Acromiohumeral Distance Research Articles

Deep learning algorithm for predicting subacromial motion trajectory: Dynamic shoulder ultrasound analysis

Subacromial motion metrics can be extracted from dynamic shoulder ultrasonography, which is useful for identifying abnormal motion patterns in painful shoulders. However, frame-by-frame manual labeling of anatomical landmarks in ultrasound images is time consuming. The present study aims to investigate the feasibility of a deep learning algorithm for extracting subacromial motion metrics from dynamic ultrasonography. Dynamic ultrasound imaging was retrieved by asking 17 participants to perform cyclic shoulder abduction and adduction along the scapular plane, whereby the trajectory of the humeral greater tubercle (in relation to the lateral acromion) was depicted by the deep learning algorithm. Extraction of the subacromial motion metrics was conducted using a convolutional neural network (CNN) or a self-transfer learning-based (STL)-CNN with or without an autoencoder (AE). The mean absolute error (MAE) compared with the manually-labeled data (ground truth) served as the main outcome variable. Using eight-fold cross-validation, the average MAE was proven to be significantly higher in the group using CNN than in those using STL-CNN or STL-CNN+AE for the relative difference between the greater tubercle and lateral acromion on the horizontal axis. The MAE for the localization of the two aforementioned landmarks on the vertical axis also seemed to be enlarged in those using CNN compared with those using STL-CNN. In the testing dataset, the errors in relation to the ground truth for the minimal vertical acromiohumeral distance were 0.081–0.333 cm using CNN, compared with 0.002–0.007 cm using STL-CNN. We successfully demonstrated the feasibility of a deep learning algorithm for automatic detection of the greater tubercle and lateral acromion during dynamic shoulder ultrasonography. Our framework also demonstrated the capability of capturing the minimal vertical acromiohumeral distance, which is the most important indicator of subacromial motion metrics in daily clinical practice.

Irreparable Rotator Cuff Tear Treated With Combined Reconstruction of the Superior Capsule and Rotator Cuff: Technique Guidelines

Irreparable rotator cuff tears in young patients can be challenging for the patient and orthopaedic surgeon. Interposition rotator cuff reconstruction has gained popularity in patients with retracted tears and a viable rotator cuff muscle belly. Superior capsular reconstruction is an emerging treatment option that was developed to restore native glenohumeral joint mechanics by creating a superior constraint, which provides a stable glenohumeral fulcrum. Reconstructing both the superior capsule and rotator cuff tendon in the setting of an irreparable tear may improve clinical results in younger patients with viable rotator cuff muscle belly and a maintained acceptable acromiohumeral distance.

Evaluation of the prognostic value of the anatomical characteristics of the bony structures in the shoulder in bursal-sided partial-thickness rotator cuff tears.

In recent studies, individual scapular anatomy has been found to be related to degenerative full-thickness rotator cuff tears. However, research on the relationship between the anatomical characteristics of shoulder radiographs and bursal-sided partial-thickness rotator cuff tears (PTRCTs) is limited, and the risk factors for this pathology still need to be determined. The bursal-sided PTRCTs group included 102 patients without a history of shoulder trauma who underwent arthroscopy between January 2021 and October 2022. A total of 102 demographically matched outpatients with intact rotator cuffs were selected as the control group. Radiographs were used to measure the lateral acromial angle (LAA), critical shoulder angle (CSA), greater tuberosity angle (GTA), β-angle, acromion index (AI), acromiohumeral distance (AHD), acromial tilt (AT), acromial slope (AS), acromial type, and acromial spur by two independent observers. Multivariate analyses of these data were used to identify potential risk factors for bursal-sided PTRCTs. Receiver operating characteristic (ROC) analysis was performed to assess the sensitivity and specificity of CSA, GTA, and AI for this type of pathology. The β-angle, AHD, AS and acromion type showed no difference between bursal-sided PTRCTs and controls (p = 0.009, 0.200, 0.747 and 0.078, respectively). CSA, GTA and AI were significantly higher in bursal-sided PTRCTs (p < 0.001). LAA, β-angle and AT were significantly lower in bursal-sided PTRCTs. Multivariate logistic regression analysis demonstrated significant correlations between the acromial spur (p = 0.024), GTA (p = 0.004), CSA (p = 0.003) and AI (p = 0.048) and bursal-sided PTRCTs. The areas under the ROC curves for AI, CSA, and GTA were 0.655 (95% CI 0.580-0.729), 0.714 (95% CI 0.644-0.784), and 0.695 (95% CI 0.622-0.767), respectively. Acromial spur, GTA, CSA, and AI were independent risk factors for bursal-sided PTRCTs. Furthermore, CSA was the most powerful predictor of bursal-sided PTRCTs compared to GTA and AI.

