急性创伤致肩袖撕裂的超声诊断

目的探讨肩袖撕裂的超声特征，评价超声检查肩袖撕裂的应用价值。方法对33例急性创伤后疑诊肩袖损伤者行超声检查，并与磁共振、肩关节造影或手术结果进行比较。结果肩袖撕裂的超声主要表现为：肩袖不显示，肩袖部分缺失，肩袖内局灶性异常回声，肩袖局部变薄。超声诊断的敏感性92％(22／24)，特异性82％(9／11)，准确性94％(31／33)。结论超声诊断肩袖撕裂有较高的应用价值，可作为急性肩部创伤而X线检查正常患者的首选检查方法。     

Ultrasonography of the rotator cuff: Surgical correlation

Rotator cuff tears are a common orthopedic problem. The portions of the cuff most commonly torn are accessible to sonographic examination with appropriate positioning of the shoulder. This study was undertaken to correlate the sonographic appearance of the pathologic rotator cuff with findings at the time of surgical repair. Rotator cuff tears are readily seen with high-resolution real-time sonography. Sonography can demonstrate tears not demonstrated arthrographically. In the appropriate clinical setting arthrography may not be necessary if the sonogram demonstrates characteristic findings.     

Impaired joint proprioception at higher shoulder elevations in chronic rotator cuff pathology

Anderson VB, Wee E. Impaired joint proprioception at higher shoulder elevations in chronic rotator cuff pathology.

Objectives

To assess the degree of impairment of shoulder proprioceptive acuity in individuals with chronic rotator cuff pathology (CRCP), and to examine the effect of impingement-related shoulder pain on acuity using a reliable laboratory technique.

Design

Case-control study.

Setting

University human movement laboratory.

Participants

A volunteer sample of individuals with CRCP (n=26) were recruited and screened, and compared with age-, sex-, and limb dominance–matched individuals (n=30) who acted as controls. Ten participants with CRCP underwent repeat assessment after 2 days to determine the intrarater reliability of proprioceptive measurement.

Interventions

Not applicable.

Main Outcome Measures

Each participant underwent assessment of joint position sense at 40° and 100° of scapular plane abduction using an active position-matching task. Movements were recorded with reflective skin markers and a multidimensional motion analysis system. Self-reported pain intensity associated with the procedure was recorded with a visual analog scale.

Results

Intraclass correlation coefficients (model 3,5) between repeat assessments ranged from .54 to .99. On average, those with CRCP demonstrated reduced acuity at 40° and 100° test angles. In comparison with the control group, proprioceptive acuity was significantly impaired (P<.01) at the 100° test angle, where the pain intensity was significantly greater (P<.01).

Conclusions

This study demonstrated impairment of shoulder joint position sense in CRCP. The degree of proprioceptive impairment was greatest at higher elevations in the setting of increased shoulder impingement and pain, which may serve to perpetuate the pathology. These findings provide a theoretic rationale for the continued implementation of proprioceptive rehabilitation programs in managing CRCP.     

本体感觉训练干预对肩袖损伤患者术后肩关节功能、生活质量的影响

目的 探究自行设计的本体感觉训练干预方案对肩袖损伤患者术后肩关节功能、生活质量的影响.方法 选取2018年3月—2020年3月于医院行肩关节镜下肩袖损伤修补术治疗的62例患者为研究对象,按照性别、年龄、病程、受累肩具有可比性的原则分为对照组和观察组,每组31例.对照组采用常规护理干预,观察组在对照组基础上联合本体感觉训...     

Gap formation in a transosseous rotator cuff repair as a function of bone quality

Background

The transosseous approach has been well known for a long time as a valid repair approach. Over time, various criticisms have been raised over this technique principally classifiable in two main categories: technical difficulty and related reproducibility in an arthroscopic environment, and repair stability (in the suture–bone contact area). About cyclic performance, several authors have conceived test setups with the aim of simulating a real environment in dynamic load conditions. The aim of this study was to monitor gap formation in a cyclic test setup.

Methods

The performance (measured as gap formation) has been monitored as a function of bone density to verify the effect of the latter. The test blocks have been shaped using sawbones® test bricks (Malmo, Sweden) of different densities, and the following values have been tested: 10, 15, 20, 30 and 40 pcf.

