Article

Abnormal Findings on Magnetic Resonance Images of Asymptomatic Shoulders

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Abstract

Magnetic resonance images of the shoulders of ninety-six asymptomatic individuals were evaluated to determine the prevalence of findings consistent with a tear of the rotator cuff. The scans were reviewed independently by two diagnostic radiologists who are experienced in the interpretation of magnetic resonance images of the shoulder. The over-all prevalence of tears of the rotator cuff in all age-groups was 34 per cent (thirty-three). There were fourteen full-thickness tears (15 per cent) and nineteen partial-thickness tears (20 per cent). The frequency of full-thickness and partial-thickness tears increased significantly with age (p < 0.001 and 0.05, respectively). Twenty-five (54 per cent) of the forty-six individuals who were more than sixty years old had a tear of the rotator cuff: thirteen (28 per cent) had a full-thickness tear and twelve (26 per cent) had a partial-thickness tear. Of the twenty-five individuals who were forty to sixty years old, one (4 per cent) had a full-thickness tear and six (24 per cent) had a partial-thickness tear. Of the twenty-five individuals who were nineteen to thirty-nine years old, none had a full-thickness tear and one (4 per cent) had a partial-thickness tear. Magnetic resonance imaging identified a high prevalence of tears of the rotator cuff in asymptomatic individuals. These tears were increasingly frequent with advancing age and were compatible with normal, painless, functional activity. The results of the present study emphasize the potential hazards of the use of magnetic resonance imaging scans alone as a basis for the determination of operative intervention in the absence of associated clinical findings.

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... The supraspinatus and infraspinatus tendons are known to be responsible for the dorsocranial displacement of this key fragment [1]. In elderly patients with humeral head fractures, concomitant chronic degenerative rotator cuff pathologies are common [3,4]. Milgrom et al., for example, found rotator cuff lesions in 80% of asymptomatic patients 80 years of age and older [5]. ...
... Overall, demographic change in western countries has led to an increased number of dislocated proximal humeral fractures in elderly patients [12]. These patients often show preexisting rotator cuff tears [4,5,13]. In the present patient population, the incidence of degenerative rotator cuff pathologies in older patients was also higher than in younger patients. ...
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It is assumed that dorsocranial displacement of the greater tuberosity in humeral head fractures is caused by rotator cuff traction. The purpose of this study was to investigate the association between rotator cuff status and displacement characteristics of the greater tuberosity in four-part humeral head fractures. Computed tomography scans of 121 patients with Neer type 4 fractures were analyzed. Fatty infiltration of the supra- and infraspinatus muscles was classified according to Goutallier. Position determination of the greater tuberosity fragment was performed in both coronary and axial planes to assess the extent of dorsocranial displacement. Considering non-varus displaced fractures, the extent of the dorsocranial displacement was significantly higher in patients with mostly inconspicuous posterosuperior rotator cuff status compared to advanced fatty degenerated cuffs (cranial displacement: Goutallier 0–1: 6.4 mm ± 4.6 mm vs. Goutallier 2–4: 4.2 mm ± 3.5 mm, p = 0.020; dorsal displacement: Goutallier 0–1: 28.4° ± 32.3° vs. Goutallier 2–4: 13.1° ± 16.1°, p = 0.010). In varus displaced humeral head fractures, no correlation between the displacement of the greater tuberosity and the condition of the posterosuperior rotator cuff could be detected (p ≥ 0.05). The commonly accepted theory of greater tuberosity displacement in humeral head fractures by rotator cuff traction cannot be applied to all fracture types.
... Partial rotator cuff injury is recognized as an important cause of shoulder dysfunction and pain. 1 Its incidence is not yet consensus in literature, although there are several studies about it. [2][3][4] Sher et al., 3 analyzing 96 asymptomatic shoulders by ultrasound, found 20% of partial lesions. By dissecting 249 shoulders of corpses, Lohr and Uhthoff 2 found 32% of partial injuries, while Fukuda 5 found 13%. ...
... Partial rotator cuff injury is recognized as an important cause of shoulder dysfunction and pain. 1 Its incidence is not yet consensus in literature, although there are several studies about it. [2][3][4] Sher et al., 3 analyzing 96 asymptomatic shoulders by ultrasound, found 20% of partial lesions. By dissecting 249 shoulders of corpses, Lohr and Uhthoff 2 found 32% of partial injuries, while Fukuda 5 found 13%. ...
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Resumo Objetivos Avaliar os resultados clínicos dos pacientes submetidos ao tratamento artroscópico da lesão parcial da porção articular do manguito rotador pelas técnicas de sutura transtendão e após completada a lesão e comparar o tempo de recuperação pós-operatório das duas técnicas. Método Estudo retrospectivo baseado na identificação de todos os casos com lesão parcial da porção articular do manguito rotador submetidos a tratamento artroscópico no período de outubro de 1999 a dezembro de 2016 pelo Grupo de Ombro e Cotovelo da nossa instituição. Foram incluídos 39 pacientes divididos em 2 grupos: os que foram submetidos à técnica transtendínea e os outros em que a lesão foi completada. Os dois grupos foram estatisticamente semelhantes. Foi realizada a análise dos respectivos prontuários, da identificação da técnica aplicada, dos resultados pós-operatórios e das complicações relacionadas. A avaliação funcional foi realizada através do escore da University of California at Los Angeles (UCLA). Resultados Não houve diferença estatisticamente relevante entre os grupos, com escore UCLA médio de 32, não havendo diferença também no tempo necessário para reabilitação. Conclusão Não houve diferença entre o resultado clínico dos pacientes, independente da técnica empregada para o reparo das lesões parciais da porção articular do manguito rotador com resultados satisfatórios em 93% dos casos.
... 51% in those aged > 60 years [6,7]. Most symptomatic RCTs when left untreated may progress in size, which can lead to rotator cuff arthropathy [8,9]. ...
... Prevention is often preferred as a course of action over cure, and, with respect to the shoulder, if patients could be successfully diverted away from developing symptomatic end-stage glenohumeral arthritis, this would offer benefits to all from both population and socio-economic perspectives. However, the clinical burden that RCTs pose is likely to evolve inextricably and as a consequence of our aging population demographics [6,7]. ...
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Background: The prognostic factors for patients with full-thickness rotator cuff tears (RCTs) include tear size, muscle atrophy and fatty infiltration. However, the influence of early coexisting degenerative changes on RCT outcomes is unappreciated. The purpose of this study was to calculate the impact that pre-existing partial glenohumeral cartilaginous changes have on patients undergoing arthroscopic RCT repair. Methods: A study of 54 patients undergoing arthroscopic RCT repair was undertaken. The presence of co-existing patches of glenohumeral degenerative cartilaginous changes and RCT size was recorded at surgery. Pre- and postoperative outcomes were assessed using traditional (Oxford Shoulder Score [OSS], 5-level EuroQol-5D [EQ-5D-5L] questionnaire and EuroQol visual analog scale [EQ-VAS]) and patient-centric re-formatted prisms. Outcomes were assessed as an entire dataset, and sub-group analysis was performed according to the grade of co-existing arthritis and tear size. Results: Significant improvements (p<0.05) in clinical outcomes were recognized when assessed using either the traditional or reformatted prisms (average % improvements in OSS, EQ-5D-5L and EQ-VAS were 47%, 33% and 43%, respectively; average improvements in pain, function, and psychological well-being were 48%, 33% and, 29%, respectively). Positive gain was noted in all sub-groups of arthritic grading and tear size. Conclusions: Good clinical outcomes can be achieved following RCT repair even in the presence of local partial degenerative cartilage changes and advancing tear size. These benefits are patient-centered but require RCT repairability.
... R otator cuff injuries are the most common type of shoulder disability, 1 leading to approximately 4.5 million physician visits each year. 2 While rotator cuff injuries can be linked to trauma, they also can be considered a part of normal degenerative changes associated with aging. 3,4 It is estimated that approximately 25% of adults in their 60s and 50% of adults in their 80s have a full thickness rotator cuff tear. 3,4 Symptoms of rotator cuff injuries often include pain, decreased strength, and range of motion, which can significantly limit the ability to complete activities of daily living. 2 In addition to direct cost to individuals for treatment, the loss of function can lead to the inability to work, loss of income, and depression. ...
... 3,4 It is estimated that approximately 25% of adults in their 60s and 50% of adults in their 80s have a full thickness rotator cuff tear. 3,4 Symptoms of rotator cuff injuries often include pain, decreased strength, and range of motion, which can significantly limit the ability to complete activities of daily living. 2 In addition to direct cost to individuals for treatment, the loss of function can lead to the inability to work, loss of income, and depression. 5,6 Furthermore, injury recurrence rates after surgical repair have been estimated at 57.8%, 7 and several studies have failed to determine a significant difference in efficacy between surgical and nonsurgical management. ...
Article
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Purpose To evaluate the completeness of patient-reported outcomes (PROs) reporting using Consolidated Standards of Reporting Trials Patient-Reported Outcome (CONSORT-PRO) in randomized controlled trials (RCTs) involving rotator cuff injuries. Methods We performed a comprehensive search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials for published RCTs focused on rotator cuff injuries that included at least one PRO measure. We included RCTs published from 2006 to 2020. Investigators extracted data from RCTs using the CONSORT-PRO and evaluated each RCT using the Cochrane Risk of Bias 2.0 tool. Our primary objective was to evaluate the mean completion percentage of CONSORT-PRO. Our secondary objective used bivariate regression analyses to explore the relationship between trial characteristics and completeness of reporting. Results The initial search returned 467 results, with 33 published RCTs meeting the prespecified inclusion criteria. The mean CONSORT-PRO completeness across all included RCTs was 49.7% (standard deviation 15.43). An increase in sample size was associated with an increase in mean completeness of reporting (t = 2.31; P = .028). The Risk of Bias assessment found 29 (of 33, 87.88%) RCTs had “some concerns” for bias. We did not find any additional significant associations between completeness of reporting and trial characteristics. Conclusions Randomized controlled trials involving rotator cuff injuries frequently use PRO measures as primary outcomes. Reporting of these PRO measures is suboptimal and may benefit from rigorous standardization. Clinical Relevance PRO measures are increasingly incorporated as primary or secondary outcomes of RCTs. Appropriate reporting and use of state-of-the-art PRO measures may improve the dissemination of clinical knowledge from RCTs to guide treatment and determine intervention effectiveness. With increased adoption of Patient-Reported Outcome Measure Information System and adherence to CONSORT-PRO, orthopaedic literature may improve PRO reporting to optimize the interpretability of PROs and facilitate patient-centered care.
... The evaluation of the dissected specimens showed an overall prevalence of 27.5% of full-thickness RCT (n = 11) which is comparable to findings of other authors 7,9 . Differences may be due dissimilarities of subject population (age, clinical history etc.) and different survey methods (MRI, ultrasound, arthroscopy, anatomical dissection etc.). ...
