Superior Migration Of Humeral Head Research Articles

Plate Osteosynthesis of Proximal Humerus Fracture is Associated with Significant Complications and Poor Functional Score for Patients Older than 45 Years Old: A Cohort Study

BackgroundDespite the introduction of new implants and biomechanical improvements for proximal humerus fractures (PHF), the complication rate remains significant, particularly in older adults. This study aimed to identify risk factors for complications and failure following plate osteosynthesis for PHF and discuss an age cut-off that surgeons should consider for complications. MethodsAdults with PHF treated with the proximal humerus internal locking system (PHILOS) at our large tertiary academic referral center between 2015 and 2020 were retrospectively identified. Univariate analysis was used to compare patients with and without complications. Then, a multivariate regression analysis was conducted to assess the possible complication risk factors. The receiver operating characteristic (ROC) curve of age was drawn to predict complication-free and favorable functional outcomes at the most recent follow-up. Oxford Shoulder Score (OSS) was considered favorable if OSS<10. ResultsA total of 135 patients were identified, with a mean age of 44 years (range 18-85 years) and a mean follow-up duration of 4.6 years (range 2-8 years). Complications were observed in 19 cases (14.1%), namely nonunion (n=5), avascular necrosis (n=1), infection (n=1), intra-articular screw perforation (n=1), arthritic changes (n=5), and superior humeral head migration (n=5). Eight patients (5.9%) needed revision surgery. Older age (OR=1.09) and Neer IV class (OR= 8.3) were associated with an increased likelihood of complication (P<0.001, P=0.02, respectively) in logistic multinominal regression analysis. The ROC curve for age in predicting complication-free cases had an area under the curve (AUC) of 0.829, indicating age as a significant predictor of ORIF outcomes in PHF (P<0.05). The optimalcut-off for age was 44 years, which yielded a sensitivity of 100% and a specificity of 65.7. The age ROC curve for predicting favorable OSS (OSS<10) had an of 0.829, indicating that age could predict the favorable OSS outcomes of ORIF in PHF. The optimal age cut-off was 46 years, yielding a sensitivity of 70.0% and a specificity of 78.6%. ConclusionThe outcomes of ORIF for PHF in patients older than 45 years are associated with significantly higher complication rates and poorer functional outcomes. Surgeons should possibly consider other treatment options for PHF in each older patient individually, especially with Neer type IV fractures.

Superior capsular reconstruction using the long head of biceps tendon: a biomechanical assessment of tenodesis location and angle of fixation

BackgroundMassive irreparable rotator cuff tears (MIRCT) treated with superior capsular reconstruction (SCR) using the long head of the biceps tendon have shown satisfactory early results. Different techniques and positions for biceps tenodesis have been described. This study aimed to evaluate the effect of tenodesis location and glenohumeral fixation angle for graft tensioning on the biomechanics of a SCR using a single strand biceps technique. MethodsEight cadaveric shoulders were mounted to a custom biomechanical simulator which employed static tone loads to the deltoid and rotator cuff muscles. All cadavers were first tested in the intact condition, and then in the simulated MIRCT condition by sectioning the tendinous insertions of the supraspinatus and upper border of the infraspinatus. SCR using the long head of the biceps tendon was then evaluated. Three biceps tenodesis locations relative to the greater tuberosity (anterior, middle, and posterior) and two glenohumeral fixation angles (0° and 30°) for graft tensioning were tested. An optical tracking system was used to quantify superior-inferior (SI) and anterior-posterior (AP) humeral head translation relative to the glenoid, while the functional abduction force was quantified using a load sensor. All tests were conducted at 0°, 30° and 60° of glenohumeral abduction in a randomized fashion. ResultsWhen assessing isolated superior humeral head migration, all biceps tenodesis locations were effective at decreasing superior migration, with no tenodesis location significantly better than the other (P=0.213). However, biceps grafts tensioned at 30° of glenohumeral abduction were significantly better at reducing proximal humeral migration as compared to graft tensioning at 0° abduction (P=0.008).Posterior humeral head translation observed in the MIRCT condition was significantly reduced when tensioning the biceps tendon at 30° of glenohumeral abduction compared to 0° for all tenodesis locations (P≤0.043). Tenodesis location also significantly influenced posterior humeral head translation (P=0.001), with middle and posterior positions restoring near normal humeral head position when fixed at 30° glenohumeral abduction. All SCR techniques using the biceps tendon improved the functional abduction force relative to the MIRCT condition, although no statistically significant differences were observed relative to the intact condition (P≥0.448). DiscussionSCR using the long head biceps tendon is biomechanically effective in reducing posterosuperior translation of the humeral head in the setting of a MIRCT. Graft tensioning and fixation at 30° of glenohumeral abduction combined with either a middle or posterior tenodesis location on the greater tuberosity most effectively restores near normal time-zero humeral head kinematics.

