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

Effect of Medial or Lateral Graft Failure on Graft Volume and Clinical Outcomes After Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears

BACKGROUND

Graft failure is a common complication after superior capsule reconstruction (SCR). The graft in SCR is fixed on the greater tuberosity and superior glenoid, and graft failure has been reported on both sides.

PURPOSE

To evaluate the clinical manifestations of patients with graft failure after SCR and identify the clinical and radiological differences between medial and lateral graft failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent SCR with a dermal allograft for symptomatic irreparable rotator cuff tears between March 2018 and September 2021 were retrospectively reviewed. All patients had minimum 2-year follow-up and underwent magnetic resonance imaging at 6 months postoperatively. Patients with graft failure were divided into 2 groups: those with lateral graft failure on the greater tuberosity side (group I) and those with medial graft failure on the glenoid side (group II). Patients with intact grafts were included in group III as a control group. Intergroup differences in clinical and radiological characteristics were analyzed, and multiple regression analysis was performed.

RESULTS

Among the 93 patients included, there were 18 patients in group I, 15 in group II, and 60 in group III. Overall, 11 patients (61.1%) in group I and 9 patients (60.0%) in group II had a partial graft rupture at one anchor. The postoperative graft volume was significantly lower in group I than in groups II and III (2514.0 ± 564.3 mm3, 3183.5 ± 547.1 mm3, and 3198.0 ± 584.8 mm3, respectively; P = .002 for group I vs II; P < .001 for group I vs III). The acromiohumeral distance (AHD) was significantly increased at 6 months postoperatively compared with before surgery in group I (6.6 ± 1.6 mm vs 4.3 ± 1.9 mm, respectively; P < .001) and group II (7.4 ± 1.3 mm vs 5.7 ± 1.7 mm, respectively; P = .002). However, group I exhibited a significantly greater decrease in the AHD over time than group II (P < .001) and a significantly lower AHD at the final follow-up than the other groups (P < .001). The postoperative American Shoulder and Elbow Surgeons score was significantly lower in group I than in the other groups (P < .001). On multiple regression analysis, fatty infiltration of the infraspinatus muscle, Hamada grade, and graft width were independent factors for lateral graft failure.

CONCLUSION

Patients with lateral graft failure had inferior clinical outcomes and lower postoperative graft volumes than those with medial graft failure after SCR using a dermal allograft. The AHD of patients with lateral graft failure improved postoperatively; however, it deteriorated over time.

F, Meisterhans M, Borbas P, Wieser K, Grubhofer F. Anterior shoulder dislocation with avulsion fracture of the greater tuberosity results in reliable good outcomes after closed reduction

Background

Avulsion of the greater tuberosity (GT) due to traumatic anterior shoulder dislocation (ASD) is a commonly observed fracture pattern. After closed reduction of the dislocated humerus, the GT typically reduces itself into its anatomic position enabling the patient to undergo conservative treatment. The aim of this study was to retrospectively review a consecutive series of patients with conservatively treated GT avulsion fractures after closed reduction of an ASD and analyze radiographic outcome, shoulder function and glenohumeral stability and the conversion rate to surgical treatment.

Methods

All patients who underwent closed reduction of a GT avulsion fracture after ASD with the primary intention of conservative treatment between 2017 and 2022 were included. Complications (i.e. conversion to surgical treatment), shoulder function assessed with the American Shoulder and Elbow Surgeons score and subjective shoulder value, instability assessed with the Western Ontario Shoulder Instability score, radiological impingement (greater tuberosity index = GTI and impingement index = II) and GT fracture pattern were assessed as outcome measurements.

Results

A total of 29 patients (mean age 44 years, 27% female) with a mean follow-up of 32.6 (range, 8-96) months were enrolled. Seven patients (24%) underwent surgery due to secondary displacement (n = 4, 14%) or impingement symptoms (n = 3, 10%). All patients who underwent secondary surgery showed a multifragmentary fracture pattern of the GT. Shoulder stiffness (n = 7) and neuropraxia of the axillary nerve (n = 3) were observed temporarily and resolved during the follow-up period. The American Shoulder and Elbow Surgeons and subjective shoulder value of the conservatively treated patients at the last follow-up was 89.2 ± 19.1 respectively 86 ± 18.2%. No recurrent glenohumeral dislocation was documented. The mean Western Ontario Shoulder Instability score at last follow-up was 8(0-71). The mean GTI decreased from 1.2 ± 0.1 after ASD to 1.1 ± 0.1 at the last follow-up (P = .002). The mean II decreased from 0.6 ± 0.5 after ASD to 0.4 ± 0.3 at the last follow-up (P = .110).

Conclusion

The GT avulsion fragment reduces typically into a close to anatomic position after closed reduction and the GTI even improves with further conservative treatment over time. Close radiological follow-up is necessary to rule out secondary displacement which occurs typically in a multifragmentary fracture pattern. Patients without the need for surgery showed good clinical outcomes without recurrence of glenohumeral instability.

