Degenerative rotator cuff tear, repair or not repair? A review of current evidence.

INTRODUCTION: We review the literature and highlight the important factors to consider when counselling patients with non-traumatic rotator cuff tears on which route to take. Factors include the clinical outcomes of surgical and non-surgical routes, tendon healing rates with surgery (radiological outcome) and natural history of the tears if treated non-operatively. METHODS: A PRISMA-compliant search was carried out, including the online databases PubMed and Embase™ from 1960 to the end of June 2018. FINDINGS: A total of 49 of the 743 (579 PubMed and 164 Embase™) results yielded by the preliminary search were included in the review. There is no doubt that the non-surgical route with an appropriate physiotherapy programme has a role in the management of degenerative rotator cuff tears. This is especially the case in patients with significant risk factors for surgery, those who do not wish to go through a surgical treatment and those with small, partial and irreparable tears. However, rotator cuff repair has a good clinical outcome with significant improvements in pain, range of motion, strength, quality of life and sleep patterns.

Tensile properties of the human glenoid labrum.

Human fresh-frozen cadaveric glenoid labrae from 16 donors were harvested and ten of these had no gross degeneration. These ten were divided into eight equal circumferential sections. Each section was cut to produce test-samples from the core layer with a cross-section of 1 x 1 mm. Tensile testing was performed within a controlled environment unit at 37 +/- 1 degrees C and 100% relative humidity. Each test-sample was precycled to a quasi-static state to alleviate the effects of deep-freezing, prior to final testing. The tangent modulus was calculated for each test-sample before and after a 5-min period of stress relaxation and at yield. The mean elastic modulus and yield stress of the glenoid labrum were 22.8 +/- 11.4 and 2.5 +/- 2.1 MPa, respectively. The anterosuperior portion had a lower elastic modulus and lower yield stress than the inferior portion (both P < 0.02). The pre-stress relaxation tangent modulus was significantly lower than the post-stress relaxation tangent modulus for all portions of the labrum. The glenoid labrum has similar tensile material properties to articular cartilage. Its elastic modulus varies around its circumference. This suggests that the labrum may encounter different forces at different positions.

Collagenous microstructure of the glenoid labrum and biceps anchor.

The glenoid labrum is a significant passive stabilizer of the shoulder joint. However, its microstructural form remains largely unappreciated, particularly in the context of its variety of functions. The focus of labral microscopy has often been histology and, as such, there is very little appreciation of collagen composition and arrangement of the labrum, and hence the micromechanics of the structure. On transmission electron microscopy, significant differences in diameter, area and perimeter were noted in the two gross histological groups of collagen fibril visualized; this suggests a heterogeneous collagenous composition with potentially distinct mechanical function. Scanning electron microscopy demonstrated three distinct zones of interest: a superficial mesh, a dense circumferential braided core potentially able to accommodate hoop stresses, and a loosely packed peri-core zone. Confocal microscopy revealed an articular surface fine fibrillar mesh potentially able to reduce surface friction, bundles of circumferential encapsulated fibres in the bulk of the tissue, and bone anchoring fibres at the osseous interface. Varying microstructure throughout the depth of the labrum suggests a role in accommodating different types of loading. An understanding of the labral microstructure can lead to development of hypotheses based upon an appreciation of this component of material property. This may aid an educated approach to surgical timing and repair.

Qualitative and quantitative descriptions of glenohumeral motion.

