Full-thickness supraspinatus tendon tears with intact superior glenohumeral capsule

Fourteen of 318 consecutive shoulder arthroscopies performed over 5 years were found to have a complete tear of the supraspinatus tendon with an intact superior glenohumeral joint capsule. All tears were surgically repaired into a bony trough in the greater tuberosity. All of these tears were found in the past 2 years, representing the last 155 arthroscopies performed. This would indicate that there were probably similar lesions that were missed in earlier cases. This represents a significant pitfall injury that may yield a negative arthrogram and may be overlooked in arthroscopic shoulder surgery unless close inspection of the bursal side of the rotator cuff is accomplished.     

Antitumor effect of DT-5461, a lipid A derivative, against human tumor xenografts is mediated by intratumoral production of tumor necrosis factor and affected by host immunosuppressive factors in nude mice

PURPOSE OF THE STUDY: The purpose of this report was to study the repercussions of rotator cuff condition on unconstrained shoulder arthroplasty results. METHODS: Between 1986 and 1993, 40 unconstrained shoulder prostheses were performed (24 total and 16 hemiarthroplasties). At the time of the operation, rotator cuff condition was reported to be normal in 15 shoulders, atrophic in 10, scarred in 3, torn in 12. Clinical and radiographical results were analyzed and supplemented with a rotator cuff echography. Postoperative follow-up averaged 42.25 months (12 to 97 months). RESULTS: When the rotator cuff was intact at the time of operation, clinical results were the best at the time of review. Constant score, overall mobility, forward elevation, external rotation with the elbow along the side were better for intact than for atrophic, scarred or torn rotator cuffs (p < 0.01). Ruptures repaired by local tissue transfer or trapezo deltoidal flap substitution (3 cases) gave satisfactory results, whereas two dacron cuff prostheses failed. In the non repaired ruptures (7 cases), arthroplasty resulted in 3/4 fair or poor results. At the time of review, the total incidence of postoperative rotator cuff tears was high (12 cases), functional repercussions were variable. Among the 15 rotator cuff tears observed at the time of the review, the long head of the biceps was present and in place in 9 cases and ruptured in 6 cases. In these latter cases, Constant score (p < 0.01), the forward elevation (p < 0.01), external rotation with elbow along side (p < 0.05) and overall mobility (p < 0.05) were worse; moreover, humeral head superior migration was greater (p < 0.01). DISCUSSION: Our study confirms the superiority of clinical results when the cuff was intact at the time of the operation. The repair of rotator cuff tears seems to be justified. When the rupture has not been repaired, clinical results were fair or poor in 5 cases out of 7, the initial rupture spread to the other tendons in 3 cases out of 7. Secondary ruptures were frequent (12 cases). No predictive factor was identified, but an overlapping of the greater tuberosity appears to be detrimental. Among rotator cuff tears present at the time of review, long head of the biceps rupture jeopardized clinical results and was associated with a proximal migration of the humeral head which was significantly more severe than with an intact non displaced long head of the biceps. CONCLUSION: During unconstrained shoulder prosthesis implantation, it is therefore recommend to systematically repair any associated rotator cuff rupture, in order to avoid any greater tuberosity overlap relative to the prosthetic head and to preserve the long head of the biceps tendon which limits upward migration of the humeral head and improves prosthetic kinetics.     

A psychoanalytic approach to the ethics of the physician-patient relationship

Thirteen patients aged 36-63 years underwent surgery for full thickness rotator cuff rupture. The average follow-up was 21.1 months (range 12-36 months). Supraspinatus tendon was torn in 7 cases, supraspinatus and infraspinatus in 4, subscapularis in 1 and all three tendons were ruptured in 1 patient. Subacromial decompression and cuff reconstruction was done in 11 cases, decompression combined with cuff debridement and partial subscapularis tendon reconstruction in 1 case and subscapularis reconstruction in 1 patient. Constant Score (version corrected for age and sex) was used for shoulder function evaluation. There were 6 very good, 4 good, 1 fair and 2 bad results. Recurrence of cuff tear was diagnosed sonographically in 2 cases of both supra- and infraspinatus rupture. Statistical analysis disclosed significant correlation between extent of the tear and final functional result. Constant Score can be recommended as an objective and useful method for shoulder function assessment.     

