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PubMed1994

Shoulder joint stability after arthroscopic subacromial decompression.

In 55 patients with type I or type II impingement lesions we performed arthroscopic subacromial decompression. Fifty-two patients are followed up 1 year postoperatively. In all patients the condition of the affected shoulder before and after decompression was documented using a 100-point shoulder score (pain on activity, 15 points; pain without activity, 15 points; function, 20 points; weight lifting, 10 points; muscle strength, 15 points; range of motion, 25 points). At follow-up we also documented the extent of passive inferior shift of the humeral head by ultrasound. The mean score preoperatively was 60.9 (+/- 13.8). Postoperatively there was a significant increase to 84.7 (+/- 12.5). The average postoperative hospital stay was 8.8 days (+/- 2.1). In 12 patients (23%) the postoperative score was less than 85 points, and in these the treatment was considered to have failed. Comparison of these patients as a group with those in whom the treatment was successful revealed no difference in age, a small but not significant difference in the preoperative duration of shoulder complaints, and no difference in the postoperative length of stay in hospital. However, there was a significant difference in the extent of passive inferior shift of the humeral head: in the failure group the mean inferior shift was 4.6 +/- 1.9 mm, while in the other patients the shift was only 2.7 +/- 1.0 mm. This difference was statistically highly significant. There was a statistical highly significant negative Pearson correlation coefficient of -5.56 between postoperative score and inferior shift of the humeral head. We conclude that patients with subacromial pathology and hypermobile glenohumeral joints may not be good candidates for subacromial decompression.

Acromion↗
PubMed1992

A note on the anatomy of the supraspinatus muscle.

The muscles and tendons of the rotator cuff of 37 fixed cadaver shoulder joints were dissected. In ten shoulder joints devoid of gross pathological lesions it was found that the supraspinatus muscle was inserted at two points--mainly into the major tubercle and partly into the lesser tubercle of the humerus. In one case of six, an additional insertion clearly occurred in a shoulder joint with rotator cuff tear.

Aged↗
PubMed1998

Rotator cuff tear associated with an acromioclavicular cyst in rheumatoid arthritis.

We report two cases of a full-thickness rotator cuff tear followed by acromioclavicular cyst formation in patients with longstanding erosive polyarticular rheumatoid arthritis. One of the consequences of a rotator cuff tear is articular instability with upward migration of the humeral head. The ensuing chronic friction against the undersurface of the acromioclavicular joint caused by arm movements can lead to a non-inflammatory effusion of the acromioclavicular joint with cyst formation. Clinical and ultrasonographic features and a pathogenetic hypothesis are discussed.

Acromioclavicular Joint↗
PubMed1994

Two portions of the supraspinatus muscle: a new finding about the muscles macroscopy by dissection and magnetic resonance imaging.

Axial MR images of the shoulder joint reveal a central linear band within the supraspinatus muscle void of signal which seems not to represent the only tendon of this muscle. Due to the importance of the supraspinatus muscle for the painful impingement syndrome of the shoulder we studied the fibrous architecture of this muscle comparing 30 MR images and 49 cadaver dissections. We found the supraspinatus muscle to be composed of two distinct portions. The mean length of the ventral portion is 88 mm and of the dorsal portion 106 mm. The angle of the central tendon which is formed by fibers of both muscle portions relative to the frontal plane is 50 degrees. Both muscle portions probably act differently in moving the arm. This finding seems to be important for the pathophysiology of rotator cuff tears which are mainly located anteriorly within the ventral muscle portion and the eccentric central tendon.

Adult↗
PubMed1996

Peri-articular injection of tenoxicam for painful shoulders: a double-blind, placebo controlled trial.

