The effect of concomitant coracohumeral ligament release in arthroscopic rotator cuff repair to prevent postoperative stiffness: a retrospective comparative study

Adduction Manipulation of the Glenohumeral Joint versus Physiotherapy for Atraumatic Rotator Cuff Tears: A Randomized Controlled Trial

BACKGROUND

Atraumatic rotator cuff tears (ARCTs) are frequently concomitant with adduction restriction of the glenohumeral joint (GHJ). Adduction manipulation (AM) removes the restriction and relieves pain. The present study aimed to investigate the clinical efficacy of AM versus physiotherapy (PT) in ARCTs.

METHODS

Eighty-eight patients with adduction restriction were allocated to the AM and PT groups (n = 44 per group). The glenohumeral adduction angle (GAA) was calculated using X-rays at the first and last follow-up appointments. We recorded pain severity (visual analog scale, VAS), flexion, abduction, external rotation (ER), internal rotation (IR), and American Shoulder and Elbow Society (ASES) and Constant scores at baseline and at 1-, 3-, 6-, and 12- month follow-ups.

RESULTS

Forty-three patients (23 males, average age 71.3 years) in the AM group and 41 (16 males, average age 70.7 years) in the PT group were consequently analyzed. At the 1-month follow-up, VAS, shoulder motion except ER, ASES and Constant scores were much better in the AM group than in the PT group, whereas those in the PT group improved gradually up to 12 months. At the final follow-up, flexion, abduction, and Constant score were significantly better in the AM group than in the PT group. The GAA at the initial and final examinations was -21.6° and -3.2°, respectively, in the AM group, and -21.1° and -14.4°, respectively, in the PT group.

CONCLUSIONS

The AM procedure, which had better clinical efficacy than PT, is recommended as the first conservative treatment option for ARCTs.

Preemptive middle glenohumeral ligament release in arthroscopic rotator cuff repair does not reduce the postoperative stiffness: a retrospective comparative study

BACKGROUND

This study aimed to evaluate the efficacy of preemptive middle glenohumeral ligament (MGHL) release in arthroscopic rotator cuff repair (ARCR) to reduce postoperative stiffness.

METHODS

Patients who underwent ARCR were enrolled and allocated into two groups retrospectively: the preemptive MGHL release group (n = 44) and the preemptive MGHL non-release group (n = 42). Clinical outcomes were assessed and compared between the two groups, including the range of motion, Japanese Orthopedic Association Shoulder Score, Constant Shoulder Score, and the University of California, Los Angeles Score preoperatively and 3 months, 6 months, and 12 months postoperatively and complications. The integrity of the repaired tendon was assessed at the 12-month follow-up using magnetic resonance imaging.

RESULTS

There were no significant differences between the groups in all range of motion and all functional scores at any of the assessed time points. There was also no significant difference in the healing failure rate 2.3% in the preemptive MGHL group and 2.4% in the preemptive MGHL non-release group (p = .97), and postoperative stiffness was 2.3% in the preemptive MGHL group and 7.1% in the preemptive MGHL non-release group (p = .28). There was no postoperative instability in both group.

CONCLUSION

ARCR effectively facilitates the recovery of range of motion and function in patients with a rotator cuff tear. However, preemptive MGHL release could not be an effective method to reduce postoperative stiffness.

Dynamic Analysis of the Coracohumeral Ligament Using Ultra-Sonography in Shoulder Contracture

The coracohumeral ligament (CHL) is related to the range of motion of the shoulder joint. The evaluation of the CHL using ultrasonography (US) has been reported on the elastic modulus and thickness of the CHL, but no dynamic evaluation method has been established. We aimed to quantify the movement of the CHL by applying Particle Image Velocimetry (PIV), a technique used in the field of fluid engineering, to cases of shoulder contracture using the US. The subjects were eight patients, with 16 shoulders. The coracoid process was identified from the body surface, and a long-axis US image of the CHL parallel to the subscapularis tendon was drawn. The shoulder joint was moved from 0 degrees of internal/external rotation to 60 degrees of internal rotation at a rhythm of one reciprocation every 2 s. The velocity of the CHL movement was quantified by the PIV method. The mean magnitude velocity of CHL was significantly faster on the healthy side. The maximum magnitude velocity was significantly faster on the healthy side. The results suggest that the PIV method is helpful as a dynamic evaluation method, and in patients with shoulder contracture, the CHL velocity was significantly decreased.

Prediction of Shoulder Stiffness After Arthroscopic Rotator Cuff Repair

BACKGROUND

Postoperative shoulder stiffness (POSS) is a prevalent adverse event after arthroscopic rotator cuff repair (ARCR) that is associated with major limitations in everyday activities and prolonged rehabilitation.

PURPOSE/HYPOTHESIS

The purpose was to develop a predictive model for determining the risk of POSS within 6 months after primary ARCR. We hypothesized that sufficient discrimination ability of such a model could be achieved using a local institutional database.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Consecutive primary ARCRs documented in a local clinical registry between 2013 and 2017 were included, and patients who experienced POSS before the final clinical 6-month follow-up were identified. A total of 29 prognostic factor candidates were considered, including patient-related factors (n = 7), disease-related factors (n = 9), rotator cuff integrity factors (n = 6), and operative details (n = 7). We used imputed data for the primary analysis, and a sensitivity analysis was conducted using complete case data. Logistic regression was applied to develop a model based on clinical relevance and statistical criteria. To avoid overfitting in the multivariable model, highly correlated predictors were not included together in any model. A final prognostic model with a maximum of 8 prognostic factors was considered. The model's predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC). Internal validation was performed using bootstrapping.

