Degeneration of the gleno-humeral joint. An anatomical study

Trends in Shoulder Arthroplasty in Germany: A 10-Year Epidemiological Analysis of Patients with Primary Osteoarthritis of the Shoulder

Shoulder arthroplasty has significantly gained popularity in orthopedic surgery, driven by progress in prosthesis design and surgical techniques. This study explored the epidemiology of shoulder arthroplasty, analyzing healthcare data from 2012 to 2022 for primary osteoarthritis of the shoulder. The data included patient demographics and types of surgical procedures. Data analysis indicates a higher utilization rate of reverse total shoulder arthroplasty (RTSA; n = 41,251) over total- (TSA; n = 18,679) and hemiarthroplasty (HSA; n = 12,827) for primary shoulder osteoarthritis. Overall, a significant increase in RTSA procedures from n = 2237 (2012) to n = 5415 (2022) was observed, representing more than a two-fold increase of 121.1%. The relative proportion of RTSA among all types of shoulder arthroplasty increased from 39% (2012) to 68.6% (2022), while HSA decreased and TSA essentially remained constant. Age analysis identified the following peaks: RTSA, 77 ± 7 y; HSA, 68 ± 12 y; and TSA, 67 ± 10 y. Among the over 60s, significantly more women were treated with any type of prosthesis, whereas in young patients (45 to 59 y), more men received HSA or TSA. Our study confirms that RTSA has become the preferred choice for elderly patients in Germany, reflecting the prevailing preference despite varying patient ages and conditions, with a noted difference in sex in treatment prevalence.

Glenohumeral Cartilage Thickness: Implications in Prosthetic Design and Osteochondral Allograft Transplantation

OBJECTIVE

A complete understanding of the glenohumeral joint anatomy is crucial for osteochondral allograft (OCA) transplantation and prosthetic design. However, existing data on the cartilage thickness distribution are not consistent. This study aims to describe the cartilage thickness distribution at both the glenoid cavity and humeral head in males and females.

DESIGN

Sixteen fresh cadaveric shoulder specimens were dissected and separated to expose the glenoid and humeral head articular surfaces. The glenoid and humeral head were cut into 5-mm coronal sections. Sections were imaged and cartilage thickness was measured at 5 standardized points on each section. Measurements were analyzed based on age, sex, and regional location.

RESULTS

For the humeral head, cartilage was thickest centrally (M = 1.77 ± 0.35 mm) and thinnest superiorly and inferiorly (M = 1.42 ± 0.37 mm, 1.42 ± 0.29 mm). At the glenoid cavity, cartilage was thickest in the superior and inferior areas (M = 2.61 ± 0.47 mm, 2.53 ± 0.58 mm) and thinnest centrally (M = 1.69 ± 0.22 mm). Males were found to have thicker cartilage at both the humeral head and glenoid (P = 0.0014, P = 0.0133).

CONCLUSIONS

Articular cartilage thickness distribution of the glenoid and humeral head is nonuniform and reciprocal in nature. These results can be used to further inform prosthetic design and OCA transplantation. We noted a significant difference in cartilage thickness between males and females. This suggests that the sex of the patient should be taken into consideration when matching donors for OCA transplantation.

Simultaneous bilateral shoulder arthroplasty: a case series

BACKGROUND

Staged bilateral shoulder arthroplasty procedures have been shown to have good functional outcomes. The next step is to explore the option of simultaneous bilateral shoulder arthroplasty (SBSA). We report on the first case series of SBSA in the United States. The purpose of this study was to examine the safety and postoperative complication profile of SBSA and provide a technique reference for surgeons considering performing or investigating this procedure.

METHODS

We conducted a retrospective record review of all the SBSA procedures performed by the senior author between 2007 and 2020. Patient demographic characteristics, surgical information, and postoperative data were collected. Data were compiled, and means, standard deviations, and ranges were calculated. Any readmissions or postoperative complications requiring revision were noted. A cohort of patients matched for age, sex, and body mass index with staged (sequential) bilateral total shoulder arthroplasty was analyzed for comparison.

RESULTS

Thirteen patients were identified in the simultaneous group (SBSA). The mean age was 64 ± 15 years, with 9 women (69%) and 4 men (31%); the mean body mass index was 29.1 ± 7.5. The mean American Society of Anesthesiologists score was 2.55 ± 0.7, average blood loss was 364 ± 170 mL (range, 50-600 mL), 5 of 13 patients (38%) underwent blood transfusions, and the mean surgical time was 183 ± 42 minutes. Postoperatively, the mean visual analog scale pain score on postoperative day 1 was 4 ± 2 (range, 0-7), and the mean length of stay was 3.3 days. Postoperative complications included urinary tract infections in 2 patients, urinary retention in 2 patients, and recurrence of paroxysmal atrial fibrillation in 1 patient. No patient was readmitted within 90 days of surgery. One patient underwent a reoperation 2 years postoperatively for symptomatic hardware removal (cerclage cables around the tuberosities). A matched cohort of staged bilateral total shoulder arthroplasty patients was analyzed for comparison. Postoperative complications in the staged group included 1 reverse total shoulder arthroplasty patient with subjective instability that was managed with additional physical therapy. There were no documented readmissions within 90 days or revision arthroplasty procedures in either cohort.

CONCLUSIONS

SBSA is a reasonable procedure that can be useful in select patients, with promising short-term safety noted in this series. Prospective randomized studies are needed to assess the long-term safety and efficacy of the procedure.

Gender Influences on Shoulder Arthroplasty

PURPOSE OF REVIEW

As the incidence of shoulder arthroplasty continues to increase, there is growing interest in patient-based factors that may predict outcomes. Based on existing literature demonstrating gender-based disparities following total hip and knee arthroplasty, gender may also influence shoulder arthroplasty. The purpose of this review is to discuss the recent literature on the influence of gender on shoulder arthroplasty, focusing on differences in preoperative parameters, perioperative complications, and postoperative outcomes.

RECENT FINDINGS

While both female and male patients generally benefit from shoulder arthroplasty, several differences may exist in preoperative factors, acute perioperative complications, and postoperative outcomes. Preoperatively, female patients undergo shoulder arthroplasty at an older age compared to their male counterparts. They may also have greater levels of preoperative disability and different preoperative expectations. Perioperatively, female patients may be at increased risk of extended length of stay, postoperative thromboembolic events, and blood transfusion. Postoperatively, female patients may achieve lower postoperative functional scores and decreased range of motion compared to male patients. Differences in postoperative functional scores may be influenced by gender-based differences in activities of daily living. Finally, female patients may be at greater risk for periprosthetic fracture and aseptic loosening while male patients appear to be at greater risk for periprosthetic infection and revision surgery. Current literature on the influence of gender on shoulder arthroplasty is limited and conflicting. Further research is necessary to delineate how gender affects patients at the pre- and postoperative levels to better inform decision-making and outcomes.