Joint modelling plays an important role in qualitative and quantitative descriptions of both normal and abnormal joints, as well as predicting outcomes of alterations to joints in orthopaedic practice and research. Contemporary efforts in modelling have focussed upon the major articulations of the lower limb. Well-constrained arthrokinematics can form the basis of manageable kinetic and dynamic mathematical predictions. In order to contain computation of shoulder complex modelling, glenohumeral joint representations in both limited and complete shoulder girdle models have undergone a generic simplification. As such, glenohumeral joint models are often based upon kinematic descriptions of inadequate degrees of freedom (DOF) for clinical purposes and applications. Qualitative descriptions of glenohumeral motion range from the parody of a hinge joint to the complex realism of a spatial joint. In developing a model, a clear idea of intention is required in order to achieve a required application. Clinical applicability of a model requires both descriptive and predictive output potentials, and as such, a high level of validation is required. Without sufficient appreciation of the clinical intention of the arthrokinematic foundation to a model, error is all too easily introduced. Mathematical description of joint motion serves to quantify all relevant clinical parameters. Commonly, both the Euler angle and helical (screw) axis methods have been applied to the glenohumeral joint, although concordance between these methods and classical anatomical appreciation of joint motion is limited, resulting in miscommunication between clinician and engineer. Compounding these inconsistencies in motion quantification is gimbal lock and sequence dependency.

Thyrotrophin concentrations in the plasma of cattle, sheep and foetal lambs as measured by radioimmunoassay.

A radioimmunoassay technique for measuring the thyrotrophin (TSH) concentration of sheep and cattle plasma is described. The sensitivity of the assay allowed the measurement of 1-50 ng TSH/ml unextracted plasma. Cross-reaction with ovine luteinizing hormone, prolactin and growth hormone was very low. The average recovery of added TSH was 103 plus or minus 4-1 (S.E.M.)% and the between-assay coefficient of variation was 13-8%. The normal plasma TSH levels of sheep and cattle were approximately 2-5 ng/ml (5 mu. bovine TSH/100ml). Foetal sheep had plasma TSH concentrations of approximately 3-2 ng/ml during the last 20 days of gestation. Levels of TSH in the circulation decreased abruptly after hypophysectomy of the foetal lamb and a decline in the plasma thyroxine (T4) concentrations was also apparent within 24 h of the operation. However, thyroidectomy of adult and foetal sheep did not increase plasma TSH concentrations until almost all the T4 had been cleared from the circulation. The injection of T4 into thyroidectomized sheep rapidly reduced plasma TSH concentrations to normal values. However, the continued injection of T4 did not further reduce TSH concentration. The injection of T4 or triiodothyronine into normal sheep was also without effect on plasma TSH concentrations.

Absorption of 125I-labelled sheep growth hormone in single proximal tubules of the rat kidney.

Techniques of kidney micropuncture and electron microscope autoradiography have been used to study the uptake of 125I-labelled sheep growth hormone (GH) in rat renal proximal tubules. After microperfusion of a proximal tubule with 125I-labelled GH, the transport of label by the tubular epithelium was studied autoradiographically at selected times up to 1 h. The sequential transfer of labelled material from tubule to microvilli, then to small and large apical vacuoles and finally to lysosomes followed the pattern of absorption that has been described for other proteins. Evidence of lysosomal degradation of the transported protein was obtained from studies in vitro; lysosomes isolated from the renal cortex rapidly converted 125I-labelled GH to products of lower molecular weight. In addition to the absorptive pathway through the intracellular vacuolar apparatus is appeared that there was also an alternative pathway, less well defined, whereby GH could be absorbed without being degraded.

Influence of nutritional status on growth hormone-dependent circulating somatomedin-C activity in mature sheep.

The effect of daily administration of ovine GH for a period of 4 weeks on somatomedin-C biological activity in plasma was investigated in mature Merino sheep fed a maintenance energy intake (low plane; LP) or 1.6 times this amount (high plane; HP). The GH treatment resulted in a significant (P less than 0.05) increase in plasma GH levels in blood samples collected 23.5 h after each daily injection in both LP and HP groups. Plasma concentrations of somatomedin-C activity and insulin were significantly stimulated to a maximum level by the third GH injection and remained at this level for 7 days. Subsequently, circulating levels of both hormones fell to 40-50% of the peak response to GH and returned to basal levels within 48 h of the cessation of GH injections. In the HP group the response of plasma insulin and somatomedin-C activity to GH injection was greater than in the LP group.

Evaluation of a rosette inhibition test for pregnancy diagnosis in pigs.