Predictive factors of acromial fractures following reverse total shoulder arthroplasty: a subgroup analysis of 860 shoulders

Acromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort. A total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n=45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation. Of the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89°±10° vs. 83°±9°, P=.015), a lower postoperative DSA (45°±8° vs. 53°±12°, P=.002), less distalization (ACHD of 33±8 mm vs. 38±10 mm, P=.049), and a more medial center of rotation preoperatively (COR-LA 16±8 mm vs. 12±7 mm, P=.048) as predictive radiographic factors. The present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.

Clinical and radiologic outcomes after tendon insertion medialized repair of large-to-massive rotator cuff tears

To evaluate the effectiveness of tendon insertion medialized repair in treatment of large-to-massive rotator cuff tears (L/MRCT). The clinical and imaging data of 46 L/MRCT patients who underwent arthroscopic insertion medialized repair between October 2015 and June 2019 were retrospectively analyzed. There were 26 males and 20 females with an average age of 57.7 years (range, 40-75 years). There were 20 cases of large rotator cuff tears and 26 cases of massive rotator cuff tears. Preoperative imaging evaluation included fatty infiltration (Goutallier grade), tendon retraction (modified Patte grade), supraspinatus tangent sign, acromiohumeral distance (AHD), and postoperative medializaiton length and tendon integrity. The clinical outcome was evaluated by visual analogue scale (VAS) score, American Society for Shoulder and Elbow Surgery (ASES) score, shoulder range of motion (including anteflexion and elevation, lateral external, and internal rotation) and anteflexion and elevation muscle strength before and after operation. The patients were divided into two groups (the intact tendon group and the re-teared group) according to the integrity of the tendon after operation. According to the medializaiton length, the patients were divided into group A (medialization length ≤10 mm) and group B (medialization length >10 mm). The clinical function and imaging indexes of the patients were compared. All patients were followed up 24-56 months, with an average of 31.8 months. At 1 year after operation, MRI showed that the medializaiton length of supraspinatus tendon was 5-15 mm, with an average of 10.26 mm, 33 cases in group A and 13 cases in group B. Eleven cases (23.91%) had re-teared, including 5 cases (45.45%) of Sugaya type Ⅳ and 6 cases (54.55%) of Sugaya type Ⅴ. At last follow-up, the VAS score, ASES score, shoulder anteflexion and elevation range of motion, lateral external rotation range of motion, and anteflexion and elevation muscle strength significantly improved when compared with those before operation ( P<0.05); there was no significant difference in internal rotation range of motion between pre- and post-operation ( P>0.05). The Goutallier grade and modified Patte grade of supraspinatus muscle in the re-teared group were significantly higher than those in the intact tendon group, and the AHD was significantly lower than that in the intact tendon group ( P<0.05). There was no significant difference in other baseline data between the two groups ( P>0.05). Except that the ASES score of the intact tendon group was significantly higher than that of the re-teared group ( P<0.05), there was no significant difference in the other postoperative clinical functional indicators between the two groups ( P>0.05). There was no significant difference in the incidence of re-tear, VAS score, ASES score, range of motion of shoulder joint, and anteflexion and elevation muscle strength between group A and group B ( P>0.05). Tendon insertion medialized repair may be useful in cases with L/MRCT, and shows good postoperative shoulder function. Neither tendon integrity nor medialization length shows apparent correlations with postoperative shoulder function.

Capsular remnant in the rotator cuff footprint is a novel arthroscopic finding may indicate the etiology of the tear.

The aim of the study was that the capsule remnant is a common indicator of sub-acromial impingement syndrome and bursal side onset rotator cuff tears. Sixty-three patients with capsule remnants in the rotator cuff footprint (Study group) were detected, while the 53 patients did not have any remnant on the tendon footprint (Control group) between 2015 and 2020 were included. Demographic data of patients, such as age, gender, and operated side information were obtained from the archive files. Acromion type, presence of osteophytes in the acromioclavicular joint, Acromiohumeral Distance (AHD), Acromial Index (AI), Critical Shoulder Angle (CSA), and Coracoacromial Ligament (CAL) degeneration values were evaluated from preoperative MRI, radiographic images, and arthroscopic video recordings. Severe stages of CAL degeneration were observed in 82.5% of the patients who had capsule remnant (p: 0.001). While type 2 acromion was found in 61.9%, and also acromioclavicular joint osteophyte was found in 58.7% of the patients in the study group. The mean AHD was 8.22 ± 1.56mm in the study group and 9.2 ± 1.3mm in the control group. The mean CSA was 43.3 ± 4.9 in the study group and 40.8 ± 4.2 in the control group. The AI was measured as 0.8 ± 0.1 in the study group and 0.8 ± 0.01 in the control group. As a result of these measurements, a statistical difference was found between the two groups in terms of type 2 acromion ratio (p < 0.001), presence of osteophytes in the acromioclavicular joint (p < 0.001), mean acromio-humeral distance (p < 0.001), critical shoulder angle (p = 0.004), and acromial index values (p < 0.001). The findings of sub-acromial impingement syndrome were found to be more prominent in patients with full-thickness degenerative tear and findings of capsular remnant in the footprint. If the presence of the current finding is detected during glenohumeral arthroscopy, sub-acromial impingement syndrome should be examined in more detail to reveal the underlying cause and prevent a recurrence.

