Effect of critical shoulder angle on deltoid muscle strength reduction in patients with rotator cuff tears / 中国修复重建外科杂志

OBJECTIVE@#To investigate the synergistic interaction between the deltoid muscle and the rotator cuff muscle group in patients with rotator cuff tears (RCT), as well as the impact of the critical shoulder angle (CSA) on deltoid muscle strength.@*METHODS@#A retrospective analysis was conducted on clinical data from 42 RCT patients who met the selection criteria and were treated between March 2022 and March 2023. There were 13 males and 29 females, with an age range of 42-77 years (mean, 60.5 years). Preoperative visual analogue scale (VAS) score was 6.0±1.6. CSA measurements were obtained from standard anteroposterior X-ray films before operation, and patients were divided into two groups based on CSA measurements: CSA>35° group (group A) and CSA≤35° group (group B). Handheld dynamometry was used to measure the muscle strength of various muscle group in the shoulder (including the supraspinatus, infraspinatus, subscapularis, and anterior, middle, and posterior bundles of the deltoid). The muscle strength of the unaffected side was compared to the affected side, and muscle imbalance indices were calculated. Muscle imbalance indices between male and female patients, dominant and non-dominant sides, and groups A and B were compared. Pearson correlation analysis was used to examine the relationship between muscle imbalance indices and CSA as well as VAS scores.@*RESULTS@#Muscle strength in all muscle groups on the affected side was significantly lower than on the unaffected side ( P<0.05). The muscle imbalance indices for the supraspinatus, subscapularis, infraspinatus, and anterior, middle, and posterior bundles of the deltoid were 14.8%±24.4%, 5.9%±9.7%, 7.2% (0, 9.1%), 17.2% (5.9%, 26.9%), 8.3%±21.3%, and 10.2% (2.8%, 15.4%), respectively. The muscle imbalance indices of the anterior bundle of the deltoid, supraspinatus, and infraspinatus were significantly lower in male patients compared to female patients ( P<0.05); however, there was no significant difference in muscle imbalance indices among other muscle groups between male and female patients or between the dominant and non-dominant sides ( P>0.05). There was a positive correlation between the muscle imbalance indices of infraspinatus and VAS score ( P<0.05), and a positive correlation between CSA and the muscle imbalance indices of middle bundle of deltoid ( P<0.05). There was no correlation between the muscle imbalance indices of other muscle groups and VAS score or CSA ( P>0.05). Preoperative CSA ranged from 17.6° to 39.4°, with a mean of 31.1°. There were 9 cases in group A and 33 cases in group B. The muscle imbalance indices of the anterior bundle of the deltoid was significantly lower in group A compared to group B ( P<0.05), while there was no significant difference in muscle imbalance indices among other muscle groups between group A and group B ( P>0.05).@*CONCLUSION@#Patients with RCT have a phenomenon of deltoid muscle strength reduction, which is more pronounced in the population with a larger CSA.

Study on the evaluation of glenoid bone defects by MRI three-dimensional reconstruction / 中国修复重建外科杂志

OBJECTIVE@#To investigate the feasibility of MRI three-dimensional (3D) reconstruction model in quantifying glenoid bone defect by comparing with CT 3D reconstruction model measurement.@*METHODS@#Forty patients with shoulder anterior dislocation who met the selection criteria between December 2021 and December 2022 were admitted as study participants. There were 34 males and 6 females with an average age of 24.8 years (range, 19-32 years). The injury caused by sports injury in 29 cases and collision injury in 6 cases, and 5 cases had no obvious inducement. The time from injury to admission ranged from 4 to 72 months (mean, 28.5 months). CT and MRI were performed on the patients' shoulder joints, and a semi-automatic segmentation of the images was done with 3D slicer software to construct a glenoid model. The length of the glenoid bone defect was measured on the models by 2 physicians. The intra-group correlation coefficient ( ICC) was used to evaluate the consistency between the 2 physicians, and Bland-Altman plots were constructed to evaluate the consistency between the 2 methods.@*RESULTS@#The length of the glenoid bone defects measured on MRI 3D reconstruction model was (3.83±1.36) mm/4.00 (0.58, 6.13) mm for physician 1 and (3.91±1.20) mm/3.86 (1.39, 5.96) mm for physician 2. The length of the glenoid bone defects measured on CT 3D reconstruction model was (3.81±1.38) mm/3.80 (0.60, 6.02) mm for physician 1 and (3.99±1.19) mm/4.00 (1.68, 6.38) mm for physician 2. ICC and Bland-Altman plot analysis showed good consistency. The ICC between the 2 physicians based on MRI and CT 3D reconstruction model measurements were 0.73 [95% CI (0.54, 0.85)] and 0.80 [95% CI (0.65, 0.89)], respectively. The 95% CI of the difference between the two measurements of physicians 1 and 2 were (-0.46, 0.49) and (-0.68, 0.53), respectively.@*CONCLUSION@#The measurement of glenoid bone defect based on MRI 3D reconstruction model is consistent with that based on CT 3D reconstruction model. MRI can be used instead of CT to measure glenoid bone defects in clinic, and the soft tissue of shoulder joint can be observed comprehensively while reducing radiation.

