Assessing Appropriateness for Shoulder Arthroplasty Using a Shared Decision-Making Process.

Purpose: The primary purpose of this study was to validate an appropriateness decision-aid tool as a part of engaging patients with glenohumeral arthritis in their surgical management. The associations between the final decision to have surgery and patient characteristics were examined. Materials and Methods: This was an observational study. The demographics, overall health, patient-specific risk profile, expectations, and health-related quality of life were documented. Visual analog scale and the American Shoulder & Elbow Surgeon (ASES) measured pain and functional disability, respectively. Clinical and imaging examination documented clinical findings and extent of degenerative arthritis and cuff tear arthropathy. Appropriateness for arthroplasty surgery was documented by a 5-item Likert response survey and the final decision was documented as ready, not-ready, and would like to further discuss. Results: Eighty patients, 38 women (47.5%), mean age: 72(8) participated in the study. The appropriateness decision aid showed excellent discriminate validity (area under the receiver operating characteristic curve value of 0.93) in differentiating between patients who were "ready" and those who were "not-ready" to have surgery. Gender (P = 0.037), overall health (P = .024), strength in external rotation (P = .002), pain severity (P = .001), ASES score (P < .0001), and expectations (P = .024) were contributing factors to the decision to have surgery. Imaging findings did not play a significant role in the final decision to have surgery. Conclusions: A 5-item tool showed excellent validity in differentiating patients who were ready to have surgery versus those who were not. Patient's gender, expectations, strength, and self-reported outcomes were important factors in reaching the final decision.

Diagnostic Value of Acromiohumeral Distance in Rotator Cuff Pathology: Implications for Advanced-Practice Physiotherapists.

Purpose: The primary purpose of this study was to examine the inter-tester reliability and criterion validity of reduced acromiohumeral distance (AHD; <6 mm) visualized on plain radiographs in detecting rotator cuff (RC) pathology. The secondary objective was to examine the relationship between this radiographic feature and patient demographics and clinical examination. Method: This was a diagnostic study of patients seen in a tertiary care centre. Two advanced-practice physiotherapists measured AHD in two radiographic views. MRI was used as the gold standard. Results: A total of 150 consecutive patients (mean age 59 [SD 11] y, 57 women, 93 men) were included. AHD less than 6 millimetres was highly specific in both views for the presence of tear (99%), tear size (96%-98%), and fatty infiltration in the supraspinatus and infraspinatus muscles (93%-96%). The absence of AHD less than 6 millimetres was associated with a lack of advanced fatty infiltration in the supraspinatus and infraspinatus muscles (92%-100%). Sensitivity values were low for the presence and size of RC tear (21%-55%). We found a statistically significant positive association between the AHD categories and clinically observed muscle wasting and weakness of the RC muscles (p < 0.05). Conclusions: AHD less than 6 millimetres was reliably measured in plain radiographs and was strongly associated with important clinical and imaging features of advanced RC pathology; this may assist with clinical decision making by allowing judicious use of more costly investigations and referral for surgery.

Objectif : la présente étude avait comme objectif primaire d'examiner la fiabilité interévaluateur et la validité critérielle d'un intervalle acromio-huméral réduit (IAH < 6 mm) observé à la radiographie simple pour déceler une pathologie de la coiffe des rotateurs (CR). Son objectif secondaire consistait à examiner la relation entre cette caractéristique radiographique, la démographie des patients et l'examen clinique. Méthodologie : étude diagnostique de patients vus dans un centre de soins tertiaires. Deux physiothérapeutes en pratique avancée ont mesuré l'IAH sur deux vues radiographiques. L'imagerie par résonance magnétique servait de norme de référence. Résultats : au total, 150 patients consécutifs (âge moyen de 59 ans [ÉT 11], 57 femmes, 93 hommes) ont été inclus dans l'étude. Dans les deux vues radiographiques, l'IAH inférieur à 6 mm était hautement spécifique de la présence d'une déchirure (99 %), de la dimension de la déchirure (96 % à 98 %) et d'une infiltration graisseuse dans les muscles supra-épineux et infra-épineux (93 % à 96 %). L'absence d'IAH inférieur à 6 mm s'associait à l'absence d'infiltration graisseuse avancée dans les muscles supra-épineux et infra-épineux (92 % à 100 %). Les valeurs de sensibilité étaient faibles pour ce qui est de la présence et de la dimension d'une déchirure de la CR (21 % à 55 %). On constatait une association statistiquement significative entre les catégories d'IAH et une observation clinique d'amyotrophie et de faiblesse musculaire de la CR (p < 0,05). Conclusion : l'IAH inférieur à 6 mm était mesuré en toute fiabilité sur des radiographies simples et s'associait fortement à des caractéristiques de pathologie avancée de la CR, tant sur le plan de la clinique que de l'imagerie. Ces constatations pourraient contribuer aux prises de décision en favorisant l'utilisation judicieuse d'explorations plus coûteuses et de l'orientation en chirurgie.

