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PubMed1996

Coracoacromial ligament: in situ load and viscoelastic properties in rotator cuff disease.

The coracoacromial ligament plays a role in rotator cuff disease. The changes in the in situ load and viscoelastic properties of the coracoacromial ligament in shoulders with rotator cuff tears were evaluated. Coracoacromial ligaments from 16 cadaveric shoulders (8 with rotator cuff tears, 8 without tears) were evaluated via biomechanical testing of bone ligament bone specimens. An in situ load existed in the coracoacromial ligaments of 19.6 +/- 15.4 N (rotator cuff tear) and 18.3 +/- 9.8 N (no rotator cuff tear). This difference was not statistically significant. Cyclic loading of the ligaments demonstrated a greater drop in peak stress in rotator cuff tear shoulders than in normal shoulders, whereas the stress relaxation response was not different. These changes in the coracoacromial ligament in shoulders with cuff tears may be attributable to ultrastructural changes within the ligament as a result of an altered loading environment. It remains unknown whether they occur as a result of a rotator cuff tear or if they contribute to the pathogenesis of cuff disease.

Aged↗

PubMed1995

[Open surgical therapy of the rotator cuff].

Almost 100 years have passed since the first report of rotator cuff repair in 1898 by W. Müller. Even now new operative techniques are being developed. Various solutions for difficult extended forms of rotator cuff lesions are available besides the closed and semi-closed arthroscopic techniques. Anatomical reconstructive procedures such as local or distant tendon transfer compete with extra-anatomical procedures such as simple debridement, equatorial partial reconstruction or replacement with a delta flap. Hemiarthroplasty of the shoulder has proven to be more and more the treatment of choice in cases of inoperable rotator cuff defects with painful arthropathy. The euphoria caused by complicated reconstructive methods for massive tears has subsided due to an awareness that loss of function is inevitable in chronic degenerative tears with muscle atrophy. Reconstruction should be coordinated step by step with the operative procedure as well as adapted to the biological situation. It should definitely not be forced at any price using an algorithm for a rotator cuff tear operation, the best operative method must be selected by clinical, radiological and intraoperative criteria. The situation is completely different for an acute traumatic rotator cuff tear. Every effort should be made to perform early anatomic reconstruction in a young patient, as the function of the rotator cuff is of great importance in the working world. In contrast to degenerative changes of the rotator cuff tendon, large ruptures can be treated successfully if early immediate repair is performed. The long head of the biceps tendon plays a special role in combination with a rotator cuff tear. The concomitant lesions of the long head of biceps should not to be over-looked when repairing the rotator cuff tear. Until now, a special form of rotator cuff pathology has not received much attention--the so-called interval lesion. It is the forerunner of the rotator cuff tear. The interval lesion is a partial tear of the ligamentous structures between the supraspinatus and subscapularis tendon and leads to damage of the long head of the biceps. The interval lesion can only be diagnosed by arthroscopy or open exploration of the rotator interval.

Age Factors↗

PubMed2002

Quantitative morphology of full thickness rotator cuff tears.

The occurrence of full thickness rotator cuff tears (RCTs) at time of death, the size and distribution of those tears among the tendons of the rotator cuff, and the anterior to posterior and medial to lateral dimensions of the RCTs were determined. A subset of 57 shoulders from a group of 414 were found to have full thickness rotator cuff tears. The three-dimensional coordinates of specific bony landmarks and points defining the circumference of the RCT were digitized using a Flock of Birds DC electromagnetic tracking device. Bony landmarks were used to determine the separation between adjacent tendons of the rotator cuff. Points describing the circumference of the RCT were used to calculate the area of the tear. The majority of tears occurred in the supraspinatus tendon alone (25), or in both the supraspinatus and infraspinatus tendons (22). The areas of the RCTs ranged from 0.07 cm(2) to 19.17 cm(2) with an average of 4.43 cm(2). The mean anterior to posterior length was 1.95 cm. The mean medial to lateral length was 1.98 cm.

Aged↗

PubMed1990

Arthroscopic assisted rotator cuff repair: preliminary results.

Arthroscopic assisted rotator cuff repair is a method of performing an arthroscopic subacromial decompression with repair of the rotator cuff through a limited deltoid splitting approach. We evaluated 25 patients with a minimum of 1 year follow-up. Based on the UCLA shoulder rating, 80% of the patients were rated as excellent or good. There was significant improvement in pain, function, motion, and strength. Ninety-six percent of the patients were satisfied with the procedure. Of the patients with small or moderate size tears, 100% received a satisfactory rating. Arthroscopic assisted rotator cuff repair is presented as an attractive alternative in treating symptomatic patients with complete tears of the rotator cuff.