Inferior subscapularis and hypertrophic teres minor contribute to preventing superior migration of humeral head

Inferior subscapularis and hypertrophic teres minor contribute to preventing superior migration of humeral head

Superior Capsular Reconstruction Combined With Lower Trapezius Tendon Transfer Improves the Biomechanics in Posterosuperior Massive Rotator Cuff Tears

Background: Surgical treatments for chronic posterosuperior massive rotator cuff tear (MRCT) are still controversial. Superior capsular reconstruction (SCR), which provides a static stabilizer to decrease superior humeral head translation, and lower trapezius tendon transfer (LTTT) with centralization of the humeral head, which prevents superior humeral head migration, are potential surgical options. To date, SCR combined with LTTT has not been fully investigated. Hypothesis: Restoration of static stabilizer and dynamic stabilizer together would effectively improve shoulder kinematics in posterosuperior MRCT. Study Design: Controlled laboratory study. Methods: A custom-made shoulder mechanics testing system was used to test 8 fresh-frozen cadaveric shoulders. The testing conditions were as follows: (1) intact; (2) posterosuperior MRCT (supraspinatus and infraspinatus removed); (3) SCR using the fascia lata; (4) LTTT; and (5) SCR combined with LTTT. The total rotational range of motion (ROM), superior translation, anteroposterior translation, and peak subacromial contact pressure were evaluated at 0°, 30°, and 60° of shoulder abduction. Repeated-measures analysis of variance and Tukey post hoc tests were performed. Results: The total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure increased in posterosuperior MRCTs (all, P < .05). The rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0° and 30° of shoulder abduction decreased in SCR (all, P < .05). However, there was no significant improvement in rotational ROM, superior translation, and peak subacromial contact pressure at 60° of shoulder abduction (P > .05). LTTT resulted in a significant decrease in the superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (P < .05). SCR combined with LTTT restored the total rotational ROM, superior translation, anteroposterior translation, and peak subacromial contact pressure at 0°, 30°, and 60° of shoulder abduction (all, P < .05). Conclusion: In the cadaveric model, SCR combined with LTTT showed improved shoulder kinematics and contact pressures in the posterosuperior MRCT model compared with SCR or LTTT alone. Clinical Relevance: SCR combined with LTTT may be regarded as an alternative surgical procedure for posterosuperior MRCTs.

Superior Capsular Reconstruction Partially Restores Native Glenohumeral Joint Loads in a Dynamic Biomechanical Shoulder Model

