Normal Cuff Research Articles

Comparative Analysis of Critical Shoulder Angle and Acromion Index in Patients with or without Rotator Cuff Tear

Background: Recent evidence suggests that a high value of radiographic acromial indices such as critical shoulder angle (CSA) and acromial index (AI) may be associated with a higher incidence of rotator cuff tears (RCTs). The objective of this observational study was to evaluate the relationship between RCTs, CSA, and AI. Materials and Methods: We divided 68 patients with shoulder pain into two groups: Group 1, RCT and Group 2, normal cuff. Patients were evaluated with standard true anteroposterior (AP) radiographs. CSA and AI were calculated on true AP X-ray. Twenty-four males and 10 females were selected for Group 1 whereas 23 males and 11 females for Group 2. Results: The mean age for Group 1 was 53.23 years and for Group 2 was 47.53 years. CSA findings (mean ± standard deviation [SD]) were 37.5 ± 4.37 for Group 1 and 32.23 ± 3.19 for Group 2. Mean ± SD for AI were 0.72 ± 0.07 and 0.66 ± 0.09 for Groups 1 and 2, respectively. CSA and AI revealed a statistically significant P < 0.0001 for both groups. Logistic regression confirmed CSA and AI to be strong predictors of an RCT. Conclusions: Higher CSA and AI are associated with degenerative RCT. Level of Study: Level III.

Educational Intervention Can Improve the Pilot Balloon Palpation Method of Tracheal Tube Cuff Pressure Monitoring: An Experimental Study

Abstract Background: Considerable morbidity is attributable to inappropriate tracheal cuff pressure. An earlier study undertaken in our hospital revealed that a normal cuff pressure of 20–30 cm H2O was achieved in only 6% of intubated patients using subjective estimation methods. Objective: To determine whether a training intervention could improve the accuracy of the subjective estimation method in our tracheal cuff monitoring. Materials and Methods: A 1-day training session was conducted in April 2022 for our anaesthesia providers. The cuffs of different sizes of endotracheal tubes were inflated to 25 cm H2O, and each staff was requested to feel the turgor of the pilot balloon. Subsequently, anaesthesia providers used pilot balloon palpation for the regulation of the tracheal cuff pressure in consecutive patients undergoing general anaesthesia with endotracheal intubation. During each intubation, a manometer was used to crosscheck the inflated cuff pressure objectively. The incidence of post-operative sore throat was also evaluated. The obtained outcomes were compared with pre-intervention data obtained from an earlier study conducted in the health facility from October 2020 to September 2021. Significant differences were considered when P < 0.05. Results: The mean tracheal cuff pressure was improved post-intervention (49.2 ± 24.1 cm H2O versus 77.1 ± 31.1 cm H2O; P < 0.001). A significantly higher proportion of tracheal cuffs (20%; 31/156) were inflated within the normal range compared to 6% (9/141) prior to the intervention (P = 0.003). Fewer patients developed post-operative sore throat following the educational intervention (32.8%; 41/125) versus pre-intervention (47.7%; 53/111; P = 0.019). Conclusion: The educational intervention improved the safety of tracheal cuff management, which could positively impact airway management, especially in poor resource settings without cuff manometers.

Dichotomisation of Rotator Cuff Tendinopathy in Shoulder MRIs Reveals the Need for Further Diagnostic Improvements: A Cohort Study

"Background: Rotator cuff tendinopathy is most often described as a continuum between the normal cuff and rotator cuff tears with calcific tendinitis having its place along this continuum. Although many studies have focused on the role of magnetic resonance imagining (MRI) in diagnosing the extent of rotator cuff tears and their associated findings with good interobserver reliability, the same cannot be stated about MRI tendinopathy findings. Because of this discrepancy in diagnostic reliability, tendinopathy tends to be overtreated with injections when associated with symptoms, thus potentially increasing the risk of calcific tendinitis and progression toward rotator cuff tears. This study aims to assess whether diagnosing shoulder MRI tendinopathy patterns through dichotomization can accelerate clinical progress toward consensus. Methods: This study is a large retrospective cohort of 184 patients that underwent a 1.5T shoulder MRI for shoulder pain. Inclusion criteria were acromioclavicular arthrosis diagnosed in patients of any age. Exclusion criteria were partial or complete rotator cuff tears. Tendinopathy was considered the dependent variable and registered as a dichotomous variable while acromioclavicular joint arthrosis together with gender was categorical and age was the continuous variable. An attempt was made to generate a clinically significant binary logistic regression to assess the odds ratio of diagnosing tendinopathy based on age, gender, and acromioclavicular joint arthrosis status. Results: An overwhelming proportion of patients was positive for tendinopathy findings (95.11%). 64.12% of patients were within the active age group with patients within the 50-59 group being diagnosed the most with rotator cuff tendinopathy. Conclusions: Due to the high variability of MRI findings that can be considered positive for rotator cuff tendinopathy, an overwhelming skew toward a positive diagnosis was observed, thus dichotomizing tendinopathy diagnosis is not appropriate for clinically relevant conclusion-making "

