The relative importance of acromial morphology and age with respect to rotator cuff pathology

Rotator Cuff Repair With or Without Acromioplasty: A Systematic Review of Randomized Controlled Trials With Outcomes Based on Acromial Type

BACKGROUND

It is unclear whether the use of concomitant acromioplasty during rotator cuff repair (RCR) improves clinical outcomes and whether the outcomes are affected by acromial type.

PURPOSE

To perform a systematic review of randomized controlled trials comparing clinical outcomes of RCR with and without acromioplasty, with a subanalysis of outcomes based on acromial type.

STUDY DESIGN

Systematic review; Level of evidence, 2.

METHODS

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that directly compared outcomes between RCR with versus without acromioplasty. A subanalysis was performed on the studies that provided outcomes based on acromial type. The search phrase used was rotator cuff repair (acromioplasty OR subacromial decompression) randomized. Patients were evaluated based on retear rate, reoperation rate, and patient-reported outcomes (PROs).

RESULTS

Application of inclusion criteria yielded 5 studies (2 studies were level 1, and 3 studies were level 2) including a total of 409 patients, with 211 patients undergoing RCR alone (group A) and 198 patients undergoing RCR with acromioplasty (group B). The mean patient age was 58.5 and 58.3 years in groups A and B, respectively. The mean follow-up time was 52.9 months, and the overall percentage of male patients was 54.1%. The rotator cuff tear size was 20.7 mm and 19.8 mm for groups A and B, respectively. No significant differences were found between groups for any of the PROs at final follow-up. Overall retear rates did not significantly differ between groups based on acromial type. Between 2 studies that measured reoperation rate, a significantly higher reoperation rate was found for the nonacromioplasty group (15%) versus the acromioplasty group (4.1%) (P = .031). One of these studies found that 5 of 9 patients (56%) with a type III acromion in the nonacromioplasty group underwent reoperation compared with 0 of 4 patients with a type III acromion in the acromioplasty group.

CONCLUSION

There is some evidence that acromioplasty during RCR reduces the risk for later reoperation. This may be particularly true for patients with type III acromions, although further studies with larger sample sizes are needed to corroborate these data.

Anterolateral Acromioplasty Reduces Gliding Resistance Between the Supraspinatus Tendon and the Coracoacromial Arch in a Cadaveric Model

Purpose

To investigate the gliding resistance dynamics between the supraspinatus (SSP) tendon and the coracoacromial arch, both before and after subacromial decompression (anterolateral acromioplasty) and acromion resection (acromionectomy).

Methods

Using 4 fresh-frozen cadaveric shoulders, acromion shapes were classified (2 type I and 2 type III according to Bigliani). Subacromial bursa and coracoacromial ligament maintenance replicated physiologic sliding conditions. Gliding resistance was measured during glenohumeral abduction (0° to 60°) in internal rotation (IR) and external rotation (ER). Peak gliding resistance between the SSP tendon and the coracoacromial arch was determined and compared between intact, anterolateral acromioplasty, and acromionectomy.

Results

Peak SSP gliding resistance during abduction in an intact shoulder was significantly higher in IR than in ER (4.1 vs 2.1 N, P < .001). The mean peak SSP gliding resistance during 0° to 60° glenohumeral abduction in IR in the intact condition was significantly higher compared with the subacromial decompression condition (4.1 vs 2.8 N, P = .021) and with the acromionectomy condition (4.1 vs 0.9 N, P < .001). During 0° to 60° glenohumeral abduction in ER, mean peak SSP gliding resistance in the intact condition was not significantly different compared with the subacromial decompression condition (2.1 vs 2.0 N, P = .999). The 2 specimens with a hooked (i.e. type III) acromion showed significantly higher mean peak SSP gliding resistance during glenohumeral abduction in IR and ER when compared with the 2 specimens with a flat (i.e. type I) acromion (IR: 5.8 vs 3.0 N, P = .006; ER: 2.8 vs 1.4 N, P = .001).

Conclusions

In this cadaveric study, peak gliding resistance between the SSP tendon and the coracoacromial arch during combined abduction and IR was significantly reduced after anterolateral acromioplasty and was significantly higher in specimens with a hooked acromion.

Clinical Relevance

The clinical benefit of subacromial decompression remains unclear. This study suggests that anterolateral acromioplasty might reduce supraspinatus gliding resistance in those with a hooked acromion and in the typical "impingement" position.

Rotator Cuff Tears to Shoulder Instability: The Relationship Between Acromial Morphology and Shoulder Pathology

» The acromion is a well-studied region of the scapula that has demonstrated substantial relationships to various shoulder pathologies.» Abnormal acromial morphology is associated with rotator cuff pathology, and our understanding of this risk factor inspired acromioplasty as an adjunctive treatment for rotator cuff tears.» The acromion is linked closely to shoulder kinematics and biomechanics, as it serves as the origin for the deltoid muscle.» In degenerative shoulder disease, eccentric glenohumeral osteoarthritis has been associated with a higher, flatter acromial roof.» Increasing literature is emerging connecting morphology of the acromion with shoulder instability.

Reliability of Bigliani's Classification using Magnetic Resonance Imaging for Determination of Acromial Morphology

Introduction

Bigliani classification is used for determination of acromial morphology, but poor inter-observer reliability has been reported on conventional radiographs. This study aims to assess inter- and intra-observer reliability using magnetic resonance imaging (MRI).

Materials and methods

Forty consecutive patients diagnosed with subacromial impingement syndrome were included to study. All subjects underwent standard shoulder MRI scan and acromial shape was evaluated by nine observers of different level of expertise (three attending surgeons, three senior orthopaedic residents and three radiologists). A second set of evaluation was performed in order to assess intra-observer reproducibility. Kappa (κ) coefficient analyses both for interobserver reliability and intra-observer reproducibility were then performed.

Results

Overall inter-observer agreement among nine observers was fair (κ=0.323). κ values for all 4 individual types ranged from 0.234 to 0.720 with highest agreement for type 4 and lowest agreement for type 3. Second evaluation did not result with an increase of inter-observer agreement (κ=0.338, fair). The κ coefficients for intra-observer reproducibility of nine observers ranged from 0.496 to 0.867. Overall intra-observer reproducibility was substantial. Comparison of inter- and intra-observer reliability among three groups showed no significant difference (p=0.92 and 0.22, respectively).

Conclusion

Results showed that MRI did not show superior reliability compared to conventional radiographs. Moreover, inter- and intra-observer agreement did not differ between observers of different level of expertise. Findings of present study suggest that despite a sophisticated imaging modality like MRI, Bigliani's classification apparently lacks accuracy and additional criteria, or different assessment methods are required to assess acromial morphology for clinical guidance.

