Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle aspiration and lavage

OBJECTIVE

To analyze the results of ultrasound (US)-guided needle puncture, aspiration and lavage in the treatment of symptomatic calcific tendinitis of the rotator cuff.

DESIGN AND PATIENTS

Atraumatic pain in 61 shoulders of 58 patients was resistant to conservative therapy. The average age of the treated patients was 42 years (range 26-49 years), follow-up was 12 months, and the mean diameter of the calcifications was 1.6 cm (range 1.1-2.9 cm). With US guidance and local anesthesia, two needles were placed within each calcification. The calcification was punctured 10-15 times and saline solution injected and aspirated using the needles until the aspirate was free of calcific particles.

RESULTS AND CONCLUSIONS

Based on radiographs at 1 year follow-up. 74% (45 of 61) of the calcifications decreased, including 28% (17 of 61) which disappeared totally, and 26% (16 of 61) were unchanged. Calcifications with a faint or absent shadow on US proved to be nearly liquid (slurry calcification in 93% (14 of 15) of cases and could be aspirated. Clinical results were excellent in 74% (45 of 61), moderate in 16% (10 of 61) and poor in 10% (6 of 61) of cases. US offers technical advantages over fluoroscopy, and the typical US image of a slurry calcification helps to select the most suitable patients for aspiration treatment. The results are comparable with those using fluoroscopic guidance.

Outcome of nonoperative management of full-thickness rotator cuff tears

The study documented the functional outcome in a consecutive series of 46 patients from an individual practice meeting the inclusion criteria of (1) a full-thickness rotator cuff tear seen by ultrasonography, arthrogram, or magnetic resonance imaging, (2) absence of a Workers' Compensation claim or previous surgery, (3) followup of at least 1 year, and (4) election of nonoperative management by the patient. Twenty-six of the tears involved only the supraspinatus, two involved the supraspinatus and infraspinatus, and two involved the supraspinatus, infraspinatus, and subscapularis (16 reports did not specify the size of the tear). Treatment consisted only of patient education and a home program of gentle stretching and strengthening. Patients completed the Simple Shoulder Test at the initial visit and sequentially at 6-month intervals thereafter. At an average followup of 2.5+/-1.6 years, 27 (59%) patients experienced improvement with nonoperative treatment, 14 (30%) patients experienced worsening, and five (11%) patients remained unchanged. The average number of Simple Shoulder Test functions the patients could perform initially was 5.6+/-3.2. At the latest followup, the average number of Simple Shoulder Test functions the patients could perform improved to 7.0 +/-3.8. The ability to sleep on the affected side and the ability to place the hand behind the head were significantly improved.

Do less medialized reverse shoulder prostheses increase motion and reduce notching?

BACKGROUND

Cuff tear arthropathy is the primary indication for total reverse shoulder arthroplasty. In patients with pseudoparalytic shoulders secondary to irreparable rotator cuff tear, reverse shoulder arthroplasty allows restoration of active anterior elevation and painless shoulder. High rates of glenoid notching have also been reported. We designed a new reverse shoulder arthroplasty with a center of rotation more lateral than the Delta prosthesis to address this problem.

QUESTIONS/PURPOSES

Does reduced medialization of reverse shoulder arthroplasty improve shoulder motion, decrease glenoid notching, or increase the risk of glenoid loosening?

PATIENTS AND METHODS

We retrospectively reviewed 76 patients with 76 less medialized reverse shoulder prostheses implanted for pseudoparalytic shoulder with rotator cuff deficiency between October 2003 and May 2006. Shoulder motion, Constant-Murley score, and plain radiographs were analyzed. Minimum followup was 24 months (mean, 44 months; range, 24-60 months).

RESULTS

The absolute Constant-Murley score increased from 24 to 59, representing an increase of 35 points. The range of active anterior elevation increased by 61°, and the improvement in pain was 10 points. The gain in external rotation with elbow at the side was 15°, while external rotation with 90° abduction increased by 30°. Followup showed no glenoid notching and no glenoid loosening with these less medialized reverse prostheses.

CONCLUSIONS

Less medialization of reverse shoulder arthroplasty improves external and medial rotation, thus facilitating the activities of daily living of older patients. The absence of glenoid notching and glenoid loosening hopefully reflects longer prosthesis survival, but longer followup is necessary to confirm these preliminary observations.

