Fatty Infiltration Of Infraspinatus Research Articles

Footprint and augmented anchorage

One-stage procedure for gaining adequate bone stock and rotator cuff repair. Tears of the rotator cuff in combination with bony cysts or reduced bone quality at the footprint. Allergies to contents of the bone void filler, fatty infiltration of infraspinatus and subscapularis of stage 3 and 4, narrowing of the subacromial space (< 7mm). We report a one-stage technique for footprint reconstruction in a rotator cuff tear-associated greater tuberosity cyst by augmenting the cystic lesion with an injectable, absorbable, biocompatible, fiber reinforced bone void filler in combination with a double row rotator cuff reconstruction technique. The arm is placed in a shoulder-immobilizing abduction pillow to achieve 30° abduction for a period of 4-6weeks. The physical therapy program includes passive mobilization of the affected shoulder to 60-90° flexion/abduction within the first 3weeks. During the next 3weeks, the passive mobilization is changed to active mobilization, starting with assisted exercises. Active exercises without limitation in range of motion are not allowed until the 7th week after surgery and moderate sports not until the third month post-surgery. Six patients have been treated using the presented technique. However, long term results are still missing.

What is the current practice in Europe when difficult shoulder injuries are treated?

In this issue of the journal, a group of Italian researchers discusses the European orthopedic surgeon’s management of choice for several difficult clinical scenarios of shoulder pathologies [1]. They divided their survey into four scenarios; i.e., anterior shoulder dislocation, shoulder arthritis combined with rotator cuff tear, large rotator cuff tendon tears combined with major fatty infiltration of the infraspinatus muscle and instability of the long head of the biceps and finally adhesive capsulitis. It might be claimed that at least three out of four are difficult cases. Therefore, the answers are of great interest. The authors used an online Web-based questionnaire and it is obvious that a questionnaire of this kind has the potential to improve our knowledge about the current trends in modern technology and ultimately might be helpful in creating clinical guidelines on a large scale. The first scenario was related to anterior dislocation of the shoulder. Interestingly, more than 70 % of the orthopedic surgeons recommended arthroscopic Bankart reconstruction, approximately half as an acute procedure and the rest as a planned procedure. This is the case description: ‘‘21-year-old male, recreational soccer player, first-time shoulder dislocation, with a minimal Hill-Sachs lesion, and a Bankart lesion’’… Less than 30 % of the surgeons recommended non-surgical treatment, which is of interest. The question is whether we really know that an acute/ semi-acute surgical procedure is the correct way to approach this particular—and in fact very common— problem. There might be arguments for instance for a more conservative approach. Also interesting is the recommendation for a brace in internal or external rotation in almost 75 %. The second scenario is a 55-year-old female with painful shoulder arthritis, total supraspinatus tear and infraspinatus fatty infiltration. In this case, the majority of surgeons (more than 60 %) recommended surgical treatment, while less than 40 % would favor a conservative regimen. Supraspinatus tendon repair/reconstruction was recommended by 85 % of all surgeons, with or without biceps tenodesis/tenotomy. The question is whether we really know if biceps tenodesis/tenotomy is needed in a case like this? Again, the dominance of surgical approach is of great interest. Only few surgeons recommended either debridement or shoulder replacement (15 %) in this patient. The third scenario is a 65-year-old male manual worker,

The Presence of Fatty Infiltration in the Infraspinatus: Its Relation With the Condition of the Supraspinatus Tendon

We aim to determine the prevalence of fatty infiltration and tears in the infraspinatus and to identify any associated risk factors. Shoulder magnetic resonance imaging scans from 2006 to 2009 were reviewed. Arthrograms, inflammatory arthropathies, neoplasms, and fractures were excluded. Rotator cuff tears were graded in 4 categories: no tear, partial tear, and complete tear with and without retraction. Fatty infiltration was graded by radiologists using the modified Goutallier classification. Supraspinatus muscle atrophy (size) was measured by use of the ratio of the cross-sectional area of the muscle to the supraspinatus fossa on a sagittal T1-weighted sequence. Three hundred seventy-seven scans were included. The prevalence of infraspinatus tears was as follows: no tear, 74.8%; partial tear, 17.5%; complete tear, 3.2%; and complete tear with retraction, 4.5%. Fatty infiltration of grade 2 or higher was found in 18.1% of the infraspinatus without tears, 39.4% with partial tears, 66.7% with a complete tear, and 82.4% with a complete tear with retraction. In the infraspinatus without tears, increasing fatty infiltration was correlated with the severity of a concomitant supraspinatus tear. Fatty infiltration of grade 2 or higher in the infraspinatus without tears was found in 7.8% of shoulders with an intact supraspinatus, 18.6% with a partial supraspinatus tear, 23.5% with a complete supraspinatus tear, and 54.6% with a retracted complete supraspinatus tear. Supraspinatus muscle atrophy was correlated with infraspinatus fatty infiltration. Increased infraspinatus fatty infiltration was correlated with the severity of an infraspinatus tear. However, substantial fatty infiltration of the infraspinatus was seen even in the absence of a tear, and it was correlated with a worsening severity of a concomitant supraspinatus tear and atrophy. Concern over tear progression and increasing fatty infiltration of the infraspinatus may impact the management of isolated supraspinatus tendon tears. Level IV, prognostic case series.

Natural history of infraspinatus fatty infiltration in rotator cuff tears

Muscular fatty infiltration (FI) represents an important prognostic factor in rotator cuff repair. The goal of this study was to analyze the natural history of infraspinatus FI in rotator cuff tears to determine the timing of the appearance and the speed of progression of this phenomenon. The preoperative MRI or CT-arthrograms of 1688 patients operated for rotator cuff tears were reviewed. The degree of infraspinatus FI was correlated with the type of tendon tear, patient sex, dominant hand, presence of traumatic injury, delay between the onset of symptoms and imaging studies, and age of the patients at imaging. Infraspinatus FI was graded on axial images according to Goutallier classification and described as minimal (stage 0 or 1), medium (stage 2), and severe (stages 3 and 4). Statistical regression was used to determine the most significant factors. Infraspinatus FI increased significantly in presence of an infraspinatus tendon tear and when multiple tendons were torn (P < .0005), with increasing delay between the onset of symptoms and imaging studies (P < .0005) and increasing patient age (P < .0005). Medium FI appeared on average 2 and a half years after the onset of symptoms, and severe FI appeared at an average of 4 years after symptom onset. Larger tendon tears, longer delays after tendon rupture and older patient age are associated with more severe and frequent FI. Stage 2 FI appears at an average of 2 and a half years after the onset of symptoms, and surgical repair should be done within this time frame if possible.

Reverse Shoulder Arthroplasty Combined with a Modified Latissimus Dorsi and Teres Major Tendon Transfer for Shoulder Pseudoparalysis Associated with Dropping Arm

Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70 degrees to 148 degrees (+78 degrees ) and external rotation from -18 degrees to 18 degrees (+36 degrees ). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.