To evaluate the effect of an irreparable posterosuperior rotator cuff tear (PSRCT) on glenohumeral joint loads and to quantify improvement after superior capsular reconstruction (SCR) using an acellular dermal allograft. Ten fresh-frozen cadaveric shoulders were tested using a validated dynamic shoulder simulator. A pressure mapping sensor was placed between the humeral head and glenoid surface. Each specimen underwent the following conditions: (1) native, (2) irreparable PSRCT, and (3) SCR using a 3-mm-thick acellular dermal allograft. Glenohumeral abduction angle (gAA) and superior humeral head migration (SM) were measured using 3-dimensional motion-tracking software. Cumulative deltoid force (cDF) and glenohumeral contact mechanics, including glenohumeral contact area and glenohumeral contact pressure (gCP), were assessed at rest, 15°, 30°, 45°, and maximum angle of glenohumeral abduction. The PSRCT resulted in a significant decrease of gAA along with an increase in SM, cDF, and gCP (P < .001, respectively). SCR did not restore native gAA (P < .001); however, SM was significantly reduced (P < .001). Further, SCR significantly reduced deltoid forces at 30° (P= .007) and 45° of abduction (P= .007) when compared with the PSRCT. SCR did not restore native cDF at 30° (P= .015), 45° (P < .001), and maximum angle (P < .001) of glenohumeral abduction. Compared with the PSRCT, SCR resulted in a significant decrease of gCP at 15° (P= .008), 30° (P= .002), and 45° (P= .006). However, SCR did not completely restore native gCP at 45° (P= .038) and maximum abduction angle (P= .014). In this dynamic shoulder model, SCR only partially restored native glenohumeral joint loads. However, SCR significantly decreased glenohumeral contact pressure, cumulative deltoid forces, and superior migration, while increasing abduction motion, when compared with the posterosuperior rotator cuff tear. These observations raise concerns regarding the true joint-preserving potential of SCR for an irreparable posterosuperior rotator cuff tear, along with its ability to delay progression of cuff tear arthropathy and eventual conversion to reverse shoulder arthroplasty.

Arthroscopic Superior Capsular Reconstruction

Background: Limited options exist for young patients with massive, irreparable rotator cuff tears. While several treatment options exist, superior capsular reconstruction (SCR) was developed to restore glenohumeral joint stability by preventing superior humeral head migration during glenohumeral motion. Indications: Arthroscopic SCR is indicated in young patients with a massive, irreparable rotator cuff tear. Patients require a functioning deltoid muscle with minimal to no glenohumeral joint arthritis. In addition, patients should have Hamada grade 2 or less and should have an intact or repairable subscapularis tendon. Technique Description: The patient is positioned in the beach chair position. Standard anterior, posterior, and mid-lateral portals are established. An accessory posterior-superior lateral portal is used for visualization. Three 3.0 mm knotless anchors are placed in the glenoid through lateral percutaneous incisions. Two 4.75 mm anchors are placed adjacent to the humeral articular cartilage for medial row fixation. The graft dimensions are measured using the distance between the anchors. The graft is prepared using a gown card as a template with 5 mm added to the medial, posterior, and anterior graft dimensions, and 10 mm added to the lateral dimension. Sutures are passed through the graft in an inverted horizontal mattress for the glenoid anchors to diminish friction and allow appropriate suture passage through the knotless mechanism of the anchor. The graft is then shuttled into the joint through a lateral PassPort button cannula. Two lateral row anchors are used to secure the lateral graft on the humerus. Native rotator cuff tissue is repaired to the graft using sutures from the medial row anchors as well as free SutureTape. Results: Outcomes following SCR have demonstrated improvements in clinical outcomes and shoulder range of motion. Similar outcomes have been identified between the use of allograft and autograft. Patients generally are able to return to light recreational activities and work. Discussion/Conclusion: Arthroscopic SCR yields favorable results in the setting of a massive, irreparable rotator cuff tear. Meticulous surgical technique is needed to avoid intraoperative surgical complications. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Biomechanical comparison of lower trapezius and latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears using a dynamic shoulder model.