How to Measure Glenoid Bone Stock and Version and Why It Is Important: A Practical Guide

Shoulder osteoarthritis (OA) is a common and debilitating condition and a source of high morbidity and medical expenditures across the world among individuals older than 60 years. Shoulder OA results in the gradual destruction of articular cartilage of the humeral head and glenoid component, causing inflammation, pain, and a restricted range of motion. Most patients are diagnosed with shoulder OA after experiencing shoulder pain and stiffness, and the diagnosis is often made after medical and physical histories are obtained and physical and imaging examinations are performed. Use of various surgical techniques such as total anatomic or reverse shoulder arthroplasty and hemiarthroplasty has increased in recent years, resulting in reduced morbidity and improved functional status of patients. However, the rate of surgical complications such as premature loosening of components is significant, reducing the effectiveness of such procedures. Data in the literature indicate that high-grade fatty infiltration of the rotator cuff muscle before surgery is associated with postoperative glenoid component loosening. High-grade rotator cuff fatty infiltration and atrophy have been found to be associated with more severe Walch classification-based glenoid morphology subtypes, increased joint line medialization, glenoid bone loss, and increased pathologic glenoid version. The authors describe how advanced imaging techniques are used for preoperative evaluation of the shoulder and discuss how to measure glenoid version and bone stock and classify glenoid morphology types on the basis of Walch classification, as these parameters are commonly used in surgical planning. Methods involving the use of Friedman and paleoglenoid lines for respective measurements are illustrated by using three-dimensional CT and MRI case examples. ^©RSNA, 2020.

Validity and Reliability of the Turkish Version of Western Ontario Osteoarthritis of the Shoulder Index

Objectives

This study aims to adapt the Western Ontario Osteoarthritis of the Shoulder (WOOS) index specific to shoulder osteoarthritis into Turkish and to evaluate its validity and reliability.

Patients and methods

The WOOS index was translated and culturally adapted into Turkish, systematically. It was applied to a total of 68 patients (17 males, 51 females; mean age: 61.5±8.7 years; range, 45 to 80 years) with osteoarthritis of the shoulder treated conservatively. The reliability of the scale was checked through internal consistency and test-retest methods. Internal consistency was analyzed with Cronbach alpha value. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC) with 25 patients. The Western Ontario Rotator Cuff (WORC), the Shoulder Pain and Disability Index (SPADI), and the Society of American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) scores were used to conduct concurrent validity.

Results

The Cronbach alpha value of the scale was found to be excellent as 0.92 (p<0.001). The ICC value was also excellent as 0.97 (p<0.001). There was an excellent positive correlation with WORC (0.847; p<0.001) and a very good positive correlation with SPADI (0.788; p<0.001). It was also negatively very good to correlate with the ASES (-0.754; p<0.001). Additionally, subsections of WOOS had a good correlation with the corresponding subsections of WORC (0.779-0.664; p<0.001).

Conclusion

The Turkish version of the WOOS index is a valid and reliable tool and is recommended for use in the assessment of patients with osteoarthritis of the shoulder.

Clinical use of autologous micro-fragmented fat progressively restores pain and function in shoulder osteoarthritis

Aim: We aim to show that the use of nondigested micro-fragmented adipose tissue (MFat™, Lipogems^®) is a viable alternative for treatment of joint pain and inflammation associated dysfunction in shoulder osteoarthritis (OA). Materials & methods: A total of 25 subjects with OA received an injection of MFat™ and were followed at 6, 18 and 52 weeks intervals. Quantitative analysis of pain and function modalities were performed using the visual analog scale and the disabilities of the arm, shoulder and hand, respectively. Results: All study participants reported significant progressive improvement (p < 0.001) from baseline in visual analog scale and disabilities of the arm, shoulder and hand in shoulder OA cases up to a year post. Conclusion: MFat™ therapy improves pain and function in patients with shoulder OA and can provide a long-term alternative to surgical intervention.

Qualitative and quantitative analysis of glenoid bone stock and glenoid version: inter-reader analysis and correlation with rotator cuff tendinopathy and atrophy in patients with shoulder osteoarthritis

PURPOSE

Glenoid bone stock and morphology and rotator cuff muscle quality and tendon integrity affect the outcome of total shoulder arthroplasty. We hypothesized that glenoid bone loss correlates with rotator cuff muscle fatty infiltration (FI), tendinopathy, and atrophy.

DESIGN

Forty-three 3D CT scans and MRIs of 43 patients (mean age 62 years; SD 13 years; range 22-77 years) referred for primary shoulder pain were evaluated. Measurements of glenoid bone stock, version, and posterior humeral subluxation index (HSI) were assessed on an axial CT image reconstructed in the true scapular plane. Measurements utilized the Friedman line to approximate the pre-pathologic surface. Glenoid morphology was assigned by modified Walch classification. Rotator cuff FI, atrophy, and tendon integrity were assessed on corresponding MRIs.

RESULTS

There was a very strong negative correlation between increasing glenoid version and HSI (r = - 0.908; p < 0.0001). There was a moderately negative correlation between anterior bone loss and HSI (r = - 0.562; p < 0.0001) and a moderately positive correlation between posterior bone loss and HSI (r = 0.555; p < 0.0001). Subscapularis muscle FI correlated moderately with increased anterior and central bone loss and increased humeral head medialization (r = 0.512, p = 0.0294; r = 0.479, p = 0.033; r = 0.494, p = 0.0294; respectively). Inter-observer reliability (intra-class correlation coefficient [ICC] and kappa) was good to excellent for all measurements and grading.

CONCLUSION

Glenoid anteversion and anterior and posterior bone loss are associated with varying HSI. Subscapularis muscle FI, not tendon integrity, correlates to anterior and central glenoid erosion. The study adds evidence that neither rotator cuff tendinopathy nor muscle atrophy exhibits a significant relationship to HSI.

Correction to: Qualitative and quantitative analysis of glenoid bone stock and glenoid version: inter-reader analysis and correlation with rotator cuff tendinopathy and atrophy in patients with shoulder osteoarthritis

Purpose Glenoid bone stock and morphology and rotator cuff muscle quality and tendon integrity affect the outcome of total shoulder arthroplasty. We hypothesized that glenoid bone loss correlates with rotator cuff muscle fatty infiltration (FI), tendinopathy, and atrophy.Design Forty-three 3-D CT scans and MRIs of 43 patients (mean age 62 years; SD 13 years; range 22-77 years) referred for primary shoulder pain were evaluated. Measurements of glenoid bone stock, version, and posterior humeral subluxation index (HSI) were assessed on an axial CT image reconstructed in the true scapular plane. Measurements utilized the Friedman line to approximate the pre-pathologic surface. Glenoid morphology was assigned by modified Walch classification. Rotator cuff FI, atrophy, and tendon integrity were assessed on corresponding MRIs.Results There was a very strong negative correlation between increasing glenoid version and HSI (r = - 0.908; p < 0.0001). There was a moderately negative correlation between anterior bone loss and HSI (r = - 0.562; p < 0.0001) and a moderately positive correlation between posterior bone loss and HSI (r = 0.555; p < 0.0001). Subscapularis muscle FI correlated moderately with increased anterior and central bone loss and increased humeral head medialization (r = 0.512, p = 0.0294; r = 0.479, p = 0.033; r = 0.494, p = 0.0294, respectively). Inter-observer reliability (intra-class correlation coefficient [ICC] and kappa) was good to excellent for all measurements and grading.Conclusion Glenoid anteversion and anterior and posterior bone loss are associated with varying HSI. Subscapularis muscle FI, not tendon integrity, correlates to anterior and central glenoid erosion. The study adds evidence that neither rotator cuff tendinopathy nor muscle atrophy exhibits a significant relationship to HSI.

What are the costs of glenohumeral osteoarthritis in the year prior to a total shoulder arthroplasty (TSA)?

