RESUMO
This article was updated on TK because of a previous error, which was discovered after the preliminary version of the article was posted online. In Table VII, the fracture rate in the study by Walch et al. that had read "4.6% (21 of 457)" now reads "0.9% (4 of 457)." BACKGROUND: Acromial and scapular fractures after reverse total shoulder arthroplasty (rTSA) are rare and challenging complications, and little information is available in the literature to identify patients who are at risk. This study analyzes risk factors for, and compares the outcomes of patients with and without, acromial and scapular fractures after rTSA with a medialized glenoid/lateralized humeral implant. METHODS: Four thousand one hundred and twenty-five shoulders in 3,995 patients were treated with primary rTSA with 1 design of reverse shoulder prosthesis by 23 orthopaedic surgeons. Sixty-one of the 4,125 shoulders had radiographically identified acromial and scapular fractures. Demographic characteristics, comorbidities, implant-related data, and clinical outcomes were compared between patients with and without fractures to identify risk factors. A multivariate logistic regression, 2-tailed unpaired t test, and chi-square test or Fisher exact test identified significant differences (p < 0.05). RESULTS: After a minimum duration of follow-up of 2 years, the rate of acromial and scapular fractures was 1.77%, with the fractures occurring at a mean (and standard deviation) of 17.7 ± 21.1 months after surgery. Ten patients had a Levy Type-1 fracture, 32 had a Type-2 fracture, 18 had a Type-3 fracture, and 1 fracture could not be classified. Patients with acromial and scapular fractures were more likely to be female (84.0% versus 64.5% [p = 0.004]; odds ratio [OR] = 2.75 [95% confidence interval (CI) = 1.45 to 5.78]), to have rheumatoid arthritis (9.8% versus 3.3% [p = 0.010]; OR = 3.14 [95% CI = 1.18 to 6.95]), to have rotator cuff tear arthropathy (54.1% versus 37.8% [p = 0.005]; OR = 2.07 [95% CI = 1.24 to 3.47]), and to have more baseplate screws (4.1 versus 3.8 screws [p = 0.017]; OR = 1.53 [95% CI = 1.08 to 2.17]) than those without fractures. No other implant-related differences were observed in the multivariate analysis. Patients with fractures had significantly worse outcomes than patients without fractures, and the difference in mean improvement between these 2 cohorts exceeded the minimum clinically important difference for the majority of measures. CONCLUSIONS: Acromial and scapular fractures after rTSA are uncommon, and patients with these fractures have significantly worse clinical outcomes. Risk factors, including female sex, rheumatoid arthritis, cuff tear arthropathy, and usage of more baseplate screws were identified on multivariate logistic regression analysis. Consideration of these findings and patient-specific risk factors may help the orthopaedic surgeon (1) to better inform patients about this rare complication preoperatively and (2) to be more vigilant for this complication when evaluating patients postoperatively. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Assuntos
Acrômio/lesões , Artroplastia do Ombro/efeitos adversos , Fraturas Ósseas/etiologia , Escápula/lesões , Acrômio/diagnóstico por imagem , Idoso , Artroplastia do Ombro/métodos , Avaliação da Deficiência , Feminino , Fraturas Ósseas/diagnóstico por imagem , Humanos , Masculino , Medição da Dor , Estudos Retrospectivos , Fatores de Risco , Escápula/diagnóstico por imagem , Prótese de OmbroRESUMO
AIMS: The purpose of this study was to compare the effectiveness of surgical repair to conservative treatment and subacromial decompression for the treatment of chronic/degenerative tears of the rotator cuff. MATERIALS AND METHODS: PubMed, Cochrane database, and Medline were searched for randomized controlled trials published until March 2018. Included studies were assessed for methodological quality, and data were extracted for statistical analysis. The systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: Six studies were included. Surgical repair resulted in a statistically significantly better Constant-Murley Score (CMS) at one year compared with conservative treatment (mean difference 6.15; p = 0.002) and subacromial decompression alone (mean difference 5.81; p = 0.0004). In the conservatively treated group, 11.9% of patients eventually crossed over to surgical repair. CONCLUSION: The results of this review show that surgical repair results in significantly improved outcomes when compared with either conservative treatment or subacromial decompression alone for degenerative rotator cuff tears in older patients. However, the magnitude of the difference in outcomes between surgery and conservative treatment may be small and the 'success rate' of conservative treatment may be high, allowing surgeons to be judicious in choosing those patients who are most likely to benefit from surgery. Cite this article: Bone Joint J 2019;101-B:1100-1106.