LEVEL OF EVIDENCE

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

Glenoid inclination is associated with full-thickness rotator cuff tears

Anatomic factors, such as a hooked acromion, have been associated with rotator cuff disorders. Orientation of the glenoid relative to the scapula has been implicated in shoulder instability, but it has not been linked to rotator cuff disorders. The purpose of the current study was to test the hypothesis that superior inclination of the glenoid is associated with full-thickness rotator cuff tears. Glenoid inclination angles were measured from 16 shoulder radiographs of a convenience sample of eight cadavers in which one shoulder had an intact rotator cuff and the other shoulder had a full-thickness rotator cuff tear. Glenoid inclination angles for shoulders with rotator cuff tears were compared with contralateral normal shoulders using nonparametric statistical analysis. The glenoid inclination angle was greater in cadaver shoulders having full-thickness rotator cuff tears (98.6 degrees ) than in shoulders without tears (91.0 degrees ). A second experiment was done to assess the reliability of using 34 Grashey view radiographs from a clinical population to measure glenoid inclination angle. A method to measure the glenoid inclination on Grashey views was tested and was found to correlate with the inclination angles measured on cadaveric scapulae. Intrarater reliability of measurements from clinical Grashey views was 0.93, and interrater reliability was at least 0.88.

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.

All-arthroscopic versus mini-open rotator cuff repair: a retrospective review with minimum 2-year follow-up

PURPOSE

To compare the clinical outcomes of patients undergoing all-arthroscopic versus mini-open rotator cuff repair. In addition, ultrasound was used to assess the integrity of the repair.

METHODS

A total of 38 patients who had undergone all-arthroscopic repair and 33 patients who had undergone mini-open repair with minimum 2-year follow-up were evaluated. All patients completed the American Shoulder and Elbow Surgeons' Scoring Survey (ASES), the Simple Shoulder Test, the L'Insalata Scoring Survey, and visual analog scales for pain. Physical examination, including strength testing and ultrasound evaluation to determine the integrity of the rotator cuff, was performed.

RESULTS

No statistical difference in ASES scores was noted between patients who had all-arthroscopic repair versus mini-open repair, and 24% of all-arthroscopic repairs and 27% of mini-open repairs showed recurrent defects on ultrasound at follow-up. This difference was not statistically significant. Patients with an original tear larger than 3 cm were 7 times more likely to have a recurrent defect at follow-up. Patients with persistent defects had statistically significant deficits in strength on forward elevation and external rotation when compared with those with a normal shoulder. However, no difference was observed with regard to pain or outcome scores between patients with intact repairs and those with persistent defects.

CONCLUSIONS

No difference in clinical outcomes was found between patients with rotator cuffs repaired arthroscopically and those repaired with use of a mini-open technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcome of pectoralis major transfer for the treatment of irreparable subscapularis tears

BACKGROUND

Chronic tears of the subscapularis tendon with or without associated tears of the supraspinatus and infraspinatus tendons may lead to pain and dysfunction of the shoulder. If conservative treatment fails and repair of the musculotendinous unit is impossible, transfer of the pectoralis major tendon can be attempted to substitute for lost subscapularis function.

METHODS

Twenty-eight patients underwent a total of thirty consecutive pectoralis major transfers at an average age of fifty-three years. There were twelve isolated subscapularis tears and eighteen subscapularis tears associated with a tear of the supraspinatus or the supraspinatus and infraspinatus. All patients were examined clinically and with standard radiographs.

RESULTS

The mean relative Constant score increased from 47% preoperatively to 70% at an average of thirty-two months postoperatively (p < 0.0001). The mean Constant scores for pain (p = 0.0009) and activities of daily living (p < 0.0001), the range of forward flexion (p < 0.05), and abduction strength (p = 0.001) also improved. Thirteen patients (14 shoulders) were very satisfied, ten patients (eleven shoulders) were satisfied, two patients (two shoulders) were disappointed, and three patients (three shoulders) were dissatisfied with the result. The average subjective shoulder value increased from 23% preoperatively to 55% postoperatively (p = 0.0009). In patients with a massive tear, the outcome was less favorable when the torn supraspinatus tendon was irreparable, as determined preoperatively or intraoperatively, than when it was reparable (average relative Constant scores, 49% and 79%, respectively; p = 0.002).

