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A patient with rheumatoid arthritis developed sudden unilateral oedema of the right arm resembling vascular obstruction and was shown to have a ruptured shoulder joint.
To assess the association between HLA-DRB1 alleles and shoulder destruction due to rheumatoid arthritis (RA) in Japanese, we typed for HLA-DRB1 alleles in 100 Japanese RA patients who could be classified into 5 groups: non-progressive (N) with normal radiographs; erosive (E) showing marginal erosion but no collapse; collapse (C) showing subchondral cysts followed by collapse; arthrosis-like (A) showing osteoarthrotic features; and the mutilating (M) showing mutilating bone destruction. The HLA-DRB1*0405 antigen frequency in N, E, C, A, and M types was 55%, 61%, 33%, 71%, 100%, respectively. That in the M type (100%) was significantly higher than that in the others (the N, E, C, and A types; 57%). These findings suggest that the most severe shoulder joint destruction pattern in RA, the M type, is associated with HLA-DRB1*0405.
We studied synovial fluid (SF) collagenase in 10 women with severe rheumatoid arthritis (RA), 10 with pyrophosphate arthropathy, and 10 with idiopathic destructive disease of the shoulder conforming to a pattern recently described. SF cell counts were highest in the RA group. Particles were detected by polarized light microscopy and alizarin red staining. Crystals were seen in fluids from all 3 groups; pyrophosphate predominated in the pyrophosphate arthropathy group and alizarin red-positive particles in the idiopathic disease group. Collagenase and tissue inhibitor of metalloproteinase levels were estimated in SF after gel filtration. Tissue inhibitor of metalloproteinase activity was detected in all fluids, but tended to be highest in the RA group. Collagenase activity was detected in 3 RA fluids only. In no sample was collagenase found in an active form. These findings support the clinical concept of an aggressive destructive process which sometimes occurs in the shoulder joints of elderly women. Because we were not able to detect free collagenase in SF from any of the patients with idiopathic shoulder disease, the data suggest that high levels of active collagenase are not characteristic of this group of patients.
Dialysis-related amyloidosis (DRA) is a serious complication in patients receiving long-term hemodialysis. Intrigued by the fact that the shoulder joint is primarily favored by DRA, we measured the shoulder-capsular distance (SCD) by ultrasonography to investigate the relationship between SCD and the duration of hemodialysis, patient age and biochemistry findings. The SCD of patients receiving hemodialysis was significantly increased, and there was a positive correlation between SCD and the duration of hemodialysis. The SCD tended to show a significant increase in patients receiving long-term hemodialysis over 10 years. Although the SCD was not significantly correlated with serum levels of beta 2-microglobulin and C-PTH, there was a significant positive correlation between the SCD and the serum levels of AI. In patients receiving long-term hemodialysis for 10 years or more, the SCD was increased significantly in the groups patients with the complications of carpal tunnel syndrome (CTS), cystic radiolucencies (CRL) or destructive spondyl arthropathy (DSA) compared with the value in complication-free patients. The results of this study suggest that the majority of patients with SCD > 8mm had the complication of DRA. Since ultrasonography is a non-invasive, east-to-perform procedure, ultrasonographic measurement of the SCD seems to be useful in the diagnosis of DRA.
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This is a case report of a congenital anomaly of the biceps tendon whereby the biceps tendon is adherent to the undersurface of the rotator cuff throughout its course in the shoulder joint.
In 11 cases of pectoralis major transfer, tracking movement was performed in the scapular and sagittal planes for both shoulder joints to compare the tracking movement ability of the operated shoulder and the unoperated shoulder. At the same time, electromyograms were taken of the upper trapezius, the middle deltoideus, the pectoralis major and the rhomboideus to compare the EMG amplitude of the operated shoulder and the unoperated shoulder. For all movement at average values, tracking movement ability was better in the operated shoulder. From these findings, it is thought that pectoralis major transfer increases shoulder stability at the time of movement. The increase in EMG amplitude of pectoralis major of the operated shoulder is considered to result from the action of the transferred pectoralis major, which serves as an effective abductor of the scapula, also taking into account the early occurrence of scapular abduction.
We examined with electrophysiological techniques the effects of experimentally induced inflammation on the mechanosensitive afferent units in the rotator cuff of the shoulder joint of 21 rabbits. We identified 21 mechanosensitive units belonging to group III. 12 units had mechanical thresholds of > 7.0 g and 9 units had thresholds of < 7.0 g. After injection of inflammatory agents, kaolin and carrageenan, into the joint space, ongoing afferent discharge rates increased in all units. The average discharge rate increased significantly from 7 imp/s to 15 imp/s after injection. 5 units had a decreased mechanical threshold after the injection. Acute inflammation seems to have an excitatory and sensitizing effect on the high- and low-threshold units in the rotator cuff.