The Effect of Acromioplasty or Bursectomy on the Results of Arthroscopic Repair of Full Thickness Rotator Cuff Tears: Does the Acromion Type Affect These Results?

Objectives:

The aim of this study was to investigate the effect of subacromial decompression on the results of full thickness rotator cuff repair applied arthroscopically. Examination was also made of the effect of acromion type on the subacromial decompression procedure in patients applied with arthroscopic rotator cuff repair.

Methods:

The study included a total of 150 patients, comprising 102 (68%) females and 48 (32%) males with a full thickness rotator cuff tear repaired arthroscopically. The patients were separated into three groups of 50. Group A comprised those with acromioplasty and bursectomy applied additional to the repair. In Group B, only bursectomy was performed additional to the repair and in Group C, only rotator cuff repair was applied. Evaluation was made of the post-operative long-term pain and functional results.

Results:

The mean age of the cases was 65.63±9.22 years (range, 46–86 years). The affected side was right side in 95 (63.3%) cases and left side in 55 (36.7%). No statistically significant difference was determined between the groups according to the post-operative Constant Murley and ASES scores (p>0.05). In the paired comparisons, the post-operative VAS scores of Group C were higher than those of Groups A and B (p=0.018, p=0.029, p<0.05). No statistically significant difference was determined between Group A and Group B in respect of the post-operative VAS scores (p>0.05).

Conclusion:

In the arthroscopic repair of full thickness rotator cuff tears, neither acromioplasty, coracoacromial ligament loosening nor bursectomy were determined to have any positive effect on the results. Whatever the acromion type, there is no need for an additional subacromial decompression procedure after rotator cuff repair, in respect of pain and functional outcomes. Only acromial spurs should be gently removed paying attention to the coraco-acromial ligament.

The Effect of Acromial Morphology on the Functional Outcomes of Degenerative Rotator Cuff Tear Surgery

PURPOSE

The aim of this study was to investigate how the critical shoulder angle (CSA) and acromion index (AI) affect the outcome of arthroscopic rotator cuff tear (RCT) repair.

METHODS

A total of 287 patients, who underwent arthroscopic surgery due to degenerative rotator cuff tear, were evaluated. The Constant Shoulder Score (CSS), Oxford Shoulder Score (OSS) and Visual Analogue Scale (VAS) were evaluated preoperatively and postoperatively. The AI and CSA were measured on true anteroposterior shoulder radiographs. The patients were separated into two groups according to their CSA and AI values (control group ≤ 38°, increased CSA > 38°, and control group ≤ 0.7, increased AI > 0.7). The relationship between CSS, OSS and VAS was examined in all the groups.

RESULT

The evaluation was made of a total of 287 patients with a mean age of 60.29 ± 8.55 years. The mean duration of follow-up of the patients was 34.00 ± 18.97 months (range 12-80 months). There was a statistically significant difference between the preoperative and postoperative clinical scores of the patients (p < 0.05). No relationship was determined between CSA, AI and CSS, OSS or VAS during follow-up (p > 0.05). The interobserver ICC for CSA and AI were determined to be 0.962 and 0.967, respectively (95% CI) indicating a high correlation (p < 0.001).

CONCLUSION

CSA and AI do not affect functional outcomes in the postoperative period, so they are not significant at the time of degenerative arthroscopic rotator cuff repair decisions.

Acromioplasty in the surgical operations of partial-thickness rotator cuff tears: A comprehensive review

The partial-thickness rotator cuff tears (PTRCTs) are known as a prevalent pathology, which cause inability mostly in athletes. So far, a number of treatments have been suggested depending on patient characteristics and size and location of the tears. Surgical repair in rotator cuff tears that include 50% or more of the tendon thickness is the accepted practice in the following failure of nonoperative treatment. In the surgical procedure, acromioplasty is known as a long-established component and used to modify the detrimental acromion morphology, which accounts for rotator cuff tearing. A range of trials has been reported that compare the results of surgical procedure with and without acromioplasty in patients undergoing rotator cuff repairs. According to the findings of 15 studies including ~1,500 patients, with mean age 60 years (range 5-80 years) and mean follow-up of 22 months (range 13-26 months) found by searching on Cochrane Register of Controlled Trials databases, Excerpta Medica/Embase, and Medline/PubMed, we revealed that acromioplasty cannot present an impressive effect on patient outcome scores at intermediate and short-term follow-ups. In fact, despite the theoretic advantages of acromioplasty in the setting of PTRCTs, it has reported little or no efficacy on outcomes of postoperative patients.

Is Bony Morphology and Morphometry Associated With Degenerative Full-Thickness Rotator Cuff Tears? A Systematic Review and Meta-analysis

PURPOSE

To scope the scientific literature and analyze the influence of bony risk factors for degenerative full-thickness primary rotator cuff tear.

METHODS

A systematic review of databases PubMed, Scopus, EMBASE, and Cochrane Library was performed up to June 30, 2018. Meta-analysis was performed with mean difference (MD) or risk ratio for degenerative full-thickness rotator cuff injury, and when there were ≥3 studies for the considered potential risk factor. Methodologic quality was assessed using the Newcastle-Ottawa scale.

RESULTS

We analyzed 34 studies comprising 5,916 shoulders (3,369 shoulders with rotator cuff tear and 2,546 controls) and identified 19 potential risk factors for degenerative full-thickness rotator cuff tears. There was moderate evidence that a higher critical shoulder angle (MD = 4.41, 95% confidence interval [CI] 3.43 to 5.39), higher acromion index (MD = 0.06, 95% CI 0.04 to 0.09), and lower lateral acromion angles (MD = -7.11, 95% CI -8.32 to -5.90) were associated with degenerative full-thickness rotator cuff tears compared with controls. Moderate evidence showed that a type III acromion significantly increases the risk for full-thickness degenerative rotator cuff tear (risk ratio = 2.26, 95% CI 1.38 to 3.70).

CONCLUSION

There is moderate evidence that larger critical shoulder angle, higher acromion index, lower lateral acromion angles, and a type III acromion are significantly associated with degenerative full-thickness rotator cuff tears. Other potential risk factors identified showed insufficient evidence.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

Relationship of the Shape of Subacromial Spur and Rotator Cuff Partial Thickness Tear

Background

The present study was undertaken to evaluate the relationship between location of the rotator cuff tear and shape of the subacromial spur.

