Can handheld dynamometry predict rotator cuff tear size? A study in 2100 consecutive patients.

BACKGROUND: This study aimed to determine whether handheld dynamometry measurements could predict rotator cuff tear size in patients who required surgical treatment of their shoulder pathology. METHODS: Handheld dynamometer readings were collected prior to surgery and analyzed retrospectively for 2100 consecutive patients. Post hoc, the cohort was divided into patients with rotator cuff tears (n = 1747) and those without rotator cuff tears (n = 353). The tear group was stratified into partial- vs. full-thickness tears and into 4 groups based on tear size area. RESULTS: Patients with partial-thickness tears had greater internal rotation (P = .03), external rotation (P < .001), and supraspinatus (P < .001) strength than patients with full-thickness tears. Patients with tears had lower supraspinatus strength than patients without tears (r = -0.82, P < .001). Patients with a larger tear size had lower values of external rotation (r = -1.46, P < .001) and supraspinatus (r = -1.18, P < .001) strength. A model involving internal rotation and supraspinatus strength could predict the presence of a tear with a sensitivity of 82% and specificity of 29%. The correct prediction rate was 73% overall (82% in tear group and 29% in no-tear group). The following formula was found to predict rotator cuff tear size, showing modest correlation with our raw data (r = 0.25, P < .001): Tear size = 482.8 + (3.9 × Internal rotation strength) + (1.6 × Adduction strength) - (7.2 × External rotation strength) - (2.0 × Supraspinatus strength). CONCLUSIONS: Handheld dynamometer readings could not reliably predict rotator cuff tear size, showing only modest correlation with our raw data. Handheld dynamometry readings could predict the presence of a tear, although tears in the intact cohort were overestimated (a specificity of 29% and negative predictive value of 25%).

Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand.

BACKGROUND: Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. OBJECTIVE: We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. METHODS: Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. RESULTS: Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. CONCLUSION: In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB.

The Relationship Between Intraoperative Tear Dimensions and Postoperative Pain in 1624 Consecutive Arthroscopic Rotator Cuff Repairs.

BACKGROUND: Rotator cuff repair often results in significant pain postoperatively, the cause of which is undetermined. Purpose/Hypothesis: The aim of this study was to evaluate the relationship between rotator cuff tear area and postoperative pain in patients who had undergone arthroscopic rotator cuff repair. We hypothesized that larger tears would be more painful because of elevated repair tension at 1 week postoperatively but that smaller tears would be more painful because of a greater healing response, especially from 6 weeks postoperatively. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1624 patients who underwent arthroscopic rotator cuff repair were included in this study. Exclusion criteria were moderate to severe osteoarthritis, isolated subscapularis repair, calcific tendinitis, synthetic patch repair, revision surgery, and retears on ultrasound at 6 months after surgery. Rotator cuff tears were subdivided into groups based on the tear size and retear rate found for each group. A modified L'Insalata questionnaire was given before surgery and at 1 week, 6 weeks, 3 months, and 6 months after surgery. Pearson and Spearman correlation coefficient tests were performed between rotator cuff tear areas and pain scores. RESULTS: Intraoperative rotator cuff tear areas did not correlate with pain scores preoperatively or at 1 week after surgery. A smaller tear area was associated with more frequent and severe pain with overhead activities, at rest, and during sleep as well as a poorer perceived overall shoulder condition at 6 weeks, 3 months, and 6 months after repair ( r = 0.11-0.23, P < .0001). Patients who were younger, had partial-thickness tears, and had occupational injuries experienced more pain postoperatively ( r = 0.10-0.28, P < .0001). Larger tears did not have more pain at 1 week after surgery. The retear rate was 7% in tears <2 cm2 but reached 44% in tears >8 cm2. CONCLUSION: There were fewer retears with smaller tears, but they were more painful than large tears postoperatively from 6 weeks to 6 months after surgery. Smaller tears may heal more vigorously, causing more pain. Patients with smaller tears experienced more pain after rotator cuff repair compared with patients with larger tears. These findings are contrary to previous ideas about tear size and postoperative pain. Healing is likely a determinant of postoperative pain.

The effect of rotator cuff repair on early overhead shoulder function: a study in 1600 consecutive rotator cuff repairs.

BACKGROUND: Rotator cuff tears are often surgically repaired, generally with good results. However, repairs not infrequently retear, and how important repair integrity is with respect to early functional outcomes after rotator cuff repair is unclear. Thus, the purpose of this study was to determine the effect of a retear on overhead activities in a large cohort of patients after rotator cuff repair. METHODS: This was a retrospective cohort study of prospectively collected data from 1600 consecutive rotator cuff repairs. Outcomes were based on patient responses to the L'Insalata Shoulder Questionnaire and findings on examination preoperatively and at 6 months of follow-up. Repair integrity was determined by ultrasound imaging at the 6-month follow-up visit. RESULTS: The 1600 patients (885 men, 715 women) were a mean age of 58 years. Postoperative ultrasound imaging found 13% (211 of 1600) of repairs had retorn. Significant improvements were seen irrespective of rotator cuff integrity in pain levels with overhead activity (P < .0001) and range of motion in forward flexion (P < .001) and abduction (P < .01). Patients with intact repairs had 9.5 N greater supraspinatus strength (P < .0001) and 6.9 N greater external rotation strength (P < .01) than those with a retear. CONCLUSION: To our knowledge, this is the largest study to evaluate the effect of rotator cuff repair integrity on shoulder function. Patients who had an arthroscopic rotator cuff repair reported significant improvements in overhead pain levels irrespective of the repair integrity at 6 months. Repair integrity influenced supraspinatus and external rotation power, where patients with intact repairs were stronger than those with a retear.

