Ruptures traumatiques de la coiffe des rotateurs chez le rugbyman

Rotator cuff tears are one of the shoulder lesions that can occur during modern Rugby. They are present in 3–10% of the traumatic lesions of the shoulder in this population and is this figure is expected to continue increasing because of the growth in popularity of the sport and the intensity of the game. The physician should be aware of the clinical signs in order to guide the correct imagery for this type of lesion to be correctly identified. The study of 29 rotator cuff tears in professional Rugby players from the French Rugby championships from 1996 to 2006 allowed us to clarify the epidemiology of these lesions and to specify the therapeutic indications. The surgical treatment, especially arthroscopic repair, proved to be efficient for the partial and full-thickness tears. Eighty-three percent of the patients were able to play Rugby at their presymptomatic competitive level with a delay of 5.5 months with a strictly normal clinical exam in more of 75% of the cases.     

Indikation und Ergebnisse debridierender Eingriffe bei irreparabler Ruptur

Arthroscopic debridement of irreparable rotator cuff tears represents a salvage procedure. It is crucial to accurately diagnose the patient according to the criteria for irreparable rotator cuff tears. The diagnosis and the therapeutic options must be explained to the patient. It is mandatory that the patient understands his condition and the primary goal of the arthroscopic debridement, which is the reduction of pain. The procedure consists of 7 distinct maneuvers to debride the soft tissues of the glenohumeral joint. There is a lack of evidence from scientific studies that this procedure is better than other therapeutic options. However, if the main complaint of the patient is pain, it has been shown that the procedure is able to significantly reduce the painful condition. The “excellent” results reported in some studies should, however, be interpreted with caution taking into consideration the substantial structural damage in irreparable defects.     

A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair

PurposeArthroscopic rotator cuff repair is often associated with severe postoperative pain. Various agents, routes, and modes are used for the treatment of postoperative pain with a minimum of side effects. This systematic work was conducted to compare the postoperative effect of subacromial patient-controlled analgesia with intravenous patient-controlled analgesia after an arthroscopic rotator cuff repair surgery.DesignA systematic review of relevant studies were retrieved from electronic databases and included based on criteria and eligibility.MethodsThe articles were retrieved from 1997 to 2018 by computerized searches of Scopus, PubMed, and EMBASE using different combinations of search terms, such as shoulder, rotator cuff, analgesic, analgesia, arthroscopic, pain, cuff repair, rotator cuff repair, acromion, and intravenous.FindingsA total of 10 articles were included in this study from the initial search of 778 records. Compared with subacromial procedure, the intravenous procedure helps in reducing the postoperative pain but with more side effects.ConclusionsThis study described that the direct continuous infusion of anesthetic under subacromial analgesic pump showed a greater pain relief with less side effects compared with intravenous infusion for arthroscopic rotator cuff repair.     

关节镜肩袖修补后早期功能锻炼的Meta分析

背景：目前关节镜肩袖修补后延期功能锻炼是否能提高肌腱的愈合率尚不清楚。关于肩袖修补后的功能锻炼时机仍无定论,且无相关系统评价发表。 目的：系统评价关节镜肩袖修补后早期与延期功能锻炼的疗效差异。 方法：检索Pubmed, EMBASE,Cochrane对照实验中心注册数据库,以及中国生物医学文献数据库、万方数据库、清华同方数据库、重庆维普数据库。英文检索词为“arthroscopy,rotator cuff,rehabilitation”,中文检索词为“肩关节镜,肩袖,康复”。对入选文献的参考文献进行二次检索。检索截止日期为2012-08-15。要求纳入文献均为关节镜肩袖修补后早期与延期功能锻炼的随机对照研究,进行方法学质量评价、筛选和异质性检验,采用REVMAN5.1软件对提取的数据进行分析。 结果与结论：共纳入3个随机对照试验,共包括237例患者,119例为早期活动组,118例为延期活动组。分析显示2组在术后1年随访时关节活动度、疼痛程度、美国肩肘外科医生评分、简明肩关节功能测试评分、肩袖再撕裂率差异均无显著性意义。提示与延期功能锻炼相比,关节镜肩袖修补后早期功能锻炼在关节功能及活动度的改善方面并无优势,但也不增加修补肩袖的再撕裂率。肩袖修补后康复方案可根据患者的实际情况进行制定。     