Objectives: To identify patterns of health-care utilization and costs associated with management of glenohumeral osteoarthritis in the year prior to undergoing an anatomic total shoulder arthroplasty (ATSA).Methods: The PearlDiver Humana database, an administrative database of Medicare Advantage (MA) and Commercial insurance beneficiaries was queried for active records of patients undergoing a primary ATSA from the fourth quarter of 2010-2015. Pre-operative health-care utilization was categorized as 1) Procedures & Anesthesia, 2) Office visits, 3) Radiology, 4) Injections - a) Steroid injections and b) Hyaluronic Acid (HA) injections, 5) Physical Therapy, 6) Non-opioid pain medications and 7) Opioids. Overall costs/reimbursement and Per-patient average reimbursements (PPARs) were calculated for each category.Results: A total of 3,920 patients (MA = 3,691; Commercial = 229) undergoing primary ATSA were retrieved. Based on defined categories, the total costs prior to ATSA were $368,137 and $2,812,617 for Commercial and MA beneficiaries, respectively. Overall 1-year PPAR for each category was as follows: Procedures & Anesthesia (MA = $1765; Commercial = $5333), Office visits (MA = $441; Commercial = $396); Radiology (MA = $253; Commercial = $558), Injections (MA = $117, Commercial = $173), Physical therapy (MA = $473; Commercial = $372), Non-opioid pain meds (MA = $49; Commercial = $147) and Opioids (MA = $26; Commercial = $49). The highest utilization was seen in the three months prior to ATSA with 42-81% of overall PPAR being accounted for various categories.Conclusion: A high utilization of all health-care resource categories was noted within three months prior to surgery. Providers should consider judicious use of such interventions, particularly in patients which ultimately require surgery in a short frame of time, to reduce the costs associated with the overall episode of care.

The role of biologic agents in the management of common shoulder pathologies: current state and future directions

The field of orthopedic surgery has seen a rapid increase in the use of various biologic agents for the treatment of common musculoskeletal injuries. Most biologic agents attempt to harness or mimic naturally occurring growth factors, cytokines, and anti-inflammatory mediators to improve tissue healing and recovery. The most commonly used biologic agents are platelet-rich plasma and cells derived from bone marrow aspirate and adipose tissue. These agents have become increasingly popular despite a relative dearth of clinical data to support their use. Much confusion exists among patients and physicians in determining the role of these agents in treating common shoulder pathologies, such as glenohumeral osteoarthritis, rotator cuff tears, and tendinopathy. This article reviews the basic science and clinical evidence for the most commonly used biologic agents in the management of common shoulder pathology.

Imaging of the B2 Glenoid: An Assessment of Glenoid Wear

Background

Glenohumeral osteoarthritis (OA) carries a spectrum of morphology and wear patterns of the glenoid surface exemplified by complex patterns such as glenoid biconcavity and acquired retroversion seen in the B2 glenoid. Multiple imaging methods are available for evaluation of the complex glenoid structure seen in B2 glenoids. The purpose of this article is to review imaging assessment of the type B2 glenoid.

Methods

The current literature on imaging of the B2 glenoid was reviewed to describe the unique anatomy of this OA variant and how to appropriately assess its characteristics.

Results

Plain radiographs, magnetic resonance imaging, and standard 2-dimensional computed tomography (CT) have all shown acceptable assessments of arthritic glenoids but lack the detailed and highly accurate evaluation of bone loss and retroversion seen with 3-dimensional CT.

Conclusion

Accurate preoperative identification of complex B2 pathology on imaging remains essential in planning and achieving precise implant placement at the time of shoulder arthroplasty.

Evaluation of humeral head cartilage using magnetic resonance imaging T1 rho mapping for patients with small-to-medium rotator cuff tears: A pilot study

BACKGROUND

It is unclear whether smaller rotator cuff tears cause cartilage degeneration. This study was designed to detect early humeral head cartilage degeneration in patients with small-to-medium cuff tears using magnetic-resonance-imaging T1 rho mapping.

METHODS

Five male and 5 female volunteers without shoulder symptoms (control group) and 5 male and 5 female patients with small-to-medium (<3 cm) rotator cuff tears underwent 3.0-T magnetic resonance imaging of a single shoulder. T1 rho values of the humeral head cartilage were measured and analyzed.

RESULTS

The total mean T1 rho value was 40.4 ± 3.4 ms for the control group and 45.0 ± 5.3 ms for the patient group. In the control group, the T1 rho values in the inferior articular cartilage were significantly higher than those in the superior and middle articular cartilage. In the patient group, there was no significant difference between all regions. A comparison between the patient and control groups showed that the mean T1 rho values in the superior-to-middle articular cartilage were significantly higher for the patient group than for the control group. However, in the inferior articular cartilage, there was no significant difference between both groups.

CONCLUSIONS

This study showed the possibility of early cartilage degenerative changes in the superior-to-middle humeral head articular cartilage of patients with small-to-medium rotator cuff tears.

Rotator cuff tear with early osteoarthritis: how does it affect clinical outcome after large to massive rotator cuff repair?

BACKGROUND

Rotator cuff tear and glenohumeral osteoarthritis are 2 common diseases, but there are few studies about their clinical correlation. The purpose of this study was to evaluate the influence of mild glenohumeral osteoarthritis on the clinical outcome after large to massive rotator cuff repair.

METHODS

This study included 146 patients who underwent rotator cuff repair for large to massive tears and were available for follow-up at a minimum of 2 years. Of the patients, 74 had mild glenohumeral osteoarthritis (group A) and 72 did not have glenohumeral osteoarthritis (group B).

RESULTS

The mean visual analog scale score during motion, mean University of California at Los Angeles score, and mean Constant score were 1.8, 30.2, and 87.4, respectively, in group A and 2.0, 30.8, and 89.2, respectively, in group B at final follow-up. The retear rates were 31.1% (23 of 74 patients) in group A and 25.0% (18 of 72 patients) in group B. The osteoarthritis progression rates were 12.1% (9 of 74) in group A and 13.8% (10 of 72) in group B. However, in group A, the osteoarthritis progression rates were 26.1% (6 of 23) for retear cases and 5.9% (3 of 51) for healed cases. There was a significant difference in the progression rates between retear and healed cases in group A (odds ratio, 5.65; P = .022).

CONCLUSIONS

There were no significant differences in clinical outcomes between patients with and without glenohumeral osteoarthritis before surgery and during final follow-up. The progression of osteoarthritis in large to massive rotator cuff tears is relatively low. However, it is significantly higher in patients with retears in whom osteoarthritis is present.

Performance of PROMIS Global-10 compared with legacy instruments in patients with shoulder arthritis

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 measures physical and mental health and provides an estimated EuroQol-5 Dimension (EQ-5D) score. The purpose of this study was to determine the correlation between the PROMIS Global-10 and several gold-standard legacy measures to validate its overall performance and usefulness in patients with shoulder arthritis.

METHODS

The study prospectively enrolled 161 patients with shoulder arthritis before treatment. Each patient completed the PROMIS, EQ-5D, American Shoulder and Elbow Surgeons (ASES) Assessment Form, Single Assessment Numeric Evaluation (SANE), and Western Ontario Osteoarthritis of the Shoulder (WOOS) Index. Spearman correlations were calculated, and Bland-Altman agreement tests were conducted between estimated EQ-5D scores from the PROMIS and actual EQ-5D scores. Ceiling and floor effects were determined.

RESULTS

Correlation between the PROMIS and EQ-5D was excellent (0.72, P < .001). However, agreement for estimated EQ-5D ranged from 0.37 below to 0.36 above actual EQ-5D scores. Correlation of the PROMIS physical score was good with the ASES score (0.57, P < .001) and poor with the SANE score (0.23, P = .0045) and WOOS score (0.11, P = .3743). Correlation of the PROMIS mental score was poor when compared with all patient-reported outcome instruments investigated (ASES score, 0.26 [P = .0012]; SANE score, 0.13 [P = .1004]; and WOOS score, 0.09 [P = .4311]). No floor or ceiling effects were observed.