Comparative analysis of superior capsule reconstruction between long head of biceps tendon autograft and human dermis allograft.

Although many superior capsule reconstruction (SCR) techniques are currently practiced in clinical settings, guidelines for choosing the appropriate graft material are lacking. Therefore, at most times, the surgeon's personal preference becomes the deciding factor. This study compared 2 fairly recent SCR techniques-SCR with biceps tendon (BT) autograft and SCR with human dermis (HD) allograft-by evaluating clinical and radiologic outcomes to aid the surgeon's decision in choosing the appropriate graft. Thirty-one patients underwent SCR using BT autograft (SCR BT), and 22 underwent SCR using HD allograft (SCR HD). SCR BT was selected for patients with a partial BT tear <20%, no severe inflammation signs, and favorable anchor conditions. SCR HD was performed in patients with a BT tear >20%, a superior labrum anterior-posterior (SLAP) lesion, severe inflammation, or subluxation. Range of motion (ROM), strength and shoulder function scoring, plain radiography, and magnetic resonance imaging were evaluated before and after surgery at regular intervals. In the SCR BT group, forward flexion ROM increased from 122°±43° to 149°±18° at 2 years postoperatively, whereas in the SCR HD group, forward flexion ROM improved from 129°±28° to 149°±18°. In the SCR BT group, internal rotation (IR) ROM increased from 5±3 to 6±2 at 2 years postoperatively, whereas in the SCR HD group, IR ROM improved from 5±3 to 6±1. Although ROM, strength, visual analog scale score, American Shoulder and Elbow Surgeons score, and Constant score all improved 2 years after surgery, no statistically significant differences were found. Six months after surgery, graft thickness was 3.58±0.384 mm in the SCR BT group and 2.49±0.326 mm in the SCR HD group (P<.001). At 2 years postoperatively, graft thickness was 3.54±0.399 mm in the SCR BT group and 2.49±0.306 mm in the SCR HD group (P<.001). The SCR HD group showed a negative correlation of -0.475 between graft thickness and IR ROM (P=.026). In the SCR BT group, a negative correlation of -0.466 was found between graft thickness and IR ROM (P=.008). A positive correlation of 0.363 was found between IR ROM and the acromiohumeral distance when the results were compared before and 2 years after surgery (P=.045). Both SCR using BT autograft and SCR using HD allograft tissue showed favorable results, and no significant difference was noted between the 2 techniques. Given that the 2 techniques show equally favorable results, the surgeon's personal preference in choosing the SCR technique appears to be acceptable. Understanding the costs and patient's characteristics may aid the surgeon in deciding on the graft material.

Computer-aided quantitative ultrasound algorithm of acromiohumeral distance among individuals with spinal cord injury

Background: Shoulder ultrasound is a well-established point-of-care diagnostic modality in orthopaedic and sports medicine. Despite offering measurements of high-quality morphology, this methodology has faced several challenges, including variability in ultrasound systems, operator dependency, and lack of reliable and objective quantitative measures to track disease progression and responses to therapeutic interventions. Computer-aided quantitative ultrasound algorithm (CAQUSA) is an emerging novelty that automates the detection of normal and abnormal structures. Although CAQUSA has been shown to improve detections and diagnoses of soft tissue lesions, the proof-of-concept of utilizing CAQUSA to measure subacromial space width and its encroachment to the rotator cuff tendon have not been tested to assist in clinical decision-making for subacromial pain syndrome.Objective: This study aimed to develop a CAQUSA that measured the acromiohumeral distance (AHD) and test the algorithm’s reliability and agreement with manual measurements in wheelchair users with spinal cord injury (SCI).Methods: 116 ultrasound video clips recorded from 10 manual wheelchair users with SCI were evaluated manually by an experienced examiner with expertise in AHD examination and by the CAQUSA, which was developed for bone segmentation with probability mapping. The reliability and agreement of the diagnostic performance between the examiner and the CAQUSA were calculated and compared in both groups of AHD measurements.Results: The CAQUSA achieved a satisfactory agreement between computer-aided (11.95 ± 2.29 mm) and manual (11.33 ± 2.48 mm) measurements. The intraclass correlation coefficient between the two measures was excellent (ICC = 0.95). The sensitivity was 0.2 mm, with 95% true positives and 5% false positives at the fixed threshold of CAQUSA.Conclusion: AHD measurements made by the clinical observer were similar to that of the CAQUSA for assessing the clinical metrics related to subacromial pain syndrome. However, the CAQUSA showed greater reliability in its unclear or misleading image analysis. Based on the findings of this proof-of-concept study, the CAQUSA has promise for clinical utilization and interchangeability to minimize examiner-dependent errors and potentially reduce the cost of care.