Ultrasound determination of rotator cuff tear repairability.

BACKGROUND: Rotator cuff repair aims to reattach the torn tendon to the greater tuberosity footprint with suture anchors. The present study aimed to assess the diagnostic accuracy of ultrasound in predicting rotator cuff tear repairability and to assess which sonographic and pre-operative features are strongest in predicting repairability. METHODS: The study was a retrospective analysis of measurements made prospectively in a cohort of 373 patients who had ultrasounds of their shoulder and underwent rotator cuff repair. Measurements of rotator cuff tear size and muscle atrophy were made pre-operatively by ultrasound to enable prediction of rotator cuff repairability. Tears were classified following ultrasound as repairable or irreparable, and were correlated with intra-operative repairability. RESULTS: Ultrasound assessment of rotator cuff tear repairability has a sensitivity of 86% (p < 0.0001) and a specificity of 67% (p < 0.0001). The strongest predictors of rotator cuff repairability were tear size (p < 0.001) and age (p = 0.004). Sonographic assessments of tear size ≥4 cm(2) or anteroposterior tear length ≥25 mm indicated an irreparable rotator cuff tear. CONCLUSIONS: Ultrasound assessment is accurate in predicting rotator cuff tear repairability. Tear size or anteroposterior tear length and age were the best predictors of repairability.

Advanced glycation end products in idiopathic frozen shoulders.

BACKGROUND: The pathophysiologic mechanisms behind proliferation of fibroblasts and deposition of dense collagen matrix in idiopathic frozen shoulder remain unclear. Accumulation of advanced glycation end products (AGEs) with cross-linking and stabilization of collagen has been hypothesized to contribute to this pathophysiologic process. This study investigated whether the immunoreactivity of AGEs is higher in patients with idiopathic frozen shoulder than in the control groups. METHODS: Shoulder capsule samples were collected from 8 patients with idiopathic frozen shoulder, 6 with unstable shoulders (control 1), and 8 with rotator cuff tears (control 2). The samples were hematoxylin and eosin stained and analyzed by immunohistochemistry using antibodies against AGEs. Immunoreactivities were rated in a blinded fashion from none (0) to strong (3). Immunohistochemical distribution within the capsule was noted. RESULTS: Frozen shoulder patients had greater frequency and severity of self-reported pain (P = .02) than rotator cuff tear patients and more restricted range of motion in all planes (P < .05) than patients of the instability and rotator cuff tear groups. Hematoxylin and eosin-stained capsular tissue from frozen shoulder showed fibroblastic proliferation, increased numbers of adipocytes, and increased subsynovial vascularity. Immunoreactivity of AGEs was stronger in frozen shoulder capsules (2.8) than in instability (0.3; P = .0001) and rotator cuff tear (1.1; P = .016) capsules. CONCLUSION: This study highlights a potential role for AGEs in the pathogenesis of frozen shoulder. The overexpression of AGEs may explain the fibroblastic proliferation and deposition of collagen matrix in idiopathic frozen shoulder. LEVEL OF EVIDENCE: Basic Science Study; Histology.

Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand.

BACKGROUND: Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. OBJECTIVE: We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. METHODS: Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. RESULTS: Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. CONCLUSION: In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB.

Surgical repair of the gluteal tendons: a report of 72 cases.

Lateral hip pain is a common problem in middle-aged women. This pain is usually attributed to trochanteric bursitis and treated as such. This study reports the results of investigation, the findings at surgery, the operative technique, the histopathologic findings, and the results of gluteal tendon repair in 72 patients with long-standing trochanteric pain and reports a classification of the operative findings. Six patients (7%) in the original study cohort of 89 patients were lost to follow-up, but of the remaining patients, 65 of 72, or 90%, were pain-free or had minimal pain (P < .00001). Surgical reconstruction of detached gluteal tendons causing chronic lateral hip pain addresses the problem directly and reliably relieves the symptoms of so-called "trochanteric bursitis."

Restore orthobiologic implant: not recommended for augmentation of rotator cuff repairs.