In the setting of irreparable posterosuperior rotator cuff tears (PSRCTs), lower trapezius transfer (LTT) may be anatomically better positioned for restoring the muscular force couple compared with latissimus dorsi transfer (LDT). The purpose of the study was to evaluate the effect of LTT and LDT on glenohumeral kinematics using a dynamic shoulder model. Ten fresh-frozen cadaveric shoulders (mean age: 56.5±17.2 years) were tested using a dynamic shoulder simulator. The maximum abduction angle (MAA), superior humeral head migration (SHM), and cumulative deltoid forces (CDFs) were compared across 4 conditions: (1) native; (2) irreparable PSRCT; (3) LTT using an Achilles tendon allograft; and (4) LDT. MAA and SHM were measured using 3-dimensional motion tracking. CDF was recorded in real time throughout the dynamic abduction motion by load cells connected to actuators. Compared to the native state, the PSRCT resulted in a significant decrease (Δ-24.1°; P<.001) in MAA, with a subsequent significant increase after LTT (Δ13.1°; P<.001) and LDT (Δ8.9°; P<.001). LTT achieved a significantly greater MAA than LDT (Δ4.2°; P=.004). Regarding SHM, both LTT (Δ-9.4 mm; P<.001) and LDT (Δ-5.0 mm; P=.008) demonstrated a significant decrease compared with the PSRCT state. LTT also achieved significantly less SHM compared with the LDT (Δ-4.4 mm; P=.011). Further, only the LTT resulted in a significant decrease in CDF compared with the PSRCT state (Δ-21.3 N; P=.048), whereas LTT and LDT showed similar CDF (Δ-11.3 N; P=.346). However, no technique was able to restore the MAA, SHM, and CDF of the native shoulder (P<.001, respectively). LTT and LDT both achieved a significant increase in MAA along with significantly less SHM compared with the PSRCT state. Although LTT required significantly less compensatory deltoid forces compared with the PSRCT state, this was not observed for the LDT. Further, the LTT prevented loss of abduction motion and SHM more sufficiently. In the challenging treatment of irreparable PSRCTs, LTT may restore native glenohumeral kinematics more sufficiently, potentially leading to improved postoperative functional outcomes.

Radiographic and Magnetic Resonance Imaging-based Evaluation of Supraspinatus Impingement Syndrome – A Narrative Review

Shoulder pain is a common debilitating problem affecting both young as well as elderly people. Its prevalence varies from 6-11% in young adults to 16-25% in elderly. Supraspinatus Impingement syndrome is the most common impingement syndrome causing shoulder pain. Primary or secondary reduction of subacromial distance due to morphological differences of acromion, acromial osteophytes, superior migration of humeral head etc. are predisposing factor for supraspinatus impingement. The aim of this review article is to understand the relevant anatomy of subacromial space and review supraspinatus impingement syndrome and its association with subacromial distance and acromion morphology. Literature search was conducted on PubMed and Google Scholar databases using MeSH terms – 'subacromial distance', 'Supraspinatus Impingement syndrome', 'Acromion', 'MRI'. 8 studies from 2006 to 2021 have been included for review. It was observed that subacromial distance and lateral acromial angle are lower in patients with supraspinatus impingement compared to the general population. Whereas the acromion index is higher in impingement syndrome. Evaluation of supraspinatus impingement syndrome can be done reliably using specialized radiographic views and MRI. Extrinsic factors like reduced subacromial distance and acromion morphology are predisposing factors for impingement of supraspinatus tendon.

Intermuscular Coherence Of Rotator Cuff And Deltoid Muscles Varies With Force Output

PURPOSE:To identify intermuscular EMG coherence patterns between the rotator cuff and deltoid muscles at different force levels. METHODS:Surface EMG electrodes were used to record activity from the anterior deltoid (AD), middle deltoid (MD), and infraspinatus (IS) muscles of the dominant shoulder in 7 healthy individuals (mean age ± SD = 19 ± 1, 6 females, 1 male). An intramuscular fine-wire EMG electrode was inserted into supraspinatus (SS). Participants performed 30s contractions of isometric shoulder abduction in the scapular plane at 30° at 25% (low-load), 50% (medium-load) and 75% (high-load) of maximum voluntary contraction with visual feedback of the force output. EMG amplitudes and coherence of each muscle pair in the common drive (0-5 Hz), physiological force tremor (5-12 Hz), beta (15-35 Hz), low-gamma (35-60 Hz) and high-gamma (60-100 Hz) bands were compared across the 3 force levels. RESULTS:EMG amplitudes of all muscles increased as force level increased (all p < 0.05). EMG coherence between IS and deltoid muscles increased as force level increased in the low-gamma band (p < 0.05). SS-IS coherence was also the highest during high-load task in the low-gamma band. These data indicate that additional neural drive with higher force levels stemming from subcortical origin likely mediate the increase in coherence between these muscles. However, SS-IS coherence during the medium and high load tasks were lower than that during the low-load task in the common drive band (p < 0.05), indicating that the increase in drive to these muscles for increasing force output is not targeted at common last-order neurons. Similarly, SS-AD coherence during the high-load task was lower than that during the medium-load task in the beta band (p < 0.05) and SS-AD and SS-MD was lower in the tremor band (p < 0.05) at higher force loads. The reduction in coherence between the SS and deltoid muscles and the SS and IS may serve to protect the humeral head from migrating superiorly at higher force loads. CONCLUSIONS:Increasing force output led to decreased coherence within the rotator cuff muscles and between supraspinatus and the deltoid muscles, but increased coherence between infraspinatus and the deltoid muscles. This likely serves as a protective mechanism against superior humeral head migration.