Methods

Totally, 80 consecutive patients who underwent arthroscopic repair for partial thickness rotator cuff tear were enrolled for the study. Bigliani’s type of the acromion, type of subacromial spur, and location of partial thickness tear of the rotator cuff were evaluated using plain X-ray and magnetic resonance imaging. We then compared the groups of no spur with spur, and heel with traction spur.

Results

Of the 80 cases, 25 cases comprised the no spur group, and 55 cases comprised the spur group. There was a significant difference in type of tear (p=0.0004) between these two groups. Bursal side tears were significantly greater (odds ratio=6.000, p=0.0007) in the spur group. Subjects belonging to the spur group were further divided into heel (38 cases) and traction spur (17 cases). Comparing these two groups revealed significant differences only in the type of tear (p=0.0001). Furthermore, the heel spur had significantly greater bursal side tear (odds ratio=29.521, p=0.0005) as compared to traction spur.

Conclusions

The heel spur is more associated to bursal side tear than the traction spur, whereas the traction spur associates greater to the articular side tear.

The Effect of Critical Shoulder Angle on Clinical Scores and Retear Risk After Rotator Cuff Tendon Repair at Short-term Follow Up

The authors aimed to investigate whether standard acromioplasty can reduce critical shoulder angle (CSA) effectively and to investigate the effects of postoperative CSA on the clinical outcomes and retear rates. Patients are divided in to three groups: group 1 (24 patients): CSA under 35° before surgery, group 2 (25 patients): CSA over 35° before surgery and under 35° after surgery and group 3 (17 patients): CSA over 35° before and after surgery. Standard acromioplasty was performed if CSA is over 35 and no acromioplasty was performed if the CSA is already under 35. Preoperative and postoperative CSAs, UCLA, Constant-Murley clinical score and visual analog scale (VAS) pain score were measured. The size of the rotator cuff tear was classified by the Patte classification in preoperative MRI and the quality of the repair was evaluated as retear if discontinuity detected in the postoperative first year MRI. There were 31 female and 35 male patients with a mean age of 59.3 ± 4.5 years (range, 48–68) at the time of surgery. The mean CSA is reduced from 37.8° ± 1.4 to 34.9° ± 1.2 (p < 0.001) significantly for patients who underwent acromioplasty. In 25 (59.5%) of the 42 patients, the CSA was reduced to under 35°, whereas in the other 17 (40.5%) patients, it remained over 35°. The mean Constant and UCLA score was 46.4 ± 6.6; 18.5 ± 1.6 preoperatively and 82.4 ± 6.2; 31.1 ± 1.9 postoperatively respectively (p < 0,001). The mean VAS decreased from 4.94 ± 1.09 to 0.79 ± 0.71 (p < 0.001). No Clinical difference was seen between patients in which CSA could be reduced under 35° or not in terms of Constant-Murley score, UCLA and VAS score. Retear was observed in 2 (8.3%) patients in group 1, in 4 (16%) patients in group 2 and in 3 patients (17.6%) in group 3. There was not any significant difference between the patients who had retear or not in terms of neither the CSA values nor the change of CSA after the surgery. Standard acromioplasty, which consists of an anterolateral acromial resection, can reduce CSA by approximately 3°. This is not always sufficient to decrease the CSAs to the favorable range of 30°–35°. In addition, its effect on clinical outcomes does not seem to be noteworthy.

Does the critical shoulder angle decrease after anterior acromioplasty?

INTRODUCTION

No clinical studies to date have analyzed the critical shoulder angle (CSA) following anterior acromioplasty. Our study's main objective was to measure the change in the CSA after acromioplasty.

MATERIALS AND METHODS

Ninety patients were included in this retrospective series. The CSA and the type of acromion were evaluated before and after surgery.

RESULTS

The average CSA for patients before surgery was 35.9° (± 3.7, 26.2, 44.2) and 33° after the acromioplasty (± 3.5, 24.8, 41.4). The decrease was significant and 2.9° on average (± 2.2, - 2.2, 11.9, p = 0.000). Preoperatively, 58% of patients had a CSA ≥ 35° (n = 52) and 24% postoperatively (n = 22, p = 0.000).

CONCLUSIONS

Standardized anterior acromioplasty allows for a significant decrease in the CSA without lateral resection of the acromion. This study confirms the tight link between the CSA and the anterior acromion as well as the interest of this angle to quantify acromioplasty whether anterior or lateral.

LEVEL OF EVIDENCE

Level IV, Case Series, Retrospective design.

Acromion morphology and prevalence of rotator cuff tear: A systematic review and meta-analysis

The causes of degenerative rotator cuff (RTC) tears are unclear but certain acromion morphology may contribute. This study's objective was to determine using a systematic review and meta-analysis the association of acromion type and acromial index with the prevalence of RTC tears. Six databases were searched electronically. Seventeen relevant studies between 1993 and 2017 were included in the meta-analyses determining the association of RTC tears with acromion type (n = 11) or acromial index (n = 10). Effect sizes were calculated as an odds ratio (OR) for the studies reporting acromion type and as raw mean difference (RMD) for the studies reporting acromial index. Meta-analysis was performed using a random-effects model. There was a significant small-to-medium effect found in the meta-analysis for acromion type (overall OR = 2.82, P = 0.000003), indicating an almost three times greater odds for a RTC tear in individuals with a type-III acromion as compared with those with a type-I or -II. A significant effect was also found for acromial index (RMD = 0.071, P < 0.0000001), indicating that a larger acromial index is associated with a greater likelihood of a RTC tear. Because of substantial heterogeneity in RMD for acromial index (Q-df = 92, P < 0.00001; I² = 89%), subgroup analyses and meta-regressions were performed. Interestingly, the continent where the study was conducted (i.e., Europe vs. Asia) was the only moderator variable that could explain some of the acromial index heterogeneity. Overall, the findings from our analyses indicate that individuals with either a type-III acromion and/or a larger acromial index have a greater likelihood for non-traumatic RTC tears. Clin. Anat. 32:122-130, 2019. © 2018 Wiley Periodicals, Inc.

A Comparative Study to Evaluate the Risk Factors for Medium-Sized Rotator Cuff Tear in Patients Younger Than 50 Years of Age

PURPOSE

The purpose of this study was to evaluate preoperative and intraoperative factors associated with rotator cuff tears (RCTs) among patients younger than 50 years and to compare arthroscopic rotator cuff repair (RCR) results in patients younger than 50 years (group A) and patients older than 70 years (group B). We also analyzed the results after arthroscopic RCR in these 2 age groups.

