A history of reverse total shoulder arthroplasty

BACKGROUND

Management of the cuff-deficient arthritic shoulder has long been challenging. Early unconstrained shoulder arthroplasty systems were associated with high complication and implant failure rates. The evolution toward the modern reverse shoulder arthroplasty includes many variables of constrained shoulder arthroplasty designs.

QUESTIONS/PURPOSES

This review explores the development of reverse shoulder arthroplasty, specifically describing (1) the evolution of reverse shoulder arthroplasty designs, (2) the biomechanical variations in the evolution of this arthroplasty, and (3) the current issues relevant to reverse shoulder arthroplasty today.

METHODS

Using a PubMed search, the literature was explored for articles addressing reverse shoulder arthroplasty, focusing on those papers with historical context.

RESULTS

Results of the early designs were apparently poor, although they were not subjected to rigorous clinical research and usually reported only in secondary literature. We identified a trend of glenoid component failure in the early reverse designs. This trend was recognized and reported by authors as the reverse shoulder evolved. Authors reported greater pain relief and better function in reverse shoulder arthroplasty with the fundamental change of Grammont's design (moving the center of rotation medially and distally). However, current reports suggest lingering concerns and challenges with today's designs.

CONCLUSIONS

The history of reverse shoulder arthroplasty involves the designs of many forward-thinking surgeons. Many of these highly constrained systems failed, although more recent designs have demonstrated improved longevity and implant performance. Reverse shoulder arthroplasty requires ongoing study, with challenges and controversies remaining around present-day designs.

Can reverse shoulder arthroplasty be used with few complications in rheumatoid arthritis?

BACKGROUND

Many patients with rheumatoid arthritis develop superior migration of the humeral head because of massive cuff tears, causing loss of active motion. Reverse shoulder arthroplasty could potentially restore biomechanical balance but a high incidence of glenoid failure has been reported. These studies do not, however, typically include many patients with rheumatoid arthritis (RA) and it is unclear whether the failure rates are similar.

QUESTIONS/PURPOSES

We therefore (1) evaluated pain relief and shoulder function after reverse arthroplasty in RA; (2) compared results between primary and revision procedures; (3) determined the incidence of scapular notching; and (4) determined the complication rate.

METHODS

We identified 29 patients with RA who had 33 reverse arthroplasties from among 412 patients having the surgery. Six patients were lost to followup. Twenty three patients (27 shoulders) were evaluated after a minimum followup of 18 months (mean, 56 months; range, 18-143 months), including 18 primary and nine revision arthroplasties. All patients were evaluated preoperatively and 23 shoulders postoperatively by an independent physiotherapist and four were assessed postoperatively by phone. Level of pain, range of motion, and Constant-Murley score were recorded and new radiographs taken.

RESULTS

Visual Analog Scale score for pain decreased from 8.0 to 1.0. Constant-Murley score increased from 13 to 52. Primary procedures had higher scores compared with revisions. Three patients had revision surgery. Notching occurred in 52% of shoulders but no loosening was seen.

CONCLUSIONS

Reverse arthroplasty in rheumatoid arthritis improved shoulder function with a low incidence of complications. We believe it should be considered in elderly patients with rheumatoid arthritis with pain and poor active range of motion resulting from massive cuff tears.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Prospective evaluation of arthroscopic rotator cuff repairs at 5 years: part II--prognostic factors for clinical and radiographic outcomes

BACKGROUND

A rotator cuff registry was established to prospectively evaluate the effectiveness of all-arthroscopic repairs. The purpose of this study is to report prognostic factors for successful clinical and radiographic outcomes at 5 years.

METHODS

One-hundred ninety-three patients underwent all-arthroscopic rotator cuff repairs. Pre- and intraoperative data were compared to the American Shoulder and Elbow Surgeon (ASES) score, range of motion, muscle strength, and ultrasound results at 5 years using univariate, and multivariate analyses.