... Differences may be due dissimilarities of subject population (age, clinical history etc.) and different survey methods (MRI, ultrasound, arthroscopy, anatomical dissection etc.). A higher prevalence and greater size of tears with increasing age as reported in the literature, was also confirmed in this study [7][8][9] . ...
Article
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The coracohumeral ligament (CHL) is an important structure of the biceps pulley which also merges with the rotator cuff. Which role it actually plays in the pathogenesis of rotator cuff degeneration (RCD) and rotator cuff tears (RCT) is still a point of discussion. The hypothesis of this study was, that macroscopic injury to the anterosuperior part of the rotator cuff also includes parts of or the whole CHL. Forty fresh-frozen shoulders were dissected and examined, the morphology of the rotator cuff and the coracohumeral ligament were evaluated and existing lesions documented. 27.5% of the shoulder joints showed an anterosuperior full-thickness RCT. 57.5% of all examined shoulder girdles showed at least a partial rupture of the CHL. A highly significant correlation ( p < 0.001, rho = 0.529) between the presence of rotator cuff tears and ruptures of the CHL was found. Cartilage damage within the anterosuperior section of the humeral head was observed in 20% cases. In rotator cuff degeneration and atraumatic rotator cuff tears of the elderly population, the pathomechanism of full-thickness RCT is based on repetitive anterosuperior glenoid impingement. This is especially supported by the identification of a higher frequency of CHL lesions compared to RCT reported in this study. No intact CHL was identified in shoulders with damaged rotator cuff tendons.
... Furthermore, previous imaging based studies have also shown that rotator cuff tearing and degeneration increases with age even in asymptomatic individuals. 48 Whilst careful patient selection remains paramount to avoid rotator cuff failure in total shoulder arthroplasty, the natural history of degenerative cuff tears with age will likely remain a contributor to revision in total shoulder arthroplasty in the future. ...
Article
Background Shoulder replacement is a reliable treatment for the relief of pain and improvement of function in patients with glenohumeral arthritis, rotator cuff arthropathy, osteonecrosis and fracture. Limited data is available comparing revision rates for the different types of shoulder replacement when used in younger patients. This study aims to compare the survivorship of hemi resurfacing, stemmed hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty in younger patients using data from a large national arthroplasty registry. Methods Data from the Australian Orthopaedic Association National Joint Replacement Registry was obtained for the period 16 April 2004–31 December 2018. The study population included all shoulder arthroplasty patients aged <65 years. These were stratified into two groups: <55 years and 55–64 years. A total of 8742 primary shoulder arthroplasty procedures were analysed (1936 procedures in the <55 years and 6806 in the 55–64 years age group). Results In the <55 years age group, there was no difference in revision rate for total shoulder arthroplasty versus reverse total shoulder arthroplasty at any time point. Reverse total shoulder arthroplasty had a lower revision rate after six months when compared to hemi resurfacing (HRA) (p = 0.031). Also, reverse total shoulder arthroplasty had a higher early rate of revision in the first 12 months compared to hemiarthroplasty (p = 0.018). However, from 2 years reverse total shoulder arthroplasty had a lower revision rate overall (p = 0.029). In the 55–64 years patient age group, reverse total shoulder arthroplasty had a lower earlier revision rate. This was statistically significant compared to hemi resurfacing (HRA) (p = 0.028), hemiarthroplasty (p = 0.049) and total shoulder arthroplasty (p < 0.001). Conclusion This study demonstrated that for patients aged <55 years there was no significant difference in the rate of revision when total shoulder arthroplasty and reverse total shoulder arthroplasty were compared. reverse total shoulder arthroplasty had a lower rate of revision when compared to hemi resurfacing and hemiarthroplasty after 2 years. reverse total shoulder arthroplasty had the lowest comparative revision rate in patients aged 55–64 years overall.
... Cependant, le plus souvent, les déchirures de la coiffe des rotateurs se produisent lentement au fil du temps, possiblement favorisée par des contraintes biomécaniques excessives sur le supraspinatus, liées à une traction supérieure excessive du deltoïde du fait de changements de son vecteur d'action 21 par un débord latéral de l'acromion 22, 23 et/ou une inclinaison glénoïdienne supérieure 23,24 . Dans ces circonstances, les premières fibres rompues sont généralement les fibres profondes du supra-épineux, à environ 1 centimètre en arrière du bord antérieur du tendon [25][26][27] . La rupture des fibres peut affecter une partie de l'épaisseur du tendon (rupture partielle) ou toute l'épaisseur du tendon (rupture transfixiante). ...
Thesis
La prothèse inversée d’épaule a été développée dans les années 80 et a permis de prendre en charge des patients atteints d’omarthrose excentrée. Progressivement, les indications de cette prothèse se sont élargies et c’est à présent le type de prothèse d’épaule le plus posé dans le monde. De plus en plus de prothèses inversées sont implantées chez des patients ayant une coiffe des rotateurs intacte. De nombreux logiciels permettent d’optimiser le positionnement des implants afin d’avoir une tenue optimale dans l’os de la scapula. Cependant, ces logiciels ne prennent en compte qu’un aspect limité du problème puisqu’ils n’incluent pas d’évaluation de l’état musculaire de la coiffe des rotateurs et les mobilités scapulo-thoraciques. L’objectif de cette thèse était de poser les bases nécessaires à l’élaboration d’un modèle biomécanique patient-spécifique. Pour ce faire, nous avons constitué une cohorte de segmentations de muscles afin de développer un algorithme de segmentation automatisée de ceux-ci. Nous avons également créé le premier modèle de planification de prothèse inversée incluant la position de la scapula par rapport au rachis. Dans l’avenir, cette segmentation automatisée des muscles et la prise en compte de l’articulation scapulo-thoracique va permettre d’améliorer nos planifications et de mieux déterminer le type d’implant et leur positionnement optimal afin d’obtenir les meilleurs résultats fonctionnels possibles après prothèse inversée.
... Partial thickness rotator cuff tears (PTRCTs) have been diagnosed with increased frequency due to heightened awareness and an improvement in diagnostic modalities. 1 The overall prevalence of rotator cuff abnormalities increases with age, from 9.7% in those 20 years and younger, to 62% in those aged 80 years and older. 2 Similarly, PTRCTs are more likely to occur in older individuals and have an estimated prevalence of between 13% and 32%. [3][4][5][6] The true scale of the problem may be greater than originally reported due to the difficulties in identifying intra-tendinous lesions, which account for over half of partial thickness defects. 7 Non-operative management can improve clinical outcomes but do not address the underlying tear. ...
Article
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Tanujan Thangarajah, Ian K Lo Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, CanadaCorrespondence: Tanujan Thangarajah, Department of Trauma and Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada, Email tanujan1@hotmail.comAbstract: Partial thickness rotator cuff tears have been diagnosed with increased frequency due to heightened awareness and an improvement in diagnostic modalities. When > 50% of the tendon thickness has ruptured, intra-tendinous strain of the residual tendon increases. Surgery is generally confined to patients who have failed non-operative measures and have persistent symptoms. The rationale for repairing partial thickness tears lies in their limited self-healing capacity, and propensity to enlarge over time and progress to a full thickness defect. Although tear debridement and acromioplasty can improve pain and function, tear progression can occur, in addition to worse results being noted in bursal-sided defects. Several surgical strategies have been recommended but there is a lack of evidence to advocate one form of treatment over another. The aim of this narrative review is to discuss the treatment options for partial thickness tears of the rotator cuff.Keywords: arthroscopy, rotator cuff, shoulder pain, tendon injuries
... Furthermore, each identified BMI cutoff had a low correct classification rate, with the highest being 12.9% for function SCB. A similar conclusion was reached by Rubenstein et al, 18 who conducted a retrospective analysis to identify BMI cutoffs for shoulder arthroscopy that would reduce postoperative complications. The authors found a significant cutoff at a BMI of 40 but noted this cutoff had a low positive predictive value (2.3%) and would avoid 12% of major complications while excluding 8% of complication-free surgeries, thus making it unsuitable for preoperative screening. ...
Article
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Introduction The purpose of our study was to examine the impact that an increased BMI has on arthroscopic rotator cuff repair (aRCR) outcomes. Methods We identified a sample of 313 patients who underwent aRCR at our institution from 2017 to 2020. Patients were classified into cohorts by BMI; normal BMI (<25), overweight (25-30), and obese (≥30). Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Pain Interference (PI), Pain Intensity (Pi), Upper Extremity (UE) scores, and Clinical Global Impressions (CGI) scale rating of pain and functional improvement after surgery were obtained at one-year postoperatively. The significance of the BMI category as a predictor for outcomes was evaluated using multiple linear and multivariable logistic regressions. Receiver operating characteristic (ROC) curve analysis with Youden’s J-statistic was used to determine optimal BMI cutoff for predicting likelihood of achieving minimum clinically important difference (MCID) and substantial clinical benefit (SCB) on the CGI scales. Results Obesity was a significant predictor of reduced pre-to-postoperative improvement in PROMIS UE score (p = 0.04). However, BMI was not predictive of other pre-to-postoperative differences in outcome scores, or the size and number of cuff tendons torn (p > 0.05). Optimal BMI cutoffs were determined for pain MCID (40.8), pain SCB (26.8), function MCID (27.4), and function SCB (26.8), but all cutoffs had low correct classification rates (≤13%). Conclusion Obesity was not found to be an independent risk factor for increased rotator cuff tear size or tendon involvement but was nonetheless associated with worse upper extremity function and pain after aRCR.
... No control population was included in the study reflecting difficulty imaging a large cohort of asymptomatic patients. Previous studies have specifically reviewed the prevalence, patterns and imaging appearances of rotator cuff derangement in asymptomatic patients [28][29][30][31][32][33][34]. In one study of 420 asymptomatic patients, full thickness rotator cuff tears were identified in 7.6% of patients with increasing prevalence with ageing [35]. ...
Article
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Background The rotator cuff is a group of muscles and tendons which support the shoulder joint. Rotator cuff disease is a frequent cause of morbidity in adulthood. Aims The aims of his study are to determine the prevalence and patterns of rotator cuff derangement in symptomatic patients using MRI and to attempt to correlate identified patterns of disease with age and gender Methods Five hundred ninety-seven patients attending for MRI of the shoulder with atraumatic shoulder pain were included for study. Patients’ age and gender was recorded. Record was made of the presence or absence of rotator cuff derangement and of degenerative change in the AC and glenohumeral joints. Correlation was made between age and gender. Results There were 358 males (60%) and 239 females (40%) with a mean age of 49.4 ± 17.1 years. Subacromial bursitis was identified in 517 patients. A normal supraspinatus tendon was identified in 219 patients and supraspinatus full thickness tearing was identified in 102 patients. A normal AC joint was identified in 267 patients while degenerative AC joint changes were identified in 370 patients. A significant correlation was identified between age and rotator cuff derangement ( p < .001) and between age and AC joint derangement ( p < .001). No significant difference was identified between gender and patterns of cuff derangement Conclusion The extent of rotator cuff and AC joint derangement increases with ageing. Impingement appears to trigger a cascade of events in sequence, from isolated subacromial bursitis through to supraspinatus tendon tearing. Patterns of rotator cuff derangement are similar in men and women.