Findings

The comparison has been made between the two groups: traditional transosseous and new approach with an interposed device. Regarding the traditional transosseous approach in a 10-pcf environment, not even the first loading cycle was completed, the whole bone bridge was destroyed in the first loading ramp and no further loading capability was present in the repair. By increasing the block density, the surface damage in the suture-block contact decreased.

Interpretation

With this work, it has been demonstrated how the traditional transosseous approach is strongly influenced by the bone quality up to the point where, in certain conditions, a safe and reliable repair is not guaranteed.     

经关节镜微创治疗肩袖损伤患者的围术期护理

目的:探讨肩袖损伤患者经关节镜修复的围手术期护理。方法:对本组13例行肩关节镜治疗患者进行术前术后系统护理、心理护理及康复功能锻炼。结果:患者均顺利完成手术。结论:精心细致的围手术期护理,可减少并发症发生,缩短住院时间,利于患者早日康复。     

Postural dependence of passive tension in the supraspinatus following rotator cuff repair: a simulation analysis

Background

Despite surgical advances, repair of rotator cuff tears is associated with 20–70% incidence of recurrent tearing. The tension required to repair the torn tendon influences surgical outcomes and may be dependent on the gap length from torn tendon that must be spanned by the repair. Detailed understanding of forces throughout the range of motion (ROM) may allow surgeons to make evidence-based recommendations for post-operative care.

Methods

We used a computational shoulder model to assess passive tension and total moment-generating capacity in supraspinatus for repairs of gaps up to 3 cm throughout the shoulder (ROM).

Findings

In 60° abduction, increased gap length from 0.5 cm to 3 cm caused increases in passive force from 3 N to 58 N, consistent with those seen during clinical repair. For reduced abduction, passive forces increased substantially. For a 0.5 cm gap, tension throughout the ROM (elevation, plane of elevation, and rotation) is within reasonable limits, but larger gaps are associated with tensions that markedly exceed reported pull-out strength of sutures and anchors. Peak moment for a large 3 cm gap length was 5.09 Nm, a 53% reduction in moment-generating capacity compared to uninjured supraspinatus.

Interpretation

We conclude that shoulder posture is an important determinant of passive forces during rotator cuff repair surgery. Choosing postures that reduce forces intraoperatively to permit repair of larger gaps may lead to failure postoperatively when the shoulder is mobilized. For larger defects, loss of strength in supraspinatus may be substantial following repair even if retear is prevented.     

The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation

Miller CA, Forrester GA, Lewis JS. The validity of the lag signs in diagnosing full-thickness tears of the rotator cuff: a preliminary investigation.

Objective

To investigate whether the lag signs were valid tools in diagnosing full-thickness tears of the rotator cuff.

Design

A same-subject, correlation, double-blinded design was used. The results of the external rotation lag sign, drop sign, and internal rotation lag sign were compared with the criterion standard of diagnostic ultrasound to establish their accuracy.

Setting

A regional orthopedic hospital.

Participants

Consecutive subjects (N=37), 21 women and 16 men, with shoulder pain referred to a consultant orthopedic surgeon specializing in shoulder conditions were recruited for this investigation.

Interventions

Not applicable.

Main Outcome Measures

Sensitivity, specificity, and positive and negative likelihood ratios of the lag signs when using ultrasound as the reference test.

Results

The specificities of the drop sign and internal rotation lag sign were 77% and 84%, respectively, which, together with low positive likelihood ratios 3.2 (95% confidence interval [CI], 1.5-6.7) and 6.2 (95% CI, 1.9-12.0), indicate that a positive result was poor at recognizing the presence of full-thickness tears. The drop sign had a sensitivity of 73% with a negative likelihood ratio of .34 (95% CI, 0.2-0.8), suggesting that a negative test was fair at ruling out the presence of full-thickness tears. The sensitivity of the internal rotation lag sign (100%) supported by the negative likelihood ratio of 0 (95% CI, 0.0-2.5) suggests that a negative test will effectively rule out the presence of full-thickness tears of the subscapularis. A positive external rotation lag sign is the clinical test most likely to indicate that full-thickness tears of the supraspinatus and infraspinatus are present (specificity, 94%). However, the external rotation lag sign did demonstrate a low sensitivity score of 46% and negative likelihood ratio of .57 (95% CI, 0.4-0.9), which means that a negative test will not rule out the presence of full-thickness tears.