CONCLUSIONS

Pectoralis major transfer results in improvement for patients with an irreparable subscapularis tear with or without an associated reparable supraspinatus tear. If an irreparable subscapularis tear is associated with an irreparable supraspinatus tear, the results are less favorable, and pectoralis major transfer may not be warranted.

A quantitative histological study of the vascularity of the rotator cuff tendon

Previous perfusion studies of the rotator cuff have demonstrated an area of hypovascularity in the distal part of the supraspinatus tendon. This has been implicated in the pathogenesis of its rupture. We performed a quantitative histological analysis of the vascularity of the tendons of supraspinatus and infraspinatus. Vessel number, size and the percentage of the tendon occupied by vessels were measured at 5 mm intervals from the humeral insertions to the muscle bellies. Both tendons were hypovascular in their distal 15 mm. No significant difference was demonstrated between the vascularity of supraspinatus and infraspinatus. We conclude that factors other than vascularity are important in the pathogenesis of supraspinatus rupture.

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.

Arthroscopic treatment of chronically painful calcifying tendinitis of the supraspinatus tendon

PURPOSE

The purpose of this study was to analyze the outcome of arthroscopic removal of calcifying tendinitis of the rotator cuff, to document the postoperative pain evolution, and to analyze structural changes of the supraspinatus tendon by use of ultrasonography.

METHODS

Fifty-four of 58 patients with a mean age of 45.4 years (+/-8 years) enrolled in the study were available for follow-up. The calcific deposits were exclusively located in the supraspinatus tendon. Shoulder function was evaluated by using the Constant score. Radiographs were obtained preoperatively, immediately postoperatively, and at 3, 6, 12, and 24 months. The integrity of the rotator cuff was assessed by using ultrasonography.

RESULTS

Shoulder function according to the Constant score improved from 32.8 points (+/-19.8) preoperatively to 90.9 (+/-13.0) at 24 months (P < 0.001). The evolution of postoperative pain was very irregular; 31% of the patients were pain free or reached their minimum pain level after 3 months, 17% after 6 months, 20% after 9 months, and 28% after 12 months; 78% of the patients returned to work within 6 weeks, irrespective of their profession. At the final follow-up 92% of the patients were very satisfied with the outcome. Ultrasonography revealed minor structural changes of the supraspinatus tendon in 66% of the patients.

CONCLUSIONS

The study confirmed previously reported successful results of arthroscopic treatment of calcifying tendinitis of the rotator cuff. Complete intraoperative removal of the deposit did not appear to be essential. Even if most of the patients were able to return to work within 6 weeks, postoperative recovery was prolonged over several months in most of the patients. The clinical relevance of the ultrasonographic changes of the supraspinatus tendon has not yet been determined.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic rotator cuff repair with double-row fixation

BACKGROUND

The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique.

METHODS

Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff.

RESULTS

The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores.

CONCLUSIONS

Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair.

LEVEL OF EVIDENCE

Therapeutic Level IV.

CT and MR arthrography of the normal and pathologic anterosuperior labrum and labral-bicipital complex

Interpretation of computed tomographic and magnetic resonance arthrograms of the shoulder is complicated by normal variants of the labrum and glenohumeral ligaments. A superior sublabral recess is located at the 12 o'clock position and represents a normal recess between the superior labrum and the cartilage of the glenoid cavity. A sublabral foramen is located at the 2 o'clock position and represents localized detachment of the labrum from the glenoid rim. Buford complex is characterized by absence of the anterosuperior labrum and cordlike thickening of the middle glenohumeral ligament. Imaging features of damage to the anterior labrum include absence or detachment of the labrum and an irregular frayed appearance. Superior labrum anterior-to-posterior (SLAP) lesions are classified as type I (tear confined to the superior labrum), type II (labrum and biceps tendon detached from the superior glenoid), type III (bucket handle tear of the superior labrum), or type IV (bucket handle tear of the superior labrum with lateral extension into the biceps tendon). Increased distance between the labrum and the glenoid, an irregular appearance of the labral margin, or lateral extension of the separation may suggest a SLAP lesion rather than a normal anatomic variant. However, differentiation between normal variants and pathologic conditions and between various types of SLAP lesions remains difficult.