Arthroscopy↗

PubMed1990

[Clinical management of lesions of the rotator cuff].

Lesions of the rotator cuff are caused in most cases by degenerative changes in the critical area around the tuberosities of the humerus. Clinical examination reveals atrophy of the supra- and infraspinatus muscles, a painful arc of movement and, especially, pain at night. There are many clinical tests that can be helpful in the diagnosis. Both ultrasonography and arthrography have proved to be very sensitive methods for the detection of rotator cuff tears. Ultrasonography allows determination of the size and location in addition. Conservative treatment includes rest, physical therapy and anti-inflammatory medication. In many cases the symptoms are improved by many weeks of conservative treatment alone. Operative treatment becomes necessary when no pain relief and no satisfactory movement can be achieved. Complete correction of the tendon defect is important for postoperative care. Passive exercise must allow the tendon repair to remain intact without subjecting it to undue stress.

Adult↗

PubMed2004

A serial comparison of arthroscopic repairs for partial- and full-thickness rotator cuff tears.

PURPOSE: To compare the outcome of arthroscopic rotator cuff repair and subacromial decompression in partial-thickness rotator cuff tears (PTRCT) with those in full-thickness rotator cuff tears (FTRCT). TYPE OF STUDY: Prospective serial follow-up study. METHODS: Of 46 consecutive patients who were treated with arthroscopic rotator cuff repair, 42 patients who were followed-up serially for 2 years were enrolled as study subjects. The average age of the patients at the time of the operation was 55 years, and the mean duration of follow-up was 34 months. The subjects included 22 cases of PTRCT and 20 cases of FTRCT. RESULTS: At the final follow-up, the PTRCT group showed changes in scores from 7.2 to 0.9 for average pain and from 34 to 91 for the shoulder functional evaluation score of the American Shoulder and Elbow Society (ASES score). The FTRCT group showed changes in scores from 7.6 to 1.2 for pain and from 29 to 88 for the ASES score. There were no significant differences between the 2 groups ( P >.05). The average range of shoulder motion was significantly improved in both groups at the final follow-up versus their preoperative values. Evaluation at the final follow-up showed that 93% of the total subjects showed good or excellent results, and 95% showed satisfactory results with regard to pain reduction and functional outcomes. The 2 fair results were the result of acromioclavicular arthritis. CONCLUSIONS: It may be anticipated that arthroscopic rotator cuff repair and subacromial decompression will give satisfactory postoperative outcomes in both PTRCT and FTRCT in terms of pain relief and functional recovery. However, careful preoperative examination of the acromioclavicular joint is critical to avoid procedural failure. LEVEL OF EVIDENCE: Level IV.

Acromioclavicular Joint↗

PubMed2000

The coracoacromial ligament: anatomical and biomechanical properties with respect to age and rotator cuff disease.

The coracoacromial ligament (CAL) plays an important role in the pathoetiology of the subacromial impingement syndrome especially in those patients who do not have bony abnormalities. A total of 40 shoulders were dissected to determine the anatomical and biomechanical properties of the CAL in shoulders with either intact rotator cuffs or rotator cuff disease, taken from cadavers of persons who were of various ages at death. The specimens from cadavers with rotator cuff degeneration had a shorter lateral and medial band of the CAL than those of the specimens taken from shoulders with intact rotator cuffs. The cross-sectional area of the lateral band was also enlarged in older specimens with rotator cuff degeneration. Analysis of the structural properties showed a higher load to failure and a higher stiffness in the younger than in older specimens. In material properties, there was a higher failure stress in specimens with normal rotator cuffs than in the specimens with rotator cuff disease but only in older specimens. The decreased material properties in older specimens with rotator cuff disease may be caused by the previously reported histological differences with tissue disorganization and a lack of parallel bundle orientation associated with rotator cuff disease.

Adult↗

PubMed1991

[Long-term results of surgical management of rotator cuff rupture].

The operative management of rotator cuff tears is gaining in importance: the growing proportion of elderly people with the consequent increase in frequency, more reliable diagnostic techniques (for clinical examinations and modern imaging techniques), more accurate indications for surgery and improved and more versatile operating techniques account for this development. Except for the rate occurrence of traumatic ruptures in young patients, which call for early surgical repair, operative treatment is indicated only in cases of failed conservative treatment, intractable pain and/or pseudoparalysis. The latter conditions are often encountered in manual workers, in whom the dominant side is affected. Very often, diminished physical demands after retirement reduce these discomforts to a tolerable level. This phenomenon also explains the surprisingly good long-term results in cases where surgical repair of the rotator cuff was performed more than 20 years ago. The reported percentages of these shoulders that are free or almost free of pain range between 80% and 90%, i.e., slightly higher than the percentage in younger, physically still active age groups a few years after surgery. Similarly, weakness is not perceived as such or at least not felt to be burden-some. Future evaluations of the outcome of rotator cuff repairs will be carried out according to the guidelines of the European Society for Shoulder and Elbow Surgery and the scoring system worked out by C. R. Constant; this puts more emphasis on the function, which itself is related to age- and sex-related standards.