Shoulder disorders—Part 2: Examination

Thorough evaluation of patients with shoulder problems should classify patients into discreet diagnostic groups—red flags, impingement syndrome, adhesive capsulitis, shoulder instability. Most rotator cuff tendonitis patients fall into the impingement category. The most important aspect of the initial evaluation is to rule out red flags suggestive of tumor, infection or fracture. If present such patients always require additional testing and often referral.A patient will be classified into the impingement category if there is (a) pain with active shoulder motions (i.e., painful arc), (b) pain with overpressure of passive shoulder elevation (i.e., a positive Neer's test) or horizontal shoulder adduction/internal rotation (Hawkins test), and (c) painfully weak resisted shoulder motions. Impingement syndrome patients should also be evaluated for partial or full-thickness rotator cuff tears, especially if the response to 4–6 weeks of rehabilitation is unsatisfactory.Patients with adhesive capsulitis have severe ROM loss. The most restricted ROMs are with shoulder abduction, external rotation, and flexion. In contrast, patients with shoulder instability are hypermobile. A history of recurrent dislocations is often present. An apprehension sign may be present. SLAP II-IV lesions are common in this patient group and the labrum can be seen to be stretched anterior during many of the functional tests.     

Chronic shoulder pain: part I. Evaluation and diagnosis

Shoulder pain is defined as chronic when it has been present for longer than six months. Common conditions that can result in chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, shoulder instability, and shoulder arthritis. Rotator cuff disorders include tendinopathy, partial tears, and complete tears. A clinical decision rule that is helpful in the diagnosis of rotator cuff tears includes pain with overhead activity, weakness on empty can and external rotation tests, and a positive impingement sign. Adhesive capsulitis can be associated with diabetes and thyroid disorders. Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination. Acromioclavicular osteoarthritis presents with superior shoulder pain, acromioclavicular joint tenderness, and a painful cross-body adduction test. In patients who are older than 50 years, glenohumeral osteoarthritis usually presents as gradual pain and loss of motion. In patients younger than 40 years, glenohumeral instability generally presents with a history of dislocation or subluxation events. Positive apprehension and relocation are consistent with the diagnosis. Imaging studies, indicated when diagnosis remains unclear or management would be altered, include plain radiographs, magnetic resonance imaging, ultrasonography, and computed tomography scans. Plain radiographs may help diagnose massive rotator cuff tears, shoulder instability, and shoulder arthritis. Magnetic resonance imaging and ultrasonography are preferred for rotator cuff disorders. For shoulder instability, magnetic resonance imaging arthrogram is preferred over magnetic resonance imaging.     

人工肱骨头置换中使用胸骨针行肱骨近端骨折肩袖重建

背景：越来越多的粉碎、移位严重而无法重建的肱骨近端骨折患者需要行人工肱骨头置换,但此类患者肩袖的重建直接影响治疗效果,置换过程中往往需要良好的肩袖重建。目的：探讨胸骨针在肱骨近端骨折人工肱骨头置换肩袖重建中的应用体会。方法：34例肱骨近端四部分骨折患者行人工肱骨头置换时使用胸骨针修复肩袖,年龄67—78岁。人工肱骨头置换时未过分剥离骨折块与肩袖组织,保留肩袖组织与骨块相连,将胸骨针沿着肩袖大小结节表面肌腱一骨结合部环形缝合备用,可用多根,假体置入后,将肱骨大、小结节及碎骨块解剖复位,收紧胸骨针,大小结节及肩袖附着的碎骨块均原位贴在人工肱骨头下方。术中应尽可能将残余的肩袖和肌肉组织损伤进行缝合修复,并要注意缝合后的动力平衡。采用Neer标准对人工肩关节功能的恢复情况进行评价。结果与结论：34例患者均获随访,随访时间1-3年,24例优,10例良,2例可;无关节脱位、半脱位等关节不稳情况,未见感染、神经损伤及假体松动病例。提示人工肱骨头置换过程中使用胸骨针进行肩袖修复及大小结节固定能使肩袖和大小结节接近解剖位置,并且比常规的涤纶线强度高,固定牢靠,能满足人工肱骨头置换后康复训练的需要,对肩关节的稳定性及功能恢复有重要作用。     