24 ENDOSCOPIC AND CLINICAL CHARACTERISTICS OF POUCHITIS INVOLVING THE RECTAL CUFF IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE TREATED BY PROCTOCOLECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS

Abstract Background For patients with inflammatory bowel disease (IBD), surgical intervention is sometimes required due to medically refractory colitis or development of neoplasia. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most common procedure for patients with colitis. However, pouchitis can develop in up to 80% of patients after the surgery and significantly impairs quality of life. Despite the high prevalence of pouchitis, endoscopic phenotypes have not been clarified. This study assessed the frequency and characteristics of inflammation involving the rectal cuff. Methods This is a retrospective study from a tertiary IBD center of IBD patients treated by total proctocolectomy with IPAA and subsequently underwent pouchoscopies at the University of Chicago between January 2007 and September 2019. We reviewed the endoscopic findings in different areas of the pouch: the pre-pouch ileum, inlet, “tip of the J”, proximal and distal pouch, anastomosis, rectal cuff, anal canal, and perianal area. This analysis evaluated all available pouchoscopies per patient and included patients with normal cuff and those with cuffitis noted in every pouchoscopy. Demographic and endoscopic data were assessed to compare patients with normal cuff and those with cuffitis. Fisher’s test was used for a univariate analysis to assess factors contributing to cuffitis. Logistic regression analysis was performed as a multivariate analysis including univariate variables with a P-value < 0.15. Results We reviewed 1,081 pouchoscopies from 426 IBD patients who underwent proctocolectomy with IPAA and identified 184 patients (43%) with normal cuff and 107 (25%) with cuffitis. Of these 291 patients, 57% were men, 92% were Caucasian, the mean age at the diagnosis (SD) was 26 ± 12 years, and mean BMI 26 ± 5 kg/m2. The diagnosis before surgery for these patients were for ulcerative colitis (91%), indeterminate colitis (5.8%), and Crohn’s disease (1.7%). A significant difference (P = 0.003) was found in the frequency of pouchitis between patients with normal cuff (126/184, 69%) and those with cuffitis (90/107, 84%) (Table 1). Although not statistically significant, the frequency of pouch failure in patients with cuffitis (13/107, 12%) was higher than those with normal cuff (12/184, 6.5%). Multivariate analysis showed pouchitis was significantly associated with cuffitis (OR = 2.2; 95% CI = 1.2–4.2; P = 0.01) (Table 2). Endoscopic data showed that the pre-pouch ileum was significantly (P = 0.001) involved in patients with cuffitis (45/90, 50%) compared with those with normal cuff (36/126, 29%). Conclusion Our analysis of 291 patients suggested that cuff inflammation can be a significant risk factor of pouchitis and is significantly associated with the development of inflammation in the pre-pouch ileum. Cuffitis can be a therapeutic target to improve J pouch outcomes.

The interaction of subglottic drainage, cuff pressure, and oral care on endotracheal tube fluid leakage: A benchtop study

