意度评分。结果 共16例（23.53%）发生手法松解损伤,其中单一损伤者12例,两种及以上损伤者4例,损伤类型为前关节囊撕裂（3例,18.75%）、下关节囊撕裂（6例,37.50%）、盂肱中韧带撕裂（7例,43.75%）、盂肱下韧带肱骨端撕裂（humeral avulsion of the glenohumeral ligament, HAGL）（3例,18.75%）、前盂唇撕裂（2例,12.50%）。松解损伤病人和未损伤病人之间的年龄（P=0.431）、性别（P=0.893）、患侧（P=0.673）、肩袖撕裂程度（P=0.723）、患肩关节疼痛时间（P=0.813）、肩关节活动受限病程（P=0.250）、实施手法松解时间（P=0.125）均未见显著差异。松解损伤组和松解无损伤组术后NRS评分均较术前明显降低,肩关节功能评分较术前明显改善（P均＜0.05）;手术前后的NRS评分、肩关节功能ASES评分、Constant-Murley评分、病人满意度评分比较,差异均无统计学意义（P均＞0.05）。结论 肩袖撕裂合并冻结肩行麻醉后肩关节手法松解联合关节镜下肩袖修复术可能导致单一或合并的镜下损伤表现,年龄、性别、患侧、肩袖撕裂程度、患肩关节疼痛时间、肩关节活动受限病程、实施手法松解时间等因素与发生手法松解损伤无明确相关性。     

The use of freeze-dried allografts in the management of global rotator cuff tears

Massive or global tears of the rotator cuff with loss of tendon substance and retracted cuff remnants pose a challenging surgical and rehabilitation problem. In seven patients, global cuff tears were reconstructed with freeze-dried rotator cuff allografts. Five of the seven patients had other significant debilitating medical problems. Three patients had received four steroid injections, one patient had six injections, and the remaining three patients had two injections in or about the affected shoulder. Five of the seven patients had their pain relieved. Only two patients had significant improvement in shoulder function after anterior acromioplasty and allografts. Freeze-dried rotator cuff allografts do not appear to be of significant value in the surgical management of chronic massive rotator cuff tears.     

Transtendon arthroscopic repair of high grade partial-thickness articular surface tears of the rotator cuff with biceps tendon augmentation: technical note and preliminary results

Introduction  

Partial articular surface of the rotator cuff tendon tears has been recognized as a source of treatable shoulder pain and a precursory pathology for full-thickness tendon tears. Arthroscopic rotator cuff repair is a possible surgical method of treatment. Recent data have shown that the treating partial-thickness rotator cuff repairs with transtendon technique shows good clinical outcome. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact bursal part. In cases of high grade partial articular-sided degenerative rotator cuff tears (involving >50% of the tendon) in older patients, there is a possibility of poor healing or re-tear of the rotator cuff repair, which may be associated with poor tendon quality and substantial thinning of the rotator cuff, subsequently revision surgery in these patients will be demanding.     

Short-term results after reversed shoulder arthroplasty (Delta III) in patients with rheumatoid arthritis and irreparable rotator cuff tear

The purpose of this study was to describe the outcome after reversed Delta III shoulder prosthesis in patients with rheumatoid arthritis (RA) and irreparable rotator cuff tear. Fifteen patients (17 joints) were prospectively analysed using the Constant-Murley score (CS). Comprehensive outcome measure was carried out by means of four widely used questionnaires as well as clinical and radiographic examinations at an average of 24.3 months postoperatively. The CS improved significantly from 19 to 59.5 points. The mental (MSC) and physical (PCS) component summary score of the Short Form 36 (SF-36) reached 108% and 77%, respectively, while the DASH (Disabilities of the Arm, Shoulder, and Hand) was 58% of a comparative norm population. Remaining deficits were documented by SPADI (Shoulder Pain and Disability; 54.4 points) and ASES (clinical and patient-orientated American Shoulder and Elbow Surgeons; 84.3 and 61.3 points, respectively). No radiological signs of loosening were found, but scapular notching occurred in four cases. Reversed arthroplasty provides a substantial improvement of shoulder function in patients with RA. The high incidence of notching is of concern.     

