Rotator cuff tears: correlation between geometric tear patterns on MRI and arthroscopy and pre- and postoperative clinical findings.

BACKGROUND: Magnetic resonance imaging (MRI) is considered to be the best non-invasive procedure for the evaluation of rotator cuff (RC) tendon tears. Burkhart's classification is a geometric classification of full-thickness RC tears on MRI. PURPOSE: To correlate MRI and arthroscopic geometric full-thickness RC tears according to the Burkhart's classification with pre- and postoperative clinical findings. MATERIAL AND METHODS: Patients who underwent arthroscopic RC repair between 2006 and 2010 were retrospectively evaluated. Preoperative MRI and arthroscopic surgical reports were reviewed for tear geometry (Burkhart's) by three (1 radiologist, 2 surgeons) and two (surgeons) readers. MRIs were also evaluated for tear size and change of tear size in successive sagittal sections and for muscle mass and fatty infiltration. Clinical examinations were performed preoperatively and at least 12 months afterwards. Postoperative function questionnaires were filled in by the patients. RESULTS: Forty-six patients (35 men, 11 women; mean age, 57 years; range, 41-72 years) were evaluated. Tears depicted on MRIs were classified as crescent in 11 patients (24%), longitudinal in three (6.5%), massive contracted in 29 (63%), and cuff arthropathy in three (6.5%). Muscle changes were noted almost exclusively in patients with massive tears and cuff arthropathy (16/32 patients, P = 0.013). MRIs and arthroscopic geometric classifications were in close agreement. Tear type did not correlate with pre- and postoperative physical examination or with postoperative clinical questionnaires scores. CONCLUSION: Geometric RC tear characterizations on preoperative MRIs were closely associated with arthroscopic findings. Postoperative results were not affected by the geometric pattern of the tears.

Upper limb kinematics after arthroscopic and open shoulder stabilization.

BACKGROUND: Shoulder joint stability mediated by proprioception is often quantified by arm repositioning tests (i.e., static end-position accuracy), overlooking ongoing movement quality. This study assessed movement quality by adopting smoothness-related kinematic descriptors. We compared performance of healthy controls with that of patients in arthroscopic shoulder stabilization and open shoulder stabilization groups. We hypothesized that arm kinematics after arthroscopic intervention would more closely resemble healthy movements compared with patients after open shoulder stabilization surgery. METHODS: Healthy controls (N = 14) were compared with patients after arthroscopic shoulder stabilization (N = 10) and open shoulder stabilization (N = 12). Right-hand dominant subjects (the affected side in patients) performed 135 unconstrained 3-dimensional pointing movements toward visual targets (seen through pinhole goggles; i.e., no arm vision). Arm kinematic data were recorded and offline analyzed to obtain hand tangential velocity profiles further used to compute the acceleration-to-movement time ratio, peak-to-mean velocity ratio, and number of velocity peaks ("symmetry," "proportion," and "fragmentation" features, respectively). Parametric and nonparametric statistics were used for comparisons (P ≤ .05). RESULTS: Control and arthroscopic shoulder stabilization groups presented similar acceleration-to-movement time ratio and peak-to-mean velocity ratio. Both groups differed from the open shoulder stabilization group (P = .001). Distributions of velocity peaks for control and arthroscopic shoulder stabilization groups were similar, whereas open shoulder stabilization and control subjects differed significantly (P = .028). CONCLUSIONS: Movement quality mediated by proprioception in arthroscopic shoulder stabilization patients matches that of healthy controls, whereas performance in open shoulder stabilization patients seems inferior compared with that in healthy controls, as assessed by smoothness-related measures (less symmetrical, more fragmented movements).

Movement control in patients with shoulder instability: a comparison between patients after open surgery and nonoperated patients.

BACKGROUND: Open surgery to correct shoulder instability is deemed to facilitate recovery of static and dynamic motor functions. Postoperative assessments focus primarily on static outcomes (e.g., repositioning accuracy). We introduce kinematic measures of arm smoothness to assess shoulder patients after open surgery and compare them with nonoperated patients. Performance among both groups of patients was hypothesized to differ. Postsurgery patients were expected to match healthy controls. METHODS: All participants performed pointing movements with the affected/dominant arm fully extended at fast, preferred, and slow speeds (36 trials per subject). Kinematic data were collected (100 Hz, 3 seconds), and mixed-design analyses of variance (group, speed) were performed with movement time, movement amplitude, acceleration time, and model-observed similarities as dependent variables. Nonparametric tests were performed for number of velocity peaks. RESULTS: Nonoperated and postsurgery patients showed similarities at preferred and faster movement speeds but not at slower speed. Postsurgery patients were closer to maximally smoothed motion and differed from healthy controls mainly during slow arm movements (closer to maximal smoothness, larger movement amplitude, shorter movement time, and lower number of peaks; i.e., less movement fragmentation). CONCLUSIONS: Arm kinematic analyses suggest that open surgery stabilizes the shoulder but does not necessarily restore normal movement quality. Patients with recurrent anterior shoulder instability (RASI) seem to implement a "safe" but nonadaptive mode of action whereby preplanned stereotypical movements may be executed without depending on feedback. Rehabilitation of RASI patients should focus on restoring feedback-based movement control. Clinical assessment of RASI patients should include higher order kinematic descriptors.

