Subacromial Balloon Spacer Does Not Reduce the Retear Rate for Massive Rotator Cuff Tears: A Comparative Study

PURPOSE

To determine whether a subacromial spacer decreases the recurrent rotator cuff tear rate in arthroscopically managed massive rotator cuff tears (MRCTs) with 1 year of follow-up.

METHODS

We selected all patients who met the following criteria: (1) an MRCT excluding Collin type A, (2) Goutallier stage equal or less than 2, and (3) complete arthroscopic repair of the MRCT. Patients were allocated into 2 groups: A (without subacromial spacer) or B (with subacromial spacer) for a prospective evaluation 1 year after surgery. The primary outcome was the retear rate, determined with magnetic resonance imaging (MRI) according to the classification of Sugaya. Secondary outcome measures were the functional outcomes using visual analog score, Shoulder Subjective Value, and Constant-Murley Score. Preoperative rotator cuff characteristics such as number of tendons involved and the tear retraction also were evaluated. Patient-related data such as sex, age, laterality, history of smoking, and diabetes mellitus were analyzed.

RESULTS

In total, 31 patients were included in group A and 33 in group B. Preoperatively, only 2 differences were found between both groups: a significant (but not clinical) greater Constant score in group A (P = .034) and a slightly greater retraction of the supraspinatus in group B (P = .0025). The overall retear rate between the 2 groups was similar regarding the number of patients (P = .746) and the total number of tendons involved in the recurrent tear (P = .112). At 1-year follow-up, no differences were found in VAS (P = .397), SSV (P = .309), and Constant score (P = .105).

CONCLUSIONS

In reparable massive rotator cuff tears (excluding Collin type A), the augmentation of repair with a subacromial spacer did not significantly reduce the number of patients with recurrent rotator cuff tears identified by MRI. It was also ineffective in reducing the number of re-ruptured tendons in these patients. No patient-reported or clinically significant findings were noted in Constant, SSV, and VAS scores at 1-year postoperative follow-up. Patients with MRI findings of a healed rotator cuff (Sugaya 1-3) had better clinical outcomes compared with those without.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Clinical and Radiological Outcomes of Arthroscopic Superior Capsular Reconstruction Versus Primary Rotator Cuff Repair in Massive Rotator Cuff Tears: A Propensity Score-Matched Study

BACKGROUND

Arthroscopic superior capsular reconstruction (aSCR) has emerged as a treatment option for managing massive rotator cuff tears (MRCTs) given the unpredictable results after an arthroscopic rotator cuff repair (aRCR). Yet, few comparative studies of aSCR and aRCR have been conducted.

PURPOSE

To compare the clinical and radiological outcomes between aRCR and aSCR in patients with MRCT.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 163 cases of MRCT from 2010 to 2020 with follow-up ≥2 years were retrospectively reviewed. Among them, 102 had aRCR and 61 had aSCR using fascia lata autograft. Propensity score matching was used to select controls matched for age, sex, diabetes mellitus, osteoporosis, preoperative American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, Constant score, pain visual analog scale (pVAS) score, range of motion (ROM), tear size, global fatty degeneration index, and acromiohumeral distance (AHD). Last, 33 cases in each group were selected after propensity score matching. Radiological assessment was conducted using serial postoperative magnetic resonance imaging. Pre- and postoperative findings-including American Shoulder and Elbow Surgeons, pVAS, Single Assessment Numeric Evaluation, and Constant scores and ROM-were assessed to compare clinical outcomes. For radiological outcomes, global fatty degeneration index, AHD, and healing rate were evaluated. Healing failure was defined as Sugaya classification IV or V in the aRCR group, as compared with a full-thickness tear of the graft in the aSCR group, which corresponded to Sugaya classification IV or V.

RESULTS

Postoperative clinical outcomes were significantly improved at the final follow-up in both groups. In the aSCR group, postoperative forward flexion, pVAS, and AHD were significantly improved as compared with the aRCR group (mean, 161° vs 148° [P = .02]; 1.03 vs 1.64 [P = .047]; 7.00 vs 5.23 mm [P < .001], respectively). The healing rate was 20 of 33 (60.6%) for aRCR and 29 of 33 (87.9%) for aSCR (P = .022).

CONCLUSION

aSCR and aRCR are effective and reliable treatment options for MRCT. However, when compared with aRCR, aSCR showed improved clinical outcomes, including pVAS score, postoperative ROM, and favorable radiological findings, including AHD and a higher healing rate.

Idiopathic humeral head osteonecrosis mimicking rotator cuff disorders: Two challenging diagnostic case reports

RATIONALE

Shoulder pain is a common complaint among patients, and rotator cuff disorders are the most common diagnoses. Humeral head osteonecrosis is easily masked by other more common diagnoses and concomitant conditions.

PATIENT CONCERNS

This challenging diagnostic report consists of 2 cases. Case 1 was that of a 59-year-old man who presented with right shoulder pain that had lasted for >1 year. Case 2 was that of a 52-year-old man who complained of right shoulder pain lasting for 6 months. They both presented with chronic right shoulder pain without relevant trauma history, and the physical examination showed a tenderness point over the right greater tuberosity.

DIAGNOSIS

These 2 patients were diagnosed with osteonecrosis involving the right greater tuberosity region via magnetic resonance imaging.