RESULTS

At 5 years, 106 patients completed follow-up. There were no pre- or intraoperative variables that were predictive of an ASES score >90. Factors predictive of a radiographic defect were larger size of the lesion (OR 1.72, 95% CI 1.04-2.85, P = .03), multiple tendon involvement (OR 5.56, 95% CI 1.23-25.22, P = .02), older age (OR 1.15, 95% CI 1.04-1.28, P = .01), concomitant biceps (OR 16.16, 95% CI 3.01-86.65, P = .001), and acromioclavicular joint procedures (OR 6.70, 95% CI 1.46-30.73, P = .01). Radiographic healing did not correspond to clinical outcomes. Resolution of a radiographic defect was seen in 14 patients. Younger age (OR 0.84, 95% CI 0.74-0.95, P = .004) and single-tendon tears (OR 7.59, 95% CI 1.71-84.45, P = .04) were predictive.

DISCUSSION

Larger tears in older patients who undergo concomitant procedures are predictive of radiographic defects at 5 years; however, radiographic healing did not correspond to clinical results. Younger patients with single tendon tears are more likely to undergo spontaneous resolution of a radiographic defect. This information can be useful in counseling patients regarding the mid-term results of this procedure.

[Ultrasonographic measurement of the effect of rotatory cuff repair with coracoacromial ligament transfer on humeral head migration]

OBJECTIVES

In this study we evaluated whether ligament transfer caused humeral head migration in patients whose massive rotator cuff ruptures were repaired with total or partial coracoacromial ligament (CAL) transfer. The necessity of harvesting the ligament totally or partially in massive rotator cuff repairs was investigated with respect to the effect of the excision and transfer of the CAL on humeral head migration.

PATIENTS AND METHODS

Forty patients (12 males, 28 females; mean age 54.3 years; range 39 to 66 years) operated on with free CAL transfer for massive rotator cuff rupture between January 2003 and June 2008 were included in the study. The operations were performed by obtaining total CAL grafts in the first 13 cases and partial CAL grafts in the other 27 cases. Mean follow-up period was 26.5 months (range 12 to 52 months). Twenty-nine patients had the rupture on the right side and 11 patients had the rupture on the left side. In 31 patients the dominant side was affected.

RESULTS

In the early postoperative period (3-6 weeks) adequate acromiohumeral (AH) distance could not be obtained in patients underwent total excision and transfer of CAL (mean 9 mm; range 8.6 to 9.2 mm). Humeral migration was found to be regressed three months after active motion and recovery of normal cuff strength. During the follow-up the mean AH distance was found to be 10 mm (range 8 to 10.5 mm). Humeral head migration was not detected by ultrasonography in the early postoperative period in patients who underwent repair with partial CAL transfer.

CONCLUSION

Functionally good results have been obtained in the rotatory cuff repairs performed by CAL excision and transfer. Although humeral head migration was not detected ultrasonographically in the patients who had partial CAL excision and transfer at the early postoperative period, we observed a decrease in the AH distance in the patients who had total CAL excision and transfer. This migration was regressed and the cuff strength was recovered after intense rehabilitation with strengthening exercises and active motion.

Contrast-enhanced sonographic characterization of the vascularity of the repaired rotator cuff: utility of maximum intensity projection imaging

OBJECTIVES

To characterize the distribution of vascularity of the postoperative rotator cuff tendon using a maximum intensity projection technique after contrast-enhanced sonography.

METHODS

We retrospectively evaluated image data on 23 patients (11 male and 12 female) with intact rotator cuff repairs who had previously undergone contrast-enhanced sonography of their shoulders using lipid microspheres before and after a standardized exercise protocol. The patients were on average 3 months out from their surgery. Using offline image analysis software, a maximum intensity projection image was obtained for each patient, reflecting the regional vascular distribution within the repair and adjacent soft tissue. Subjective analysis was performed in 4 regions of interest: peribursal, articular medial, articular lateral, and suture anchor, independently by 2 musculoskeletal radiologists using a semiquantitative scale ranging from 0 to 4 for each region (0, no enhancement; 1, 1%-25% enhancement; 2, 26%-50%; 3, 51%-75%; and 4, 76%-100%). A combined vascularity score (0-8) was produced for each region and formed the basis for the subjective analysis.

RESULTS

Using a Mann-Whitney nonparametric test, the data showed significantly higher regional enhancement in the peribursal and suture anchor regions compared to the tendon (P < .001). Exercise resulted in a statistically significant increase in the extent of enhancement in all regions (P < .002). Inter-rater reliability analysis using a weighted κ statistic showed strong agreement (0.63-0.64) for the suture anchor site and moderate agreement for the others (peribursal, 0.35-0.39; articular medial, 0.45-0.55; and articular lateral 0.32-0.33).