BackgroundThe types of endotracheal tube, positive end-expiratory pressure (PEEP) level, endotracheal tube cuff pressure level, and nursing activity may influence the occurrence of pulmonary aspiration in ventilated patients with an endotracheal tube, but the evidence on their degree of influence is still inconclusive. AimThe aim of this study was to examine the effect of endotracheal tubes with or without subglottic secretion drainage on fluid leakage across endotracheal tube cuffs under different PEEP levels, different cuff pressures, and with or without oral care. MethodThis was a benchtop study with a multifactorial experimental design using two sets of airway. The two types of endotracheal tubes were tested through 12 scenarios with 240 combinations of different PEEP levels (0, 5, and 10 cmH2O), endotracheal tube cuff pressures (15 and 25 cmH2O), and oral care (with or without) using two sets of airway manikins. Each scenario lasted for 30 min, and fluid leakage was measured at the end of each scenario. Generalised Linear Model test was used to analyse fluid leak at 30 min (with and without interaction effect). ResultsA total of 100 cases showed fluid leakage, with more fluid leakage occurring in low cuff pressure (15 cmH2O), no PEEP, and with oral care. Results of the Generalised Linear Model revealed that endotracheal tubes with subglottic secretion drainage, high PEEP (at 10 cmH2O), normal cuff pressure (at 25 cmH2O), and no oral care demonstrated a significant effect in reducing fluid leakage than endotracheal tubes without subglottic secretion drainage, low PEEP (at 5 or 0 cmH2O), and low cuff pressure (at 15 cmH2O) (all p < 0.001). However, only the interaction effect of endotracheal tubes with subglottic secretion drainage*high PEEP showed a significant effect on fluid leakage (p < 0.001), with the combination of endotracheal tube*no PEEP producing the greatest volume of fluid leak. ConclusionUsing endotracheal tubes with subglottic secretion drainage, high PEEP, and normal cuff pressure and avoiding excessive endotracheal tube movement during oral care reduced fluid leakage. This study provided strong evidence to inform practice on reducing microaspiration in ventilated patients.

Bone healing potential of fascia lata autografts to the humeral head footprint in rotator cuff reconstruction based on magnetic resonance imaging and histologic evaluations

The purpose of the study was to evaluate the bone healing potential of fascia lata autograft (FLA) by magnetic resonance imaging (MRI) and histologicanalysis. The study included 69 patients assessed by MRI after an FLA patch procedure. Three of the 69 patients underwent a revision procedure after the primary FLA procedure; 1 underwent a second-look arthroscopy and 2 underwent reverse shoulder arthroplasties (RSAs). In the 2 RSA patients, we histologically evaluated greater tuberosities with the repaired graft. Moreover, as a control, we harvested the greater tuberosity with the cuff tendon at the time of RSA for failed open reduction-internal fixation of 4-part proximal humeral fracture. Based on MRI, retear cases were divided into type 1 (the graft did not remain on the greater tuberosity) and type 2 (the graft remained on the greater tuberosity). Histologicsections were evaluated to examine fascia-bone or rotator cuff-bone interfaces. There were 35 intact repairs: 7 type 1 and 27 type 2 shoulders (type 1 vs. type 2, P < .001). Second-look arthroscopic findings confirmed that the graft was securely attached to the greater tuberosity. Histologicanalysis of greater tuberosities in RSA patients showed solid continuity of the graft to the bone, with cells with nuclei in the collagen matrix oriented in parallel. The FLA to bone junction consisted of the FLA, fibrocartilage, and bone, which is similar to the normal cuff tendon to bone junction. These results indicate that a fresh cellular FLA has good to excellent bone healing potential.

Difference of Critical Shoulder Angle (CSA) According to Minimal Rotation: Can Minimal Rotation of the Scapula Be Allowed in the Evaluation of CSA?

BackgroundMinimal rotation of the scapula may affect the measurement of critical shoulder angle (CSA). We investigated the difference in the CSA measured in minimal rotation between the patients with rotator cuff tear and those without non-rotator cuff tear and the CSA measurement error by comparing with computed tomography (CT).MethodsWe retrospectively reviewed patients with full-thickness rotator cuff tear and whose X-ray views correspond to Suter-Henninger classification type A1 and C1. The CSA values between the normal control group (without rotator cuff tear) and the rotator cuff tear group were compared according to A1 type and C1 type. In the rotator cuff tear group, we compared the CSA values measured by using X-ray and CT.ResultsA total of 238 patients (rotator cuff tear group, 139 patients; normal cuff group, 99 patients) were included in this study. The mean CSA of the rotator cuff tear group was 33.4° ± 3.5°, and that of the normal cuff group was 32.6° ± 3.9° (p = 0.085). On comparison of the CSA according to the Suter-Henninger classification type, the CSA values on the A1 type view and C1 type view were 32.7° ± 3.5° and 33.7° ± 3.5°, respectively, in the rotator cuff tear group and 30.5° ± 3.1° and 33.1 ± 3.9°, respectively, in the normal cuff group (p = 0.024 and p = 0.216, respectively). The mean CSA was 32.5° ± 3.1° in CT and 33.3° ± 3.2° in X-ray (p = 0.184). On comparison of the CSA according to the Suter-Henninger classification type, the CSA values on the A1 type view and C1 type view were 32.6° ± 3.6° and 32.5° ± 2.4°, respectively, in CT and 32.5° ± 3.5° and 34.2° ± 2.6°, respectively, in X-ray (p = 0.905 and p = 0.017, respectively).ConclusionsThe X-ray view corresponding to Suter-Henninger classification type A1 or CT-reconstructed image can be used to reduce the measurement error and obtain reliable CSA values. The CSA measured on the X-ray view corresponding to Suter-Henninger classification type A1 may be related with rotator cuff tear.

