Cuff Tears Research Articles

The effect of a rotator cuff tear and its size on three-dimensional shoulder motion

BackgroundRotator cuff-disease is associated with changes in kinematics, but the effect of a rotator cuff-tear and its size on shoulder kinematics is still unknown in-vivo. MethodsIn this cross-sectional study, glenohumeral and scapulothoracic kinematics of the affected shoulder were evaluated using electromagnetic motion analysis in 109 patients with 1) subacromial pain syndrome (n=34), 2) an isolated supraspinatus tear (n=21), and 3) a massive rotator cuff tear involving the supraspinatus and infraspinatus (n=54). Mixed models were applied for the comparisons of shoulder kinematics between the three groups during abduction and forward flexion. FindingsIn the massive rotator cuff-tear group, we found reduced glenohumeral elevation compared to the subacromial pain syndrome (16°, 95% CI [10.5, 21.2], p<0.001) and the isolated supraspinatus tear group (10°, 95% CI [4.0, 16.7], p=0.002) at 110° abduction. Reduced glenohumeral elevation in massive rotator cuff tears coincides with an increase in scapulothoracic lateral rotation compared to subacromial pain syndrome (11°, 95% CI [6.5, 15.2], p<0.001) and supraspinatus tears (7°, 95% CI [1.8, 12.1], p=0.012). Comparable differences were observed for forward flexion. No differences in glenohumeral elevation were found between the subacromial pain syndrome and isolated supraspinatus tear group during arm elevation. InterpretationThe massive posterosuperior rotator cuff-tear group had substantially less glenohumeral elevation and more scapulothoracic lateral rotation compared to the other groups. These observations suggest that the infraspinatus is essential to preserve glenohumeral elevation in the presence of a supraspinatus tear. Shoulder kinematics are associated with rotator cuff-tear size and may have diagnostic potential.

Os acromiale: frequency and a review of 726 shoulder MRI.

Os acromiale consist in a lack of fusion between the different ossification spots of the acromial side of scapula from the age of 23-25years. A relation between os acromiale and some shoulder pathology like impingement syndrome, cuff tear and subacromial bursitis has been described. The etiology is not already known. The aim of this study was to evaluate the frequency of os acromiale in our population, the link between os acromiale and sex, side and shoulder pathology. 1042 shoulder MRI were evaluated to find out os acromiale and the linked cuff pathology. In our population, the frequency of os acromiale was 3.44% without differences between sexes, with prevalence on the right shoulder. No differences in cuff and bursa pathology were present between affected and unaffected subjects. Os acromiale is an anomaly still underdiagnosed. It is important to be recognized because it allows to make an accurate pre-surgical plan. To make a correct diagnosis, axial MRI cut or TC is necessary.

Arthroscopic trans-osseous rotator cuff repair.

Mechanical factors are at the basis of any tendon healing process, being pressure an aspect able to positively influence it. For this reason transosseous rotator cuff repair represents the gold standard procedure for patients affected by a cuff tear, maximizing the tendon footprint contact area and reducing motion at the tendon to bone interface. The Authors present an all arthroscopic suture bridge-like transosseous repair with the preparation of a single transosseous tunnel perfor med thanks to a precise dedicated instrument (Compasso®) and one implant (Elite-SPK®) with the use of only 3 suture wires. In addition this technique permits to accurately prepare the bony side of the lesion without any risk or complication, such as anchor pull-out and greater tuberosity bone osteolysis. However, even if this technique seems less demanding, the arthroscopic transosseous repair is still an advanced procedure, and should be performed only by well prepared arthroscopic shoulder surgeons. V.

Influence of Thyroid Hormones on Tendon Homeostasis.

Tendinopathies have a multifactorial etiology driven by extrinsic and intrinsic factors. Recent studies have elucidated the importance of thyroid hormones in the alteration of tendons homeostasis and in the failure of tendon healing after injury. The effects of thyroid hormones are mediated by receptors (TR)-α and -β that seem to be ubiquitous. In particular, T3 and T4 play an antiapoptotic role on tenocytes, causing an increase in vital tenocytes isolated from tendons in vitro and a reduction of apoptotic ones; they are also able to influence extra cellular matrix proteins secretion in vitro from tenocytes, enhancing collagen production. From a clinical point of view, disorders of thyroid function have been investigated only for rotator cuff calcific tendinopathy and tears. In this complex scenario, further research is needed to clarify the role of thyroid hormones on the onset of tendinopathies.