The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration

We sought to determine how various types of full-thickness rotator cuff tears, fatty degeneration of the rotator cuff muscles, duration of symptoms, and mechanism of injury affect the sizes of the acromiohumeral and coracohumeral intervals. We studied 206 shoulders with rotator cuff tears that had surgical treatment. The acromiohumeral interval (anteroposterior radiograph) and the coracohumeral interval (computed tomogram) were measured on preoperative imaging studies. An abnormal acromiohumeral interval was associated with multiple-tendon rotator cuff tears involving the infraspinatus, fatty degeneration of the supraspinatus or infraspinatus, and duration of symptoms longer than 5 years. An abnormal coracohumeral interval was associated with a combined tear of the supraspinatus and subscapularis and fatty degeneration of the infraspinatus or subscapularis. Fatty degeneration of the infraspinatus therefore was associated with an abnormal acromiohumeral interval and an abnormal coracohumeral interval. Evaluation of a patient who has a diminished acromiohumeral or coracohumeral interval should involve examination with computed tomography or magnetic resonance imaging of the rotator cuff tendons to determine the type of tear and of the rotator cuff muscles to determine the degree of fatty degeneration.

LEVEL OF EVIDENCE

Diagnostic study, Level II-1 (development of diagnostic criteria on basis of consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic repair of full-thickness supraspinatus tears (small-to-medium): A prospective study with 2- to 4-year follow-up

PURPOSE

The objective of this study is to report on the complete arthroscopic repair of full-thickness tears of the supraspinatus.

TYPE OF STUDY

Prospective cohort study.

METHODS

Between 1995 and 1999, 139 full arthroscopic rotator cuff repairs were performed; 37 were repairs of full-thickness supraspinatus tears. Between 1997 and 1999, there were 24 patients who had a complete arthroscopic repair of supraspinatus tears. The preoperative and postoperative status of these patients was analyzed using the Constant score, American Shoulder and Elbow Society Index (ASES Index), a Visual Analog Pain Scale (VAS), a single question of percent function compared with the opposite unaffected extremity, and a single question reflecting satisfaction, "Would you undergo the surgery and the postoperative rehabilitation to achieve the result you have today?" There were 37 patients who had preoperative to postoperative VAS, percent function, postoperative acromiohumeral interval, and clinical rerupture incidences evaluated. The null hypothesis was tested and there was no difference between the preoperative to postoperative outcomes. Two groups were evaluated, those who had concomitant decompression and those who did not.

RESULTS

The null hypothesis was not supported. The 4 scoring systems used for evaluation showed statistically significant improvement from preoperative to postoperative. There were no differences in outcome based upon sex or age as a variable. All patients would have surgery again to achieve their postoperative state.

CONCLUSIONS

The arthroscopic repair of supraspinatus tears is effective for improving the functional status of the shoulder.

Measuring dynamic in-vivo glenohumeral joint kinematics: technique and preliminary results

Rotator cuff tears are a common injury that affect a significant percentage of the population over age 60. Although it is widely believed that the rotator cuff's primary function is to stabilize the humerus against the glenoid during shoulder motion, accurately measuring the three-dimensional (3D) motion of the shoulder's glenohumeral joint under in-vivo conditions has been a challenging endeavor. In particular, conventional motion measurement techniques have frequently been limited to static or two-dimensional (2D) analyses, and have suffered from limited or unknown in-vivo accuracy. We have recently developed and validated a new model-based tracking technique that is capable of accurately measuring the 3D position and orientation of the scapula and humerus from biplane X-ray images. Herein we demonstrate the in-vivo application of this technique for accurately measuring glenohumeral joint translations during shoulder motion in the repaired and contralateral shoulders of patients following rotator cuff repair. Five male subjects were tested at 3-4 months following arthroscopic rotator cuff repair. Superior-inferior humeral translation was measured during elevation, and anterior-posterior humeral translation was measured during external rotation in both the repaired and contralateral shoulders. The data failed to detect statistically significant differences between the repaired and contralateral shoulders in superior-inferior translation (p=0.74) or anterior-posterior translation (p=0.77). The measurement technique overcomes the limitations of conventional motion measurement techniques by providing accurate, 3D, in-vivo measures of glenohumeral joint motion during dynamic activities. On-going research is using this technique to assess the effects of conservative and surgical treatment of rotator cuff tears.