Reduced acromiohumeral distance and increased critical shoulder angle: implications for primary care clinicians.

Objectives: The literature indicates that reduced acromiohumeral distance (AHD) and increased critical shoulder angle (CSA) are associated with large and massive rotator cuff (RC) tears which may not be amenable to a successful repair. The purpose of this study was to examine the overall accuracy of these two radiographic features in diagnosing significant RC pathology. Methods: This was a diagnostic study of patients with shoulder pain. To examine the overall accuracy of the measurements, the area under the Receiver Operating Characteristic curves (AUC) were calculated. The validity indices (sensitivity, specificity and likelihood ratios) examined the predictive value of specific cutoff categories of AHD<6 mm and the CSA >35°. Results: Data of 200 consecutive patients; mean age: 59(11), 117 males were used for analysis. There was a weak inverse correlation (r = 0.46) between the AHD and CSA. The AUCs for presence and size of RC tear and different stages of fatty infiltration of supraspinatus and infraspinatus muscles varied from fair to excellent for AHD and poor to good for CSA. Specificity was high for the cutoff categories of both AHD and CSA (>90%). The positive LRs were large for AHD and small to moderate for CSA. Conclusion: The AHD and CSA were reliably measured in the true AP radiographic view. Both radiographic features (AHD<6mm and CSA>35°) were able to confirm the presence of a major RC pathology. However, the AHD<6 mm, an acquired radiologic abnormality secondary to failure of the RC muscles/tendons had better measurement properties. This information is of value to primary care physicians, sports medicine specialists and advanced practice physiotherapists in their clinical decision making.

Accuracy of infraspinatus isometric testing in predicting tear size and tendon reparability: comparison with imaging and arthroscopy.

BACKGROUND: The purpose of this study was to examine the accuracy of external rotation in neutral (0° external position) and in shortened position (45° external position) in relation to rotator cuff tear size, tendon reparability, and other clinical, surgical, and imaging findings. METHODS: This was a prospective blinded diagnostic study of consecutive surgical candidates for rotator cuff repair using magnetic resonance imaging and arthroscopic surgery as the "gold standards." The area under a receiver operating characteristic (AUROC) curve was calculated for each position. RESULTS: Eighty-five patients (35 female [41%] and 50 male [59%]; age, 65 years [standard deviation = 10]) were included. Sixty patients (71%) had a minor tear (4 small, 56 moderate), and 25 patients (29%) had a major tear (17 large and 8 massive). Seventy patients (82%) had a full repair, and 15 (18%) patients underwent a partial repair. There were 26 (31%) associated full-thickness tears of the infraspinatus. The isometric strength testing in both positions had good to excellent accuracy (range, 0.80-0.90) for detecting reparability, tear retraction, infraspinatus atrophic changes observed by the clinician, and infraspinatus fatty infiltration on magnetic resonance images. The shortened position had an overall higher accuracy than the neutral position and was more clinically useful for detecting an infraspinatus full-thickness tear (AUROC = 0.84 vs 0.78) and rotator cuff tear size (AUROC = 0.80 vs. 0.75). CONCLUSIONS: The isometric external rotation is an accurate test in diagnosing different aspects of rotator cuff disease and specifically of the infraspinatus muscle. The isometric strength at the shortened position was a better predictor of clinical, surgical, and imaging findings.

Efficacy of postoperative radiation treatment for bone metastases in the extremities.

BACKGROUND AND PURPOSE: Impending or pathological fractures due to bone metastases may require surgical fixation. Postoperative radiation is often recommended to reduce local progression and prevent prosthesis displacement, hence reducing the need for second surgery. The objectives of this study were to investigate the need for second surgery, and to report on rates of re-irradiation, tumor progression and prosthesis displacement following postoperative radiation. MATERIALS AND METHODS: Data were collected from 65 patients who received postoperative radiation to 74 sites in the extremities in a palliative radiation clinic between January 2009 and January 2017. Descriptive statistical analyses were performed. RESULTS: Only 2 patients required a second surgery (2.7%) at 9 and 10months after postoperative radiation. Increase in pain requiring re-irradiation was reported in 7 patients (9.5%), at a median time of 9.3months after the delivery of radiation. Of the 47 patients who had radiological imaging available post-radiation, local progression of bone metastases was seen in 8 patients (17.0%) and displacement of the prosthesis in 1 patient (2.1%). CONCLUSION: Rates of prosthesis displacement and progression of bone metastases at site of surgery were low after postoperative radiation. There were few incidences of second surgery and re-irradiation observed in the cohort. These findings provide support for the benefit of postoperative radiation.

Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist's Approach.

Purpose: Recent care innovations using advanced-practice physical therapists (APPs) as alternative health care providers are promising. However, information related to the clinical decision making of APPs is limited with respect to ordering shoulder-imaging investigations and the impact of these investigations on patient management. The purpose of this study was twofold: (1) to explore the clinical decision making of the APP providing care in a shoulder clinic by examining the relationship between clinical examination findings and reasons for ordering imaging investigations and (2) to examine the impact on patient management of ordered investigations such as plain radiographs, ultrasound (US), magnetic resonance imaging (MRI), and magnetic resonance arthrogram (MRA). Method: This was a prospective study of consecutive patients with shoulder complaints. Results: A total of 300 patients were seen over a period of 12 months. Plain radiographs were ordered for 241 patients (80%); 39 (13%) received MRI, 27 (9%) US, and 7 (2%) MRA. There was a relationship between clinical examination findings and ordering plain radiographs and US (ps=0.047 to <0.0001). Plain radiographs ordered to examine the biomechanics of the glenohumeral joint affected management (χ2 1=8.66, p=0.003). Finding a new diagnosis was strongly correlated with change in management for all imaging investigations (ps=0.001 to <0.0001). Conclusion: Skilled, extended-role physical therapists rely on history and clinical examination without overusing costly imaging. The most important indicator of change in management was finding a new diagnosis, regardless of the type of investigation ordered.

Objectif : innovation récente, la prestation de certains actes autrefois réservés aux chirurgiens orthopédistes par les physiothérapeutes en pratique avancée (PPA) est prometteuse. Cependant, on en connaît peu sur le lien entre la prise de décision clinique des PPA et les demandes de tests d'imagerie de l'épaule, ainsi que sur l'influence de ces tests sur la prise en charge des patients. Cette étude avait deux objectifs : 1) étudier la prise de décision clinique de PPA exerçant dans une clinique de l'épaule en examinant la relation entre les résultats de l'examen clinique et les motifs des demandes de tests d'imagerie et 2) examiner l'influence des tests demandés sur la prise en charge du patient, par exemple les radiographies simples, les échographies, les imageries par résonance magnétique (IRM) et les arthrographies par résonance magnétique (ARM). Méthodologie : cette étude prospective a été menée auprès de patients consécutifs se plaignant de problèmes à l'épaule. Résultats : au total, 300 patients ont été pris en charge sur une période de 12 mois. On a demandé des radiographies simples pour 241 patients (80 %), dont 39 (13 %) ont subi une IRM, 27 (9 %) une échographie et 7 (2 %) une ARM. On a observé un lien entre les résultats de l'examen clinique et la demande de radiographies simples et d'échographies (valeurs ps de 0,047 à <0,0001). Les radiographies simples demandées pour examiner la biomécanique de l'articulation scapulo-humérale ont eu une influence sur la prise en charge (χ2 1=8,66, p=0,003). La pose d'un nouveau diagnostic a été fortement corrélée à un changement de la prise en charge pour tous les tests d'imagerie (valeurs ps de 0,001 à <0,0001). Conclusion : les physiothérapeutes compétents ayant un champ de pratique élargi se fient à l'historique du patient et aux examens cliniques sans abuser des tests d'imagerie coûteux. L'indicateur de changement le plus important dans la prise en charge a été la pose d'un nouveau diagnostic, peu importe le type de test demandé.

Impact of Platelet-Rich Plasma on Arthroscopic Repair of Small- to Medium-Sized Rotator Cuff Tears: A Randomized Controlled Trial.