Morphological determination of glenohumeral joint and acromioclavicular joint with computed tomography / Determinación morfológica de la articulación glenohumeral y la articulación acromioclavicular con tomografía computarizada

SUMMARY: Although acute and chronic pathologies of the glenohumeral and acromioclavicular joints are frequently encountered in the population, the anatomy and morphometry are not fully known. The aim of this study is to determine the measurements of morphometric parameters according to age groups and sex in a large series of Turkish population. Nine hundred and forty-one shoulders computed tomography (CT) images were screened and those of subjects with healthy anatomical structure were included. Humeral head diameter (HDD) was measured on CT images. Measurements were made using 3D-CT images of: width (GW) and height (GH) of the glenoid cavity; width (CW) and height (CH) of the distal clavicular joint surface; and width (AW) and height (AH) of the acromial joint surface. Data were compared, stratified by age and sex. Images of 223 patients (118 men, 105 women) were analyzed. The following mean measurements were determined: HDD, 41.77±3.77 mm; GH, 34.66±3.26 mm; GW, 25.50±2.90 mm; CW, 14.85±3.51 mm; CH, 8.49±2.27 mm; AW, 12.97±2.94 mm; AH, 7.01±1.77 mm. When startified by sex, HDD (p<0.001), GH (p<0.001), GW (p<0.001), CW (p<0.001), CH (p=0.002), AW (p<0.001) and AH (p<0.001) measurements were significantly different and mean values were greater in men. Similarly for age, significant differences were found for GH (p=0.028), CW (p<0.001), AW (p<0.001), AH (p<0.001). The parametric values we have obtained in the Turkish population we measure differ from the measurements made in different populations according to age groups and sex. Knowing these features will contribute to treatment planning, implant and prosthesis applications.

Aunque las patologías agudas y crónicas de las articulaciones glenohumeral y acromioclavicular son frecuentes en la población, la anatomía y morfometría no se conocen por completo. El objetivo de este estudio fue determinar las medidas de los parámetros morfométricos según grupos de edad y sexo en una serie de individuos de población turca. Se examinaron 941 imágenes de tomografía computarizada (TC) de hombro y se incluyeron las de sujetos con una estructura anatómica sana. El diámetro de la cabeza humeral (HDD) se midió en imágenes de TC. Las mediciones se realizaron utilizando imágenes 3D-CT de: ancho (GW) y altura (GH) de la cavidad glenoidea; anchura (CW) y altura (CH) de la superficie articular clavicular; y anchura (AW) y altura (AH) de la superficie articular acromial. Los datos fueron comparados, estratificados por edad y sexo. Se analizaron imágenes de 223 pacientes (118 hombres, 105 mujeres). Se determinaron las siguientes medidas medias: HDD, 41,77±3,77 mm; GH, 34,66 ± 3,26 mm; GW, 25,50±2,90 mm; CW, 14,85±3,51 mm; CH, 8,49±2,27 mm; AW, 12,97±2,94 mm; AH, 7,01±1,77 mm. Cuando se inicia por sexo, HDD (p<0,001), GH (p<0,001), GW (p<0,001), CW (p<0,001), CH (p=0,002), AW (p<0,001) y AH (p <0,001) las mediciones fueron significativamente diferentes y los valores medios fueron mayores en los hombres. De igual forma para la edad se encontraron diferencias significativas para GH (p=0,028), CW (p<0,001), AW (p<0,001), AH (p<0,001). Los valores paramétricos que hemos obtenido en la población turca difieren de las medidas realizadas en diferentes poblaciones según grupos de edad y sexo. El conocimiento de estas características contribuirá a la planificación del tratamiento, aplicaciones de implantes y prótesis.

