The reconstruction of inveterate rotator cuff lesions and lesions of the glenoid labrum of the shoulder with open and arthroscopic techniques

Background. The purpose of the paper is to present the treatment results of patients with injured rotator cuff, based on 6 months study, major limb dysfunction and severe pain.
Material and methods. Study is based on 14 patients, who underwent arthroscopic and open surgery of the shoulder. After arthroscopic repair of coexisting injuries and curbed mobility of the rotator cuff, open method was employed to reinsert rotator cuff with decompression of subacromial space. After the surgery, the arm was immobilised using orthosis with about 20-30 degrees abduction. Limited exercises of mobility range was started in the 4rd week after the surgery, increasing slightly the intensity and character of the exercises. External rotation movement was introduced in the third month after the surgery.
Results. The decrease of pain score has been observed from 6.28 points before surgery to 1.87 points after the treatment. The UCLA score increased after the surgery by about 26 points. In Simple Shoulder Test the score of positive answers increased from 2.2 to 7.6 after surgery. Results of the treatment were lack off pain and restored stability of the shoulder.
Conclusions. Decreased pain and better mobility seem to prove the efficacy of treatment of inveterate massive rotator cuff lesions.     

Ultrasound-guided shoulder injections in the treatment of subacromial bursitis

OBJECTIVE: To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis. DESIGN: A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study. These patients were divided into blind and ultrasound-guided injection groups. The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups. RESULTS: The shoulder abduction range of motion before injection in the blind injection group was 71.03 +/- 12.38 degrees and improved to 100 +/- 18.18 degrees 1 wk after the injection treatments. However, the improvement did not reveal significant statistical differences (P > 0.05). The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 +/- 14.72 degrees and improved to 139.29 +/- 20.14 degrees 1 wk after the injection treatments (P < 0.05). CONCLUSIONS: Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis.     

Immediate Effects of Thoracic Spine Manipulation Upon Shoulder Functionality in Patients With Sutured Rotator Cuff Repair: A Prospective Study

Objectives

The purpose of this study was to evaluate the immediate effect of thoracic spine manipulation upon active flexion and abduction mobility of the shoulder, spine temperature, and the size of the subacromial space as measured by ultrasound in 3 positions (internal, neutral, and external rotation) of the glenohumeral joint in patients who have undergone surgery because of subacromial impingement.

Die arthroskopische AC-Gelenkresektion—Technik und Ergebnisse

In our retrospective study there is shown how 37 patients were examined and operated on in the period from January 1997 to February 2001. All patients were followed in a spell of 3.8 years in average after an arthroscopic acromioclavicular joint resection and concomitant subacromial decompression from a bursal approach. The indication was primary and secondary osteoarthritis and painful osteolysis of the lateral clavicle of various etiologies. All patients had failed a conservative treatment of at least 6 months. The amount of distal clavicular resection averaged 8.9 mm (range 5 to 13 mm). 35 of our 37 patients have reported a significant pain reduction. The main pain level at a VAS scale reduced from a 7.2 preoperative to a 1.9 postoperative one. The horizontal adduction was possible for all patients without any pain. The Constant score has improved from 53 to 92 points. The operated lateral clavicle osteolysis tends to result in a better range of motion, pain relief and Constant score compared to other indications. The overall results regarding the rating system of Zawadsky et al. [30] for 37 shoulders were excellent in 19 (51%), good among 14 patients (38%), and poor in 4 shoulders (11%). The present study shows that the AC joint resection by indirect bursal approach in conjunction with subacromial decompression is a safe, less complicated minimal invasive method available leading to a high percentage of good and excellent results in compliance with strong indication criteria.     

Komplikationen nach arthroskopischer subakromialer Dekompression (ASD)

Objective: In general, arthroscopic subacromial decompression is a safe procedure. The objective of this study was to assess the incidence of surgery-related complications. Methods: Between October 1994 and July 1998, 173 patients with grade II impingement underwent arthroscopic subacromial decompression (ASD). Surgery was done in the beach-chair position. All patients were available for follow-up 6?weeks, and 3 and 6 months after surgery. Results: The incidence of surgery-related complications was 4% (n = 7). We found three frozen shoulders (1.7%), one infection (positive cultures; 0.6%), one seroma (negative cultures; 0.6%), one incomplete lesion of the plexus which resolved partly after 1 year (0.6%), and one stress fracture of the acromion (0.6%). Conclusions: ASD has a low incidence of surgery-related complications; secondary frozen shoulder seems to be relevant. The beach-chair position should be carefully monitored because plexus injury is a possible complication.     