Assuntos
Artroscopia , Tratamento Conservador , Lesões do Manguito Rotador/terapia , Acrômio/cirurgia , Doença Crônica , Descompressão Cirúrgica , Humanos , Manguito Rotador/cirurgia , Lesões do Manguito Rotador/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: Joint surgery is often complicated by gradual bone and cartilage deterioration that eventually leads to secondary osteoarthritis. The primary objective of this study was to identify preoperative risk factors for gleno-humeral osteoarthritis after rotator cuff repair. The secondary objectives were to assess whether the risk of gleno-humeral osteoarthritis was influenced by the operative technique, occurrence of postoperative complications, cuff healing, and muscle degeneration and to determine whether gleno-humeral osteoarthritis affected the clinical outcome. HYPOTHESIS: The development of gleno-humeral osteoarthritis affects the postoperative clinical outcome. MATERIAL AND METHOD: A retrospective multicentre study of patients who underwent rotator cuff repair in 2003 and were re-evaluated at least 10 years later was conducted under the aegis of the Société française de chirurgie orthopédique et traumatique (SOFCOT). Osteoarthritis severity was graded according to the Samilson-Prieto classification. RESULTS: Four hundred and one patients were included. At last follow-up, at least 10 years after surgery, the radiological Samilson-Prieto grades were distributed as follows: 0, n=181 (45%); 1, n=142 (n=35%); 2, n=57 (14%); 3, n=14 (4%); and 4, n=7 (2%). The mean Constant score was significantly higher in the patients without than with osteoarthritis at last follow-up (79/100 vs. 73/100, P<0.001). MRI assessment of cuff healing showed that the proportion of patients with osteoarthritis was significantly higher in the group with unhealed or re-torn cuffs (Sugaya type 4 or 5) than in the group with healed cuffs (Sugaya type 1, 2, or 3) (46% vs. 25%, P=0.012). DISCUSSION: Our study showed no associations linking the risk of gleno-humeral osteoarthritis to the patient activity profile, history of shoulder injury, or preoperative symptom duration. In contrast, statistically significant associations were identified between gleno-humeral osteoarthritis and age, male gender, initial tear severity, and the pain and mobility components of the preoperative Constant score. Decreased invasiveness of the operative technique probably diminishes the long-term risk of osteoarthritis. An unhealed or re-torn cuff increases the risk of osteoarthritis. Osteoarthritis is associated with poorer final clinical outcomes. LEVEL OF EVIDENCE: IV, retrospective non-randomised study.
Assuntos
Osteoartrite/epidemiologia , Lesões do Manguito Rotador/cirurgia , Articulação do Ombro , Adulto , Idoso , Artroplastia , Feminino , Seguimentos , França/epidemiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Osteoartrite/diagnóstico por imagem , Osteoartrite/etiologia , Medição da Dor , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Amplitude de Movimento Articular , Estudos Retrospectivos , Dor de Ombro , Resultado do TratamentoRESUMO
INTRODUCTION: There are no published studies on bone density of the greater tuberosity of the humerus, which could influence the stability of reinsertion by suture anchors. The goal of our study was to determine the influence of age, gender and the type of tear on the quality of bone in the greater tuberosity. METHODOLOGY: Ninety-eight patients over the age of 60 were included, 41 without a rotator cuff tear and 57 with an isolated stage 1 or 2 supraspinatus tear and fatty infiltration (FI) ≤ 2. The areas of measurement included cancellous bone located under the cortex of the greater tuberosity. Measurements were obtained either across from the tear or from the middle facet with greater tuberosity if the cuff was not torn. We measured average, maximum and minimum bone density and the standard deviation (SD) in each region with Osirix software. RESULTS: The two groups were similar for age (73), investigated side and mean densities (0.282 g/cm(2) vs 0.210 g/cm(2)). Age over 70 was a predictive factor for osteoporosis of the greater tuberosity whether or not a rotator cuff tear was present (P<0.0001). There was less trabecular bone in women with cuff tears (P=0.009). Stage 2 cuff retraction was predictive of osteoporosis of the greater tuberosity (P=0.0001). CONCLUSION: This is the first study in the literature to evaluate bone density of the greater tuberosity in relation to the presence or not of a rotator cuff tear in an elderly population. Female gender, age over 70 and stage 2 cuff retraction are factors responsible for osteoporosis of the greater tuberosity of the humeral head. The osteoporosis is not severe, and normally the quality of bone of the greater tuberosity should not limit stability of suture anchors. LEVEL OF EVIDENCE: 3.