INTERVENTIONS

In case 1, the patient underwent cord decompression and artificial bone grafting with C-arm guidance. In case 2, the patient refused surgical intervention and decided to continue receiving physical therapy for symptom control.

OUTCOMES

In case 1, the patient responded well to cord decompression and artificial bone grafting. After the surgery, the active range of motion was restored and the pain in the right shoulder diminished further. In case 2, conservative treatment helped alleviate the patient's shoulder pain but did not entirely eliminate it.

LESSONS

Physicians should always have a high index of suspicion for osteonecrosis, especially when treating chronic shoulder pain, regardless of whether there are typical symptoms/known risk factors or not.

Prospective Randomized Clinical Trial of Arthroscopic Repair Versus Debridement for Partial Subscapularis Tendon Tears More Than Half of the Entire First Facet

BACKGROUND

Most outcome studies on subscapularis (SSC) tendon tears have focused on large SSC tears rather than partial SSC tendon tears. Therefore, the optimal treatment for partial SSC tendon tears more than half of the first facet of the entire SSC footprint has not yet been clearly defined.

PURPOSE

To prospectively investigate the clinical and radiological results between the arthroscopic repair group and the debridement group in SSC partial tear (Yoo and Rhee classification, type 2B: SSC tendon tears of more than half of the entire first facet).

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 65 patients with SSC tendon type 2B tears were randomized to arthroscopic debridement (n = 33) or arthroscopic repair (n = 32). Clinical evaluation of the patients was performed on the day before surgery and 6 months, 1 year, 2 years, and 5 years postoperatively using active range of motion measurements and other validated scores (pain visual analog scale scores, function visual analog scale scores, Constant score, American Shoulder and Elbow Surgeons score). In addition, SSC muscle strength was measured using instruments in the belly-press position. Magnetic resonance imaging (upper and lower SSC muscle diameters, Goutallier grades) was performed on the day before operation as well as 6 months and 2 years postoperatively.

RESULTS

There were no clinically or statistically significant differences between the arthroscopic debridement and arthroscopic repair groups with respect to active range of motion, pain visual analog scale scores, function visual analog scale scores, Constant scores, or American Shoulder and Elbow Surgeons scores. There was a statistically significant increase in SSC muscle strength in the repair group compared with the debridement group at 5 years postoperatively (P = .013). Magnetic resonance imaging assessment was also not significantly different between the 2 groups.

CONCLUSION

There were no differences in the patient-reported outcomes of patients with partial SSC tears treated with either arthroscopic debridement or repair, although there was an increase in SSC muscle strength associated with repair, the clinical importance of which may warrant further research.

REGISTRATION

NCT03183466 (ClinicalTrials.gov identifier).

Healing of partial tear of the supraspinatus tendon after atelocollagen injection confirmed by MRI: A case report

RATIONALE

Recently, collagen therapy has been made available for treating rotator cuff tendon injuries. However, to our knowledge, there are no clinical studies objectively investigating the effect of collagen therapy.

PATIENT CONCERNS

A 53-year-old female patient visited our pain clinic because of pain in the right shoulder. Although she had never experienced trauma and had not overused her shoulder and arm, the patient showed limited range of motion with painful arc syndrome. Moreover, the Neer test and Hawkins-Kennedy test were positive with subacromial tenderness.

DIAGNOSES

The MRI findings revealed partial tears on the articular surface of the anterior supraspinatus tendon in the rotator cuff.

INTERVENTIONS

The patient was treated with injections of exogenous collagen at the site of the partial tear under ultrasound guidance.

OUTCOMES

Follow-up MRI after injection of collagen revealed healing of the previous partial rupture of the tendon without any complications. Moreover, the patient reported reduction in pain and improvement in the movement of her shoulder during the follow-up period.

LESSONS

In this report, we demonstrate healing of a partial tear of the supraspinatus tendon in the rotator cuff after injection of exogenous collagen, as confirmed by MRI.

ABER Position in Direct MR Arthrography of the Shoulder: Useful Adjunct or Waste of Imaging Time?

PURPOSE

The usefulness of direct MR arthrography of the shoulder with additional ABER position (ABER-MRA) has always been discussed. The goals of the following review are to analyze the usefulness of this technique according to the available literature and present recommendations with respect to indications and benefits in diagnostic imaging of shoulder abnormalities in the clinical routine.

METHOD

For this review we assessed the current literature databases of the Cochrane Library, Embase, and PubMed with regard to MRA in the ABER position up to the February 28, 2022. Search terms were "shoulder MRA, ABER", "MRI ABER", "MR ABER", "shoulder, abduction external rotation MRA", "abduction external rotation MRI" and "ABER position". The inclusion criteria were prospective and retrospective studies with surgical and/or arthroscopic correlation within 12 months. Overall, 16 studies with 724 patients fulfilled the inclusion criteria: 10 studies dealing with anterior instabilities, three studies with posterior instabilities and seven studies with suspected rotator cuff pathologies (some studies addressing multiple items).