Eighty out-patients (50 F, 30 M), aged 58 +/- 12 years (range: 26-84) and weighing 72 +/- 10 kg (range: 50-97), presenting with an acute or subacute (< 3 months) episode of rotator cuff tendinitis without (n = 28) or with movement restriction (n = 52) of the shoulder and having a pain intensity of at least 4 on VAS for pain at rest or on active movement, were treated at random and in double blind conditions for 1 to 4 weeks with 1 weekly periarticular anterior injection of tenoxicam 20 mg or placebo. Tenoxicam treated patients improved more than placebo-injected patients in a statistically highly significant manner with regard to clinical index, pain on VAS during active movement and at rest, active mobility (degrees), pain or pressure and clinical global impression (assessed by investigator and patient). There was a nonsignificant opinion that placebo treated patients consumed more rescue medication. Safety assessments were not significantly better in the placebo-treated patients through local tolerability tended to be better in that group. These results indicate that tenoxicam 20 mg injected locally is effective in alleviating pain and in improving shoulder mobility in patients with a painful shoulder episode and suggest that such a treatment is safe and well tolerated. Local injection of tenoxicam seems to be a promising new treatment of acute, painful, local inflammatory processes in Rheumatology, Orthopaedics, Physical Medicine and Sports Medicine. Further studies in other pathologies are warranted.

Adult↗
PubMed2006

Comparison of the MR findings on indirect MR arthrography in patients with rotator cuff tears with and without symptoms.

PURPOSE: To compare indirect magnetic resonance (MR) arthrography findings in patients with rotator cuff tears with and without symptoms. MATERIALS AND METHODS: Indirect MR arthrography results of 15 asymptomatic and 23 symptomatic rotator cuff tears were retrospectively reviewed, comparing the type and size of tears and amount of subacrominal-subdeltoid bursal fluid. RESULTS: There were 14 partial-thickness tears and one full-thickness tear in the asymptomatic group, with 4 small and 11 medium tears. In the symptomatic group, there were 16 partial-thickness and 7 full-thickness tears, with 14 small, 5 medium, and 4 large tears. In the asymptomatic group, the amount of subacrominal-subdeltoid bursal fluid was grade 0, 6 patients; grade 1, 6 patients; grade 2, 2 patients; and grade 3, 1 patient. In the symptomatic group, the amount of subacrominal-subdeltoid bursal fluid was grade 0, 4 patients; grade 1, 3 patients; grade 2, 8 patients; and grade 3, 8 patients. We found no statistically significant difference between symptomatic and asymptomatic tears in the kind and size of tears, and in the amount of subacrominal-subdeltoid bursal fluid. CONCLUSION: We found no difference in the MR findings between symptomatic and asymptomatic rotator cuff tears.

Aged↗
PubMed1997

Anatomy of the normal acromion investigated using MRI.

The shape of the acromion is strongly associated with impingement syndrome and with rotator cuff tears. It is notoriously difficult to image the acromion with conventional radiography. We have developed MRI techniques to depict the acromion in its longitudinal axis. Furthermore, we have measured the subacromial space in both external and internal rotation. In previous studies, three types of acromial shape have been described with the type III or hooked acromion being present in 66% of cases with rotator cuff tears. We studied 31 normal shoulders in 29 people using MRI. Within this population aged 24-36 years, mean age 31 years, no type III acromions were found. Twenty-one were type I (67.7%) and 10 were type II (32.3%). In addition, we found no difference in subacromial height in external or internal rotation. Low rates of intra- and interobserver error were found. These results imply that the hooked acromion is not present in the normal population and is, therefore, likely to be an acquired abnormality.

Acromion↗
PubMed1994

The coracoacromial arch: MR evaluation and correlation with rotator cuff pathology.

The relative prevalence of various acromial shapes, appearance of the coracoacromial ligament and enthesophytes along the inferior aspect of the acromioclavicular joint in patients with and without rotator cuff tears were evaluated. Of 76 patients with clinical instability and impingement, 31 had a normal rotator cuff and 45 demonstrated a partial or full tear of the supraspinatus tendon at surgery. Results were compared with those from magnetic resonance (MR) scans of 57 asymptomatic volunteers. Of the 45 patients with a supraspinatus tear, 38% (17) had a flat acromial undersurface (type I), 40% (18) had a concave acromial undersurface (type II), 18% (8) had an anteriorly hooked acromion (type III), and 4% (2) had an inferiorly convex acromion (type IV). Among the 31 patients with a normal rotator cuff at surgery and the 57 asymptomatic volunteers, the respective prevalences of the type I acromion were 39% (12) and 44% (25), of type II 48% (15) and 35% (20), type III 3% (1) and 12% (7), and type IV 10% (3) and 9% (5). Shoulders with surgically proven rotator cuff tears showed a tendential association with a type III acromion (8/45) and statistically significant associations with a thickened coracoacromial ligament (17/45) and acromioclavicular enthesophytes (18/45). For the association between inferiorly directed acromioclavicular joint enthesophytes and rotator cuff tears, age appears to be a confounding factor. The type IV acromion, newly classified by this study, does not have a recognizable association with rotator cuff tears.(ABSTRACT TRUNCATED AT 250 WORDS)

