Clinical features of partial anterior bursal-sided supraspinatus tendon (PABST) lesions.

BACKGROUND: We characterized partial anterior and bursal supraspinatus tendon (PABST) lesions and compared their clinical features, postoperative functional scores, and healing rate with full-thickness rotator cuff tears (FTRCTs) and small FTRCTs. MATERIALS AND METHODS: There were 31 PABST lesions (6.2%), 392 FTRCTs, and 32 small FTRCTs among 495 shoulders with rotator cuff disorders. The mean patient age was 52.7 years in the PABST group, 60.1 years in the FTRCT group, and 56.9 years in the small FTRCT group. Functional and clinical variables were compared between the groups, and cuff healing was evaluated with computed tomography arthrography or ultrasonography. RESULTS: The mean patient age was statistically lower, the mean symptom duration was shorter, and trauma was more frequent in the PABST group compared with the FTRCT and small FTRCT groups. Coronal acromial spurs were found more frequently in the PABST group than in the FTRCT group. In all groups, range of motion, visual analog scale for pain, and functional scores improved continuously throughout the follow-up. There were 2 unhealed cuffs (10.5%) in the PABST group, 72 (35.6%) in the FTRCT group (P = .146), and 5 (25%) in the small FTRCT group (P = .238). CONCLUSIONS: We characterized PABST lesions that may be overlooked because of their peculiar location in the far anterolateral insertional section of the supraspinatus tendon at the bursal side. PABST lesions usually occur in younger patients, and trauma is frequently associated with acute symptom onset. Surgical treatment was effective for pain reduction and functional improvement.

Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study.

BACKGROUND: Glenohumeral (GH) joint steroid injection is one of the most well-known treatments for frozen shoulder. However, the low accuracy of GH joint injections and the improvement of symptoms after subacromial (SA) steroid injections led us to design a study that compares the efficacy of a steroid injection for primary frozen shoulder according to the injection site. MATERIALS AND METHODS: Patients with primary frozen shoulder were randomly divided into 2 groups according to the location of the injection: a GH group of 37 for the glenohumeral joint and an SA group of 34 for the subacromial space. Injections were completed using ultrasonographic guidance. Evaluations using a visual analog scale (VAS) for pain, the Constant score, and passive range of motion (ROM) were completed at 3, 6, and 12 weeks after the injection. RESULTS: The GH group showed lower pain VAS at 3 weeks, but no statistical difference was found between the 2 groups at 6 and 12 weeks. Improvement in pain was evident at every follow-up visit compared with the preinjection evaluation. There was no significant difference between the 2 groups with respect to the Constant score or ROM at serial follow-up. CONCLUSIONS: The GH steroid injection was not superior to a SA injection for patients with primary frozen shoulder even though injection at the GH joint led to earlier pain relief compared with the SA injection. SA steroid injection along with a GH injection is an alternative modality, and the treatment should be individualized and tailored appropriately.

The prevalence of shoulder osteoarthritis in the elderly Korean population: association with risk factors and function.

BACKGROUND: The purpose of this study was to document the prevalence of shoulder osteoarthritis (OA) in the elderly population in South Korea, to determine the risk factors for shoulder OA, and to evaluate the relationship with function. MATERIALS AND METHODS: This project was part of a population-based prospective cohort study of health, aging, and common geriatric diseases in the elderly population of the authors' area of Seongnam. A total of 1118 residents were randomly invited, and 679 participated. The mean age of respondents was 71.8 ± 5.7 years (range, 65-97 years), and 396 (58.3%) were women. Bilateral shoulder radiographs were taken, and the grade of OA was evaluated using the Samilson-Prieto method. Functional status was evaluated using the Disabilities of Arm, Shoulder and Hand (DASH) instrument. RESULTS: Radiographic primary shoulder OA was detected in 109 people (16.1%), and secondary OA in 9 (1.3%). There were 77 shoulders of grade 1 (11.3%), 23 of grade 2 (3.4%), and 9 of grade 3 (1.3%). The risk of shoulder OA increased according to age, with odds ratio (OR) of 2.20 in patients aged 70 to 74 years (P = .004) and 3.42 in patients aged 75 years and older (P < .001). Knee OA was also a significant risk factor for shoulder OA (OR, 1.96; P = .002). The DASH score was significantly higher in the OA group and increased according to the grade of shoulder OA (P < .001). CONCLUSION: Primary shoulder OA is not as rare as previously reported. Our data also demonstrated that older age and knee OA were determining risk factors for shoulder OA, and shoulder OA was related to poor function.

Effectiveness of subacromial anti-adhesive agent injection after arthroscopic rotator cuff repair: prospective randomized comparison study.