... This demanding function renders RC tendons an ideal candidate for degenerative problems. The prevalence of RC tears in the general population is 34% and even higher in the elderly population exceeding 50% (Sher et al., 1995;Tempelhof et al., 1999). RC tears enlarge over time because RC muscles undergo atrophy and fatty degeneration (Yamaguchi et al., 2001). ...
... [1][2][3] The prevalence of RCT is 34% in the general population and 54% in people over 60 years old. 4 There are more than 4.5 million hospital visits for RCT in the United States each year. 5 The demographic and professional features of RCT patients have been investigated. ...
Article
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Purpose: We aim to present unsupervised machine learning-based analysis of clinical features, bone mineral density (BMD) features, and medical care costs of Rotator cuff tears (RCT). Patients and methods: Fifty-three patients with RCT were reviewed, the clinical features, BMD features, and medical care costs were collected and analyzed by descriptive statistics. Furtherly, unsupervised machine learning (UML) algorithm was used for dimensionality reduction and cluster analysis of the RCT data. Results: There were 26 males and 27 females. The patients were divided into four subgroups using the UML algorithm. There were significant differences among four subgroups regarding trauma exposure, full-thickness supraspinatus tendon tears, infraspinatus tendon tear, subscapularis tendon tear, BMD distribution, medial row anchors, lateral row anchors, total medical care costs, and consumables costs. We observed the highest frequency of trauma exposure, infraspinatus tendon tear, subscapularis tendon tear, osteoporosis, the highest number of medial row anchors, lateral row anchors, total medical care costs, and consumables costs in subgroup II. Conclusion: The unsupervised machine learning-based analysis of RCT can provide clinically meaningful classification, which shows good interpretability and contribute to a better understanding of RCT. The significance of the results is limited due to the small number of samples, a larger follow-up study is needed to confirm the encouraging results.
... A typical rotator cuff injury in shoulder pain is reported to affect more than 40% of adults over 60 years of age [1]. Also, more than 60% of adults over 70 years of age showed abnormal findings on magnetic resonance imaging (MRI) of the rotator cuff [2]. In a systematic review of the guidelines for rotator cuff repair, it was reported that non-surgical treatment (physical therapy and non-steroidal anti-inflammatory drugs) is more effective when the duration of symptoms in rotator cuff tear is 3 months to less than 1 year [3]. ...
... A rotator cuff tear is the leading cause of shoulder pain and dysfunction, and the prevalence of rotator cuff tears increases with age, with rates as high as 30% to 54% in adults over the age of 60 years [1][2][3]. There are several repair techniques for a rotator cuff tear, and suture bridge repair is preferred for its mechanical superiority to single-row repair [4][5][6][7]. ...
Article
Background: This study was performed to identify the incidence of screw in-type lateral anchor pull-out in patients older than 60 years who underwent rotator cuff repair for large to massive rotator cuff tears (RCT). Methods: We reviewed 25 patients over 60 who were diagnosed with large to massive RCT and underwent arthroscopic rotator cuff repair in our hospital from March 2017 to February 2021. Preoperative tear size (anterior to posterior, medial to lateral) was measured via preoperative magnetic resonance imaging (MRI). All 25 patients underwent MRI scanning on postoperative day 1 and at 3 months after surgery. The change of anchor position was measured in axial views on MRI images postoperative day 1 and 3 months after surgery. And it was statistically compared according to bone mineral density (BMD), sex, and number of lateral anchors. Results: Two MRIs (postoperative day 1 and 3 months) in 25 patients were compared. Anchor pull-out occurred in six patients during 3 months (6.7%), and the mean pull-out length difference was 1.56 mm (range, 0.16-2.58 mm). There was no significant difference in the number of pull-out anchors, degree of pull-out difference by comparing BMD (A, BMD≤-2.5; B, BMD>-2.5), sex, or number of anchors used in each surgery (C, two anchors; D, three anchors) (p>0.05). Conclusions: Pull-out of screw in-type anchors was rarely observed and the mean pull-out length difference was negligibly small in our study. The screw in-type lateral anchor seems to be a decent option without concern of anchor pull-out even in elderly patients.
... Rotator cuff tears rank among the most common musculoskeletal injuries encountered by orthopedic surgeons, with a reported prevalence of 20% in the general population and 30% in cadaveric studies [1,2]. Rotator cuff pathology is most often due to age-related degeneration, with studies reporting tears in up to 54% of those over 60 and 62% of those over 80 years old, but can also result from traumatic injury such as shoulder dislocation [1,[3][4][5]. Among rotator cuff tears, massive tears present a particular challenge due to high rates of retear ranging from 18 to 94% in recent studies, failure of healing after repair, and the potential for irreparability [6]. ...
Article
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Purpose of review: Massive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience. Recent findings: Partial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands. Irreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.
... These results are significant as they provide impetus for translation of a single-growth factor delivery biomaterial device for the regenerative healing of the rotator cuff in patients with full-thickness tears. It also lays the ground-work for the repair of partial-thickness tears, which are two or three times more common than full-thickness rotator cuff tears 49 and have a 26% risk of tear progression within 2 years. 50 Our technology of using anabolic growth factors to promote neotendon and fibrocartilage formation may delay the progression of these tears to full-thickness and may provide an off-the-shelf surgically viable therapeutic option for the treatment of other fibrocartilaginous interfaces as well, such as in the temporomandibular joint. ...
Article
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Tears in the rotator cuff are challenging to repair because of the complex, hypocellular, hypovascular, and movement‐active nature of the tendon and its enthesis. Insulin‐like Growth Factor‐1 (IGF‐1) is a promising therapeutic for this repair. However, its unstable nature, short half‐life, and ability to disrupt homeostasis has limited its clinical translation. Pegylation has been shown to improve the stability and sustain IGF‐1 levels in the systemic circulation without disrupting homeostasis. To provide localized delivery of IGF‐1 in the repaired tendons, we encapsulated pegylated IGF‐1 mimic and its controls (unpegylated IGF‐1 mimic and recombinant human IGF‐1) in polycaprolactone‐based matrices and evaluated them in a pre‐clinical rodent model of rotator cuff repair. Pegylated‐IGF‐1 mimic delivery reestablished the characteristic tendon‐to‐bone enthesis structure and improved tendon tensile properties within 8 weeks of repair compared to controls, signifying the importance of pegylation in this complex tissue regeneration. These results demonstrate a simple and scalable biologic delivery technology alternative to tissue‐derived grafts for soft tissue repair.
... Rotator cuff pathology is one of the leading orthopedic injuries with an increased prevalence of both partial and full-thickness tears as individuals age [17][18][19]. What makes this pathology even more difficult is that reliance on imaging (MRI, diagnostic ultrasound) alone can be detrimental due to the increased risk of inaccurate diagnoses [20][21][22]. ...
Article
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To determine how the internal rotation and shift (IRO/shift) test compares to the gold standard of clinical tests (Jobe test) for diagnosing supraspinatus lesions and to confirm these clinical results with surgical findings, 100 symptomatic patients were clinically examined between October 2018 and November 2019. All 100 patients were evaluated using both the IRO/shift test and Jobe test. A total of 48 of these patients received surgical intervention. Based on these data, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for both the IRO/shift test and Jobe test were calculated. The IRO/shift test had a sensitivity of 96% (95% CI: 82–100%), specificity of 50% (95% CI: 27–73%), PPV of 73% (95% CI: 56–86%), NPV of 91% (95% CI: 59–100%), and an accuracy of 77% (95% CI: 63–88%). The Jobe test had a sensitivity of 89% (95% CI: 72–98%), specificity of 60% (95% CI: 36–81%), PPV of 76% (95% CI: 58–89%), NPV of 80% (95% CI: 52–96%), and an accuracy of 77% (95% CI: 54–81%). These results suggest that the IRO/shift test is comparable to the Jobe test, which is often viewed as the gold standard clinical examination for assessing supraspinatus lesions. This study was approved by the Ethics Commission of the Martin Luther University Halle-Wittenberg (reference number: 2018-05).
... 30% bei über 60 Jährigen fest (33). Weitere Studien bestätigten, dass mit zunehmendem Alter der Patienten die Prävalenz an RM-Rupturen zu erkranken signifikant ansteigt (16,20,23,34). Bei der asymptomatischen Bevölkerung über 80 Jahren wird sogar eine Prävalenz von bis zu 51% beschrieben (20). ...
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Aufgrund der divergierenden Studienlage bezüglich der physiotherapeutischen Nachbehandlung nach operativer Rotatorenmanschettenrefixation erfolgte im Rahmen einer prospektiv randomisierten Studie die Evaluation zweier Nachbehandlungsmodelle nach operativer Refixation vollschichtiger RM-Rupturen in Mini-Open-Technik. Hierfür wurden 57 Patienten präoperativ, 3 Wochen, 6 Wochen sowie 6 Monate postoperativ nachuntersucht und ausgewertet. Die Scores beinhalteten den NRS-Score, Constant-Score, DASH-Score, ASES-Score, NHP-Score, SF-36-Score sowie eine sonographische Untersuchung zur Beurteilung der Reruptur nach 6 Monaten postoperativ. Einheitlich erfolgte die Ruhigstellung im Gilchrist-Verband für 6 Wochen. In der konservativen Nachbehandlungsgruppe wurden bis 6 Wochen postoperativ lediglich Pendelübungen durchgeführt, in der progressiven Nachbehandlungsgruppe erfolgte eine passive Beübung direkt postoperativ bis an die Schmerzgrenze mit Ausnahme der Adduktion. Im Gesamtkollektiv war eine Rerupturrate von 5,3% zu verzeichnen mit 3,7% in der konservativen und 6,7% in der progressiven Nachbehandlungsgruppe ohne signifikanten Gruppenunterschied (p=0,540). Bezüglich der klinischen und psychischen Ergebnisse zeigte sich 6 Monate postoperativ lediglich eine Einschränkung der aktiven Außenrotation in der konservativen Nachbehandlungsgruppe (46,2∘ vs. 39,7∘, p=0,031), sonst war kein signifikanter Gruppenunterschied zu sehen. Weiterhin erfolgten Subgruppenanalysen insbesondere hinsichtlich Alter und Geschlecht der Patienten. Dabei haben Patienten über 65 Jahren unabhängig von der Nachbehandlungsgruppe kürzer Analgetika eingenommen und waren 6 Wochen postoperativ weniger bewegungseingeschränkt. Aufgrund einer Tendenz zu vermehrten Rerupturen nach progressiver Nachbehandlung in der Literatur werden daher weiterführende Studien benötigt um zu evaluieren, ob ältere Patienten von einer vermehrten Ruhigstellung profitieren könnten. Diese Studie präsentiert im Gegensatz zu der überwiegend in der Literatur verwendeten arthroskopischen OP-Technik Ergebnisse nach RM-Refixation in Mini-Open-Technik. Damit liefert sie eine gute Grundlage für weiterführende Studien insbesondere in der Behandlung von größeren RM-Rupturen, welche ein erhöhtes Rerupturrisiko besitzen und von einer konservativen Nachbehandlung profitieren könnten.