反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

目的探讨反式全肩关节置换术治疗盂肱关节骨关节炎合并巨大肩袖撕裂的近期临床疗效。 方法回顾性分析2016年1月至2018年12月在南部战区总医院接受初次反式全肩关节置换术治疗的15例盂肱关节骨关节炎合并巨大肩袖撕裂患者,均有肩关节持续性疼痛、功能障碍,且三角肌无损伤具有功能;排除有臂丛或腋神经损伤以及有肩关节手术史的患者。评估其术前、术后1年的肩关节主动活动度,使用美国肩肘外科协会(ASES)肩关节评分、加州大学洛杉矶分校(UCLA)最终结果评分评价肩关节功能,分析X线及CT并发症出现情况。采用配对t检验对术前及术后的活动度和评分差异进行性分析。 结果15例患者均顺利完成手术并获得随访,随访时间17个月(范围12～36个月)。反式全肩关节置换术后1年肩关节主动前屈(124±11)°较术前(58±18)°提高(t＝14.316,P<0.01),外展(120±12)°较术前(58±20)°提高(t＝9.959,P<0.01),内旋较术前改善,外旋(26±8)°较术前(25±9)°无明显变化(t＝1.598,P>0.05),术后1年ASES评分(78±7)显著高于术前(33±8)(t＝16.487,P<0.01);术后1年UCLA评分(31±4)显著高于术前(15±3)(t＝12.826,P<0.01)。 结论RTSA能够有效治疗盂肱关节骨关节炎合并巨大肩袖撕裂,取得了良好的早期临床效果,但术后肩关节外旋无明显改善,术前需评价小圆肌情况以确定相关治疗方案。     

Outcome assessment of hemiarthroplasty of the shoulder: A 5-year follow-up with 4 evaluation tools

Background?Outcome measurement of shoulder arthroplasty is not standardized. We compared 3 scores and 1 evaluation form.

Patients and methods We report on 35 hemiarthroplasties of the shoulder (32 cementless). Mean age of the patients was 62 (29–87) years. After a mean follow-up of 6 years (range 2–18 years) patients were evaluated with the Neer score, the Constant-Murley score, the score of the University of California in Los Angeles (UCLA) and the Society of Shoulder and Elbow Surgeons Basic Shoulder Evaluation Form. We also performed radiographic evaluation and sonographic evaluation of the rotator cuff.

Results?Although pain relief and patient satisfaction were promising, the overall results of the respective score showed low values (Neer score 56/100 points, Constant-Murley score 43/100 points, and UCLA score 19/35 points on average).

Interpretation?We recommend choice of a score with a high impact of pain and patient satisfaction. Furthermore, ability to cope with activities of daily living should be of more importance than strength.     

Compensatory Movement Patterns Are Based on Abnormal Activity of the Biceps Brachii and Posterior Deltoid Muscles in Patients with Symptomatic Rotator Cuff Tears