Arthrographic and clinical findings in patients with hemiplegic shoulder pain11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify the etiology of hemiplegic shoulder pain by arthrographic and clinical examinations and to determine the correlation between arthrographic measurements and clinical findings in patients with hemiplegic shoulder pain.

DESIGN

Case series.

SETTING

Medical center of a 1582-bed teaching institution in Taiwan.

PARTICIPANTS

Thirty-two consecutive patients with hemiplegic shoulder pain within a 1-year period after first stroke were recruited.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clinical examinations included Brunnstrom stage, muscle spasticity distribution, presence or absence of subluxation and shoulder-hand syndrome, and passive range of motion (PROM) of the shoulder joint. Arthrographic measurements included shoulder joint volume and capsular morphology.

RESULTS

Most patients had onset of hemiplegic shoulder pain less than 2 months after stroke. Adhesive capsulitis was the main cause of shoulder pain, with 50% of patients having adhesive capsulitis, 44% having shoulder subluxation, 22% having rotator cuff tears, and 16% having shoulder-hand syndrome. Patients with adhesive capsulitis showed significant restriction of passive shoulder external rotation and abduction and a higher incidence of shoulder-hand syndrome (P=.017). Those with irregular capsular margins had significantly longer shoulder pain duration and more restricted passive shoulder flexion (P=.017) and abduction (P=.020). Patients with shoulder subluxation had significantly larger PROM (flexion, P=.007; external rotation, P<.001; abduction, P=.001; internal rotation, P=.027), lower muscle tone (P=.001), and lower Brunnstrom stages of the proximal upper extremity (P=.025) and of the distal upper extremity (P=.001). Muscle spasticity of the upper extremity was slightly negatively correlated with shoulder PROM. Shoulder joint volume was moderately positively correlated with shoulder PROM.

CONCLUSIONS

After investigating the hemiplegic shoulder joint through clinical and arthrographic examinations, we found that the causes of hemiplegic shoulder pain are complicated. Adhesive capsulitis was the leading cause of shoulder pain, followed by shoulder subluxation. Greater PROM of the shoulder joint, associated with larger joint volume, decreased the occurrence of adhesive capsulitis. Proper physical therapy and cautious handling of stroke patients to preserve shoulder mobility and function during early rehabilitation are important for a good outcome.

Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction

The aim of this study was to investigate tendon integrity after surgical repair of single-tendon rotator cuff lesions. In 31 patients, 31 single-tendon repairs were evaluated. Thirty-one patients were available for clinical assessment and magnetic resonance imaging (MRI) at follow-up. A standard series of MR images was obtained for each. The results of functional assessment were scored according to the system of Constant. According to MRI evaluation, 21 (68%) patients had an intact or thinned rotator cuff and 10 (32%) had recurrence of a full-thickness cuff defect at follow-up. Patients with an intact or thinned rotator cuff had a median Constant score of 75.5 points; patients with a full-thickness cuff defect had a median score of 62 points. There was no correlation between tendon integrity on postoperative MR images and functional outcome. Patients with intact or thinned cuffs did not have significantly better functional results than patients with retorn cuffs. Because of the presence of metal artifacts and the difficulty in distinguishing postoperative scar tissue from partial tears or thinning, MRI is of minor diagnostic value in assessing the shoulder after cuff repair. However, full-thickness tears are readily diagnosed after operation with MRI.

Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation

OBJECTIVE

To evaluate the sonographic findings of the rotator interval in patients with clinical evidence of adhesive capsulitis immediately prior to arthroscopy.

DESIGN AND PATIENTS

We prospectively compared 30 patients with clinically diagnosed adhesive capsulitis (20 females, 10 males, mean age 50 years) with a control population of 10 normal volunteers and 100 patients with a clinical suspicion of rotator cuff tears. Grey-scale and colour Doppler sonography of the rotator interval were used.

RESULTS

Twenty-six patients (87%) demonstrated hypoechoic echotexture and increased vascularity within the rotator interval, all of whom had had symptoms for less than 1 year. Three patients had hypoechoic echotexture but no increase in vascularity, and one patient had a normal sonographic appearance. All patients were shown to have fibrovascular inflammatory soft-tissue changes in the rotator interval at arthroscopy commensurate with adhesive capsulitis. None of the volunteers or the patients with a clinical diagnosis of rotator cuff tear showed such changes.