A rosette inhibition test was developed using pig lymphocytes and sheep red blood cells. Antilymphocyte serum (ALS) in the presence of complement inhibited rosette formation by greater than 95% at 1/250 declining to no inhibition at 1/8000. Sera obtained from a total of 14 pregnant sows before and 1, 2, 3 and 4 wk after mating were tested for their ability to augment the rosette depression caused by ALS. In one experiment in which the responses of 4 pregnant sows were compared to 4 non-pregnant sows by discriminant analysis, sera were classified correctly in 83% of the samples taken from either pregnant or non-pregnant sows. When the more usual method of calculating the rosette inhibition titre was used, the responses of sera from pregnant pigs were classified with 31% accuracy and those from non-pregnant pigs with 80% accuracy. In a second experiment, sera from 10 pregnant sows were classified with 25% accuracy using the rosette inhibition titre. Thus 4 of these pigs were classified as non-pregnant by this method. Data from the second experiment were not suitable for discriminant analysis. It was concluded that there was some factor present in the sera of pregnant pigs, particularly by 3 or 4 wk post-mating, which could be detected by the rosette inhibition test. However, the test is not sensitive enough to allow specific diagnosis of early pregnancy in pigs.

Resurfacing of the glenoid in total shoulder arthroplasty. A comparison, at a mean of five years, of prostheses inserted with and without cement.

BACKGROUND: Clinically evident loosening of a glenoid component inserted with cement in total shoulder arthroplasty is infrequent, but radiographic changes that indicate loosening at the implant-bone interface are common and have been associated with functional limitation. We compared the results of total shoulder arthroplasties in which the glenoid implant had been inserted with cement with those of arthroplasties in which a bone-ingrowth glenoid implant had been inserted without cement. METHODS: The results of eighty-six consecutive total shoulder arthroplasties, performed by the same surgeon, were retrospectively reviewed between four and seven years after the operation. Fifty-eight shoulders in which the primary glenoid implant was in situ were assessed with use of the Simple Shoulder Test and Short Form-36 questionnaires, clinical examination, and fluoroscopic imaging of the glenoid implant-bone interface. Thirty-two of the glenoid components had been fixed with cement and twenty-six, without cement. RESULTS: Complications occurred in 16 percent (fourteen) of the eighty-six shoulders, and 9 percent (eight) of the shoulders needed a revision operation. None of the revisions were done because of loosening of the glenoid component. Five of the eight revisions involved implants that had been inserted without cement. Three of these implants were revised because of early instability and two, because the polyethylene component had separated from the metal tray of the glenoid implant. With the numbers available, we could not detect any significant differences between the groups with respect to pain, range of motion, function of the shoulder, or general health. Radiographic analysis demonstrated a high level of interobserver agreement (kappa = 0.89). Radiolucent lines were observed after 41 percent (thirteen) of the thirty-two arthroplasties performed with cement compared with 23 percent (six) of the twenty-six arthroplasties performed without cement. The proportion of implants classified as probably loose was approximately three times greater in the group in which cement had been used. Eccentric wear of the posterior rim of the metal tray and focal osteolysis under the metal tray were observed in the group in which the component had been inserted without cement; these findings may indicate a potential for progression of radiographic loosening with increased durations of follow-up. CONCLUSIONS: We concluded that, despite the higher rate of early complications, the intermediate-term outcomes of arthroplasties in which the glenoid implant is inserted without cement are comparable with those of arthroplasties with cementing of the glenoid component.

In vitro properties of diffuse cytoplasmic esterase-positive canine mononuclear leukocytes.

Depletion of cytoplasmic esterase-positive canine peripheral blood monocytes from mononuclear cell suspensions was attempted using plastic adherence, carbonyl iron ingestion and/or Sephadex G-10 filtration. An esterase-positive, nonadherent, nonphagocytic subpopulation was identified and further characterized by the presence or absence of cell membrane receptors for the Fc portions of immunoglobulin and the activated third component of complement. The majority of these nonadherent cells lacked these receptors. The data suggests that canine peripheral blood monocytes are a heterogenous cell population.

Humoral regulation of blood flow in the vertebral endplate.