BACKGROUND: Arthroscopic rotator cuff repair generally has a good clinical outcome but shoulder stiffness after surgery due to subacromial adhesion is one of the most common and clinically important complications. Sodium hyaluronate (HA) has been reported to be an anti-adhesive agent in a range of surgical procedures. However, there are few reports of the outcomes of arthroscopic rotator cuff repair of the shoulder. This study examined whether a subacromial injection of HA/carboxymethylated cellulose (CMC) affected the postoperative shoulder stiffness and healing of rotator cuff repair, as well as the safety of an injection. METHODS: Between January 2008 and May 2008, 80 consecutive patients with arthroscopic rotator cuff repair were enrolled. The patients were assigned randomly to the HA/CMC injection group (n = 40) or control group (n = 40). All patients were evaluated using the visual analog scale (VAS) for pain, passive range of motion at 2, 6 weeks, 3, 6, 12 months after surgery, and the functional scores at 6, 12 months postoperatively. Cuff healing was also evaluated using CT arthrography or ultrasonography at 6 or 12 months after surgery. RESULTS: The HA/CMC injection group showed faster recovery of forward flexion at 2 weeks postoperatively than the control group but the difference was not statistically significant (p = 0.09). There were no significant difference in pain VAS, internal rotation, external rotation and functional scores between two groups at each follow-up period. The functional scores improved 6 months after surgery in both groups but there were no differences between the two groups. The incidence of unhealed rotator cuff was similar in the two groups. There were no complications related to an injection of anti-adhesive agents including wound problems or infections. CONCLUSIONS: A subacromial injection of an anti-adhesive agent after arthroscopic rotator cuff repair tended to produce faster recovery in forward flexion with no adverse effects on cuff healing. However, its anti-adhesive effects after rotator cuff repair should be considered carefully with further studies.

Results of concomitant rotator cuff and SLAP repair are not affected by unhealed SLAP lesion.

HYPOTHESIS: To verify the anatomic results of combined repair of a full-thickness rotator cuff tear and superior labral anterior and posterior (SLAP) lesion. In addition, we compared the anatomic and functional outcomes according to the status of the repaired SLAP lesion. METHODS: We enrolled 61 patients who underwent cuff repair with concomitant SLAP repair and were available for both functional and radiologic outcome evaluation at least 1 year after the operation. There were 40 male and 21 female patients with a mean age of 57.4 years (range, 39-70 years). We measured various clinical outcomes and evaluated the structural outcomes of the rotator cuff and the superior labrum and rotator cuff using computed tomography arthrography at the final follow-up visit. We also evaluated the functional outcome according to anatomic healing of the superior labrum. RESULTS: Labral healing to the bony glenoid was achieved in 49 patients (80.3%), and anatomic healing of the rotator cuff was observed in 44 patients (72.1%). The retear rate of the rotator cuff was not statistically different with respect to labral healing status. All functional outcomes improved significantly (P < .001), and there were no statistical differences in functional outcome with respect to postoperative healing of the superior labrum. CONCLUSIONS: An unhealed SLAP lesion did not preclude the successful outcome of concomitant rotator cuff repair. Therefore, repair of a concomitant SLAP lesion may not be an essential procedure for a successful outcome of a rotator cuff repair.

Modified impingement test can predict the level of pain reduction after rotator cuff repair.

BACKGROUND: Most patients experience a significant reduction in pain after rotator cuff repair. However, there is currently no method to predict the level of pain reduction that each patient will experience. This report explores the usefulness of the modified impingement test for prognosis in cases of rotator cuff repair. HYPOTHESIS: The amount of pain reduction after injection of lidocaine into the subacromial space preoperatively correlates with the level of pain reduction after rotator cuff repair. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: Preoperatively, a visual analog scale for pain was measured in 153 patients (59 males and 94 females) with a rotator cuff tear before and after injection of lidocaine into the subacromial space. Subsequently, rotator cuff repair was performed. At least 1 year after surgery, the visual analog scale for pain and satisfaction, Constant score, Simple Shoulder Test, American Shoulder and Elbow Surgeons (ASES) score, and University of California, Los Angeles shoulder rating scale were evaluated. Correlation analyses were performed between the change in visual analog scale after the modified impingement test and after surgery. RESULTS: The amount of pain reduction after the modified impingement test was significantly related to improvement of pain postoperatively (P < .001), as measured using the visual analog scale for pain. The change in ASES score was also related to the amount of pain reduction after the modified impingement test (P = .001); however, the other tests showed no statistical significance (P > .05). Univariate regression analysis revealed that a 0.621-unit reduction in postoperative pain on the visual analog scale could be expected for each 1 unit (on a scale of 10) reduction in pain after lidocaine injection preoperatively. CONCLUSION: The amount of pain reduction after the modified impingement test preoperatively correlated with the improvement of pain after rotator cuff repair. This simple preoperative test could help patients understand the subjective level of pain reduction that they may experience after rotator cuff repair.