Glenoid track «off-track¼ as a risk factor for recurrence of anterior glenohumeral instability in postoperative patients / El encarrilamiento glenoideo off-track como factor de riesgo de recidiva de inestabilidad glenohumeral en pacientes postoperados

Abstract: Introduction: Glenoid track is used to assess the engagement of Hill-Sachs lesions. The objective of this study was to identify if off-track glenoid track was a risk factor for recurrence of anterior glenohumeral instability in postoperative patients with arthroscopic anterior labrum repair. Material and methods: Sixty patients with glenohumeral instability who underwent arthroscopic repair of the anterior labrum were studied. Study group (patients with recurrence of postoperative dislocation) and control (no dislocation). Radiographic measurements were made on magnetic resonance imaging and computed tomography. Measurements of glenoid diameter, glenoid bone loss, as well as the presence and size of Hill-Sachs lesions were obtained. Later they were classified as «on-track¼ or «off-track¼. Results: Seven (11.67%) patients suffered recurrence, of which six (10%) were carriers of an off-track injury and 1 (1.67%) on-Track. 53 (88.33%) patients did not experience recurrence, of which 11 (18.33%) were carriers of an off-track injury and 42 (70%) on track. A 23.47 increased risk of recurrence of instability was interpreted in patients with «off-track¼ lesions compared to patients with «On track¼ lesions. Conclusions: Off-track injuries were a risk factor for recurrence of instability in patients who underwent Bankart-type arthroscopic repair. This allows us to recommend that the presence of lesions be routinely studied and classified as «on-track¼ or «off-track¼ to provide a better therapeutic approach.

Resumen: Introducción: El encarrilamiento glenoideo se emplea para valorar el enganche de lesiones Hill-Sachs. El objetivo de este estudio fue identificar si el encarrilamiento glenoideo off-track fue un factor de riesgo de recidiva de inestabilidad glenohumeral anterior en pacientes postoperados de reparación de labrum anterior por vía artroscópica. Material y métodos: Se estudiaron 60 pacientes sometidos a reparación artroscópica del labrum anterior. Grupo de estudio (pacientes con recidiva de luxación postoperatoria) y control (sin luxación). Las mediciones radiográficas se realizaron en resonancia magnética y en tomografía axial computarizada. Se obtuvieron mediciones del diámetro glenoideo, pérdida ósea glenoidea así como la presencia y tamaño de lesiones de Hill-Sachs. Posteriormente se clasificaron como on-track u off-track. Resultados: Siete (11.67%) pacientes sufrieron recidiva, de los cuales seis (10%) eran portadores de lesión off-track y uno (1.67%) on-track. 53 (88.33%) pacientes sin recidiva, de los cuales 11 (18.33%) eran portadores de lesión off-track y 42 (70%) on-track. Se interpretó un aumento de riesgo de recidiva de inestabilidad de 23.47 en los pacientes portadores de lesión de tipo off-track en comparación con los pacientes portadores de lesiones on-track. Conclusiones: Las lesiones off-track fueron un factor de riesgo de recidiva de inestabilidad en los pacientes a quienes se realizó reparación artroscópica tipo Bankart, lo cual nos permite recomendar que de forma rutinaria se estudie la presencia de lesiones y clasificarlas como on-track u off-track para brindar un mejor abordaje terapéutico.

