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What’s New in Shoulder and Elbow Surgery

Dr. Gary Gartsman — Mon, 01 May 2006 14:00:00 GMT

The sources for this annual update on shoulder and elbow surgery were presentations and symposia at meetings of The American Orthopaedic Society for Sports Medicine (Specialty Day, February 26, 2005, Washington, DC), the Arthroscopy Association of North America (Specialty Day, February 26, 2005, Washington, DC; Twenty-fourth Annual Meeting, May 12-15, 2005, Vancouver, British Columbia, Canada; and Twenty-third Fall Course, December 2-4, 2004, Palm Desert, California), the American Academy of Orthopaedic Surgeons (Seventy-second Annual Meeting, February 23-27, 2005, Washington, DC), the Orthopaedic Research Society (Fifty-first Annual Meeting, February 20-23, 2005, Washington, DC), the American Shoulder and Elbow Surgeons (Twenty-first Open Meeting, Specialty Day, February 26, 2005, Washington, DC; and Twenty-first Annual Meeting, September 29-October 2, 2004, New York, NY) and the American Orthopaedic Association (118th Annual Meeting, June 22-25, 2005, Huntington Beach, California).

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1-May-06 9:00 AM

Adhesive Capsulitis

Gary Gartsman — Fri, 17 Jun 2005 21:00:00 GMT

I feel that the cause of your pain is a condition called Adhesive Capsulitis or “Frozen Shoulder.” This is a common shoulder problem that affects thousands of people every year.

We do not know the cause of frozen shoulder. It does not seem to result from an injury. While some people relate the onset of their pain to an injury or illness, many more say the problem began “out of the blue,” without any cause.

Pain may start suddenly or begin slowly. Pain and stiffness in the shoulder increase. Often patients report difficulty with sleep as the shoulder is particularly painful at night. Reaching up to get items off shelves, reaching behind the back to tuck in a shirt or blouse become difficult or impossible.

Adhesive capsulitis is not a disease or aging. Most patients are between the ages of 40 and 60. The condition does not increase as you get older. Let me emphasize that this is a condition, not an injury. Like any condition it has a beginning, a middle and an end. You know the beginning. That is why you came to the office for an examination. The middle occurs as the pain decreases but the stiffness remains. The condition ends as range of motion returns.

Why does adhesive capsulitis occur? Medical science has not found a cause of this process. We know what happens, but not why. Normally the shoulder joint ligaments are folded, like the folds of curtain or fan. When the arm moves upward, the folds expand. When the arm is lowered the folds contract. In frozen shoulder the folds stick to one another. The scar tissue prevents normal shoulder movements and causes pain.

The good news is that most individuals regain excellent use of their shoulder with none or minimal discomfort. The bad news is that this process of healing and recovery can take 1-2 years.

What can be done? Regrettably we have no proven method to speed the natural healing process. Intensive physical therapy, shots, pill, and injections have all been shown to improve the condition but do not improve the condition more quickly than simple exercises that one may do at home.

We will show you the exercises that are beneficial. You cannot break the scar tissue loose. It is too strong. The purpose of these is to gently stretch the shoulder joint and encourage the return of motion. Muscle strengthening exercises help you maintain tone so that when your shoulder motion recovers, the muscles are strong.

You should not be afraid to use your shoulder. Use your shoulder for any and all activities that are not painful, but if pain occurs, stop the activity. Do not try to work through the pain.

I know that this is a frustrating condition as I see hundreds of patients each year with the same problem. Hopefully now that you know why your shoulder is painful and understand what will happen and what you can do about it you will feel more at ease.

Again if you have questions or your condition worsens, please return for another examination or discussion.

17-Jun-05 4:00 PM

Radiographic comparison of pegged and keeled glenoid

Wed, 18 May 2005 22:00:00 GMT

Glenoid loosening is one reason for failure of tota shoulder arthroplasty. Several factors, including radiographic lucency, have been shown to be associated with glenoid loosening. The purpose of this study was to assess the correlation between glenoid design and immediate radiographic lucency in a prospective randomized clinical trial. Total shoulder arthroplasty was performed in 43 patients over a 2-year period. Twenty-three patients were randomized into the keel group and twenty patients into the pegged group. Postoperative radiographs obtained within 6 weeks of surgery were evaluated by 3 raters to determine glenoid lucency. On a scale from 0 (no lucency) to 5 (gross lucency and component loosening), the rate of lucency was 39% (9/23) in the keeled components, which was significantly higher than the rate of 5% (1/20) observed in the pegged components (P = .026). Patient age, gender,and glenoid size did not significantly affect glenoid component lucency (P > .05). The consistency reliability among raters was 0.87,and the intertester reliability was 0.87. Pegged glenoid components have less radiographic lucency when compared with keeled glenoid components in the immediate postoperative period. (J Shoulder Elbow Surg 2005;14:252-257.)