Assuntos
Densidade Óssea , Úmero/anatomia & histologia , Úmero/fisiologia , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
INTRODUCTION: Whether rotator cuff repair is indicated in an elderly subject depends on the patient's activity profile and functional demand. A Senior Shoulder Activity (SSA) score is described, as a support for indications and analysis of clinical results according to activity level. MATERIAL AND METHOD: The SSA score, comprising 4 levels from "sedentary" to "very active", was validated by comparison against a control group of 113 asymptomatic patients. It was included in the protocol of the French Arthroscopy Society's comparative study of repair versus simple decompression in 143 rotator cuff tears. Recovery of activity was assessed according to procedure. RESULTS: At 1-year follow-up, suturing was associated with recovery of previous activity level in 87% of the cases and in 80% for decompression, a non-significant difference. When, however, less active patients (SSA 1 and 2) were contrasted with the more active (SSA 3 and 4), clinical results with suture versus decompression on Constant score showed a greater difference in the SSA 3-4 group. DISCUSSION: The SSA score is not the same as the activity item of the Constant score, as it assesses the patient's usual activity level, before symptom onset, whereas the Constant item assesses activity at a given moment, independently of the patient's normal activity profile. CONCLUSION: The Senior Shoulder Activity score is a simple, reproducible complement to the Constant score, revealing differences in clinical results on the latter, according to activity profile. Rotator cuff repair or simple decompression provided recovery of previous SSA activity level in more than 80% of the cases. The difference in clinical results between the two was significantly greater in more active patients. It would seem to follow that suture is more beneficial for more active subjects while simple decompression may be suitable for those with lower functional demand.
Assuntos
Artroscopia/métodos , Amplitude de Movimento Articular/fisiologia , Manguito Rotador/cirurgia , Índice de Gravidade de Doença , Fatores Etários , Idoso , Estudos de Casos e Controles , Descompressão Cirúrgica/métodos , Feminino , Avaliação Geriátrica , Humanos , Escala de Gravidade do Ferimento , Masculino , Atividade Motora , Medição da Dor , Prognóstico , Recuperação de Função Fisiológica , Lesões do Manguito Rotador , Lesões do Ombro , Articulação do Ombro/cirurgia , Técnicas de Sutura , Resultado do TratamentoRESUMO
INTRODUCTION: The level of activity of patients older than 70 years is tending to increase, as are their expectations in terms of joint function recuperation. It has not been proven that rotator cuff repair healing is satisfactory in the elderly. The main hypothesis of this study was: repair of supraspinous lesions in patients older than 70 years is reliable in terms of both clinical results and healing. The secondary hypothesis was: tendon healing is significantly correlated with the Constant, ASES, and SST scores as well as with age, tendon retraction, and fatty infiltration. MATERIAL AND METHODS: Multicenter prospective study on 145 patients older than 70 years, with 135 patients reviewed at 1 year (93%). The mean age was 73.9 years. Full-thickness tears of the supraspinatus extended at most to the upper third of the infraspinatus and retraction limited to Patte stages 1 and 2 were included. Clinical assessment was carried out in accordance with the Constant, ASES, and SST scores. Healing was evaluated with ultrasound. RESULTS: A significant improvement was noted in the Constant (44/76)+31.5 (P<0.0001), ASES (35/90)+54.4 (P<0.0001), and SST (3.5/10)+6.6 (P>0.0001) scores at 1 year of follow-up. The healing rate was 89% with 15 re-tears, nine