Glenoid size and orientation in the Chilean population / Tamaño y orientación glenoidea en la población chilena

Glenoid morphology is a key factor in determining the success of shoulder surgery. The purpose of this experimental study was to precisely determine the anatomical size and orientation of the glenoid in the Chilean population. 122 CT scans from asymptomatic Chilean patients were obtained. The mean age was 43.8 years (SD 12.3; range, 17-53 years) with 63 female and 59 male patients. For each of the scapulae, were obtained the glenoid version and inclination, maximum glenoid width and height, superior glenoid width, glenoid surface area, glenoid vault depth, and maximum scapular width. The glenoid size showed an average width of 26 ± 2.7 mm, a height of 40.3 ± 3.5 mm and a vault depth of 26.5 ± 3.7 mm. There were significant differences between men and women. The glenoid orientation showed an average of -13.9 ± 4.8° of retroversion and a superior inclination of 11.1 ± 4.7°. Significant differences between men and women were seen only for version. We conclude, that in this Chilean sample the morphological parameters of the glenoid correspond to the published literature, however, some characteristics in this cohort must be further confirmed using other methods.

La morfología glenoidea es un factor clave para determinar el éxito de la cirugía de hombro. El propósito de este estudio experimental fue determinar con precisión el tamaño anatómico y la orientación de la glenoides en la población chilena. Se obtuvieron 122 tomografías computarizadas de pacientes chilenos asintomáticos. La edad media fue de 43,8 años (DE 12,3; rango, 17-53 años) con 63 pacientes femeninos y 59 masculinos. Para cada una de las escápulas, se obtuvieron la versión glenoidea y la inclinación, el ancho y la altura glenoidea máxima, el ancho glenoideo superior, el área de superficie glenoidea, la profundidad de la bóveda glenoidea y el ancho escapular máximo. El tamaño glenoideo mostró un ancho promedio de 26 ± 2,7 mm, una altura de 40,3 ± 3,5 mm y una profundidad de bóveda de 26,5 ± 3,7 mm. Hubo diferencias significativas entre hombres y mujeres. La orientación glenoidea mostró un promedio de -13,9 ± 4,8 ° de retroversión y una inclinación superior de 11,1 ± 4,7 °. Se observaron diferencias significativas entre hombres y mujeres solo para la versión. Concluimos que en esta muestra chilena los parámetros morfológicos de la glenoides corresponden a la literatura publicada, sin embargo, algunas características de esta cohorte deben confirmarse aún más utilizando otros métodos.

Reconstrucción con bloque óseo tricortical cadavérico en luxación glenohumeral anterior recurrente con pérdida ósea glenoidea: técnica modificada de Eden Hybinette / Reconstruction with cadaveric tricortical bone block in recurrent anterior glenohumeral dislocation with glenoid bone loss: modified Eden Hybinette technique

Resumen: La luxación glenohumeral recurrente suele asociarse a pérdida ósea de la porción glenoidea, siendo la localización anteroinferior la más afectada. El entendimiento de las estructuras relacionadas así como el uso de estudios de imagen actuales tales como la tomografía axial computarizada y la resonancia magnética han permitido avanzar respecto a la comprensión de la patología, asimismo el desarrollo de materiales quirúrgicos y herramientas de mínima invasión nos permiten continuar innovando respecto a los tratamientos previamente descritos, siendo posible intervenir en detalles técnicos con la intención de mejorar los resultados. Es por eso que hemos realizado lo descrito por Eden-Hybinette utilizando injerto tricortical cadavérico con tornillos canulados como método de fijación, limitando las comorbilidades asociadas a la toma de autoinjerto, dando como resultado un amplio beneficio para el paciente durante el procedimiento quirúrgico y en el período de recuperación.

Abstract: Recurrent glenohumeral dislocation is usually associated with bone loss of the glenoid portion, with the anteroinferior location being the most affected. The understanding of the related structures, as well as the use of current imaging studies such as computed axial tomography and magnetic resonance imaging, have made progress in understanding the pathology, as well as the development of surgical materials and minimally invasive tools, they allow us to continue innovating with respect to the previously described treatments, being possible to intervene in technical details with the intention of improving the results. That is why we have done what described by Eden-Hybinette, using tricortical cadaveric graft and as fixation method, limiting the comorbidities associated with the autograft taking, resulting a wide benefit for the patient, during the surgical procedure and in the recovery period.