RESULTS

For anterior instability the use of ABER-MRA in the ABER position led to a significant increase in sensitivity for detecting lesions of the labral ligamentous complex compared with standard 3-plane shoulder MRA (81 % versus 92 %, p = 0.001) while maintaining high specificity (96 %). ABER-MRA demonstrated high sensitivity and specificity (89 % and 100 %, respectively) for SLAP lesions and was able to detect micro-instability in overhead athletes, but case counts are still very small. With regard to rotator cuff tears, no improvement of sensitivity or specificity could be shown with use of ABER-MRA.

CONCLUSION

Based on the currently available literature, ABER-MRA achieves a level of evidence C in the detection of pathologies of the anteroinferior labroligamentous complex. With regard to the evaluation of SLAP lesions and the exact determination of the degree of rotator cuff injury, ABER-MRA can be of additive value, but is still a case-by-case decision.

KEY POINTS

· ABER-MRA is useful in the evaluation of pathologies of the anteroinferior labroligamentous complex. · ABER-MRA does not increase sensitivity or specificity with regard to rotator cuff tears. · ABER-MRA may be helpful for the detection of SLAP lesions and micro-instability in overhead athletes.

CITATION FORMAT

· Altmann S, Jungmann F, Emrich T et al. ABER Position in Direct MR Arthrography of the Shoulder: Useful Adjunct or Waste of Imaging Time?. Fortschr Röntgenstr 2023; 195: 586 - 595.

Factors Influencing the Size of a Non-Traumatic Full-Thickness Rotator Cuff Tear: Focusing on Socioeconomic Factors

This study aimed to identify the risk factors for non-traumatic rotator cuff tears in Korean adult patients who underwent surgical treatment, focusing on socioeconomic factors. A retrospective study was conducted with 659 patients who were diagnosed with a full rotator cuff tear and underwent surgical treatment. The outcome variable was the rotator cuff tear size (mm), as indicated by preoperative magnetic resonance imaging. Socioeconomic variables included occupation, education level, insurance type, and residential area. Univariate analyses were used to evaluate the relation between tear size and independent variables, and multivariate regression was used to estimate the effects of socioeconomic factors on tear size after adjusting for other variables. Significant differences were found in mean tear size according to age, occupation, residence area, and symptom duration (p < 0.05) in multivariate regression analysis. Rural residents had a 2.12 mm larger tear size than urban residents. Compared to National Health Insurance patients, the tear size of Medicaid beneficiaries was significantly larger (6.79 mm) in urban areas. The larger the rotator cuff tear, the greater the risk of retear and poor shoulder function. Therefore, policy efforts are required to expand access to medical care for the vulnerable.

Morphologic and radiologic parameters correlating to shoulder function at diagnosis for patients with rotator cuff tear

BACKGROUND

The magnetic resonance imaging (MRI) parameters used to diagnose rotator cuff tears are weakly correlated to shoulder function. Our hypothesis was that adding 3-dimensional morphologic parameters resulting from biplanar radiographs (3DXR parameters) to the MRI parameters would improve this correlation.

METHODS

We assessed 52 patients with rotator cuff tears with an EOS Imaging radiographic examination, MRI study, and clinical evaluation of the shoulder, as well as the Constant score. The bones of the 52 shoulders were reconstructed 3-dimensionally, and eleven 3DXR parameters were automatically extracted. First, the trueness and reliability of these parameters were evaluated. Then, bivariate correlations between each parameter and the Constant score were made. A linear regression model was subsequently built to correlate the 11 parameters and 5 MRI findings with shoulder function at diagnosis, as assessed by the Constant score.

RESULTS

The parameters showed good trueness and reliability of most 3DXR parameters. Supraspinatus tear extension, muscle atrophy, and the distance between the greater and deltoid tuberosities were the only parameters with a statistically significant correlation to a lower Constant score (P < .05) in the bivariate study. These correlations were either weak or negligible. A regression model was successfully built with one MRI parameter and four 3DXR parameters. Correlation to function increased from 16.7% to 43.3% with this model.

CONCLUSION

For patients with rotator cuff tears, the combination of MRI and 3DXR parameters of the shoulder in a linear regression model improves the correlation with the Constant score (shoulder function) at diagnosis.

MR imaging signs of shoulder adhesive capsulitis: analysis of potential differentials and improved diagnostic criteria

OBJECTIVE

To evaluate the prevalence of shoulder adhesive capsulitis (AC) signs on MR studies of patients with various common shoulder conditions.

METHODS

MR images of 316 patients were retrospectively evaluated. Patients were divided into three groups: controls (66 patients), clinical AC (63 patients), and study group (187 patients). The final diagnosis of AC was reached clinically. The study group was composed of patients with focal and massive rotator cuff tears, active hydroxyapatite deposition disease, fractures around the shoulder, and post-surgery. The following AC signs were evaluated: inferior glenohumeral ligament (IGHL) thickening; coracohumeral ligament (CHL) thickening; and hyperintensity of the inferior glenohumeral ligament, which was graded in four classes.

RESULTS

The IGHL signal intensity was statistically higher in patients with fractures than in controls (P = 0.008). There was no statistically significant difference in IGHL signal between the AC group and patients with massive rotator cuff tears and active hydroxyapatite deposition disease (P > 0.1). IGHL thickness in patients with fractures, massive rotator ruptures, and active hydroxyapatite deposition disease was significantly higher compared to controls (P < 0.02) and significantly lower compared to the AC group (P < 0.0001). Based on these findings, a grading system for fibro-inflammatory capsular changes is proposed.