Comparison of tracheal tube cuff pressure with two technique: fixed volume and minimal leak test techniques.

Introduction: There is a correlation between endotracheal cuff pressure and airway complication; therefore, cuff pressure measurement is of an essential importance. The gold standard technique is measuring the cuff pressure by a calibrated manometer. However, there are several methods that injects air into balloon pilot and measures the cuff pressure. The aim of this study is to compare the tracheal cuff pressure measurement by two methods: fixed volume and minimal leak test (MLT). Methods: This descriptive study was performed at the emergency department on 110 patients. Patients were randomized into two groups. For one group, fixed volume technique and for the other group MLT was used. Results: Mean cuff pressure was 46.07±23.54 cmH2O in the fixed volume group and 33.72±9.14 cmH2O in the MLT group (P=0.05) which is significantly higher in the fixed volume group (P=0.028). In addition, 56.4% and 78.2% of the subjects had normal cuff pressure in the fixed volume group and MLT group, respectively; indicating a significantly higher rate in MLT group (P=0.025). Conclusion: Both techniques cause above normal intracuff pressure; however, MLT produces more acceptable pressure than fixed volume. It seems that the volume of 10 cc produces high pressures; therefore, fixed values may yield more appropriate results in lower volumes.

Comparison of Different Cuff Pressure Use with the Supreme Laryngeal Mask Airway on Haemodynamic Response, Seal Pressure and Postoperative Adverse Events: A Prospective Randomized Study.

The Supreme™ laryngeal mask airway (SLMA) is a supra glottic airway (SGA) device that is used as an alternative to endotracheal tubes. In the present study, we aimed to compare the use of the SLMA with normal cuff pressure and low cuff pressure, primarily for haemodynamic response. In the present study, 120 patients diagnosed with hypertension and scheduled for varicose vein or inguinal hernia operation were enrolled and 99 patients finished. Using randomization, patients were divided into two groups according to cuff pressure as a low-pressure group (Group L, 45 cm H2O) and a normal-pressure group (Group N, 60 cm H2O). Demographics, Mallampati score and the type and duration of surgery, heart rate (HR), mean arterial pressure (MAP), percentage of tidal volume leakage, Ppeak, Pmean, etCO2, seal pressure, fibreoptic scores and postoperative adverse effects of all patients were recorded. MAP and HR values immediately and 2 minutes after SLMA insertion were significantly lower in Group L (p<0.001). In Group L and Group N, the seal pressures were 24.1±3.1 cm H2O and 26.2±3.9 cm H2O, respectively (p=0.003). Also, blood staining and sore throat occurred less frequently in Group L (p<0.05). The fibreoptic average score, insertion features and ventilation parameters were similar between the groups (p>0.05). SLMA use with a cuff pressure of 45 cm H2O significantly decreases haemodynamic response and post-operative side effects compared with a normal cuff pressure. Therefore, except for some specific surgeries that require higher seal pressures, we recommend the use of the SLMA with cuff pressures as low as 45 cm H2O.

Does scapular morphology affect the integrity of the rotator cuff?

