Rasch validation of the Danish version of the shoulder pain and disability index (SPADI) in patients with rotator cuff-related disorders.

PURPOSE: The psychometric properties of the shoulder pain and disability index (SPADI) have been extensively evaluated using classical test theory, but very few studies have applied Rasch analysis. The purpose of this study was to validate the Danish version using Rasch analysis. METHODS: Responses to the SPADI from 229 patients (48% female, mean age 54.5) were included in the Rasch analysis. Overall fit, individual item fit, local response dependence, dimensionality, targeting, reliability, and differential item functioning (DIF) were examined. RESULTS: After iterative analyses, good fit to the Rasch model was observed, with acceptable targeting and uni-dimensionality. SPADI should be reported as two separate subscales: Pain and Functional Disability. The pain subscale initially demonstrated misfit due to local dependence and DIF, but a log linear Rasch model showed good fit to the Rasch model with acceptable targeting and uni-dimensionality. A six-item version of the disability subscale exhibited adequate fit in the Danish version. The same items were also found to fit the Rasch model in the English version. CONCLUSIONS: The measurement properties of the Danish SPADI are similar to those of the English version. SPADI should be reported as two separate subscales. For the pain subscale, DIF with respect to age was disclosed, but the impact was small. The eight-item disability subscale did not fit the Rasch model. A six-item version of the disability subscale exhibited adequate fit in the Danish version. The same items were also found to fit the Rasch model in the English version.

Effects of selected rehabilitative exercises on external rotator muscles and trapezius muscles of masonry workers.

BACKGROUND: Masonry workers engaged in occupational work-activities have high risk of shoulder injury that often develops to functional loss and disability. Rehabilitative exercises (REs) have potential for slowing this development. OBJECTIVE: The objective is to study the effects of three selected REs on integrated electromyography activations of the external rotator muscles and trapezius muscles of masonry workers. METHODS: Ten subjects, masonry workers having shoulder pain, have volunteered for this study. Each subject performs three selected REs: (1) Prone horizontal abduction at 90° with full external rotation with thumb right up. (2) Side lying external rotation (ER) with elbow on the trunk. (3) ER at 90° abduction and elbow flexion at 90° in standing position. Selection of REs is based on their superior performance in earlier studies. Electromyography (EMG) differences among the exercises are tested for statistical significance. RESULTS: A cross comparison of REs shows that exercises (1) and (3) produce high rotator cuff synergy, an average of infraspinatus and teres-minor activities. Exercise (3) minimizes the risk of subacromial impingement by presenting the least posterior deltoid activity. However, exercise (1) reduces the risk of abnormal scapular movement by producing higher middle trapezius and lower trapezius activities than upper trapezius activity. CONCLUSION: The results provide basic information to design appropriate rehabilitation programs for masonry workers having shoulder pain.

Reparación de las lesiones crónicas del manguito rotador mediante diferentes compuestos / Repair of rotator cuff injuries using different composites

Objetivo. La reparación del manguito rotador se acompaña de una elevada tasa de rerrotura. Nuestro objetivo es determinar si el empleo de rhBMP-2 vehiculizada en un transportador híbrido mejora el proceso de reparación en lesiones crónicas del manguito. Material y métodos. Estudio experimental en 62 ratas. A las 4 semanas de la lesión se llevó a cabo una sutura transósea y la asignación aleatoria a uno de los 5 grupos de estudio: 1) grupo control: solo sutura; 2) grupo doble-control: se aplicó además un transportador de alginato-quitina; 3) grupo control-alginato: se añadió rhBMP-2 al alginato; 4) grupo control-quitina: se añadió rhBMP-2 a la quitina, y 5) grupo doble-muestra: se añadió rhBMP-2 a ambos componentes. A los 4 meses se evaluaron los resultados mediante estudios biomecánicos e histológicos. Resultados. En todos los casos se observó una brecha osteotendinosa macroscópicamente a las 4 semanas. La tasa de rerrotura fue del 7,5%, ocurriendo el 20% de ellas en el grupo control-alginato. En la evaluación histológica los mejores resultados se obtuvieron en el grupo doble muestra: 4,5 (3,3-5). La carga máxima soportada fue mayor en el grupo doble muestra 62,9N (59,8-69,4) presentando además una menor rigidez 12,7 (9,7-15,9). Conclusiones. El empleo de la rhBMP-2 vehiculizada en un transportador híbrido de alginato-quitina parece mejorar las características histológicas de la reparación e incrementar las propiedades biomecánicas del tendón en el contexto de una lesión crónica del manguito rotador (AU)