CONCLUSION

MR AC signs are frequent in patients with shoulder conditions other than AC; however, in these patients, capsular changes are less prominent than in patients with clinical AC.

Magnetic resonance imaging evaluation of the correlation between calcific tendinitis and rotator cuff injury

BACKGROUND

This study aims to evaluate the incidence of calcific tendinitis (CaT) in rotator cuff tears (RCTs) and to assess the correlation between CaT and RCTs with magnetic resonance imaging (MRI).

METHODS

The MRI of 108 patients with rotator cuff CaT admitted to our hospital from January 2019 to January 2021 were retrospectively analyzed. Another retrospective analysis was made of 108 patients with similar age, gender, occupation, and shoulder injury side to those in the first group. The incidence of RCTs and their correlation with CaT were assessed based on an MRI of shoulder joints.

RESULTS

There was a statistical difference (p < 0.05) in the incidence of RCTs between the CaT group (23.4%) and the control group (37.2%). No significant difference was observed in the size of the RCTs between the two groups (P = 0.422). In the CaT group, 17.4% of patients had complete tears, compared with 26.3% in the control group. There was no significant correlation between the calcification site and RCTs in the CaT group, and only 3.7% of patients suffered calcification and a tear in the exact location of the same tendon (P > 0.05, r = 0.03).

CONCLUSIONS

Compared with patients with shoulder pain without CaT, patients with rotator cuff CaT suffered no increased risk of RCTs on MRI, so CaT and RCTs may have different pathological causes, and there is no significant correlation between the two.

Isolated tear of the cord-like middle glenohumeral ligament in Buford complex: A case report

RATIONALE

We describe a rare case of the isolated tear in the cord-like middle glenohumeral ligament (MGHL) in Buford complex. To the best of our knowledge, this is the first report in the English literature about the isolated tear of cord-like MGHL in Buford complex. The present report describes in detail our experience with the diagnosis of isolated tear of the cord-like MGHL in Buford complex and management.

PATIENT CONCERNS

A 50-year-old female patient visited our hospital with pain and stiffness in the right shoulder that lasted for 9 months.

DIAGNOSES

The clinical impression was frozen shoulder by primary impingement syndrome of right shoulder and the magnetic resonance (MR) images showed tear of cord-like MGHL.

INTERVENTIONS

We repaired the torn MGHL with the arthroscopic technique.

OUTCOMES

Positive outcome by arthroscopic repair demonstrates that this disease entity is one of spectrum of pathologic condition in shoulder joint.

LESSONS

Isolated tear of cord-like MGHL should be restored to the original anatomy for positive outcome.

Use sonoelastography to predict the reparability of large-to-massive rotator cuff tears

INTRODUCTION

Most symptomatic large-to-massive rotator cuff tears (RCTs) should be operated, but the surgical reparability depended on the degree of rotator cuff muscle atrophy or fatty infiltration. The orthopedic surgeons will decide whether the teared stump is reparable during the surgery, but preoperative evaluation can be done by some assessment tools. Magnetic resonance imaging (MRI) was used in recent studies to predict the reparability of large-to-massive RCTs, but the clinical availability was not as good as ultrasound. We hypothesize that the ultrasound elastography can predict the reparability of large-to-massive RCTs.

METHODS

This is a prospective observational study and participants with large-to-massive RCTs who are going to have surgeries will be included. Out investigators will evaluate the shoulder passive range of motion (ROM) and strength of all participants. Participants' degree of shoulder pain and activities of daily living (ADLs) will be assessed by American Shoulder and Elbow Surgeons (ASES) score. The ultrasound elastography will be used to evaluate the tissue quality of supraspinatus muscle and infraspinatus muscle. To test the reliability of the ultrasound elastography, two physicians will perform the ultrasound elastography independently and twenty participants will be selected for the reliability test. Besides, MRI will be used to evaluate the size of tear, the degree of tendon retraction, fatty infiltration of rotator cuff muscles, and muscle atrophy. Finally, the orthopedic surgeons will perform surgeries and decide whether the teared stump can be completely repaired intraoperatively. The primary analysis is the predictive validity of ultrasound elastography for the reparability of large-to-massive RCTs. Before the predictive validity of ultrasound elastography is measured, our investigators will assess the reliability of ultrasound elastography when administered to cases with large-to-massive RCTs, and we will check the correlations between the findings of ultrasound elastography and MRI.

DISCUSSION

The outcome will provide the evidence of ultrasound elastography for preoperative evaluation of large-to-massive RCTs. The relationships between the findings of ultrasound elastography and MRI will also be examined for further analysis.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03682679. Date of Registration: 25 September 2018, https://clinicaltrials.gov/ct2/show/NCT03682679?cond=rotator+cuff&cntry=TW&draw=2&rank=1.

Finite element analysis of the rotator cuff: A systematic review

BACKGROUND

Finite element modeling serves as a promising tool for investigating underlying rotator cuff biomechanics and pathology. However, there are currently no concrete guidelines for reporting in finite element model studies. This has compromised the reliability, validity, and reproducibility of literature due to omission of pertinent items within publications. Recently a Finite Element Model Grading Procedure has been proposed as a reporting guideline for model developers. The aim of this study was to conduct a systematic review of rotator cuff focused finite element models and characterize the reporting quality of those articles.