Adult↗

PubMed1997

Pathology of failure of the rotator cuff tendon.

In failure of the rotator cuff tendon, interference with its function prevents the rotator cuff from fulfilling its physiologic role. Trauma in younger individuals, calcifying tendinitis, degenerative changes of cuff tendon, and partial- or full-thickness tears cause cuff failure intrinsically. Degenerative changes constitute the most frequent cause of cuff failures and correlate with tendon tearing. An acromial spur, long coracoid process, subacromial bursitis, and thickening of the corocoaromial ligament causes cuff failure extrinsically.

Humans↗

PubMed2000

Repair of the rotator cuff. Mini-open and arthroscopic repairs.

The repair of rotator cuff tears by traditional open subacromial decompression and rotator cuff tendon reapproximation has proved successful in restoring function and decreasing pain, but open rotator cuff repair has some inherent disadvantages. Postoperative detachment of the deltoid repair has been reported and results in significant morbidity. The open technique may also require a longer period of limited motion resulting in greater stiffness. Arthroscopically assisted mini-open repairs and, more recently, completely arthroscopic repairs of the rotator cuff have been developed and increasingly are being applied. Both techniques avoid detachment of the deltoid. The mini-open and arthroscopic approaches to rotator cuff repair have the added benefit of arthroscopic evaluation of the glenohumeral joint. The mini-open technique has the advantage of allowing the direct visualization of the cuff repair and allows surgeons to place the stitches in an open fashion, which is familiar to all surgeons. The mini-open technique also allows the placement of tension-absorbing stitches in the rare cases that they are needed. Mini-open techniques also allow the choice of bone anchors or osseous tunnels for fixation. The completely arthroscopic cuff repair has several potential advantages over the open and mini-open cuff repair techniques; first is the decreased disruption of the soft tissues, which may result in less scarring and adhesions. The procedure is the most cosmetically appealing of the techniques. Reduced postoperative pain is also cited as an advantage but has been demonstrated only in a single, nonrandomized study. Finally, if technical difficulties arise, the conversion to a mini-open repair can be done easily. In a few studies, arthroscopic cuff repair techniques have shown promise as an alternative to mini-open or open repair, but these results have been at the hands of a few surgeons who have extensive experience in arthroscopy of the shoulder. In contrast, the mini-open procedure requires modest arthroscopic skills and has a documented history of success. Nevertheless, arthroscopic rotator cuff repair is a viable and effective technique in the hands of surgeons with adequate skills, and this procedure is likely to become more commonly performed in the future as shoulder arthroscopic skills and instrumentation improve.

Arthroscopy↗

PubMed2003

MRI-negative rotator cuff tears.

We report two cases of rotator cuff tear in which the T(2)-weighted MRI signal was negative at the first examination, but positive by the second examination without any changes in symptoms. Many authors have reported on correlations between the MRI and operative findings of rotator cuff tears. However, MRI findings, history of symptoms and operative findings in our patients suggest that there was a discrepancy between symptoms and MRI findings dependent on the period from the injury. Operative findings also indicate that intratendinous tears might have occurred first in these patients then progressed to partial or full thickness tears over time. We concluded that physicians should keep rotator cuff pathology in mind even in patients whose MRI findings are negative but symptoms of rotator cuff tear persist.

Adult↗

PubMed2003

Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively.