Conclusions

The findings of this investigation suggest that a clinical diagnosis of a full-thickness tear of the rotator cuff cannot be conclusively reached using one or more of the lag signs.     

康复训练在全关节镜下修复肩袖损伤术后的疗效分析

目的 观察康复训练对全关节镜下修复肩袖损伤术后肩关节功能的疗效.方法 选取肩袖损伤后行全关节镜肩袖修补术的患者共74例,将其分为治疗组39例和对照组35例,2组均在术后进行肩关节被动训练,治疗组在肩关节被动训练的基础上增加3阶段康复训练.2组患者均于术前、术后6个月、术后1年、术后2年、术后3年采用美国肩肘医师协会评分(ASES)、加州大学肩关节评分系统UCLASS评分(UCLASS)、视觉模拟评分(VAS)进行肩关节功能评定.结果 术前,2组患者ASES、UCLASS、VAS评分的组间差异均无统计学意义(P＞0.05),术后6月、1年、2年、3年时,治疗组的ASES、UCLASS、VAS评分明显优于对照组同时段(P＜0.05),术后6月、1年、2年、3年,治疗组的VAS评分分别为(1.3±0.3)分、(1.00±0.3)分、(0.8±0.3)分、(0.8±0.2)分,均显著优于治疗前的(6.6±0.9)分(P＜0.01).术后,2组患者各时段肩关节的疼痛、功能、主动前屈活动度、前屈力量和主观满意度较术前均显著改善(P＜0.05),且显著优于同时段的对照组,差异均有统计学意义(P＜0.05).结论 对关节镜修复肩袖损伤术后患者提供早期系统个性化的肩关节康复训练可促进肩关节功能有效恢复,治疗效果更好.     

The relationship of preoperative factors to patient-reported outcome in rotator cuff repair: a systematic review

Background: Understanding preoperatively available factors that predict valid, patient-reported outcomes following rotator cuff repair can assist clinicians and their patients in making an informed, shared-decision on rotator cuff repair, and assist in setting an evidence-based prognosis.

Objectives: To perform a systematic review of the preoperative factors related to patient-reported outcome following rotator cuff repair.

Methods: A systematic review of the literature was performed to identify studies analyzing the relationship of preoperative factors to valid, patient-reported outcome measures. To be included in the review, outcome had to be measured by at least one valid upper extremity or shoulder-specific patient-reported outcome.

Results: Twenty-three studies met the criteria for inclusion. Of these, 15 studies scored 3 or less on a 7-point scale of study quality indicating a paucity of strong trials investigating these prognostic factors. Prognostic factors reviewed included age, sex, worker’s compensation status, involvement of dominant arm, fatty infiltration of the cuff musculature, duration of symptoms, comorbidities, and smoking status. Increasing age predicted worse Disabilities of Arm, Shoulder and Hand Scores (DASH) but did not predict outcome of any other patient-reported outcome. A worker’s compensation claim predicted a negative impact on patient-reported outcome. Evidence for the remaining factors indicated they do not predict patient-reported outcome.

Conclusion: Six of the eight preoperative factors reviewed did not show a relationship with patient-reported outcome following rotator cuff repair. Evidence indicates a worker’s compensation claim negatively impacts patient-reported outcomes and increasing age resulted in a less favorable DASH score. However, age was not predictive of other patient-reported outcomes such as the Constant score or American Shoulder and Elbow Surgeons Shoulder Score. Overall quality of the included studies was low and future studies with stronger methodologies should be conducted.     

肩关节镜下肩袖修复术治疗肩袖损伤的临床效果

目的探讨肩关节镜下肩袖修复术治疗肩袖损伤的临床效果。方法将我院2018年2月至2019年2月收治的52例肩袖损伤患者随机分为对照组(26例,开放式肩袖修复术)和观察组(26例,全肩关节镜下肩袖修复术)。比较两组的治疗效果。结果治疗后,两组的肩关节前屈、内旋、外旋活动度及Constant-Muley肩关节评分均增加,数字评估量表(NRS)评分均降低,且观察组显著优于对照组(P<0.05);观察组的治疗优良率显著高于对照组(P<0.05)。结论肩关节镜下肩袖修复术治疗肩袖损伤的临床效果显著,能够有效减轻患者疼痛,加快患者术后肩关节功能的恢复,值得临床推广应用。     

Biomechanics of latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears

Background

Latissimus dorsi transfer is the treatment most frequently used for restoring function in shoulders with irreparable posterosuperior rotator cuff tears. Yet, functional outcomes of the transfers are unpredictable and vary among patients.