METHODS

A comprehensive literature search was performed in PubMed, Web of Science, and Embase to find relevant articles. Each article was graded and given a reporting quality ranking based on a score generated from the Finite Element Model Grading Procedure.

FINDINGS

We found that only 5/22 articles had scores of 75% or higher and fell within the "exceptional" reporting quality range. Most of the articles (16/22) fell within the "good" reporting quality range with scores between 50% and 75%. However, 9/16 articles within the "good" reporting quality range had scores below 60%.

INTERPRETATION

This study indicates that improved guidelines and standards for good reporting practices must be made in the field of finite element modeling. Furthermore, it supports the use of the Finite Element Model Grading Procedure as an objective method for evaluating the quality of finite element model reporting in the literature.

BET 2: Is ultrasound a reliable way of detecting rotator cuff injuries of the shoulder?

A shortcut review was carried out to establish whether ultrasonography was a reliable and accurate imaging modality to detect rotator cuff tears in adult patients. Four papers were found to be relevant to the clinical question following the below-described search strategies. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of those best papers are tabulated. It is concluded that ultrasound has a diagnostic accuracy high enough to detect full-thickness rotator cuff tears. It is, however, less accurate in detecting partial-thickness ruptures.

Lugol's solution but not formaldehyde affects bone microstructure and bone mineral density parameters at the insertion site of the rotator cuff in rats

BACKGROUND

This study aimed to investigate whether rodent shoulder specimens fixed in formaldehyde for histological and histomorphometric investigations and specimens stained using Lugol's solution for soft tissue visualization by micro-computed tomography (microCT) are still eligible to be used for bone architecture analysis by microCT.

METHODS

In this controlled laboratory study, 11 male Sprague-Dawley rats were used. After sacrifice and exarticulation both shoulders of healthy rats were assigned into three groups: (A) control group (n = 2); (B) formaldehyde group (n = 4); (C) Lugol group (n = 5). Half of the specimens of groups B and C were placed in a 4% buffered formaldehyde or Lugol's solution for 24 h, whereas the contralateral sides and all specimens of group A were stored without any additives. MicroCT of both sides performed in all specimens focused on bone mineral density (BMD) and bone microstructure parameters.

RESULTS

BMD measurements revealed higher values in specimens after placement in Lugol's solution (p < 0.05). Bone microstructure analyses showed increased BV/TV and Tb.Th values in group C (p < 0.05). Specimens of group C resulted in clearly decreased Tb.Sp values (p < 0.05) in comparison to the control group. Formaldehyde fixation showed minimally altered BMD and bone microstructure measurements without reaching any significance.

CONCLUSIONS

MicroCT scans of bone structures are recommended to be conducted natively and immediately after euthanizing rats. MicroCT scans of formaldehyde-fixed specimens must be performed with caution due to a possible slight shift of absolute values of BMD and bone microstructure. Bone analysis of specimens stained by Lugol's solution cannot be recommended.

Minimal inter-surgeon agreement on the diagnosis of pseudoparalysis in patients with massive rotator cuff tears

BACKGROUND

Pseudoparalysis is commonly used to describe patients with severe loss of active elevation associated with advanced rotator cuff disease, but its definition in the literature has been variable. This study aimed to determine how 15 expert shoulder surgeons use the term "pseudoparalysis" when presented with clinical cases and assess clinical agreement on the diagnosis of pseudoparalysis.

METHODS

Fifteen expert shoulder surgeons were surveyed regarding 18 patients with magnetic resonance imaging-diagnosed massive rotator cuff tears, restricted active range of motion (ROM), full passive ROM, and without advanced rotator cuff arthropathy (Hamada grade <3). The survey included 18 patient vignettes with key clinical details and a deidentified video demonstrating the physical examination of the patient. For all patients, surgeons were instructed to assume that the patient has a full passive ROM. An anteroposterior radiograph and T2 sequences of the patient's coronal, axial, and sagittal magnetic resonance imaging were also provided. After each case, the surgeons were asked: (1) does the patient have pseudoparalysis, and (2) if so, how severe it is. At the end of the patient vignettes, surgeons were asked to define pseudoparalysis using a checklist with predefined options. Surgeons were also asked if there was a difference between the term pseudoparalysis and pseudoparesis. Fleiss' kappa (κ) correlation coefficient was used to determine intersurgeon agreement.

RESULTS

There was minimal inter-rater agreement on the diagnosis of pseudoparalysis (κ = 0.360) and no agreement on describing the severity of pseudoparalysis (κ = -0.057). Although 80% of surgeons stated that an active glenohumeral elevation less than 90° was a diagnostic feature of pseudoparalysis, there was disagreement on the remaining criteria, leading to no agreement on a set of universal criteria that defines pseudoparalysis. A total of 67% included maintained full passive elevation, 33% included the absence of pain, 67% included elevation causing anterosuperior escape, and 27% included an additional unlisted factor. There was minimal agreement among the 15 surgeons on the diagnostic criteria of pseudoparalysis (κ = 0.092). Finally, 7 surgeons stated that pseudoparalysis and pseudoparesis are identical, whereas 8 surgeons stated that they are 2 different clinical diagnoses.