BACKGROUND: Evaluation of the rotator cuff in a shoulder that has been persistently painful postoperatively could be challenging. Magnetic resonance imaging has been the preferred imaging method, but accuracy rates have been lower for those shoulders than for shoulders that have not been operated on; also, magnetic resonance imaging is susceptible to suture anchor artifact. The purpose of this study was to evaluate the diagnostic accuracy of ultrasound for evaluating the rotator cuff in shoulders that are painful postoperatively. METHODS: The records of forty-four consecutive patients who had undergone both a high-resolution ultrasound examination and subsequent shoulder arthroscopy were retrospectively reviewed. Thirty-four patients underwent rotator cuff repair at the time of the arthroscopy, and ten had subacromial decompression or another procedure without cuff repair. The results of the ultrasound examination were compared with the intraoperative findings of the arthroscopic examination (the "gold standard"). RESULTS: Ultrasound led to a correct diagnosis for forty of the forty-four patients. Twenty-two recurrent rotator cuff tears and twenty-two intact rotator cuffs were found at surgery. Ultrasound correctly identified twenty of the twenty-two rotator cuff tears (true-positive results) and twenty of the twenty-two intact rotator cuffs (true-negative results). Two intact cuffs were identified as having a full-thickness tear (false-positive results), and two cuffs with a full-thickness rotator cuff tear were identified as being intact (false-negative results). The sensitivity and specificity of ultrasound for identifying rotator cuff integrity postoperatively were 91% and 86%, respectively. The accuracy was 89%. CONCLUSIONS: Ultrasound is a highly accurate imaging study for evaluating the integrity of the rotator cuff in shoulders that have undergone an operation. Its accuracy for operatively treated shoulders appears to be comparable with that previously reported for shoulders that had not been operated on.

Adult↗

PubMed2006

Clinical and structural results of open repair of an isolated one-tendon tear of the rotator cuff.

BACKGROUND: The clinical outcomes of open rotator cuff repair are well established, but the structural results and their effect on clinical outcome are poorly known. We assessed the structural changes in the musculotendinous units after open rotator cuff repair and correlated these findings with the clinical outcome to establish a benchmark for future series. METHODS: Thirty-two consecutive standardized open repairs of a single tendon tear of the rotator cuff were analyzed in twenty-one men and eleven women with an average age of 59.0 years. The supraspinatus tendon was involved in twenty-two patients and the subscapularis tendon, in ten. The clinical outcome, including the Constant score, was assessed prospectively for all patients at an average of thirty-eight months postoperatively. The structural outcome was assessed on standardized magnetic resonance imaging scans. RESULTS: The mean overall subjective shoulder value was 82.8% of the value for a normal shoulder. On the average, the age and gender-adjusted Constant score increased from 63.9% preoperatively to 94.5% postoperatively (p < 0.0001); the score for pain, from 6.8 points to 13.2 points (p < 0.0001); and the score for activities of daily living, from 11.2 points to 17.9 points (p < 0.0001). The overall rerupture rate was 13% (four of the thirty-two shoulders). All reruptures were distinctly smaller than the original tear. Muscular atrophy or fatty infiltration did not significantly decrease after the tendon repair. In fact, fatty infiltration in the supraspinatus (p < 0.0053) and infraspinatus (p < 0.003) muscles increased significantly. CONCLUSIONS: Direct open repair of a complete, isolated tear of one tendon of the rotator cuff resulted in significant subjective and objective improvement and very high patient satisfaction. Successful direct repair was not associated with a decrease in preoperative muscular atrophy and was associated with increased fatty infiltration of the muscle.

Adult↗

PubMedDate not supplied

Hemiarthroplasty of the shoulder for rotator cuff arthropathy.

Sixteen patients underwent hemiarthroplasty for rotator cuff arthropathy between June 1989 and March 1992, and evaluations obtained before and after surgery in all patients were compared. A modular head large enough to articulate with the coracoacromial arch but not so large as to prevent approximately 50% of humeral head translation on the glenoid was used in these cases. Each patient was evaluated with Neer's limited goals rating scale after an average follow-up of 33 months (24 to 55 months). Ten patients were rated as successful and six as unsuccessful. Four of the six unsuccessful patients had undergone at least one attempt at rotator cuff repair with acromioplasty before the index procedure, and two of these four patients had deficient deltoid function after this rotator cuff surgery as a result of postoperative deltoid detachment. Also, three of these four patients who had previously undergone acromioplasty subsequently had anterosuperior subluxation after hemiarthroplasty. Hemiarthroplasty did not provide for a successful outcome in all patients with rotator cuff arthropathy. However, 10 of the 12 patients in this series with good deltoid function and an adequate coracoacromial arch were rated as successful by Neer's limited goals criteria. In addition, this study illustrates that formal acromioplasty carried out during attempts at rotator cuff repair in such patients may jeopardize the subsequent success of hemiarthroplasty.

Aged↗

PubMed1999

Greater tuberosity changes as revealed by radiography: lack of clinical usefulness in patients with rotator cuff disease.