Prolonged survival in patients with advanced melanoma treated with neoadjuvant chemotherapy followed by resection

We conducted this cadaveric study to define a biomechanical rationale for rotator cuff function in several deficiency states. A dynamic shoulder testing apparatus was used to examine change in middle deltoid muscle force and humeral translation associated with simulated rotator cuff tendon paralyses and various sizes of rotator cuff tears. Supraspinatus paralysis resulted in a significant increase (101%) in the middle deltoid force required to initiate abduction. This increase diminished to only 12% for full glenohumeral abduction. The glenohumeral joint maintained ball-and-socket kinematics during glenohumeral abduction in the scapular plane with an intact rotator cuff. No significant alterations in humeral translation occurred with a simulated supraspinatus paralysis, nor with 1-, 3-, and 5-cm rotator cuff tears, provided the infraspinatus tendon was functional. Global tears resulted in an inability to elevate beyond 25 degrees of glenohumeral abduction despite a threefold increase in middle deltoid force. These results validated the importance of the supraspinatus tendon during the initiation of abduction. Glenohumeral joint motion was not affected when the "transverse force couple" (subscapularis, infraspinatus, and teres minor tendons) remained intact. Significant changes in glenohumeral joint motion occurred only if paralysis or anatomic deficiency violated this force couple. Finally, this model confirmed that rotator cuff disease treatment must address function in addition to anatomy.     

Arthroscopic assessment of rotator cuff tear reparability

To evaluate the efficacy of arthroscopic techniques in determining the potential reparability of complete rotator cuff tears, a clinical investigation was performed. The parameters of tear size measurement, tendon quality, tendon mobility, and suture anchor placement were evaluated. These parameters were determined using both arthroscopic and open surgical technique. No statistically significant differences were noted when the arthroscopic findings were compared with the findings at open rotator cuff repair. Arthroscopic techniques can reliably assess rotator cuff tear size, tendon quality, tendon mobility, and suture anchor placement.     

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

Os acromiale, failure of fusion of the secondary centers of ossification of the acromion process, has been noted as a contributing factor in shoulder impingement syndrome and rotator cuff tears. Treatments for symptomatic os acromiale with or without rotator cuff tears have been reported in the literature and range from excision of small fragments to fusion of larger, fragments with internal fixation and bone grafting. Generally, rotator cuff repairs have been performed when possible. We report an acromion splitting approach through an existing os acromiale to gain exposure for the repair of a massive rotator cuff tear. Subsequent to this repair, the acromion was repaired with internal fixation. Good functional use of the patient's upper extremity was obtained and the patient expressed satisfaction with the surgical outcome. The acromion splitting approach is a viable approach in patients with an os acromiale and a coexistent rotator cuff tear.     

Degeneration at the insertion weakens the tensile strength of the supraspinatus tendon: a comparative mechanical and histologic study of the bone-tendon complex

The purpose of this investigation was to determine the relationship between the degree of degeneration at the supraspinatus insertion, the tensile strength, and the site of failure of this tendon. Thirty-three fresh cadaveric shoulders (average age: 62 years; range: 39-83 years) were examined. A tensile load to failure was applied at a constant crosshead speed of 25.4 mm/min to a 10 mm wide strip of the supraspinatus tendon that remained attached to the bone. Preexisting degenerative changes at the insertion were assessed and scored histologically and compared with the ultimate tensile stress. Twenty tendons failed at the insertion (the insertion group), and 11 failed in the midsubstance (the midsubstance group). The histologic score of degeneration for the insertion group was significantly higher than that for the midsubstance group (p = 0.0026). There was a negative correlation between the ultimate tensile stress at the insertion and the degeneration score for the insertion group (r = -0.60; p = 0.013). Histologic observations revealed that disruptions of tendon fibers were located mostly in the articular half of the tendon and that they enlarged during mechanical testing in 90% of the specimens of the insertion group. It seems that degenerative changes at the supraspinatus insertion reduce the tensile strength of the tendon and constitute a primary pathogenetic factor of rotator cuff tear.     

MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears

OBJECTIVE: The purpose of this study was to determine whether occult bony injuries or other characteristic MR abnormalities are frequent in patients suspected of having traumatic tears of the rotator cuff. SUBJECTS AND METHODS: MR arthrography of the shoulder was performed in 24 consecutive patients with suspected traumatic tears of the rotator cuff. MR findings were analyzed with regard to abnormalities of the supraspinatus, infraspinatus, and subscapularis tendons; and the humeral head. A comparison group of 24 consecutive patients with symptoms of nontraumatic tears of the rotator cuff was included in the investigation. RESULTS: Radiographically occult fractures of the greater tuberosity were found in nine (38%) of 24 patients with clinically suspected traumatic tears of the rotator cuff (seven of which occurred in patients <40 years old). Nine partial-thickness and five full-thickness supraspinatus tears were found in the trauma group. In the comparison group, the corresponding numbers were 13 and 10, respectively. Seven partial lesions of the cranial border of the subscapularis and six complete subscapularis tears (all six in patients >40 years old) were found in the trauma group (nine and one in the comparison group). CONCLUSION: Occult greater tuberosity fractures and complete subscapularis tears are commonly seen on MR images in patients suspected of having traumatic tears of the rotator cuff. Greater tuberosity fractures should be looked for specifically in patients younger than 40 years, and subscapularis tears should be looked for specifically in patients older than 40 years.     

Posterior superior impingement of the rotator cuff on the glenoid rim as a cause of shoulder pain in the overhead athlete

A case of impingement of the deep surface of the supraspinatus tendon on the posterior superior rim of the glenoid and mild anterior laxity has been presented. The partial-thickness tear of the undersurface rotator cuff tendon, degenerative tear of the posterior superior labrum, and osteochondral impression fracture of the humeral head have been documented. The purpose of this case report is to present the pathological findings associated with posterior superior glenoid rim impingement and emphasize its role as a cause of shoulder pain in the overhead athlete. In addition it is important to stress the fact that shoulder pain in the overhead athlete may be multifactorial.     

Arthrography and computed arthrotomography study of seventy patients with primary glenohumeral osteoarthritis

Seventy patients with primary glenohumeral osteoarthritis underwent roentgenographic and computed tomography studies. Glenohumeral joint space loss and a normal acromiohumeral space were the roentgenographic inclusion criteria. Women made up 61% of the sample. The dominant shoulder was affected in 95% of cases and both shoulders in 41%. Mean age at first evaluation was 65 years. Arthrography showed a tear confined to the supraspinatus tendon in 16 cases (23%); no patients had tears involving more than one tendon. Computed tomography demonstrated glenoid retroversion (mean 16 degrees) but was unable to differentiate primary glenoid dysplasia from wear due to osteoarthritis. Posterior subluxation of the humeral head was found in 28 cases (40%) but was not consistently correlated with the presence of glenoid retroversion.     

Temperature-controlled release property of phospholipid vesicles bearing a thermo-sensitive polymer

The supraspinatus, infraspinatus, teres minor and subscapu?aris muscles form a musculotendinous rotator cuff that provides dynamic stability to the shoulder joint. Symptoms of rotator cuff injury include limitation of motion, weakness and pain that often radiates down the upper arm and is present at night. Examination may reveal deltoid and rotator cuff atrophy, tenderness, limited passive range of motion and weakness on abduction and external rotation. Radiographs may show degenerative changes of the acromion or acromioclavicular joint, cysts, sclerosis and spurs of the greater tuberosity, and calcific deposits within the supraspinatus tendon. In most patients with subacromial impingement, conservative management, including physical therapy, nonsteroidal anti-inflammatory drugs and subacromial injections, is successful. Failure of conservative therapy after six to 12 weeks merits further evaluation with magnetic resonance imaging or arthrography, and consideration of surgery.     

Magnetic resonance imaging assessment of the rotator cuff: is it really accurate?

Magnetic resonance imaging (MRI) is used increasingly for evaluating the rotator cuff. This study of 39 shoulders (38 patients) compared the accuracy of MRI interpretation of rotator cuff integrity by a group of community hospital radiologists (clinical community scenario, CCS) with that of a musculoskeletal radiologist (experienced specialist scenario, ESS), relative to arthroscopy. For the CCS subgroup, the sensitivity, specificity, positive predictive value (PV), negative PV, and accuracy for partial tears were: 0%, 68%, 0%, 82%, and 59%, respectively; for complete tears: 56%, 73%, 36%, 86%, and 69%, respectively; and for all tears combined: 85%, 52%, 50%, 87%, and 64%, respectively. For the ESS subgroup, the respective values for partial tears were: 20%, 88%, 20%, 88%, and 79%, respectively; for complete tears: 78%, 83%, 58%, 92%, and 82%, respectively; and for all tears: 71%, 71%, 59%, 81%, and 71%, respectively. We concluded that MRI assessment of the rotator cuff was not accurate relative to arthroscopy. MRI was most helpful if the result was negative, and MRI diagnosis of partial tear was of little value. Considering the high cost of shoulder MRI, this study has significant implications for the evaluation of patients with possible rotator cuff pathology.     