CONCLUSION

Among this panel of expert shoulder surgeons, there was a lack of consensus on the definition of pseudoparalysis and minimal agreement on the diagnosis of pseudoparalysis based on clinical scenarios. In addition, half the surgeons believed that pseudoparalysis and pseudoparesis are identical, whereas the other half believed that they represent 2 separate clinical entities. A standardized definition of pseudoparalysis would be of value to facilitate communication and research efforts.

Pseudoparesis and pseudoparalysis in the setting of massive irreparable rotator cuff tear: demographic, anatomic, and radiographic risk factors

BACKGROUND

The primary purpose of this study was to identify demographic, anatomic, and radiographic risk factors for active forward elevation (AFE) <90° in the setting of massive, irreparable rotator cuff tear (miRCT). The secondary purpose was to identify characteristics differentiating between patients with pseudoparalysis (AFE <45°) and pseudoparesis (AFE >45° but <90°).

METHODS

This was a retrospective case-control study reviewing patients with miRCTs at a single institution between January 12, 2016 and November 26, 2020. Patients were separated into 2 cohorts based on presence or absence of preoperative AFE <90° with maintained passive range of motion. Demographics, RCT pattern, and radiographic parameters were assessed as risk factors for AFE <90°. A secondary analysis was conducted to compare patients with pseudoparalysis and pseudoparesis.

RESULTS

There were 79 patients in the AFE <90° cohort and 50 patients in the control cohort. Univariate analysis confirmed significant differences between the AFE <90° and control cohort in age (71.9 ± 11.0 vs. 65.9 ± 9.1 years), arthritis severity (34.2% vs. 16.0% grade 3 Samilson-Prieto), acromiohumeral distance (AHD; 4.8 ± 2.7 vs. 7.6 ± 2.6 mm), fatty infiltration of the supraspinatus (3.3 ± 0.9 vs. 2.8 ± 0.8) and subscapularis (2.0 ± 1.2 vs. 1.5 ± 1.0), and proportion of subscapularis tears (55.7% vs. 34.0%). On multivariate analysis, age (odds ratio [OR] 1.08, P = .014), decreased AHD (OR 0.67, P < .001), severe arthritis (OR 2.84, P = .041), and subscapularis tear (OR 6.29, P = .015) were independent factors predictive of AFE <90°. Secondary analysis revealed tobacco use (OR 3.54, P = .026) and grade 4 fatty infiltration of the supraspinatus (OR 2.22, P = .015) and subscapularis (OR 3.12, P = .042) as significant predictors for pseudoparalysis compared to pseudoparesis.

CONCLUSIONS

In patients with miRCT, increased age, decreased AHD, severe arthritis, and subscapularis tear are associated with AFE <90°. Furthermore, patients with AFE <90° tend to have greater supraspinatus and subscapularis fatty infiltration. Lastly, among patients with AFE <90°, tobacco use and grade 4 fatty infiltration of the supraspinatus and subscapularis are associated with pseudoparalysis compared with pseudoparesis.

Development and Clinical Application of Artificial Intelligence Assistant System for Rotator Cuff Ultrasound Scanning

OBJECTIVE

We developed an intelligent assistance system for shoulder ultrasound imaging, incorporating deep-learning algorithms to facilitate standard plane recognition and automatic tissue segmentation of the rotator cuff and its surrounding structures. We evaluated the system's performance using a dedicated data set of rotator cuff ultrasound images to assess its feasibility in clinical practice.

METHODS

To fulfill the system's primary functions, we designed a standard plane recognition module based on the ResNet50 network and an automatic tissue segmentation module using the Mask R-CNN model. The modules were trained on carefully curated data sets. The standard plane recognition module automatically identifies a specific standard plane based on the ultrasound image characteristics. The automatic tissue segmentation module effectively delineates and segments anatomical structures within the identified standard plane.

RESULTS

With the use of 59,265 shoulder joint ultrasound images, the standard plane recognition model achieved an impressive recognition accuracy of 94.9% in the test set, with an average precision rate of 96.4%, recall rate of 95.4% and F1 score of 95.9%. The automatic tissue segmentation model, tested on 1886 images, exhibited a commendable average intersection over union value of 96.2%, indicating robustness and accuracy. The model achieved mean intersection over union values exceeding 90.0% for all standard planes, indicating its effectiveness in precisely delineating the anatomical structures.

CONCLUSION

Our shoulder joint musculoskeletal intelligence system swiftly and accurately identifies standard planes and performs automatic tissue segmentation.

Superior Capsular Reconstruction Versus Middle Trapezius Tendon Transfer for Isolated Irreparable Supraspinatus Tendon Tears: Static Versus Dynamic Reconstruction

BACKGROUND

Both superior capsular reconstruction (SCR) and middle trapezius tendon (MTT) transfer can be performed in nonarthritic young and active patients with isolated irreparable supraspinatus tendon tears (IISTTs). However, to our knowledge, no comparative clinical studies have been conducted on these procedures.

PURPOSE

To evaluate and compare the clinical and radiological outcomes of SCR and arthroscopic-assisted MTT transfer in patients with IISTTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 60 patients with IISTTs were categorized into 2 groups according to the surgical procedure-Group S underwent SCR (n = 34); Group M underwent MTT transfer (n = 26). The clinical outcomes included the visual analog scale score for pain, active shoulder range of motion, American Shoulder and Elbow Surgeons score, and University of California, Los Angeles, shoulder score. Radiological outcomes included the assessment of the acromiohumeral distance, progression of cuff tear arthropathy (Hamada grade), subacromial bone erosion, and graft failure.