Rotator cuff pathology and subacromial impingement

Musculoskeletal complaints are one of the most common reasons for primary care office visits, and rotator cuff disorders are the most common source of shoulder pain. Subacromial impingement with subsequent tendinitis and bursitis is frequently found in young adult patients. Rotator cuff tears are a common cause of shoulder pain in patients over age 40. The majority of subacromial impingement and incomplete rotator cuff tears may be successfully managed with conservative treatment. This article discusses anatomic function of the glenohumeral joint and subacromial space, etiology of subacromial impingement and rotator cuff disorders, examination of the shoulder, diagnostic testing, and treatment of subacromial impingement and rotator cuff disorders in the primary care setting.     

Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia

Effective management of chronic pain has become an increasingly critical issue in health care. Opioid agonists are among the most effective analgesics available for reducing pain perception; however, their chronic use is controversial. This is primarily due to regulatory barriers, misunderstandings about pain management among primary caregivers, fear of adverse side effects, and misconceptions about the potential risks of addiction. Short-acting opioids provide effective analgesia for acute pain but should be avoided as primary analgesics for chronic pain management. Long-acting opioids have greater utility than short-acting opioids in treating chronic pain in patients with consistent pain levels. Results of studies show that improved quality of life is directly related to the use of long-acting opioids in patients with chronic pain of both cancer and noncancer etiology. Short-acting opioids may be used during the initial dose titration period of long-acting formulations and as rescue medication for episodes of breakthrough pain. Clinical experience reveals that selection of an effective pain regimen for the patient with chronic pain, combined with aggressive management of side effects, leads to improved overall functioning and quality of life.     

Effect of sternoclavicular joint mobilization on pain and function in a patient with massive supraspinatus tear

Massive irreparable rotator cuff tears can be difficult to treat conservatively, especially when the patient has multiple comorbidities. Although there is evidence to support interventions aimed at the spine, there is paucity in the literature describing interventions to the sternoclavicular joint (SCJ) in individuals with rotator cuff pathology. A 57-year-old female with multiple comorbidities and a body mass index of 59 was referred to physical therapy with a 4-month history of right shoulder pain, significant functional limitations, and magnetic resonance imaging (MRI), demonstrating a full-thickness supraspinatus tear. She presented initially with active shoulder flexion range of motion (ROM) 0–80°, numeric pain rating scale (NPRS) 7/10, and QuickDASH 65.9%. After six physical therapy sessions, the patient had plateaued with improvements in pain and ROM. SCJ mobilizations at visit 7 immediately improved pain, active ROM, and subjective reports of function. The patient was discharged after 13 visits with increased active shoulder flexion ROM to 0–170°, NPRS 1/10, QuickDASH 31.8%, and Global Rating of Change (GROC) +5. This case highlights the successful conservative treatment of an individual with an irreparable rotator cuff tear and numerous comorbidities by using a multimodal approach including SCJ mobilizations.     

Strategien in der arthroskopischen Behandlung von Massenrupturen der Rotatorenmanschette

Shoulder arthroscopy offers several advantages for the treatment of massive rotator cuff tears as it enables exact identification of the geometry of the tendon rupture and thereby allows anatomical reconstruction. This article emphasizes 10 important steps in the arthroscopic treatment of massive rotator cuff tears. We pursue the strategy that every effort should be made to reconstruct, as far as feasible, in symptomatic and functionally demanding patients. Even in case of partial repair, significant improvements in pain relief and function are well documented. Fatty infiltration and tendon atrophy affect the decision-making and the results of reconstructive procedures but the significance seems to depend on the particular rotator cuff tendon affected. The primary goal in massive rotator cuff reconstruction is to repair the balance between the transversal forces of the subscapularis and the infraspinatus. Rehabilitation is time-consuming and rerupture rates are higher than in single tendon injuries, therefore, particular attention must be paid to a carefully explained informed consent.     