METHODS

Data were collected from 56 patients allocated to group A and 55 patients allocated to group B who had medium-sized RCTs and had undergone arthroscopic RCR between January 2006 and August 2015. Preoperative variables included demographic data, radiologic data, and surgical procedure. We evaluated fatty degeneration on preoperative magnetic resonance imaging (MRI) and intraoperative variables, including concomitant subscapularis repair, as well as repair technique. Pain visual analog scale, functional visual analog scale, American Shoulder and Elbow Surgeons, and Constant scores were documented to compare functional results in each age group. Postoperative MRI scans were conducted to evaluate the retear rate after RCR after a mean postoperative duration of 5.4 months (range, 2-48 months).

RESULTS

Multivariate regression analysis showed acute-on-chronic injury and a history of hypertension were independent factors for differentiation of the groups. Stepwise regression analysis found sex, hypertension, and fatty infiltration of the supraspinatus and infraspinatus to be comparable factors for each group. All patients showed improved results after arthroscopic RCR, but there was no difference between the 2 groups in functional outcomes. However, cuff retears on postoperative MRI scans were found in only 3.9% of the patients in group A versus 16% of the patients in group B.

CONCLUSIONS

The results of this study showed that sex, acute-on-chronic injury, and preoperative fatty infiltration of the rotator cuff were significant factors affecting medium-sized RCTs in patients younger than 50 years. In addition, there were no significant differences in functional outcomes after arthroscopic RCR in both groups at 2 years, but postoperative MRI showed a lower retear rate in group A.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Evaluation of risk factors for irreparable rotator cuff tear in patients older than age 70 including evaluation of radiologic factors of the shoulder

BACKGROUND

Rotator cuff tears (RCTs) are generally considered to occur at the age of 40 to 50, but some becomes massive tears at the age of 60 to 70 if neglected. This study evaluated preoperative factors affecting tear size and reparability of rotator cuffs based on magnetic resonance imaging findings among patients older than age 70.

METHODS

We identified 270 patients with full-thickness RCTs (175 reparable tears, group A; 95 irreparable tears, group B) that were confirmed with magnetic resonance imaging findings from January 2009 to March 2016. Irreparable tear was identified if all of the following criteria were met: (1) a large to massive RCT based on the DeOrio and Cofield classification, (2) sum of preoperative global fatty degeneration index of the supraspinatus and infraspinatus ≥6, and (3) positive tangent sign. Preoperative variables included demographic data, medical history, and radiologic data. Acromial index, critical shoulder angle, and acromiohumeral interval (AHI) were evaluated to investigate the relationship between anatomic factors and reparability of RCT.

RESULTS

Stepwise multivariated regression analysis revealed older age, longer symptom duration, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI as risk factors for irreparable RCTs.

CONCLUSIONS

This study suggests that older age at surgery, longer duration of symptoms, longer duration of overhead sports activity, lower preoperative forward elevation of the shoulder joint, and shorter AHI are independent risk factors for irreparable RCT.

Critical Shoulder Angle and Acromial Index Do Not Influence 24-Month Functional Outcome After Arthroscopic Rotator Cuff Repair

BACKGROUND

Recent studies have shown a correlation between scapular geometry and the development of atraumatic rotator cuff tears. However, a paucity of literature is available on the effects of critical shoulder angle (CSA) and acromial index (AI) on functional outcomes after arthroscopic rotator cuff repair. Hypothesis/Purpose: The purpose was to investigate the influence of CSA and AI on 24-month functional outcomes after arthroscopic rotator cuff repair. The hypothesis was that a larger CSA or AI would result in poorer postoperative outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The study included 147 patients who underwent arthroscopic double-row rotator cuff repair for radiologically documented full-thickness supraspinatus tears. An independent reviewer measured the CSA and AI on preoperative radiographs. These patients were prospectively enrolled and were evaluated preoperatively as well as at 3, 6, 12, and 24 months postoperatively. Functional outcome was assessed with the Constant Shoulder Score (CSS), Oxford Shoulder Score (OSS), and University of California at Los Angeles (UCLA) Shoulder Rating Scale. The patients were first divided based on CSA: (1) ≤35° (control CSA) and (2) >35° (increased CSA); and then based on AI: (1) ≤0.7 and (2) >0.7. The Student unpaired t test, Pearson chi-square test, and Pearson correlation were performed to examine the influence of CSA and AI on postoperative functional outcome scores.

RESULTS

At 6 months of follow-up, the CSS, OSS, and UCLA Shoulder Rating Scale were 10 ± 1, 4 ± 2, and 3 ± 1 points poorer in the increased CSA group compared with the control CSA group ( P = .005, P = .030, and P = .035, respectively). These scores were not significantly different between both AI groups. By 24 months of follow-up, all outcome scores were comparable between both CSA groups as well as between both AI groups. No significant correlation was found between either CSA or AI when compared with CSS, OSS, or UCLA Shoulder Rating Scale at 24 months of follow-up.

CONCLUSION

CSA and AI do not appear to influence 24-month functional outcomes postoperatively and hence are not contraindications to arthroscopic rotator cuff repair.

Relationship between acromial morphological variation and subacromial impingement: A three-dimensional analysis

Purpose: To evaluate the association of acromial morphology and subacromial impingement. Methods: Bilateral shoulder computed tomography was performed in 138 patients who received shoulder arthroscopy. Measured parameters included: acromial tilt (AT), modified acromial tilt (mAT), acromial slope (AS), acromiohumeral interval (AHI), lateral acromial angle (LAA), acromial index (AI), critical shoulder angle (CSA), acromial anterior protrusion (AAP), and acromial inferior protrusion (AIP). Acromial morphological characteristics were compared between groups. Side-to-side differences were assessed between affected and non-affected shoulders. Intra- and inter-observer agreements for each parameter were calculated. Results: AT (25.90 vs. 29.41°), mAT (18.88 vs. 22.64°), and AHI (5.46 vs. 6.47 mm) were significantly smaller in impinged patients. The impingement group demonstrated significantly larger AI (63.50 vs. 59.84%), CSA (31.78 vs. 28.74°), AAP (7.13 vs. 5.32 mm), and AIP (5.51 vs. 4.04 mm). Regarding side-to-side comparison, the acromial morphology was significantly different between the affected and non-affected shoulders in impinged patients, while the difference was slight and insignificant in control patients. All, except AS and LAA, measured parameters demonstrated good intra- and inter-observer agreements. Conclusions: Three-dimensional reconstructed CT scan is a reliable method to measure shoulder morphology. The acromial morphological variation is related with sub acromial impingement, however, the causal relationship of them should be further explored.