[Middle third clavicle fractures--diagnosis, complications and treatment].

Clavicle fractures compose 2.5% to 5% of all fractures, and usually occur due to a direct blow to the shoulder. The incidence of these fractures persistently increases. Most of the fractures are in the middle third--a result of the unique structure of the clavicle and its ligamentous and muscular attachments. The fracture diagnosis includes focused physical examination, radiographic evaluation, and comprehensive evaluation of the patient, considering the fact that the fracture can be the result of significant energy absorption and can hide other injuries. Usually treatment is non-operative, and results in fracture union of 95%. Healing is achieved with a certain amount of deformity. The most common treatment is a sling or figure-of-8 dressing worn for several weeks. When absolute surgical indications (open fracture or neurovascular injury) or relative surgical indications (multiple injuries or floating shoulder) exist, several surgical procedures can be chosen. The fracture displacement as a predictive factor for union or function after healing is controversial. Complications associated with clavicle fractures are the result of either conservative or surgical treatment. The most common complication is an esthetic defect. Other complications are non-union, mal-union, limited range of motion and neurovascular injury.

[Significance of plain radiography in shoulder pain diagnosis].

Shoulder pain is a common complaint--almost 20% of the population will suffer shoulder pain during their life time. Despite the availability of newer imaging techniques for evaluation of the shoulder, the first imaging study should be radiography. Recently, ultrasonography of the shoulder has become one of the first studies performed. Sometimes, ultrasonography is conducted before radiography; moreover, many patients are being referred to a shoulder specialist without performing an X-ray. There is a plethora of pathologies that can cause shoulder pain--rotator cuff tears, impingement syndrome, calcified tendinitis, osteoarthritis, rheumatoid arthritis, neoplasms and more. This review aims to show the significance of plain radiography in the diagnosis of shoulder pathologies, in order to encourage the use of this modality. In this paper we shall review the different causes of shoulder pain and their radiographic characteristics.

Patients education of a self-reduction technique for anterior glenohumeral dislocation of shoulder.

BACKGROUND: : Anterior dislocation of the shoulder (glenohumeral joint) is one of the most prevalent dislocations. Following a first dislocation recurrence rates of up to 80% have been reported. Many patients will seek medical assistance for reduction of the shoulder after each of these recurrent dislocations. We describe the results of reduction of anterior glenohumeral dislocation using a modified self manipulated Milch technique that can be performed by the patients themselves after simple guidance and demonstration. This method is directed to patients who are not willing or cannot have surgical stabilization and may be in a place where medical assistance is not available. PATIENTS: : The patient is placed in a supine position, and begins slowly to actively abduct and externally rotate the dislocated shoulder until the arm is overhead. Once the overhead position has been achieved, the arm is gently lowered back to the side of the body. Simultaneously, the patient has to apply pressure to the front of the shoulder with the other hand to maintain position until the reduction is complete. RESULTS: : Thirty-two dislocated shoulders in 33 consecutive patients suffering from recurrent dislocations were successfully reduced by this technique. Mean reduction time was 10 minutes. DISCUSSION: : The results illustrate the fact that most patients are able to reliably and reproducibly reduce glenohumeral dislocations by themselves. Subsequent dislocations can be reduced promptly decreasing the dislocation time thus avoiding further damage to the shoulder, achieving immediate pain relief, and removing the immediate necessity for medical attendance.

A Multicenter Retrospective Study With a Minimum 5-Year Follow-up Comparing Arthroscopic Bankart Repair and the Latarjet Procedure.

BACKGROUND: Arthroscopic Bankart repair (ABR) and the Latarjet procedure are surgical techniques commonly used to treat anterior shoulder instability. There is no consensus among shoulder surgeons regarding the indications for choosing one over the other. PURPOSE: To compare the results of the Latarjet procedure with those of ABR for the treatment of anterior shoulder instability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Data on all patients who were treated surgically for recurrent anterior shoulder instability between 2006 and 2011 were retrospectively collected at 4 medical centers. The minimum follow-up was 5 years. Data were retrieved from medical charts, and patients were interviewed to assess their level of satisfaction (range, 0-100), functional outcomes (using the American Shoulder and Elbow Surgeons shoulder score; the Subjective Shoulder Value; and the Disabilities of the Arm, Shoulder and Hand score), and quality of life (using the 12-Item Short Form Health Survey [SF-12]). Information on return to sports activities and postoperative level of activity compared with that of the preinjury state, complications, reoperations, and recurrent instability were recorded and evaluated. RESULTS: A total of 242 patients were included. The Latarjet procedure was performed in 27 shoulders, and ABR was performed in 215 shoulders. Patients in the ABR group had significantly higher rates of redislocation (18.5%; P = .05) and subluxation (21.4%; P = .43) but a lower rate of self-reported apprehension (43.0%; P = .05) compared with patients in the Latarjet group (3.7%, 14.8%, and 63.0%, respectively). There were 5 patients in the ABR group who underwent reoperation with the Latarjet procedure because of recurrent instability. The functional scores in the Latarjet group were better than those in the ABR group. The SF-12 physical score was significantly better in the Latarjet group than in the ABR group (98.1 vs 93.9, respectively; P = .01). Patient satisfaction and subjective scores were similar in both groups. CONCLUSION: These results support recently published data on the Latarjet procedure that showed its superiority over ABR in midterm stability (dislocations or subluxations). The contribution of self-reported apprehension to the broad definition of stability is not clear, and apprehension rates were not correlated with satisfaction scores or the recurrence of dislocation or subluxation.