Comparison of scapular upward rotation during arm elevation in the scapular plane in healthy volunteers and patients with rotator cuff tears pre- and post-surgery

BackgroundFunction loss caused by rotator cuff tears alters the scapular orientation, however, few prior studies have reported on scapular movements after rotator cuff repair. The purpose was to determine the scapular orientations before and after rotator cuff repair.MethodsWe recruited 14 healthy controls, 10 small and six massive rotator cuff tear in patients. The scapular upward rotation during arm elevation was analyzed using fluoroscopic imaging.FindingsBefore surgery, both rotator cuff groups demonstrated greater scapular upward rotation compared to healthy controls. Two months postoperation, the analyses showed significant differences between the patients with small rotator cuff tears and healthy controls at arm elevations of 90°, and between patients with both rotator cuff tear groups and healthy controls at arm elevations of 120°. At five months post-operation, significant differences still existed between the healthy controls and both rotator cuff groups. In regard to the temporal effects in the patients with small rotator cuff tears, the scapular upward rotation decreased significantly over time (2–5 months postoperation) at arm elevations of 120°. We did not identify a main effect owing to time in the patients with massive rotator cuff tears.InterpretationIn patients with small rotator cuff tears, scapular upward rotation was reduced over the period of 2–5 months postoperation, however, the patients with massive rotator cuff tears showed greater scapular upward rotation throughout the experimental period. The results suggested that the execution of the rehabilitation program should consider that the tear size could affect scapular motion.     

The role of subacromial shoulder irrigation in the treatment of calcific rotator cuff tendinosis: a case series

OBJECTIVE: To study the efficacy of subacromial shoulder irrigation in the treatment of calcific rotator cuff tendinosis. DESIGN: Consecutive case series. SETTING: Musculoskeletal rehabilitation clinic. PARTICIPANTS: Twenty-eight tennis players (16 women, 12 men; mean age, 44.3y) with calcific rotator cuff tendinosis, who failed conservative measures. INTERVENTION: Subjects underwent fluoroscopically guided subacromial shoulder irrigation (50-75 mL of normal saline in 10 mL aliquots) followed by a corticosteroid injection (5 mL solution of 1 mL triamcinolone [40 mg/mL] and 4 mL of 0.5% bupivacaine). After the procedure, all patients completed the same exercise regimen. MAIN OUTCOME MEASURES: LInsalata Shoulder Rating Questionnaire (LSRQ) score, visual numeric pain score, and patient satisfaction. RESULTS: At 1-year follow-up, 85.7% reported a successful outcome with significant improvements in the LSQR and numeric pain scores. CONCLUSIONS: Our minimally invasive approach was safe, well tolerated, and effective, which should make it useful in providing relief for patients with rotator cuff tendinosis.     

Medikamentöse Therapie bei Rückenschmerzen

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.     

Adhesive capsulitis: a review

Adhesive capsulitis is a common, yet poorly understood, condition causing pain and loss of range of motion in the shoulder. It can occur in isolation or concomitantly with other shoulder conditions (e.g., rotator cuff tendinopathy, bursitis) or diabetes mellitus. It is often self-limited, but can persist for years and may never fully resolve. The diagnosis is usually clinical, although imaging can help rule out other conditions. The differential diagnosis includes acromioclavicular arthropathy, autoimmune disease (e.g., systemic lupus erythematosus, rheumatoid arthritis), biceps tendinopathy, glenohumeral osteoarthritis, neoplasm, rotator cuff tendinopathy or tear (with or without impingement), and subacromial and subdeltoid bursitis. Several treatment options are commonly used, but few have high-level evidence to support them. Because the condition is often self-limited, observation and reassurance may be considered; however, this may not be acceptable to many patients because of the painful and debilitating nature of the condition. Nonsurgical treatments include analgesics (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs), oral prednisone, and intra-articular corticosteroid injections. Home exercise regimens and physical therapy are often prescribed. Surgical treatments include manipulation of the joint under anesthesia and capsular release.     

Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study

Background and purpose. Arthroscopic repair of rotator cuff tears can produce excellent results. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe, and produces results which do not deteriorate over time.

Methods. A total of 14 patients undergoing arthroscopic repair of a rotator cuff tear received an intra-operative application of autologous platelet rich plasma in combination with an autologous thrombin component after tear repair. Following the procedure, patients were given a standardized rehabilitation protocol, and followed for 24 months. Outcome measures included a pain score (VAS) as well as functional scoring (UCLA and Constant scores).