Current Concepts in the Diagnosis and Treatment of Shoulder Impingement

Subacromial impingement syndrome (SIS) is a very common cause of shoulder pain in the young adults. It can cause debilitating pain, dysfunction, and affects the activities of daily living. It represents a spectrum of pathology ranging from bursitis to rotator cuff tendinopathy which can ultimately lead to degenerative tear of the rotator cuff. Various theories and concepts have been described and it is still a matter of debate. However, most published studies suggest that both extrinsic and intrinsic factors have a role in the development of SIS. The management is controversial as both nonoperative and operative treatments have shown to provide good results. This article aims to provide a comprehensive current concepts review of the pathogenesis, etiologies, clinical diagnosis, appropriate use of investigations, and discussion on the management of SIS.

Anatomical and morphological study of the subcoracoacromial canal

INTRODUCTION

Many clinical anatomy studies have looked into how variations in the acromion, coracoacromial ligament (CAL) and subacromial space are associated with rotator cuff injuries. However, no study up to now had defined anatomically the fibro-osseous canal that confines the supraspinatus muscle in the subcoracoacromial space. Through an anatomical study of the scapula, we defined the bone-related parameters of this canal and its anatomical variations.

MATERIALS AND METHODS

This study on dry bones involved 71 scapulas. With standardised photographs in two orthogonal views (superior and lateral), the surface area of the subcoracoacromial canal and the anatomical parameters making up this canal were defined and measured using image analysis software. The primary analysis evaluated the anatomical parameters of the canal as a function of three canal surface area groups; the secondary analysis looked into how variations in the canal surface area were related to the type of acromion according to the Bigliani classification.

RESULTS

Relative to glenoid width, the group with a large canal surface area (L) had significantly less lateral overhang of the acromion than the group with a small canal surface area (S), with ratios of 0.41±0.23 and 0.58±0.3, respectively (P=0.04). The mean length of the CAL was 46±8mm in the L group and 39±9mm in the S group (P=0.003). The coracoacromial arch angle was 38°±11° in the L group and 34°±9° in the S group; the canal surface area was smaller in specimens with a smaller coracoacromial arch angle (P=0.20).

CONCLUSION

Apart from acromial morphology, there could be innate anatomical features of the scapula that predispose people to extrinsic lesions to the supraspinatus tendon (lateral overhang, coracoacromial arch angle) by reducing the subcoracoacromial canal's surface area.

LEVEL OF EVIDENCE

Anatomical descriptive study.

The Incidence of Subsequent Surgery After Outpatient Arthroscopic Rotator Cuff Repair

PURPOSE

To quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient arthroscopic rotator cuff repair (ARCR).

METHODS

We examined the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. The impact of age, sex, insurance, concomitant acromioplasty, and tobacco use on reoperation was explored.

RESULTS

Between 2003 and 2012, 30,430 patients underwent isolated ARCR. The mean age was 56.6 ± 11.5 years, and 55.1% were male patients. A total of 1,826 patients (6.0%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3 ± 27.1 months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 ± 10.9 years v 56.8 ± 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%, P = .044) and accelerated time to reoperation (16.9 months v 24.7 months, P < .001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers' Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P < .001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval, 1.09-1.34; P < .001).

CONCLUSIONS

We identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers' Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

No difference in long-term development of rotator cuff rupture and muscle volumes in impingement patients with or without decompression

Background and purpose - Arthroscopic acromioplasty is still commonly used in the treatment of shoulder impingement syndrome, even though its benefits are questioned; randomized controlled studies have not shown any benefits when compared to non-operative treatment. In this randomized study, we investigated whether operative treatment protects from later rotator cuff rupture and whether it has any effect on the development of rotator cuff muscle volume. Patients and methods - 140 stage-II impingement patients were randomized to a structured exercise group (n = 70) or to an operative group (n = 70). In the operative group, arthroscopic acromioplasty was performed, after which a similar structured exercise program was begun. MRI of the shoulder was done at baseline and at 5 years. Results - There were no statistically significant differences in either the amount of perforating ruptures of the supraspinatus tendon or in the changes in muscle volume at 5 years. The grading of muscle fatty degeneration showed worse results in the operative group, but this difference was not statistically significant. Interpretation - In this study, we found that arthroscopic acromioplasty does not have any long-term benefit based on radiological findings of muscle volumes. Also, the frequency of later rotator cuff rupture was similar irrespective of whether or not surgery was performed. Acromioplasty is not justified as a treatment for dynamic shoulder impingement syndrome.

Risk Factors, Pathobiomechanics and Physical Examination of Rotator Cuff Tears

Background:

It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers.

Methods:

A selective literature search was performed.

Results:

Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced.

Conclusion:

Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers.

Differences in acromial morphology of shoulders in patients with degenerative and traumatic supraspinatus tendon tears

PURPOSE

Distinct characteristics of acromial morphology seem to be one factor for the development of degenerative supraspinatus tendon tears. Thus, it is questionable whether patients with traumatic tendon tears also present these parameters. The hypothesis of the present study was that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears.

METHODS

One hundred and thirty-six patients that were treated by arthroscopic rotator cuff repair from 2010 to 2013 were included in this study. Seventy-two patients had degenerative (group 1), and 64 had traumatic (group 2) supraspinatus tendon tears. On preoperative radiographs the Bigliani type, acromial slope, acromiohumeral (AH) distance, lateral acromial angle (LAA), acromion index (AI), and critical shoulder angle (CSA) were measured. Medians of these parameters as well as of age of both groups were compared using the t test.

RESULTS

The percentaged distribution of the Bigliani type differed (group 1 vs. 2: type 1: 18/38, type 2: 56/55, type 3: 26/8). All parameters showed significant differences between degenerative and traumatic tears. Slope: 21.2° (SD 7.6°) versus 19.2° (SD 7.9°, p = 0.026), AH distance: 8.4 mm (SD 2.3 mm) versus 9.9 mm (SD 1.9 mm, p = 0.0006), LAA: 77.0° (SD 4.0°) versus 82.5° (SD 4.7°, p < 0.0001), AI: 0.77 (SD 0.07) versus 0.73 (0.06, p = 0.0239), and CSA: 36.8° (SD 3.6°) versus 35.3° (SD 2.9°, p = 0.007). An LAA <70° or an AH distance of <5 mm only occurred in degenerative tears. Patients with degenerative tears were significantly older (60 vs. 54 years).

CONCLUSIONS

The hypothesis that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears was confirmed. Shoulders with degenerative tears show a narrower subacromial space and a larger lateral extension as well as a steeper angulation of the acromion than with traumatic tears. Thus, the results of this study support the theory of external impingement as a cause for degenerative rotator cuff tears.

LEVEL OF EVIDENCE

IV.