Methods

A three-dimensional upper-extremity computational model was used to simulate and analyze the biomechanical consequences of transferring the latissimus dorsi to four attachment sites: the infraspinatus, supraspinatus, subscapularis and teres minor insertions. Functions of a normal shoulder were simulated, as well as those and of a shoulder with a posterosuperior rotator cuff tear before and after muscle transfers were simulated. Parameters such as active and passive moment-generating capacity, and the moment arm and fiber excursion ratio of the transferred muscle were analyzed.

Findings

All muscle transfers resulted in a large increase in shoulder external rotation strength. The latissimus dorsi was an external rotator after the transfer, but the fiber excursion ratio decreased accordingly. When the latissimus dorsi was transferred to the infraspinatus, supraspinatus or subscapularis insertion, it changed from extensor to flexor at the beginning of flexion. The flexion moment arm of the latissimus dorsi after the transfers was generally decreased. Shoulder abduction strength did not improve. Decrease in fiber excursion ratio during abduction and flexion was observed after the transfer. Side effects of the muscle transfers, such as the reduction of active adduction, extension and internal rotation of the shoulder, were explored.

Interpretation

A transfer to teres minor insertion was not recommended. Infraspinatus insertion was found to be a preferred attachment site in latissimus dorsi transfer, provided that the patient had a strong deltoid.     

Ultrasonography of rotator cuff tears: a review of 500 diagnostic studies

Ultrasonography of the rotator cuff has been shown to be of value in diagnosing rotator cuff tears. This report summarizes our experience with our first 500 diagnostic examinations. All patients were examined in the hyperextended internal rotation view with commercially available high-resolution real-time ultrasound equipment. Patients were diagnosed as having a rotator cuff tear if a focal echogenic lesion or a defect within the rotator cuff was identified. This study confirmed the value of ultrasonography for the diagnosis of rotator cuff tears. Accuracy, sensitivity, and specificity all exceeded 90%, and correlated with surgical findings. This was better than arthrography in the same patient population. Ultrasound is an accurate noninvasive method of examining the rotator cuff for the presence of tears. We suggest that rotator cuff ultrasonography is the procedure of choice for the diagnosis of tears if adequate instrumentation is available.     

The stabilizing role of the rotator cuff at the shoulder--responses to external perturbations

Background

The rotator cuff has been hypothesized as a dynamic stabilizer at the shoulder joint yet evidence supporting this role remains inconclusive. We aimed to investigate the activity levels and recruitment patterns between the rotator cuff and superficial shoulder muscles in response to external perturbations to provide insight into the stabilizing role of the rotator cuff.

Methods

Surface and intramuscular electromyography (EMG) were used to measure timing of onset and level of activation (EMG amplitude as a percentage of maximum voluntary isometric contraction, % MVIC) of rotator cuff (supraspinatus, infraspinatus and subscapularis) and superficial muscles (anterior and posterior deltoid) on 19 healthy participants. Participants received expected and unexpected externally applied perturbations in directions of internal and external rotation at the glenohumeral joint.

Findings

All three rotator cuff muscles demonstrated pre-activation in anticipation of the perturbation prior to their representative global synergists, anterior and posterior deltoid (P < 0.05). Subscapularis and infraspinatus were activated prior to all other muscles during external rotation and internal rotation perturbation trials respectively (P < 0.01). Direction specific activation levels were observed; subscapularis was moderately strongly active (37% MVIC) in response to an external rotation perturbation and infraspinatus was moderately active (28% MVIC) in response to an internal rotation perturbation. No muscle was activated > 10% MVIC when not acting as the main muscle opposing the movement.

Interpretation

The rotator cuff may function in part as a dynamic stabilizing unit of the shoulder demonstrating a feedforward muscle activation pattern. These results may assist in improving assessment and treatment of shoulder dysfunction.     