CONCLUSIONS

Sonography can provide an early accurate diagnosis of adhesive capsulitis by assessing the rotator interval for hypoechoic vascular soft tissue.

Rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study

OBJECTIVE

To determine the prevalence and clinical impact of rotator cuff tears in asymptomatic volunteers.

MATERIALS AND METHODS

Sonographic examinations of the shoulder of 212 asymptomatic individuals between 18 and 85 years old were performed by a single experienced operator. The prevalence and location of complete rotator cuff tears were evaluated. The clinical assessment was based on the Constant Score. Magnetic resonance imaging (MRI) of the shoulder was obtained in those patients where US showed rotator cuff pathology.

RESULTS

Ultrasound showed a complete rupture of the supraspinatus tendon in 6% of 212 patients from 56 to 83 years of age (mean: 67 years). MRI confirmed a complete rupture of the supraspinatus tendon in 90%. All patients reported no functional deficits, although strength was significantly lower in the patient group with complete supraspinatus tendon tear (P < 0.01).

CONCLUSION

There is a higher prevalence in older individuals of rotator cuff tendon tears that cause no pain or decrease in activities of daily living.

Patterns of vascular and anatomical response after rotator cuff repair

BACKGROUND

It has been assumed that a robust vascular response at the tendon to bone interface during rotator cuff repairs is an integral part to the healing process. There are few studies that have explored this in an in-vivo prospective fashion.

PURPOSE

To prospectively characterize vascular and anatomical patterns in repaired rotator cuff tendons using Power Doppler sonography in a double-blinded fashion.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Fifty patients undergoing rotator cuff repair were enrolled: 28 mini-open, 14 open, and 8 arthroscopic repairs; 20 patients were controls. Patients underwent Power Doppler sonography at 6 weeks, 3 months, and 6 months postoperatively. Power Doppler sonography analysis examined 6 areas of the rotator cuff repair: discretely marginated intrasubstance, partial-thickness defects, full-thickness defects, focal thinning of repair, presence of bursal or joint fluid, and location of anchors. A subjective scoring system assessed blood flow in each region.

RESULTS

There was a predictable, significant decrease in vascular scores after rotator cuff repair over time. The mean vascular score was 11.6 at 6 weeks, 8.3 at 3 months, 7.0 at 6 months, and 2.4 for controls. There was a significant difference (P < .05) in vascular recruitment scores between each time period, with the most robust flow at the peritendinous region. The lowest vascular score was at the anchor site or cancellous trough. Forty-eight percent of the patients had a rotator cuff repair defect postoperatively. These findings did not correlate with functional assessment and outcome at 6 months. There was no significant difference in vascular scores between the defect and no-defect groups. Mean University of California, Los Angeles; L'Insalata; and American Shoulder and Elbow Surgeons scores at 6 months were 28.6, 86.3, and 81.5, respectively. Thirty-three percent of asymptomatic controls had a rotator cuff tear that averaged 7.6 x 7.1 mm.

CONCLUSION

The robust vascular response dropped with time, which is not seen in asymptomatic shoulders. Nearly half of the patients demonstrated persistent rotator cuff defects after rotator cuff repair that did not correlate with functional outcome and physical findings at 6 months.

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.

Long-term clinical and ultrasound evaluation after arthroscopic acromioplasty in patients with partial rotator cuff tears

PURPOSE

Clinical and ultrasound evaluation of patients who had undergone debridement of a partial rotator cuff tear in conjunction with an arthroscopic acromioplasty.

TYPE OF STUDY

Retrospective follow-up study.

METHODS

Thirty-three consecutive patients were included in the study; 26 of the 33 (79%) patients underwent ultrasound evaluation of both shoulders and were examined by independent observers after a follow-up period of 101 months (range, 60 to 128 months; minimum, 5 years).