Deltoid muscle tropism does not influence the outcome of arthroscopic rotator cuff repair

BACKGROUND

Several different factors have been identified as causes of failure of rotator cuff (RC) repair. However, no studies focused on the role of the deltoid muscle. The aim of this study was to investigate the role of the deltoid tropism in the outcomes of arthroscopic RC repair procedures.

MATERIALS AND METHODS

Nine male (45 %) and 11 female (55 %) patients who underwent arthroscopic RC repair were included in the study. The mean age was 63.5 ± 8.1 years (range 50-74 years), and the follow-up averaged 1.9 ± 1.3 years (range 1-5 years) after surgery. Clinical outcomes were assessed using the modified University of California, Los Angeles (UCLA) shoulder rating scale, Wolfgang criteria shoulder score and Oxford shoulder score (OSS). Functional outcomes were evaluated considering active and passive range of motion of the shoulder and muscle strength. The deltoid tropism was measured pre-operatively and post-operatively using T2-weighted transverse MRI images.

RESULTS

No statistically significant correlation was found between the thickness of each portion of the deltoid muscle (vD, lD and dD) and the UCLA shoulder rating scale, Wolfgang shoulder score and OSS. At the same time, no statistically significant relationship was detected between the thickness of each portion of the deltoid muscle (vD, lD and dD) and the functional outcomes.

CONCLUSIONS

The deltoid tropism does not influence the results of arthroscopic RC repair. Early RC repair may prevent the reduction in the tropism of the deltoid muscle. Nevertheless, further prospective randomized studies with larger samples are necessary to clarify the role of deltoid tropism in the outcomes of arthroscopic RC repair procedures.

How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging

BACKGROUND

Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs.

METHODS

Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol.

RESULTS

No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups.

CONCLUSION

MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Does physiotherapy diagnosis of shoulder pathology compare to arthroscopic findings?

AIMS

To explore the ability of a physiotherapist, using a standardised musculoskeletal physiotherapy assessment protocol, to accurately identify the structures potentially responsible for shoulder symptoms against a standardised arthroscopic shoulder diagnostic assessment, and to determine the physiotherapists' ability to influence post-test diagnostic accuracy.

STUDY DESIGN

Consecutive case-based cohort study.

SUBJECT SELECTION

All participants were selected by two orthopaedic surgeons for arthroscopic investigation during a 6-month period.

SETTING

Private orthopaedic clinic.

METHOD

All consenting participants selected for arthroscopic investigation were examined by the physiotherapist prior to arthroscopy. Presence and priority of impairments/diagnoses were recorded on a standardised form. Inter and intra-rater reliability and diagnostic accuracy were tabulated.

STATISTICAL ANALYSIS

Proportional agreement on diagnostic incidence (broad) and priority (strict) using 2×2 contingency tables for sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratios were calculated. Post-test probabilities were analysed to determine the influence of a positive or a negative finding.

RESULTS

211 participants, aged 14-79 years were included. Overall prevalence of subacromial pathology was (77%) and, disorders of the passive restraints (29%). For both negative and positive findings, post-test probabilities were not notably altered; although positive findings yielded greater value in the decision-making modelling. The physiotherapist's ability to identify individual pathology (eg, tendon rupture vs tendinopathy, capsular vs labral) was lower than recognition of pathology within the broader diagnostic category.

CONCLUSIONS

The physiotherapist's ability to diagnose individual pathologies was inconsistent. Indirectly, this raises the issue of whether signs and symptoms identified under arthroscopic surgery are reflective of a lesion/pathology reflective of a specific tissue.

Is acromioplasty necessary in the setting of full-thickness rotator cuff tears? A systematic review

BACKGROUND

The benefits of acromioplasty in treating rotator cuff disease have been debated. We systematically reviewed the literature regarding whether acromioplasty with concomitant coracoacromial (CA) release is necessary for the successful treatment of full-thickness rotator cuff tears.

MATERIALS AND METHODS

We identified randomized controlled trials that reported on patients who underwent rotator cuff repair with or without acromioplasty and used descriptive statistics to summarize the findings.

RESULTS

Four studies fulfilled the inclusion criteria. They reported on 354 patients (mean age, 59 years; range 3-81 years) with a mean follow-up of 22 months (range 12-24 months). There were two level-I and two level-II studies. Two studies compared rotator cuff repair with versus without acromioplasty, and two studies compared rotator cuff repair with versus without subacromial decompression (acromioplasty, CA ligament resection, and bursectomy). The procedures were performed arthroscopically, and the CA ligament was released in all four studies. There were no statistically significant differences in clinical outcomes between patients treated with acromioplasty compared with those treated without acromioplasty.

CONCLUSIONS

This systematic review of the literature does not support the routine use of partial acromioplasty or CA ligament release in the surgical treatment of rotator cuff disease. In some instances, partial acromioplasty and release of the CA ligament can result in anterior escape and worsening symptoms. Further research is needed to determine the optimum method for the operative treatment of full-thickness rotator cuff tears.

LEVEL OF EVIDENCE

Level I, systematic review of level I and II studies.

Distribution of bone and tissue morphological properties related to subacromial space geometry in a young, healthy male population

PURPOSE

Particular bone and tissue morphological features of the scapula and humerus often exist disproportionately in persons with subacromial impingement syndrome (SAIS) and/or rotator cuff pathology. However, the origins of morphological variation, genetic or mechanistic, remain unclear. This research evaluated the distribution of and correlation between several bone and tissue characteristics associated with these pathologies amongst a baseline cohort population consisting of young, healthy, males. As well, the predisposition to SAIS was estimated by calculating the ratio (occupation ratio) of subacromial tissue thickness to minimum subacromial space width (SAS).

METHODS

Anterior-posterior and trans-scapular radiographs and musculoskeletal ultrasound were used to measure morphological characteristics related to the subacromial space. Each bone morphological characteristic was classified as healthy or unhealthy based on previous definitions. Supraspinatus tendon and subacromial bursa thicknesses were used to calculate the occupation ratio from both radiographic and ultrasonic measures of the SAS.

RESULTS

Each characteristic demonstrated considerable variability, with some participants having 'unhealthy' variants for each bone characteristic examined. The percentage of the population with bone characteristics classified as "unhealthy" ranged from 15 to 55 % across characteristics evaluated. The strongest correlation existed between the acromion index and the minimum subacromial space width (-0.59) suggesting that a larger lateral extension of the acromion may predispose an individual to SAIS. The average occupation ratio was 65.3 % with a 1-99 % confidence interval ranging from 21.6 to 108.9 %.