Dynamic Superior Capsular Reconstruction for Irreparable Massive Rotator Cuff Tears: Histologic Analysis in a Rat Model and Short-term Clinical Evaluation

Background: Superior capsular reconstruction (SCR) has been demonstrated to be a valuable treatment for patients with irreparable massive rotator cuff tears (IMRCTs). However, the torn medial supraspinatus (SSP) tendons, which acted as dynamic stabilizers, were left untreated in conventional SCR, and the dynamic force from the SSP tendon was not restored. Purpose: To evaluate the effect of dynamic SCR (dSCR) on fascia-to-bone healing in a rat model, and to compare the short-term clinical effectiveness of dSCR and SCR using autologous fascia lata (FL) in patients with IMRCTs. Study Design: Controlled laboratory study and cohort study; Level of evidence, 3. Methods: A total of 50 rats were divided randomly into 2 groups: the dSCR group and the SCR group (25 rats per group). First, chronic IMRCTs were created, and then the torn tendons in both groups were subjected to SCR using autologous thoracolumbar fascial (TLF) grafts. The remnant of the SSP tendon was sutured to the medial part of the TLF graft in the dSCR group but not in the SCR group. Histologic sections were assessed at 1, 2, 4, 8, and 16 weeks postoperatively. In the clinical study, 22 patients (9 SCR, 13 dSCR) were analyzed. The recovery of shoulder function, including the active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons score, Constant score, and University of California Los Angeles score, acromiohumeral distance (AHD), and fatty infiltration, was evaluated before surgery and at the last follow-up. Results: Histologic analysis of the fascia-to-bone junction in the rat model showed that the TLF gradually migrated into tendon-like tissue over the rotator cuff defects in both groups, and the modified tendon maturation score of the fascia-to-bone interface in the dSCR group was higher than that in the SCR group at 4 weeks (12.20 ± 1.30 vs 14.60 ± 1.52; P = .004), 8 weeks (19.60 ± 1.14 vs 22.20 ± 1.10; P = .019), and 16 weeks (23.80 ± 0.84 vs 26.20 ± 0.84 P = .024). The dSCR group showed earlier fibrocartilage cell formation and angiogenesis. In the clinical study, all 22 patients completed a minimum of 12 months of follow-up after surgery, and the mean follow-up duration was 22.89 ± 7.59 months in the SCR group and 25.62 ± 7.32 months in the dSCR group. The patients in both groups showed significant improvements in terms of ROM, shoulder function scores, and AHD. At the last follow-up, abduction (56.67°± 27.39° vs 86.54°± 30.37°; P = .029), external rotation (25.00°± 9.35° vs 33.08°± 8.55°; P = .049), internal rotation cone rank (–2.78 ± 2.44 vs –4.38 ± 1.12; P = .049), VAS (–3.00 ± 0.87 vs –3.92 ± 0.95; P = .031) and Constant (47.89 ± 15.39 vs 59.15 ± 9.74; P = .048) scores, and the AHD improvement degree (3.06 ± 1.41 mm vs 4.38 ± 1.35 mm; P = .039) in the dSCR group were significantly improved compared with those in the SCR group. The results of fatty infiltration at the last follow-up showed that there was significant improvement compared with the preoperative results in both the conventional SCR (P = .036) and the dSCR (P = .001) groups. However, there were no significant differences between the 2 groups (P = .511). Conclusion: dSCR can promote faster fascia-to-bone healing in a rat model, and the dSCR technique could provide a preferable treatment option for patients with IMRCTs. Clinical Relevance: dSCR might restore the dynamic of SSP in some sense and then improve the fatty infiltration in the SSP.