TGF-β rescues extracellular matrix turnover in rotator cuff pathology

Introduction: Tendinopathies are the most frequent causes of chronic shoulder pain. Long head of the biceps (LHB) tendon lesions are often associated with massive rotator cuff (RC) tears. Palliative LHB tenotomy decreases RC disease patient’s pain and disability. The aim of this work was to identify the biological changes of LHB in RC disease and assess its association with clinical manifestations. Methods: RC disease patients submitted to LHB tenotomy were evaluated using a clinical protocol in order to retrieve information regarding shoulder pain duration and intensity (visual analogue scale) and shoulder function (Constant score). LHB tendon samples from these patients were compared with cadaver controls. Tendon tissue was qualitatively studied by conventional histology and immunohistochemistry was used to access semi quantitatively the presence of substance P and calcitonin gene-related peptide (CGRP). Tendon cell cultures were used to determine the gene expression of several extracellular matrix genes with and without stimulation with transforming growth factor (TGF)-β, TNF, IL-10 or dexamethasone. Results: Histologically, LHB tendon from RC patients and cadaver controls had similar characteristics. RC patients had a significantly higher CGRP immunohistochemistry score as compared to controls (p=0.010) but there was no correlation with patient clinical features. On the contrary, regarding substance P no differences were found between RC patients and controls immunohistochemistry score but a correlation with shoulder pain (r=0.828, p=0.021) was identified. Through gene expression analysis we found a downregulation of the extracellular matrix genes type I collagen and thrombospondin 4, as well as vascular endothelial growth factor (VEGF) and nerve growth factor (NGF) in Manuscript Click here to download Manuscript manuscript.docx 2 patients with RC disease. However, in vitro stimulation of RC tenocytes with TGF-β rescued their ability to produce type I collagen and VEGF. Conclusion: LHB tendon from RC disease patients had neurotransmitter disturbances that could be related to shoulder pain. Moreover, we demonstrated that LHB from RC disease patients had a downregulation of extracellular matrix genes, as well as of VEGF and NGF genes. We showed that TGF-β can partially normalize the expression of these genes, suggesting that modulating TGF-β could be a therapeutic opportunity for improving tendon quality in the context of chronic tendinopathies.

Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears

Background: Arthroscopic partial repair is a treatment option in irreparable large-to-massive rotator cuff tears without arthritic changes. However, there are indications that arthroscopic partial repair does not yield satisfactory outcomes. Purpose: To report the clinical and radiographic results of arthroscopic partial repairs in patients with irreparable large-to-massive cuff tears. In addition, an analysis was performed regarding preoperative factors that may influence patient outcomes and patient-rated satisfaction over time. Study Design: Case series; Level of evidence, 4. Methods: From 2005 to 2011, a total of 31 patients who underwent arthroscopic partial repair for irreparable large-to-massive cuff tears were retrospectively evaluated. Partial repair was defined as posterior cuff tissue repair with or without subscapularis tendon repair to restore the transverse force couple of the cuff. Pain visual analog scale (PVAS), questionnaire results (American Shoulder and Elbow Surgeons [ASES] and Simple Shoulder Test [SST]), and radiographic changes (acromiohumeral distance and degenerative change) were assessed preoperatively, at first follow-up (roughly 1 year postoperatively), and at final follow-up (>2 years postoperatively). Patients rated their satisfaction level at each postoperative follow-up as well. Preoperative factors that might influence outcomes, such as patient demographics, tear size, and fatty infiltration, were investigated. Results: The preoperative, first follow-up, and final follow-up results for mean PVAS (5.13, 2.13, and 3.16, respectively) and questionnaires (ASES: 41.97, 76.37, and 73.78; SST: 3.61, 6.33, and 6.07, respectively) improved significantly (all P < .05). Radiographic evaluation showed no difference compared with preoperative status. Nevertheless, patient-rated satisfaction at final evaluation was inferior: 16 good responses (“very satisfied” and “satisfied”) and 15 poor responses (“rather the same” and “dissatisfied”). Despite initial improvements in both groups (P < .05), patients with poor satisfaction demonstrated statistically significant deterioration in mean PVAS (from 2.07 to 4.67), questionnaire scores (ASES: from 74.56 to 59.80; SST: from 5.11 to 3.81), and acromiohumeral distance (from 7.19 to 5.06 mm) between the first and final follow-up (all P < .05). Patients with good satisfaction showed no significant difference or they improved (P > .05) from the first to the final follow-up. Among preoperative factors, fatty infiltration of the teres minor was identified as the only statistically significant factor affecting patient-rated satisfaction (P = .007). Conclusion: This study showed that arthroscopic partial repair may produce initial improvement in selected outcomes at 2-year follow-up. However, about half of the patients in the study were not satisfied with their outcomes, which had deteriorated over time. Preoperative fatty infiltration of the teres minor was the only factor that correlated with worse final outcomes and poor satisfaction after arthroscopic partial repair.