CONCLUSIONS

The maximum intensity projection technique after contrast-enhanced sonography provides a topographic map of rotator cuff vascularity; the latter has been implicated as an important factor in promoting bone-tendon healing. Approximately 3 months after rotator cuff repair, the suture anchor and peribursal regions showed the most robust vascularity. Maximum intensity projection imaging further establishes that there is a global increase in vascular response at the repair site after exercise.

Diagnostic accuracy of ultrasound for rotator cuff tears in adults: a systematic review and meta-analysis

AIM

To determine the diagnostic accuracy of ultrasound to detect partial and complete thickness rotator cuff tears based on all available clinical trials.

MATERIALS AND METHODS

An electronic search of databases registering published and unpublished literature was conducted. All diagnostic accuracy studies that directly compared the accuracy of ultrasound (the index test) to either arthroscopic or open surgical findings (the reference test) for rotator cuff tear were included. The methodological quality of each included study was assessed using the QUADAS form. When appropriate, pooled sensitivity and specificity analysis was conducted, with an assessment of the summary receiver operating characteristic (ROC) curve for each analysis.

RESULTS

Sixty-two studies assessing 6007 patients and 6066 shoulders were included. Ultrasonography had good sensitivity and specificity for the assessment of partial thickness (sensitivity 0.84; specificity 0.89), and full-thickness rotator cuff tears (sensitivity 0.96; specificity 0.93). However, the literature poorly described population characteristics, assessor blinding, and was based on limited sample sizes. The literature assessing transducer frequency was particularly small in size.

CONCLUSION

Ultrasonography is an appropriate radiological technique for the assessment of rotator cuff tears with an acceptable sensitivity and specificity. The diagnostic test accuracy of ultrasound is superior for the detection of full-thickness compared to partial-thickness cuff tears. Further study assessing the effect of transducer frequency is warranted.

The MRI geyser sign: acromioclavicular joint cysts in the setting of a chronic rotator cuff tear

We present the case of a 71-year-old man with a large acromioclavicular (AC) joint cyst successfully managed with surgical excision. AC joint cysts are soft tissue masses generally signifying underlying rotator cuff pathology. Traditionally, these cysts were identified with shoulder arthrography as a "geyser" of fluid escaping through the AC joint. Magnetic resonance imaging (MRI) is today's preferred imaging modality; we describe the MRI equivalent of the "geyser sign," signifying synovial fluid escaping through the cuff defect, across the subacromial bursa, and decompressing superiorly through a degenerated AC joint. Surgical management is preferred for symptomatic cysts. Based on a review of limited retrospective case series, recommendations for management of these lesions are as follows. Repair of the rotator cuff is preferable whenever possible. In the case of an irreparable defect, good results can be achieved through excisional AC joint arthroplasty and resection of the cyst base. Aspiration of these cysts should not be attempted, due to the high recurrence rate and potential for a draining sinus. Hemiarthroplasty also may be effective in indirectly decompressing these cysts; but given the invasive nature of this procedure, it should be reserved for patients who are also symptomatic from cuff arthropathy.

[Rotator cuff tear: correlation between ultrasound and arthroscopic findings]

OBJECTIVE

To analyze the preoperative shoulder ultrasound (US) findings in patients with a diagnosis of rotator cuff (RC) tear and correlate them with the arthroscopic findings.

METHODS

Retrospective analysis of a consecutive series of patients with a diagnosis of RC pathology in whom US was performed and who underwent surgery (shoulder arthroscopy). The US/arthroscopic findings were correlated with Fisher's and chi2 tests.

RESULTS

The total number of patients was 53. We identified US/arthroscopic correlation in 22/34 cases for the total tears (64.7%) and in 7/19 cases for the partial tears (36.8%) (p = 0.048). Overall correlation (total and partial tears) was seen in 29/53 patients (54.7%). Of the 24 patients without correlation, 11 (45.8%) had ultrasound reports of tendinitis; 75% of the cases in this group had findings of partial supraspinous tear during arthroscopy (p = 0.006).