Postoperative Graft Volume Reduction Is Associated With Inferior Clinical Outcomes of Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft

PURPOSE

To evaluate whether postoperative graft volume reduction is associated with clinical outcomes after superior capsule reconstruction (SCR) and to identify factors related to graft volume change.

METHODS

Between May 2018 and June 2021, patients who underwent SCR with acellular dermal matrix allograft for irreparable rotator cuff tear with a minimum 1-year follow-up and who had intact graft continuity in postoperative 6-month magnetic resonance imaging were retrospectively reviewed. The lateral half to the medial half of the graft volume ratio was defined as lateral half graft volume ratio. The difference between the preoperative and postoperative lateral half graft volume ratio was defined as lateral half graft volume change. Patients were divided into 2 groups: those with preserved graft volume (group I) and those with reduced graft volume (group II). Intergroup differences in clinical and radiological characteristics were analyzed.

RESULTS

A total of 81 patients were included, with 47 (58.0%) in group I and 34 (42.0%) in group II. Group I showed significantly lower lateral half graft volume change (0.018 ± 0.064 vs 0.370 ± 0.177; P < .001) than group II. Group II showed significantly greater preoperative Hamada grade (1.3 ± 0.5 vs 2.2 ± 0.6, P < .001), an anteroposterior distance of the graft at the greater tuberosity (APGT) (30.3 ± 4.8 vs 35.2 ± 3.8, P < .001), and fatty infiltration of infraspinatus (2.3 ± 0.9 vs 3.1 ± 0.8, P < .001) and subscapularis (0.9 ± 0.9 vs 1.6 ± 1.3, P = .009) than group I. Group II had a significantly lower proportion of patients achieving MIC in Constant score than group I (70.2% vs 47.1%, P = .035). The Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were independent factors of graft volume change.

CONCLUSIONS

Although SCR improved pain and shoulder function, postoperative graft volume reduction was related to a lower rate of minimal important change achievement in the Constant score compared with preserved graft volume. The preoperative Hamada grade, APGT, and fatty infiltration of infraspinatus and subscapularis were associated with graft volume reduction.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

Shoulder adhesive capsulitis: can clinical data correlate with fat-suppressed T2 weighted MRI findings?

Background

Adhesive capsulitis (AC) of the shoulder or frozen shoulder is a debilitating condition characterized by progressive pain, stiffness and limited range of motion about the glenohumeral joint, the term (adhesive capsulitis) to describe the findings of chronic inflammation and fibrosis of the joint capsule, characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. The goal of the trial was to examine the association between clinical features (stages) and magnetic resonance imaging (MRI) findings in adhesive capsulitis of the shoulder.

Results

In our study, Regarding the diagnostic performance of shoulder MRI there is a statistically significant difference between degree of pain intensity according to Capsular thickening regarding humeral “mm” with p-value (p < 0.05). The highest value was found moderate and severe pain group (5.67 ± 1.39) compared to absent, minimal and mild pain group (4.42 ± 1.29), there was a statistically significant difference between two groups according to axillary recess regarding height “mm” with p-value (p < 0.05). The highest value was found absent, minimal and mild pain group (7.02 ± 2.68) compared to moderate and severe pain group (5.73 ± 2.25). There is no statistically significant association between pain intensity and MRI finding regarding capsular edema, extra capsular edema, obliteration of subcoracoid fat triangle, effusion of biceps tendon sheath, capsular thickening of glenoid (mm) and humeral portions of axillary recess and axillary recess width and height (mm), with p-value (p > 0.05 NS).

Conclusions

MRI is useful for assessing clinical impairment and predicting the clinical stage of adhesive capsulitis.

The differences of the acromiohumeral interval between supine and upright radiographs of the shoulder

The acromiohumeral interval (AHI) is a measurement used to determine the superior migration of the humeral head in rotator cuff (RC) tear patients. The purpose of this study was to compare the AHI of; supine, upright shoulder radiographs, and magnetic resonance imaging (MRI) of the shoulder. The 86 shoulders were divided into 3 groups that included; (1) non-full thickness tear (50%), (2) full thickness (FT) tear ≤3 cm (33.7%), and (3) FT tear > 3 cm (16.3%). The mean difference of AHI noted was significantly lower in the supine radiographs and MRIs than with the upright (1.34–1.37 mm, 1.62–1.87 mm, respectively). Upright AHI ≤ 7.0 mm had 27.9% sensitivity and 100% specificity in diagnosing FT tears with 64% accuracy (p < 0.001). The supine AHI ≤ 6.5 mm had 32.6% sensitivity, 100.0% specificity, and 66.3% accuracy (p < 0.01). The results revealed the AHI in supine radiographs were significantly lower than upright shoulder radiographs. For AHI ≤ 7 mm in upright shoulder radiographs, this remains as an appropriate diagnostic test for ruling in shoulders with full thickness rotator cuff tears. This value was not relevant for use as the cut point in the supine radiographs and MRIs.