Effect of age on functional and structural outcome after rotator cuff repair.

BACKGROUND: There are numerous reports on the outcome of rotator cuff repair according to age. However, the results are conflicting and driven by univariate analysis, which is not free of confounding factors. HYPOTHESIS: Age does not affect the anatomical and functional outcomes of rotator cuff repair. STUDY DESIGN: Case series; Level of evidence, 4. MATERIALS AND METHODS: Eighty-one men and 96 women underwent rotator cuff repair at one institution and received computed tomography arthrography and functional evaluations at least 1 year after surgery. Various structural and clinical features according to age were evaluated. The correlation was assessed between age and outcomes, with adjustment for the preoperative score. RESULTS: Patient mean age was 60.0 +/- 8.7 years. The mean ages were higher in women, nonsmokers, and those with positive paradoxical abduction, lower level of sports activity, the presence of biceps injury, higher fatty degeneration in cuff muscles, inferior isokinetic muscle performance, bigger tear size, more retraction of tear, and symptomatic acromioclavicular arthritis. For the integrity of the repair, the mean age was higher in the retear group (31.1%) than in the intact group (68.9%)-that is, 63.7 +/- 7.5 and 58.4 +/- 8.7 years, respectively (P <.001). Only the Constant score exhibited a positive correlation with age after adjustment (P = .009). Univariate regression analysis revealed that a 0.313-point increment of Constant score could be expected for each year of age. CONCLUSION: On univariate analysis, older age was related with poor postoperative integrity and better functional improvement in Constant score. Multivariate regression revealed that age was not an independent determinant for anatomical or functional outcome whereas the tear retraction and fatty degeneration of the infraspinatus were independent factors for the integrity of repair and the presence of the paradoxical abduction and abduction torque of the unaffected shoulder for the Constant score.

Reliability of the grading system for fatty degeneration of rotator cuff muscles.

UNLABELLED: Fatty degeneration of the rotator cuff muscles is considered one of the most important factors for the outcomes of cuff repair. However, the reliability of the grading system is not well validated. Two specialists in musculoskeletal radiology and three shoulder fellowship-trained orthopaedic surgeons reviewed the fatty degeneration grades of each cuff muscle of consecutive 75 full-thickness cuff tears. Fatty degeneration grades were assessed according to the systems of Goutallier et al. and Fuchs et al. using preoperative MR and postoperative CT arthrographies. The interclass correlation coefficient was analyzed to assess interobserver and intraobserver reliabilities. For interobserver reliability using the system of Goutallier et al. the interclass correlation coefficient was higher in MR arthrography (0.6-0.72) than in CT arthrography (0.43-0.6) and higher for radiologists (0.58-0.78) than for orthopaedic surgeons (0.32-0.68). There was no difference between the systems of Goutallier et al. and Fuchs et al. Intraobserver reliabilities showed a similar pattern (0.26-0.81), but the level of experience should be considered. Although the system of Goutallier et al. is most widely used in orthopaedics, reported data should be interpreted carefully because of the relatively low reliability. LEVEL OF EVIDENCE: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Isokinetic muscle performance test can predict the status of rotator cuff muscle.

BACKGROUND: The isokinetic muscle performance test (IMPT) is a validated and objective method used to evaluate muscle function but it is unknown whether it correlates with severity of rotator cuff tears. QUESTIONS/PURPOSES: We asked whether peak torque and total work deficit on the IMPT correlated with the preoperative manual muscle test (MMT), tear size, fatty degeneration (FD) of cuff, and postoperative cuff integrity in patients after rotator cuff surgery. METHODS: We evaluated 221 patients who had undergone rotator cuff repair; of these 86 had the IMPT and a CT arthrogram (CTA) 1 year after surgery. RESULTS: We found a correlation (r = 0.125 approximately 0.464) between the preoperative IMPT and MMT. The IMPT deficit was greater in rotator cuff muscles with larger tears and greater degree of FD. Preoperative external and internal rotation deficits on the IMPT were related to the risk of cuff detachment on the postoperative CTA (r = 0.290, 0.319), and the postoperative abduction deficit was greater than 40% of the contralateral side indicating cuff detachment. CONCLUSIONS: The IMPT provides objective and quantitative data for estimating the preoperative status of rotator cuff tear and can provide baseline data for postoperative anatomic assessment in patients with rotator cuff disorders. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.