CONCLUSIONS

The distributions of both morphological characteristics and occupation ratios indicate that individuals within this healthy, baseline population have a highly differential predisposition for subacromial tissue compression solely based on inherent morphological variation. This suggests that while mechanistic and/or age-related degenerative changes may contribute to SAIS and eventual rotator cuff pathology, intrinsic predisposing geometry should not be discounted.

An evidence-based review of current perceptions with regard to the subacromial space in shoulder impingement syndromes: Is it important and what influences it?

BACKGROUND

Reduction of the subacromial space as a mechanism in the etiology of shoulder impingement syndromes is debated. Although a reduction in this space is associated with shoulder impingement syndromes, it is unclear if this observation is cause or consequence.

METHOD

The purposes of this descriptive review are to provide a broad perspective on the current perceptions with regard to the pathology and pathomechanics of subacromial and internal impingement syndromes, consider the role of the subacromial space in impingement syndromes, describe the intrinsic and extrinsic mechanisms considered to influence the subacromial space, and critique the level of evidence supporting these concepts.

FINDING

Based on the current evidence, the hypothesis that a reduction in subacromial space is an extrinsic cause of impingement syndromes is not conclusively established and the evidence permits no conclusion.

INTERPRETATION

If maintenance of the subacromial space is important in impingement syndromes regardless of whether it is a cause or consequence, research exploring the correlation between biomechanical factors and the subacromial space, using the later as the outcome measure, would be beneficial.

Shoulder Impingement Syndrome, a Common Affliction of the Shoulder: A Comprehensive Review

The shoulder joint is the most mobile joint in the human body. It comprises a ball and socket structure that enables a series of functional movements to be carried out. These range from simple movements such as reaching for the top shelf to highly explosive overhead activities which involve throwing a baseball or serving with a tennis racquet as seen in athletes. Shoulder impingement syndrome (SIS) is one of the most common shoulder disorders seen in general practice. It is caused by a multitude of factors. Pathology can arise either from the rotator cuff tendon itself, structures external to this tendon or both in combination. The resultant shoulder pain with SIS not only causes distress but also limits the quality of life of patients. This article aims to provide a comprehensive review of the pathogenesis, aetiologies, clinical tests, investigations and management options for SIS based on current literature and research.

Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association

Treatment of "subacromial impingement syndrome" of the shoulder has changed drastically in the past decade. The anatomical explanation as "impingement" of the rotator cuff is not sufficient to cover the pathology. "Subacromial pain syndrome", SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows: (1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

[Functional outcome of arthroscopic rotator cuff repair]

INTRODUCTION

Functional outcome after rotator cuff reconstruction is influenced by several factors of which re-rupture is probably the most important.

AIM

The aim of the study was to evaluate the postoperative outcome including re-rupture rate after arthroscopic rotator cuff reconstruction.

METHOD

23 shoulders of 22 patients were examined prospectively. Physical examination, ultrasound and radiography were performed. Quality of life and functional outcome were evaluated using Constant Score and Visual Analog Scale.

RESULTS

Excellent or good results were found in 80% of the patients. The Constant Score has increased from 45 to 79, and the level of pain decreased from 6.6 to 2.5. Full-thickness rotator cuff tear was absent, but partial tear occurred in 7 cases (30%). Average acromiohumeral distance in the operated side was 8.5 mm compared to 9.5 mm measured on the contralateral shoulder.

CONCLUSIONS

Arthroscopic rotator cuff repair is a safe and reliable procedure that provides good results.

Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committee's (UEC's) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Correlation of acromial morphology with impingement syndrome and rotator cuff tears

BACKGROUND AND PURPOSE

Indications for acromioplasty are based on clinical symptoms and are generally supported by typical changes in acromial morphology on standard radiographs. We evaluated 5 commonly used radiographic parameters of acromial morphology and assessed the association between different radiographic characteristics on the one hand and subacromial impingement or rotator cuff tears on the other.

PATIENTS AND METHODS

We measured acromial type (Bigliani), acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), and acromion index (AI) on standard radiographs from 50 patients with full-thickness supraspinatus tendon tears, 50 patients with subacromial impingement, and 50 controls without subacromial pathology.

RESULTS

The acromial type according to Bigliani was not associated with any particular cuff lesion. A statistically significant difference between controls and impingement patients was found for AS. AT of controls was significantly smaller than that of impingement patients and cuff-tear patients. LAA of cuff-tear patients differed significantly from that of controls and impingement patients, but LAA of controls was not significantly different from that of impingement patients. Differences between impingement patients and cuff-tear patients were also significant. AI of controls was significantly lower than of impingement patients and of cuff-tear patients. A good correlation was found between acromial type and AS.

INTERPRETATION

A low lateral acromial angle and a large lateral extension of the acromion were associated with a higher prevalence of impingement and rotator cuff tears. An extremely hooked anterior acromion with a slope of more than 43° and an LAA of less than 70° only occurred in patients with rotator cuff tears.

The effects of thoracic spine manipulation in subjects with signs of rotator cuff tendinopathy

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To assess scapular kinematics and electromyographic signal amplitude of the shoulder musculature, before and after thoracic spine manipulation (TSM) in subjects with rotator cuff tendinopathy (RCT). Changes in range of motion, pain, and function were also assessed.

BACKGROUND

There are various treatment techniques for RCT. Recent studies suggest that TSM may be a useful component in the management of pain and dysfunction associated with RCT.

METHODS

Thirty subjects between 18 and 45 years of age, who showed signs of RCT, participated in this study. Changes in scapular kinematics and muscle activity, as well as changes in shoulder pain and function, were assessed pre-TSM and post-TSM using paired t tests and repeated-measures analyses of variance.

RESULTS

TSM did not lead to changes in range of motion or scapular kinematics, with the exception of a small decrease in scapular upward rotation (P = .05). The only change in muscle activity was a small but significant increase in middle trapezius activity (P = .03). After TSM, subjects demonstrated decreased pain during performance of the Jobe empty-can (mean ± SD change, 2.6 ± 1.1), Neer (2.6 ± 1.3), and Hawkins-Kennedy (2.8 ± 1.3) tests (all, P<.001). Subjects also reported decreased pain with shoulder flexion (mean ± SD change, 2.0 ± 1.5; P<.001) and improved shoulder function (force production, 2.5 ± 1.4 kg; Penn Shoulder Score, 7.7 ± 9.4; sports/performing arts module of the Disabilities of the Arm, Shoulder and Hand questionnaire, 16.4 ± 13.2) (all, P<.001).