关节镜下肩峰成形术治疗肩峰下撞击综合征

目的探讨关节镜下肩峰成形术治疗肩峰下撞击综合征的方法和效果。方法分析应用关节镜行肩峰成形术治疗68例经保守治疗无效的2期肩峰下撞击综合征的情况。随访12个月以上纳入分析。采用洛杉矶加洲大学（UCLA）肩关节功能标准评价疗效。结果平均随访16．4个月，术后3-24个月有持续的症状和功能的改善，UCLA评分从术前18．3分改善到31．7分，优良率为89．7％。结论关节镜能明确诊断，镜下肩峰成形术治疗肩峰下撞击综合征能达到减压要求，效果良好。早期、持久地术后锻炼是康复的保证。     

Application of arthroscopy in anterior luxation of the shoulder

Background. Arthroscopy is undoubtly the most comprehensive procedure for shoulder lesions providing even better inspection of the interior of the joint than conventional open procedures.
Material and methods. The atrthroscopic Bankart procedure by suture and MITEK technique was performed in 102 patients (1992-2003) with acute anterior shoulder dislocations. The minimum follow-up was 1 year. Clinical examination demostrated positive labrum pathology in all cases.
Results. Arthroscopic treatment of acute shoulder dislocations has been succesfull in 100%. None of 102 patients experienced intraoperative complications or infections. A slight loss of abduction and minimal loss of external rotation was found in patients but there was no recurrence of complete dislocations or subluxations.
Conclusions. We believe that arthroscopic surgical intervention after the initial shoulder dislocations can dramatically lower the recurrence rate and should be considered as a treatment option in young patients.     

Application of arthroscopy in interior luxation of the shoulder

Background. Arthroscopy is undoubtly the most comprehensive procedure for shoulder lesions providing even better inspection of the interior of the joint than conventional open procedures.
Material and methods. The atrthroscopic Bankart procedure by suture and MITEK technique was performed in 102 patients (1992-2003) with acute anterior shoulder dislocations. The minimum follow-up was 1 year. Clinical examination demostrated positive labrum pathology in all cases.
Results. Arthroscopic treatment of acute shoulder dislocations has been succesfull in 100%. None of 102 patients experienced intraoperative complications or infections. A slight loss of abduction and minimal loss of external rotation was found in patients but there was no recurrence of complete dislocations or subluxations.
Conclusions. We believe that arthroscopic surgical intervention after the initial shoulder dislocations can dramatically lower the recurrence rate and should be considered as a treatment option in young patients.     

肩峰下撞击综合征治疗：关节镜下肩峰减压与开放性手术的系统评价

背景：关于肩峰下撞击综合征选择关节镜下肩峰下减压术还是开放性手术治疗,目前尚存争议。目的：系统评价关节镜下肩峰下减压术与开放性手术治疗肩峰下撞击综合征的疗效。方法：计算机检索国内外各数据库自建库以来关于关节镜下肩峰下减压术与开放性手术治疗肩峰下撞击综合征的对照试验。不限语种,无论是否为RCTs或是否使用盲法。采用RevMan 5.0软件进行Meta分析。结果与结论：最终纳入10个对照试验,其中随机对照试验4篇,非随机对照试验6篇,共583例肩峰下撞击综合征患者。Meta分析结果显示在住院天数及恢复工作时间方面,关节镜组均少于开放手术组;而在术后肩功能评分、手术时间、患者满意度、术后加利福尼亚大学洛杉矶评分标准（UCLAs）优良率方面,两组差异无显著性意义。但由于纳入的研究在数量和质量上有一定的限制和不足,尚需开展更多大样本、多中心、高质量的随机对照试验加以验证。     

Arthroscopic treatment of traumatic shoulder instability

Background. Traumatic shoulder instability is a common sequel following first shoulder dislocation, especially in young population (< 30 y.a). Shoulder arthroscopy is getting more and more popular among orthopaedic community. Efficacy of arthroscopic treatment of shoulder instability approaches that of conventional operative techniques.
Aim. The purpose of the study was the analysis of arthroscopic treatment of traumatic shoulder instability.
Material and methods. Study was based on 22 patients, 24 shoulders were operated. Capsulolabral complex has been stabilized arthroscopically in all patients.
Functional was assessed by means of ASES, UCLA and SST scores. Function was improved significantly. There has been no recurrence of instability in follow-up period.
Conclusions. We have proved good efficacy of arthroscopic techniques in treatment of the instability.
Joint stability was restored with decreased invasiveness of operation (better cosmesis, easier rehabilitation).     