Risk factors of radiographic severity of massive rotator cuff tear

As massive rotator cuff tears progress, various radiographic changes occur; however, the factors associated with radiographic changes remain largely unknown. This study aimed to determine the factors that affect radiographic severity in massive rotator cuff tears using multivariate analyses. We retrospectively reviewed 210 shoulders with chronic massive rotator cuff tears. The dependent variables were superior migration of the humeral head (Hamada grades 2–3), narrowing of the glenohumeral joint (grade 4), and humeral head collapse (grade 5). Baseline variables that were significant in univariate analyses were included in multivariate models. There were 91, 59, 43, and 17 shoulders classified as Hamada grades 1, 2–3, 4, and 5, respectively. Multivariate analysis showed that infraspinatus tear (P = 0.015) and long head of biceps (LHB) tendon rupture (P = 0.007) were associated with superior migration of humeral head. Superior subscapularis tear (P = 0.003) and LHB tendon rupture (P < 0.001) were associated with narrowing of glenohumeral joint. Female sex (P = 0.006) and superior subscapularis tear (P = 0.006) were associated with humeral head collapse. This study identified the rupture of infraspinatus and LHB as risk factors of superior migration of humeral head, and the rupture of subscapularis and LHB and female sex as risk factors of cuff tear arthropathy.

The InSpace Balloon: Useful Augmentation or First-Line Therapy?: Commentary on an article by Nikhil Verma, MD, et al.: "InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears. A Multicenter, Single-Blinded, Randomized Controlled Trial".

The InSpace Balloon: Useful Augmentation or First-Line Therapy?: Commentary on an article by Nikhil Verma, MD, et al.: "InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears. A Multicenter, Single-Blinded, Randomized Controlled Trial".

Correlation between superior humeral head migration and proximal long head of biceps tendon pathology in patients with and without rotator cuff tears using magnetic resonance imaging and radiography.

BackgroundThe biomechanical role of the proximal long head of the biceps tendon (PLHB) in glenohumeral joint stability remains controversial. This retrospective study aims to correlate between humeral head migration and PLHB pathology in patients with and without rotator cuff tendon tears using imaging.MethodsSeventy-nine patients who underwent 3T magnetic resonance imaging of the shoulder were retrospectively reviewed. Imaging findings were documented by a fellowship-trained musculoskeletal radiologist. PLHB tendon diameter change, contour irregularity, and signal intensity change were assessed. Rotator cuff status was given a binary assignment of intact vs. torn. Radiographs were used for measurement of the acromiohumeral distance and a cutoff value of 7 mm was set as a lower limit of normal.ResultsIn the cohort of 79 shoulders, 41.8% (33/79) of patients had intact PLHB tendon and rotator cuff, 26.6% (21/79) demonstrated isolated PLHB tendon pathology, 13.9% (11/79) demonstrated isolated rotator cuff tears, and 17.7% (14/79) demonstrated concomitant PLHB tendon pathology and rotator cuff tears. Acromiohumeral distance was preserved in 97.0% (32/33) of patients with intact PLHB tendon and rotator cuff, 28.6% (6/21) of patients with isolated PLHB tendon pathology, 81.8% (9/11) of patients with isolated rotator cuff tears, and 14.3% (2/14) of patients with concomitant PLHB tendon pathology and rotator cuff tears (P < .0001).ConclusionResults of this study have shown that a statistical correlation was present between superior humeral head migration and PLHB tendon pathology with or without rotator cuff tears, compared to rotator cuff pathology alone. Findings suggest that intact PLHB tendon plays an important role in glenohumeral stability.