CONCLUSION

US shows an appropriate correlation with the diagnosis of RC total tear confirmed with arthroscopy, and the correlation is significantly lower for partial tears. In cases of an ultrasound-diagnosed lesion, such as tendinitis, most cases showed a partial tear during arthroscopy.

Shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears

BACKGROUND

Complex regional pain syndrome (CRPS) is one of the serious complications after surgical treatment of a rotator cuff tear. Both a measurement of body surface temperature and bone scintigraphy have been used as diagnostic tools for the early phase of CRPS.Unfortunately, few studies have been carried out that applied these methods to the patients after rotator cuff repair.

PURPOSES

To clarify both shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears.

SUBJECTS AND METHODS

Subjects comprised patients with unilateral rotator cuff tears (five men and five women, mean age 61 years). For measurements of shoulder surface temperature, a Thermochron was attached to both shoulders. As for bone scintigraphy, intravenous injection of technetium-labelled hydroxymethylenebisphosphonic acid (99mTc-HMDP)was performed, and then images were taken with a gamma camera.

RESULTS

During the measurements, the changes in body surface temperature for the affected and healthy shoulders remained within the standard deviation of the reference group. The intensity of radioisotope (RI) uptake for the affected shoulder joint was significantly increased compared to that for the healthy shoulder joint (P < 0.05).

CONCLUSION

RI uptake is increased in shoulders with rotator cuff tears, whereas shoulder surface temperature shows no differences on the affected and unaffected sides.

Milwaukee shoulder syndrome

Milwaukee shoulder syndrome or rapid destructive arthritis of the shoulder; is a particular form of arthritis which affects mainly elderly patients, predominantly women, with limited pain and sometimes neuropathic joints, rotator cuff tear, joint instability, mildly inflammatory or noninflammatory, blood-stained effusion, calcium apatite crystals, and marked joint and bone destruction. This is very uncommon condition and very sparsely reported and so far, there is no case report from India, hence, we report a case of Milwaukee shoulder syndrome from India.

Ultrasonographic measures of subacromial space in patients with rotator cuff disease: A systematic review

PURPOSE

Recently sonography (US) has been used to measure the subacromial space outlet with a linear measurement of the acromiohumeral distance (AHD). The purpose of this article is to systematically review the literature on the influence of rotator cuff disease (RCD) on AHD using US.

METHODS

Computer-aided searches of databases were performed to identify comparative studies that measured US-generated AHD in adults with symptomatic RCD.

RESULTS

Five studies met the inclusion/exclusion criteria.

CONCLUSIONS

US images of AHD are smaller in patients with full-thickness tears than healthy individuals and subjects with subacromial impingement. AHD is potentially useful to prognosticate outcome in patients with subacromial impingement.

US-guided therapy of calcific tendinopathy: clinical and radiological outcome assessment in shoulder and non-shoulder tendons

PURPOSE

To analyze the effectiveness and complication rate of ultrasound (US)-guided perforation and lavage using a two-needle technique with 16 - 18 G needles in the treatment of patients with calcific tendinopathy in the shoulder, elbow, hip, and knee by radiological and clinical follow-up.

MATERIALS AND METHODS

A retrospective chart review was performed and 40 patients (13 male, 27 female; mean age, 53.5 years; range 24 -74 years) were identified as having received US-guided perforation and lavage due to symptomatic calcific tendinopathy of the rotator cuff tendons, triceps, extensor and flexor tendons at the elbow, rectus femoris tendon and patellar tendons. The radiographic outcome was assessed by comparison of the size and quality of the calcification before and 6 weeks after the procedure. On US images, the quality of the acoustic shadow was assessed, together with other alterations of the tendon and surrounding tissue. Patients were interviewed by telephone to assess the clinical outcome regarding pre-treatment and post-treatment pain and tendon function.

RESULTS

34 shoulder tendons and 6 non-shoulder tendons were identified. The mean calcium reduction was 39.9 mm(2) (range, 0 - 215; p < 0.001), while 80 % of patient showed a resolution of more than 60 % resulting in good clinical improvement. A very low complication rate was found (1 partial tear).

CONCLUSION

The US-guided perforation and lavage technique is an effective and safe treatment for rotator cuff calcifications as well as for other body tendons. Although the two-needle technique and large needles were used in this study, a very low complication rate was detected.