Aim. Rotator cuff repairs have shown a high level of re-ruptures. It is hypothesised that the use of rhBMP-2 in a carrier could improve the biomechanical and histological properties of the repair. Material and methods. Controlled experimental study conducted on 40 rats with section and repair of the supraspinatus tendon and randomisation to one of five groups: Group 1 (control) only suture; Group 2 (double control), suture and alginate-chitin carrier; Group 3 (alginate-control), the rhBMP-2 was added to the alginate; Group 4 (chitin-control) application of the rhBMP-2 to the chitin, and Group 5 (double sample): The two components of the carrier (alginate and chitin) have rhBMP-2. A biomechanical and histological analysis was performed at 4 weeks. Results. A gap was observed in all cases 4 weeks after supraspinatus detachment. The re-rupture rate was 7.5%, with 20% of them in the control-alginate Group. Histologically the best results were obtained in the double sample group: 4.5 (3.3-5.0). Double sample were also able to support higher loads to failure: 62.9N (59.8 to 69.4) with lower rigidity 12.7 (9.7 to 15.9). Conclusions. The use of alginate-chitin carrier with rhBMP-2 improves the biomechanical and histological properties of the repair site in a chronic rotator cuff tear (AU)

Unilateral ectopic insertion of the pectoralis minor: Clinical and functional significance.

During routine dissection of a 70-year-old female, we observed a unilateral ectopic insertion of the left pectoralis minor muscle. The tendon was cord-like and passed through a tendon sheath superior to the coracoid process to insert on the greater tubercle of the humerus. Additionally, an aponeurosis extended from the distal aspect of the muscle's tendon and passed medially to insert near the base of the coracoid process. This is the first report of an additional aponeurosis extending from the tendon of the pectoralis minor and attaching to the coracoid process. We also observed that the pectoralis minor tendon caused an unusually smooth deep indentation on the superior aspect of the coracoid process; considering its insertion on the humerus, we hypothesize that the muscle acted as an abductor of the shoulder along with the supraspinatus. The medial extension of an aponeurotic tendon from the pectoralis minor tendon near its insertion, to the base of the coracoid process further suggests that the muscle provided stability to the glenohumeral joint while acting as an abductor. Pectoralis minor variations have been described since 1897; however, few studies have demonstrated functional or clinical significance. The redundancy of the actions of this muscle along with its long tendon suggests a potential source for autograft.

Nature abhors a vacuum: bilateral prominent rotator cable in bilateral congenital absence of the long head of the biceps tendon.

Bilateral agenesis of the long head of the biceps tendon is an exceedingly rare anomaly and can be a challenging diagnostic dilemma whose differential diagnosis includes tear. We present the third case of bilateral agenesis of the long head of the biceps tendon. Absent or shallow intertubercular sulcus is a constant finding and serves to differentiate this entity from tear. Our case is unique in that there was a radial ray anomaly, where prior reports of bilaterality did not demonstrate associated congenital anomalies. We also describe the newly reported finding of thickening of the rotator cable without the presence of rotator cuff tear. Thickening of the rotator cable may be an associated finding with agenesis of the biceps tendon.

Variations in the anatomy of the anterior-inferior rotator cuff: the "infraglenoid muscle".