... [8][9][10][11][12][13][14] Full thickness tears are recognised to be common and associated with increasing age [15][16][17][18] ; however, prevalence in symptomatic and asymptomatic shoulders varies widely across cadaveric, 19 radiological 19 and retrospective cohort studies. 16-18 20-28 Furthermore, the presence of selection bias in studies undertaken in rotator cuff tendon tears [16][17][18][19][20][21][22][23][24][25][26][27][28] has meant population-based studies available are not representative of Western demographics. Thus, research in this area may lead to a better understanding of the natural history of rotator cuff tears. ...
Article
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Objectives To define the population prevalence of rotator cuff tears and test their association with pain and function loss; determine if severity symptom correlates with tear stage severity, and quantify the impact of symptomatic rotator cuff tears on primary healthcare services in a general population cohort of women. Design Cross-sectional observational study. Participants Individuals were part of the Chingford 1000 Women cohort, a 20-year-old longitudinal population study comprising 1003 women aged between 64 and 87, and representative of the population of the UK. Main outcome measures Rotator cuff pathology prevalence on ultrasound, shoulder symptoms using the Oxford Shoulder Score and resultant number of general practitioner (GP) consultations. Results The population prevalence of full-thickness tears was 22.2%, which increased with age (p=0.004) and whether it was the dominant arm (Relative Risk 1.64, OR 1.58, 95% CI 1.07 to 2.33, p=0.021). Although 48.4% of full-thickness tears were asymptomatic, there was an association between rotator cuff tears and patient-reported symptoms. Individuals with at least one full-thickness tear were 1.97 times more likely than those with bilateral normal tendons (OR 3.53, 95% CI 2.00 to 5.61, p<0.001) to have symptoms. Severity of symptoms was not related to the severity of the pathology until tears are >2.5 cm (p=0.009). In the cohort, 8.9% had seen their GP with shoulder pain and a full-thickness rotator cuff tear, 18.8% with shoulder pain and an abnormality and 29.3% with shoulder pain. Conclusion Rotator cuff tears are common, and primary care services are heavily impacted. As 50% of tears remain asymptomatic, future research may investigate the cause of pain and whether different treatment modalities, aside from addressing the pathology, need further investigation.
... Even in asymptomatic patients in the general community, full-thickness rotator cuff injuries are rather common. Rotator cuff tears are found in 20-54% of individuals older than 60 years, and 51-80% of patients older than 80 years, according to studies on asymptomatic patients [1,2]. The surgical repair of rotator cuff tears can be divided into three categories: open, mini-open, and arthroscopic. ...
... 27 The prevalence of rotator cuff tears increases with age, with approximately 50% of patients aged >65 years presenting with a tear. 19,20 Muscle quality remains an important factor in determining outcomes of attempted rotator cuff repair, and long-term changes such as fatty infiltration and fibrosis are associated with worse postoperative functional outcomes in patients who undergo rotator cuff repair. 5,9,22,23 Based on our current understanding of rotator cuff muscle degeneration, the atrophy and fatty degeneration of rotator cuff muscle that occur in the setting of chronic tendon tears appear to be irreversible even after successful repair. ...
Article
Background Fatty infiltration of rotator cuff muscle is a limiting factor in the success of repairs. Fibroadipogenic progenitors (FAPs) are a population of stem cells within the rotator cuff that can differentiate into white adipocytes, fibroblasts, and beige adipocytes. The effects of patient age and rotator cuff tendon tear size on the number, differentiation patterns, and gene expression profiles of FAPs have not yet been analyzed. Purpose To determine if patient age and rotator cuff tear size independently regulate FAP number, differentiation patterns, and gene expression profiles. Study Design Controlled laboratory study. Methods Supraspinatus muscle samples were collected from 26 patients between the ages of 42 and 76 years with partial- or full-thickness rotator cuff tears. FAPs were quantified using fluorescence-activated cell sorting. Gene expression analysis was performed across a custom 96-gene panel using NanoString. In vitro differentiation assays of FAPs were conducted using adipogenic, fibrogenic, and beige-inducing (amibegron-treated) media, and quantitative polymerase chain reaction was used to assess gene expression differences between adipogenic and amibegron media conditions. Multivariable linear regressions were performed using Stata to independently analyze the effects of age and rotator cuff tear size on FAP number, differentiation, and gene expression. Results Increasing age and tear size were independently correlated with increased FAP number (β age = 0.21, P = .03; β tear size = 3.86, P = .05). There was no clear association between age and gene expression of freshly sorted FAPs. Under adipogenic and fibrogenic media conditions, increasing age and tear size were independently associated with increased adipogenic and fibrogenic differentiation of FAPs. Under amibegron treatment conditions, age positively correlated with increased beige differentiation (β = 1.03; P < .0001), while increasing tear size showed a trend toward decreased beige differentiation (β = −4.87; P = .1). When gene expression patterns between adipogenic and amibegron media conditions were compared, larger tear size strongly inhibited beige gene expression, while advanced age did not. Conclusion Patient age and rotator cuff tear size independently regulated FAP number, differentiation, and gene expression. Age and tear size were positively correlated with increased FAP number and fibrogenic/adipogenic differentiation. Advancing patient age did not limit FAP beige differentiation and gene expression, while increasing rotator cuff tear size strongly inhibited these processes.
... Conditions affecting skeletal muscle, such as chronic rotator cuff tears, low back pain, whiplash, dystrophies, Huntington's disease, and many others often share a similar change in muscle phenotype: contractile tissue portions decrease while adipose and fibrotic tissues increase [5][6][7][8][9]. Chronic rotator cuff tears affect approximately 50% of the population over 50 years of age, roughly a third of these tears are symptomatic, and most asymptomatic tears will become symptomatic within 3 years of diagnosis [10][11][12][13]. In these patients, outcomes after surgical repair are directly related to the grade by which contractile tissue has been replaced by adipose and fibrotic tissue, and this degenerative process continues even after repair [14][15][16]. ...
Article
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Background Conditions affecting skeletal muscle, such as chronic rotator cuff tears, low back pain, dystrophies, and many others, often share changes in muscle phenotype: intramuscular adipose and fibrotic tissue increase while contractile tissue is lost. The underlying changes in cell populations and cell ratios observed with these phenotypic changes complicate the interpretation of tissue-level transcriptional data. Novel single-cell transcriptomics has limited capacity to address this problem because muscle fibers are too long to be engulfed in single-cell droplets and single nuclei transcriptomics are complicated by muscle fibers’ multinucleation. Therefore, the goal of this project was to evaluate the potential and challenges of a spatial transcriptomics technology to add dimensionality to transcriptional data in an attempt to better understand regional cellular activity in heterogeneous skeletal muscle tissue. Methods The 3′ Visium spatial transcriptomics technology was applied to muscle tissue of a rabbit model of rotator cuff tear. Healthy control and tissue collected at 2 and 16 weeks after tenotomy was utilized and freshly snap frozen tissue was compared with tissue stored for over 6 years to evaluate whether this technology is retrospectively useful in previously acquired tissues. Transcriptional information was overlayed with standard hematoxylin and eosin (H&E) stains of the exact same histological sections. Results Sequencing saturation and number of genes detected was not affected by sample storage duration. Unbiased clustering matched the underlying tissue type-based on H&E assessment. Connective-tissue-rich areas presented with lower unique molecular identifier counts are compared with muscle fibers even though tissue permeabilization was standardized across the section. A qualitative analysis of resulting datasets revealed heterogeneous fiber degeneration–regeneration after tenotomy based on (neonatal) myosin heavy chain 8 detection and associated differentially expressed gene analysis. Conclusions This protocol can be used in skeletal muscle to explore spatial transcriptional patterns and confidently relate them to the underlying histology, even for tissues that have been stored for up to 6 years. Using this protocol, there is potential for novel transcriptional pathway discovery in longitudinal studies since the transcriptional information is unbiased by muscle composition and cell type changes.
... Students, if necessary, underwent MRI and were excluded from the study. It should be emphasized that US is easily available, cheaper, has no negative radiation, and is repeatable [44]. Also, the US method is used to monitor local findings, and larger partial and total ruptures can be seen; so, a differential diagnosis can be made in relation to inflammatory rheumatic diseases. ...
Article
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Rotator cuff disease, external and internal impingement syndromes, low shoulder stability, various types of trauma, and overuse injuries are all related to sports activities. In order to check symptoms in patients with disability and shoulder pain, clinicians use different methods and diagnostic imaging assessment. The research is aimed at evaluating whether there is a difference between provocation function tests (PFT) and ultrasonographic (US) testing of muscles within the rotator cuff in elite collegiate athletes. Patients (n=184) were recruited from university team sports selections and tested with a standardized US examination of the shoulder and five PFTs (Speed’s test, Neer’s test, Hawkins test, lift-off test, Yergason’s test). Based on the VAS pain assessment scale, 60 subjects had some pain, which was taken for further processing in the work (124 subjects did not have the presence of pain and were excluded from further processing). The US examination was conducted using Voluson 730 apparatus, by a linear probe, with the frequency in the range of 6-12 MHz. The chi-square test showed significant differences between PFT and the occurrence of shoulder muscle tendinitis for the following variables: Speed’s test and subscapularis tendinitis (p=0.02) and Speed’s test and infraspinatus tendinitis (p=0.01); Neer test and biceps brachii caput longum tendinitis (p=0.01), Neer test and supraspinatus tendinitis (p=0.02) and Neer test and infraspinatus tendinitis (p=0.01); lift-off test and subscapularis tendinitis (p=0.05); and Yergason’s test and biceps brachii caput longum tendinitis (p=0.03) and Yergason’s test and subscapitis tendinitis (p=0.01). The greatest effect of differences was observed in Neer’s test and biceps brachii caput longum tendinitis (φ=0.60), while the other effects can be described as medium and small in most cases. It can be concluded that functional tests are good predictors of soft tissue changes in the muscles of the rotator cuff of the shoulder. Further monitoring and analysis are needed on a larger number of athletes.
... Partial-thickness rotator cuff tears (PTRCTs) are common injuries that may cause pain through normal range of motion and shoulder dysfunction in affected patients. 24,36 Over 70% of patients undergoing surgical treament for rotator cuff tears were diagnosed with PTRCTs through arthroscopy, and the overall prevalence rate of PTRCTs in the population was 13% to 40% 24,28,33,40 ; however, the ideal repair techniques for bursal-sided PTRCTs remain controversial. 35,36 Two main techniques have been reported: conversion to a full-thickness tear followed by repair (tear completion repair [TCR]) and in situ repair (ISR) with preservation of the remaining articular-sided tendon. ...