Acromioclavicular Joint↗
PubMed1995

[Roentgen morphometry of the shoulder in diseased rotator cuff. Value of plain roentgen examination in comparison with arthroscopy].

A comparison between the pathomorphological substrate and the X-ray morphometry of the shoulder joint was made with 482 arthroscopically treated patients. Radiological parameters and indices for the prediction of the development of the impingement-syndrome were developed from this comparison. With these parameters and indices is it possible to predict the pathomorphological substrate and to differentiate between subacromial and coracoidal impingement.

Acromioclavicular Joint↗
PubMed1997

[Rotator cuff rupture. Vascular supply and collagen fiber processes as pathogenetic factors].

Light and polarization microscopic appraisal of the pathways of fibers and blood vessels in the region of the rotator cuff shows branches of the suprascapular artery. These initially radiate into the insertion tendon parallel to the muscle fibers. They do not continue there, i.e. the vessel branches have blind endings, or they branch and anastomose with each other. Outliers of the transverse branch of the anterior circumflex artery of the humerus come from lateral (from the direction of the deltoid muscle). They pass from the bony insertion of the supraspinatus tendon into the tendon plate, but only run together with the fibers for a short distance. Consequently, a zone low in vessels or free of vessels can be constantly demonstrated under a magnifying glass in the course of the supraspinatus and to a small extent also of the infraspinatus in the fetus or neonate as well as in the adult in the region of the zone of interweaving of the tendinous muscle outlier with the capsule at length magnification. In the genesis of rotator cuff rupture, the presence of hypovascularity must be considered to be a predisposing factor which is present from birth onwards. It affects the clinical course during the process of aging as the point of least resistance in consequence of arteriosclerosis, collagen degeneration physiological wear and tear friction at the lower surface of the acromion and inflammatory swellings of the subacromial bursa.

Aged↗
PubMed2006

Arthroscopic transosseous reinsertion of the rotator cuff.

OBJECTIVE: Arthroscopic reinsertion of the supraspinatus and infraspinatus tendons by means of imitation of an open transosseous reinsertion technique. INDICATIONS: Tears in the tendon cuffs of the supraspinatus and infraspinatus muscles. Patients < 75 years of age. CONTRAINDICATIONS: Retracted tendons that cannot be sufficiently mobilized to provide a tension-free reinsertion. Tears of the tendon cuff of the subscapsularis muscle. SURGICAL TECHNIQUE: The free edges of the tendons are sparingly resected. The tendon attachment site on the greater tuberosity is freed of soft tissue and decorticated using an arthroscopic bone burr. A full-radius burr is used to drill insertion sites for the sutures in the tuberosity. A hollow needle is inserted percutaneously to puncture the free edges of the tendon for a single reinsertion suture. The hollow needle is then fed through the greater tuberosity to the lateral portal. The suture is guided through the needle and advanced via a working cannula. If the tear is > 2 cm in width, a mattress suture should be placed via another channel in the bone. This is to provide plane contact of the tendon to the reinsertion site. POSTOPERATIVE MANAGEMENT: Restriction of movement using a shoulder bandage for 6 weeks after the operation. RESULTS: In the 75 patients treated using a single suture, there was an improvement compared to the related Constant Score from 55.8% before the operation to 80.4% at the follow-up examination, after an average of 26.8 months. The average age in this group was 58.2 years (range 35-75 years). In the 21 patients treated with a mattress suture, there was an improvement compared to the related Constant score from 59% before the operation to 83% at 14.3 months after the operation. The average age in this group was 58 years (range 35-75 years).