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In addition to conventional radiography using standard and special projections, CT offers valuable information in selected cases. Native CT allows detection of minimal bony lesions, which may cause severe pain that is resistant to therapy. Small amounts of joint effusion as well as the Hill-Sachs impression fracture of the humeral head can be detected with a high degree of accuracy. Following intra-articular injection of contrast medium, CT-arthrography enables visualization of capsular and ligamentous injuries of the shoulder joint. Lesions of the glenoid labrum following shoulder dislocation can be detected and classified by this method.
Inevitable complications after total shoulder replacements, mainly due to wear and loosening of glenoid components, have stimulated research on a new glenoid implant design. The aim of this study is to analyse a new design concept of the glenoid component with the articular surface made of artificial cartilage-specifically a poly(vinyl-alcohol)cryogel (PVA-c). Based on the performed experiments and hyperelasticity law the material model of the PVA-c is defined. Mechanical effects of using a cryogel layer with different geometries in glenoid components are analysed using a finite element method. The analysis allows for identification of design solutions with reduced, lower than failure, strains and stresses in the cryogel. The layer shape similar to the glenoid cartilage shows the most favourable mechanical effects. This indicates a high potential of using this soft material for the articular surface. Replacing the polyethylene with a cryogel layer results in a significant reduction in contact stresses together with the growth in contact area. This can promote fluid film lubrication and lower the wear, thus lower implant failure. Moreover, soft cryogel, having shock absorbing properties, may result in lower stresses at the implant-bone, thus lowering the risk of implant loosening. This study indicates a high importance of an elastic implant for restoring full function of the articular surface in a glenoid component.
UNLABELLED: In 4 fresh specimens and in 14 healthy volunteers we studied normal anatomy of the glenoid labrum by MRI. In a total of 124 patients we examined the shoulder joints by MRI. 69 patients had any kind of subacromial pathology. 55 patients showed a glenohumeral instability. All MRI findings were compared with the surgical findings during arthroscopy and during open surgery. 44 patients showed a recurrent anterior instability, 7 patients showed a multidirectional instability, 2 patients showed a posterior instability, and 2 patients presented acute anterior dislocation. We found significant variability in the labral shape as well as significant variability of anterior capsular attachment. The pathologic changes of the glenoid labrum were classified in four different types. In 78% we found a concomitant Hill-Sachs lesion of various diameter. 5 patients suffered from an additional complete rotator cuff tear. Compared to the intraoperative findings MRI had a sensitivity of 95%, a specificity of 94%, an accuracy of 94%, a positive predictive value of 91%, and a negative predictive value of 96% in detecting labral pathology. CLINICAL RELEVANCE: Presenting a high diagnostic value for detecting Bankart lesions, MRI may replace other diagnostic modalities like CT-arthrography.
Radiologically apparent unilateral changes at the intertubercular groove of the humerus were investigated histologically in three dogs and compared with the findings in an unaltered shoulder joint of a dog. Polymethylmethacrylate embedded, undecalcified sections were cut through the sulcus area at the head of humerus and through the biceps tendon, its synovial sheet and the transverse ligament, and were evaluated by light microscopy. While the tendon and soft tissue features were for the most part typical for a normal "gliding" tendon, the respective groove exhibited an again groove-like, 10-12 mm wide and up to 2 mm high exostosis consisting mainly of lamellar bone, filled with hemopoietic and fatty marrow. The normal fibrocartilaginous lining of the groove showed degenerative arthrotic changes in the altered grooves, pointing to mechanical overloading. The possible mechanisms of these ossifications are discussed.
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A careful selection of 19 patients fitting the classical description of polymyalgia rheumatica have been examined by arthroscopy and thoroughly screened and followed up to exclude rheumatoid arthritis and other disease processes. Synovitis of the shoulder joint has been observed through the arthroscope in 17 and synovitis of varying degrees noted histologically, 4 of whom were studied by immunofluorescence. Five patients had radioactive joint scans.
A 48-year-old patient sustained depressed fracture dislocations of both shoulder joints during a grand mal epileptic seizure. Surgical treatment consisting of implantation of two Neer total replacements was successful: the functional result was good, and within 12 weeks the patient was free of pain and able to resume work.