of which were stage 1 and six stage 2. The clinical result was not correlated with patient age (Constant, P=0.24; ASES, P=0.38; SST, P=0.83) nor with the retraction stage (Constant, P=0.71; ASES, P=0.35; SST, P=0.69) or the stage of fatty infiltration (P>0.7). Healing was correlated with the quality of the clinical result (Constant, P=0.02; ASES, P=0.03) and age (P=0.01) but was not correlated with retraction or the fatty infiltration stage (P>0.3). DISCUSSION/CONCLUSION: Arthroscopic repair significantly improves the clinical results, even in patients older than 70 years. The clinical results are not correlated with age (but deterioration of the result was not noted after 75 years) or frontal retraction (but the study only included retractions limited to stages 1 and 2). The healing rate is satisfactory, but this study is limited to small ruptures of the supraspinatus, and the postoperative ultrasound analysis probably inferior to CT imaging with contrast agent injection, often used as the reference. Healing proves to be correlated with the quality of the clinical result and patient age.
Assuntos
Artroscopia/métodos , Amplitude de Movimento Articular/fisiologia , Manguito Rotador/cirurgia , Traumatismos dos Tendões/cirurgia , Fatores Etários , Idoso , Feminino , Avaliação Geriátrica , Humanos , Escala de Gravidade do Ferimento , Masculino , Medição da Dor , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Recuperação de Função Fisiológica , Medição de Risco , Lesões do Manguito Rotador , Traumatismos dos Tendões/diagnóstico , Resultado do Tratamento , Cicatrização/fisiologiaRESUMO
INTRODUCTION: Arthroscopic repair of rotator cuff tears leads to better clinical outcomes than subacromial decompression alone; however the former is rarely proposed to patients above 70 years of age. Our hypothesis was that arthroscopic repair would be superior to decompression in patient 70 years or older. The primary goal was to compare the clinical results obtained with each technique. The secondary goal was to analyze the effects of age, tendon retraction and fatty infiltration on the outcome. METHODS: This was a prospective, comparative, randomized, multicenter study where 154 patients were included who were at least 70 years of age. Of the included patients, 143 (70 repair and 73 decompression) were seen at one-year follow-up; these patients had an average age of 74.6 years. Shoulders had a complete supraspinatus tear with extension limited to the upper-third of the infraspinatus and Patte stage 1 or 2 retraction. Clinical outcomes were evaluated with the Constant, ASES and SST scores. RESULTS: All scores improved significantly with both techniques: Constant +33.81 (P<0.001), ASES +52.1 (P<0.001), SST +5.86 (P<0.001). However, repair led to even better results than decompression: Constant (+35.85 vs. +31.8, P<0.05), ASES (+56.09 vs. +48.17, P=0.01), SST (+6.33 vs. +5.38, P=0.02). The difference between repair and decompression was not correlated with age; arthroscopic repair was also better in patients above 75 years of age (Constant, ASES and SST scores P<0.01). There was no significant correlation between the final outcomes and initial retraction: Constant (P=0.14), ASES (P=0.92), SST (P=0.47). The difference between repair and decompression was greater in patients with stages 0 and 1 fatty infiltration (Constant P<0.02) than in patients with stages 2 and 3 fatty infiltration (Constant P<0.05). CONCLUSION: There was a significant improvement in all-clinical scores for both techniques 1 year after surgery. Repair was significantly better than decompression for all clinical outcomes, even in patients above 75 years of age. The difference observed between repair and decompression was greater in patients with more retracted tears and lesser in patients with more severe fatty infiltration.
