Effect of pre-operative expectations on the outcomes following total shoulder arthroplasty.

AIMS: Few studies have evaluated the relationship between patients' pre-operative expectations and the outcome of orthopaedic procedures. Our aim was to determine the effect of expectations on the outcome after primary anatomical total shoulder arthroplasty (TSA). We hypothesised that patients with greater expectations would have better outcomes. PATIENTS AND METHODS: Patients undergoing primary anatomical TSA completed the Hospital for Special Surgery's Shoulder Expectations Survey pre-operatively. The American Shoulder and Elbow Surgeons (ASES), Shoulder Activity Scale (SAS), Short-Form-36 (SF-36), and visual analogue scale (VAS) for pain, fatigue, and general health scores were also collected pre-operatively and two years post-operatively. Pearson correlations were used to assess the relationship between the number of expectations and the outcomes. Differences in outcomes between those with higher and lower levels of expectations for each expectation were assessed by independent samples t-test. Multivariable linear regression analysis was used to control for potential confounding factors. RESULTS: A total of 67 patients were evaluated two years post-operatively. Most parameters of outcome improved significantly from baseline and most patients were satisfied. A greater number of expectations was associated with a significantly greater improvement in the ASES score (p = 0.02). In the multivariable analysis, a greater number of expectations was an independent predictor of better ASES, VAS and SF-36 scores, as well as improvements in ASES and VAS pain scores (p < 0.05). Greater expectations for many specific expectation questions were significantly associated with better outcomes (p < 0.05). CONCLUSION: TSA is a successful procedure with significant improvements in outcome, and greater pre-operative expectations are associated with better outcomes. Cite this article: Bone Joint J 2017;99-B:1190-6.

Anterior deltoid deficiency in reverse total shoulder replacement: a biomechanical study with cadavers.

Reverse total shoulder replacement (RTSR) depends on adequate deltoid function for a successful outcome. However, the anterior deltoid and/or axillary nerve may be damaged due to prior procedures or injury. The purpose of this study was to determine the compensatory muscle forces required for scapular plane elevation following RTSR when the anterior deltoid is deficient. The soft tissues were removed from six cadaver shoulders, except for tendon attachments. After implantation of the RTSR, the shoulders were mounted on a custom-made shoulder simulator to determine the mean force in each muscle required to achieve 30° and 60° of scapular plane elevation. Two conditions were tested: 1) Control with an absent supraspinatus and infraspinatus; and 2) Control with anterior deltoid deficiency. Anterior deltoid deficiency resulted in a mean increase of 195% in subscapularis force at 30° when compared with the control (p = 0.02). At 60°, the subscapularis force increased a mean of 82% (p < 0.001) and the middle deltoid force increased a mean of 26% (p = 0.04). Scapular plane elevation may still be possible following an RTSR in the setting of anterior deltoid deficiency. When the anterior deltoid is deficient, there is a compensatory increase in the force required by the subscapularis and middle deltoid. Attempts to preserve the subscapularis, if present, might maximise post-operative function.

Soft-tissue balancing in total shoulder arthroplasty.

When a total shoulder arthroplasty is performed, restoration of the anatomy to near normal is important in order to achieve a stable implant. So as not to sacrifice stability, it is not uncommon for soft tissues to be either over tightened or insufficiently released. This article analyzes the various factors to consider in order to obtain appropriate soft-tissue balancing for a successful total shoulder arthroplasty.

The combined dynamic and static contributions to subacromial impingement. A biomechanical analysis.

Ten human cadaveric shoulders were tested with a dynamic shoulder model simulating physiologic rotator cuff, deltoid, and biceps muscle forces. The combined effect of the muscle forces and acromial structure on subacromial impingement was measured with minimally invasive, miniature pressure transducers. Shoulders with large acromial spurs had significantly greater impingement pressures at the anterolateral acromion in neutral, internal, and external rotation compared with those with flatter acromia. Application of a biceps muscle force reduced anterolateral acromial pressures by 10%. Failure to simulate a supraspinatus force decreased acromial pressure 52% in shoulders with type III acromia in neutral rotation. Without rotator cuff forces applied, the maximum deltoid muscle force required to elevate the arm increased by 17%. Acromial pressures were increased when no rotator cuff forces were applied, but the increases were not significant. After an anterior acromioplasty, pressures decreased by 99% anteriorly. However, failure to achieve a flat surface posteriorly increased pressures in this location, especially with the shoulder in external rotation. Modeling the rotator cuff and deltoid muscle forces demonstrated the importance of the muscular force couple to center the humeral head during elevation of the arm. The inferior forces of the infraspinatus, teres minor, and subscapularis muscles were necessary to neutralize the superior shear force produced by the deltoid and supraspinatus muscles.