Arthroscopic Superior Capsule Reconstruction With Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum 2-Year Follow-Up

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs). The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely repaired massive RCT (dimension >5 cm and 2 tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up). Clinical outcomes were evaluated preoperatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed, according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI). A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range: 24 to 64). All clinical scores also improved at the 2-year follow-up (mean: VAS 0.7 [SD 0.7] vs 5.4 [SD 1.1]; P < .001; mean: ASES 92.6 [SD 8.0] vs 34.8 [SD 13.4]; P < .001; mean UCLA 31.5 [SD 3.9] vs 11.0 [SD 3.2]; P < .001; and mean CMS 86.6 [SD 7.2] vs 40.0 [SD 11.6]; P < .001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%). ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the 2-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences [MCID]) on ASES, UCLA, and VAS with improved abduction strength restoration. Level IV, retrospective case series.

Mid-term effects of two different Kinesio tape treatments in female patients with subacromial impingement syndrome: Randomized controlled ultrasonographic study

Randomized controlled study. To evaluate the effect of Kinesio Tape (KT) applied differently in patients diagnosed with Subacromial Impingement Syndrome (SIS) on acromiohumeral distance (AHD) and supraspinatus tendon (SsT) thickness using ultrasound (US) and its effect on pain, upper limb functional status and hand grip muscle strength in the short and mid-term. The 90 patients diagnosed with unilateral SIS by clinical examination were randomized into 3 groups. In addition to exercise therapy, the deltoid in group 1 and the supraspinatus muscle in group 2 were taped from insertion to origin. Group 3, which was the control group, was applied 9 sessions of sham taping for 3 weeks. Cases were evaluated for AHD and SsT thickness, pain was evaluated with the Visual Analog Scale (VAS), function with the Disabilities of the arm, shoulder and hand (DASH) and the Western Ontario Rotator Cuff Index (WORC), and hand grip strength (HGS) using a dynamometer before, and 3rd week and 3rd month after the KT application. There was a significant improvement in all parameters in the short and mid-term intra group comparisons in Group 1 and 2 after taping (P < .05). In intergroup comparisons, significant improvement was achieved in all parameters in Group 1 and Group 2 in the mid and short term compared to the control group (P < .05). In comparison of Group 1 and Group 2, HGS in the short term (p: 0.07) and the SsT thickness in the short and mid-term (p: 0.36, p: 0.85) did not exhibit any difference. The improvement in all other parameters in group 1 was statistically significant. The findings of our study provide definitive evidence for the effectiveness of KT treatment depending on the method of tape application employed.

Arthroscopic Autologous Coracoacromial Ligament Augment Technique for Particle Thickness of Rotator Cuff with at Least Two Years Follow-Up.

Patch technology has been the new technique in the treatment of partial thickness of the rotator cuff tear (PTRCTs) to address the limitation of traditional techniques. Compared with allogeneic patches and artificial materials, coracoacromial ligament is obviously closer to their own biology. The purpose of the study was to evaluate the functional and radiographic outcomes following arthroscopic autologous coracoacromial ligament augment technique for treatment of PTRCTs. This study included three female patients with PTRCTs who underwent arthroscopy operation in 2017 with an average age of 51 years (range from 50 to 52 years). The coracoacromial ligament implant was attached to the bursal side surface of the tendon. The clinical results were evaluated by American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), acromiohumeral distance (AHD) and muscle strength before and 12months after operation. Magnetic resonance imaging (MRI) was performed 24months after operation to assess the integrity of the anatomical structure of the original tear site. The average ASES score improved significantly from 57.3 preoperatively to 95.0 at 1-year follow-up. The strength improved significantly from grade 3 preoperatively to grade 5 at 1 year. Two of three patients underwent the MRI at 2-year follow-up. Radiographic released the complete healing of rotator cuff tear. No implant-related serious adverse events were reported. The new technique of using autogenous coracoacromial ligament patch augment provides good clinical results on patients with PTRCTs.

Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment

Vitality-threatening proximal humerus fractures often provide an indication for prosthetic treatment. We investigated the issue of how anatomic hemiprostheses perform in younger, functionally challenging patients with the use of a specific fracture stem and systematic tuberosity management in medium-term follow-up. Thirteen skeletally mature patients with a mean age of 64±9years and a minimum follow-up of 1year after primary open-stem hemiarthroplasty for 3- and 4-part proximal humeral fractures were included. All patients were followed up regarding their clinical course. Radiologic follow-up included fracture classification, healing of tuberosities, proximal migration of the humeral head, evidence of stem loosening, and glenoid erosion. Functional follow-up included range of motion, pain, objective and subjective performance scores, complications, and return to sports rates. We statistically compared treatment success based on the Constant score between the cohort with proximal migration and the cohort with regular acromiohumeral distance by means of the Mann-Whitney U test. After an average follow-up period of 4.8years, satisfactory results were obtained. The absolute Constant-Murley score was 73.2±12.4 points. The disabilities of the arm, shoulder, and hand score was 13.2±13.0 points. Patients reported their mean subjective shoulder value as 86.6%±8.5%. Pain was reported as 1.1±1.3 points on a visual analog scale. Flexion, abduction, and external rotation values were 138±31°, 134±34°, and 32±17°, respectively. 84.6% of the referred tuberosities healed successfully. Proximal migration was observed in 38.5% of cases and was associated with worse Constant score results (P=.065). No patient showed signs of loosening. Mild glenoid erosion was apparent in 4 patients (30.8%). All patients who were interviewed and participated in sports before surgery were able to return to their primary sport after surgery and continued to do so during the final follow-up. With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8years after hemiarthroplasty for primary nonreconstructable humeral head fractures. Accordingly, open-stem hemiarthroplasty appears to remain a possible alternative to reverse shoulder arthroplasty in younger, functionally challenging patients with primary 3- or 4-part proximal humeral fractures.

Paper 18: Minimum 10-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears: Graft survival rate and progression of cuff tear arthropathy

Objectives: Superior capsule reconstruction (SCR) was developed as an alternative treatment for irreparable rotator cuff tears. Previous studies showed graft healing is key to improve shoulder function and pain relief after SCR. Graft healing rate after SCR have been reported for irreparable rotator cuff tears in short-term follow-up studies. The objective of this study was to assess graft survival rate and progression of cuff tear arthropathy in minimum 10-year follow-up of arthroscopic SCR. Methods: A total of 48 consecutive patients with 50 affected shoulders underwent SCR using fascia lata autograft for the treatment of irreparable rotator cuff tears by a single surgeon between 2007 to 2011. Of these 48 initially identified patients, 5 had died, 5 had moved and were unable to be contacted, 2 had severe health problems that were unrelated to SCR, 1 refused to participate, and 1 was unable to participate because she was caring for her child with terminal cancer, thus leaving 34 patients with 36 affected shoulders for review. Structural outcomes were evaluated for a minimum of 10 years of follow-up (range, 10–13 years). Acromiohumeral distance (AHD) and Hamada grade (stage of cuff tear arthropathy) were evaluated by using standard radiography. Fatty degeneration of the rotator cuff muscles was evaluated according to the Goutallier grading system. Graft healing and thickness were assessed by using T2-weighted MRI (1.5-T closed-type scanner). By using SYNAPSE software (accuracy, 0.05 mm; FUJIFILM Medical System, Loveland, CO), graft thickness at 1 cm posterior to the bicipital groove in the coronal plane of T2-weighted MRI was measured at the greater tuberosity side (medial aspect of the footprint on the greater tuberosity), at midgraft (top of the humeral head), and at the glenoid side (5 mm posterior to the articular surface on the glenoid). Results: Graft survival rate was 94% (34 of 36 shoulders) at 1 year after SCR, 92% (33 of 36 shoulders) at 2 to 4 years after SCR, and 89% (32 of 36 shoulders) at 5 to 10 years after SCR. Regarding the 30 patients (32 shoulders) whose grafts remained intact, graft thickness at 1 year after SCR was 8.1 ± 1.9 mm on the greater tuberosity, 6.8 ± 1.5 mm at midgraft, and 11.4 ± 2.0 mm on the glenoid. At 10 years after SCR, graft thickness (7.8 ± 1.6 mm on the greater tuberosity, 7.5 ± 1.8 mm at midgraft, 11.2 ± 2.2 mm on the glenoid) did not significantly differ from that at 1 year after SCR (P = 0.14 to 0.52). Although the rate of low intensity on T2 MRI of the grafts at 1 year after SCR was 53% (17 of 32 shoulders), all grafts had become low intensity on T2 MRI by 10 years after SCR (P &lt; 0.001). Compared with the preoperative measurement, AHD was increased significantly at 1, 5, and 10 years after SCR (P &lt; 0.001). Average AHD did not differ among 1, 5, and 10 years after SCR (P = 0.09 to 0.87). Because of the increase in AHD, the Hamada grade at 1, 5, and 10 years after SCR was significantly decreased (i.e., reduced cuff tear arthropathy) (P &lt; 0.001) compared with the preoperative grade. Before SCR, the AHD was significantly narrower and the Hamada grade was significantly higher in the affected shoulder compared with the unaffected shoulder. At 10 years after SCR, neither AHD nor Hamada grade differed significantly between the affected and unaffected shoulders (i.e., cuff tear arthropathy had not progressed during the 10 years or more after SCR) in patients with healed grafts, whereas all 4 of the remaining patients with postoperative graft tear showed increased cuff tear arthropathy to grade 4a or 4b. One patient with graft tear was converted to reverse shoulder arthroplasty. Conclusions: The graft survival rate at 10 years follow-up was 89%. Graft thickness was maintained at 10 years after SCR when graft was healed. Graft healing prevented progression of cuff tear arthropathy after arthroscopic SCR.