RESULTS

The mean follow-up time was 39.3 ± 5.2 months (range, 26-59 months) and 37.6 ± 9.8 months (range, 27-54 months) in Group S and Group M, respectively. Significant improvements in clinical outcomes were observed in both groups, while the active forward flexion (148.2°± 24.1° vs 165.9°± 8.7°; P = .003) and abduction (131°± 37.3° vs 152.5°± 17.9°; P = .035) were significantly higher in Group M at the final follow-up. No significant differences were found in the postoperative Constant, American Shoulder and Elbow Surgeons, and University of California, Los Angeles, shoulder scores between the 2 groups. Radiologically, although no difference was found in the Hamada grade at the final follow-up between the 2 groups (P = .143), the rates of acromial wear (58.8% vs 15.4%; P < .001) and graft retear (47.1% vs 7.7%; P < .001) were significantly higher in Group S than in Group M.

CONCLUSION

Both SCR and MTT transfer improved the overall clinical outcomes of IISTTs postoperatively, whereas MTT transfer was superior to SCR in terms of active forward flexion and abduction range of motion. Although higher rates of graft failure and subacromial bone erosion were observed in Group S, no difference was found in the clinical scores between the 2 groups at the short-term follow-up. However, further well-structured, prolonged comparative trials should be conducted in the future.

Risk factors of acromial and scapular spine stress fractures differ by indication: a study by the ASES Complications of Reverse Shoulder Arthroplasty Multicenter Research Group

BACKGROUND

Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status.

METHODS

Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis.

RESULTS

Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort.

CONCLUSION

Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.

Midterm results after revision rotator cuff reconstruction: Can ultrasound predict outcome of revision surgery?

PURPOSE

Structural failures after rotator cuff repair are well known, and despite advances and improved techniques in rotator cuff repair (RCR), retear rates remain high. The aim of this study was to (1) evaluate the midterm clinical and radiological outcomes after revision RCR and to (2) analyze whether preoperative ultrasound can predict outcome of open revision rotator cuff repair.

METHODS

Twenty-five patients who underwent revision RCR in a single institution between 2010 and 2012 were retrospectively reviewed at a minimum follow-up of 2 years. The Constant Score (CS) and the Disabilities of the Arm, Shoulder and Hand score were collected. Ultrasound examination was used both before revision surgery and at follow-up to determine tendon integrity.

RESULTS

At the final follow-up, 69.6% patients showed an intact rotator cuff and their CS had improved from 28.3 to 77. 30.4% patients had a persisting rotator cuff defect, and the CS had improved from 24 to 47.7. A preoperative tear size of more than 20 mm from an ultrasound examination could be identified as a factor that would risk structural failure of revision RCR.

CONCLUSION

(1) Clinical outcomes after revision RCR improve in both patients with an intact RC and those with a retear at midterm follow-up. (2) Ultrasound seems to be a useful tool to predict whether reconstruction of recurrent rotator cuff tears is feasible.

LEVEL OF EVIDENCE

IV, Case series.

The Double-Circle System in the Greater Tuberosity: Using Radius to Predict Rotator Cuff Tear

OBJECTIVE

In this study we concerned on the morphological characteristics of the greater tuberosity of humerus and proposed the double-circle radius ratio as a new predictor for the diagnosis of rotator cuff tears.

METHODS

This was a retrospective study and patients who visited our hospital and were diagnosed with or without rotator cuff tears via magnetic resonance imaging from January 2018 to July 2021 were enrolled and classified into two groups respectively. In a standard anteroposterior view, the radius of the best-fit circle of humeral head and the radius of the concentric circle passing through the most lateral edge of the greater tuberosity were measured in each shoulder. The ratio of these two radiuses was named as the double-circle radius ratio. Angular parameters including the greater tuberosity angle and the critical shoulder angle were also measured in the anteroposterior view. Independent samples t tests and chi-square tests were used to find significant differences between groups. Significant associations between those measured variables and demographic characteristics were analyzed with simple linear regression analysis. Receiver operating characteristic curves were pictured to determine applied cutoff values by using Youden index. Multivariable-adjusted analysis for the occurrence of rotator cuff tears was carried out by using multiple logistic regression analysis. For all tests a p value of <0.05 was considered statistically significant.

RESULTS

One hundred and twelve shoulders with rotator cuff tears and 42 shoulders without rotator cuff tears were included. The mean value of the double-circle radius ratio was significantly larger in shoulders with rotator cuff tears (1.42 ± 0.09 vs. 1.30 ± 0.07, P = 0.000). With simple linear regression analysis, the radiuses of the humeral head and the greater tuberosity were significantly associated with heights and weights. In receiver operating characteristic curves, the largest area was found under the curve of the double-circle radius ratio as 0.846 (95% CI, 0.781-0.911; P = 0.000) with an applied cutoff value as 1.38 (sensitivity, 70.5%; specificity, 88.1%). Multivariable-adjusted analysis showed that a value of the double-circle radius ratio >1.38 resulted in 11.252-fold odds of developing rotator cuff tears (95% CI, 3.388-37.368; P = 0.000).