Sensitivity and specificity of ultrasonography in diagnosing supraspinatus lesions: a prospective accuracy diagnostic study

ABSTRACT BACKGROUND: This study was designed to define the accuracy of shoulder ultrasonography for diagnosing supraspinatus tendon tears. This examination is routinely used by orthopedists and may do away with the need for other examinations for diagnosing these tendon injuries. The aim of this study was to evaluate the sensitivity and specificity of shoulder ultrasonography for diagnosing supraspinatus tendon injuries, using magnetic resonance imaging as the reference. DESIGN AND SETTING: Prospective accuracy study at a single center: the Shoulder and Elbow Surgery Clinic of the Department of Orthopedics and Traumatology. METHODS: Shoulder ultrasonography was performed on 80 patients of both genders, over 18 years of age, with complaints of shoulder pain and clinically suspected supraspinatus tendon lesions. Jobe's test and a full can test were performed. In addition, they underwent magnetic resonance imaging in a 3.0-tesla machine, as the reference standard. The examinations were performed and interpreted by radiologists. RESULTS: Ultrasonography showed sensitivity of 36.3% and specificity of 91.7% for supraspinatus tears overall: sensitivity of 25.8% and specificity of 91.8% for partial tears and sensitivity of 46.2% and specificity of 100% for full-thickness tears. Ultrasonography showed high accuracy for diagnosing full-thickness tears: 91.3%. The p-values were 0.003 for tears overall, 0.031 for partial tears and < 0.001 for full-thickness tears. CONCLUSIONS: Ultrasonography showed low sensitivity for detecting supraspinatus tears, but high specificity for both partial and full-thickness tears.

Frecuencia de diagnóstico de lesiones óseas en luxación glenohumeral anterior / Frecuency of diagnosis of bone lesions in cases of anterior glenohumeral dislocation

Resumen: Antecedentes: Las luxaciones de hombro son motivo común de consulta en las salas de emergencia; presentan un alto índice de recurrencia (hasta 96%) a causa de las lesiones óseas asociadas. El objetivo de este estudio fue identificar un subregistro de lesiones identificadas en radiografía inicial comparada con radiografía postreducción. Material y métodos: Se evaluaron las radiografías de 46 pacientes con sospecha de luxación glenohumeral anterior para diagnóstico e identificación de lesiones óseas iniciales; posteriormente, se realizó reducción y se analizó la serie ósea radiográfica postreducción (AP, Stryker y West Point) para evidenciar lesiones óseas subdiagnosticadas inicialmente. Resultados: Se identificó lesión ósea en 26.1% de los individuos en la radiografía AP en un primer momento; de las personas que no mostraron fractura prerreducción, en 67.6% se encontró lesión ósea en las series radiográficas postreducción. Conclusiones: Se encontró un subdiagnóstico de 67.6% de las lesiones evidentes en la serie ósea postreducción en comparación con la radiografía AP inicial.

Abstract: Background: Shoulder dislocation is a common reason for admission in the emergency room. Its recurrence rate may be as high as 96% due to the associated bone lesions. The purpose of this study is to identify the underreporting of lesions comparing those identified in the initial X-ray with those identified in the post-reduction X-ray. Material and methods: X-rays of 46 patients with suspected anterior glenohumeral dislocation were assessed for diagnostic purposes and to identify the initial bone lesions. After patients had undergone reduction, post-reduction serial bone X-rays (AP, Stryker, Westpoint) were taken and analyzed looking for bone lesions that were initially missed. Results: Bone lesions were identified in 26.1% of the patients based on the initial AP X-rays. In 67.6% of the patients without a pre-reduction fracture a bone lesion was found in the post-reduction serial X-rays. Conclusions: The underreporting rate of bone lesions was 67.6% comparing the initial AP X-rays with the post-reduction serial bone X-rays.