RESULTS

Of 1330 ARCR cases (N = 1330 patients), 112 (8.4%) patients had POSS. Our final model had a moderate predictive ability with an AUC of 0.67. The predicted risks of POSS ranged from 2.3% to 38.9% and were significantly higher in women; patients with partial tears, low baseline passive shoulder abduction, and lack of tendon degeneration; and when no acromioplasty was performed.

CONCLUSION

A prognostic model for POSS was developed for patients with ARCR, offering a personalized risk evaluation to support the future decision process for surgery and rehabilitation.

Significance of the acromiohumeral distance on stress radiography for predicting healing and function after arthroscopic repair of massive rotator cuff tears

BACKGROUND

A decreased acromiohumeral distance (AHD) is commonly detected in patients with massive rotator cuff tears (mRCTs). Most studies evaluating fixed humeral elevation have used preoperative or postoperative standardized radiography and not stress radiography. This study aimed to evaluate the predictive role of the preoperative AHD measured using stress radiography (AHD_stress) in rotator cuff healing and function after arthroscopic repair of mRCTs.

METHODS

The data of 113 patients who underwent arthroscopic repair of mRCTs were analyzed. Postoperative cuff integrity was evaluated using magnetic resonance imaging at 1 year, and shoulder function was evaluated at a mean of 34.9 ± 17.8 months (range, 24-92 months) postoperatively. Forty-seven patients showed healing failure. Propensity score matching (1-1) was performed between the healed group and healing failure group. Thirty-eight patients in each group were matched in the final analysis. The AHD and AHD_stress were defined as the shortest distances from the inferior acromion to the superior humerus on standard anteroposterior radiography and stress radiography (5.4-kg weight applied inferiorly in a neutral position), respectively. The AHD difference (AHD_diff) was defined as the difference between the AHD and AHD_stress values. Receiver operating characteristic curve analysis was performed to determine cutoff values for significant variables.

RESULTS

No difference in the mean preoperative AHD was found between the healed group (7.5 ± 2.0 mm) and healing failure group (6.9 ± 2.2 mm, P = .234). The AHD_diff value was significantly higher in the healed group (4.4 ± 2.1 mm) than in the healing failure group (3.0 ± 2.0 mm, P = .002; cutoff, 3.2 mm). Patients with an AHD_diff value ≥ 3.2 mm showed a lower healing failure rate (28.9% vs. 71.1%, P < .001) and higher functional scores than patients with an AHD_diff value < 3.2 mm. The AHD_diff value was higher in patients with an American Shoulder and Elbow Surgeons (ASES) score ≥ 80 (4.9 ± 1.9 mm) than in those with an ASES score < 80 (3.1 ± 2.1 mm, P = .024). Among patients with healing failure, only the postoperative AHD showed a significant difference between those with an ASES score ≥ 80 (7.0 ± 2.5 mm) and those with an ASES score < 80 (4.8 ± 2.1 mm, P = .009; cutoff, 4.8 mm).

CONCLUSION

A reducible AHD, which increased by ≥ 3.2 mm under stress radiography, can be a favorable predictor of rotator cuff healing and function after arthroscopic repair of mRCTs. Our findings suggest that this new and simple radiologic parameter should be considered preoperatively and would be helpful to determine appropriate treatment strategies.

Correlations Between Range of Motion and Elasticity of the Coracohumeral Ligament Evaluated With Shear-Wave Elastography

Context: Range of motion (ROM) in the glenohumeral joint decreases with age in healthy subjects; however, the underlying mechanism remains unclear. The process of aging of the joint capsule, including the coracohumeral ligament (CHL), could affect ROM limitation. Objective: This study investigated correlations between elasticity of the CHL, evaluated by means of shear-wave elastography, and age, side dominance, and ROM in healthy individuals. Design: Experimental study. Setting: Laboratory. Subjects: Eighty-four healthy volunteers (39 men and 45 women, mean age: 42.6 y) were included. Main Outcome Measures: Subjects were divided into 3 age groups: younger (20–39 y), middle (40–59 y), and older (≥60 y) age groups. With participants in the supine position, CHL elasticity in both shoulders was evaluated in both neutral and 30° external rotation, with arms at the sides. ROM, including forward flexion, lateral elevation, external rotation, 90° abduction with external rotation, and hand behind the back were measured with participants in the standing position. Results: The CHL elastic modulus was higher in the older group than in the younger group in the neutral (78.4 kPa [SD: 37.1] and 56.6 kPa [SD: 31.7], respectively) and 30° external rotation positions (135.5 kPa [SD: 63.5] and 71.4 kPa [SD: 32.2], respectively). Negative correlations were found between the CHL elastic modulus and ROM in terms of 30° external rotation and both external rotation (R = −.59, P = .02) and 90° abduction with external rotation (R = −.71, P = .003) in the older group, with correlation coefficients increasing with age. Conclusions: Significant correlations were identified between CHL elasticity and ROM in both external rotation and 90° abduction with external rotation with increasing age. Decreased CHL elasticity was strongly associated with decreased shoulder ROM in middle-aged and older individuals.