CONCLUSION

The double-circle radius ratio is significantly larger in patients with rotator cuff tears and could be regarded as an eligible predictor for rotator cuff tears.

Enhancement of Tendon-to-Bone Healing: Choose a Monophasic or Hierarchical Scaffold?

BACKGROUND

To enhance the healing of tendon to bone, various biomimetically hierarchical scaffolds have been proposed. However, the fabrication of such scaffolds is complicated. Furthermore, the most significant result after a routine repair is loss of the transition zone between the tendon and bone, whose main components are similar to fibrocartilage.

PURPOSE

To compare tendon-to-bone healing results in a rabbit model using a monophasic graft (decellularized fibrocartilage graft; DFCG) and hierarchical graft (decellularized tendon-to-bone complex; DTBC) that contain the native hierarchical enthesis.

STUDY DESIGN

Controlled laboratory study.

METHODS

DFCG and DTBC were harvested from allogenic rabbits. A rabbit model of a chronic rotator cuff tear was established, and 3 groups were assessed: direct repair or repair with DFCG or DTBC fixed between the tendon and bone. Hierarchical evaluations of the repaired tendon-to-bone interface were performed with regard to the tendon zone, transition zone, and bone zone using histological staining and micro-computed tomography scanning. Biomechanical analysis was performed to evaluate the general healing strength.

RESULTS

The healing results in the tendon zone exhibited no significant difference among the 3 groups at any time point. In the transition zone, the grade in the direct repair group was significantly lower than that in the DFCG and DTBC groups at 4 weeks, and the grade in the DFCG group was significantly lower than that in the DTBC group at this time point. However, any significant difference between the DFCG group and DTBC group could no longer be detected at 8 and 16 weeks, which was inconsistent with the results of the biomechanical analysis. Micro-computed tomography analysis showed no significant difference among the 3 groups with regard to bone mineral density at 16 weeks.

CONCLUSION

A monophasic DFCG was able to achieve enhanced tendon-to-bone healing similar to that with hierarchical DTBC over the long term, with regard to both histological and biomechanical properties.

CLINICAL RELEVANCE

Fabrication of a monophasic scaffold instead of a hierarchical scaffold to promote regeneration and remodeling of a transition zone, which was mainly composed of fibrocartilaginous matrix between the tendon and bone, may be sufficient to enhance tendon-to-bone healing.

MRA improves sensitivity than MRI for the articular-sided partial-thickness rotator cuff tears

BACKGROUND

This study aims to compare the diagnostic accuracy of magnetic resonance imaging (MRI) and MR arthrography (MRA) for the articular-sided partial-thickness rotator cuff tear (PTRCT).

METHODS

Three electronic databases, PubMed/Medline, Embase and Cochrane Library, were utilized to retrieve articles comparing the diagnostic value of MRA and MRI for detecting articular-sided PTRCTs. The pooled statistical indexes included sensitivity, specificity, positive/negative predictive value, diagnostic odds ratio (DOR) and the area under the receiver operating characteristic curve (AUC).

RESULTS

Eleven studies involving 1703 patients and 1704 shoulders were included. The pooled sensitivity, specificity, DOR and AUC and their 95% CIs of MRA to diagnose articular-sided PTRCTs were 0.81 (95% CI, 0.65-0.90), 0.96 (95% CI, 0.91-0.98), 68.14 (95% CI, 33.20-139.84) and 0.96 (95% CI, 0.94-0.97), respectively. The pooled sensitivity, specificity, DOR and AUC and their 95% CIs of MRI were 0.78 (95% CI, 0.65-0.87) and 0.97 (95% CI, 0.84-0.99), 47.82 (95% CI, 8.29-275.89) and 0.89 (95% CI, 0.86-0.92), respectively.

CONCLUSIONS

This meta-analysis reveals that MRA has a better diagnostic value than that of MRI for the diagnosis of articular-sided partial-thickness rotator cuff tears because of an improvement of sensitivity.

Are differences in shoulder morphology and hand dominance risk factors for rotator cuff tears?

OBJECTIVE

The purpose of this study was to evaluate whether there was a difference in shoulder morphology and hand dominance between a healthy shoulder and a shoulder with rotator cuff tear (RCT) in the same patient.

PATIENTS AND METHODS

Between 2015 and 2020, 120 shoulders from 60 patients with complete RCT and contralateral intact rotator cuffs were enrolled in this retrospective analysis. Physical examinations, shoulder radiographs, and magnetic resonance imaging (MRI) pictures of the patients were reviewed. On radiographs, the AT, CSA, LAA, and AI values were compared between shoulders with complete RCT and contralateral healthy shoulders from the same individuals. Additionally, the association between hand dominance and RCT was evaluated.

RESULTS

This study enrolled 60 patients. 59.17% of the participants are female, and 40.83% are male. The mean age of the patients was 54.5±7.1 years. There were statistically significant differences in AI, CSA, and LAA measurements between the study group (RCT group) and the control group. There was no significant difference in AT between the two groups.

CONCLUSIONS

There are morphological differences between a healthy shoulder and a shoulder with an RCT in the same patient, and these differences (LAA/CSA/AI/AT) may have an effect on the prevalence of RCT.