Shoulder &amp; Elbow

The December 2014 Shoulder &amp; Elbow Roundup360 looks at: cuff tears and plexus injury; corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?

An Augmentation Suture Technique for Arthroscopic Rotator Cuff Repair

The double-row suture technique and the suture-bridge technique have been used for rotator cuff repair to decrease the occurrence of retears. However, when only the degenerated tendon end is sutured, the risk of retear remains. The augmentation suture technique is a new procedure that connects the intact medial tendon to the lateral greater tuberosity, and this approach may protect the initial repair site. The procedures for this technique are as follows: 2 sutures are placed through the medial intact tendon, the cuff tear is repaired by the single-row technique, 2 sutures are pulled laterally over the single-row repair site, and 2 sutures are fixed at the lateral greater tuberosity with a push-in–type anchor. This technique is simple and easy and does not require special equipment. Moreover, this approach can augment the single-row repair technique without creating high tension at the cuff end.

Shoulder & Elbow

The April 2014 Shoulder &amp; Elbow Roundup360 looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?

Review: Some clinical tests performed by specialists identify rotator cuff disease or tears

Source Citation Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA. 2013;310:837-47. ...

Shoulder &amp; Elbow

The February 2014 Shoulder &amp; Elbow Roundup360 looks at: whether arthroscopic acromioplasty is a cost-effective intervention; shockwave therapy in cuff tear; whether microfracture relieves short-term pain in cuff repair; the promising early results from L-PRF augmented cuff repairs; rehabilitation following cuff repair; supination strength following biceps tendon rupture; whether longer is better in humeral components; fatty degeneration in a rodent model; and the controversial acromioclavicular joint dislocation.

Imaging of shoulder pain in overhead throwing athletes

Overhead sports are widely practiced around the world and overhead athletes can present with pain and dysfunction in the throwing shoulder, generally due to degenerative changes secondary to overuse. Numerous etiologies can be taken into account, including rotator cuff and glenoid labrum tears, biceps pathologies, internal impingement, and gleno-humeral instability. In this setting, imaging plays a central role in early diagnosis, thus allowing for a prompt management, correct rehabilitation, and quick return to competition. This review is aimed to discuss the role of imaging to diagnose the most common types of overhead-related shoulder injuries.

Shoulder &amp; Elbow

The February 2013 Shoulder &amp; Elbow Roundup360 looks at: whether we should replace fractured shoulders; the limited evidence for shoulder fractures; cuffs and early physio; matrix proteins and cuff tears; long-term SLAP tear outcomes; suture anchors; recurrent Bankart repairs; and acromial morphology and calcific tendonitis.

Can Handheld Dynamometers Diagnose Partial-thickness Rotator Cuff Tears?

Background Partial tears of the rotator cuff tendons of the shoulder are a common cause of significant pain and disability, yet are difficult to diagnose clinically. Handheld dynamometry has demonstrated good sensitivity and specificity in the diagnosis of full-thickness rotator cuff tears. The present study aimed to determine whether handheld dynamometer measurements could predict the presence of a partial-thickness rotator cuff tear among patients with shoulder pain. Methods Handheld dynamometer measurements and signs of impingement were collected before surgical evaluation in 450 patients with a partial-thickness rotator cuff tear ( n = 150), full-thickness rotator cuff tear ( n = 150) or nonrotator cuff pathology ( n = 150). Results Patients with partial-thickness tears did not have significantly different strength compared to patients without rotator cuff tears. Patients with full-thickness tears had a decrease in abduction and external rotation strength ( p &lt; 0.001). Patients with any rotator cuff tear were more likely to have signs of impingement during internal rotation ( p &lt; 0.001) and impingement during external rotation ( p = 0.004). Conclusions Handheld dynamometer measurements were unable to reliably distinguish patients with partial-thickness rotator cuff tears from patients with other causes of shoulder pain. The abduction and external rotation muscle strength tests demonstrated their usefulness when distinguishing partial-thickness rotator cuff tears from full-thickness rotator cuff tears.