Arthroscopic treatment of partial rotator cuff tears in young athletes. A preliminary report.

Forty-three athletes under age 40, more than half of which were collegiate or professional, with partial rotator cuff tears were treated arthroscopically and observed for a minimum of 24 months. By history and mechanism of injury, two main groups were identified. Group A had 14 patients with acute, traumatic injuries. All 14 had inflamed subacromial bursas, but increased glenohumeral translation and labral lesions were uncommon. Twelve patients (86%) had satisfactory postoperative results and nine (64%) returned to preinjury sports after arthroscopic subacromial decompression and tear debridement. Group B had 29 overhead athletes with insidious, atraumatic shoulder pain. They were not as successful with debridement (19 [66%] satisfactory and 13 [45%] return to preinjury sports). Within Group B, three subgroups were identified based on the examination under anesthesia and subacromial inflammation. Group B1 (8 patients) had normal-appearing subacromial spaces and often increased anterior glenohumeral translation with posterior labral tears. These patients did poorly after arthroscopic tear debridement (3 [38%] satisfactory and 2 [25%] return to sports). Group B2 (12 patients) had inflamed subacromial bursas and increased glenohumeral translation. This group had marginal results with debridement (7 [58%] satisfactory and 6 [50%] return to sports). Group B3 (9 patients) with subacromial inflammation, yet without increased glenohumeral translation, had excellent pain relief (100%) but less than half (4) returned to preinjury sports.

Partial-thickness rotator cuff tears. Pathogenesis and treatment.

Partial-thickness rotator cuff tears are now acknowledged to be an important entity in the spectrum of the impingement syndrome. The pathogenesis of partial-thickness tears is often age- and activity-related. Surgical decision making is influenced by the extent of the tear and the associated bony and soft-tissue pathology.

Shoulder arthroscopy in the throwing athlete.

The throwing athlete is a unique patient. High demands on the shoulder, combined with poor tolerance for slight changes in performance, make this a particularly difficult group of patients to treat successfully. In addition, there is overlap between multiple pathologic conditions in the shoulder, including rotator cuff tendinopathy, shoulder instability, SLAP lesions, acromioclavicular arthrosis, and scapulothoracic problems. These disorders rarely occur in isolation in the throwing athlete. Arthroscopy of the shoulder may be invaluable as a diagnostic tool to confirm clinical and radiographic abnormalities, to identify associated intra-articular and extra-articular pathologic conditions, and to treat a variety of these lesions without the attendant morbidity of open surgical repair and reconstruction.

The clinical presentation of shoulder instability including on field management.

In the athlete, shoulder instability may result from external high-energy trauma or repetitive overuse. Our understanding of how shoulder instability may contribute to and result from shoulder injury has improved considerably during the past decade. In addition, the delicate balance between mobility and stability and the interrelationship between instability and rotator cuff disease make the clinical management of the unstable shoulder and its field treatment a challenge for physicians, therapists, trainers, and others responsible for the care of injured athletes.

The radiology of total shoulder replacement.

The indications for total shoulder replacement and the radiologic evaluation prior to the operation are discussed in depth in this article. Different approaches to clinical problems are also discussed and illustrated, as are normal findings. This is followed by a discussion of the complications of shoulder reconstruction, including infection, fractures, and heterotopic bone formation. A review of the results is also given followed by a brief mention of a number of other orthopedic shoulder devices and plates.

MRI of the shoulder.

MRI of the shoulder is widely considered the imaging modality of choice in the evaluation of shoulder pain and the clinical impingement syndrome. This is because of its direct evaluation of all of the soft tissue structures of the subacromial space, as well as its ability to depict the relationship of the overlying osseous and soft tissue structures of the coracoacromial arch. It also provides information regarding the capsulolabral anatomy and, with the addition of MR arthrography, is becoming recognized as the imaging modality of choice for instability workup. MRI evaluation, when combined with the always important clinical history, physical examination, and radiographs, provides the referring clinician and orthopedic surgeon with the most anatomic and pathological information possible. This, in turn, allows the most informed decision making possible regarding conservative management or surgical treatment.

[Evaluation of the rotator cuff with magnetic tomography]. / Evaluering av skulderens rotatormuskulatur med magnettomografi.