Article
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Background There is an ongoing debate on the treatment of bursal-sided partial-thickness rotator cuff tears (PTRCTs), including ideal repair techniques. Augmentation using a collagen patch has been introduced as a new surgical approach to treat PTRCTs, while the effect of autogenous biceps augmentation (BA) has not been investigated. Purpose To analyze the effects of BA on bursal-sided PTRCTs and compare its histological and biomechanical results with those of tear completion followed by repair and in situ repair (ISR). Study Design Controlled laboratory study. Methods Unilateral chronic PTRCTs were created in 96 mature New Zealand White rabbits, which were randomly divided into 4 groups: no repair, tear completion repair (TCR), ISR, and BA. A new bicipital groove was fabricated in BA for the biceps tendon that was transferred to augment the bursal-sided PTRCT repair. In each group, we sacrificed 6 rabbits for biomechanical testing of the whole tendon-to-bone complex (WTBC) and 6 for histological evaluation of bursal- and articular-sided layers at 6 and 12 weeks postoperatively. Healing responses between the biceps and new bicipital groove in the BA group were determined using histological analysis, and final groove morphologies were evaluated using micro–computed tomography. Results The remaining tendon and enthesis in bursal-sided PTRCTs progressively degenerated over time. WTBCs of ISR exhibited a larger failure load than those of TCR, although better healing properties in the bursal-sided repaired site were achieved using TCR based on histological scores and superior articular-sided histological scores were observed using ISR. However, WTBCs of BA displayed the best biomechanical results and superior histological scores for bursal- and articular-sided regions. The new bicipital groove in BA remodeled over time and formed similar morphologies to a native groove, which provided a mature bone bed for transferred biceps tendon healing to augment bursal-sided PTRCTs. Conclusion BA achieved better biomechanical and histological results for repairing bursal-sided PTRCTs as compared with TCR and ISR. When compared with that of TCR, the WTBC of ISR exhibited a higher failure load, showing histological superiority in the articular-sided repair and inferiority in the bursal-sided repair. Clinical Relevance BA may be an approach to improve bursal-sided PTRCT repair in humans, which warrants further clinical investigation.
... Rotator cuff disease is a wide spectrum that includes acute injury, chronic injury, tendonitis, tendinosis, partial tears, and complete tears. It is a common cause of shoulder pain leading to more than 4.5 million physician visits per year; rotator cuff tears have a prevalence of 13-54% in the general population, with higher rates in patients over 60 years old [1, 2,3]. The incidence of rotator cuff repair (RCR) has increased over the past two decades to become the most commonly performed shoulder surgery in the USA with an estimated annual cost of $1.2-1.6 billion [4,5,6]. ...
Article
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Purpose of Review This paper should serve as a guide for nonoperative physicians in the management of rotator cuff tears and provide an algorithm of when to refer patients for potential operative repair. Recent Findings While physical therapy remains the mainstay of conservative treatment, recent studies have examined various injections to improve pain and function in partial- and/or full-thickness rotator cuff tears, such as suprascapular nerve blocks, subacromial hyaluronic acid, and intratendinous platelet-rich plasma. Summary Patients who experience an acute, full-thickness rotator cuff tear should be referred as soon as possible for potential surgical repair; however, clinicians should consider the patient’s age and activity level. The algorithms for both acute partial-thickness tears and chronic degenerative rotator cuff tears are similar and should initially include a conservative approach of pain control, physical therapy, and potentially various injections before possible referral for surgical evaluation. We anticipate future research examining the role for biologic agents in the conservative treatment of rotator cuff tears.
Chapter
Identifying the source of one's pain has been a significant clinical challenge since the physical sensation of pain is felt to be subjective in nature and difficult to quantify. Also referred to as “pain drivers” or “pain generators,” diagnosing the source of pain is complicated by a lack of tools sufficiently sensitive and specific enough to pinpoint the location. Additionally, the experience of pain is not only modulated by the individual's threshold to painful stimuli but also a product of the individual's affective contributions, such as fear, anxiety, and previous experiences. Perhaps then to quantify and localize pain generators is to examine the degree of nociception and pronociceptive inflammation—that is, the extent of cellular, chemical, and molecular changes that occur in pain generating processes. Measuring changes in the local density of receptors, ion channels, mediators, and inflammatory/immune cells that are involved in the painful phenotype using targeted, highly sensitive, and specific molecular imaging approaches is, therefore, a promising approach toward objectively identifying peripheral pain generators. There are a growing number of ongoing clinical and preclinical imaging approaches, especially with inflammatory or pain-related positron emission tomography (PET) radiotracers, that can measure the degree of target concentration and thus serve as a readout for sites of pain generation. Further, when PET is combined with the spatial and contrast resolution afforded by MRI, nuclear medicine physicians and radiologists can potentially identify pain drivers with greater accuracy and confidence. Several of these molecular imaging approaches that are currently being developed to isolate the source of pain are described herein.
Chapter
Performing the ultrasound of the shoulder can only be done after a clinical examination directed toward a pathology of the rotator cuff, because in case of instability or articular pathology, the role of ultrasound examination is much less important.
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Background Rotator cuff tears are one of the more frequent pathologies of the shoulder. Arthroscopic techniques and biological augmentation have been developed to improve the rate and quality of healing. The crimson duvet procedure (CDP) theoretically provides mesenchymal stem cells (MSCs) through microfracture treatment of the footprint. The aim of this research was to evaluate the effect of the CDP in patients who underwent arthroscopic surgery for complete rotator cuff repair. Methods A prospective randomized clinical trial was performed in a total of 123 patients, consisting of 59 women and 64 men, with a mean age of 58 years. We included patients with a clinical and radiological diagnosis of a complete rotator cuff tear. All patients were treated with arthroscopic rotator cuff repair. In group I, the surface of the footprint was débrided; in group II, the footprint underwent microfracture. The primary outcome was the nonhealing rate, which was detected by magnetic resonance imaging (MRI) or ultrasound (US), and the secondary outcome was the functional result. A Sugaya classification of I to III was considered to indicate healing. 20,28 For clinical evaluation, the ASES and Constant scores were evaluated, along with the range of motion. The functional evaluation was performed preoperatively and at 6 months and one year postoperatively. The radiological (MRI or ultrasound) evaluation was performed at 6 months. Neither the patients nor the radiologists and physical therapists who performed the postoperative evaluations were informed of the random selection. Results We observed a healing rate of 85.11% in the control group and 93.7% in the CDP group without statistical significance (p=0.19). A significant improvement in function was observed in all patients. The ASES score improved from 68.9 (SD: 13.8) preoperatively to 92.2 at sixth months and 96.4 (SD: 6,2) at twelve months (p<0.05), but no difference was observed between the groups. A similar amount of improvement was observed in the Constant score. Conclusion The arthroscopic repair of complete rotator cuff tears presents good and excellent clinical results in most patients. Nevertheless, nonhealing occurs at a rate that depends mainly on the age of the patient and the size of the tear. The addition of the CDP did not improve the functional results, neither the healing rate.
Article
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Background Proper diagnosis of rotator cuff tears is typically established with magnetic resonance imaging (MRI); however, studies show that MRI-derived measurements of tear severity may not align with patient-reported pain and shoulder function. The purpose of this study is to investigate the capacity for the Patient-Reported Outcomes Measurements Information System (PROMIS) computer adaptive tests (CAT) to predict rotator cuff tear severity by correlating preoperative tear morphology observed on MRI with PROMIS Upper Extremity (UE) and Pain Interference (PI) scores. This is the first study to investigate the relationship between tear characteristics and preoperative patient-reported symptoms using PROMIS. Considering the essential roles MRI and patient-reported outcomes play in the management of rotator cuff tears, the findings of this study have important implications for both treatment planning and outcomes reporting. Methods Two PROMIS-CAT forms (PROMIS-UE and PROMIS-PI) were provided to all patients undergoing rotator cuff repair by one of three fellowship-trained surgeons at a single institution. Demographic information including age, sex, race, employment status, body mass index, smoking status, zip code, and preoperative PROMIS-UE and -PI scores were prospectively recorded. A retrospective chart review of small to large full- or partial-thickness rotator cuff tears between May 1, 2017 and February 27, 2019 was used to collect each patient’s MRI-derived tear dimensions and determine tendon involvement. Results Our cohort consisted of 180 patients (56.7% male, 43.3% female) with an average age of 58.9 years (standard deviation, 9.0). There was no significant difference in PROMIS-UE or -PI scores based on which rotator cuff tendons were involved in the tear (p > 0.05). Neither PROMIS-UE nor PROMIS-PI significantly correlated with tear length or retraction length of the supraspinatus tendon (p > 0.05). Sum of tear lengths in the anterior-posterior and medial-lateral directions was weakly correlated with PROMIS-UE (p = 0.042; r = -0.152, r² = 0.031) and PROMIS-PI (p = 0.027; r = 0.165, r² = 0.012). Conclusions Rotator cuff tear severity does not significantly relate to preoperative PROMIS-UE and -PI scores. This finding underscores the importance of obtaining a balanced preoperative assessment of rotator cuff tears that acknowledges the inconsistent relationship between rotator cuff tear characteristics observed on MRI and patient-reported pain and physical function.
Article
Background and purpose The purpose of this study was to analyze midterm functional outcomes and tendon integrity in patients treated with in situ arthroscopic repair of Partial Bursal Rotator Cuff Tears (PBRCTs) without acromioplasty. Material and methods Sixty two patients were included. Clinical assessment consisted of glenohumeral range of motion measurement and the American Shoulder and Elbow Surgeons (ASES) score. Pain was rated by using a visual analog scale (VAS). A postoperative ultrasound image control was performed at a minimum 5 years follow up to assess tendon integrity. Results Mean age was 57.2 years (range, 44–77 years) and mean follow up was 7 years (range of 5–9 years). Significant improvements in range of motion, functional outcomes and pain were observed postoperatively (p < .0001). The ASES score improved from 46.5 to 90.2; and the VAS improved from 6.5 to 1.73 (p < .0001). Fifty six patients (90%) performed ultrasound evaluation at the end of follow up. Fifty-one patients (91%) presented tendon integrity on ultrasound. Five patients presented re-tears (9%). Three patients (5%) had a complete tendon re-tear and two patients (4%) had a partial re-tear. No difference in range of motion or functional outcomes were found between patients with intact tendon and those who had re-tears. Conclusions In the midterm follow-up, arthroscopic in situ repair PBRCTS without acromioplasty showed excellent functional outcomes and high healing rates in most patients with low complication rates.