Suppression of alloreactivity with gamma delta T-cells: relevance to increased gamma delta T-cells following bone marrow transplantation

Morphologic changes in the long head of the biceps brachii (LHB) and bicipital groove associated with cuff tears were studied in 170 cadavers. In specimens with minimum or moderate cuff tears, the primary finding was relative stenosis at the bicipital groove induced by enlargement of the LHB. However, this stenosis was not apparent in specimens with massive cuff tears and in these specimens, the medial wall of the groove exhibited wear and tear, a potential cause of LHB instability. We suggest that the long head of the biceps brachii muscle can potentially compensate for inadequate rotator cuff function. This increasing activity could lead to enlargement of the tendon and cause deterioration of the bicipital gliding mechanism.     

A comparison of results in acute and chronic anterior cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon reconstruction

We conducted a prospective study of 94 consecutive patients who received a patellar tendon autograft for anterior cruciate ligament rupture. Eighty-seven patients (93%) returned for followup a mean of 28 months postoperatively; 57 had chronic and 30 had acute or subacute ruptures. There were no significant differences between the subgroups for age, sex, articular cartilage lesions, or months of followup. Forty-six meniscal tears were repaired; 27 of these extended into the central avascular region. Rehabilitation emphasized immediate knee motion, but strenuous activity was delayed for at least 4 months. Only one patient had a knee motion complication, and stability (<3 mm, KT-2000 arthrometer, 134 N) was restored in 85% of knees with chronic ruptures and 92% of knees with acute ruptures. Earlier reconstruction should be considered in active persons as symptoms and limitations continued postoperatively in knees with chronic ruptures, leading to overall less satisfactory results. In patient rating of the overall knee condition, 69% of knees with chronic ruptures and 100% of knees with acute ruptures scored in the normal or very good range. Repair of meniscal tears that extend into the central avascular region should be considered, as 24 of the 27 (89%) menisci repaired showed clinical evidence of healing and did not require reoperation.     

Fodrin inhibits phospholipases A2, C, and D by decreasing polyphosphoinositide cell content

We evaluated the effect of adjunctive healing measures on central tears of the adult goat medial meniscus and the role of magnetic resonance arthrography in the assessment of menisci that have undergone a repair. Peripheral tears were made unilaterally in the medial menisci of seven goats in Group I and repaired with nonabsorbable suture. Six Group II goats had central medial meniscal tears repaired as in Group I plus an exogenous fibrin clot. Eight Group III goats had central tears plus abrasion of the parameniscal synovium and tear edges. Six months after surgery, a magnetic resonance imaging scan and a magnetic resonance arthrogram were obtained and the menisci were examined grossly. Group I goats showed healing in all seven knees. Central tears repaired with a fibrin clot (Group II) showed healing in one of six knees (17%). Central tears repaired with abrasion (Group III) showed healing in seven of eight knees (87.5%). Magnetic resonance arthrography was 100% accurate in detecting the presence or absence of complete residual tears. This study supports the current trend of using adjunctive measures for repair of central tears. Furthermore, abrasion of the parameniscal synovium and the tear edges appears to be more effective than the use of an exogenous fibrin clot. Magnetic resonance arthrography is useful in the evaluation of menisci that have undergone repair.     