During the dissection course, 67 shoulders from 35 cadavers were investigated for an "infraglenoid muscle" (IGM). Of the 67 shoulders, 43 cases showed an IGM. When present, the IGM originated at the so-called "marginal axillary groove" of the Scapula. Of these, 86% of the muscles inserted at the crest of the lesser tubercle, 12% at the lesser tubercle itself and 2% at both anatomical structures. During its twisted course it was observed near the capsule of the shoulder joint. All detected IGMs were separated from the subscapular muscle (SM) by a distinct fascia. Due to its anatomical position and its innervation by the axillary nerve, demonstrated in 19 of 43 shoulders, the IGM should be considered to be independent of the SM. The accessory subscapular muscle, previously described by other authors, must be distinguished from our IGM, mainly due to its origin on the surface of the SM. Considering our mere descriptive findings the biomechanical implications of the IGM concerning the rotator cuff will have to be investigated in future studies.

Unusual variation of the rotator interval: insertional abnormality of the pectoralis minor tendon and absence of the coracohumeral ligament.

OBJECTIVE: To evaluate the anomalous insertion of the pectoralis minor tendon with absence of the coracohumeral ligament on MR arthrography and to demonstrate the associated findings seen with this anatomical variation. MATERIALS AND METHODS: We retrospectively reviewed the 335 MR arthrograms of the shoulder joint (mean age 37.8 years) performed from March 2000 to February 2008. Images were evaluated with attention to anomalous insertion of the pectoralis minor tendon and the coracohumeral ligament. RESULTS: Anomalous insertion of the pectoralis minor tendon was demonstrated in 5 out of 335 shoulders (1.5%). The pectoralis minor tendons crossed over the coracoid process and attached directly to a glenohumeral joint capsule, and the coracohumeral ligament was absent in these 5 patients. In these patients, injected contrast material was noted to extend over the coracoid process along the course of the pectoralis minor tendon. Among 5 patients, 3 patients (60%) were diagnosed with SLAP (superior labrum anterior to posterior) lesions. CONCLUSION: Anomalous insertion of the pectoralis minor tendon to the glenohumeral joint capsule and associated absence of the coracohumeral ligament is well demonstrated on MR arthrography. It is an unusual variant of the pectoralis minor muscle insertion, and may be a possible contributing factor in the development of a SLAP lesion.

Anatomía del manguito rotador / Rotator cuff anatomy

Introducción: en la región del hombro encontramos cuatro grupos musculares. Dentro del segundo grupoesta el manguito de rotadores. Objetivo: resaltar la importancia del manguito rotador, su constitución, inserciones, ubicación y dirección. Material y métodos: se utilizaron cincuenta hombros formolizados de la Cátedra de Anatomía Normal de la Facultad de Ciencias Médicas de la Universidad Nacional de Córdoba. Con disección clásica. Resultados: la ubicación del manguito de rotadores en su totalidad fue por debajo del arco córaco-acromial. Encontramos las tres variantes anatómicas del acromion. Su constitución se puede describir como una estructurade cinco capas. La orientación de las fibras y capas tienen relación con las lesiones del manguito rotador. Conclusión: es importante el estudio anatómico detallado, en particular su constitución y la irrigación de lazona, en la patogénesis de estas lesiones y para la aplicación clínica e implementar la técnica quirúrgica más adecuada.

Introduction: in the region of the shoulder we find four muscular groups. Inside the second group the rotator cuff is located. Objective: the objective of this work is to stand out of the same one, its constitution, inserts, location anddirection. Material and methods: fifty formalized shoulders of the class of Normal Anatomy of the Facultad de Ciencias Médicas of the Universidad Nacional de Córdoba were used. With classic dissection. Results: the location of the rotators cuff is entirety under the coraco-acromial arch. We find the three anatomical variants of the acromion according to Neer. The constitution can describe like an structure of 5 layers. The orientations of the fibers and layers have relationship with the lesions of the cuff rotator. Conclusion: is important the detailed anatomical study, the irrigation and constitution in pathogenesis and forthe clinical application and to implement the appropriate surgical technique.

Deformities associated with the suture-bridge technique for full-thickness rotator cuff tears.