Rotator cuff tears are difficult to diagnose clinically, both in the acute and the chronic phase. Both conservative and surgical treatment give the best results if the injury is detected early. Magnetic resonance imaging (MRI) has recently been introduced for diagnoses of cuff tears. The purpose of this study was to establish the accuracy of MRI in relation to surgical findings in the same patient group. MRI was used in the diagnosis of 25 patients who later underwent surgery for injury to the rotator cuff. During the surgery, 19 total tears were identified, of which 15 had been described by MRI. MRI showed a sensitivity of 79% and a specificity of 83%. The predictive value of a positive test was 83%. In experienced hands, MRI is extremely accurate for detecting rotator cuff injuries, but ultrasonography should still be the first method of diagnosis in Norway, because of its accuracy when used by experienced practitioners, and its availability and low cost.

Radiologic features of shoulder instability.

Roentgenographic studies in a patient with shoulder instability generally identify the presence of a Hill-Sachs lesion, the presence of bony abnormalities of either the anterior or posterior rim, the presence or absence of fractures, and thick pathologic changes in the joint structure, which not only may provide insight into the diagnosis, but also may give the clinician insight into whether these pathologic changes are likely to be improved with operative and nonoperative treatment modalities. Clearly, the anteroposterior view, particularly with internal rotation, seems important in the diagnosis of the unstable shoulder. The West Point axillary view seems to be a useful one to identify the presence of glenoid rim problems. An additional view, such as the Stryker notch view, may identify the extent and presence of Hill-Sachs lesion when this may not be present on the other two views. Computed tomography arthrography, magnetic resonance imaging scan, and stress testing probably has limited applicability in the routine roentgenographic diagnosis of the unstable shoulder.

Shoulder problems in the weekend athlete.

With more competitive and recreational athletic pursuits now being undertaken by an aging population, the painful shoulder is seen frequently in the weekend athlete. Episodic stresses to soft-tissue restraints and musculotendinous units around the shoulder lead to a variety of overused pathologic entities. The two most common shoulder problems in the weekend athlete are irritation, swelling, and mechanical impingement; and tearing of the rotator cuff with traumatic shoulder instability (typically of an anterior direction).

Rheumatoid disease.

This article documents the developments in surgery for the rheumatoid hand that have been made during the last 40 years and reviews the pertinent literature.

Clinical significance of sonographic findings in the abnormal but intact rotator cuff: a preliminary report.

Shoulder pain is a common orthopedic problem. Clinical examination is often nonspecific and arthrography is normal in those patients with the most frequent cause of shoulder pain--noncalcific tendonitis secondary to impingement. Ultrasonography has recently shown itself to be of value in the diagnosis of rotator cuff tears. In addition to the diagnosis of tears, however, sonography can demonstrate abnormalities within the intact rotator cuff tendon. These abnormalities consist of changes in echogenicity and thickness of the tendon. The patterns of abnormality demonstrated correlate with pathologic changes seen in tendonitis. This preliminary study suggests that the ability to demonstrate an abnormal rotator cuff tendon has potential for becoming a valuable aid to the orthopedist in allowing confident diagnosis of rotator cuff disease in the presence of nonspecific symptomatology and an intact tendon.

Ultrasonography of rotator cuff tears: a review of 500 diagnostic studies.

Ultrasonography of the rotator cuff has been shown to be of value in diagnosing rotator cuff tears. This report summarizes our experience with our first 500 diagnostic examinations. All patients were examined in the hyperextended internal rotation view with commercially available high-resolution real-time ultrasound equipment. Patients were diagnosed as having a rotator cuff tear if a focal echogenic lesion or a defect within the rotator cuff was identified. This study confirmed the value of ultrasonography for the diagnosis of rotator cuff tears. Accuracy, sensitivity, and specificity all exceeded 90%, and correlated with surgical findings. This was better than arthrography in the same patient population. Ultrasound is an accurate noninvasive method of examining the rotator cuff for the presence of tears. We suggest that rotator cuff ultrasonography is the procedure of choice for the diagnosis of tears if adequate instrumentation is available.

Total shoulder replacement.

It appears that total shoulder replacement can be performed with a high degree of patient satisfaction, with few complications, and with long-term results which certainly appear to rival the success of other arthroplasties. However, the technique is extremely demanding and requires an experienced shoulder surgeon, who must successfully resolve numerous intraoperative variables and problems, must be able to deal with factors which may affect the stability and strength of the implant, and must individualize the postoperative rehabilitation according to quality of bone and soft tissue, as well as the specific needs and desires of the patient. However, when performed technically satisfactorily with proper patient selection, with meticulous attention to the details of the soft tissue surrounding the implant, and with attention to the postoperative rehabilitation, the results have been impressive. Total shoulder replacement has successfully taken its place in the armamentarium of other total joint replacements which have dramatically altered the quality of life in the arthritic patient.