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

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

Geometric and mechanical properties of the coracoacromial ligament and their relationship to rotator cuff disease

One of the most common causes of pain and disability in the upper limb is inflammation of the rotator cuff tendons. When no significant bony abnormality exists in the surrounding structures, the coracoacromial ligament has been implicated as a possible cause of impingement on the cuff tendons. Geometric and mechanical properties of 20 coracoacromial ligaments, 10 from shoulders with rotator cuff tears and 10 from normal shoulders, were accurately determined. In comparing rotator cuff tear and normal specimens, statistically significant changes in geometric properties were measured in the lateral band, but not in the medial band, of the ligament. The lateral band, which is the region most likely to impinge on the rotator cuff, was shorter and had a larger cross-sectional area in specimens with rotator cuff tears. Although there were no statistical differences in structural properties of the ligament between normal and rotator cuff tear groups, significant changes were evident in material properties. Previously reported histologic differences in the ligament in shoulders with rotator cuff tears are supported by the decreased material properties measured in the current study. Whether the differences in the coracoacromial ligament cause impingement or are due to impingement is still unknown at this time.     

Lag signs in the diagnosis of rotator cuff rupture

We assessed the relative value of lag signs for the evaluation of rotator cuff rupture in a prospective study of 100 consecutive painful shoulders with impingement syndrome, stages 1 to 3. Lag signs were compared with the Jobe and lift-off signs. Three tests were designed to assess the main components of the rotator cuff: the external rotation lag sign (ERLS) for the supraspinatus and the infraspinatus tendons, the drop sign for the infraspinatus, and the internal rotation lag sign (IRLS) for the subscapularis tendon. For assessment of the supraspinatus and infraspinatus the ERLS was less sensitive but more specific than the jobe sign. The drop sign was the least sensitive but was as specific as the ERLS. Partial ruptures of the supraspinatus remained concealed to the ERLS. For assessment of the subscapularis the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS. The magnitude of the lag correlated with the size of the rupture for both the ERLS and the IRLS. Clinical testing for lag signs was efficient, reproducible, and reliable. In patients with little or no restriction of motion it enhanced the accuracy of clinical diagnosis in rotator cuff lesions.     

Force analysis of rotator cuff muscles

A 3-dimensional static biomechanical model of the glenohumeral joint was used to investigate rotator cuff muscle forces during maximal isometric exertions (abduction, adduction, internal rotation, and external rotation) and static arm elevation. Muscle moment arms and cross sectional areas were determined from studies of cadaveric specimens, and maximal isometric strength data were collected using a Cybex II dynamometer. Predicted posterior deltoid forces were very low during abduction in the scapular plane. The model predicted the highest rotator cuff muscle forces during maximal internal rotation (subscapularis) and external rotation (infraspinatus, teres minor, and supraspinatus) exertions. The results indicate that abduction exertions may not produce the greatest loads on the supraspinatus tendon, and that analyses of arm elevation may underestimate the potential loads on the rotator cuff. The strong effect of external rotation exertions on supraspinatus and infraspinatus forces suggest that ergonomic efforts to prevent rotator cuff disease should include reduction of internal rotation loading on the arm. Moreover, it may be important to include warnings about external rotation exertions, in addition to arm elevation, in patient education.     

MR imaging of tears of discoid lateral menisci

OBJECTIVE: The purpose of this study was to determine the positive predictive value (PPV) for diagnosis of discoid lateral meniscal tear using MR imaging and to describe various patterns of such tears in the knee. SUBJECTS AND METHODS: MR reports of 77 patients (10-67 years old) who underwent prospective MR imaging that led to a diagnosis of discoid lateral meniscal tear were correlated with arthroscopic results. MR images obtained in 71 patients confirmed to have discoid lateral meniscial tear were retrospectively reviewed for the presence, site, and pattern of discoid lateral meniscal tear, including type of displacement of the torn segment. MR abnormalities were correlated with arthroscopic findings. RESULTS: For the prospective MR interpretations, the PPV for discoid meniscus was 92%. PPV for discoid meniscal tear was 57%. PPVs for individual types of discoid meniscal tears were 46% (peripheral tear, 19/41), 76% (peripheral tear with horizontal tears, 16/21), 56% (horizontal tear, 5/9), 50% (transverse tear, 1/2), 67% (horizontal tear combined with transverse tear, 2/3), and 100% (longitudinal tear, 1/1). Peripheral tear alone and peripheral tear with horizontal tear were the most common types of tears (n = 20, 28%). Multiple tears (n = 34, 48%) were common. Displacement of the torn segments was seen in 51 patients (72%). CONCLUSION: MR imaging has a low PPV for diagnosing discoid lateral meniscal tear. Peripheral tear alone and peripheral tear with horizontal tear were the most common types of tears, and displacement of the torn segment was frequent.