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Background Using reliable and valid clinical tests are essential for proper diagnosis and clinical outcomes among injuries involving the rotator cuff. The addition of a new clinical examination test could improve the clinical diagnosis and informative value of the sensitivity and specificity of pathology. This study of diagnostic accuracy evaluated the use of a new rotator cuff test, called the internal rotation and shift-test (IRO/Shift-test), to determine its‘ reliability and clinical performance (sensitivity, specificity, positive (PPV)/negative predictive value (NPV)). Clinical diagnostic outcomes were confirmed with radiological findings (MRI). Methods 100 patients from a specialized shoulder unit participated (64 male, 36 female, mean age: 55 ± 13.5 years). A single blinded (no knowledge of prior clinical or technical diagnostics) study design was used with two experienced physicians performing the IRO/Shift-test. For clinical performance, all clinical testing was compared with MRI. Results The intrarater (ICC=0.73, 95% CI: 60-82) and interrater (ICC=0.89, 95% CI: 81-94) coefficients for the IRO/Shift-test showed good-to-excellent reliability. 75% of the patients showed a positive IRO/Shift-test, while 65% had a radiologically diagnosed superior rotator cuff tear. 60% of these patients had both a positive IRO/Shift-test and objective rotator cuff tear via MRI. The sensitivity of the IRO/Shift-test to detect superior rotator cuff lesions based on MRI diagnosis was calculated at 92% (95% CI: 86-99%), while specificity was 67% (95% CI: 50-84%). Predictive values were also found to be high with 86% PPV (95% CI: 78-94%) and 80% NPV (95% CI: 64-96%). Conclusion Our results demonstrate that the IRO/Shift-test is a reliable and valid tool for assessing superior rotator cuff pathology. With good-to-excellent intra- and interrater reliability and strong sensitivity and specificity this test should be considered a valuable addition to clinicians‘ cadre of clinical evalation tools.
Chapter
Rotator cuff tears are very common and can cause important disability, especially massive tears. When facing patients with this pathology, knowledge of natural history, adequate physical examination, comprehensive analysis of imaging studies, and awareness of risk factors for repair failure are essential for the selection of the best treatment. If repair is performed, a deep understanding of anatomy, tear geometry, and surgical techniques available is necessary. Our recommendation is to choose between open or arthroscopic repair according to the surgeon’s preference and experience. Complete single-row repair must be attempted, and geometric pattern of the tear must be taken into account for it. Double-row repair and augmentation techniques must be considered in specific cases. No additional surgical gestures are recommended as a routine.KeywordsShoulderRotator cuffMassive tearsTreatment
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Purpose The study aimed to describe the distal triceps brachii insertion on the olecranon and to correlate the findings with those seen in normal MR (Magnetic Resonance) anatomy of the triceps brachii insertion. Materials and methods 14 un-paired fresh frozen elbows were included according to the institution guidelines and dissected. Histologic examination was performed to the distal triceps brachii insertion. The dimension of the distal triceps brachii tendon insertion was measured and defined based on its layer. The measurement of distal triceps brachii insertion was performed with image processing program (Image J, National Institute of Health, Bethesda, Maryland). T1-weighted elbow MR images (3.0 T) of a 102 patients were acquired and analyzed according to its sagittal plane. Results All specimens shows that distal triceps brachii tendon is with three distinct insertional areas in the olecranon which are: (1) capsular, (2) deep muscular, (3) superficial tendinous insertion with the areas of 80.7 mm ² , 56.4 mm ² , and 175.2 mm ² , respectively. The superficial tendinous insertion was observed with a thickened portion, the “central cord” with 0.5 occupation ratio. MR analysis showed that 30% (31/102) of the distal biceps brachii insertion was with a cleft between the bipartite insertion of the superficial tendinous and the deep muscular insertion on olecranon which designated as the “lacuna” which was also found in 35% (5/14) of the specimens. Conclusions The distal triceps brachii has three distinct insertion on the olecranon. The superficial tendinous layer was separated with the deep muscular layer by a cleft in one third of the cases. Knowledge of this anatomy will help surgeon to understand the partial triceps injury and to avoid iatrogenic injury to the distal triceps tendon during surgery.
Chapter
Rotator cuff repair, reattaching the torn tendon to the head of humerus, is one of the most common orthopedic surgeries. However, the failure in reconstructing tendon‐to‐bone enthesis structure, muscle atrophy, impaired mobility in irreparable rotator cuff tears and low bone mineral density‐induced suture anchor pullout make the repair surgeries with high failure rates. To overcome these challenges, various biofabrication techniques for rotator cuff repair have been explored and applied in recent years. In this chapter, we will summarize and analyze the research progress in this field. For the follow‐up research, we will propose some possible directions in designing more advanced biofabrication techniques.
Article
Background: Partial-thickness rotator cuff tears (PTRCTs) is not uncommon, and various nonsurgical injection therapy for PTRCTs emerged. Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection were proposed for treating PTRCTs, however, the relation of dose among injectates was still lacking. Methods: This was a prospective, non-randomized, comparative study. The aim of the study was to compare the effects of ultrasound-guided single PRP injection with three doses of HA injection, combination of post-injection rehabilitation, for treating PTRCTs.Subjects received either ultrasound-guided PRP injection and rehabilitation exercise, or ultrasound-guided subacromial HA injection and rehabilitation exercise. Shoulder Pain and Disability Index (SPADI), range of motion (ROM), pain visual analog scale (VAS), and Constant-Murley Shoulder Score (CMSS) were recorded before injection, and at 1 and 3 months after injection. Results: Forty-eight patients were enrolled. They received either ultrasound-guided single PRP (n = 24) intralesional and peritendinous injection or three doses of HA (n = 24) subacromial injection plus rehabilitation exercise. In the PRP group, SPADI scores, VAS scores, CMSS significantly improved at 1-month and 3-month follow-up; flexion and abduction ROM significantly increased at 3-month follow-up. In the HA group, SPADI scores, VAS during overhead activities, VAS night pain, and CMSS significantly improved in the first and third months; flexion and active abduction ROM significantly increased in the third month. The PRP group revealed significantly better passive abduction ROM and CMSS at third month than HA group. Conclusion: Ultrasound-guided single PRP injection exhibited comparable benefit to three doses of HA injection in patients with PTRCTs short-termly, with an extended effect regarding passive shoulder abduction ROM and CMSS.
Article
Purpose The purpose of this study was to determine the use of operative rotator cuff repair for rotator cuff pathology in New York State and analyze the racial, ethnic, and income-based disparities in receiving rotator cuff repair. Methods A retrospective review of the Statewide Planning and Research Cooperative System (SPARCS) Database of New York State was conducted to include patients with a new diagnosis of rotator cuff tear between July 1, 2017, and June 30, 2019, with at least 6 months follow-up. Bivariate analysis using chi-square tests and multivariable logistic regression models were used to determine racial, ethnic, and income-based disparities in the use of surgical treatment with rotator cuff repair. Results A total of 87,660 patients were included in the study. Of these, 36,422 patients (41.5%) underwent surgical treatment with rotator cuff repair. Multivariable analysis showed that Black race (Adjusted Odds Ratio [AOR]: 0.78; 95% Confidence Interval [CI]: 0.69 to 0.87; p < 0.001), Hispanic/Latino ethnicity (AOR: 0.91; 95% CI: 0.85 – 0.97); p = 0.004), and Medicaid (AOR: 0.75; 95% CI: 0.70 to 0.80; p < 0.001), or other government insurance (AOR: 0.82; 95% CI: 0.78 to 0.86; p < 0.001) were independently associated with lower rates of rotator cuff repair. Male gender (AOR: 1.18; 95% CI: 1.14 to 1.22; p < 0.001), Asian race (AOR: 1.27; 95% CI: 1.00 to 1.62; p = 0.048), Workers’ Compensation insurance (AOR: 1.12; 95% CI: 1.07 to 1.18; p < 0.001), and higher home ZIP code income quartile (AOR: 1.19; 95% CI: 1.09 to 1.30; p < 0.001) were independently associated with higher rates of operative management. Although race was an independent covariate affecting rate of rotator cuff repair, the effects of race were altered when accounting for the other covariates, suggesting that race alone does not account for the differences in rate of surgery for rotator cuff pathology. Conclusion In this analysis of all adult patients presenting with rotator cuff tears to New York hospital systems from 2017-2019, we identified significant racial, ethnic, and socioeconomic disparities in the likelihood of rotator cuff repair surgery for patients with rotator cuff tears. These include lower rates of rotator cuff repair for those Black, Hispanic, and low-income populations as represented by Medicaid insurance and low home zip code income quartile.
Article
Aims: - Metformin has been mentioned to be protective against inflammation, degeneration, and oxidative stress, conditions that are associated with rotator cuff disease. To access the association between metformin use and risk of rotator cuff disease in patients with type 2 diabetes mellitus (DM). Methods: - This was a retrospective cohort study utilizing Taiwan National Health Insurance Research Database between January 1, 2000, and December 31, 2012 to retrieved participants. Metformin and propensity score matched never metformin users were determined at baseline (between the date of onset of DM and the index date), and followed to December 31, 2013. Propensity scores were adopted to address measurable confounders (including demographic variables, Diabetes Complications Severity Index, and relevant comorbidities and co-medication). A multivariable Cox proportional hazards regression model was applied to estimate the adjusted hazard ratios (HRs) for the risk of the first diagnosis of rotator cuff disease on the full cohort and on the propensity score matched cohort. Results: - In the propensity score matched cohort, a total of 34,964 individuals (19,416 [55.5%] men), 17,482 individuals were taking metformin, 559 [3.2%] of whom developed rotator cuff disease. Incidence of rotator cuff disease was 4.51 per 10,000 person-months in the metformin users and 5.11 in the controls. Among metformin group, the aHR (95% CI) was 0.879 (0.784-0.984) after full adjustment. The potential beneficial effect on the risk of rotator cuff disease was consistently observed across all subgroups, including sex, age, concomitant other glucose lowering drugs, and level of Diabetes Complications Severity Index (all P for interaction > 0.050). Conclusion: - Metformin use was associated with a lower risk of rotator cuff disease in patients with type 2 DM.
Article
Background: Current nonoperative treatments for partial-thickness rotator cuff tears (PTRCTs) have limited effectiveness in preventing tear progression or promoting tendon healing. This study aimed to establish a rabbit model using in situ-forming fibrin gel containing adipose stem cell-derived exosomes (ASC-Exos/fibrin) to treat PTRCTs. Methods: Fifty-six rabbits (112 shoulders) were included in this study and assigned to 4 groups: the control group (32 shoulders; PTRCTs without treatment), the fibrin group (32 shoulders; PTRCTs treated with fibrin gel), the ASC-Exo/fibrin group (32 shoulders; PTRCTs treated with ASC-Exos/fibrin), and the sham group (16 shoulders; sham surgery). Bilateral, 50%-thickness, bursal-side PTRCTs of 1 mm (depth) × 3 mm (width) × 5 mm (length) on the supraspinatus tendon were established by a number-11 scalpel blade, with accuracy of the measurement ensured by a digital vernier caliper. At 6 and 12 weeks postoperatively, gross observation, measurement of the thickness of residual supraspinatus tendons, and histological and biomechanical analyses were performed to analyze tendon repair. Results: At 12 weeks postoperatively, the tendon thickness in the ASC-Exos/fibrin group (mean and standard deviation, 1.63 ± 0.19 mm) was significantly greater than in the control group (0.85 ± 0.09 mm) (p < 0.0001) and fibrin group (1.16 ± 0.17 mm) (p < 0.0001). The histological score in the ASC-Exos/fibrin group (6.25 ± 0.53) was significantly better than in the control group (11.38 ± 0.72) (p < 0.0001) and fibrin group (9.00 ± 0.54) (p < 0.0001). Overall, immunohistochemical staining of types-I and III collagen and biomechanical testing also showed ASC-Exos/fibrin to be more effective in repairing PTRCTs than fibrin alone and no treatment. Conclusions: Local administration of in situ-forming ASC-Exos/fibrin effectively facilitated the healing of bursal-side PTRCTs in rabbits. This approach may be a candidate for the nonoperative management of PTRCTs. Clinical relevance: Ultrasound-guided injection of ASC-Exos/fibrin may be a novel nonoperative strategy to treat PTRCTs.