Current evidence suggests that distinct scapular morphologies may predispose patients to a rotator cuff tear. The objective of this longitudinal study was to evaluate the relationship between symptomatic degenerative cuff tears and different radiographic acromial characteristics, including acromion shape, indices (acromial index [AI], critical shoulder angle [CSA]), and acromial spur. We divided 166 patients into 3 groups matched for age and sex: group 1, degenerative full-thickness tear; group 2, partial thickness bursal tear; and group 3, normal cuff. Patients were evaluated with standard radiographs and ultrasonography. The presence of an acromial spur was strongly associated with a full-thickness cuff tear (odds ratio, 3.5; P = .001). AI and CSA revealed a statistically significant difference between means of group 1 (P = .006) and group 3 (P < .001). There was no statistically significant difference in means of AI between groups 1 and 2 (P = .695) and between groups 2 and 3, with respect to AI (P = .071) and CSA (P = .125). Receiver operating characteristic curve revealed a higher area for CSA (0.70) than for AI (0.61). Stepwise logistic regression rejected AI as a cuff tear predictor but confirmed CSA and a spur to be stronger predictors of a full-thickness cuff tear. There was no association between the Bigliani acromial type and rotator cuff tear (P = .06). The presence of an acromion spur is strongly associated with full-thickness cuff tear. Higher AI and CSA are associated with a full-thickness tear but not with partial tears. The type of acromion is not related to cuff tear.

Microvascular blood flow in normal and pathologic rotator cuffs

Microvascular blood flow in the tendon plays an important role in the pathogenesis of rotator cuff abnormalities. There are conflicting views about the presence of a hypovascular zone in the supraspinatus tendon. Besides, no studies have looked at the pattern of blood flow around a partial-thickness tear. Our aim was to measure microvascular blood flow in normal and a range of pathologic rotator cuff tendons using laser doppler flowmetry. A total of 120 patients having arthroscopic shoulder surgery were divided into 4 equal groups on the basis of their intraoperative diagnosis: normal rotator cuff, subacromial impingement syndrome, and partial-thickness or full-thickness rotator cuff tear. Microvascular blood flow was measured at 5 different regions of each cuff using a laser doppler probe. The values were compared to assess variability within and between individuals. Total blood flow was greater in the normal rotator cuff group compared with the groups with pathologic rotator cuffs, with the largest difference seen in the subacromial impingement group. Within individuals, blood flow was highest at the musculotendinous junction and lowest at the lateral insertional part of the tendon. Among groups, the blood flow was significantly lower at the anteromedial and posteromedial cuff in the groups with impingement and full-thickness tears compared with the group with normal cuff. Real-time in vivo laser doppler analysis has shown that microvascular blood flow is not uniform throughout the supraspinatus tendon. Blood flow in the pathologic supraspinatus tendon was significantly lower compared with the normal tendon.

The management of acute peripheral arterial bleeding in emergencies: a plastic surgeon’s perspective

Sir, Peripheral arterial bleeding following trauma commonly presents to the emergency department. There is currently no national guideline for achieving haemostasis in the acute setting prior to definitive management. As plastic surgeons, we are often referred patients with uncontrolled bleeding in the accident and emergency (AE the other two said they would apply manual pressure without attempting to dress the wound. Twenty-two described a compression bandage comprising multiple layers of tight bandage around the wrist. The remaining nine described a point pressure dressing, using a solid object to focus the pressure of the bandage over the wound, such as a specimen lid or folded gauze placed over a non-adherent dressing over the wound. Twenty-one clinicians would apply manual pressure directly over the wound with or without a dressing. Surprisingly, only 14 mentioned elevation of the limb and 7 mentioned application of a tourniquet. Several other suggestions were made, such as underrunning the vessel with a suture, applying a surgical clip to the vessel or administering a local anaesthetic containing epinephrine. Although these suggestions can obtain haemostasis, it is preferable to stop bleeding without invasive measures that will potentially traumatise the vessel further endangering viable tissue for repair later, and this is only recommended as a last resort in order to preserve life. Often when faced with an acute traumatic arterial bleed, manual digital pressure is appropriate initially; however, this is impractical over prolonged periods and an appropriate dressing to control the bleeding is required until definitive surgical management is achieved. Rudge [1] et al. described using a specimen pot lid filled with cotton wool, placed over a non-adherent dressing over the wound and bandaged into position, with the bandage twisted over the lid to increase compression. We have also found this technique to be effective. Our management differed as we placed the lid flat side down and bandaged over the lid without twisting the bandage or filling the lid with cotton wool and still found this to be effective. In practice, the specimen lid can be interposed with anything that is relatively firm and can focus the compressive force over the desired point. This allows pressure to be localised to the desired point without compromising distal blood flowwhich commonly occurs with traditional tight bandaging. Our questionnaire identified elevation is not commonly implemented by over half of our cohort. This is easily rectifiable by educating and training staff. Furthermore, a tourniquet can be applied proximally to the wound to prevent blood loss if other methods fail. If provision allows, an improvised tourniquet can be made using a normal blood pressure cuff. This allows an easily applicable and controllable method of * Metin Nizamoglu mnizam@doctors.org.uk