Preliminary ultrasound evaluation of the rotator cable in asymptomatic volunteers

PurposeTo characterize the rotator cable high-resolution ultrasound appearance in asymptomatic shoulders of volunteers of different age. Materials and methodsIRB approval and volunteers’ written consent was obtained. Excluding subjects with known shoulder affections, we screened 24 asymptomatic volunteers. Supraspinatus and infraspinatus tendons high-resolution ultrasound evaluation was performed according to standard scan protocols, further excluding shoulders with partial/full-thickness cuff tears. Thus, we studied 24 shoulders in 12 young volunteers (age range 21–39 years, mean age 33 ± 8 years) and 21 shoulders in 11 elderly volunteers (age range 62–83 years, mean age 75 ± 45 years). For each shoulder, we noted rotator cable visibility and its thickness and width. Fisher’s and U Mann–Whitney statistics were used. ResultsRotator cable was less frequently detected in young than in elderly volunteers (5/24 vs. 11/21 shoulders; P = 0.034). When detected, rotator cable was significantly thicker in young (range 1.2–1.5 mm, mean thickness 1.3 ± 0.1 mm) than in elderly (range 0.9–1.4 mm, mean thickness 1.2 ± 0.1 mm) volunteers (P = 0.025), while its width was not significantly different in young (range 4.5–7.1 mm, mean 5.6 ± 1.1 mm) compared to elderly (range 2.5–7.1 mm, mean 4.2 ± 1.4 mm) volunteers (P = 0.074) although a tendency can be highlighted. ConclusionsUltrasound demonstrated the different consistency of rotator cable in young and elderly asymptomatic patients, with high interobserver reproducibility.

Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons

The aim of this study was to report orthopedic surgeons' management of choice for difficult clinical scenarios of shoulder pathologies. A web questionnaire was developed including four clinical scenarios of shoulder pathologies. Subsequently, opinions were solicited from more than 1,000 members of an international association of surgeons specialized in sports traumatology and knee surgery (ESSKA). The response rate was 40% (412 questionnaires). For scenario 1, first anterior dislocation of the shoulder, the most indicated treatment for 71% of respondents was an arthroscopic Bankart repair (P < 0.001). For scenario 2, shoulder arthritis with concentric erosion and cuff tear, 38% chose a shoulder replacement, while 37% preferred a supraspinatus tendon repair in combination with long head of biceps (LHB) tenodesis or tenotomy. For scenario 3, large tendon tears with 70% fatty infiltration of the infraspinatus tendon and lateral LHB instability, 70% of surgeons considered that, among conservative treatments, hyaluronic acid injection was not an appropriate management. Arthroscopic rotator cuff repair, arthroscopic acromioplasty, and LHB tenotomy gained larger consensus (81, 80, and 79% of respondents, respectively). A double-row technique for rotator cuff repair was preferred to a single-row technique (P = 0.02). Scenario 4, adhesive capsulitis, split the respondents equally, with 51% in favor of a surgical approach and 49% in favor of a conservative approach (N.S.). On-line questionnaires have the potential to improve knowledge about current trends in clinical practice and can help orthopedic surgeons to develop guidelines. Cross-sectional; Level V (expert opinion).

Paper # 219: Cell Therapies Enhance Bone Tendon Healing in a Degenerative Model of Enthesis Lesion

Mesenchymal stem cell therapy regenerates the enthesis In order to explore the efficiency of adjuvant therapies to restore the enthesis in cuff tear, we conduct and animal study which the aim was first to validate a degenerative small animal model exploring global healing rate after surgical repair and second to evaluate the effect of several cell therapies compare to single repair. Achilles' tendon of 3 months wistar rats were released from the calcaneum. The enthesis was destroyed, and the tendon was fixed back by sutures to the bone (G1). Animals were sacrificed to explore histological and biomechanical data. Failure of the healing was defined by 3 reproducible criteria (kappa=1). The global healing rate was 40%, close to degenerative data in clinical practice. Fresh chondrocytes (G2) and expended MSC's (G3) from 4 days-old wistar rats were then injected during repair of 30 animals in a fibrin glue solution. For the global healing rate, a statistically significant difference occurred between G1 and G3 (p=0,006) and G1 and G2 (p=0,0028). At 45 days load to failure was 80,3 N (SD=13,0) in G2 versus 65,8 N (SD=12,9) in G1 and 87,8 (SD=19,6) in G3 with a statistically significant difference (p<0,05). No type II collagen was identified in 15 days in any group. At 30 days, the major production of type II collagen occurred in G2. The enthesis induced by MSC therapy has histological criteria of a native enthesis at 45 days (p<0,05). The current study, validating a small animal model, demonstrates that cell therapy enhances bone tendon healing. Chondrocytes produce type II collagen at an earlier stage, but MSC induced enthesis has biomechanical and histological aspect close to the native one, thus suggesting that MSC's induce the regeneration of the all enthesis.