CONCLUSION

PROMIS Global-10 physical scores show excellent correlation with the EQ-5D. However, the PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population because of the large variance in agreement between actual and PROMIS Global-10-estimated EQ-5D scores. PROMIS Global-10 physical scores showed good correlation with the ASES score but poor correlation with other gold-standard patient-reported outcome instruments, suggesting that it is an inappropriate instrument for outcome measurement in populations with shoulder arthritis.

The relationship of age, activity, and body size on osteoarthritis in weight-bearing skeletal regions

This study examined the simultaneous impact of multiple underlying factors on OA expression in weight-bearing joints of the vertebrae and lower limb of a modern European skeletal sample (Lisbon and Sassari). OA was evaluated using standard ranked categorical scoring; composite OA scores derived through principal component analysis. Body size was calculated from postcranial measurements; torsional strength (J) of the femoral midshaft was calculated from three-dimensional surface models, size standardized and used as a proxy for activity. A standard multiple regression was applied. In all regions, the linear combination of age, body mass, stature, and J was significantly related to differences in OA. Across all joints, age was the strongest predictor; neither body size, nor activity variables demonstrated a statistical relationship with OA at the lumbar or knee; J demonstrated a negative correlation with pelvic OA. Variation in OA can be explained by age, stature, body mass, and structural adaptation related to habitual use. The negative correlation between femoral torsional strength with OA suggests that long-term, repetitive physical work capacity in childhood may be protective against OA development later in life. The multifactorial aetiology of OA requires incorporating multiple lines of evidence to interpret individual or population health from bone samples.

Primary and Secondary Consequences of Rotator Cuff Injury on Joint Stabilizing Tissues in the Shoulder

Rotator cuff tears (RCTs) are one of the primary causes of shoulder pain and dysfunction in the upper extremity accounting over 4.5 million physician visits per year with 250,000 rotator cuff repairs being performed annually in the U.S. While the tear is often considered an injury to a specific tendon/tendons and consequently treated as such, there are secondary effects of RCTs that may have significant consequences for shoulder function. Specifically, RCTs have been shown to affect the joint cartilage, bone, the ligaments, as well as the remaining intact tendons of the shoulder joint. Injuries associated with the upper extremities account for the largest percent of workplace injuries. Unfortunately, the variable success rate related to RCTs motivates the need for a better understanding of the biomechanical consequences associated with the shoulder injuries. Understanding the timing of the injury and the secondary anatomic consequences that are likely to have occurred are also of great importance in treatment planning because the approach to the treatment algorithm is influenced by the functional and anatomic state of the rotator cuff and the shoulder complex in general. In this review, we summarized the contribution of RCTs to joint stability in terms of both primary (injured tendon) and secondary (remaining tissues) consequences including anatomic changes in the tissues surrounding the affected tendon/tendons. The mechanical basis of normal shoulder joint function depends on the balance between active muscle forces and passive stabilization from the joint surfaces, capsular ligaments, and labrum. Evaluating the role of all tissues working together as a system for maintaining joint stability during function is important to understand the effects of RCT, specifically in the working population, and may provide insight into root causes of shoulder injury.

Classification of humeral head pathomorphology in primary osteoarthritis: a radiographic and in vivo photographic analysis

BACKGROUND

The purpose of this study was to characterize the pathologic changes of the osteoarthritic humeral head.

METHODS

The study included 55 patients with primary osteoarthritis who underwent anatomic shoulder arthroplasty. Several radiologic parameters (radiography, magnetic resonance imaging) were assessed. Humeral head deformity in the transverse plane and humeral cartilage erosion in the coronal plane were chosen for photographic measurements from the resected humeral heads.

RESULTS

In the coronal plane, 82% of patients presented with an aspherical humeral head shape with a significantly longer caudal osteophyte. In the transverse plane, 50% of all patients showed a decentered apex. Patients with an aspherical humeral head shape in the transverse plane showed an aspherical humeral head shape in the coronal plane in 94% and a significantly longer osteophyte than patients with spherical humeral head shape, showing a 3-dimensional deformity of the humeral head during progression of primary osteoarthritis. Patients with an osteophyte length between 7 and 12 mm were associated with a glenoid type B2 in 30% and a decentered apex in the transverse plane in 38%. Patients with a humeral osteophyte longer than 13 mm were significantly more frequently associated with a type B2 glenoid (71%; P < .0001) and a decentered apex in the transverse plane in 52%.

CONCLUSION

It seems that the progression of primary osteoarthritis of the glenohumeral joint is characterized by an increasing 3-dimensional deformity of the humeral head related to the glenoid morphology. We therefore propose an extended Samilson-Prieto classification with type A (spherical) and type B (aspherical) and grade I-IV osteophytes.

Are degenerative rotator cuff disorders a cause of shoulder pain? Comparison of prevalence of degenerative rotator cuff disease to prevalence of nontraumatic shoulder pain through three systematic and critical reviews

HYPOTHESIS AND BACKGROUND

The role of degeneration is not well understood for rotator cuff pain. If age-related degenerative changes would be the cause of symptoms, degeneration would precede or concur with self-reported pain. We performed 3 systematic literature reviews. Our objectives were to determine the prevalence estimates for rotator cuff partial or complete tears (1) in cadavers and (2) in the general population and (3) to estimate the incidence/prevalence of self-reported nontraumatic shoulder pain in the general population in order to compare their respective age-related profiles.

METHODS

We searched PubMed and ScienceDirect, including 2015, for cadaveric studies and transverse and longitudinal studies of the general population reporting the incidence/prevalence of rotator cuff disorders or nontraumatic shoulder pain, or both, according to age. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results were interpreted visually.

RESULTS

We found 6 cadaveric studies, 2 studies from the general population reporting complete tears, and 10 articles on nontraumatic shoulder pain in the general population that met our criteria. The profiles of degeneration vs. pain were very similar in early years. Although degenerative rotators cuff lesions increased gradually after 50 years, the incidence/prevalence of nontraumatic shoulder pain decreased after 65 years.

CONCLUSION

The profile of age-related degenerative rotator cuff disorders fails to correlate systematically with self-reported nontraumatic shoulder pain, particularly in older age; thus, it appears that degeneration should not be considered the primary source of the pain. Physical activity may play an important role in the production of the pain, a theory that warrants further study.

Thickness Distribution of Glenohumeral Joint Cartilage

High-resolution 3-dimensional cartilage-specific magnetic resonance imaging (MRI) was performed at 3 T to test the following hypotheses: (1) there is a nonuniform cartilage thickness distribution both on the proximal humerus and on the glenoid surface and (2) the glenohumeral joint as a combined system is congruent with the level of the joint cartilage surface without substantial radial mismatch. Inclusion of 38 volunteers (19 females, mean age 24.34 ± 2.22 years; range 21-29 years) in a prospective study. Measurements of: cartilage thickness in 3 regions and 3 zones; radius of both circles (glenoid and humeral cartilage) for congruency calculation using 3-T MRI with 3-dimensional dual-echo steady-state sequence with water excitation. A homogenous mean cartilage thickness (1.2-1.5 mm) and slightly higher values for the glenoidal articulating surface radii both in the mid-paracoronar section (2.4 vs. 2.1 cm, P < 0.001) and in the mid-paraaxial section (2.4 vs. 2.1 cm, P < 0.001) compared with the humeral side were observed. The concept of a radial mismatch between the humeral head and the glenoid in healthy human subjects can be confirmed. This study provides normative data for the comparison of joint cartilage changes at the shoulder for future studies.