Assuntos
Artroscopia/métodos , Descompressão Cirúrgica/métodos , Amplitude de Movimento Articular/fisiologia , Manguito Rotador/cirurgia , Traumatismos dos Tendões/cirurgia , Idoso , Artroscopia/reabilitação , Descompressão Cirúrgica/reabilitação , Feminino , Seguimentos , Avaliação Geriátrica/métodos , Humanos , Masculino , Medição da Dor , Satisfação do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/métodos , Estudos Prospectivos , Recuperação de Função Fisiológica , Lesões do Manguito Rotador , Estatísticas não Paramétricas , Traumatismos dos Tendões/diagnóstico , Resultado do TratamentoRESUMO
BACKGROUND: During the symposium held by the French Arthroscopy Society on rotator cuff tears in patients over 70 years of age, the absence of studies into potential specific pathological features in this age group was pointed out. Here, our main objective was to describe magnetic resonance imaging (MRI) findings in this patient population. HYPOTHESIS: Tendons and muscles are smaller, lamellar dissection more prominent, and dystrophic changes more marked in patients over 70 years of age. MATERIAL AND METHOD: We retrospectively studied 50 patients with isolated supraspinatus tears, including 25 younger than 50 and 25 older than 70 years of age. Tear size and retraction were evaluated according to Patte; tendon thickness, lamellar dissection, and fatty infiltration according to Goutallier; muscle size according to Thomazeau; and the tangent sign according to Zanetti. RESULTS: In contradiction to our study hypothesis, lateral tendon thickness was similar in the two age groups. Medial thickness of the tendon-muscle junction, however, was greater in the younger group. Lamellar dissection was more marked and fatty infiltration more severe in the older group. As expected, marked muscle wasting and a positive tangent sign were noted in over two-thirds of patients in the older group. CONCLUSION: This preliminary study in a small number of patients identified specific MRI features of supraspinatus tears in patients older than 70 years compared to younger patients. A larger study would be useful to confirm these findings.
Assuntos
Imageamento por Ressonância Magnética/métodos , Lesões do Manguito Rotador , Manguito Rotador/patologia , Entorses e Distensões/diagnóstico , Traumatismos dos Tendões/diagnóstico , Fatores Etários , Idoso , Artroscopia/métodos , Estudos de Coortes , Feminino , Seguimentos , Avaliação Geriátrica/métodos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Entorses e Distensões/cirurgia , Traumatismos dos Tendões/cirurgiaRESUMO
This study provides recommendations on the position of the implant in reverse shoulder replacement in order to minimise scapular notching and osteophyte formation. Radiographs from 151 patients who underwent primary reverse shoulder replacement with a single prosthesis were analysed at a mean follow-up of 28.3 months (24 to 44) for notching, osteophytes, the position of the glenoid baseplate, the overhang of the glenosphere, and the prosthesis scapular neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four Grade 2) and 47 (31.1%) had an osteophyte. In patients without either notching or an osteophyte the baseplate was found to be positioned lower on the glenoid, with greater overhang of the glenosphere and a lower PSNA than those with notching and an osteophyte. Female patients had a higher rate of notching than males (13.3% vs 13.0%) but a lower rate of osteophyte formation (22.9% vs 50.0%), even though the baseplate was positioned significantly lower on the glenoid in females (p = 0.009) and each had a similar mean overhang of the glenosphere. Based on these findings we make recommendations on the placement of the implant in both male and female patients to avoid notching and osteophyte formation.