STUDY DESIGN: Blood flow in the sheep lumbar spine was measured. OBJECTIVES: The effect of vasoactive agents, noradrenaline and acetylcholine, on blood flow adjacent to the disc--bone interface was determined. SUMMARY OF BACKGROUND DATA: The main route for disc nutrition is through the vertebral endplate. Although the vascular anatomy in this region has been well described, its response to neurohumoral influences has not been quantified. METHODS: Blood flow in bone adjacent to the lumbar intervertebral discs was measured using the microsphere technique before and after infusions of noradrenaline and acetylcholine in two groups of five female sheep. Systemic arterial pressure was measured during each infusion. RESULTS: Vertebral bone blood flow was unchanged during noradrenaline infusion, but increased by 60% during acetylcholine infusion. This was associated with a significant decrease in systemic arterial pressure. CONCLUSIONS: These data are consistent with the existence of muscarinic receptors in vessels of the vertebral endplate, which suggests that the vasculature may influence disc nutrition.

Structural properties of the intact and the reconstructed coracoclavicular ligament complex.

Numerous procedures have been described for the operative management of acromioclavicular joint injuries, but surprisingly little information is available on the ultimate mechanical behavior of the native coracoclavicular ligament complex or on the various methods of reconstruction. We tested 19 fresh-frozen cadaveric bone-ligament-bone preparations of the coracoclavicular ligament in uniaxial tension at 25 mm/min until failure. Seven specimens were left intact, six had the trapezoid ligament sectioned, and six had the conoid ligament sectioned. Reconstruction of the coracoclavicular ligament was achieved using coracoacromial ligament transfers, woven polyester slings, suture anchors, and Bosworth screws; all reconstructions were also tested to failure. The intact coracoclavicular ligament failed by avulsion or midsubstance tear at 500 (+/-134) N, with a stiffness of 103 (+/-30) N/mm and elongation to failure of 7.7 (+/-1.9) mm. There was no significant difference between the contributions of the conoid or trapezoid ligaments in this loading configuration. Coracoclavicular slings and suture anchors provided strength similar to that of the coracoclavicular ligament, but with significantly greater deformations (14 to 26 mm). Screw fixation resulted in comparable stiffness and superior strength to the coracoclavicular ligament, but only if bicortical purchase was obtained. Coracoacromial ligament transfers were the weakest and least stiff, and augmentation with another form of coracoclavicular fixation is recommended. These results provide a useful baseline for comparison of the initial performance of reconstructive techniques with the performance of the native coracoclavicular ligament.

The effect of devascularisation upon early bone healing in dynamic external fixation.

We examined the effect of periosteal devascularisation upon the early healing of osteotomies of sheep tibiae held in an instrumented external fixation system with an axial stiffness of 240 N/mm. At 14 days, cortical blood flow measured by the microsphere technique was 19.3 ml/min/100g in the well-vascularised osteotomies, but only 1.7 ml/min/100g in the devascularised osteotomies, despite an increase in medullary flow (p less than 0.0005). Delay in healing of the devascularised osteotomies was suggested by an in vivo monitoring system and confirmed by post-mortem mechanical testing. We suggest that the osteogenic stimulus of dynamic external fixation is dependent on the early restoration of cortical blood flow in devascularised fractures.

The interosseous membrane in radio-ulnar dissociation.

In severe forearm injuries, the diagnosis of disruption of the interosseous membrane is frequently delayed and sometimes missed, giving difficulties in the salvage of forearm stability. We studied the structure and function of the interosseous membrane in 11 cadaver preparations, using mechanical and histological analysis. Seven of the specimens tested in uniaxial tension sustained a mid-substance tear of the central band of the membrane at a mean peak load of 1038 +/- 308 N. The axial stiffness was 190 +/- 44 N/mm with elongation to failure of 10.34 +/- 2.46 mm. These results provide criteria for the evaluation of reconstructive methods. A preliminary clinical investigation of the use of ultrasound suggests that this may be of value in the screening of patients with complex fractures of the forearm, and for investigating the natural history of tears of the interosseous membrane.