A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients

This study analyzed the demographic and morphologic features of rotator cuff disease in paraplegic patients who presented with or without shoulder pain. Clinical and magnetic resonance imaging examinations of both shoulders were performed in 317 paraplegic patients. Mean age was 49 (range, 19-76) years. The level of spinal cord injury was between T2 and T7 In 54% of patients and between T8 and L3 in 46%. Constant scores were measured for all shoulders. Pain was analyzed using a visual analog scale. Rotator cuff tears were not present in 51%, were unilateral in 20%, and were bilateral in 29%. Age was older and duration of spinal cord injury was significantly longer in patients with bilateral tears than in patients without or with unilateral tears (P < .001). In patients with unilateral tears, a full-thickness rupture of the supraspinatus tendon was found in 67%, whereas a partial-rupture was detected in 33%. Of the patients with bilateral tears, 75% presented with a full-thickness rupture and 25% with a partial rupture. The mean Constant score was 76 (range, 37-98) in patients without cuff tears, 69 (range, 16-94) for patients with unilateral tears, and 64 (16-96) for patients with bilateral tears (P < .001). Rotator cuff disease is common and correlates highly with age and duration of spinal cord injury, which underlines the theory of "wear and tear" in wheelchair-dependent patients.

Arthroscopic rotator cuff repair: suture anchor properties, modes of failure and technical considerations

Rotator cuff injury and tears are a common source of shoulder pain, particularly among the elderly. Arthroscopic repair has now become the mainstay in the treatment of significant injuries that have failed conservative therapy. Compared with the traditional open technique, arthroscopic repair offers patients smaller incisions and less soft-tissue trauma, which result in improved postoperative pain and rehabilitation. The advances that have made arthroscopic repairs a reality includes improvement in arthroscopic rotator cuff instrumentation, particularly suture anchors. Suture anchors are used to reattach the torn rotator cuff tissue back onto the bone. Current rotator cuff anchors vary by design, anchor composition and suture materials. A treating physician should be aware of the advantages and limitations of these implants, which may influence the choice of one anchor over another. In addition to anchor variables, other factors that may affect the success of the repair include the local environment and surgical technique. In this article, various aspects of anchor design will be discussed. In addition, a concise review of technical considerations will also be discussed.

Reverse Prostheses in Arthropathies With Cuff Tear: Are Survivorship and Function Maintained Over Time?

The use of reverse shoulder arthroplasty has considerably increased since first introduced in 1985. Despite demonstrating early improvement of function and pain, there is limited information regarding the durability and longer-term outcomes of this prosthesis. We determined complication rates, functional scores over time, survivorship, and whether radiographs would develop signs of loosening. We retrospectively reviewed 527 reverse shoulder arthroplasties performed in 506 patients between 1985 and 2003. Clinical and radiographic assessment was performed in 464 patients with a minimum followup of 2 years and 148 patients with a minimum followup of 5 years (mean, 7.5 years; range, 5-17 years). Cumulative survival curves were established with end points being prosthesis revision and Constant-Murley score of less than 30 points. Eighty-nine of 489 had at least one complication for a total of 107 complications. Survivorship free of revision was 89% at 10 years with a marked break occurring at 2 and 9 years. Survivorship to a Constant-Murley score of less than 30 was 72% at 10 years with a marked break observed at 8 years. We observed progressive radiographic changes after 5 years and an increasing frequency of large notches with long-term followup. Although the need for revision of reverse shoulder arthroplasty was relatively low at 10 years, Constant-Murley score and radiographic changes deteriorated with time. These findings are concerning regarding the longevity of the reverse shoulder arthroplasty, and therefore caution must be exercised when recommending reverse shoulder arthroplasty, especially in younger patients. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.