Assessment of the rotator cable in various rotator cuff conditions using indirect MR arthrography

The rotator cable is an important structure providing stress shield to the rotator cuff, similar to the mechanism of suspension bridge. To evaluate the visibility and appearance of the rotator cable in various conditions of the rotator cuff, using indirect magnetic resonance (MR) arthrography. Indirect MR arthrography images from 27 patients (age range, 20-63 years) with normal rotator cuffs, and 47 (age range, 20-73 years) with tendinosis, 32 (age range, 49-71 years) with partial-thickness tears, and 55 (age range, 44-75 years) with full-thickness tears in the supraspinatus and infraspinatus tendons (SST-ISTs) were included in this study. In these various rotator cuff conditions, the visibility and appearance (thickness and width) of the rotator cable and the relationships between the rotator cable appearance, rotator cuff tear size, rotator cuff thickness, and patient's age were assessed. On the sagittal MR images, all rotator cables were visible in the normal rotator cuffs and tendinosis/partial-thickness tears of SST-ISTs. In the order of normal cuff, tendinosis, partial-thickness tear, and full-thickness tear of SST-ISTs, the rotator cable tended to become thicker (1.07, 1.27, 1.32, and 1.59 mm, respectively) and narrower (12.1, 10.68, 10.90, and 8.55 mm, respectively). The thickness of the rotator cable was significantly positively correlated with the rotator cuff thickness in the normal rotator cuffs (coefficient, 0.49; P = 0.010) and tendinosis of SST-ISTs (coefficient, 0.53; P < 0.001), but was not correlated with patients' age. On sagittal plane of indirect MR arthrography, most rotator cables were visible. The appearance of the rotator cable changed according to the rotator cuff condition.

The Professional Experience of Anaesthesiologists in Proper Inflation of Laryngeal Mask and Endotracheal Tube Cuff.

Cuffs inflated to inappropriately high pressures cause ischemia, reducing tracheal mucosal blood flow, while cuffs inflated at lower pressure than necessary give rise to inadequate ventilation, aspiration of gastric contents, or extubation due to air leakage. In this study, we aimed to investigate the effect of the experience of anaesthesia staff on endotracheal tube and laryngeal mask airway cuff inflation. The study included 348 elective patients scheduled to undergo surgery under general anaesthesia, with 34 anaesthesia technicians, 16 anaesthesia residents, and 12 anaesthesiologists with different years of professional experience. The participants were told to inflate the cuff balloon with air to the level of the pressure that was appropriate for them. No information was provided to the participants about the values of the cuff pressure pending the completion of all measurements. After placement of the laryngeal mask airway and endotracheal tube, the success of the procedure was checked by monitoring square-wave capnograph tracing and thoracoabdominal motion. Each participant performed the procedures on three patients, and the mean cuff pressures were measured. There was no significant correlation between duration of experience of technicians, residents, and experts in using laryngeal mask airway pressure (r=-0.192/p=0.278, r=0.225/p=0.402, r=-0.476/p=0.118, respectively) and endotracheal tube (r=-0.306/p=0.079, r=-0.060/p=0.826, r=-0.478/0.116, respectively). It has been concluded that professional experience does not contribute to achieving normal cuff pressure without monitoring. Introduction of the cuff manometer into routine anaesthesia practice will be useful, irrespective of anaesthesiologists' experience.

What Is the Prevalence of Senior-athlete Rotator Cuff Injuries and Are They Associated With Pain and Dysfunction?