Mechanical factors in the initiation and propagation of tears of the rotator cuff. Quantification of strains of the supraspinatus tendon in vitro.

Differential strain has been proposed to be a causative factor in failure of the supraspinatus tendon. We quantified the strains on the joint and bursal sides of the supraspinatus tendon with increasing load (20 to 200 N) and during 120 degrees of glenohumeral abduction with a constant tensile load (20 to 100 N). We tested ten fresh frozen cadaver shoulders on a purpose-built rig. Differential variable reluctance extensometers allowed calculation of the strain. Static loading to 100 N or more increased strains on the joint side significantly more than on the bursal side. During glenohumeral abduction an increasing and significant difference in strain was measured between the joint and bursal sides of the supraspinatus tendon, which reached a maximum of 10.6% at abduction of 120 degrees. The joint side strain of 7.5% reached values which were previously reported to cause failure. Differential strain causes shearing between the layers of the supraspinatus tendon, which may contribute to the propagation of intratendinous defects that are initiated by high joint side strains.

Measurement of serum angiogenic factor in devascularized experimental tibial fractures.

Early recovery of the vasculature is of profound importance in healing fractures, but the exact role of the regenerating endothelium remains controversial. Serum activity of endothelial cell-stimulating angiogenesis factor (ESAF) was measured after tibial osteotomy in two groups of sheep over a period of 42 days. Each osteotomy was held in an instrumented external fixator, and in one group the musculoperiosteal vasculature was excluded from the osteotomy site. In the well-vascularized group (n = 4), ESAF activity was significantly higher 2-5 days after osteotomy, with a peak at 4 days (21.1 +/- 5.4, p < 0.05), and displayed a biphasic pattern of secretion with a second peak at 7 days (24.3 +/- 5.5). In the devascularized group (n = 4) overall activity was lower, with only a single peak occurring at 9 days (17.5 +/- 3.2). These findings were correlated with significant differences in structural properties and on histological examination. The early detection of such regional vascular responses may prove to be of significant clinical value in high-energy trauma, enabling prediction of those fractures at risk of delayed or nonunion.

The design and performance of an experimental external fixation device with load transducers.

It is becoming increasingly common that fracture healing is modelled in the laboratory with an osteotomy in the diaphysis of the ovine tibia. External fixation is often used to hold the bones in these models, presenting the problem that the loads on such devices are poorly understood. To help investigate this, a unilateral device has been developed which is capable of measuring the two components of load considered to be the most important, that of axial compression and bending in the plane of the fixator. The device was found to be a rigid system and easy to apply, with the in-vivo measurements being straightforward. The estimated limits of error of the compression transducer are +37.9 N and -21.4 N and those of the bending transducer are +3.6 Nm and -4.2 Nm. Preliminary measurements showed the maximum load during normal walking to 345 N compression and 28 Nm in-plane bending.

Lymphocyte-associated immune responses to canine distemper and measles viruses in distemper-infected gnotobiotic dogs.

Cellular immune responses of peripheral blood lymphocytes to canine distemper virus and measles virus were determined in vaccinated or infected gnotobiotic dogs, using the technique of syncytia inhibition. Cross-reactivity between viruses was detected in both groups of dogs. Peak responses in vaccinated dogs occurred 11 days after vaccination and declined to base-line levels by 3 weeks, whereas responses in infected dogs were present 30 days after inoculation. Fractionation experiments with peripheral blood lymphocytes indicated that synctia inhibition is probably mediated by T lymphocytes.

Evaluation of B-lymphocyte levels and functions in gnotobiotic dogs.

Quantitative and qualitative aspects of B-lymphocyte functions in gnotobiotic dogs and conventional dogs were determined. Using 3 different methods to identify B-cells by surface markers and 3 different methods to measure immunoglobulins (eg, serum electorphoresis, immunoelectrophoresis, and radial immunodiffusion), it was determined that gnotobiotic dogs were B-cell deficient. Related studies, however, indicate that the capacity to develop humoral immune responses was unimpaired. It is presumed that lack of immunogenic stimulation within the gnotobiotic isolation units accounts for this observation.