A Brief Review of Reverse Shoulder Arthroplasty for Rotator Cuff Arthropathy

Reverse total shoulder arthroplasty is an increasingly popular procedure performed by orthopedic surgeons. The indications have expanded over the past two decades with well documented success in the treatment of rotator cuff arthropathy. Patients with loss of rotator cuff function experience altered shoulder biomechanics that lead to superior humeral head migration, acetabulization of the acromion and progressive glenohumeral arthritis. Clinically, patients present with chronic shoulder pain, weakness and loss of range of motion that impacts activities of daily living. To address this, a reverse total shoulder can be performed. The procedure is normally done in the beach chair position utilizing the deltopectoral approach. A humeral stem with liner and glenosphere is implanted into the humerus and scapula, respectively. The procedure has shown consistent improvements in pain, strength, range-of-motion and function. Complications include dislocation, instability, fracture and infection.

Risk Factors for Loss of Active Shoulder Range of Motion in Massive Rotator Cuff Tears.

Background:Patients with massive rotator cuff tears often exhibit loss of active range of shoulder motion, which can interfere with activities of daily living. The risk factors for loss of motion remain largely unknown.Purpose:To clarify the predictive factors that affect the range of motion in chronic massive rotator cuff tears using multivariate analyses.Study Design:Case-control study; Level of evidence, 3.Methods:The authors retrospectively reviewed 204 consecutive patients who were evaluated at their institution with chronic massive rotator cuff tears. In this study, the dependent variable was determined to be active anterior elevation limited to ≤90° or external rotation (ER) with the arm at the side limited to ≤0°. Explanatory variables included age; sex; affected side; duration of symptoms; smoking history; existence of diabetes, hypertension, or rheumatoid arthritis; involved tendons; presence of a 3-tendon tear; rupture of the long head of biceps tendon; superior migration of the humeral head; and cuff tear arthropathy. Baseline variables that were observed to be significant in the univariate analyses were included in multivariate models, which used logistic regression to identify independent predictors of loss of motion.Results:Overall, 73 patients (35.8%) exhibited limited anterior elevation, and 27 (13.2%) exhibited limited ER. Multivariate analyses showed that inferior subscapularis tear (odds ratio [OR], 14.66; 95% CI, 2.95-72.93; P = .001), smoking (OR, 4.13; 95% CI, 1.94-8.79; P < .001), superior migration of humeral head (OR, 3.92; 95% CI, 1.80-8.53; P = .001), and 3-tendon tear (OR, 3.29; 95% CI, 1.32-8.20; P = .011) were significantly associated with the loss of anterior elevation. Teres minor tear (OR, 73.37; 95% CI, 9.54-564.28; P < .001) and superior migration of the humeral head (OR, 3.55; 95% CI, 1.04-12.19; P = .044) were significantly associated with loss of ER.Conclusion:In the current study, a history of smoking, type of torn tendons, and superior migration of the humeral head were associated with loss of active shoulder motion. In particular, the status of inferior subscapularis or teres minor contributed to the onset of pseudoparalysis in massive rotator cuff tears.

Increased Glenohumeral Joint Loads Due to a Supraspinatus Tear Can Be Reversed With Rotator Cuff Repair: A Biomechanical Investigation