RESULTS

The median time between onset of symptoms and surgery was 24 months (range, 6 to 360 months). At follow-up, the Constant score was 65 points (range, 15-98). The Constant score on the contralateral side was 84 points (range, 15-96; P < .0001). The strength in abduction was 4.7 kg (range, 1.2 to 11.1 kg) on the operated side and 5.1 kg (range, 1.8 to 10.4 kg) on the contralateral side (not significant). Twelve of the 26 patients reported discomfort or pain in the contralateral shoulder and during the follow-up period, and 3 of 26 had undergone an arthroscopic acromioplasty of the contralateral shoulder. Two of 26 patients underwent further surgery of the index shoulder during the follow-up period. The visual analogue score for pain for the index shoulder was 20 mm (range, 0 to 85). The ultrasound evaluation revealed that 9 of 26 patients had a full-thickness rotator cuff tear in the index shoulder and, of these, 3 of 9 were bilateral.

CONCLUSIONS

It appears that an arthroscopic acromioplasty and rotator cuff debridement in patients with partial tears does not protect the rotator cuff from undergoing further degeneration.

LEVEL OF EVIDENCE

Level IV.

Glenoid wear after shoulder hemiarthroplasty: quantitative radiographic analysis

Symptomatic glenoid arthrosis may limit the long-term success of shoulder hemiarthroplasty in patients who are young and functionally demanding. The principal objective of the current study was to quantify glenoid wear after proximal humeral replacement in young, active subjects. Eight patients, ages 21 to 60 years (mean, 45 years), met inclusion criteria. The mean followup was 43 months. Functional scores for the cohort averaged 60% of age and gender-adjusted healthy subjects (range, 28%-84%). Glenohumeral joint space was measured on serial axillary radiographs using a Microscribe 3-DX digitizing device (measurement accuracy, 0.23 mm). Progressive glenoid wear was found in all eight patients. The mean decrease was 2 mm (range, 1.3-2.8 mm), a 68% decrease in glenohumeral joint space. Glenoid cartilage wear also was correlated with Constant and Murley scores. Patients with residual joint spaces less than 1 mm had a mean score of 50%, compared with a score of 71% for patients with joint spaces greater than 1 mm. There were no correlations between wear and mechanism of injury, duration of symptoms, and prior surgery. This study suggests that glenoid cartilage erosion can be expected routinely after humeral head replacement in young, active individuals, and that such wear may adversely affect function or necessitate conversion to total shoulder arthroplasty.

High-energy extracorporeal shock-wave therapy for calcifying tendinitis of the rotator cuff

In a prospective randomised trial of calcifying tendinitis of the rotator cuff, we compared the efficacy of dual treatment sessions delivering 2500 extracorporeal shock waves at either high- or low-energy, via an electromagnetic generator under fluoroscopic guidance. Patients were eligible for the study if they had more than a three-month history of calcifying tendinitis of the rotator cuff, with calcification measuring 10 mm or more in maximum dimension. The primary outcome measure was the change in the Constant and Murley Score.

A total of 80 patients were enrolled (40 in each group), and were re-evaluated at a mean of 110 (41 to 255) days after treatment when the increase in Constant and Murley score was significantly greater (t-test, p = 0.026) in the high-energy treatment group than in the low-energy group. The improvement from the baseline level was significant in the high-energy group, with a mean gain of 12.5 (−20.7 to 47.5) points (p < 0.0001). The improvement was not significant in the low-energy group. Total or subtotal resorption of the calcification occurred in six patients (15%) in the high-energy group and in two patients (5%) in the low-energy group.

High-energy shock-wave therapy significantly improves symptoms in refractory calcifying tendinitis of the shoulder after three months of follow-up, but the calcific deposit remains unchanged in size in the majority of patients.

Sonographic findings of rotator cuff calcifications

We studied the findings and value of sonography in the diagnosis of rotator cuff calcifications in comparison to plain radiographs. Sonograms were correlated with plain radiographs in 951 patients. The diagnosis of rotator cuff calcifications was made by ultrasonography in 87 and with plain films in 93 of 951 patients. Sonography displayed two additional bursal slurry calcifications were found on plain films. Three types of calcifications were found with ultrasonography: (1) a hyperechoic focus with a well-defined shadow (79%); (2) a hyperechoic focus with a faint shadow (14%); and, (3) a hyperechoic focus with no shadow (7%). Large and slurry calcifications and bursal calcifications were better seen with ultrasonography, but small and more scattered deposits were better found on plain radiographs. Sonography proved to be reliable in the detection and localization of rotator cuff calcifications, but classification into a formative or resorptive phase could not be done. Because of this and the possibility of pathologic conditions of bone, plain radiographs should always be obtained prior to doing sonography.