Shoulder arthroplasty for the treatment of rotator cuff insufficiency

Irreparable rotator cuff tendon tears result from chronic tears, failed cuff repairs, and fracture sequelae and occur in patients with rheumatoid arthritis. The management of patients with cuff tear arthropathy can be challenging. When pain is severe and function is poor, surgical options include hemiarthroplasty, bipolar arthroplasty, extended head arthroplasty, arthroplasty with tendon transfer, reverse shoulder arthroplasty, and fusion. A review of the literature shows good pain relief with hemiarthroplasty in carefully selected patients; however, the reverse prosthesis has been found to better restore motion in patients with pseudoparalysis, failed fracture treatment, or a failed prosthesis.

Comparison between exclusively long-axis and multiple-axis sonographic protocols for screening of rotator cuff lesions in symptomatic shoulders

OBJECTIVE

The purpose of this study was to determine whether exclusively long-axis sonography differs from a multiple-axis scanning protocol as a screening tool for rotator cuff lesions in symptomatic shoulders when compared with magnetic resonance imaging (MRI).

METHODS

A total of 509 consecutive patients (mean age, 52.8 years) referred for MRI were also routinely evaluated by sonography. We initially performed exclusively long-axis sonography and graded the rotator cuff as normal or abnormal. Patients subsequently underwent a full sonographic protocol using multiple-axis views. Magnetic resonance imaging findings were compared with sonographic findings for both techniques.

RESULTS

The overall accuracy of sonography was greater than 90%. We found divergent results from different sonographic techniques in 34 patients. Of these, 8 were multiple-axis false-negative; 14 were exclusively long-axis false-negative; 6 were exclusively long-axis false-positive; and 6 were multiple-axis false-positive. All cases with divergent false-negative findings on multiple-axis sonography showed tendinosis on MRI. Causes for false-negative findings on exclusively long-axis sonography included tendinosis and partial-thickness tears of the supraspinatus. No statistically significant difference was seen between both sonographic techniques compared with MRI in terms of accuracy, sensitivity, specificity, positive predictive value, and negative predictive value (P > .05).

CONCLUSIONS

Sonography is reliable for detecting rotator cuff abnormalities. Exclusively long-axis sonography seems appropriate as a screening tool for rotator cuff lesions in symptomatic shoulders.

Detection and quantification of rotator cuff tears with ultrasonography and magnetic resonance imaging - a prospective study in 77 consecutive patients with a surgical reference

The aim of this study was to compare the accuracy of ultrasonography (US) and magnetic resonance artrography (MRA) for the detection and measurement of rotator cuff tears, using surgical findings as a standard. A total of 77 consecutive patients with suspected rotator cuff tears were prospectively studied with US and MRA. Rotator cuff tears were identified by US with sensitivity, specificity, positive predictive and negative predictive values of 92%, 45%, 91% and 50%, respectively, and by MRA with values of 97%, 82%, 97% and 82%, respectively. US was not reliable for differentiating between partial and full thickness tears. US and MRA underestimated the tear sizes by an average of 15 mm and 4 mm, respectively. Our results suggest that US could be used as a screening test to confirm a suspected rotator cuff tear. In patients with negative findings, an MRA should be considered for substantiation.

Comparison of ultrasonographic findings of the rotator cuff between diabetic and nondiabetic patients with chronic shoulder pain: a retrospective study

It is still unclear whether diabetic mellitus (DM) is associated with rotator cuff lesions. The object of this retrospective study was to compare the ultrasonographic (US) findings of rotator cuffs in diabetic patients with those of nondiabetic patients with chronic shoulder pain. In total, 419 patients (80 diabetic, 339 nondiabetic) who had chronic shoulder pain and had been referred to receive US examination between January 2005 and January 2008 in a medical center were included in this study. The US findings of rotator cuff lesions were classified into two main categories: rotator cuff tears (RCTs) and calcifying tendinopathy (CT). In total, 114 (25.2%) shoulders with CT of the rotator cuff and 160 (35.3%), 15 (3.3%) and 5 (1.1%) shoulders with supraspinatus, infraspinatus and subscapularis tears, respectively, were noted. No difference in the ratio of tears of RCTs was found on US examinations between two groups. The crude odds ratio (OR) for CT of diabetic patients was 1.85 (p = 0.014); however, the adjusted OR for CT in diabetic patients became insignificant after controlling for the other variables (OR = 1.59, p = 0.08). To our knowledge, this is the first study to explore US findings among diabetic and nondiabetic patients with chronic shoulder pain. Further study is advised to confirm our findings.