Book
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The GP book is a clinical guide for licensed practioners who are looking for an inexpensive easy-to-learn injection technique for the treatment of nonrheumatic musculoskeletal conditions. We use isotonic glucose (or dextrose) injections into dermis, muscles and ligaments as an alternative for cortisone injections. It describes the history of glucopuncture, the difference with prolotherapy, the ATP hypothesis, indications and clinical cases. Doctors who become aware of the benefits of glucose 5% injections, can afterwards specialize in nerve hydrodissection according to dr Lam, epidural glucose injections according to dr Maniquis-Sigel, intraarticular injections, perineural injections according to dr WU, or PIT according to dr Lyftogt. Glucopuncture is originally designed for doctors / patients who have no access to MRI, ultrasound-guided hydrodissection, and state of the art surgery. We also want to introduce GP in low-income countries for doctors who work with very limited means in remote regions. Projects in Africa, Asia and America are about to start. It is obvious that more research and clinical studies are warranted to confirm our anecdotal findings and to convince our colleagues. All suggestions are welcome. This project is a work in progress. The book is free for download on the website www.glucopuncture.com.
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Background: Shoulder injuries tend to present mainly as pain and often leads to considerable disability. It is essential that a diagnosis of the shoulder pathology is made and treatment started immediately to attain prompt recovery and avoid chronicity and complications. The current gold standard diagnostic investigation is arthroscopy. MRI is a proven sensitive and accurate non-invasive tool for detecting internal derangement and assessing overall joint structures, but many studies have reported false positive and negative results. The aim of the study is to compare the accuracy of the two Diagnostic Modalities, Arthroscopy and MRI, in bony and ligamentous structure injury of the shoulder joint. Methods: Twenty one cases of the age group 18-60 years presenting with shoulder pain following injury were included in our study, where MRI was performed followed by Arthroscopy. The data were analyzed for sensitivity, specificity, positive predictive value and negative predictive value and the correlation between MRI and Arthroscopy is done with the help of these statistics. Results: In the study highest sensitivity was found in full-thickness Supraspinatus tear, Bankart’s lesion and Hill-Sachs lesion. The highest specificity and highest positive predictive value was found in Impingement syndrome, full thickness supraspinatus tear, Hill-Sachs lesion and Adhesive capsulitis. The highest negative predictive value was found in full-thickness supraspinatus tear, Bankart’s lesion and Hill-Sachs lesion. Conclusion: MRI is an accurate, practical, efficient, non-invasive diagnostic modality in shoulder injuries, specially in conditions like full- thickness supraspinatus tear, impingement syndrome, Hill-Sachs lesion and Bankart’s lesion.
Article
Background: Proximal humerus fractures and shoulder dislocations are relatively common. However, an associated rotator cuff tear is often missed with these injuries. The objective of this study was to assess the prevalence of a concomitant rotator cuff tear associated with common shoulder injuries. Methods: A cross-sectional epidemiological study of three patient populations: Group 1. Proximal Humerus Fractures; Group 2. Shoulder Dislocations; Group 3. Proximal Humerus Fracture-Dislocations. All patients within these three groups presented to and underwent subsequent management of their shoulder injury at a trauma unit. Management included both non-operative and operative intervention. Patients were evaluated for associated rotator cuff tears. Results: This study included a total of 196 patients: Group 1 = 146 Proximal Humerus Fractures; Group 2 = 37 Shoulder Dislocations; Group 3 = 13 Proximal Humerus Fracture-Dislocations. Of the 196 patients in total, 23 (11.7%) sustained a concomitant rotator cuff tear. The highest number of tears was found in Group 1 ( n = 14). However, the highest percentage prevalence of tears was in Group 2 (18.9%). There was noted to be a higher prevalence of rotator cuff tears with increasing age. Twenty-two (95.7%) rotator cuff tears were detected in patients over 50 years of age. The vast majority of rotator cuff tears were detected by ultrasound (78.3%) as opposed to magnetic resonance imaging (21.7%). The majority of tears were full-thickness (60.9%). Of the 23 patients with a concomitant rotator cuff tear, 17 involved a single tendon (73.9%) and supraspinatus was most common (69.6%). Conclusions: A concomitant rotator cuff tear in association with a proximal humerus fracture, shoulder dislocation or proximal humerus fracture-dislocation is relatively common. The overall rotator cuff tear prevalence in this study was 11.9%. Rotator cuff tears are more likely to occur in patients over 50 years old and those sustaining a shoulder dislocation.
Article
Regeneration of the gradient structure of the tendon-to-bone interface is still a significant clinical challenge. This study reports a novel therapeutic method combining three-dimensional (3D) bioprinting and melt electrospinning writing techniques to regenerate a functional tendon-to-bone interface. We generated biomimetic multilayered scaffolds with 3D-bioprinted pre-differentiated autologous adipose-derived mesenchymal stem cells (ADMSC), which recapitulated compositional and cellular structures of the interface. The hydrogel-based bioinks offered high cell viability and proliferative capability for rabbit ADMSCs. The hydrogels with pre-differentiated (into tenogenic, chondrogenic, and osteogenic lineages) or undifferentiated rabbit ADMSCs were 3D-bioprinted into zonal-specific constructs to mimic the structure of the tendon-to-bone interface. These scaffolds were tested in a rabbit rotator cuff injury model and the histological, radiological, and biomechanical changes were analyzed. The in vivo studies demonstrated that the scaffold with spatially differentiated autologous ADMSCs had a superior histological score and improved collagen organization when compared to acellular scaffolds and similar T2 value as the normal interface tissue. The biomechanical characterization demonstrated that the application of multilayered scaffolds improved the biomechanical properties of the tendon-to-bone interface at 12 weeks after rotator cuff reconstruction surgery, but the incorporation of autologous ADMSCs within the multilayered scaffolds showed a limited contribution. Thus, our work provides a 3D-bioprinting-based strategy with the application of autologous ADMSCs to reconstruct massive rotator cuff tendon tears.
Article
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Twenty-five patients with known or suspected tears of the rotator cuff in 26 shoulders underwent MR imaging. All patients also underwent arthrography or surgery. MR visualized abnormalities consistent with a tear in 20 of the 22 tears diagnosed by arthrography or surgery. In most cases, tears were seen as regions of increased signal intensity within the cuff on long-TR pulse sequences, although two cases simply showed an almost complete absence of normal cuff. The MR appearance of the two cases with partial tears was similar to that of full-thickness tears. Of the four cases with normal arthrograms, one case had MR findings consistent with a tear. We conclude that MR has good potential for the noninvasive diagnosis of rotator cuff tears. Its ultimate role in this diagnosis must await prospective studies comparing its accuracy with that of sonography, CT, and arthrography.
Article
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MR imaging has been shown to be accurate in the diagnosis of rotator cuff disruption and tear. Uncertainty remains about the significance of increased signal intensity in the critical zone of the supraspinatus tendon without visible disruption of tendon fibers and about the significance of other secondary findings commonly encountered with rotator cuff abnormalities, such as musculotendinous retraction or obliteration and fluid in the subacromial space. We evaluated proton density-weighted and T2-weighted coronal images (obtained on a 1.5-T superconductive MR imager) of 55 shoulders in 32 asymptomatic volunteers for signal intensity in the supraspinatus tendon, location of the musculotendinous junction, fluid in the subacromial-subdeltoid space, and appearance of the fat plane. In 89% of shoulders, the supraspinatus tendon showed focal, linear, or diffuse increased signal intensity with or without loss of the low-signal-intensity tendon margin on proton density-weighted images. None of these findings were confirmed on T2-weighted images. The musculotendinous junction was always located within an area 15 degrees medial to 30 degrees lateral to the highest point (12 o'clock) on the humeral head convexity. A peribursal fat plane was poorly defined or absent in 49%, and fluid in the subacromial-subdeltoid space was found in 20%. Increased signal intensity in the supraspinatus tendon on proton density-weighted images without a corresponding increase on T2-weighted images, the presence of small amounts of fluid in the subacromial space, and the lack of preservation of the subdeltoid fat plane are common findings in asymptomatic shoulders and by themselves are poor predictors of rotator cuff disease.
Article
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Because it can demonstrate a wide range of tissue contrast with excellent resolution, magnetic resonance (MR) imaging has revolutionized imaging in many areas of the musculoskeletal system and has generated excitement among those interested in the painful shoulder. Shoulder impingement syndrome and glenohumeral instability constitute the two major categories of shoulder derangements. Correct diagnosis requires the use of appropriate pulse sequences and imaging planes, proper patient positioning, and a satisfactory surface coil. In addition the imager must have a thorough understanding of shoulder anatomy and pathology. We present a summary of the current status of MR imaging of the shoulder including technical, anatomic, and pathologic considerations and a review of the pertinent literature.
Article
Full-text available
Thirty-one symptomatic patients were studied with MR imaging to evaluate the sensitivity and specificity of shoulder MR in the diagnosis of rotator cuff tears. Correlative studies included arthroscopy in 19 patients and arthrography in 12 patients. Images were obtained on either a 0.5- or 1.5-T Philips superconducting magnet using spin-echo pulse sequences (650-850/30 [TR, TE], 2000/30, 100) with 5-mm slices oriented in an oblique coronal plane perpendicular to the glenohumeral joint. The MR studies were initially interpreted without knowledge of the results of other diagnostic procedures. The MR diagnosis of cuff tear was made when irregularity, discontinuity, and increased signal were identified in the rotator cuff. MR images showed tears in 10 patients (32%) and were negative for tear in 21 patients (68%). MR correlated with arthroscopy and arthrography in 17 of 18 normal patients, in eight of 10 patients with complete tears, and in one of three patients with partial tears. For complete rotator cuff tears, the sensitivity, specificity, and accuracy were 80%, 94%, and 89%, respectively. For all tears (partial and complete), the sensitivity, specificity, and accuracy were 69%, 94%, and 84%, respectively. These data suggest that MR imaging is an accurate procedure for the diagnosis of complete rotator cuff tears. The number of partial tears (three) in this series is too small to evaluate the value of MR imaging in the diagnosis of partial tears.