A Bayesian Approach to Age-at-Death Estimation from Osteoarthritis of the Shoulder in Modern North Americans

Osteoarthritis (OA) is a marker of degeneration within the skeleton, frequently associated with age. This study quantifies the correlation between OA and age-at-death and investigates the utility of shoulder OA as a forensic age indicator using a modern North American sample of 206 individuals. Lipping, surface porosity, osteophyte formation, eburnation, and percentage of joint surface affected were recorded on an ordinal scale and summed to create composite scores that were assigned a specific phase. Spearman's correlation indicated a positive relationship between each composite score and age (right shoulder = 0.752; left shoulder = 0.734). Transition analysis revealed a tendency toward earlier degeneration of the right shoulder. Bayesian statistics generated phase-related age estimates based on highest posterior density regions. Best age estimates were into the seventh decade at the 90th and 50th percentile. The proposed method supplements traditional techniques by providing age estimates beyond a homogenous 50+ age cohort.

Prevalence and Risk Factors of Spine, Shoulder, Hand, Hip, and Knee Osteoarthritis in Community-dwelling Koreans Older Than Age 65 Years

BACKGROUND

Osteoarthritis (OA) is common and disabling among older patients around the world. Data exploring the prevalence and risk factors of OA are of paramount importance in establishing healthcare policies. However, few studies have evaluated these topics among Asian populations.

QUESTIONS/PURPOSES

This study was conducted to determine the prevalence and risk factors of radiographic OA in the spine, shoulder, hand, hip, and knee in Koreans older than age 65 years.

METHODS

A simple random sample (N = 1118) was drawn from a roster of elderly individuals older than age 65 years in Seongnam. Of the 1118 invited subjects, 696 (males = 298, females = 398) participated in this study (a response rate of 62%). The mean age of respondents was 72 ± 5 years (range, 65-91 years). Radiographs of the lumbar spine, shoulder, hand, hip, and knee were taken and afterward evaluated for radiographic OA. The Kellgren-Lawrence grading system was used for all mentioned joints, and radiographic OA was defined as Grade 2 changes or higher. The association of sex, aging, and obesity with OA in each of the mentioned joints was determined with the help of multivariate logistic regression.

RESULTS

The highest prevalence of radiographic OA was seen in the spine (number of subjects with OA/number of whole population = 462 of 696 [66%]) followed by the hand (415 of 692 [60%]), knee (265 of 696 [38%]), shoulder (36 of 696 [5%]), and hip (15 of 686 [2%]). Female sex was associated with knee OA (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.9-8.4; p < 0.001) and hand OA (OR, 2.3; 95% CI, 1.6-3.1; p < 0.001), and male sex was associated with spine OA (OR, 0.7; 95% CI, 0.5-1.0; p = 0.025). Aging was associated with radiographic OA in the spine, knee, and hand (OR per 5-year increments, 1.3 [95% CI, 1.1-1.6; p = 0.001], 1.6 [95% CI, 1.4-1.9; p < 0.001], and 1.4 [95% CI, 1.2-1.7; p < 0.001]), respectively) but not associated with OA in the hip and shoulder. Obesity was associated with knee OA (OR, 3.4; 95% CI, 2.4-5.0; p < 0.001) and spine OA (OR, 1.5; 95% CI, 1.1-2.2; p = 0.014) but not with OA in other joints.

CONCLUSIONS

OA of the spine, hand, and knee is likely to become a major public health problem rather than shoulder and hip OA in Korea. Associations of demographic factors with radiographic OA differed among each joint, and that would be valuable information to assess the role and influence of risk factors of OA in various joints.

LEVEL OF EVIDENCE

Level III, prognostic study.

Age-related joint space narrowing independent of the development of osteoarthritis of the shoulder

Purpose:

It is commonly accepted that the glenohumeral joint space remains unchanged until the onset of osteoarthritis, at which point progressive degenerative changes, and joint space narrowing occur. The aim of this study was to evaluate the radiographic width of the glenohumeral joint space in patients of different ages: Those with otherwise normal radiographs, those with a history of instability, those with calcific tendonitis, and those with a radiologic diagnosis of osteoarthritis.

Materials and Methods:

In this retrospective study, two independent investigators measured the glenohumeral joint width on true anteroposterior and axillary views of standardized shoulder radiographs taken from 2002 to 2009. The digital image resolution was 0.01 mm. Group I comprised 60 patients with normal shoulder radiographs, Group II comprised 53 patients with instability but normal radiographs, Group III comprised 109 patients with radiologically proven calcific tendonitis, and Group IV comprised 120 patients with manifest osteoarthritis.

Results:

The interobserver reliability (r) was 0.621-0.862. The mean joint space width was significantly different among Groups I-IV (central anteroposterior: 4.28 ± 0.75 mm, 3.12 ± 0.73 mm, 2.87 ± 0.80 mm, and 1.47 ± 1.07 mm, respectively; P = 0.001; central axillary: 6.12 ± 1.09 mm, 3.92 ± 0.77 mm, 3.34 ± 0.84 mm, and 1.08 ± 1.12 mm, respectively; P = 0.001). There was a significant negative correlation between the joint space width and age at all measured levels in both projections (P < 0.001).

Conclusions:

The glenohumeral joint space width decreases with increasing age beginning in early adulthood, and this effect is enhanced by osteoarthritis.

Level of Evidence:

Level II, retrospective study.

A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age

Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older).

RESULTS

Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation.

DISCUSSION AND CONCLUSION

The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms.

Prevalence of and risk factors for shoulder osteoarthritis in Japanese middle-aged and elderly populations

BACKGROUND

The purpose of this study was to determine the prevalence of shoulder osteoarthritis (OA) in populations older than 40 years and to examine risk factors and the relationship with shoulder function.

METHODS

The respondents in this study consisted of 541 patients who underwent general medical examinations in April 2012 as residents of a single village. The mean age was 65.2 ± 11.0 years (range, 40-89 years), and 341 (63.0%) of the respondents were women. Anteroposterior radiographs of the bilateral shoulder joints were obtained, and the subjects were classified into 3 groups (non-OA, mild OA, and moderate-severe OA) according to the Samilson-Prieto method. With respect to risk factors for shoulder OA, a logistic regression analysis was performed.

RESULTS

Shoulder OA was detected in 17.4% (94 of 541) of the patients. The incidence of OA in both shoulders was 3.1% (17 of 541), and the prevalence of shoulder OA among the respondents 65 years of age or older (20.3%) was significantly higher than that observed among the respondents younger than 65 years (11.1%). The risk of shoulder OA increased according to age, with an odds ratio of 5.59 in the respondents 60 to 69 years of age (P = .027), 11.59 in the respondents 70 to 79 years of age (P = .004), and 10.77 in the respondents 80 years of age and older (P = .004).

CONCLUSIONS

The prevalence of shoulder OA was 17.4%, and the risk factor for shoulder OA was age.

The effect of glenohumeral osteoarthritis on the outcome of isolated operatively treated supraspinatus tears

BACKGROUND

Rotator cuff tear is considered to be a common source of shoulder pain and dysfunction. Osteoarthritis of the glenohumeral joint (OAG) may coexist with rotator cuff tear, especially in elderly patients. The aim of the study was to evaluate the effect of associated OAG on the treatment outcome of rotator cuff repair.