BackgroundAbnormal movement patterns due to compensatory mechanisms have been reported in patients with rotator cuff tears. The long head of the biceps tendon may especially be overactive and a source of pain and could induce abnormal muscle activation in these patients. It is still unknown why some patients with a rotator cuff tear develop complaints and others do not.Questions/purposes(1) Which shoulder muscles show a different activation pattern on electromyography (EMG) while performing the Functional Impairment Test-Hand and Neck/Shoulder/Arm (FIT-HaNSA) in patients with a symptomatic rotator cuff tear compared with age-matched controls with an intact rotator cuff? (2) Which shoulder muscles are coactivated on EMG while performing the FIT-HaNSA?MethodsThis comparative study included two groups of people aged 50 years and older: a group of patients with chronic symptomatic rotator cuff tears (confirmed by MRI or ultrasound with the exclusion of Patte stage 3 and massive rotator cuff tears) and a control group of volunteers without shoulder conditions. Starting January 2019, 12 patients with a chronic rotator cuff tear were consecutively recruited at the outpatient orthopaedic clinic. Eleven age-matched controls (randomly recruited by posters in the hospital) were included after assuring the absence of shoulder complaints and an intact rotator cuff on ultrasound imaging. The upper limb was examined using the FIT-HaNSA (score: 0 [worst] to 300 seconds [best]), shoulder-specific instruments, health-related quality of life, and EMG recordings of 10 shoulder girdle muscles while performing a tailored FIT-HaNSA.ResultsEMG (normalized root mean square amplitudes) revealed hyperactivity of the posterior deltoid and biceps brachii muscles during the upward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 111% ± 6% versus 102% ± 10%, mean difference -9 [95% confidence interval -17 to -1]; p = 0.03; biceps brachii: 118% ± 7% versus 111% ± 6%, mean difference -7 [95% CI -13 to 0]; p = 0.04), and there was decreased activity during the downward phase in patients with rotator cuff tears compared with controls (posterior deltoid: 89% ± 6% versus 98% ± 10%, mean difference 9 [95% CI 1 to 17]; p = 0.03; biceps brachii: 82% ± 7% versus 89% ± 6%, mean difference 7 [95% CI 0 to 14]; p = 0.03). The posterior deltoid functioned less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than in the control group.ConclusionPatients with a symptomatic rotator cuff tear show compensatory movement patterns based on abnormal activity of the biceps brachii and posterior deltoid muscles when compared with age-matched controls. The posterior deltoid functions less in conjunction with the other deltoid muscles, and lower coactivation was seen in the remaining intact rotator cuff muscles in the rotator cuff tear group than the control group.Clinical RelevanceThis study supports the potential benefit of addressing the long head biceps tendon in the treatment of patients with a symptomatic rotator cuff tear. Moreover, clinicians might use these findings for conservative treatment; the posterior deltoid can be specifically trained to help compensate for the deficient rotator cuff.     

Outcomeanalyse nach offener Rekonstruktion von Rotatorenmanschettenrupturen Eine vergleichende Beurteilung neuer Bewertungsverfahren

Outcome evaluation is becoming increasingly important for reconstructive surgery in musculoskeletal diseases. In addition to established shoulder-scores, new outcome-scores are being developed to cover all effects caused by a disease or intervention. Three validated, self-administered shoulder questionnaires were applied prospectively in 23 otherwise healthy patients suffering from rotator cuff deficiency. These were correlated to the Constant-Murley Shoulder Score and to a visual analogue scale for satisfaction. 7 women and 16 men with combined tears of supraspinatus and infraspinatus (mean age 55.3 +/- 10.5, r/l: 14/9, FU 57.8 +/- 15.7 weeks) were gathered prospectively and evaluated pre- and postoperatively with the American Shoulder and Elbow Surgeons Shoulder Index (ASES), the Simple Shoulder Test (SST) and the Disabilities of the Arm, Shoulder and Hand Module (DASH questionnaire). In addition, a visual analogue scale for satisfaction was employed. All four scores as well as the visual analogue scale revealed improvement at a statistically significant level (paired, two-tailed t-test, P < 0.01) after surgery. All questionnaires had a significant correlation with the Constant-Murley Shoulder Score (Pearson's correlation coefficient: ASES: r = 0.871, P < 0.01; DASH: r = -0.758, P = < 0.01; SST: r = 0.494, P < 0.05). All were easy to apply and provided a reliable, postoperative evaluation of shoulder function. The SST was easy to apply, however compound outcome analysis was only possible with the ASES Shoulder Index and the DASH questionnaire. The DASH scale was the most complex evaluation instrument. The Constant-Murley Shoulder Score comprises a physical examination which is advantageous but must be carried out in the clinic. For postoperative assessment, without the patient having to return to the clinic, the ASES Shoulder Index is preferred as it correlates well with the Constant-Murley Shoulder Score (r = 0.871) and the visual analogue scale for satisfaction (r = 0.762).     