Neuroartropatia de Charcot secundária à siringomielia: relato de caso / Charcot neuroarthropathy by syringomyelia: case report

A neuroartropatia de Charcot é uma das complicações da siringomielia, podendo ocasionar deformidades osteoarticulares e incapacidade funcional, com comprometimento das atividades da vida diária. Relatamos um caso de paciente com neuroartropatia de Charcot do ombro associada a siringomielia e malformação de Arnold-Chiari tipo I, acompanhado no Instituto Nacional de Traumatologia e Orto-pedia do Rio de Janeiro, RJ, Brasil.

Charcot neuroartropathy is one of the complications of syringomyelia and can lead to joint deformity and disability, affecting patients in activities of daily living. We report a case of a patient with shoulder Charcot neuroarthropathy associated with syringomyelia and Arnold-Chiari malformation type I, from the National Institute of Traumatology and Orthopedics of Rio de Janeiro, RJ, Brazil.

Bilateral Scapulohumeral Ankylosis after Prolonged Mechanical Ventilation

This case demonstrates a rarely reported bilateral scapulohumeral bony ankylosis. A young woman developed extensive heterotopic ossifications (HOs) in both shoulder joints after being mechanically ventilated for several months at the intensive care unit in a comatose status. She presented with a severe movement restriction of both shoulder joints. Surgical resection of the bony bridges was performed in 2 separate sessions with a significant improvement of shoulder function afterwards. No postoperative complications, pain, or recurrence of HOs were noted at 1-year follow-up. Mechanical ventilation, immobilization, neuromuscular blockage, and prolonged sedation are known risk factors for the development of HOs in the shoulder joints. Relatively early surgical resection of the HOs can be performed safely in contrary to earlier belief. Afterwards, nonsteroidal anti-inflammatory drugs and/or radiation therapy can be possible treatment modalities to prevent recurrence of HOs.

Comparison of four imaging examinations of shoulder joint injury in forensic expertise / 法医学杂志

OBJECTIVE@#To compare the value of four imaging examinations, including the X-ray, CT, MRI and gas-iodine double contrast CT analyses, in the forensic expertise of shoulder joint injury.@*METHODS@#Imaging data of shoulder joint injury, by the X-ray, CT, MRI and gas-iodine double contrast CT were retrieved and analyzed.@*RESULTS@#The correct diagnosis rates of fracture and soft tissue injury by X-ray, CT and MRI were 52.8%, 72.0% and 63.2%, as well as 0.0%, 32.9% and 82.5%, respectively. The correct diagnosis rate of soft tissue injury by gas-iodine double contrast CT was 100%.@*CONCLUSION@#X-ray is a useful screening method, CT is better for diagnosis of fracture, and MRI is fit for diagnosis of soft tissue injury. Gas-iodine double contrast CT can reflect not only the soft tissue injury but also its severity. Thus, combined application of X-ray, CT, MRI and gas-iodine double contrast CT can provide important imaging information for forensic expertise in shoulder joint injury.

Evaluation of Shoulder Disorders by 2-F-18-fluoro-2-deoxy-D-glucose Positron Emission Tomography and Computed Tomography

BACKGROUND: Although flourine-18-flourodeoxyglucose (FDG) positron emission tomography (PET) has a limitation for localizing anatomical structures, combining it with computed tomography (CT) has made it more efficient for overcoming such limitations. This study aims to evaluate the efficacy of PET/CT for evaluating diseases of the shoulder. METHODS: Retrospective examination was performed on 25 patients who underwent FDG-PET/CT scanning. All the patients were over 60 years of age, and they were evaluated both clinically and radiologically for shoulder pain. The study period was from May, 2006 to May, 2008. One of the patients had metastatic lesion in a shoulder and this patient was excluded from the study, so the total number of subjects in the study was finally 24 patients. RESULTS: PET/CT showed 67% sensitivity, 73% specificity, a positive predictive value of 60%, a negative predictive value of 79%, 27% false positivity and 33% false negativity concerning shoulder pain. PET/CT showed negative finding in 4 cases that were successfully treated by operative treatment (rotator cuff tear [RCT], 3 cases; impingement syndrome, 1 case). Negative findings were also noted in 6 cases in which the pain subsided after conservative treatment (RCT, 1 case; suspected RCT, 2 cases; impingement syndrome, 3 cases). All the patients with osteoarthritis and rheumatoid arthritis had positive findings on PET/CT scanning. CONCLUSIONS: PET/CT is a useful adjunct to the existing imaging modalities to assess functional and pathophysiologic processes and at a very early stage, and so PET/CT can help physicians make better preoperative and postoperative decisions on treatment.