PURPOSE: This study was performed to evaluate the incidence and cause of deformities associated with the suture-bridge technique in rotator cuff tears. METHODS: We performed a prospective review of a consecutive series of 100 shoulders with full-thickness tears (50 with medium tears, 43 with large tears, and 7 with massive tears) treated by use of the suture-bridge technique in 2007. The surgical technique was classified according to the number of suture anchors inserted in the medial and lateral rows (2 x 2 suture bridges in 82 cases, 3 x 2 in 12, and 3 x 3 in 6). On arthroscopy, the development of a marginal dog-ear deformity and central bird-beak deformity during the repair was investigated. These deformities were corrected by use of the modified suture-bridge technique or by insertion of an additional suture anchor. RESULTS: Dog-ear deformities occurred in 47 cases and were most frequent in large tears treated with a 2 x 2 suture bridge (21 cases). Dog-ear deformities in 2 x 2 suture bridges were more frequent in large tears than in medium tears (P < .05), and with large tears, they were more frequent with 2 x 2 suture bridges than with 3 x 2 suture bridges (P < .05). Bird-beak deformities occurred in 13 cases and were most frequent in large tears treated with 2 x 2 suture bridges (9 cases). Bird-beak deformities with 2 x 2 suture bridges were more frequent in large tears than in medium tears (P < .05), and with large tears, they were more frequent with 2 x 2 suture bridges than with 3 x 2 suture bridges (P < .05). CONCLUSIONS: To reduce deformities associated with the suture-bridge technique during rotator cuff repair, individualized repair methods may be applied according to the size and pattern of the rotator cuff tear. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Anomalous biceps tendon insertion into the rotator cable: a case report.

An anomalous origin of the long head of the biceps tendon (LHBT) from the rotator cable has not been described in the orthopaedic surgery literature. This case report describes the intraoperative findings of this aberrant origin, found incidentally during diagnostic arthroscopy. The concept of the rotator cable and crescent is discussed, and a literature review of aberrant anatomy of the LHBT origin is included.

Problems getting back in the swing after breast cancer: gaps in rehabilitative care.

For more than 50 years, Cancer has explored every facet of malignant disease, including morphology, therapy, epidemiology, biology, historical perspective, and basic science. However, the Editors of Cancer believe that the human beings who bear the burden of this illness have much to teach us, and we now solicit essays from patients and family members about their experience.

Shoulder pathoanatomy in marathon kayakers.

OBJECTIVES: To determine the prevalence of soft and hard tissue abnormalities and their interrelations in the shoulders of marathon kayakers and to examine the pathoanatomical factors that predispose these athletes to injury. METHODS: Fifty two long distance kayakers completed a questionnaire. Their shoulders were examined for range of motion, pain, and stability using a standard set of 10 clinical tests. The shoulder was subsequently scanned by magnetic resonance imaging (MRI) in three planes and evaluated for evidence of injury or other abnormality. The relation of clinical symptoms and MRI findings was investigated with respect to kayaker's age, number of years kayaking, and number of marathon races completed. RESULTS: Thirty subjects were asymptomatic at the time of scanning, and twenty two showed symptoms of pain and/or instability. MRI showed acromioclavicular hypertrophy, acromial or clavicular spur, supraspinatus tendinitis, and partial tear of the supraspinatus as the most common abnormalities. Kayaker's age, number of years kayaking, and number of races completed did not relate significantly to symptoms or to the presence of an abnormality on MRI scan. Of all the pathoanatomical findings that are reported to predispose to rotator cuff injury, only acromial and clavicular spurs were found to correlate highly with supraspinatus muscle pathology. CONCLUSIONS: Rotator cuff injuries make up a large portion of the injuries seen in marathon kayakers, about twice the number reported for sprint kayakers. These injuries are the result of secondary impingement factors associated with overuse, possibly specific to kayakers, and not the result of bony restrictions around the shoulder joint. Acromioclavicular hypertrophy is a common finding in marathon kayakers, but is possibly the result of portaging or a previous injury.

Isolated closure of rotator interval defects for shoulder instability.

Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an isolated procedure for recurrent instability symptoms. Intraoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthesia revealed increased inferior translation in all patients, as illustrated by at least a 1+ sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were freshened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation possible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent result using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.