Unsuspected sonographic findings in patients with posttraumatic shoulder complaints

PURPOSE

To prospectively assess the frequency of abnormal sonographic findings in patients with posttraumatic shoulder pain and/or disability in whom ultrasound (US) was not considered and to assess the effect of sonographic findings on working diagnosis and therapeutic strategy, to analyze the possible role of US in the diagnostic workup of these patients.

METHODS

A survey was performed under general practitioners and orthopedic surgeons. They were requested to refer patients with persistent posttraumatic complaints for an US examination of the shoulder and to fill out a questionnaire concerning working diagnosis and therapy. In 50 patients examinations were performed separately by two radiologists. Findings were confirmed with additional radiographs and/or MRI and/or surgery. Four weeks after the US examination, the survey was repeated to inquire about changes in diagnosis and/or treatment that resulted from US.

RESULTS

US showed relevant pathology in 45 (90%) of 50 patients, a proximal humerus fracture in 25 (50%) patients, and a rotator cuff tear in 43 (86%) patients. Twenty-three (92%) fractures were accompanied by a rotator cuff tear, and 23 (54%) rotator cuff tears were accompanied by a fracture. Ten fractures were initially missed radiographically. US findings changed the working diagnosis and therapeutic strategy in 37 (74%) and 26 (52%) patients, respectively.

CONCLUSION

In patients with posttraumatic shoulder complaints, US showed a high rate (90%) of relevant pathology. This changed the initial working diagnosis in 74% of the patients and the therapeutic strategy in more than half of the patients. Active referral for US examination may identify these abnormalities in an earlier phase and improve clinical outcome.

Are intra-articular corticosteroid injections better than conventional TENS in treatment of rotator cuff tendinitis in the short run? A randomized study

AIM

Rotator cuff problems are common causes of pain and restriction of movement in shoulder. The aim of this study to compare the effect of intra-articular injection of corticosteroid and conventional transcutaneous electrical nerve stimulator (TENS) treatment in treatment of rotator cuff tendinitis.

METHODS

Subjects were randomly allocated into Group 1 (intra-articular injection of corticosteroid) and Group 2 (conventional transcutaneous electrical nerve stimulation-TENS). Outcome measurements were performed using the Visual Analogue Scale (VAS) for pain, range of motion (ROM), the Shoulder Disability Questionnaire (SDQ), the Short Form-36 (SF-36), and Beck Depression Scale (BDS) questionnaires and paracetamol consumption.

RESULTS

In both groups, significant improvement was observed in all weeks in VAS, ROM and SDQ scores (P<0.05). Improvement was detected in most of the SF36 scores at the end of the treatment in both groups (P<0.05), while no significant change was observed in BDI score (P>0.05). In both treatment groups, paracetamol consumption decreased in time (P<0.05). When the groups were compared, a significant difference was found between the groups in favor of Group 1 in terms of VAS-at night and VAS-at rest in weeks 1, 4 and 12, and VAS-during movement in week 1 and 12 (P<0.05). The comparison of two groups revealed a significant difference in favor of Group 1 in weeks 1 in the passive abduction and the active and passive IR ROM measurements (P<0.05). There was also a significant difference in favor of Group 1 observed in weeks 1 in SDQ scores (P<0.05).

CONCLUSION

Intra-articular injection of corticosteroid and conventional TENS are efficient in the treatment of rotator cuff tendinitis. When two treatments are compared, it may be concluded that intra-articular steroid injection was more effective especially in the first weeks regarding pain, ROM and disability. Otherwise, use of TENS allow to patients to increase activity level, improve function and quality of life like that in our study. TENS, as it is cheaper, non-invasive, more easily performed and efficient, may be preferable for the treatment of shoulder pain. Further studies are needed to include these results in the prospective treatment guidelines.

