Does the Extent of Tear Influence Pseudoparesis in Patients With Isolated Subscapularis Tears?

BACKGROUND: Surgeons tend to associate pseudoparesis with massive rotator cuff tears. However, little is known about the degree to which isolated subscapularis tears might be associated with pseudoparesis of the shoulder. QUESTION/PURPOSE: Is the extent of subscapularis tears associated with pseudoparesis? METHODS: A retrospective analysis identified all patients with subscapularis tears from 2010 to 2021 in the longitudinally maintained shoulder arthroscopy archive of one university hospital's shoulder section of the orthopaedic department. After exclusion, 106 of 152 patients with isolated subscapularis tears who underwent arthroscopic surgery were included in the study. Sixty percent of the patients were women, and the mean ± SD age was 52 ± 11 years. Patients who were scheduled for arthroscopic surgery were divided into two groups according to the presence or absence of pseudoparesis preoperatively. Pseudoparesis was considered to be active forward elevation > 45º but < 90º, which is a simple and reproducible measurement that can be taken using a goniometer, and demonstrated complete passive forward elevation. Pseudoparesis was present in 41% (43 of 106) of patients with an isolated subscapularis tear. Data on tear severity (according to Lafosse type, noted during arthroscopy), integrity of the subscapularis tendon (noted during arthroscopy), fatty degeneration (using the Goutallier grading system on MRI), arthroscopic findings of biceps disorder, superior labrum anterior to posterior (SLAP) lesions, and pain severity (measured by VAS score) were recorded. We used logistic regression analysis to examine the relationship between pseudoparesis and disruption of the tendinous part of the subscapularis. RESULTS: After accounting for potentially confounding factors such as biceps disorders and muscle atrophy, we found that pseudoparesis was associated with decreased tear severity according to the Lafosse classification (adjusted OR 0.2 [95% CI 0.1 to 0.7]; p = 0.01) and with disruption of the tendinous portion of the subscapularis (adjusted OR 21 [4 to 128]; p = 0.001). Patients with less severe tears (Lafosse type I) have lower odds of experiencing pseudoparesis compared with those with more severe tears (Lafosse types II, III, and IV), and patients with disruption of the tendinous portion of the subscapularis have substantially higher odds of pseudoparesis compared with those with an intact tendinous portion. No association was found between pseudoparesis and subscapularis fatty degeneration, biceps disorder, or SLAP lesions. CONCLUSION: This study provides initial evidence suggesting that isolated subscapularis tears are associated with pseudoparesis. The main finding of this study is that isolated subscapularis tears that involve the tendon extending to the inferior part of the subscapularis have higher odds of being found with pseudoparesis. These findings highlight the importance of maintaining the integrity of the superior tendinous part of the subscapularis for active forward elevation > 90°. LEVEL OF EVIDENCE: Level III, therapeutic study.

Platelet-rich plasma in the management of rotator cuff tendinopathy.

Platelet-rich plasma (PRP) is an autologous blood-derived product that has gained significant attention in the treatment of tendinopathies as one of many treatment modalities in the field of regenerative medicine. Rotator cuff pathologies are the leading cause of shoulder pain. Despite the high success rate with conservative treatment and arthroscopic surgical repair, the search for a nonsurgical treatment has made PRP a trending topic recently. The purpose of this article is to review the recent literature data on the possible role of PRP in different rotator cuff pathologies. The limited data in the literature about isolated tendinopathies without a tear (tendonitis and tendinosis) suggests potential benefit from conservative treatment with PRP. Many studies exist for the treatment of rotator cuff tears solely using PRP or as an augmentation to arthroscopic repair. Despite the large number of randomized clinical trials and meta-analyses about the topic, there is no consensus in favor of routine application of PRP in this patient population. The existing reliable evidence of benefit seems to be restricted to its use in only inflammatory tendinopathies with preserved tendon integrity.

A brief introduction to medical image processing, designing and 3D printing for orthopedic surgeons.

Advancements in technology and the industry have changed the way that physicians deliver healthcare to their patients. Orthopedic surgery is one of the medical fields chasing advancing technology closely and making it a part of routine practice quickly. Patient-centric approach and customization of the care according to patient's needs are the key components in this new concept. Customized surgical planning with three-dimensional (3D) modelling and printing of the anatomy of each patient scheduled for surgery, custom made implants are on their ways to become the standard of the care. As a result, a higher proportion of technical personnel than before is expected to be involved in the healthcare. Orthopedic surgeons need to be familiar with this new working model and technical terminology to be able to communicate with the technical members of healthcare thoroughly. Processing of the medical images, computer-aided design (CAD) programs and 3D printing are the crucial parts of this workflow. In this review, we discuss the basics concepts of these components with the examples from 3D Slicer as a medical image processing platform and Shapr3D as a CAD platform, with the aspect of orthopedic surgeons.

Can subcoracoid effusion be a more specific finding for subscapularis tear among rotator cuff pathologies on magnetic resonance imaging?

HYPOTHESIS AND BACKGROUND: Magnetic resonance imaging (MRI) is a well-known, noninvasive diagnostic method for rotator cuff tendon pathologies that are not very sensitive for subscapularis tendon tears. Subcoracoid effusion (SE) is an easily recognizable radiologic sign on MRI. In this study, we aimed to examine the relationship of SE with rotator cuff tear and to investigate whether SE could be a supportive finding in the diagnosis of subscapularis tear in preoperative MRI. Our hypothesis was that SE was a more specific finding of subscapularis tear than other rotator cuff tears. METHODS: The data of patients who underwent shoulder arthroscopy in our clinic between 2017 and 2021 were analyzed retrospectively. Four groups were included in the study: patients with a rotator cuff tear accompanied by a subscapularis tear (group 1, n = 273), patients with isolated subscapularis tear (group 2, n = 57), patients with rotator cuff tear with intact subscapularis tendon (group 3, n = 190), and patients without any rotator cuff pathology (group 4, n = 263). Arthroscopic video records and MRIs of all patients were evaluated retrospectively. Subscapularis tendon tears were classified according to the Lafosse classification. RESULTS: There was a statistically significant difference between the groups in terms of the presence of SE on MRI (P = .001). The presence of SE in group 1 and group 2 was statistically significantly higher than that in both group 3 and group 4 (P = .001), and there was no significant difference between group 3 and group 4 (P > .05). A significant relationship was found between Lafosse classification and SE (P = .001). When the diagnostic powers of the detection of SSC tear and the presence of SE on MRI for SSC tear were compared, Kappa values were 0.615 (P = .001) and 0.701 (P = .001), and overall diagnostic accuracy rates were 80.3% and 85.5%, respectively. CONCLUSION: We conclude that SE is a more specific finding for subscapularis tears than other rotator cuff pathologies. We suggest that SE on MRI should also be considered in patients with a rotator cuff tear in whom a subscapularis tear was not detected in preoperative MRI and that the subscapularis tendon should be carefully evaluated during surgery in cases where the effusion is positive.

Localized pigmented villonodular synovitis in a child knee.

Pigmented villonodular synovitis is a benign proliferative tumor of the synovium. It is very rare, and most cases occur in the knee joint. In this article, we report a case of localized pigmented villonodular synovitis in the knee joint of a 14-year-old boy. This condition is rare in the knees of the children. We preferred to remove the tumor with arthrotomy instead of arthroscopy for two reasons: (i) the patient was obese, (ii) we thought that recurrence risk was high after arthrotomy.