Erratum to “Comparison of shoulder muscle strength, cross-sectional area, acromiohumeral distance, and thickness of the supraspinatus tendon between symptomatic and asymptomatic patients with rotator cuff tears” J Shoulder Elbow Surg. 2020; 29(10):2043-2050. https://doi.org/10.1016/j.jse.2020.02.017.

Erratum to “Comparison of shoulder muscle strength, cross-sectional area, acromiohumeral distance, and thickness of the supraspinatus tendon between symptomatic and asymptomatic patients with rotator cuff tears” J Shoulder Elbow Surg. 2020; 29(10):2043-2050. https://doi.org/10.1016/j.jse.2020.02.017.

Comparison of suture-bridge and independent double-row techniques for medium to massive posterosuperior cuff tears: a two-year retrospective study

BackgroundTransosseous-equivalent suture-bridge (TOE-SB) and independent double-row (IDR) repair techniques were developed to treat rotator cuff tears. The study was designed to prove that both TOE-SB and IDR techniques provided comparable clinical results and retear rate for medium to massive posterosuperior rotator cuff tears, while the surgical time and number of suture anchor used were less in the IDR group.Study designLevel of evidence: level III, Retrospective comparative study.MethodsPatients with medium to massive posterosuperior rotator cuff tears receiving arthroscopic TOE-SB and IDR between November 2016 to October 2019 were retrospectively enrolled. All patients were confirmed to have grade ≤ 2 fatty infiltration in the muscles of the torn tendons. Revision, concomitant subscapularis tear, acromiohumeral distance < 7 mm, glenohumeral osteoarthritis, partial repair, incomplete repair, partial thickness, or irreparable posterosuperior cuff tear were excluded. Surgical time, number of suture anchor used for the surgery, pre-operative, and post-operative clinical scores such as Constant-Murley score, subjective shoulder value (SSV), and visual analog scale (VAS) were compared. The retear rates between groups were evaluated by ultrasound.ResultsThirty-five IDR and thirty-five TOE-SB repairs were enrolled. The IDR technique required much fewer anchors than TOE-SB did to complete the cuff repair. The mean operation time in IDR and TOE-SB group were 86(18.23), and 114(18.7) (min), respectively (P < 0.01). The mean number of anchors used to complete the cuff repair was 2(0.17) in IDR and 3(0.61) in TOE-SB (P < 0.01). The Constant-Murley score improved from 34.9 ± 6.6 to 80.6 ± 9.4 in the IDR group, and 37.4 ± 6 to 81.9 ± 4.6 in the TOE-SB group (both P < 0.001). SSV improved from 24.6 ± 9.6 to 79.3 ± 10.6 in the IDR, and 27.9 ± 9 to 82.9 ± 6.9 in the TOE-SB group (both P < 0.001). VAS improved from 7.9 ± 0.6 to 1.5 ± 0.7 in the IDR, and 8 ± 0.5 to 1.3 ± 0.6 in the TOE-SB group (both P < 0.001) at final follow-up. No significant difference was found between the retear rates (14.3% in the IDR vs. 17.1% in the TOE-SB, respectively) in the 2-year follow-up.ConclusionsBoth IDR and TOE-SB group provided comparable clinical results and retear rates for medium to massive posterosuperior rotator cuff tears. The surgical time and number of anchors used were less in the IDR group than in the TOE-SB group.

CORR Insights®: High Acromial Slope and Low Acromiohumeral Distance Increase the Risk of Retear of the Supraspinatus Tendon After Repair.

1Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA H. P. Gould, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, 3333 North Calvert Street, Baltimore, MD 21218, USA, Email: [email protected] This CORR Insights® is a commentary on the article “High Acromial Slope and Low Acromiohumeral Distance Increase the Risk of Retear of the Supraspinatus Tendon After Repair” by Caffard and colleagues available at: DOI: 10.1097/CORR.0000000000002520. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

The clinical results of lower trapezius tendon transfer with the peroneus longus allograft augmentation combined with interpositional repair with fascia lata in massive irreparable rotator cuff tears.