Sub-acromial balloon spacer for irreparable rotator cuff tears: Is it an appropriate salvage procedure?

INTRODUCTION: Irreparable rotator cuff tear (RCT) presents a difficult treatment challenge for the orthopaedic surgeon. Many treatment strategies with varying degrees of success have been performed over the years. One of the suggested surgical treatment options is the use of a biodegradable sub-acromial balloon spacer. METHODS: A retrospective study of patients treated with sub-acromial balloon spacer between the years 2011 and 2016 was conducted. Mean follow-up time was 14.4 months. Patient charts were reviewed to evaluate the early clinical results and complications of sub-acromial spacer for irreparable RCTs. RESULTS: The study cohort included 24 shoulders in 22 patients. The average postoperative Disability of the Arm, Shoulder and Hand score was 62.4. The average preoperative University of California at Los-Angeles Shoulder score was 10.9 and improved to 15.9 ( p = 0.001). Forty-six per cent of patients were satisfied with their clinical postoperative outcome. We found moderate-strong positive correlation ( r = 0.64) between preoperative range of motion (ROM) and general satisfaction. None of the postoperative radiographs showed an improvement regarding the proximal migration of the humeral head. In total, four (16.7%) patients experienced postoperative complications, and two (8.3%) patients required an additional surgery as a consequence of a postoperative complication. CONCLUSION: Our results show unsatisfactory improvement in patients with irreparable RCT treated with the sub-acromial balloon spacer. Careful patient selection with attention to preoperative ROM should be considered. LEVEL OF EVIDENCE: Therapeutic level IV.

Idiopathic adhesive capsulitis: long-term results of conservative treatment.

BACKGROUND: Adhesive capsulitis, also termed "frozen shoulder," is controversial by definition and diagnostic criteria that are not sufficiently understood. The clinical course of this condition is considered self-limiting and is divided into three clinical phases. Several treatment methods for adhesive capsulitis have been reported in the literature, none of which has proven superior to others. OBJECTIVES: To evaluate the long-term follow-up of patients with idiopathic adhesive capsulitis who were treated conservatively. METHODS: We conducted a long-term follow-up (range 5.5-16 years, mean 9.2 years) of 54 patients suffering from idiopathic adhesive capsulitis. All patients were treated with physical therapy and non-steroidal anti-inflammatory drugs. RESULTS: An increased statistically significant improvement (P < 0.00001) was found between the first and last visits to the clinic in all measured movement directions: elevation and external and internal rotation. CONCLUSIONS: Conservative treatment (physical therapy and NSAIDs) is a good long-term treatment regimen for idiopathic adhesive capsulitis.

Percutaneous pinning using threaded pins as a treatment option for unstable two- and three-part fractures of the proximal humerus: a retrospective study.

A retrospective study was designed to evaluate the results of closed reduction and percutaneous pinning using threaded pins as a treatment option for fractures of the humeral head. Patients who suffered two- and three-part fractures of the proximal humerus treated by this method of fixation were included. Fifty patients (32 females and 18 males) with an average age of 50 years were clinically evaluated at an average of 2.5 years after this procedure (range 1-4 years). The Constant score was used to evaluate the clinical outcome. Preoperative and postoperative X-rays were also assessed. Out of 50 patients, 18 (36%) obtained excellent results, 17 (34%) good results, eight (16%) fair results and seven (14%) achieved only poor results. The average Constant score was 81 (range 60-100). Fractures confined to the surgical or anatomical neck generally did better than those associated with a greater tuberosity fragment (average score 86 versus 78). Patients who required shaft stabilisation and in addition to reduction and fixation of the greater tuberosity showed a lower average score (68). There were no cases of avascular necrosis, neurovascular complications or deep infections. A significant loss of fracture position due to failure of internal fixation occurred in seven cases, three of these patients underwent revision surgery. Closed reduction and percutaneous pinning offers a good fracture position and stability with minimal soft tissue damage. We recommend that displaced two- and three- part fractures of the humeral head should be treated in this manner. However these patients should be monitored closely for a period of four weeks, since secondary displacement and failure of fixation can occur in this period. Careful patient selection may minimise these complications.