Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals--initial experience.

PURPOSE: To assess the magnetic resonance (MR) imaging appearance of the successfully repaired rotator cuff in an asymptomatic population. MATERIALS AND METHODS: Fifteen subjects who had undergone clinically successful rotator cuff repair were included in the study. All underwent functional testing of the affected shoulder and had good to excellent scores on the Constant scale. Standard MR imaging sequences were performed at 1.5 T, including oblique coronal fast spin-echo T2-weighted MR imaging with fat saturation. RESULTS: Three (10%) of 30 supraspinatus and infraspinatus tendons had normal signal intensity, and 16 (53%) had mildly increased signal intensity on fast spin-echo T2-weighted fat-saturated images, compatible with tendonitis or tendinosis. Three partial and four complete tears of the supraspinatus tendon and two partial and two complete tears of the infraspinatus tendon were seen. Other findings included subacromial-subdeltoid effusion (10 subjects), joint effusions (five subjects), and bone marrow edema (six subjects). CONCLUSION: Postoperative signal intensity changes consistent with tendonitis or tendinosis were common, and clinically "silent" partial and complete rotator cuff tears were seen. Such postoperative MR imaging findings should be interpreted with caution, and meticulous correlation with symptoms and clinical results is recommended.

Glenoid osteotomy for recurrent posterior subluxation of the shoulder: assessment by computed axial tomography.

Computed axial tomography was used to measure the change in articular alignment of 12 patients who underwent glenoid osteotomy for recurrent posterior subluxation of the shoulder. The average correction was 10.8 degrees and varied from -1 degree to +24 degrees. Local complications were intraarticular fracture because of osteotomy too close to the articular surface, lack of correction caused by loss of the anterior cortical hinge, and graft extrusion causing loss of correction. Osteoarthritis was noted in one case after 8 years. Only 2 of the 12 patients had clinical instability after surgery; however, 3 others continued to feel some shoulder discomfort. Despite uniform surgical technique for osteotomy, graft size, and graft placement, more variability was seen in articular realignment than expected. Given this unpredictability and the known risks of articular damage inherent in osteotomy near a joint surface, glenoid osteotomy for recurrent posterior subluxation should be used with caution.

Nonoperative treatment of rotator cuff tears.

In this study, 33 patients with full-thickness tears of the rotator cuff were given a supervised nonoperative program of rotator strengthening exercises and then were seen at followup an average of 3.8 years later. Of the 14 patients who were dissatisfied with nonoperative care, 12 eventually had opted for surgery and 2 were dissatisfied with their status at followup. In attempting to identify patients who would benefit from nonoperative care, the authors were unable to show that individual parameters such as rotator strength, symptom duration, or functional impairment were useful to predict outcome. However, it was found that those who have an insurance claim or who experience significant sleep loss due to shoulder pain are unlikely to be satisfied with nonoperative treatment. Patient satisfaction with nonoperative treatment is best correlated with improved pain relief, the ability to carry a 10- to 15-pound suitcase at one's side, the ability to use the arm at shoulder level, and the ability to eat using a utensil. Objective variables such as rotator strength and active motion are not correlated with ultimate patient satisfaction.

Neuralgic amyotrophy.

Thirty-nine patients with neuralgic amyotrophy were reviewed. In addition to the clinical findings reported in the neurological literature, we commonly found pain throughout the upper limb, and diffuse involvement of the brachial plexus. Five patients had spinal accessory nerve lesions and five had glenohumeral instability. Sixty-four per cent of the patients had had an orthopaedic consultation during their acute illness. It is therefore important that orthopaedic surgeons are aware of this clinical syndrome and its management. The prognosis is excellent with non-invasive treatment.

Anterior dislocation of the shoulder in the older patient.

A significant number of rotator cuff defects are brought to light following a first-time dislocation in older patients. Recurrence in this group of patients is low; however, standard anterior repairs may be employed effectively in such situations. Neurologic and vascular injuries, although infrequent, should be carefully ruled out as accompanying the initial injury. Knowledge of these facts will allow a better appreciation of the pathology associated with the anterior dislocation in the older patient. From this, more confident recommendations may be made regarding management of these difficult problems.

Failed anterior reconstruction for shoulder instability.

We report a retrospective study of 46 patients with continuing difficulties after anterior reconstruction of a shoulder for instability. In 31 patients instability was still present; in 12 of these, posterior or multidirectional instability had not been recognised and a further 11 had an uncorrected anatomical defect. In 20 patients with significant pain there was often more than one cause: impingement syndrome was seen in nine, osteoarthritis in seven, implant irritation in four and instability alone in two. A disabling medial rotation contracture was seen in 10 patients, four of whom had painful osteoarthritis. We conclude that recurrence of symptoms may imply that the direction of the instability was not recognised, that an anterior repair should not be too tight, and that pain after successful stabilisation is often due to impingement.