METHODS

A total of 85 consecutive shoulders with an arthroscopically repaired isolated full-thickness supraspinatus tendon tear in males were included in this study. The grade of OAG was estimated preoperatively from shoulder radiographs using the Kellgren-Lawrence (K-L) classification, and peroperatively using the Outerbridge classification. Supraspinatus tendon tear was re-inserted anatomically to the native footprint in all cases. The Constant score was used as an outcome measure and was measured preoperatively and 1 year after the operation. The effect of OAG on the Constant score was analyzed statistically.

RESULTS

82 shoulders (96.5 %) were available for the 1-year follow-up. Preoperative OAG was detected in 22/82 patients (26.8 %). Any OAG above K-L grade 0 was associated with a lower Constant score preoperatively [49.9 (SD 17.6) vs. 60.1 (SD 16.7) (p = 0.0185)] and also at the 1-year follow-up [73.9 (SD 17.5) vs. 82.8 (SD 10.9) (p = 0.0074)]. 16/60 patients (26.7 %) with K-L grade 0 radiographs had peroperatively detected OAG. Furthermore, any peroperatively detected OAG was associated with a lower Constant score preoperatively [53.2 (SD 19.0) vs. 60.9 (SD 15.2) (p = 0.0445)] and at the 1-year follow-up 76.8 [(SD 14.8) vs. 83.5 (SD 11.4) (p = 0.0223)].

CONCLUSION

OAG is a relatively common finding in operated supraspinatus tear patients. Pre- and peroperatively detected OAG during rotator cuff reconstruction is predictive for lower pre- and postoperative Constant scores.

The impact of aging on rotator cuff tear size

INTRODUCTION

The aim of our study was to establish if aging influences rotator cuff tear size.

PATIENTS AND METHODS

We studied 586 consecutive patients (280 M, 306 F) mean age 59 years old (range 46-73) who underwent arthroscopic rotator cuff repair. Tear size was determined during surgery. For the purpose of our study, patients were divided into two groups based on age older than 60 years. A multinomial logistic regression model was applied to explore the association between age older than 60 years and tear size. We used the ANCOVA method to determine whether the aging influences the severity of the tear. All analyses were adjusted for gender.

RESULTS

Age older than 60 years was associated with a twofold higher overall risk of tear occurrence (OR = 2.12, 95 % CI 1.44-3.01). While no association was detected between age older than 60 years and the probability of a small tear (OR = 0.58, 95 % CI 0.27-1.07), subjects older than 60 years were twice more likely to experience a large tear (OR = 2.29, 95 %CI 1.51-3.27) and three times more likely to experience a massive tear (OR = 3.09, 95 % CI 2.07-5.38) as opposed to younger subjects. Mean age significantly increased from small tear (53.8 years) to large tear (66.8 years) to massive tear (69.4 years) patients (ANCOVA: F(2, 437) = 16.487, p = 1.51 × 10(-7)).

DISCUSSION

We found a significantly older mean age in patients with a more severe tear. Our data provide and confirm evidence that aging is a significant risk factor for the occurrence and severity of rotator cuff tears.

Shoulder osteoarthritis

Osteoarthritis (OA) is the most frequent cause of disability in the USA, affecting up to 32.8% of patients over the age of sixty. Treatment of shoulder OA is often controversial and includes both nonoperative and surgical modalities. Nonoperative modalities should be utilized before operative treatment is considered, particularly for patients with mild-to-moderate OA or when pain and functional limitations are modest despite more advanced radiographic changes. If conservative options fail, surgical treatment should be considered. Although different surgical procedures are available, as in other joints affected by severe OA, the most effective treatment is joint arthroplasty. The aim of this work is to give an overview of the currently available treatments of shoulder OA.

Morphology of the normal and arthritic glenoid

The normal glenoid has a pear-shape aspect and is slightly retroverted. It has a variable orientation in the sagittal plane. The cartilage surface area corresponds to 28 % of the area of the humeral head with a radius of curvature greater than the humeral head. Mechanical properties are significantly higher at the center and posterior edge of the glenoid. With osteoarthritis, the glenoid becomes larger with a greater width and an increasing of the retroversion angle. The wear can be centric or excentric. Mechanical properties are significantly higher at the center and posterior edge of the glenoid.

Glenoid cartilage mechanical properties decrease after rotator cuff tears in a rat model

Rotator cuff repairs are commonly performed to reduce pain and restore function. Tears are also treated successfully without surgical intervention; however, the effect that a torn tendon has on the glenohumeral cartilage remains unknown. Clinically, a correlation between massive rotator cuff tears and glenohumeral arthritis has often been observed. This may be due to a disruption in the balance of forces at the shoulder, resulting in migration of the humeral head and subsequently, abnormal loading of the glenoid. Our lab previously demonstrated changes in ambulation and intact tendon mechanical properties following supraspinatus and infraspinatus rotator cuff tendon tears in a rat model. Therefore, the purpose of this study was to investigate the effects of supraspinatus and infraspinatus rotator cuff tears on the glenoid cartilage. Nine rats underwent unilateral detachment of the supraspinatus and infraspinatus tendons and were sacrificed after 4 weeks. Cartilage thickness significantly decreased in the antero-inferior region of injured shoulders. In addition, equilibrium elastic modulus significantly decreased in the center, antero-superior, antero-inferior, and superior regions. These results suggest that altered loading after rotator cuff injury may lead to damage to the joint with significant pain and dysfunction. Clinically, understanding the mechanical processes involved with joint damage will allow physicians to better advise patients.

The current state of imaging the articular cartilage of the upper extremity

MR imaging has increasingly been used to image joints since its inception. Historically, there has been more emphasis on the evaluation of internal derangement rather than cartilaginous disease. This article reviews cartilaginous diseases of the upper extremity emphasizing those that can be assessed using current clinical MR imaging protocols and addresses the limitations of current imaging techniques in evaluating the articular cartilage of smaller joints. It also provides a brief overview of novel techniques that may be instituted in the future to improve the diagnostic performance of MR imaging in the evaluation of the articular cartilage of the upper extremity.

The long-term outcome of recurrent defects after rotator cuff repair

BACKGROUND

Retears of the rotator cuff are not uncommon after arthroscopic and mini-open rotator cuff repairs. In most studies, the clinical results in patients with persistent defects demonstrated significantly less pain and better function and strength compared with their preoperative state at an early follow-up.

HYPOTHESIS

The clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L'Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound.

RESULTS

At the 7.9 year follow-up the average scores were 95 (American Shoulder and Elbow Surgeons), 95 (L'Insalata), 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (P < .001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm(2) to 467 mm(2) (P < .001). Finally, the size of the defect increased in all patients, and no defects healed structurally.

CONCLUSION

At an average of 7.9 years, patients with recurrent defects after rotator cuff repair still had an improvement in terms of pain, function, and satisfaction. However, the rotator cuff defect significantly increased in size, and there was a progression of strength deficits. These findings suggest that patients with recurrent defects can remain asymptomatic over the long term but will predictably lose strength in the involved extremity. Furthermore, the study demonstrated that defects after rotator cuff repair increase in size but often remain asymptomatic.

Is there an association between a low acromion index and osteoarthritis of the shoulder?