Rotator Cuff Deficient Arthritis of the Glenohumeral Joint

Rotator cuff deficient arthritis of the glenohumeral joint, especially cuff tear arthropathy, has proved a challenging clinical entity for orthopaedic surgeons ever since Charles Neer originally detailed the problem in 1983. Understanding has improved regarding the pathophysiology and pathomechanics underlying cuff tear arthropathy. Surgical reconstruction options can lead to excellent outcomes for patients afflicted with these painful and functionally limited shoulders. Humeral hemiarthroplasty and reverse total shoulder arthroplasty have jumped to the forefront in the treatment of cuff tear arthropathy. As studies continue to look at the results of these procedures in cuff tear arthropathy, existing indications and treatment algorithms will be further refined. In this article the history and pathophysiology of cuff tear arthropathy are reviewed. Additionally, the clinical findings and results of surgical reconstruction are discussed.

Joint involvement in asymptomatic Egyptian patients with HCV infection; ultrasonographic study

This case control diagnostic ultrasonographic study was undertaken to detect the presence of early articular and peri-articular involvement in Egyptian patients infected with hepatitis C virus [HCV] without any articular manifestation. The knee, hip and shoulder were evaluated clinically and by ultrasonography in a cohort of fifty patients with HCV without any current or previous articular manifestations in comparison with twenty healthy controls who were negative for HCV and HBV infections. Ultrasonographic alterations were detected in 96% of the HCV patients with highly significant difference in comparison to controls [p < 0.000]. Slight inflammatory changes were found in all the joints examined more than the moderate or severe changes. The knee and shoulder joints were involved in 74% of the HCV patients for each and the hip in 68%. There were higher prevalence and highly significant differences as regard the knee synovial thickening and effusion, hip effusion, trochanteric bursitis, supraspinatus tendon fluid collection and acromioclavicular joint effusion in comparison to the control group. Our study demonstrated the presence of joint changes in near all the asymptomatic patients with HCV with the prevalence of slight inflammatory alterations that can be explained by the presence of sub-clinical synovitis as well as the presence of significant changes in some of peri-articular structures. In countries like Egypt, the HCV is an endemic disease, so it is thus recommended that patients with rheumatic symptoms should be tested for the HCV infection and conversely that sign and symptoms of articular involvement should be evaluated in HCV patients

calcified intraarticular mass in a man with severe shoulder osteoarthritis: what are the implications?

Rapidly progressive osteoarthritis in the shoulder in the elderly is often associated with chronic rotator cuff calcifications and damage and with apatite crystals identifiable in the joint fluid. The key roles of the crystals and rotator cuff lesions although suspected have been disputed. We describe a 57-year-old man with severe degenerative changes at the right shoulder and other joints. A calcified mass 2-cm in length was found on radiographs medially in relation to the proximal humeral diaphysis. At arthroscopy, the mass was confirmed to be in the joint and due to calcified synovium. Biopsy revealed synovium with apatite like crystal clumps in this mass. Calcium pyrophosphate crystals were also found but in the cartilage only. This case with the apatite crystals only in synovium and with destructive arthritis without a complete rotator cuff tear raise the possibility that synovium as a primary site for apatite deposition might be important in the destructive arthritis. Management of this patient like many with rotator cuff tear arthropathy has been difficult. Rapidly destructive osteoarthritis at the shoulder, much like that in the patient reported here, has been described under a variety of terms that suggest implications for pathogenesis. Neer et al used the term cuff tear arthropathy to describe glenohumeral degenerative arthritis and a rotator cuff tear in twenty-six patients who had required a total shoulder replacement.[1] McCarty et al described 4 elderly women with destructive arthropathy of the shoulder, large effusions, apatite crystals present in the joint effusions and massive tears of the rotator cuffs and coined the term Milwaukee shoulder syndrome.[2],[3],[4]. Dieppe et al suggested the terms apatite-associated destructive arthritis and idiopathic destructive arthritis.[5] Calcifications have been noted in the rotator cuff structures but have not been reported in the joint or synovium.[3] We describe a patient with a similar destructive arthropathy, who had a calcified mass about 2-cm in length in the right shoulder, well visible by X-ray and arthroscopy, that was localized to synovium at arthroscopy. Since this patient did not have prominent rotator cuff disease, our case suggests that intraarticular crystals can be associated with difficult to manage progressive shoulder osteoarthritis without a prominent primary rotator cuff cause