BACKGROUND: Increased interest in using platelet-rich plasma (PRP) as an augment to rotator cuff repair warrants further investigation, particularly in smaller rotator cuff tears. PURPOSE: To examine the effectiveness of PRP application in improving perioperative pain and function and promoting healing at 6 months after arthroscopic repair of small- or medium-sized rotator cuff tears. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: This was a double-blinded randomized controlled trial of patients undergoing arthroscopic repair of partial- or full-thickness rotator cuff tears of up to 3 cm who were observed for 6 months. Patients were randomized to either repair and PRP application (study group) or repair only (control group) groups. The patient-oriented outcome measures utilized were the visual analog scale (VAS), the Short Western Ontario Rotator Cuff Index (ShortWORC), the American Shoulder and Elbow Surgeons (ASES) form, and the Constant-Murley Score (CMS). Range of motion (ROM) and inflammatory and coagulation markers were measured before and after surgery. Magnetic resonance imaging was used at 6 months to assess retear and fatty infiltration rate. RESULTS: Eighty-two patients (41 males) with a mean age of 59 ± 8 years were enrolled; 41 patients were included in each group. Both the PRP and control groups showed a significant improvement in their pain level based on the VAS within the first 30 days (P < .0001), with the PRP group reporting less pain than the control group (P = .012), which was clinically significantly different from days 8 through 11. The PRP group reported taking less painkillers (P = .026) than the control group within the first 30 days. All outcome measure scores and ROM improved significantly after surgery (P < .0001), with no between-group differences. No differences were observed between groups in inflammatory or coagulation marker test results (P > .05), retear (14% vs 18% full retear; P = .44), or fatty infiltration rate (P = .08). CONCLUSION: The PRP biological augmentation for repair of small- to medium-sized rotator cuff tears has a short-term effect on perioperative pain without any significant impact on patient-oriented outcome measures or structural integrity of the repair compared with control group.

Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy.

BACKGROUND: There is limited information on the validity of magnetic resonance imaging (MRI) in detection of biceps disease. The purpose of this study was to examine the measurement properties of noncontrasted MRI in diagnosis of biceps disease using arthroscopic surgery as the "gold standard." MATERIALS AND METHODS: Prospectively collected surgical data of patients with impingement syndrome or rotator cuff tear, with biceps disease (study group) or without biceps disease (control group), were reviewed. MRI reports of radiologists with fellowship training in musculoskeletal imaging were retrospectively reviewed and compared with surgical findings. RESULTS: Data of 183 (130 study and 53 control) patients (73 women [40%], 110 men [60%]; mean age, 62 years [standard deviation, 9]) who had undergone arthroscopic rotator cuff-related surgery during a period of 11 years were used for analysis. Sensitivity and specificity of MRI for detection of full tears of the biceps tendon were 0.54 and 0.98, respectively. Sensitivity and specificity were 0.27 and 0.86 for partial tears of the biceps tendon, respectively. For biceps subluxation or dislocation, sensitivity was 1.00 and specificity was 0.83. The areas under the receiver operating characteristic curves, which quantify the overall accuracy of the tests, were 0.57, 0.75, and 0.92 for partial tear, full tear, and instability of the biceps tendon, respectively. CONCLUSIONS: Noncontrasted MRI has a low sensitivity and high specificity for detection of full-thickness tears of the biceps tendon. It is highly sensitive for diagnosis of instability of the long head of the biceps. However, its usefulness for diagnosis of partial tears of the biceps tendon remains limited.

Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study.

BACKGROUND: This prospective longitudinal study compared clinical and radiologic outcomes of total shoulder arthroplasty (TSA) using 3 different prosthetic designs, the Neer II system, the Bigliani-Flatow (BF), and a stemless prosthesis, the Total Evolutive Shoulder System (TESS). MATERIALS AND METHODS: Patients with advanced osteoarthritis of the glenohumeral joint who underwent TSA were followed up for 2 years. Four patient-oriented disability outcomes were used. The clinical data collected before surgery and at follow-up assessments during a 2-year period included active range of motion (ROM) in 6 directions and strength. Radiographic signs of glenoid and humeral component loosening were recorded. The incidence of humeral head subluxation was documented. RESULTS: Seventy-four patients completed the study. There was a significant improvement in the 4 disability measures, ROM, and strength at 2 years in all 3 groups (P < .0001). Active external rotation at 90° abduction was statistically significantly lower in the Neer II group (P = .001). The incidence of lucent lines around the glenoid component was higher in the Neer II group (P = .0002). No statistically significant relationship was seen between type of prosthesis and patient satisfaction (P > 0.05). CONCLUSIONS: The 3 types of TSA prostheses used in this study all provided significant improvement in pain and function and were associated with high patient satisfaction. The Neer II was associated with less active external rotation and more lucent lines.

Correlation of computed tomography imaging features with pain response in patients with spine metastases after radiation therapy.