The aim of this study was to evaluate the relationship between a low acromion index and osteoarthritis of the shoulder. Three patient groups were used: (I) instability, n = 53; (II) calcifying tendonitis, n = 109; and (III) osteoarthritis, n = 120. Standardised digital X-rays were evaluated from the true anteroposterior and axillary views. Joint space width at three levels in each plane and the size of humeral osteophytes were measured and osteoarthritis was graded according to Samilson. The acromion index was calculated according to Nyffeler et al. (J Bone Joint Surg Am 88:800-805, 2006) in the true anteroposterior view. There were two independent investigators. Interobserver reliability was excellent for all measurements in the anteroposterior (AP) projection but inferior in the axillary projections, especially in group III. The mean acromion index was 0.64 ± 0.07 in group I, 0.64 ± 0.08 in group II and 0.73 ± 0.12 in group III. The acromion index was not correlated with the joint space width nor with the size of the osteophytes or the Samilson grading in group III. The data of the study did not show a significant association between a low acromion index and typical signs of osteoarthritis at the shoulder. The theoretical concept of a small acromion index associated with the development of osteoarthritis of the shoulder is not supported.

How much are radiological parameters related to clinical symptoms and function in osteoarthritis of the shoulder?

Loss of joint space, formation of osteophytes and deformation are common features of osteoarthritis. Little information exists about the radiological features of arthrosis in relation to clinical findings and the radiological appearance in degenerative shoulder joint disease especially with regard to decision making about the timing of joint replacement. We retrospectively examined 120 standardised X-rays of patients with advanced osteoarthritis of the shoulder. Exclusion criteria included rotator cuff tear, severe glenoid erosion or protrusion. Measurements of joint space width at three levels in each plane (anteroposterior and axillary view), humeral head diameter and size of humeral osteophytes were made by two independent examiners. Osteoarthritis was graded according to Samilson and Prieto. Seventy-five of these patients had a complete record from the clinical investigation (pain record on VAS scale, active and passive range of motion) and the constant score (CS). Mean joint space width in the central anteroposterior level was 1.46 mm +/- 1.08 and in the central axillary 0.98 mm +/- 1.02. Increasing age was positively correlated with joint space narrowing at all measured levels. The joint space width was not correlated with the Samilson grade or the size of osteophytes. The joint space width was neither correlated with pain nor active or passive ROM. Pain was correlated with active and passive flexion and abduction but not for internal or external rotation. The size of the osteophytes was negatively correlated (active and passive) with flexion, abduction and external and internal rotation. The study illustrates that joint space narrowing and development of osteophytes are reliable but independent parameters of primary shoulder arthrosis and should be recorded separately. The size of the caudal humeral osteophyte is a predictive factor for function and should be taken into account for clinical decision making. The primary clinical feature, pain, as the main indication for surgery is not related to radiological parameters.

Long head of the biceps tendon pain: differential diagnosis and treatment

Though the role of the long head of the biceps tendon (LHBT) in shoulder pathology has been extensively investigated, it remains controversial. Historically, there have been large shifts in opinions on LHBT function, ranging from being a vestigial structure to playing a critical role in shoulder stability. Today, despite incomplete understanding of its clinical or biomechanical involvement, most investigators would agree that LHBT pathology can be a significant cause of anterior shoulder pain. When the biceps tendon is determined to be a significant contributor to a patient's symptoms, the treatment options include various conservative interventions and possible surgical procedures, such as tenotomy, transfer, or tenodesis. The ultimate treatment decision is based upon a variety of factors, including the patient's overall medical condition, severity, and duration of symptoms, expectations, associated shoulder pathology, and surgeon preference. The purpose of this manuscript is to review current anatomic, functional, and clinical information regarding the LHBT, including conservative treatment, surgical treatment, and postsurgical rehabilitation regimens.

LEVEL OF EVIDENCE

Level 5.

Post-traumatic glenohumeral cartilage lesions: a systematic review

Background

Any cartilage damage to the glenohumeral joint should be avoided, as these damages may result in osteoarthritis of the shoulder. To understand the pathomechanism leading to shoulder cartilage damage, we conducted a systematic review on the subject of articular cartilage lesions caused by traumas where non impression fracture of the subchondral bone is present.

Methods

PubMed (MEDLINE), ScienceDirect (EMBASE, BIOBASE, BIOSIS Previews) and the COCHRANE database of systematic reviews were systematically scanned using a defined search strategy to identify relevant articles in this field of research. First selection was done based on abstracts according to specific criteria, where the methodological quality in selected full text articles was assessed by two reviewers. Agreement between raters was investigated using percentage agreement and Cohen's Kappa statistic. The traumatic events were divided into two categories: 1) acute trauma which refers to any single impact situation which directly damages the articular cartilage, and 2) chronic trauma which means cartilage lesions due to overuse or disuse of the shoulder joint.

Results

The agreement on data quality between the two reviewers was 93% with a Kappa value of 0.79 indicating an agreement considered to be 'substantial'. It was found that acute trauma on the shoulder causes humeral articular cartilage to disrupt from the underlying bone. The pathomechanism is said to be due to compression or shearing, which can be caused by a sudden subluxation or dislocation. However, such impact lesions are rarely reported. In the case of chronic trauma glenohumeral cartilage degeneration is a result of overuse and is associated to other shoulder joint pathologies. In these latter cases it is the rotator cuff which is injured first. This can result in instability and consequent impingement which may progress to glenohumeral cartilage damage.

Conclusion

The great majority of glenohumeral cartilage lesions without any bony lesions are the results of overuse. Glenohumeral cartilage lesions with an intact subchondral bone and caused by an acute trauma are either rare or overlooked. And at increased risk for such cartilage lesions are active sportsmen with high shoulder demand or athletes prone to shoulder injury.

A quantitative study of humeral cartilage in individuals with spinal cord injury

STUDY DESIGN

Cross-sectional design.

OBJECTIVES

In this in vivo study, we investigated the influence of different load situations on humeral cartilage thickness in individuals with paraplegia and quadriplegia.

SETTING

ETH Zurich and Swiss Paraplegic Centre Nottwil, Switzerland.

METHODS

A previously validated three-dimensional (3D) gradient echo MRI-sequence with selective water excitation was used. Three groups were compared: individuals with paraplegia with high shoulder demand (n=11), individuals with quadriplegia with reduced load on the shoulder joint (n=8) and a control group (n=9). After 3D reconstruction, the mean cartilage thickness, local thicknesses (superior, medial, inferior) and the minimum joint space were calculated.

RESULTS

The mean humeral cartilage thickness (1.40+/-0.14 mm) as well as the minimum joint space (2.57+/-0.50 mm) did not differ between groups. In individuals with paraplegia, the superior cartilage thickness was significantly greater than in individuals with quadriplegia (1.47 mm compared to 1.28 mm, P<0.05). In the control group, there was a significant negative correlation between mean cartilage thickness and age (r=-0.81).

CONCLUSION

Neither higher shoulder demand nor reduced shoulder loading leads to thinning of humeral cartilage. It is hypothesized that higher local stresses prevent local cartilage degeneration, as in normal load situations humeral cartilage thinning is occurring with age. Furthermore, joint space narrowing was only associated with inferior cartilage thickness and cartilage thickness is not related to shoulder pain.