Ultrasonographic Findings of the Shoulder in Patients with Rheumatoid Arthritis and Comparison with Physical Examination

The objectives of this study were: 1) to identify the ultrasonographic (US) abnormalities and 2) to compare the findings of physical examination with US findings in rheumatoid arthritis (RA) patients with shoulder pain. We studied 30 RA patients. Physical examination was performed systemically as follows: 1) area of tenderness; 2) range of passive and active shoulder motion; 3) impingement tests; 4) maneuvers for determining the location of the tendon lesions. US investigations included the biceps, the supraspinatus, infraspinatus, and subscapularis tendons; the subacromial-subdeltoid bursa; and the glenohumeral and acromioclavicular joints. Thirty RA patients with 35 painful and 25 non-painful shoulders were examined. The range of motion affected the most by shoulder pain was abduction. The most frequent US finding of shoulder joint was effusion in the long head of the biceps tendon. Among the rotator cuff tendons, subscapularis was the most frequently involved. Tendon tear was also common among non-painful shoulders. Physical examination used for the diagnosis of shoulder pain had low sensitivity and specificity for detecting abnormalities in the rheumatoid shoulder joint. In conclusion, US abnormalities showed frequent tendon tears in our RA patients. Physical examination had low sensitivity and specificity for detecting rotator cuff tear in the rheumatoid shoulder joint.

Arthrographic distension of the shoulder joint in the management of frozen shoulder.

The study was an open randomized controlled trial to compare the outcome at 8 weeks with two different modalities in the treatment of 'Frozen shoulder'. Clinical cases with painful limitation of movement of shoulder were randomized to receive physical therapies alone versus physical therapies and shoulder arthrography with intra-articular steroid in a sequential randomization process. Cases suspected of having a concomitant illness and has potential to cause secondary frozen shoulder were excluded, such as, history of trauma to shoulder over the last 6 months, symptomatic clinical cervical degenerative diseases, and causes in and around the shoulder (infective and non-infective). Physical Therapies provided to all patients were therapeutic exercises, transcutaneous electrical nerve stimulation (TENS) and infra-red radiation (IRR). Outcome measures were improvement of pain on a Visual Analogue Scale (VAS) score and range of motion measured by Goniometer at 8 weeks. Patients were followed weekly for 8 weeks and outcome parameters were recorded on every evaluation. The baseline range of motion in the two groups was comparable. At 8 weeks a statistically significant difference in outcome were observed in the two groups. The chi-square means difference of improvement in range of motion for abduction was p <0.00 and for external rotation was p <0. 00. The pain reduction on VAS score was not significant in the two groups (p <0. 40). In the present small series, the distension arthrography with intra-articular (IA) steroid plus physical therapy was superior over physical therapy alone in the functional improvement of the frozen shoulder. Further studies with larger sample size are required to confirm the observations.

Shoulder arthrography

Shoulder arthroqraphy had been performed for 33 patients [22 females, 11 males] with a mean age of 55 years presented with shoulder pain and restriction of movement, of the 34 cases, there were 10 cases [2 males, 8 females] of rotator cuff tear, 6 cases of frozen shoulder [all females], 3 cases [2 males, 1 female] of subluxation of the shoulder joint, and two cases [males] of repeated anterior shoulder dislocation with Bankart lesion. 12 cases [5 males. 7 females] presenting with shoulder pain and limitation of movement had been referred with diagnosis of frozen shoulder and rotator cuff tear were found to be normal on arthrography [negative arthrography]. The result compares with result of similar study in the west