BACKGROUND: Following repairs of large-to-massive tears of the rotator cuff, the rates of tendon retears are high and often involve tissue deficiency. Animal studies of the Restore Orthobiologic Implant, a collagen-based material derived from the small intestine mucosa of pigs, have indicated that it might be used to help overcome such problems. We carried out a study to determine whether patients who received this xenograft to augment a rotator cuff repair exhibited greater shoulder strength, shoulder function, and/or resistance to retearing. METHODS: We compared data from a group of patients who had undergone conventional rotator cuff repair with xenograft augmentation (the xenograft group) with data from a group in whom a repair had been done by the same surgeon without augmentation (the controls). The groups were matched for gender, mean age, and mean size of the rotator cuff tear. All subjects completed a pain and function questionnaire and were given a systematic clinical shoulder examination preoperatively and at three, six, and twenty-four months postoperatively. The twenty-four-month visit included magnetic resonance imaging to determine whether a retear had occurred. RESULTS: Four patients who had received a xenograft had a severe postoperative reaction requiring surgical treatment. At two years after the surgery, six of the ten tendons repaired with a xenograft and seven of the twelve control tendons had retorn, as documented by magnetic resonance imaging. The patients with a xenograft had significantly less lift-off strength, as measured with a dynamometer, and significantly less strength in internal rotation and adduction than the controls at two years after the surgery (all p < 0.05). Also, the xenograft group had significantly more impingement in external rotation, a slower rate of resolution of pain during activities, more difficulty with hand-behind-the-back activities, and less sports participation (all p < 0.05). CONCLUSIONS: Two years after surgical repair of a large rotator cuff defect supplemented with a xenograft, patients had several persisting deficits and no recognizable benefit as compared with the results in a control group. In view of these findings, together with the unsatisfactorily high proportion of patients with a severe inflammatory reaction to the xenograft, we do not recommend use of the Restore Orthobiologic Implant in its present form. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Prevention of shoulder stiffness after rotator cuff repair.

UNLABELLED: Predisposing factors for shoulder stiffness after rotator cuff repair have yet to be determined. The potential for recovery of range of motion and amelioration of pain in patients with this complication also remains unclear. Accordingly, data collected prospectively for 209 patients with a primary rotator cuff repair were retrospectively reviewed. Two groups, Group A (early motion recovery) and Group B (shoulder stiffness), were selected according to passive shoulder range of motion outcomes 6 weeks postoperatively. Both groups were compared for 10 descriptive and clinical characteristics, and for passive range of motion, muscle force, and functional outcomes obtained 0, 6, 12, 24, and 76 weeks postoperatively. Of the potential prognostic factors examined, restriction of range of motion for the preoperative hand behind the back best predicted shoulder stiffness at 6 weeks postoperatively. For patients with postoperative shoulder stiffness, pain had subsided by 24 weeks postoperatively, whereas range of motion steadily improved between 6 weeks and 76 weeks postoperatively. Results of the current study support a predictive role for restriction of range of motion for the preoperative hand behind the back, and affirms the potential for nearly complete recovery of range of motion and amelioration of pain in patients who have shoulder stiffness after rotator cuff repair. LEVEL OF EVIDENCE: Prognostic study, Level I-1 (prospective study).

A randomised clinical trial evaluating the efficacy of physiotherapy after rotator cuff repair.

The optimal form of rehabilitation after rotator cuff repair has yet to be determined. A randomised clinical trial was undertaken to compare outcomes for two forms of rehabilitation for this condition: individualised supervised physiotherapy treatment, and a standardised unsupervised home exercise regime. Fifty-eight volunteers with all sizes of operatively repaired rotator cuff tears were allocated randomly to one of the two treatment groups. All subjects received a standardised home exercise regime. Subjects who were randomised to the physiotherapy group received additional individualised treatment. Independent, blinded assessments of range of motion, muscle force and functional outcome measures were performed pre-operatively, and at six, 12 and 24 weeks postoperation. At six, 12 and 24 weeks post-operation, comparable outcomes were demonstrated for both rehabilitation groups. By 24 weeks post-operation, most subjects demonstrated outcomes that were consistent with a favourable recovery, regardless of rehabilitation mode. On the basis of these results, outcomes for subjects allocated to individualised physiotherapy treatment after rotator cuff repair are no better than for subjects allocated to a standardised home exercise regime.

Reliability of 3 methods for assessing shoulder strength.

The reliability of tests for isometric strength of the shoulder joint in symptomatic subjects has yet to be established. For this purpose, interrater and intrarater agreement trials were undertaken to ascertain the reliability of manual muscle tests, a handheld dynamometer, and a spring-scale dynamometer for 5 different shoulder movements in symptomatic subjects. Intraclass correlation coefficients were calculated from a random-effects model. All movements tested with the handheld dynamometer demonstrated excellent reliability for the interrater trial (rho = 0.79-0.92). Excellent reliability was also demonstrated for elevation, external rotation, and internal rotation for the intrarater trial (rho = 0.79-0.96). For the interrater trial, measurement of the lift-off maneuver with the handheld dynamometer was significantly more reliable than with manual muscle tests (P =.002). In summary, the handheld dynamometer was the most reliable and discriminatory means for assessing strength of the rotator cuff in symptomatic subjects.