Assuntos
Artroplastia de Substituição/efeitos adversos , Artroplastia de Substituição/métodos , Osteófito/diagnóstico por imagem , Osteófito/prevenção & controle , Escápula/patologia , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Radiografia , Estudos Retrospectivos , Fatores SexuaisRESUMO
INTRODUCTION: The goal of this study was to evaluate the effectiveness of individual exercises performed as classic rehabilitation or a home program on the clinical progression of patients with shoulder stiffness. Based on this information, the secondary goal was to develop a new rehabilitation protocol. PATIENTS AND METHODS: This prospective, comparative series included 148 cases of shoulder stiffness. There were three treatment groups: T1: classic rehabilitation performed below the pain threshold (58 cases); T2: home program with provocation above the pain threshold (59 cases); T3: home program supervised by a physical therapist (31 cases). The execution, pain level and time spent doing each exercise were compiled for each work session - every day for the first 6 weeks, then every week up to 3 months. Clinical (Constant score) and range of motion evaluations were performed at enrollment, week 6 and month 3.Changes were compared between groups; correlation tests were used to analyse the effectiveness of each exercise during each session. RESULTS: Other than physical therapy and balneotherapy, classic rehabilitation exercises had a negative effect on clinical progression during the first 3 to 5 weeks (P<0.05), but this did not hinder the occurrence of a slow, continuous clinical improvement (P<0.05). Home programs led to rapid functional progression with improvement directly related to the number of exercises actually performed (P<0.05), however, pain during the day increased and pain at night decreased. Supervision by a physical therapist helped to optimize the home program, with the same result at week 6, but a better result at month 3 (P<0.05). CONCLUSIONS: Based on the results of this study, a new treatment protocol for shoulder stiffness was proposed that combines an intensive patient home program with a well-informed physical therapist, who progressively adds classic rehabilitation techniques when they provide the best treatment value for each exercise. Patient education is the key to treatment success.
Assuntos
Balneologia/métodos , Terapia por Exercício/métodos , Serviços de Assistência Domiciliar/organização & administração , Dor de Ombro/reabilitação , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Stiffness in the shoulder is a frequent symptom associated with a number of clinical entities whose management remains inadequately defined. PATIENTS AND METHODS: This prospective study of 235 cases of stiffness in the shoulder compared six therapeutic techniques with a mean follow-up of 13 months (range, 3-28 months) (T1: 58 cases, conventional rehabilitation under the pain threshold, T2: 59 cases, self-rehabilitation over the pain threshold, T3: 31 cases, T2 + supervision, T4: 11 cases, T1 + capsular distension, T5: 31 cases, T1 + locoregional anesthesia, T6: 45 cases, T1 + T5 + capsulotomy). The therapeutic power of each technique and its impact on the result were assessed at each self-rehabilitation and rehabilitation session during the first 6 weeks and then at 3 months, 6 months, and at the final revision depending on subjective criteria (pain, discomfort, and morale) and objective criteria (Constant score, goniometric measurements). RESULTS: Conventional rehabilitation (T1) is less effective than self-rehabilitation over the pain threshold (T2 & T3) during the first 6 weeks (P<0.05). Self-rehabilitation stagnates between the 6th and 12th week except when it is supervised by a therapist (T3). Anesthesia (T4) and capsular distension (T5) do not lead to significantly different progression beyond 6 months. Capsulotomy does not demonstrate greater therapeutic power but its failure rate (persisting stiffness at 1 year) is 0% versus 14-17% for the other techniques (P<0.05). DISCUSSION: The techniques are complementary and therapeutic success stems from an algorithm adapted to the individual patient with, over the first 3 months, successive self-rehabilitation and conventional rehabilitation, possibly completed by capsular distension or anesthesia between the 3rd and 6th months. In case of failure at 6 months, endoscopic capsulotomy can be proposed. Therapeutic patient education and active participation are the key to treatment success or failure.