Comparison of acromiohumeral distance in symptomatic and asymptomatic patient shoulders and those of healthy controls

BackgroundThe reduction of the subacromial space has traditionally been linked to rotator cuff pathology. The contribution of this narrowing, both in the development and maintenance of rotator cuff tendinopathy, is still under debate. The objective of the present study was compare the acromiohumeral distance at 0 and 60 degrees of active shoulder abduction in scapular plane, static position, in both symptomatic and contralateral shoulders, between participants with unilateral rotator cuff related shoulder pain, and in asymptomatic participants.MethodThis was a cross-sectional observational study. Seventy-six participants with chronic shoulder pain were assessed. Forty participants without shoulder pain were also recruited to compare the acromiohumeral distance with symptomatic participants. The acromiohumeral distance was measured at 0 and 60 degrees of active shoulder abduction in all the groups by ultrasound imaging. Mean differences between symptomatic versus contralateral shoulders, and versus healthy controls, were calculated.FindingsThere were no statistical significant differences (p > .05) in the acromiohumeral distance at 0 degrees of shoulder elevation between the groups. However, significant differences were found at 60° between symptomatic and contralateral shoulder groups (0,51 mm; 95% CI: −0.90 to −0.12).InterpretationsDifferences in shoulder pain perception at 0° are not attributable to acromiohumeral distance differences. However, treatments focused on increasing AHD at 60° could be prescribed, as a significantly reduced AHD was found in symptomatic shoulders when compared with contralateral shoulders. Further research is needed to determine, not only static differences in AHD, but also dynamic differences.     

Sonographic assessment of subacromial bursa distension during arm abduction: establishing a threshold value in the diagnosis of subacromial impingement syndrome

Purpose

In this study, we aimed to establish a quantitative threshold value in the diagnosis of subacromial impingement syndrome by measuring the thickness of the subacromial bursa during abduction and adduction.

Materials and methods

Forty-five patients with subacromial impingement syndrome and 54 healthy individuals underwent dynamic shoulder ultrasonography. The subacromial bursa, between the supraspinatus tendon margin and peribursal adipose tissue, was measured between the acromion and humeral head at its widest part. The subacromial impingement ratio was calculated by dividing the subacromial bursa thickness during abduction to the subacromial bursa thickness during adduction. Shapiro–Wilk test was used in the assessment of normal distribution of parameters.

Results

The mean subacromial bursa thickness in the abduction position was 1.8 ± 1.1 mm in the study group and 0.9 ± 0.3 mm in the control group. The mean subacromial bursa thickness in the adduction position was 0.9 ± 0.5 mm in the study group and 0.8 ± 0.3 mm in the control group. The subacromial impingement ratio showed a statistically significant difference between groups (p < 0.0001), and the ratio being 2.0 ± 0.5 in the study group and 1.2 ± 0.1 in the control group. For measurements performed in the abduction position, the best cut-off value was calculated as 1.3 mm, and sensitivity and specificity were 70.6 and 85.2%, respectively. The best cut-off value was 1.4 for the subacromial impingement ratio, and sensitivity and specificity were 88.2 and 96.3%, respectively.

Conclusion

Subacromial impingement ratio is a very practical and reliable method in subacromial impingement syndrome diagnosis.

     

Analyse von Therapieversagern nach subakromialer arthroskopischer Dekompression

Problem: In the present study, we evaluated the failure and revisions rates after arthroscopic subacromial decompression (SAD). Method: We examined 70 patients who were treated with arthroscopic subacromial decompression for primary shoulder impingement stage II according to Neer at an average follow-up time of 30 months. Hereby, special attention was paid to the revision operations resulting from our treatment. Results: Revision operation had to be performed in nine patients (13%). Reasons for revisions were persisting or increasing pain as well as functional dissatisfaction. At the follow-up examination, six of these revised patients (66%) were satisfied with the result. The mean follow-up CONSTANT score in the revised patients was 80.3 (SD ± 15.4). In patients with impingement stage II, the mean follow-up CONSTANT score was 84.7 (SD ± 16.7). In 60% of the revised patients, the necessity for revision operation was directly related to the technical problems of the primary operation, in 40% we found reasons not related to the primary SAD. Conclusions: Technical failures are the most common cause for the need of revision operations after SAD. This demonstrates how demanding this kind of operation procedure is. In case of revision operations, individual strategies should be developed in which the decision of whether to perform arthroscopic or open revision procedures is of special importance.     