OBJECTIVE: Studies linking greater tuberosity findings on radiographs with rotator cuff disease have largely been uncontrolled and biased toward more severe disease. We correlated greater tuberosity changes seen on radiography with rotator cuff disease seen on MR images in a broadly symptomatic patient population. MATERIALS AND METHODS: Both radiography and MR imaging were performed in 108 shoulders. Unaware of the MR imaging findings, three radiologists independently reviewed the radiographs for cortical thickening, subcortical sclerosis, and cystlike lesions in the humeral greater tuberosity. Interobserver agreement was analyzed using kappa statistics. We correlated the radiographic findings with MR imaging evidence of rotator cuff tears and tendonopathy. The positive predictive value of each finding for rotator cuff disease was also calculated. RESULTS: Interobserver agreement for the three radiographic findings was poor to fair: Kappa values ranged from .06 to .41. Cortical thickening and subcortical sclerosis were not seen more frequently in shoulders with rotator cuff disease than in normal shoulders. Cystlike lesions were more prevalent in shoulders with rotator cuff disease, but the association reached statistical significance (p < .05) for one observer only. Positive predictive values for each finding were low (14-48% for predicting full-thickness rotator cuff tears). CONCLUSION: Cortical thickening of the greater tuberosity and subcortical sclerosis are not associated with rotator cuff disease. For some observers, identifying cystlike lesions is associated with rotator cuff disease, but the clinical usefulness of the observation is limited by high interobserver variability and poor positive predictive value.

Female↗

PubMed2005

Management of irreparable rotator cuff tears and glenohumeral arthritis.

Glenohumeral arthritis with irreparable rotator cuff tears remain a difficult entity to treat. Varied causes include rotator cuff tear arthropathy, osteoarthritis, or rheumatoid arthritis with irreparable cuff tear. Common symptoms are progressive pain and dysfunction. Physical examination may reveal pain, crepitance, rotator cuff weakness, and loss of motion and function. Radiographs may reveal varying degrees of osteophyte formation, sclerotic bone, superior humeral head migration, and bony erosion. Additional imaging modalities may reveal cuff tear size, retraction, atrophy, and fatty infiltration. Failure of nonoperative management may lead to operative intervention. Rotator cuff repair or reconstruction may help prevent progression of tears and future arthritic changes. In patients with moderate to severe glenohumeral arthritis and irreparable rotator cuff tears, hemiarthroplasty is currently the procedure of choice. For patients with severe cuff dysfunction or loss of coracoacromial arch, or for patients who require revision, the reverse shoulder prosthesis may offer a treatment option. Future management continues to be defined with additional study.

Acromion↗

PubMed1992

Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears. A suspension bridge model.

Twelve shoulders with known massive rotator cuff tears were imaged fluoroscopically. The observed kinematic patterns were correlated with the known locations of the rotator cuff tears. Three kinematic patterns emerged: Type I, stable fulcrum kinematics associated with tears of the superior rotator cuff (supraspinatus and a portion of the infraspinatus); Type II, unstable fulcrum kinematics associated with tears that involved virtually all of the superior and posterior rotator cuff; and Type III, captured fulcrum kinematics associated with massive tears that involved the supraspinatus, a major portion of the posterior rotator cuff, and a major portion of the subscapularis. In Type III, an "awning effect" of the acromion was observed to influence active motion. Based on the recorded kinematic patterns, a biomechanical model was developed comparing the rotator cuff tear to a suspension bridge (loaded cable). A biomechanical analysis of forces acting on the rotator cuff according to this model yielded data that supported the contention that certain rotator cuff tears in older individuals may be adequately treated with debridement and decompression, without repair.

Fluoroscopy↗

PubMedDate not supplied

MR imaging of rotator cuff injury: what the clinician needs to know.

The rotator cuff muscles generate torque forces to move the humerus while acting in concord to produce balanced compressive forces to stabilize the glenohumeral joint. Thus, rotator cuff tears are often associated with loss of shoulder strength and stability, which are crucial for optimal shoulder function. The dimensions and extent of rotator cuff tears, the condition of the involved tendon, tear morphologic features, involvement of the subscapularis and infraspinatus tendons or of contiguous structures (eg, rotator interval, long head of the biceps brachii tendon, specific cuff tendons), and evidence of muscle atrophy may all have implications for rotator cuff treatment and prognosis. Magnetic resonance imaging can demonstrate the extent and configuration of rotator cuff abnormalities, suggest mechanical imbalance within the cuff, and document abnormalities of the cuff muscles and adjacent structures. A thorough understanding of the anatomy and function of the rotator cuff and of the consequences of rotator cuff disorders is essential for optimal treatment planning and prognostic accuracy. Identifying the disorder, understanding the potential clinical consequences, and reporting all relevant findings at rotator cuff imaging are also essential.

Health Knowledge, Attitudes, Practice↗