To evaluate the effect of an isolated full-thickness supraspinatus (SSP) tear on glenohumeral kinematics and contact mechanics, as well as to quantify improvement following rotator cuff repair (RCR). Ten fresh-frozen cadaveric shoulders (mean age: 63.1 ± 4.6 years) were tested using a dynamic shoulder simulator. A pressure-mapping sensor was placed between the humeral head and the glenoid. Each specimen underwent the following three conditions: 1) native, 2) isolated full-thickness SSP tear, and 3) RCR. Maximum abduction angle (MAA) and superior humeral head migration (SHM) were measured using 3D motion tracking software. Cumulative deltoid force (CDF) and glenohumeral contact mechanics, including contact area (GCA) and contact pressure (GCP), were assessed at the resting position, as well as at 15°, 30°, 45°, and 60° of glenohumeral abduction. Compared to native, the SSP tear resulted in a significant decrease in MAA (Δ-8.3°; P < .001) along with a SHM of 6.4 ± 3.8 mm, while significantly increasing CDF (Δ20.5 N; P=.008), GCP (Δ63.1 kPa; P < .001), and peak GCP (Δ278.6 kPa; P < .001), as well as decreasing GCA (Δ-45.8 mm2; P<.001) at each degree of abduction. RCR reduced SHM to 1.2 ± 2.5 mm, while restoring native MAA, CDF (Δ1.8 N), GCA (Δ4.5 mm2), GCP (Δ-4.5 kPa) and peak GCP (Δ19.9 kPa) at each degree of abduction (P > .999, respectively). In a dynamic biomechanical cadaveric model, increased glenohumeral joint loads due to a full-thickness SSP tear can be reversed with RCR. More specifically, RCR restored native glenohumeral contact area and contact pressure, while preventing superior humeral head migration and decreasing compensatory deltoid forces. These time 0 observations indicate that undergoing rotator cuff repair may prevent the development of degenerative changes by significantly reducing glenohumeral joint loads and ensuring sufficiently stable joint kinematics.

Superior capsular reconstruction for management of massive irreparable rotator cuff tears: current concepts

Irreparable massive rotator cuff tears in active middle-aged patients result in significant shoulder dysfunction and challenge surgeons in their treatment selection. Superior capsular reconstruction (SCR) is a joint-preserving surgical option that restores glenohumeral stability and prevents superior humeral head migration, thereby improving shoulder function, lessening pain, and limiting development of rotator cuff arthropathy. Indications for SCR are irreparable supraspinatus and/or infraspinatus tears with persistent shoulder pain and/or dysfunction for which conservative treatment has failed in a patient who is not an ideal candidate for arthroplasty because of age or activity level. Patients must have relatively preserved glenohumeral cartilage, an intact or repairable subscapularis tendon, and a fully functioning deltoid muscle to be an appropriate candidate for SCR. The procedure was originally described by Dr. Teruhisa Mihata using fascia lata autograft; however, in North America, dermal allograft has become the most common graft choice. The graft is secured medially to the superior glenoid with two or three suture anchors and laterally to the tuberosity commonly using four anchors in a double-row configuration. Preliminary clinical studies demonstrate significant improvement in pain, function, muscle strength, active shoulder range of motion with resolution of pseudoparalysis, normalization of the acromiohumeral interval, and no rapid progression of osteoarthritis. Superior capsular reconstruction is a viable, joint-sparing surgical option for irreparable massive rotator cuff tears.

Immunologic Contributions Following Rotator Cuff Injury and Development of Cuff Tear Arthropathy.

Rotator cuff tear arthropathy (RCTA) describes a pattern of glenohumeral degenerative changes following chronic rotator cuff tears that is characterized by superior humeral head migration, erosion of the greater tuberosity of the humeral head, contouring of the coracoacromial arch to create a socket for the humeral head, and eventual glenohumeral arthritis. Acute and chronic inflammatory changes following rotator cuff tears are thought to contribute to cartilage damage, muscle fibrosis, and fatty infiltration in the glenohumeral joint. In vitro animal studies targeting various inflammatory modulators, including macrophages, insulin-like growth factor-I, and transforming growth factor-beta pathways, provide promising therapeutic targets to improve healing after rotator cuff tears. The role of platelet-rich plasma in the treatment and prevention of RCTA has been investigated, with conflicting results.

Superior humeral head migration might be a radiological aid in diagnosing patients with adhesive capsulitis of the shoulder.