Assuntos
Artropatias/terapia , Procedimentos Ortopédicos/métodos , Articulação do Ombro/cirurgia , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Cápsula Articular/cirurgia , Artropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Amplitude de Movimento Articular , Articulação do Ombro/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: The present study investigated the impact of respecting pain threshold on clinical recovery in stiff shoulder. PATIENTS AND METHODS: A prospective multicenter comparative study followed up 193 cases of shoulder stiffness for a mean 12-month period (range, 8-31 months) after four different treatment protocols: (1) conventional sub-pain-threshold rehabilitation (58 cases); (2) self-rehabilitation exceeding the pain threshold (59 cases); (3) supervised suprathreshold rehabilitation (31 cases); and (4) capsulotomy with sub-threshold rehabilitation (45 cases). Follow-up was daily for the first 6 weeks then weekly for the next 6; each session included assessment of the painfulness, feasibility and duration of each rehabilitation and self-rehabilitation exercise and of pain status, disability and psychological status. The surgeon followed patients up at 6 weeks, 3 months, 6 months, 1 year and at last follow-up. RESULTS: Sub-threshold rehabilitation provided progressive results, limited in time (P<0.05). Suprathreshold self-rehabilitation provided reduced pain (P<0.05) as of the first days, with nocturnal pain ceasing after 7 days' rehabilitation in 43% of cases. Supervision of self-rehabilitation exercises optimized the clinical result (P<0.05). Capsulotomy did not influence pain evolution over the first 8 weeks, but then improved it. Failure (at 1 year, 14-17%; last follow-up, 3.5%) correlated directly with the number of exercises performed by the patient (P<0.05). DISCUSSION: The dogma of respecting the pain threshold is dated: pain inflicted on a passive patient impairs clinical evolution, but pain managed by an informed active patient under experienced supervision provides rapid recovery of function and pain-free status.
Assuntos
Terapia por Exercício/métodos , Manejo da Dor/métodos , Dor de Ombro/reabilitação , Adolescente , Adulto , Idoso , Seguimentos , Humanos , Pessoa de Meia-Idade , Medição da Dor , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Recuperação de Função Fisiológica , Articulação do Ombro/fisiologia , Dor de Ombro/diagnóstico , Dor de Ombro/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
Glenoid loosening is a common failure mode observed in total shoulder arthroplasty. In an effort to isolate the affect of differing fixation techniques on loosening, an edge displacement test was conducted using two, pear-shaped, UHMWPE glenoid designs: one keel and one peg, each having a glenohumeral radial mismatch of 4.3 mm. The susceptibility of each design to loosening was established by quantifiably comparing the maximum glenoid edge displacement before and after 100,000 cycles of eccentric loading by the humeral head along both the superoinferior (SI) and anteroposterior (AP) glenoid axes. Regardless of the axes tested, the results of this study indicate that no discernable difference in edge displacement (distraction and compression) occurred before or after cyclic, eccentric loading for either the keeled or pegged glenoid designs. Additionally, each keel andpeg glenoid remained firmly fixed after testing, suggesting that either fixation technique provides sufficient resistance to edge displacement.
Assuntos
Artroplastia de Substituição/métodos , Prótese Articular , Falha de Prótese , Escápula/fisiopatologia , Articulação do Ombro/fisiopatologia , Análise de Falha de Equipamento , Humanos , Teste de Materiais , Desenho de Prótese , Suporte de CargaRESUMO
An anatomic study was conducted on 49 dried cadaveric humeri and 24 dried cadaveric scapula to ascertain the variability of the following parameters: humeral neck angle, humeral head retroversion, humeral head medial offset, humeral head posterior offset, humeral head diameter glenoid height, glenoid width, and the glenoid height to width ratio. For verification purposes, the results of this study were found to be within 1.5% to 14.3% of other anatomic studies published in the literature. This observed variability was then compared to that provided by an "anatomic" shoulder prosthesis (Equinoxe, Exactech, Inc.); viewed independently, this prosthesis can restore humeral neck angle in 94% of humeri, "secondary" retroversion in 92% of humeri, medial offset in 100% of humeri, posterior offset in 100% of humeri, and humeral head diameter in 96% of humeri. Additionally, the glenoid prosthesis height to width ratio was found to be within 5% and 10% of 71% and 96% of cadaveric glenoids, respectively. The results of this analysis indicate that a dual-offset "anatomic " shoulder prosthesis has the capability to successfully restore glenohumeral anatomy in this representative population.
Assuntos
Úmero/anatomia & histologia , Escápula/anatomia & histologia , Articulação do Ombro/anatomia & histologia , Artroplastia , Cadáver , Humanos , Próteses e Implantes , Valores de Referência , Reprodutibilidade dos TestesRESUMO
INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/-10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/-3.7) to 13.6 (+/-5.4). Ninety-four percent of the results were rated as excellent or good (Constant score>65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.