Results. Of the original 14 patients, 13 were seen at a final follow-up appointment 24 months after the index operation. Patients demonstrated a significant decrease in VAS scores and significant increases in the UCLA and Constant scores at 6, 12 and 24-month follow-ups compared to a pre-operative score.

Conclusion. No adverse events related to this application were noted during the procedure. The application of platelet rich plasma during arthroscopic rotator cuff repair is safe and effective, and produces results which seem to be stable with time. A prospective randomized investigation will be necessary to ascertain the efficacy of platelet rich plasma application to improve or expedite the surgical outcome following arthroscopic rotator cuff repair.     

Effects of a structured educational programme on patient‐controlled analgesia (PCA) for gynaecological patients in South Korea

Aims and objectives. The purpose of the study was to evaluate the effects of a structured educational programme on the patient‐controlled analgesia device in terms of postoperative pain, dose of analgesics used, adverse reactions, patient knowledge and attitudes of patient‐controlled analgesia and patient satisfaction with postoperative pain management among gynaecological patients in South Korea. Background. Patient‐controlled intravenous analgesia has become the most common method to manage postoperative pain. Although the patient‐controlled analgesia device can be very effective in managing pain, patients using external pump delivery have several problems because of their lack of knowledge of patient‐controlled analgesia. To minimise these problems, nursing interventions that may decrease the number of problems should be developed and adopted into clinical practice. Design. A non‐equivalent control group, non‐synchronised design. Methods. The participants were 79 patients who had gynaecological surgery under general anaesthesia. Of the 79 patients, 39 were assigned to the experimental group and 40 to the control group. A day before surgery, 40 minutes of structured education on the patient‐controlled analgesia device was provided individually to the patients in the experimental group using both a CD‐ROM and brochure. Results. Pain level and adverse reactions were significantly lower in the experimental group than in the control group. Furthermore, the analgesic dose administered and the level of patient satisfaction with postoperative pain management increased significantly in the experimental group compared with the control group. Conclusion. A structured educational programme on the patient‐controlled analgesia can be an effective nursing intervention for pain management in gynaecological patients. Relevance to clinical practice. Nurses caring for the patients who are using the patient‐controlled analgesia should provide a structured educational programme to increase knowledge of pain management with patient‐controlled analgesia, patient satisfaction with pain management, as well as more effective management of the pain and adverse reaction caused by patient‐controlled analgesia.     

Ketamine for pain relief in acute pancreatitis

Patients with acute pancreatitis are often admitted to critical care unit and present with a spectrum of multiorgan problems. The commonest presenting symptom of acute pancreatitis is upper abdominal pain. The pain can be very severe and refractory to the treatment with conventional analgesics. The pain not only adds to the patient's distress but may also have adverse effects on the cardio-respiratory systems, which can be affected by acute pancreatitis itself. The pain in acute pancreatits is usually controlled by conventional analgesics, morphine/pethidine PCA or epidural analgesia. But at times all these measures of pain control fail and additional methods of pain relief become necessary. We encountered a patient with acute pancreatits with severe abdominal pain in whom conventional methods of pain relief failed to provide adequate analgesia. The patient had respiratory impairment secondary to upper abdominal pain and improved pain relief avoided the possible need for invasive ventilation. We used an intravenous ketamine infusion to supplement the analgesic regimen with a significant improvement in pain relief without any adverse psycho mimetic effects. The probable mechanisms of action of ketamine in improving pain relief are discussed. On search of the literature, the use of ketamine for pain relief in acute pancreatitis has never been reported.     

Oxycodone accumulation in a hemodialysis patient

Oxycodone and oxycodone-containing analgesics are often used for the relief of pain. In the presence of renal dysfunction, the half-life of oxycodone and metabolites can be prolonged. We describe the case of a 41-year-old chronic hemodialysis patient who received multiple doses of oxycodone/acetaminophen resulting in accumulation of the medication and consequent lethargy, hypotension and respiratory depression. These adverse effects were reversed with multiple bolus doses of naloxone, followed by a continuous infusion administered for 45 hours. Utilizing the Naranjo probability scale, the patient had a "probable" adverse drug reaction to the oxycodone. Oxycodone should be used with caution in patients with chronic renal failure.