Older individuals with rotator cuff injuries may have difficulties not only with activities of daily living, but also with sports activities. (1) How frequent and severe are rotator cuff abnormalities, as identified by ultrasound, in senior athletes? (2) To what degree does the severity of ultrasound-identified rotator cuff pathology correlate with pain and shoulder dysfunction? We assessed pain and shoulder function in 141 elite athletes older than 60 years of age (median age, 70 years; range 60-84) at the Senior Olympics who volunteered to participate. An ultrasound evaluation of the rotator cuff of the dominant shoulder was performed by an experienced musculoskeletal radiologist in all of these elite athletes. We then determined the relationship between ultrasound findings and shoulder pain and shoulder function as assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeons (ASES) scores. There were 20 shoulders with a normal cuff (14.2% [20 of 141], of which 5% [one of 20] were painful), 23 with tendinosis (16.3% [23 of 141], of which 30% [six of 20] were painful), 68 with a partial-thickness rotator cuff tear (48.2% [68 of 141], of which 32% [20 of 63] were painful), and 30 with a full-thickness rotator cuff tear (21.3% [30 of 141], of which 25% [seven of 28] were painful). Only 5% of athletes (one of 20) with a normal cuff on ultrasound evaluation reported shoulder pain, whereas 30% of athletes (33 of 111) with any degree of rotator cuff damage on ultrasound evaluation reported shoulder pain, This resulted in an odds ratio of 8.0 (95% confidence interval, 1.0-62.5). The proportion of patients who had pain was not different in those with different severities of rotator cuff pathology. Neither the ASES nor the DASH was different in those with different severities. The frequency of full-thickness rotator cuff tears in senior athletes was 21.3% (30 of 141). Pain was a predictor of rotator cuff injury but not of its severity. The odds of having shoulder pain was eight times greater in those athletes with any rotator cuff damage as compared with those without any rotator cuff damage. Those with pain had poorer shoulder function but the ASES and DASH were poor predictors of the severity of rotator cuff pathology. Rotator cuff tears in older individuals are often not painful and may not need to be repaired for successful participation in athletics. Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Intraoperative Surgical Suction Curettage to Facilitate Vaginal Surgery in a Morbidly Obese Woman with Endometrial Cancer

Abstract Background: Surgery was performed via the vaginal route on a morbidly obese and medically compromised woman with an enlarged uterus, possibly caused by endometrial cancer. Case: To debulk the uterus, suction curettage was performed after bisecting the cervix, and complete vaginal surgery was performed with zero contamination of healthy tissues. Results: The postoperative period was uneventful. Histopathology confirmed the presence of < ½ myometrial invasion and endometrioid adenocarcinoma of the endometrium with normal or uninvaded vaginal cuff, tubes, and ovaries. Conclusions: When feasible, safe intraoperative debulking should be considered, to enable use of the vaginal route for surgery on a woman with endometrial cancer, to spare her from the more morbid abdominal route. (J GYNECOL SURG 28:67)

How to Reduce Recurrent Laryngeal Nerve Palsy in Anterior Cervical Spine Surgery

Recurrent laryngeal nerve palsy (RLNP) occurs as a complication during anterior cervical spine surgery. In 2005 the authors demonstrated the high incidence of asymptomatic RLNP in a right-sided approach. This follow-up prospective observational study was designed to test 2 options said to reduce the rate of RLNP: reduced endotracheal cuff pressure and sinistral approach. Two hundred forty-two patients in whom anterior cervical spine surgery was performed were examined postoperatively with indirect laryngoscopy to evaluate the status of the vocal cords. All patients had a left-sided approach but 1 group (A, 149 patients) was operated on with an additional reduction of endotracheal cuff pressure to below 20 mm Hg. In 93 patients we could not reduce the cuff pressure. This group served as a control group (B). Both groups were compared with a historic control group with a right-sided approach and no cuff pressure reduction. In cases of vocal cord malfunction a follow-up examination was done 3 months later. Group A (low cuff pressure) had a total rate of persisting symptomatic and asymptomatic RLNP of 1.3% and group B had a rate of 6.5% (normal cuff pressure). Compared with the historic study (N = 120) with a right-sided approach and a total rate of persisting RLNP of 13.3% in the left-sided approach, a marked reduction to 6.5% and 1.3% with an additional reduction of cuff pressure was seen. The left-sided approach in anterior cervical spine surgery reduces the incidence of postoperative and permanent RLNP significantly. Endotracheal cuff pressure reduction used additionally decreases the rate of RLNP even more. These results indicate that anterior cervical spine surgery should be performed with a left-sided approach and, if possible, with an additional reduction of the endotracheal cuff pressure while the retractors are inserted.