CONCLUSION

Immediate improvements in shoulder pain and function post-TSM are not likely explained by alterations in scapular kinematics or shoulder muscle activity. For people with pain associated with RCT, TSM may be an effective component of their treatment plan to improve pain and function. However, further randomized controlled studies are necessary to better validate this treatment approach.

LEVEL OF EVIDENCE

Therapy, level 4.

Relationship of radiographic acromial characteristics and rotator cuff disease: a prospective investigation of clinical, radiographic, and sonographic findings

BACKGROUND

Many studies have attempted to correlate radiographic acromial characteristics with rotator cuff tears, but the results have not been conclusive. Therefore, the purpose of this study was to determine the relationship between rotator cuff disease and the development of symptoms with different radiographic acromial characteristics, including shape, index, and presence of a spur.

MATERIALS AND METHODS

The records of 216 patients enrolled in an ongoing prospective, longitudinal study investigating asymptomatic rotator cuff tears were reviewed. All patients underwent standardized radiographic evaluation, clinical evaluation, and shoulder ultrasonography at regularly scheduled surveillance visits. Three blinded observers reviewed all radiographs to determine the acromial morphology, presence, and size of an acromial spur, as well as the acromial index. These findings were analyzed to determine an association with the presence of a full-thickness rotator cuff tear.

RESULTS

The 3 observers demonstrated poor agreement for acromial morphology (κ = 0.41), substantial agreement for the presence of an acromial spur (κ = 0.65), and excellent agreement for the acromial index (κ = 0.86). The presence of an acromial spur was highly associated with the presence of a full-thickness rotator cuff tear (P = .003), even after adjusting for age. No association was found between the acromial index and rotator cuff disease (P = .92).

CONCLUSION

The presence of an acromial spur is highly associated with the presence of a full-thickness rotator cuff tear in symptomatic and asymptomatic patients. The acromial morphology classification system is an unreliable method to assess the acromion. The acromial index shows no association with the presence of rotator cuff disease.

Evaluation and treatment of rotator cuff tears

Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.

The relationship between acromion thickness and body habitus: practical implications in subacromial decompression procedures

To define the bone's amount that should be removed during an acromioplasty has always been a challenge. We aimed to verify the correlations between scapular dimensions and acromial thickness, assess the differences between the two genders, investigate the relationship between acromial type and thickness. We examined 500 dried scapulae, measuring the major axis of the scapular body and the acromial thickness; these were also catalogued according to gender. Acromial shape was classified according to Bigliani's method. Frequencies: Type I 38.9 %, Type II 39.4 %, Type III 21.7 %. The mean acromial thickness was 0.85 cm, and it resulted wider in men. There was a direct linear relationship between scapular dimensions and acromial thickness. The range of thickness of Type III acromion was significantly different from the others. We should be aware that gender, scapular dimensions and acromial shape should be evaluated preoperatively since they influence the acromial thickness.

Midterm outcome after rotator cuff reconstruction

Rotator cuff tear is a common degenerative shoulder disorder that often requires surgical treatment. However, the correlation between the size of the tear and the functional results is somewhat controversial, which generates inconsistency among orthopaedic surgeons about the indications for and methods of rotator cuff reconstruction. Aims: The aim of the authors was to evaluate the midterm functional outcome after rotator cuff reconstruction and the possible connection between the results and the surgical technique or the postoperative ultrasound examination. In addition, recently published corresponding studies are also reviewed by the authors. Methods: Twenty-seven patients with full thickness rotator cuff tear were enrolled into the study who were treated either by arthroscopic (14 patients) or by open repair (13 patients) technique. Functional results were assessed using clinical tests. Ultrasound examination was also performed. Results: The average postoperative Constant Score was 73, the average DASH (Disabilities of the arm, shoulder and hand score) was 14. The Constant scores averaged 80 for the arthroscopic and 70 for the open group. Ultrasound examination showed partial or full thickness retear of the cuff in 40% of the cases. Conclusion: More than 70% of the patients had excellent or good results two years after the reconstruction. The change in the acromiohumeral distance or partial retear failed to affect the results significantly, but full thickness tear had an effect on them. Orv. Hetil., 2012, 153, 655–661.

Reliability of determining and measuring acromial enthesophytes

BACKGROUND

Although the reliability of determining acromial morphology has been examined, to date, there has not been an analysis of interobserver and intraobserver reliability on determining the presence and measuring the size of an acromial enthesophyte.

QUESTIONS/PURPOSES

The hypothesis of this study was that there will be poor intraobserver and interobserver reliability in the (1) determination of the presence of an acromial enthesophyte, (2) determination of the size of an acromial enthesophyte, and (3) determination of acromial morphology.

PATIENTS AND METHODS

Fifteen fellowship-trained orthopedic shoulder surgeons reviewed the radiographs of 15 patients at two different intervals. Measurement of acromial enthesophytes was performed using two techniques: (1) enthesophyte length and (2) enthesophyte-humeral distance. Acromial morphology was also determined. Interobserver and intraobserver agreement was determined using intraclass correlation and kappa statistical methods.

RESULTS

The interobserver reliability was fair to moderate and the intraobserver reliability moderate for determining the presence of an acromial enthesophyte. The measurement of the enthesophyte length showed poor interobserver and intraobserver reliability. The measurement of the enthesophyte-humeral distance showed poor interobserver reliability and moderate intraobserver reliability. The interobserver and intraobserver reliability in determining acromial morphology was found to be moderate and good, respectively.

CONCLUSIONS

There is fair to moderate reliability among fellowship-trained shoulder surgeons in determining the presence of an acromial enthesophyte. However, there is poor reliability among observers in measuring the size of the enthesophyte. This study suggests that the enthesophyte-humeral distance may be more reliable than the enthesophyte length when measuring the size of the enthesophyte.

Partial-thickness rotator cuff tears

Although the incidence of partial-thickness rotator cuff tears (PTRCTs) was reported to be from 13% to 32% in cadaveric studies, the actual incidence is not yet known. The causes of PTRCTs can be explained by either extrinsic or intrinsic theories. Studies suggest that intrinsic degeneration within the rotator cuff is the principal factor in the pathogenesis of rotator cuff tears. Extrinsic causes include subacromial impingement, acute traumatic events, and repetitive microtrauma. However, acromially initiated rotator cuff pathology does not occur and extrinsic impingement does not cause pathology on the articular side of the tendon. An arthroscopic classification system has been developed based on the location and depth of the tear. These include the articular, bursal, and intratendinous areas. Both ultrasound and magnetic resonance image are reported with a high accuracy of 87%. Conservative treatment, such as subacromial or intra-articular injections and suprascapular nerve block with or without block of the articular branches of the circumflex nerve, should be considered prior to operative treatment for PTRCTs.