Article
1. Radiographs of both shoulders were performed on 106 unselected necropsy subjects and those found to be abnormal were examined pathologically. 2. Radiological abnormalities were found in sixty-eight shoulders of thirty-eight subjects. Pathological examination showed rotator cuff tears and associated abnormalities in thirty-five of these, rheumatoid arthritis in one, a previous fracture in one, and one was not examined. 3. The criteria for radiological diagnosis of rotator cuff tears are examined and discussed. 4. The radiological changes give little indication of the severity of the tears or associated abnormalities except in the case of complete rupture of the cuff when acromio-humeral articulation occurs. 5. The lesions are all explicable on a traumatic basis. There is no correlation with the presence or absence of osteoarthritic disease of the joint. 6. The biceps tendon may become damaged or even ruptured in this condition. 7. Villous synovial proliferation was found in fourteen cases, in five of which it was pigmented with histological appearances resembling pigmented villonodular synovitis. The significance of this finding is briefly discussed.
Article
Rupture of the tendons of the short rotator cuff of the shoulder joint, notably the supraspinatus tendon, is important because of the frequency of its occurrence and because of the disability that may follow. The whole subject of rupture of the short rotator tendons of the shoulder has been reviewed at length by one of us (C. L. Wilson) in another publication.1 The purpose of this paper is to present a gross and microscopic study of the supraspinatus tendon at various ages made especially with a view to amplifying the present rather scanty information regarding the pathologic changes in the tendon leading to rupture.McMaster,2 from experiments on rabbits, has shown that when a system composed of a muscle and its tendon, together with their bony attachments, is stretched to the breaking point by a force exerted through the bones the break occurs anywhere but in the tendon
Article
We performed a blind prospective analysis of the shoulders of 20 asymptomatic volunteers, aged 25 to 55 years, to determine the frequency of magnetic resonance (MR) findings considered abnormal in symptomatic patients. Twenty symptomatic patients were used as controls. With regard to the asymptomatic shoulders, all 20 had intact rotator cuff tendons, although six (30%) of the tendons had abnormal internal signal, and one (5%) had abnormal morphology. Subdeltoid and subacromial fat planes were intact in 20 (100%) and 19 (95%) shoulders respectively. Subdeltoid or subacromial fluid was not present in any shoulder. Acromioclavicular osteophytes and supraspinatus depression were seen in seven (35%) and six (30%) respectively. The glenoid labrum was intact in all volunteers, although it had abnormal internal signal in 10 (50%). MR findings of abnormal signal in the glenoid labrum, and of abnormal signal and morphology of the rotator cuff tendons, supraspinatus depression, and acromioclavicular osteophytes have been reported as signs of instability, tendinitis, and impingement. Similar findings were seen in asymptomatic volunteers, indicating that these findings may not be a sign of clinically significant pathology.
Article
In 30 volunteers with normal shoulders, the following conclusions were made with regard to normal anatomic features at magnetic resonance (MR) imaging: (a) The supraspinatus tendon has low signal intensity, except for a 1-cm area with intermediate signal intensity in the region of the "critical zone." (b) The deltoid tendon attachment on the inferior surface of the acromion may simulate a subacromial spur if not imaged in continuity. (c) Fluid in the long head of the biceps tendon sheath is normal if not completely surrounding the tendon. (d) The anterolateral branch of the anterior humeral circumflex vessels in the proximal bicipital groove adjacent to the biceps tendon mimics fluid in the tendon sheath. (e) Continuity or obliteration of the subacromial-subdeltoid bursal fat plane is an unreliable diagnostic sign since the fat plane is often focally absent. (f) Fluid is not detected in subacromial-subdeltoid bursae. (g) Undercutting of the anterior glenoid labrum by hyaline cartilage or a closely apposed middle glenohumeral ligament may simulate an anterior labral tear.
Article
The signal intensity and morphologic characteristics of the rotator cuff and surrounding structures at magnetic resonance (MR) imaging were investigated with five pulse sequences in 15 asymptomatic subjects. In all subjects, a focal region of relative increased signal intensity corresponding to the critical zone was observed in the supraspinatus tendon just proximal to its insertion. Soft-tissue signal intensity (isointense with muscle) was also located between the supraspinatus tendon and underlying joint capsule, interposed between the conjoined leaves of the supraspinatus and infraspinatus tendons, and superolateral to the conjoined cuff tendon, near its insertion. These regions were most conspicuous and most clearly defined with fat-suppression imaging. Small amounts of fluid were observed within the joint space and its recesses, the bicipital tendon sheath, and the subacromial-subdeltoid bursa. These and other MR imaging findings of this study previously have been regarded as indicative of rotator cuff abnormalities. These results will help refine the criteria for diagnosis of rotator cuff disorders with MR imaging.
Article
The signal intensity patterns of rotator cuff lesions at magnetic resonance (MR) imaging were evaluated in 80 patients who had surgical correlation and in 13 asymptomatic individuals (14 shoulders). Six cadaver shoulders were examined with MR, and histologic correlation was obtained in four. All studies were performed at 1.5 T with a flexible circular surface coil. The accuracy of MR imaging in detection of full-thickness cuff tears (31 patients) was 0.95 and of partial thickness tears (16 patients), 0.84. The most common and accurate pattern for full-thickness cuff tears (22 of 31 tears) was a region of intense signal seen on T2-weighted images. Less often the torn region consisted of an extremely degenerated and attenuated tendon with moderate signal intensity or was obscured by low-signal-intensity scar. The intense signal pattern on T2-weighted images was also accurate, although a less common finding (seven of 16 cases), in the diagnosis of partial tears. Tendinitis was recognized as focal or diffuse regions of increased signal intensity or a nonhomogeneous pattern of increased signal often associated with tendinous enlargement. In some patients, manifestations of subacromial-subdeltoid bursitis was present. Tendon degeneration was also manifested as regions of increased signal intensity. Some similarity and overlap of signal patterns of partial interstitial tears, tendinitis, and tendon degeneration are observed.
Article
Ilizarov procedures, introduced recently in the United States, were performed in 163 patients aged 2-53 years who underwent pure limb lengthening for inherited conditions such as achondroplasia (37 procedures), correction of angular deformity secondary to nonunion or malunion of fractures (62 procedures), or correction of congenital/developmental angular deformities of the limbs (64 procedures). Before surgery, every patient was evaluated with plain radiography; after surgery, every patient was evaluated at weekly or biweekly intervals with standard plain anteroposterior and lateral radiography, with acquisition of additional radiographs centered over the distraction site. Every patient had complete bone healing, which took 3-14 months. In all patients, new bone formation was evident within 15 weeks after surgery. Complications associated with the Ilizarov technique were minimal (delayed formation in two cases and cyst formation within the distraction site in two cases), but success relies heavily on radiographic evaluation. Radiographs of the whole bone or joint must be obtained for overall assessment of bone alignment; specific views of the distraction site, with the x-ray beam centered over this site, may be required.
Article
Thirty-eight patients with suspected rotator cuff tears were examined at 1.5 T by using a loop-gap resonator surface coil. The MR findings were compared prospectively in a blinded fashion with the results from double-contrast arthrography in all 38 patients, high-resolution sonography in 23 patients, and surgery in 16 patients. In the total group of 38 patients, MR imaging detected 22 of 22 tears and 14 of 16 intact cuffs as determined by arthrography. In the 16 surgically proved cases, MR and arthrography showed identical results, with 92% sensitivity in the diagnosis of 12 tears and 100% specificity in the diagnosis of four intact cuffs. In a subgroup of 23 patients, sonography detected nine of 15 tears and seven of eight intact cuffs as determined by comparison with arthrography. In 10 surgically proved cases, sonography was 63% sensitive in the diagnosis of eight rotator cuff tears and 50% specific in the diagnosis of two intact cuffs. For the diagnosis of rotator cuff tears, MR imaging is comparable to arthrography in both sensitivity and specificity. In this study, sonography was not as accurate in the diagnosis of rotator cuff tears as were the other two techniques. These results suggest that MR imaging should be considered the noninvasive test of choice for patients with suspected rotator cuff disease.
Article
To determine the diagnostic performance of magnetic resonance (MR) imaging in the evaluation of suspected rotator cuff tears, eight asymptomatic volunteers and 32 patients with rotator cuff tendonopathy who underwent surgery were examined with MR imaging. Twenty-four of these patients also underwent contrast arthrography. The ability of MR imaging to depict the size of cuff tears and the quality of torn tendon edges was also evaluated. The MR imaging and arthrographic studies were reviewed without knowledge of surgical results or of the other studies. A scoring system was developed and a score assigned to each patient's MR study. The sensitivity of MR imaging for all tears (partial and full thickness) was 0.91, and the specificity was 0.88; whereas the sensitivity and specificity of arthrography were each 0.71. The scoring system improved the sensitivity to 1.0 and the specificity to 0.92. Linear regression analysis showed excellent correlation between preoperative assessment of the size of rotator cuff tears and measurement at surgery (r = .95).
Article
We used magnetic resonance imaging in 41 patients with shoulder pain. Magnetic resonance was found useful in depicting the spectrum of rotator cuff abnormalities associated with mechanical impingement including both large and small rotator cuff tears as well as tendinitis. Abnormalities of the capsular mechanism, osseous tumors, osteonecrosis, and injuries to the supporting musculature are also well depicted.
Article
Instability of the glenohumeral joint is a common cause of chronic shoulder pain and disability. One or more episodes of subluxation or dislocation may result in a tear, detachment, or attenuation of the glenoid labrum, stripping of the joint capsule from the scapula, or trauma to the tendons or muscles of the rotator cuff. A series of 27 shoulders examined with magnetic resonance (MR) imaging showed changes of glenohumeral instability, which were confirmed with open or arthroscopic surgery. MR imaging was capable of displaying common types of pathologic conditions resulting from instability, including labral trauma, capsular detachment, and retraction of the subscapularis muscle. MR imaging is a valuable diagnostic tool for the evaluation of glenohumeral instability.
Article
In 200 shoulders from cadavera, we studied the pathological changes on the undersurface of the acromion as associated with tears of the rotator cuff. After radiographic and histological analysis, we found that in the specimens that had a partial tear of the cuff the undersurface of the acromion was almost intact. Although a lesion in the anterior one-third of the undersurface of the acromion was always associated with a tear of the cuff, the reverse was not true. We concluded that the pathogenesis of most of the tears probably is a degenerative process.
Article
Through the application of oblique planes and flexible surface coil techniques, magnetic resonance imaging (MRI) promises to be of great clinical value in the evaluation of a variety of pathologic conditions affecting the shoulder. In patients with joint effusions, the tendinous portion of the rotator cuff, glenoid labrum, and bicipital tendon can be readily visualized. This capability has particular relevance in patients with inflammatory disease and traumatic conditions. Rotator cuff atrophy and impingement of the coracoacromial arc upon the supraspinatus muscle and tendon can also be demonstrated. MRI is also useful in the evaluation of shoulder instability.
Article
Double-contrast shoulder arthrograms were performed in 20 patients at an average of 30 months after operative repair of a torn rotator cuff. In 18 out of 20 shoulders the contrast medium leaked into the subacromial bursa indicating a defect in the rotator cuff. Despite this, 17 patients had complete relief of pain and 15 had a full range of shoulder elevation. The results suggest that a completely watertight closure is not essential for a good functional result, and that arthrography may not be helpful in the investigation of failure of repair.