微创手术与药物治疗对早期原发性冻结肩患者近期和远期效果的比较

目的比较微创手术与药物治疗对早期原发性冻结肩(PFS)患者的近期和远期效果。方法选取2014年6月-2015年9月该科收治入院的82例PFS患者为研究对象,随机分为药物组与手术组两组,各41例。对照组患者行关节腔内固醇激素注射治疗,观察组患者行关节镜下盂肱关节与肩峰下间隙的清理松解术。比较两组的基线资料、治疗前后的视觉模拟评分(VAS)、Constant肩关节评分、内旋、外旋、外展、前屈的主动关节活动度(ROM)。结果两组的基线资料、治疗前的VAS评分、Constant肩关节评分、主动ROM比较,差异无统计学意义(P0.05),具有可比性。与治疗前相比,两组患者治疗后的VAS评分均明显降低,Constant肩关节评分、主动ROM均明显升高,差异有统计学意义(P0.05)。在治疗后4周,手术组患者的VAS评分明显高于药物组,Constant肩关节评分、主动ROM明显低于药物组,差异有统计学意义(P0.05)。在治疗后12周、半年和1年,手术组患者的VAS评分明显低于药物组,Constant肩关节评分、主动ROM明显高于药物组,差异有统计学意义(P0.05)。结论肩关节镜下微创手术与药物注射都是早期PFS患者的有效治疗方法,药物注射的近期疗效显著,但远期疗效较差,而微创手术的远期效果更加突出,配合术后的药物口服和康复锻炼能显著改善其肩关节功能和生活质量,值得临床推广应用。     

内排锚钉缝合桥技术联合传统缝合桥技术在重度肩袖撕裂肩关节镜中的应用

目的 探讨内排锚钉缝合桥技术联合传统缝合桥技术在重度肩袖撕裂伤肩关节镜中的应用效果。方法 收集重度肩袖撕裂伤且接受肩关节镜修复手术的63例患者为研究对象,将术中采用内排锚钉缝合桥技术联合传统缝合桥技术的患者设为联合组（30例）,采用传统缝线桥技术的患者设为传统组（33例）,对比2组手术前后疼痛[疼痛视觉模拟评分（VAS）]、肩关节活动度（前屈、内旋、外展和外旋）、肩关节功能[Constant-Murley肩关节功能评分（Constant-Murley）、美国肩肘外科医师协会评分（ASES）]及再撕裂发生情况、并发症发生率和预后（Neer评分）。结果 联合组术后1个月VAS评分低于传统组（P < 0.05）;联合组术后1个月、6个月肩关节内旋主动活动度与传统组比较差异均无统计学意义（P均> 0.05）,前屈、外展、外旋活动度大于传统组（P均< 0.05）;联合组术后1个月、术后6个月Constant-Murley、ASES均高于传统组;联合组术后6个月Sugaya分级优于传统组（P均< 0.05）。联合组术后没有伤口不愈合、持续性肿胀、感染等并发症。术后1年Neer评分显示联合组预后优良率高于传统组（P < 0.05）。结论 在重度肩袖撕裂伤肩关节镜中采用内排锚钉缝合桥技术联合传统缝合桥技术可获得更好的修复效果,有助于更好地改善肩关节活动度,提升肩关节功能。     

In vivo measurements of subacromial impingement: substantial compression develops in abduction with large internal rotation

BACKGROUND: Subacromial impingement is a widely recognized mechanism of chronic shoulder pain. The magnitudes of the compressive forces that impinge the subacromial structures were often measured from cadaveric specimens, but it is questionable to use this data as a sole basis to determine the shoulder motions and/or shoulder configurations that induce impingement in live subjects performing active motion. The purpose of the present study was to determine in vivo the magnitude of the compressive force at selected shoulder configurations. METHODS: The subacromial structures may be impinged by the downward-directed forces exerted by the coraco-acromial ligament. The reactions of these forces push the ligament upwards and deform it into a curved shape. A single resultant of these reaction forces was determined with an inverse approach to quantify the magnitude of the impingement force. An ultrasound unit was used to visualize the deformed shape of the coraco-acromial ligament for thirteen subjects with no symptomatic shoulder problem actively holding their shoulders in five configurations. FINDINGS: The impingement force in 90 degrees abduction+maximum internal rotation (mean=21.3N) and that in the Hawkins test position (mean=18.3N) were significantly greater than those in 90 degrees abduction+neutral and external rotation (means < or = 3N). INTERPRETATION: For young asymptomatic shoulders, the motions that induce impingement are not any arm abduction, but the arm abduction with a large internal rotation. Further study is indicated to examine the impingement force among various age groups.     