Indications for reverse total shoulder arthroplasty in rotator cuff disease

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA's approval in 2004, the appropriateness in patients with rotator cuff disease is unclear.

QUESTIONS/PURPOSES

We review the use of RTSA in patients with rotator cuff disease to (1) describe classification of rotator cuff tear reparability and the concept of a balanced shoulder; (2) explore the theory behind RTSA design relative to rotator cuff arthropathy; (3) discuss the indications and contraindications for RTSA; and (4) review published outcomes of RTSA for rotator cuff arthropathy.

METHODS

We performed a selective review of the literature on the use of RTSA in the treatment of rotator cuff disease.

RESULTS

Modern RTSA designs restore deltoid tension and a functional fulcrum to the rotator cuff deficient shoulder, which allows recovery of active shoulder elevation and effectively restores function in short- and medium-term followup studies.

CONCLUSIONS

In short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA.

CLINICAL RELEVANCE

For properly selected patients who have symptomatic and disabling rotator cuff deficiency, RTSA can result in life-changing improvements in pain, motion, function, and patient satisfaction.

LEVEL OF EVIDENCE

Level V therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Attachments of muscles as landmarks for implantation of shoulder hemiarthoplasty in fractures

BACKGROUND

The attachments of muscles and the position of the humeral head are important for a good functional outcome of shoulder hemiarthroplasties after displaced fractures of the proximal humerus. Deviations in the attachments and changes in their spatial position with respect to the humeral head during surgical reconstruction change the biomechanics and reduce the range of motion of the should joint postoperatively.

METHODS AND RESULTS

We used 198 humerus preparations and using 3-dimensional analysis measured the angular relationships between the humeral head axis and medial margin of the greater tuberosity (11.9 degrees +/- 9.1 degrees ), lateral margin of the lesser tuberosity (48.0 degrees +/- 7.8 degrees ), and the crest of the greater tuberosity (27.1 degrees +/- 9.6 degrees ).

CONCLUSION

This study provides average values of the positions of the greater and lesser tuberosities with respect to the humeral head axis. We show that the greater and lesser tuberosities are more reliable than the transepicondylar line for reconstruction of humeral head retroversion.

LEVEL OF EVIDENCE

Basic Science.

Dynamic visualization of the coracoacromial ligament by ultrasound

Subacromial impingement syndrome (SIS) is prevalent in athletes who make throwing motions over their heads, as well as in the normal population, but it is difficult to diagnose precisely using physical examination and traditional imaging modalities. Furthermore, the diagnostic testing protocols have not been strictly standardized. We used ultrasound to dynamically visualize coracoacromial ligament (CAL) morphology during shoulder impingement tests: the CAL is the key impinging structure in SIS. Fifty normal shoulders were examined. With the transducer placed on the CAL, the shoulders were examined with seven different testing protocols described in the literature. The degree of CAL bulge from the resting position was measured, and the degree of bulge in different testing protocols was compared. We found that the Hawkins-Kennedy impingement test caused more CAL bulge than the Neer's impingement test, and the most prominent morphological change in the CAL occurred with an internally rotated and horizontally abducted shoulder. We conclude that high-resolution ultrasound is an excellent tool for dynamically inspecting the impinging structures, is applicable in clinical settings, and allows more accurate diagnosis of SIS.

Open versus arthroscopic subacromial decompressionA prospective, randomized study of 34 patients followed for 8 years

In a randomized prospective study, we selected 15 patients for arthroscopic subacromial decompression (ASD) and 19 patients for open subacromial decompression (OSD). All had impingement syndrome (Neer grade II), and had been unsuccessfully treated without surgery for more than 6 months. The UCLA Shoulder Rating Scale, Visual Analogue Scales for pain and satisfaction, isokinetic dynamometer recordings and physical testing were assessed preoperatively and at 1 (except isokinetic testing), 3, 6, and 12 months, and, finally, 8 years after surgery. We found essentially no differences in the clinical tests between the groups during this period. The use of ASD or OSD seems to be a matter of cosmesis and personal preference.

Prospective analysis of arthroscopic rotator cuff repair: subgroup analysis

BACKGROUND

The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome.

METHODS

A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography.

RESULTS

The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P < .0001) and 92.65 +/- 11.36 at 2 years (P < 0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity.

CONCLUSION

Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.