Adult↗
PubMed2003

[Proximal humeral fracture in the elderly. Primary head replacement as one alternative].

The treatment of humeral fractures in old patients is still an orthopedic problem. Different surgical schools suggest different treatments for head-preserving procedures. Because of new implants and functionally disappointing results in primary hemiarthroplasty, the indication for hemiarthroplasty was examined more critically. The decision of which procedure to choose is complicated by the lack of proper studies with comparable fracture types and enough cases regarding the specific problems of operative fracture treatment in the elderly. Correctly, besides range of movement, the number of necessary reoperations, length of time until pain reduction, and earliest possible axial weight-bearing of the injured limb should influence the therapeutic decision. Regarding all these topics, primary hemiarthroplasty in old patients and specific fracture situations is still to be recommended.

Age Factors↗
PubMed2003

[Intraarticular pathology of atraumatic shoulder dislocations. An arthroscopic study].

AIM OF THE STUDY: According to the literature, atraumatic shoulder dislocations occur without or only minor trauma,self-reduction and no or little pain. Little is known about intraarticular pathology in this entity. It was the purpose of our study to evaluate such findings. METHODS: During a 2-year period,226 patients had surgery for shoulder dislocation.28 patients met the criteria for atraumatic dislocation as above (group A). Patients with bony pathology or recurrent microtrauma were excluded. All had been treated with a rehabilitation program without success.28 consecutive patients with surgery after posttraumatic dislocation served as a control group (group B). At the beginning of the surgery,arthroscopy was performed in all patients and the intraarticular findings were recorded. For the capsulo-labral pathology,we determined 3 types: type I had capsular elongation or scarring and included so called "non-Bankart-lesions"; type II had classic "Bankart"-lesions and type III more complex capsulo-labral lesions like e.g. "ALSPA"-lesions. RESULTS: The mean age in group A was 27.6 y and 26.2 y in group B.12 patients in group A and 5 in group B were female. The average no.of dislocations was 10 (1-30) or 9 (1-28), respectively. In group A we saw type I lesions in 11 patients (39.3%), type II lesions in 9 (32.1%) and type III lesions in 8 (28.6%) patients. In group B we found type I lesions in 8 (28.6%), type II lesions in 4 (14.3%) and type III lesions in 16 (57.1%) patients.Hill-Sachs lesions were found in 22 (78.6%) and 23 (82.1%) of the patients, respectively.Also, we saw chondral glenoid damage, cuff lesions and SLAP-lesions in both groups. CONCLUSION: The above mentioned criteria for atraumatic shoulder dislocation do not exclude intraarticular pathology comparable to posttraumatic cases, at least for patients, who do not respond to a conservative treatment. Besides the etiology, the given pathology must be considered for therapy.

Adult↗
PubMed2003

[Reconstruction of big rotator cuff ruptures. A new technique of tendon refixation with the corkscrew suture anchor system].

Tendon retraction and fatty degeneration is a major problem in repair of massive rotator cuff tears. Especially in the transosseous refixation technique, a tension-free refixation cannot be obtained in all cases. The purpose of this prospective study was to evaluate the postoperative results using a new tension-free reinsertion technique with a Corkscrew suture anchor system. Thirty patients (25 males, 5 females) with complete one and two tendon tears underwent open rotator cuff repair (rupture of one tendon: n=14, 47%). The torn tendons were mobilized and reinserted medially to reduce tension. Medialization was achieved by inserting tendon near the osteochondral border in a bony trough. The number of implanted suture anchors ranged from 2 to 6 (mean: 3.56). The mean age was 56 years (39-68 years) with a follow-up of 24 months (17-33 months). In one patient physical and sonographic examination showed a complete and in two patients a partial rerupture. A temporarily frozen shoulder occurred in two cases. No infection or rejection response was seen. In no case was revision surgery necessary. No displacement or loosening of the Corkscrew anchors was noticed. The constant score improved from 45 points preoperatively to 85 points at the time of follow-up (mean). The Corkscrew suture anchor system in combination with the new suture technique offers the possibility of a stable reinsertion even in reduced calcified bone structure. This facilitates good conditions for stable fibroblastic healing. Our midterm results show good osseous union combined with a low rerupture rate.