Cartilage lesions of the glenohumeral joint: diagnostic effectiveness of multidetector spiral CT arthrography and comparison with arthroscopy

This study assessed the diagnostic effectiveness of multidetector spiral CT arthrography (MDCTa) in detecting hyaline cartilage abnormalities of the shoulder joint, with correlation to arthroscopy. Shoulder MDCTa images prospectively obtained in 22 consecutive patients (mean age, 50 years; age range, 23-74 years; 12 female, 10 male) were evaluated for glenohumeral cartilage lesions. Two musculoskeletal radiologists independently analysed the cartilage surfaces of the humeral head and of the glenoid fossa in nine anatomical surface areas. Observations of MDCTa were compared to arthroscopic findings. The sensitivity and specificity of MDCTa for grade 2 (substance loss <50%) or higher and grade 3 (substance loss >or=50%) or higher cartilage lesions, the Spearman correlation coefficient between arthrographic and arthroscopic grading, and K statistics for assessing Intra and Interobserver reproducibility were determined. At MDCTa, sensitivities and specificities ranged between 80% and 94% for the detection of grade 2 or higher cartilage lesions, and between 88% and 98% for the detection of grade 3 or higher cartilage lesions. Spearman correlation coefficients between MDCTa and arthroscopic grading of articular surfaces ranged between 0.532 and 0.651. Interobserver agreement was moderate for grading all articular surfaces (kappa = 0.457), but substantial to almost perfect for detecting lesions with substance loss (kappa, 0.618-0.876). In conclusion, MDCTa is accurate for the study of cartilage surface in the entire shoulder joint. This technique may beneficially impact patient's management by means of selecting the proper treatment approach.

[Effect of age on the natural history of the shoulder: a clinical and radiological study in the elderly]

PURPOSE OF THE STUDY

Classically, the shoulder joint is thought to age more by its tendons than by its cartilages, the incidence of rotator cuff tears being considered to increase with age. The purpose of this work was to assess the natural history of the shoulder joint based on a clinical and radiological study of 200 patients aged 70 to 101 years.

MATERIAL AND METHODS

The cohort was composed of 48 men (34%) and 152 women (76%), aged 84.25 +/- 6.7 years. All patients underwent a physical examination and the Constant score was established. The radiographic examination included an AP view in neutral rotation of both shoulders. The Hamada classification was used to stage full thickness cuff tears. The glenohumeral compartment was analyzed to search for osteophyte formation and joint narrowing.

RESULTS

The subacromial height was greater than 6 mm, mean 9.89 +/- 2 mm, in 349 shoulders (87.25%), corresponding to stage I in the Hamada classification; it measured less than 6 mm, mean 3.08 +/- 1.7 mm in 51 shoulders (12.75%) in 38 subjects (19% of the total cohort). The Hamada classification for the other shoulders was stage II (n = 21 shoulders, 5.25%), and stage III (n = 16 shoulders, 4%), stage IV (n = 5, 1.25%) and stage V (n = 5, 1.25%). The Hamada stage could not be determined for four shoulders. There was a strong statistical correlation between the Constant score and Hamada stage. The glenohumeral space was normal in 288 shoulders (72%). Ninety-three shoulders (23.25%) in 62 patients (31%) presented humeral and/or inferior glenoid osteophytes without glenohumeral impingement and 19 shoulders (4.75% in 14 patients (7%) presented complete glenohumeral impingement. There was a significant correlation between the Constant score and severity of the glenohumeral degradation. The proportion of subacromial impincement increased significantly and regularly with degradation of the glenohumeral space (p < 104). For half of the shoulders, glenohumeral impingement was associated with subacromial impingement (eccentric osteoarthritis).

DISCUSSION

The results of this study confirm that the frequency of rotator cuff tears increases with age. One out of five patients aged 70-90 years presented subacromial impingement versus one out of three among patients aged over 90 years. Clinical tolerance of subacromial impingement or subacromial osteoarthritis is good. Glenohumeral impingement, associated or not with subacromial impingement, is poorly tolerated, the patients presenting shoulder pain and marked stiffness.

CONCLUSION

Our results demonstrate that the natural history of the shoulder does not exhibit a regular linear relationship with the Hamada radiological classification.

Conventional Radiography of the Shoulder

Conventional radiography is a useful tool in the evaluation of shoulder pain whether in the setting of acute trauma or chronic pain and in most clinical situations should be the first imaging modality performed. Knowledge of the various projections and radiographic findings described above will ensure an optimal evaluation of the shoulder regardless of the suspected etiology of the shoulder pain.

Medicolegal aspects of the orthopaedic care for shoulder injuries

The medicolegal aspects of orthopaedic care increasingly are becoming an important focus of physicians. Because of the rarity of publications on the subject, I will examine medical litigation in orthopaedics, specifically in regards to shoulder injuries. There are several reasons for recent increases in malpractice litigation. Increased orthopaedic specialization and advanced technologies have raised patient expectations while the media have informed patients of the potential financial rewards of litigation. I will discuss three cases of litigation regarding shoulder injuries including reasons for malpractice and what can be done to avoid it. In Case 1 I examine an implant failure of a rotator cuff repair. The failure was caused by a manufacturing error; therefore, the importance of being familiar with the equipment and the companies that a physician deals with is emphasized in this case. Case 2 is another failed rotator cuff repair; this litigation stemmed from poor patient selection and a lack of preoperative patient-physician communication. Finally, Case 3 involved retained hardware, a surgical mistake that often results in a substantial settlement because it is considered indefensible. These cases highlight the potential for malpractice and can be applied more broadly to all branches of orthopaedics. Most litigation, however, can be avoided with careful diagnostic procedures, greater experience with equipment, and better communication.

The biceps tendon footprint

BACKGROUND

By arthroscopy, we observed a phenomenon that, according to our knowledge not previously described, we call the "biceps tendon footprint" (BTF)--an area of chondromalacia beside the bicipital groove.

PATIENTS AND METHODS

We studied 118 shoulder arthroscopies prospectively. We documented whether a BTF could be observed and what the main pathology associated with it was. We used 3 grades of cartilage wear to describe BTF, and we analyzed pathological changes in associated structures (subscapularis, biceps tendon and humeral head).

RESULTS

We found a BTF in 16% of the cases. Associated diagnoses were cuff tears and instabilities, most often multidirectional. We observed all 3 grades of cartilage wear, grade 3 being the commonest. Biceps synovitis occurred more often in the BTF group.

INTERPRETATION

BTF is not a rare phenomenon. Maltraction of the intraarticular biceps tendon in MDI and cuff tears in addition with biceps synovitis appear to cause BTF.

Conservative treatment for shoulder pain: prognostic indicators of outcome

OBJECTIVES

To investigate the long-term clinical outcome and to identify factors that predict that outcome, after conservative treatment of patients who have shoulder pain with or without accompanying stiffness.

DESIGN

Cohort study.

SETTING

Outpatient clinic.

PARTICIPANTS

Eighty-two subjects who had participated in a randomized controlled trial that compared the short-term effectiveness of conservative treatment for chronic, unilateral shoulder pain of mechanical origin with and without accompanying stiffness, and who were available for longer term follow-up 6 months after the cessation of formal treatment.

INTERVENTIONS

Conservative treatment consisting of various combinations of exercise therapy, passive joint mobilization, electrophysical modalities, and corticosteroid injections.

MAIN OUTCOME MEASURES

Pain intensity, functional limitation, perceived change in symptoms, active range of motion, muscle force, and clinical and demographic variables.

RESULTS

Patients showed significant improvement in all outcome measurements in the long-term whether or not their shoulder pain was accompanied by stiffness. Long-term outcome was not predicted by hand dominance, clinical history of the shoulder condition, severity of the shoulder problem, or shoulder mechanics.

CONCLUSIONS

Patients with chronic shoulder pain, with or without accompanying stiffness, can expect significant decreases in shoulder pain and improvements in shoulder function in the long term after conservative treatment.