Glenohumeral motion in patients with rotator cuff tears: a comparison of asymptomatic and symptomatic shoulders.

The purpose of this study was to determine whether there was a relationship between altered scapular plane glenohumeral kinematics end shoulder pain. Subjects were divided into 3 groups: normal volunteers (n = 10), patients with symptomatic rotator cuff tears severe enough to warrant surgery (n = 10), and subjects with no symptoms who had tears documented on magnetic resonance imaging and normal examination (n = 10). Humeral kinematics were observed with a computer-enhanced modification of the Poppen and Walker technique. Scapular plane x-ray films were obtained at 0 degree, 30 degrees, 60 degrees, 90 degrees, 120 degrees, and 150 degrees of elevation. Measurements were made by 3 independent observers blinded to the diagnosis, and data interpretation was performed based on mean values for independent observers. Results showed a high degree of interobserver and intraobserver reliability (coefficients = 0.96 and 0.95, respectively). The symptomatic and asymptomatic groups showed progressive superior translation of the humeral head on the glenoid with increasing arm elevation. The normal group, in contrast, maintained a constant center of rotation along the geometric center of the glenoid. Symptomatic and asymptomatic rotator cuff tear groups showed superior head migration from 30 degrees to 150 degrees, which was significantly different from those seen in the normal group. No significant difference between the symptomatic and asymptomatic groups was demonstrated with the small numbers used in this study. The presence of a rotator cuff tear was associated in a disruption of normal glenohumeral kinematics in the scapular plane. Because significant superior migration of the humeral head was seen in both the asymptomatic and symptomatic rotator cuff groups, painless and normal shoulder motion is possible in the presence of abnormal glenohumeral kinematics. Abnormal glenohumeral kinematics alone was not an independent factor, which could explain the occurrence of symptoms.

Evaluation and management of failed rotator cuff repairs.

Revision rotator cuff reconstruction should be based on the clinical problem, not the mere presence of a cuff defect. A functional deltoid is critical to the success of such surgery. Reconstructive procedures on the cuff include direct repair, interpositional grafting, and tendon transfers associated with an appropriate decompression. Decompression without repair-merely de bridement of the cuff-carries a significant risk of creating a severe functional loss and a poor outcome.

Biceps activity during shoulder motion: an electromyographic analysis.

Electromyographic responses in 44 shoulders from 30 subjects were examined. Fourteen shoulders from 13 patients had documented rotator cuff tears. The remaining volunteers had normal cuff integrity by history and examination. Electromyographic responses were recorded from the long head of the biceps, brachioradialis (elbow control), and from the supraspinatus (shoulder control). Elbow related biceps activity was minimized by using a brace locked in neutral forearm rotation and 100 degrees flexion. Analysis of normal and rotator cuff deficient data was performed in a masked fashion and electromyographic activity normalized as a percent of maximal muscle contraction during 10 shoulder motions based on the scapular plane. Normal shoulders in all ranges of active motion exhibited significant supraspinatus activity (20%-50% maximum muscle contraction). The response followed patterns expected for a shoulder stabilizer. In contrast, with every normal shoulder, biceps and brachioradialis activity remained insignificant (1.7%-3.6% maximum muscle contraction) and did not follow a patterned response. In patients with rotator cuff tears, biceps activity remained low (1.6%-4.4% maximum muscle contraction). As opposed to previous studies using electromyography about the shoulder, this trial examined shoulder specific biceps activity by relaxing the elbow. No significant biceps activity was observed in any shoulder, including patients with rotator cuff tears. Given these findings, any function of the long head of the biceps in shoulder motion does not involve active contractions.

Recurrent instability of the shoulder after age 40.

Twelve patients who had recurrent instability of the shoulder with onset after age 40 were reviewed. Eleven had anterior instability, and one had a posterior dislocation. The average age of the patients was 62.7 years. Symptoms began soon after initial injury. All patients with anterior instability had ruptured the subscapularis and anterior capsule from the lesser tuberosity, whereas the posterior dislocator had torn the infraspinatus and upper teres minor with the posterior capsule from the greater tuberosity. No patient had a Bankart lesion. Stability was restored in all cases by reattaching the ruptured tendons and capsule to the tuberosities. Follow-up was from 2 to 13 years. One patient required a reoperation. All patients now have a stable shoulder. Recurrent instability of the shoulder after age 40 can be caused by rotator cuff and capsular rupture from the tuberosities without additional significant injury to the ligamentolabral complex. In such cases, repairing the torn structures is sufficient to restore stability.

Incomplete rotator cuff tears. A technique for diagnosis and treatment.

The size and location of intratendinous and joint side rotator cuff tears can be diagnosed by a technique known as positional arthrography. The site and extent of the tears diagnosed preoperatively by this technique correlated well with intraoperative findings in a study group of 200 patients who underwent a combined arthroscopic and open procedure to localize, identify, and repair incomplete rotator cuff tears.

Anterior dislocation of the shoulder and rotator cuff rupture.

Thirty-seven patients older than 40 years of age were seen after sustaining primary anterior dislocations of the shoulder. An associated rupture of the rotator cuff in each patient had been missed, often being mistaken for an axillary neuropathy. Eleven of these patients developed recurrent anterior instability that was due to rupture of the subscapularis and anterior capsule from the lesser tuberosity. In no patient was there a Bankart lesion. Repair of the capsule and subscapularis restored stability in all of the patients with recurrence.