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。     

肩袖炎症性病变的超声诊断价值

目的探讨超声对肩袖炎症性病变的定位和定性诊断价值。方法高频超声检测162例患有肩痛和不同程度的肩关节活动障碍的患肩，对声像图进行分型研究。结果超声将162例患肩的声像图分为肱二头肌长头肌腱腱鞘炎（39例）、肱二头肌长头肌腱炎（33例）、冈上肌腱炎症（51例）、钙化性肌腱炎（19例）和肩关节周围滑囊炎（20例）六种类型，各型超声分别分为几个亚型。结论高频超声可以提供某些肩袖软组织病变的定位和定性诊断，对于临床针对性的治疗具有重要的价值。     

Ultrasound assessment of the rotator cuff cable: comparison between young and elderly asymptomatic volunteers and interobserver reproducibility

Our aim was to characterize rotator cable ultrasound appearance in shoulders of different-aged asymptomatic volunteers, also estimating interobserver reproducibility. We studied 83 shoulders in 42 young volunteers (mean age 26 ± 7.0 years, range 21-35 years) and 66 shoulders in 36 elderly volunteers (65-81 years, 73 ± 4.9 years), noting rotator cable visibility and its minimum thickness and width. Interobserver reproducibility was tested in elderly volunteers by two blinded observers. χ², U Mann-Whitney, t-test, Bland-Altman, and κ statistics were used. Rotator cable was less frequently detected in younger than elderly volunteers (25/83 vs. 36/66 shoulders; p = 0.002). Young subjects had thicker (1.5 ± 0.2 mm, range 1.3-1.8 mm vs. 1.1 ± 0.1 mm, 0.9-1.3 mm; p < 0.001) and wider rotator cable (5.8 ± 0.7 mm, 4.5-7.1 mm vs. 4.0 ± 1.2 mm, 2.5-7.1 mm; p < 0.001) than elderly volunteers. Thickness and width reproducibility index were 89% and 94%, respectively; κ = 0.87. Ultrasound demonstrated different rotator cable consistency in younger and elderly asymptomatic patients, with high interobserver reproducibility.     

Fracture of the scapular neck combined with rotator cuff tear: A case report

BACKGROUNDScapular fracture has a low incidence rate, accounting for 0.4%-0.9% of all fractures, and scapular neck fractures are extremely rare, comprising approximately 7%-25% of all scapular fractures. Scapular neck fractures are often studied as case reports mostly accompanied by other injuries, thus leading to confusion. All previous cases of scapular neck fractures are not associated with rotator cuff injuries.CASE SUMMARYA 62-year-old man was admitted to our emergency department 6 h after his right shoulder and back were impacted by heavy objects. The patient presented chest tightness and shortness of breath. Chest computed tomography (CT) showed pneumohemothorax, multiple rib fractures, and right scapula fractures. Three-dimensional CT reconstruction of the right shoulder joint showed a trans-spinous scapular neck fracture with a glenohumeral joint dislocation. Rotator cuff injury was suspected because the patient had a glenohumeral joint dislocation and was then confirmed by shoulder magnetic resonance imaging. A staged surgery was performed, including open reduction and internal fixation of the right scapula fracture and repairing of rotator cuff by right shoulder arthroscopy. At the 5-mo follow-up, the fracture line was blurred and the shoulder joint function was good.CONCLUSIONFracture of the scapular neck combined with rotator cuff tear is rare and the rotator cuff injury should not be ignored in clinical work. Stable internal fixation combined with secondary arthroscopic repair of rotator cuff tear can achieve good results.     

Clinical significance of sonographic findings in the abnormal but intact rotator cuff: a preliminary report

Shoulder pain is a common orthopedic problem. Clinical examination is often nonspecific and arthrography is normal in those patients with the most frequent cause of shoulder pain--noncalcific tendonitis secondary to impingement. Ultrasonography has recently shown itself to be of value in the diagnosis of rotator cuff tears. In addition to the diagnosis of tears, however, sonography can demonstrate abnormalities within the intact rotator cuff tendon. These abnormalities consist of changes in echogenicity and thickness of the tendon. The patterns of abnormality demonstrated correlate with pathologic changes seen in tendonitis. This preliminary study suggests that the ability to demonstrate an abnormal rotator cuff tendon has potential for becoming a valuable aid to the orthopedist in allowing confident diagnosis of rotator cuff disease in the presence of nonspecific symptomatology and an intact tendon.