PURPOSE: To correlate computed tomography (CT) imaging features of spinal metastases with pain relief after radiotherapy (RT). METHODS AND MATERIALS: Thirty-three patients receiving computed tomography (CT)-simulated RT for spinal metastases in an outpatient palliative RT clinic from January 2007 to October 2008 were retrospectively reviewed. Forty spinal metastases were evaluated. Pain response was rated using the International Bone Metastases Consensus Working Party endpoints. Three musculoskeletal radiologists and two orthopaedic surgeons evaluated CT features, including osseous and soft tissue tumor extent, presence of a pathologic fracture, severity of vertebral height loss, and presence of kyphosis. RESULTS: The mean patient age was 69 years; 24 were men and 9 were women. The mean worst pain score was 7/10, and the mean total daily oral morphine equivalent was 77.3 mg. Treatment doses included 8 Gy in one fraction (22/33), 20 Gy in five fractions (10/33), and 20 Gy in eight fractions (1/33). The CT imaging appearance of spinal metastases included vertebral body involvement (40/40), pedicle involvement (23/40), and lamina involvement (18/40). Soft tissue component (10/40) and nerve root compression (9/40) were less common. Pathologic fractures existed in 11/40 lesions, with resultant vertebral body height loss in 10/40 and kyphosis in 2/40 lesions. At months 1, 2, and 3 after RT, 18%, 69%, and 70% of patients experienced pain relief. Pain response was observed with various CT imaging features. CONCLUSIONS: Pain response after RT did not differ in patients with and without pathologic fracture, kyphosis, or any other CT features related to extent of tumor involvement. All patients with painful spinal metastases may benefit from palliative RT.

Immediate pain relief and improved structural stability after percutaneous vertebroplasty for a severely destructive vertebral compression fracture.

Approximately 10% to 30% of patients with cancer have metastases to the spine that require treatment. Spinal metastases can cause acute and chronic pain, compression fractures, spinal instability, and neurologic deficits. Vertebral compression fractures can be a significant cause of pain and impaired function. Radiation therapy is the standard treatment for patients with spinal metastases. However, this may not be the optimal treatment by itself for some patients when immediate pain relief is desirable. Percutaneous vertebroplasty is a mildly invasive treatment which involves the injection of cement, polymethylmethacrylate (PMMA) into a diseased vertebral body. We report a patient who presented with a severely destructive lesion and compression fracture at T9 with severe pain and impaired mobility. Percutaneous vertebroplasty provided immediate pain relief and restored structural stability of the diseased vertebra.

The role of plain radiographs in management of bone metastases.

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare false-positive results. We present a case with a false-positive result in a patient with lung cancer.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.

Sonographically guided ilioinguinal nerve block.

OBJECTIVE: The aim of this study was to describe a sonographically guided ilioinguinal nerve block in adults. METHODS: We developed a useful step-by-step technique of sonographically guided ilioinguinal nerve block based on visualization of abdominal muscles, fascial planes, and the branch of the deep circumflex iliac artery. RESULTS: We performed 9 sonographic examinations with subsequent blockade of the ilioinguinal nerve. All injections resulted in a clinically successful sensory block. CONCLUSIONS: This technique is reliable and reproducible. The block is achievable by a low-volume local anesthetic injection. Visualization of the intestines and blood vessels in the abdominal wall may help prevent an inadvertent injury.

MR pulse sequences: what every radiologist wants to know but is afraid to ask.

The use of magnetic resonance (MR) imaging is growing exponentially, in part because of the excellent anatomic and pathologic detail provided by the modality and because of recent technologic advances that have led to faster acquisition times. Radiology residents now are introduced in their 1st year of training to the MR pulse sequences routinely used in clinical imaging, including various spin-echo, gradient-echo, inversion-recovery, echo-planar imaging, and MR angiographic sequences. However, to make optimal use of these techniques, radiologists also need a basic knowledge of the physics of MR imaging, including T1 recovery, T2 and T2* decay, repetition time, echo time, and chemical shift effects. In addition, an understanding of contrast weighting is very helpful to obtain better depiction of specific tissues for the diagnosis of various pathologic processes.

Computed tomography (CT) evaluation of breast cancer patients with osteolytic bone metastases undergoing palliative radiotherapy--a feasibility study.

Twenty-five patients with osteolytic metastases had computed tomography (CT) scans before and 3 months after palliative radiotherapy. The median % density change following single 8Gy, 20Gy/5#, 30Gy/10# were: 128 (range 98-255), 141 (79-342), and 145 (65-235), respectively. It is feasible to evaluate remineralization of osteolytic lesions with palliative radiotherapy.