RESUMO
INTRODUCTION: Shoulder arthroscopy was only at first a surgical technique for subacromial decompression and has been progressively extended to the cuff repairs. This surgery remains nevertheless difficult and requires to be described exactly. A multicenter study of the French Arthroscopic Society allowed to analyse and to underline the quality of the clinical and anatomical results. SURGICAL TECHNIQUE: The technique is described exactly as well as the necessary material. Repair will be adapted to the size and the location of the tear. The technical skill should be simple, effective and reproducible to obtain the best anatomical result. RESULTS: The Constant score improved from an average 46.3 (13.4) to 82.7 (+/- 10.3) at the last follow-up, with 62% of patients' symptom free. Strength improved from 5.8 (+/- 3.7) to 13.6 (+/- 5.4). Ninety-four percent of the results were rated as excellent or good (Constant score >65). A watertight repair was found in 74.1% of the cases. DISCUSSION: Numerous correlations allow to confirm the results found in the literature: the healing of the cuff improves global functional results even when the tear is massive; anatomical result depends on the size of the initial tear; preoperative fatty degeneration is an important predictive factor; the healing of the cuff is related to the age. The quality of the results, the evolution of the material, the simplification and the codification of the surgical technique make it an accessible, effective reproducible surgery.
Assuntos
Artroscopia , Lesões do Manguito Rotador , Manguito Rotador/cirurgia , Desenho de Equipamento , Humanos , Instrumentos CirúrgicosRESUMO
PURPOSE OF THE STUDY: Totally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy. MATERIAL AND METHODS: The series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 +/- 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%. RESULTS: On average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 +/- 13.4 to 82.7 +/- 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 +/- 3.7 to 13.6 +/- 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.ANATOMOCLINICAL CORRELATIONS: The Constant score was strongly correlated with rotator cuff integrity (p<0001). This correlation was also found for force (p<0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome. CONCLUSION: Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.
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PURPOSE OF THE STUDY: The aim of this study was to evaluate the anatomical and technical limits of endoscopic rotator cuff repair. Anatomical results were also compared with functional assessment of the shoulder. MATERIAL AND METHODS: A multicentric serie of 87 patients presenting a full thickness rotator cuff tear repaired endoscopically was retrospectively reviewed at 25.4 months (mean) post surgery. Limits of the surgical technique were studied in correlation with functional results and anatomic radiographic evaluation (arthroscans in 93 p. 100). RESULTS: Anatomical repair (normal thickness and no contrast in the subacromial space on arthroscan) was achieved in 83 p. 100 of the rotator cuffs with limited damage to the frontal part of the supra spinatus tendon. This percentage fell to 57.8 p. 100 in case of posterior extension of the tear to the supra spinatus tendon and further dropped to 40.8 p. 100 in case of retraction to the apex of the humeral head. Functional outcome evaluated with the Constant score was strongly related to the radiographic cuff condition (p <0.05). For distal and anterior tears of the supra spinatus tendon, the Constant score at revision was 89.8 points in cases with anatomic repair at revision. This score fell to 75 when the rotator cuff tear was evidenced radiographically (p <0.0001). For tears involving the entire supra spinatus tendon repaired by arthroscopy, the functional difference at revision was 8 points on the Constant scale. Objective and subjective analysis of the surgical procedure identified significant peroperative elements predictive of clinical and anatomical outcome (difficult reduction, p <0.05; subjective degree of solidity, p <0.0001; anatomical aspect of the repaired cuff, p <0.05). DISCUSSION: A comparison of our findings with data on equivalent lesions reported in the literature suggests that endoscopic surgery for rotator cuff tears offers both functional and anatomic results equivalent to those achieved with conventional open surgery. This assumes that the surgical procedure is carried out by surgeons experienced in shoulder arthroscopy who can precisely gauge the posterior/anterior extension of the tears and the limits of the surgical technique.