Restoration of Normal Rotator Cuff Function after Successful Treatment of a Displaced Non-union of a Fracture of the Body of the Scapula

No previous reports have identified the mechanical disadvantage created by scapular body fractures or quantified the improvement in cuff function achieved by restoration of the scapular anatomy. We report a displaced non-union of the scapular body in a veteran pentathlete with weakness and early fatigue of rotator cuff function. Electromyography and magnetic resonance imaging excluded denervation, tendon rupture or muscle scarring. Characteristic anteromedial displacement of the lateral column fragment caused shortening of the transverse diameter of the scapula and the effective length of cuff muscle. Isokinetic dynamometry quantified cuff weakness, particularly in internal rotation. Healing of the non-union was demonstrated following open reduction, internal fixation, and bone grafting. Isokinetic dynamometry quantified restoration of normal cuff function, and an excellent clinical outcome was achieved. We conclude that measurable deficits in cuff function may follow scapular body fractures. Operative management to union can restore normal scapular and rotator cuff function.

Variations in endotracheal cuff pressure in intubated critically ill patients: prevalence and risk factors

An endotracheal cuff pressure of 20-30 cmH(2)O is recommended. Underinflation and overinflation are associated with complications such as aspiration and tracheal wall damage. The aim of this study was to identify prevalence of, and risk factors for, endotracheal cuff underinflation and overinflation. Prospective observational cohort study. All critically ill patients intubated with a high-volume lowpressure endotracheal tube were eligible. After manual adjustment of cuff pressure at 25 cmH(2)O, continuous recording of cuff pressure and airway pressure was performed for 8 h. Underinflation and overinflation of the endotracheal cuff were defined as cuff pressure less than 20 cmH(2)O and more than 30 cmH(2)O, respectively. In all patients, the time spent with normal cuff pressure or with underinflation or overinflation of the endotracheal cuff was measured. Univariate and multivariate analyses were used to determine risk factors for cuff underinflation and overinflation. Eight hundred and eight hours of cuff pressure recordings were analysed in 101 patients. Eighteen per cent of study patients spent 100% of recording time with normal (20-30 cmH(2)O) cuff pressure. Fifty-four per cent of study patients developed cuff underinflation, 73% developed cuff overinflation, and 44% developed both. Thirty- three per cent of study patients developed underinflation or overinflation for more than 30 min. Absence of sedation [odds ratio (95% confidence interval)=2.51 (1-6), P=0.03] and duration of prior intubation [1.16 (1.04-1.29), P<0.01] were independently associated with cuff underinflation. No risk factor for overinflation could be determined. The percentage of time spent with underinflation significantly (P<0.01) increased during the recording period. Variations in endotracheal cuff pressure are common in ICU patients. Duration of prior intubation and absence of sedation are independently associated with increased risk for cuff underinflation.

Measurement of blood flow in the rotator cuff using laser Doppler flowmetry

The aim of this study was to define the microcirculation of the normal rotator cuff during arthroscopic surgery and investigate whether it is altered in diseased cuff tissue. Blood flow was measured intra-operatively by laser Doppler flowmetry. We investigated six different zones of each rotator cuff during the arthroscopic examination of 56 consecutive patients undergoing investigation for impingement, cuff tears or instability; there were 336 measurements overall. The mean laser Doppler flowmetry flux was significantly higher at the edges of the tear in torn cuffs (43.1, 95% confidence interval (CI) 37.8 to 48.4) compared with normal cuffs (32.8, 95% CI 27.4 to 38.1; p = 0.0089). It was significantly lower across all anatomical locations in cuffs with impingement (25.4, 95% CI 22.4 to 28.5) compared with normal cuffs (p = 0.0196), and significantly lower in cuffs with impingement compared with torn cuffs (p < 0.0001). Laser Doppler flowmetry analysis of the rotator cuff blood supply indicated a significant difference between the vascularity of the normal and the pathological rotator cuff. We were unable to demonstrate a functional hypoperfusion area or so-called 'critical zone' in the normal cuff. The measured flux decreases with advancing impingement, but there is a substantial increase at the edges of rotator cuff tears. This might reflect an attempt at repair.