Reoperation for failed rotator cuff repair: Analysis of fifty cases.

Fifty patients who underwent reoperation for failure of previous repair of rotator cuff rupture were evaluated 24 to 84 months after final repair (mean 30 months). Forty-eight of these patients had undergone all previous attempts at repair elsewhere. Most patients had had one or two earlier attempts, but four patients had had three, and three patients had had four. Forty-six (92%) patients reported pain improvement, and four were unchanged. Twenty-six patients showed an average increase in elevation of 50° (range 10° to 130°). Twenty-two retained their preoperative motion, and two lost motion (mean 45°) but still had more than 90°. Overall mean elevation increased from 92° to 137°. Compared with 17 patients before surgery, only six had less than 90° motion after surgery-and all six had deltoid abnormalities. The size of the rupture, the number of previous operations, and dysfunction of the biceps did not affect the result. The following factors were associated with success: adequate decompression, closure of all defects with tendon-to-bone junctures (by direct repair, interpositional grafting, or local tendon transfers), avoiding use of weights or resistive exercises during the early (first 3 months) postoperative rehabilitation period, and an intact, functioning deltoid.

Observations on impingement.

The combined interaction of four elements produces lesions of the rotator cuff, commonly known as impingement. The elements are: vascular, degenerative, traumatic, and mechanical or anatomic factors. The elements are interrelated, and each affects the tendons in a manner that contributes to tendon weakening. It is unlikely that any one element is solely responsible for cuff lesions; the nature of each lesion is determined by the factors that predominate in that individual case. The net result is degeneration of the tendons.

Tenosynovitis.

The two types of tenosynovial infections in the hand are acute pyogenic and chronic atypical mycobacterial. Each has specific diagnostic criteria and a different therapeutic approach. If untreated or maltreated through misdiagnosis, either type can lead to significant long-term disability.

Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient.

Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. All of the patients were more than thirty-five years old. Twenty-nine of them were initially presumed to have had an injury to the axillary nerve, although this injury was confirmed in only four of the twenty patients who had electrodiagnostic studies. In eight patients, the subscapularis tendon and anterior part of the capsule had ruptured from the lesser tuberosity. Recurrent instability developed in all eight patients, and repair of these structures alone was successful in restoring stability. The association between primary anterior dislocation of the glenohumeral joint and rupture of the rotator cuff in the older patient who cannot abduct the arm after reduction is poorly appreciated, as it is often missed. In our series of such patients, the incidence of injury to the axillary nerve was 7.8 per cent, as compared with 100 per cent for rupture of the rotator cuff. However, the comparative rates of occurrence of these two entities in older patients who have an anterior dislocation have not been determined.

The frozen shoulder. Diagnosis and management.

The differentiation between the stiff and painful shoulder without any joint capsule involvement and with capsule involvement (true adhesive capsulitis) must be established before a rational treatment can be prescribed. Arthrography establishes the correct diagnosis of adhesive capsulitis. Treatment of the stiff and painful shoulder is through prevention and exercise. The treatment of adhesive capsulitis includes prevention, exercises, manipulation, and capsulotomy. Each treatment method is determined by specific criteria. Arthroscopy is not useful for either diagnosis or treatment of adhesive capsulitis but may be useful for recognition of the four stages of the disease.

Ruptures of the rotator cuff.

Tears of the rotator cuff are a common entity. These tears frequently require surgical decompression and reconstruction. A number of options are available, depending on the quality of the tissues and one's ability to close the tear directly. Fortunately, in almost all cases direct closure of the cuff is possible after decompression. Early postoperative passive motion is useful in hastening recovery. Resistive exercises should be avoided early in the rehabilitation period.

Radiologic assessment of the shoulder. Plain and arthrographic.

Five standard radiographic projections are useful in screening patients with shoulder complaints. Three are AP views: internal rotation, external rotation, and 100-degree abduction. The other two are the axillary and bicipital groove views. Single-contrast arthrography is valuable in diagnosing full-thickness rotator cuff tears, adhesive capsulitis, and lesions of the biceps. It also is useful in determining deep-surface, incomplete cuff tears and, occasionally, anterior instability.

Injuries to the clavicle and acromioclavicular joint.

Fractures of the clavicle are a common lesion best treated by closed means. In the unusual instance that nonunion develops or early irreversible vascular or neurologic compromise is present, an intramedullary Knowles pin is the preferred method of fixation. Injuries of the acromioclavicular joint usually can be treated symptomatically. Types 3A and B require early operative intervention. For the few patients who have late symptoms from types 2 or 3, an acromioclavicular arthroplasty, joint stabilization, and transference of the coracoacromial ligament to form a superior acromioclavicular ligament are used.

On resection of the proximal carpal row.

Thirty-one patients (30 men and one woman) ranging from 19 to 64 years of age underwent proximal row carpectomy for posttraumatic arthrosis of the carpus. The injuries included transscaphoid perilunate dislocations with late subluxation and arthritis, ununited scaphoid fractures with arthritis, scapholunate dissociations with arthritis, and acute carpal injuries, including dislocations and comminuted fractures. The follow-up period ranged from two to 12 years. Wrist motion and grip strength were satisfactory. There were two failures, both of which converted to wrist arthrodesis.