Arthroscopic subacromial decompression: Two- to seven-year follow-up

Arthroscopic subacromial decompression (ASD) was performed in 88 patients (90 shoulders) with stage II or early III impingement syndrome of the shoulder unresponsive to nonoperative treatment. The purpose of this retrospective study was to evaluate the follow-up an average of 41 months (range 24 to 82 months) after surgery. We wished to compare results in (1) patients with and without rotator cuff tears, (2) in athletes and nonathletes, and (3) in throwers and nonthrowers. Patients were evaluated by (1) Neer's Criteria for Satisfactory Result, (2) the UCLA Shoulder RAting Scale, (3) the Shoulder and Elbow Surgeons Rating Scale, (4) a detailed questionnaire, and (5) patient satisfaction. In the follow-up group (n = 90), 80% met Neer's criteria for satisfactory result; 94% had satisfactory results by the UCLA Shoulder Scale; 95% had a satisfactory result by the Shoulder and Elbow Society Scale; and 93% of shoulder patients expressed satisfaction at follow-up. There were no statistically significant differences in function between the group without rotator cuff tear (n = 47) and the group with rotator cuff tear (n = 43). Satisfactory results were obtained in 68% of throwing athletes and in 90% of nonthrowing athletes (P < .05) by the Neer Rating, whereas only 50% of competitive baseball and softball pitchers had satisfactory results. Out impression is that ASD is an acceptable alternative to open anterior acromioplasty with comparable results for the treatment of the impingement lesion. There were no differences in result in patients who had a partial rotator cuff tear and those who had no tear. Throwing athletes do not have as good a prognosis to maintain high-caliber painfree shoulder activities as do nonthrowing athletes.     

The time of postoperative corticosteroid injection can be individualized after arthroscopic rotator cuff repair

BackgroundIntra-articular corticosteroid injection is an effective treatment for pain and to improve the range of motion (ROM) of the shoulder joint. However, consideration of when it would be effective to inject corticosteroids after rotator cuff repair is more limited. The purpose of this study was to compare the outcomes of corticosteroids injection given at 4 and 8 weeks after arthroscopic rotator cuff repair.MethodsBetween December 2016 and January 2018, 42 patients who underwent arthroscopic supraspinatus tendon repair were enrolled. Nineteen patients received 40 mg of triamcinolone injection 4 weeks after surgery (group 1), while 23 patients received the same injection 8 weeks after surgery (group 2). Clinical outcome was evaluated using ROM, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Korean Shoulder score, and a visual analog scale (VAS) score before surgery and at 3, 6, and 12 months after surgery. Tendon integrity was assessed with magnetic resonance imaging (MRI) and sonography at 12 months after surgery.ResultsSignificant improvements in pain and functional scores were observed at the last follow-up in both groups (p < 0.05). There was no significant difference in VAS pain score between the two groups at any time point after surgery (p > 0.05). Functional scores and ROM in all directions also showed no statistical difference between the two groups (p > 0.05). Retears of the repaired tendon, assessed at 12 months postoperatively, were observed in two patients from group 1 (10.5%) and two patients from group 2 (8.7%), thus indicating no significant difference between the two groups (p > 0.05).ConclusionSince there was no significant difference in clinical outcomes and tendon integrity, postoperative corticosteroid injection can be individualized according to the patient for 4–8 weeks after the rotator cuff repair.     

Rotator cuff tears after total shoulder arthroplasty in primary osteoarthritis: A systematic review

Rotator cuff tears have been reported to be uncommon following total shoulder arthroplasty (TSA). Postoperative rotator cuff tears can lead to pain, proximal humeral migration, and glenoid component loosening. The purpose of this paper was to evaluate the incidence of post-TSA rotator cuff tears or dysfunction in osteoarthritic patients. A systematic review of multiple databases was performed using preferred reporting items for systematic reviews and meta-analyses guidelines. Levels I-IV evidence clinical studies of patients with primary osteoarthritis with a minimum 2-year follow-up were included. Fifteen studies with 1259 patients (1338 shoulders) were selected. Student''s t-tests were used with a significant alpha value of 0.05. All patients demonstrated significant improvements in motion and validated clinical outcome scores (P < 0.001). Radiographic humeral head migration was the most commonly reported data point for extrapolation of rotator cuff integrity. After 6.6 ± 3.1 years, 29.9 ± 20.7% of shoulders demonstrated superior humeral head migration and 17.9 ± 14.3% migrated a distance more than 25% of the head. This was associated with an 11.3 ± 7.9% incidence of postoperative superior cuff tears. The incidence of radiographic anterior humeral head migration was 11.9 ± 15.9%, corresponding to a 3.0 ± 13.6% rate of subscapularis tears. We found an overall 1.2 ± 4.5% rate of reoperation for cuff injury. Nearly all studies reported indirect markers of rotator cuff dysfunction, such as radiographic humeral head migration and clinical exam findings. This systematic review suggests that rotator cuff dysfunction following TSA may be more common than previously reported. IV, systematic review of Levels I-IV studies.     