Adult↗
PubMed2006

[Arthroscopic reconstruction of the rotor cuff].

Over the last years treatment of rotator cuff tears is evolving gradually from open to complete arthroscopic repair. There had been fast developments in arthroscopic techniques and instruments and there is a better understanding of biomechanical backgrounds. For a good clinical outcome it is not necessary to obtain a watertight closure in all cases but to balance the force couples in the coronal and transverse plane. There is recent discussion regarding the optimum techniques and stitches for cuff reconstruction and resulting developments in this field. To determine the individual reconstruction technique it is crucial to recognize the different tear categories. Based on these findings we are now able to treat nearly every cuff tear arthroscopically, even a retracted massive lesion.

Arthroscopy↗
PubMed2007

[Biomechanical evaluation of glenohumeral stability through muscle force vector analysis. Effect of a decreased glenoid inclination in shoulders with global rotator cuff tears].

OBJECTIVES: The aim of the study was to quantify the decrease in glenohumeral stability following a global rotator cuff tear and to evaluate the effect of a decreased glenoid inclination angle through analysis of muscle force vectors in a computer model. MATERIAL AND METHODS: The lines of action of eight shoulder muscles were integrated into a standard geometric model. Muscle force magnitudes were estimated based on physiological cross-sectional area and normalized electromyographic activity. The magnitude and elevation angle of the resultant force vector was calculated at 0, 30, 60, and 90 degrees of abduction. A rotator cuff tear was simulated by reduction of the corresponding muscle force vectors. RESULTS: At 0 and 30 degrees of glenohumeral abduction a global rotator cuff tear showed a resultant force vector pointing outside the glenoid. In the computer model, decreasing the inclination angle of the glenoid by 30 degrees increased the stability in rotator cuff-deficient shoulders. CONCLUSIONS: The results of this study provide a biomechanical rationale for clinical complications of global rotator cuff tear such as superior humeral head translation. The decreased glenoid inclination simulated in the computer model may represent a biomechanical basis for the development of new operative techniques to treat global rotator cuff tears.

Biomechanical Phenomena↗
PubMed1998

[Rupture of the rotator cuff and skeletal muscle metastasis of primary lung carcinoma. A rare disease picture in differential diagnosis of shoulder pain].

Skeletal muscles is an uncommon site for metastatic spreading of malignancies such as carcinoma of the lung. Thus, to date, there have been only a small number of reports of carcinoma of the lung spreading to the skeletal muscles. This case study reports the rare combination of a rotator cuff lesion of the shoulder with the late occurrence of the metastasis of a squamous cell carcinoma of the lung in the ipsilateral deltoid muscle. The problems that result from this combination concerning diagnosis and therapy are discussed.

Aged↗
PubMed1998

[Lifting osteotomy of the acromion as a new principle in treatment of impingement syndrome, especially in correlation with reconstruction of large rotator cuff lesions].

There are many different causes leading to impingement lesions of the shoulder (e.g., architecture of the acromion, arthritis of the acromioclavicular joint, bursitis subacromialis, chronic instability). There are also different ways of treating it. Neer described his technique of anterior acromioplasty in 1972. With this technique there is sometimes a limitation in the amount of resection possible because of the anatomical findings (i.e., very curved or small acromion). We developed a new technique: the lift-up osteotomy of the acromion (LOA). This technique allows us to gain as much subacromial space as needed (e.g., for large anterior deltoid flaps). Osteotomy of the acromion gives an excellent view of the rotator cuff. Even large lesions can easily be repaired. After the cuff repair is done, the acromion is refixed with two canulated screws. So far, we have used this LOA technique in more than 100 patients in impingement operations, cuff repairs and anterior deltoid flaps all with good results.

Acromion↗