To investigate the clinical results of lower trapezius (LT) tendon transfer and interpositional repair that were performed simultaneously in patients with massive irreparable rotator cuff tears. Between 2018 and 2020 years, 16 patients with massive irreparable rotator cuff tears that were treated with LT tendon transfer and interpositional repair at the same time were included in this study. The mean follow-up period was 29±3 months (24-39 months) and the mean age of patients was 62±9 years (42-73 years). The acromio-humeral distance, active range of motions, Visual Analog Scale (VAS) scores, University of California-Los Angeles (UCLA) scores and Constant-Murley scores were made preoperatively and at the final follow-up. At the final follow-up, forward flexion was increased from 109˚±24.7 to 144˚±22.21 (p=0.005), abduction from 60˚±16.33 to 135˚±16.33 (p=0.005) and external rotation from 12˚±16.87 to 35˚±14.34 (p=0.005). Total UCLA scores were 5.9±2.13 to 22.7±5.29 (p=0.005), Constant-Murley scores were 24±9.43 to 50.2±14.28 (p=0.008), VAS scores were 6.1±1.1 to 2.4±1.35 (p=0.007), mean acromio-humeral distances were 4.64±0.85mm (3.42-6.23mm) to 6.58mm (5.25-8.21mm) (p=0.005) preoperatively and at the final follow-up. Except one patient who had a frozen shoulder any significant complication was detected. Adding interpositional repair to the LT tendon transfer in patients with posterior superior irreparable rotator cuff tear seems to have satisfactory short to mid-term clinical outcomes without an increase in complications.

Superior capsular reconstruction using hybrid graft for irreparable massive rotator cuff tear.

To evaluate the clinical and radiological outcomes of arthroscopic superior capsular reconstruction (SCR) using hybrid grafts composed of tensor fascia lata autografts and human dermal allografts. This study included 30 patients with chronic irreparable posterosuperior rotator cuff tears (RCTs) who underwent arthroscopic SCR using a hybrid graft composed of tensor fascia lata autograft and human dermal allograft. Clinical outcomes were evaluated using the pain visual analogue scale score, shoulder range of motion, American Shoulder and Elbow Surgeons score, constant score, University of California-Los Angeles score, and simple shoulder test score preoperatively and at least 2years after surgery. Radiographic analysis included the Hamada classification grade, acromiohumeral distance (AHD), and graft integrity at 2years after surgery. All patients exhibited significant clinical improvement in all functional outcome measurements, except external rotation (all P < 0.05). The number of patients who exhibited pseudoparalysis decreased from 7 (23.3%) to 2 (6.7%) postoperatively. Complications were not observed. Radiologically, the mean postoperative AHD increased significantly from 6.9 ± 1.6cm to 8.8 ± 2.1cm at 2years postoperatively (P < 0.001). Twenty five out of the 30 (83.3%) patients showed successful graft healing, and all healing failures occurred on the humeral side. The differences between the healed-graft and failed-graft groups were significantly lower graft thickness (P = 0.001) and smaller AHD (P < 0.001) in the failed-graft group. Every functional outcome scores were not statistically different between healed-graft and failed-graft groups. An arthroscopic SCR technique using a hybrid graft consisting of a tensor fascia lata autograft and human dermal allograft showed satisfactory clinical outcomes in patients with irreparable RCTs. IV.

Age- and Gender-Related Differences in the Morphology of Cuff Tear Arthropathy: A Cross Sectional Analysis.

Rotator cuff tear arthropathy (CTA) is the most common reason for reverse total shoulder arthroplasty (RSA). There is minimal understanding of the natural progression of osteoarthritis of the shoulder and of the morphologic differences between men and women and between younger and older patients. This trial comprised 309 patients (342 shoulders) who underwent RSA due to CTA in the period between January 2009 and September 2019. The patients were divided into gender and age groups. Preoperative X-rays, computed tomography and magnetic resonance imaging were conducted using various classifications to describe the morphology of the CTA. Of all 342 analyzed shoulders, 209 were right and 133 were left shoulders. A total of 257 female shoulders and 85 male shoulders were assessed. Both mean age and age distribution were significantly different (74.37 years in female and 70.11 years in male patients, p = 0.001; 70.2% female patients in the age group <75.5 years and 80.1% in the age group >75.5 years, p = 0.045). A larger extent of progression of the fatty infiltration was detected both in the female cohort (p = 0.006) and in the older age group (p = 0.001). Additionally, older patients had significantly higher levels of muscle retraction (Patte; p = 0.003), a lower acromiohumeral distance (p = 0.042) and more advanced CTA (Seebauer; p = 0.006).