Kinematics and muscle activation in subacromial pain syndrome patients and asymptomatic controls

BackgroundConflicting theories exist about the underlying cause of chronic subacromial pain in the middle-aged population. We aim to improve our understanding of kinematics and muscle activation in subacromial pain syndrome to provide insight in its pathophysiology.MethodsIn a cross-sectional comparison of 40 patients with subacromial pain syndrome and 30 asymptomatic controls, three-dimensional shoulder kinematics and electromyography-based co-contraction in 10 shoulder muscles were independently recorded. Glenohumeral and scapulothoracic kinematics were evaluated during abduction and forward flexion. Co-contraction was expressed as an activation ratio, specifying the relative agonistic and antagonistic muscle activity in each muscle.FindingsDuring abduction and forward flexion, the contribution of glenohumeral motion to elevation and glenohumeral external rotation was lower in subacromial pain syndrome (at 120⁰ abduction: −9°, 95% CI -14°- -3°; and − 8°, 95% CI -13°--3°, respectively), and was compensated by more scapulothoracic motion. The pectoralis major's activation ratio was significantly lower (Z-score: -2.657, P = 0.008) and teres major's activation ratio significantly higher (Z-score: -4.088, P < 0.001) in patients with subacromial pain syndrome compared to the control group.InterpretationReduced glenohumeral elevation and external rotation in subacromial pain syndrome coincided with less teres major antagonistic activity during elevation. These biomechanical findings provide a scientific basis for intervention studies directed at stretching exercises to reduce glenohumeral stiffness in the treatment of subacromial pain syndrome, and teres major strengthening to improve humeral head depressor function.     

A Systematic Comparison on Postoperative Analgesia Effect Between Subacromial and Intravenous Analgesia Pumps for Arthroscopic Rotator Cuff Repair

PurposeArthroscopic rotator cuff repair is often associated with severe postoperative pain. Various agents, routes, and modes are used for the treatment of postoperative pain with a minimum of side effects. This systematic work was conducted to compare the postoperative effect of subacromial patient-controlled analgesia with intravenous patient-controlled analgesia after an arthroscopic rotator cuff repair surgery.DesignA systematic review of relevant studies were retrieved from electronic databases and included based on criteria and eligibility.MethodsThe articles were retrieved from 1997 to 2018 by computerized searches of Scopus, PubMed, and EMBASE using different combinations of search terms, such as shoulder, rotator cuff, analgesic, analgesia, arthroscopic, pain, cuff repair, rotator cuff repair, acromion, and intravenous.FindingsA total of 10 articles were included in this study from the initial search of 778 records. Compared with subacromial procedure, the intravenous procedure helps in reducing the postoperative pain but with more side effects.ConclusionsThis study described that the direct continuous infusion of anesthetic under subacromial analgesic pump showed a greater pain relief with less side effects compared with intravenous infusion for arthroscopic rotator cuff repair.     

Effects of Shoulder Stabilization Exercise on Pain and Functional Recovery of Shoulder Impingement Syndrome Patients

[Purpose] This study examined the effects of scapular stabilization exercises immediately after surgery on pain and function in patients diagnosed with shoulder impingement syndrome. [Subjects] The subjects were assigned by random sampling to an experimental group (n=15) to which stabilization exercise was applied and a control group (n=15) to which ordinary physical treatment was applied. [Methods] To evaluate the degree of pain, a 100 mm visual analogue scale (VAS) was used. The Constant-Murley Scale (CMS) was used to evaluate the functions of the shoulder joints. To determine the range of motion, a goniometer was used to measure range of shoulder motion. The simple shoulder test (SST) was used to determine the condition of the shoulder joints of the subjects. [Results] There were significant differences in all the items of the experimental group. The results of comparison of the therapeutic effect in the experimental and control groups revealed significant differences in active abduction, passive abduction, VAS, SST, and the CMS, except for pain. [Conclusion] The results suggest that shoulder stabilization exercise positively affects pain alleviation and functional recovery in shoulder impingement patients.Key words: Shoulder, Impingement syndrome, Stabilization exercise