Does Preoperative Conservative Management Affect the Success of Arthroscopic Repair of Partial Rotator Cuff Tear?

BackgroundThe aim of this study is to examine the effect of preoperative conservative treatment on the success of high-grade bursal/articular-sided partial rotator cuff repair.MethodsPatients who had undergone shoulder arthroscopy in institution for Ellman Stage 3 bursal-side or articular-side partial tears between January 2008 and April 2018 were investigated retrospectively. This study assessed 201 patients diagnosed with isolated partial rotator cuff tears with a history of failed conservative management and persistent shoulder pain who underwent arthroscopic surgery. The demographic data of patients and pre- and postoperative The American Shoulder and Elbow Surgeons Shoulder Scores (ASES) that were recorded in the archive were evaluated.ResultsWhile 55 of the patients with Ellman grade 3 bursal-sided partial tears received preoperative conservative management for at least 6 months (Group 1), 62 of them could not tolerate conservative management and early arthroscopic repair was performed (Group 2). On the other hand, 42 of the patients with Ellman grade 3 articular-sided tears received preoperative conservative management (Group 3), 42 of them could not tolerate preoperative conservative management (Group 4). The mean ASES score improvement was 52.33 ± 8.55 for Group 1, 54.68 ± 11.29 for Group 2, 48.4 ± 7.77 for Group 3 and 49.33 ± 10.05 for Group 4. A statistically significant difference was found between the groups with one-way ANOVA test (p = 0.05). With the Tukey test, this difference was seen to be caused by Group 2.ConclusionAlthough there are many factors affecting its success, conservative management should be the first option in the treatment of partial rotator cuff tears. However, we think that it should not be insisted especially in patients with bursal-sided tears (> 50% of the tendon thickness) that cannot tolerate conservative management due to severe pain since the results of early arthroscopic repair of bursal-sided tears were found to be better.Level of EvidenceRetrospective comparative study, Level III.     

Treatment of massive irreparable rotator cuff tears using dermal allograft bridging reconstruction

AimsVarious options are available for treating massive irreparable rotator cuff tears, but all have their own limitations and no gold standard currently exists. Our aim was to report on outcomes of bridging repair with a dermal allograft for symptomatic massive irreparable rotator cuff tears where primary or partial repair was not possible.Patients and methodsWe prospectively reviewed 22 patients who underwent an open interposition bridging repair with an allograft (GraftJacket) sutured medially to the residual rotator cuff stump and laterally to the footprint with suture anchors. Mean age at time of surgery was 59 years (range 53–66 years). The Oxford Shoulder Score, pain visual analogue scale and range of motion were compared pre-operatively and at mean follow up of 2.8 years. All patients had a postoperative MRI scan.ResultsThere was a significant improvement in mean Oxford Shoulder Score from a pre-operative score of 14.2–34.3 points (p < 0.01) at final follow up. Pain VAS score improved from 6.6 points to 2.8 points (p < 0.05). Significant improvements in range of motion were also seen. Postoperative MRI scans showed a retear in 8 patients (36%), but the retear size was smaller and an improvement in outcomes maintained at final follow up.ConclusionOpen dermal allograft bridging repair for massive irreparable rotator cuff tears can lead to satisfactory outcomes and delay the need for a reverse shoulder arthroplasty.