BackgroundThe diagnosis of adhesive capsulitis (AC) of the shoulder might be challenging, as it is a diagnosis of exclusion and mainly based on the clinical examination. The purpose of the present study was to investigate the validity and reliability of 4 commonly reported radiological parameters suggesting a superior humeral head migration on anteroposterior (a/p) shoulder radiograph in identifying patients with AC.MethodsThe a/p shoulder radiographs of 100 patients with AC and 100 control subjects were retrospectively reviewed. A disruption of the normal scapulohumeral arch (≥2 mm), the acromiohumeral interval (AHI), the inferior glenohumeral distance (IGHD), and the upward migration index (UMI) were measured.ResultsA disruption of the scapulohumeral arch was observed in 80% in the AC and 20% in the control group. The mean AHI was 9.3 ± 1.3 mm and 11.0 ± 1.7 mm (P < .001), the mean IGHD was 3.9 ± 3.0 mm and 0.9 ± 1.9 mm (P < .001), and the mean UMI was 1.37 ± 0.1 and 1.44 ± 0.1 (P < .001) in patients with AC and control subjects, respectively. The scapulohumeral arch's disruption demonstrated the best test characteristics with a sensitivity and specificity of 80% in detecting patients with an AC. Patients with a disruption of the scapulohumeral arch had 16 times increased odds of having an AC.ConclusionMeasuring the superior humeral head migration might be a simple and clinically relevant tool in diagnosing an AC of the shoulder and could be reliably used by clinicians adjacent to the clinical examination without any additional cost. Especially a disruption of the scapulohumeral arch on the a/p shoulder radiograph should raise concerns of AC in the absence of a massive rotator cuff tear.

Biologic Tuberoplasty With an Acellular Dermal Allograft for Massive Rotator Cuff Tears

We present the technique of biologic tuberoplasty, where an acellular dermal allograft is used to cover the tuberosity in patients with massive irreparable cuff tears to prevent bone-to-bone contact between the tuberosity and acromion when active elevation is attempted. This technique can be performed in patients with massive rotator cuff tears who are low-demand and have significant medical comorbidities, poor bone quality, or who are not candidates for a reverse shoulder arthroplasty or who cannot tolerate a lengthy rehabilitation protocol. It is less time-consuming than a superior capsule reconstruction and more bone-sparing than traditional tuberoplasty. Patients with massive rotator cuff tears involving the supraspinatus and a portion of the infraspinatus lose their force couple, leading to superior humeral head migration with abutment of the tuberosity against the acromion upon deltoid activation. The center of rotation moves superiorly with deltoid contraction, developing an acromiohumeral articulation. This results in bone-to-bone contact between the acromion and humerus, leading to pain and acetabularization of the acromion over time. Coverage of the tuberosity with the acellular dermal allograft acts as an interpositional tissue and prevents bone-to-bone contact between the tuberosity and acromion.

Outcome and revision rate of uncemented humeral head resurfacing: Mid-term follow-up study.

BACKGROUNDGlenohumeral osteoarthritis (OA) is a common cause of pain and disability affecting nearly a third of the world’s population over 60 years of age. As in other joints, shoulder arthroplasty appears to be the most effective treatment. The implant design has evolved during time transitioning to shorter humeral stem lengths or even stemless components.AIMTo evaluate the medium-term outcome and survival of a cementless humeral head resurfacing (HHR) in a group of patients affected with OA or avascular necrosis.METHODSThis is a retrospective study of prospectively collected data using HHR in 23 patients (15 female and 8 male) after a 7.4 year follow-up. The collected data included clinical and radiographical evaluation. The Constant score, the visual analogue scale, and a clinical evaluation of range of motion were registered pre- and postoperatively. Fifteen patients affected with OA (2 cases of mild, 6 moderate, and 7 severe) and 10 with avascular necrosis (stage III according to Cruess classification) were enrolled. X-rays were evaluated to detect loosening signs, degenerative changes, and superior humeral head migration. Magnetic resonance preoperatively was also performed to assess the rotator cuff status. Tendon integrity was mandatory to implant the HHR.RESULTSIn total, 19 patients (21 shoulders) completed the follow-up. Data on 4 shoulders, in 4 patients, were lost because of prosthesis failure. The global revision rate was 16%. A statistically significant improvement in the mean Constant score, visual analogue scale, and range of motion have been reported. No signs of loosening were registered, while in 12 cases a glenoid erosion was found. The osteophytes appeared 7 times on the humeral side and 12 on the glenoid. Superior humeral migration was recorded in only 1 case.CONCLUSIONHHR remains a reasonable option in patients with an intact rotator cuff for the treatment of OA and avascular necrosis.