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18-May-05 5:00 PM

The relationship among strength and mobility measures and self-report outcome scores in persons after rotator cuff repair surgery:Impairment measures are not enough

Thu, 31 Mar 2005 13:00:00 GMT

Until recently, few investigators challenged the pre-vailing medical view of health. Medicine perceived health as an observable, biologic fact, and the goal of medical assessment was to objectively evaluate the body’s status. Because patient reports of health status are subjective, they were considered unreliable and unscientific. The use of self-reports to evaluate health and health outcomes, however, has burgeoned in the last 10 to 20 years, as has the authority assigned to patients’ evaluations. Sullivan 14 described this move toward a “new subjective medicine” as a change in medicine’s focus from patients’ bodies to patients’ lives. In the current milieu, self-reported perceptions of health, function, and health-related quality of life (of-ten called patient-centered outcomes) are prominent. These outcomes have authority not in spite of their subjectivity but because of their subjectivity. The inter-est of health policy agents and third-party insurers in health care value and cost-effectiveness may have been at the root of the shift toward patient-centered outcomes.14

31-Mar-05 8:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2005)

Tue, 01 Feb 2005 17:00:00 GMT

Sources

The sources for this annual update on shoulder and elbow surgery were presentations and symposia at meetings of the American Shoulder and Elbow Surgeons (October 8 through 11, 2003, and March 13, 2004), the Arthroscopy Association of North America (November 13 through 16, 2003; March 13, 2004; and April 23 through 25, 2004), the Orthopaedic Re-search Society (March 6 through 9, 2004), the American Academy of Orthopaedic Surgeons (March 9 through 13, 2004), the American Orthopaedic Society for Sports Medi-cine (March 13, 2004), and the American Orthopaedic Asso-ciation (June 23 through 26, 2004).

Shoulder
Rotator Cuff
Basic Science

Zuckerman discussed the early work on cartilage-derived morphogenetic protein-2 (CDMP-2). Rat tendon repairs that had been treated with CDMP-2 were stronger than untreated repairs at four weeks. Dines discussed his initial investigations involving platelet-derived growth factor (PDGF) and insulin-like growth factor-1 (IGF-1). Studies at his laboratory demon-strated that cultured rat fibroblasts could be transduced with the genes from the growth factors and then seeded onto a polymer scaffold and cultured to form tissue-engineered ten-don constructs. Fibroblasts apposed to the tissue engineered constructs containing the IGF gene demonstrated up to a ten-fold stimulation of collagen synthesis compared with con-structs with the gene. The author stated that he hopes that this research can lead to the development of biologically active patches capable of accelerating and modulating rotator cuff repair.

Kikugawa reported on the effects of synovial tissue and growth factors on rotator cuff healing. A supraspinatus ten-don defect was created in forty-eight rats. In half of the rats, the defect was filled with synovial tissue. Compared with the specimens without synovial tissue-filled defects, specimens with filled defects appeared to be more mature, with more-intense staining for TGF-α and increased production of type-I and type-III procollagen. These findings suggest that synovial tissue plays an important role in modulating tendon-healing and that expression of TGF-α may influence the synovial tis-sue in this role.

Sprott investigated the potential for reversal of fatty infiltration following rotator cuff repair in a rabbit model. Fifteen rabbits underwent unilateral detachment of the su-praspinatus tendon from the greater tuberosity. Six weeks following detachment, five rabbits were killed to halt the fatty infiltration process and ten underwent repair of the rotator cuff followed by unrestricted activity. The ten rabbits in the repair group were killed at six months. At six weeks following detachment, significant fatty infiltration was demonstrated (p = 0.001). At six months following repair, the muscle dem-onstrated no further increase in fat (p = 0.03), suggesting that the process of fatty infiltration associated with chronic rotator cuff detachment can be halted, but not reversed, by repair.

Meyer used computerized tomography and both light and electron microscopy to study fatty muscle changes that occur after a rotator cuff tear in a sheep model. Eight sheep underwent unilateral infraspinatus tendon release and delayed repair. Seventy-five weeks after the repair, significant in-creases in muscle retraction and pennation angle as well as significant muscle-fiber shortening (p < 0.0001) were identi-fied. Interstitial fat and fibrous tissue increased from 4% to 46% of the muscle volume. On the basis of geometric model-ing, the authors concluded that the fatty tissue may fill spaces created by the combination of retraction, shortening, and changes in pennation angle. These findings contradict cur-rent thinking that the fatty changes represent primarily a de-generative process.

Bishop evaluated the changes in muscle fatty infiltration and atrophy following rotator cuff repair. Preoperative and postoperative magnetic resonance imaging was used to grade fatty infiltration on a 5-point scale and muscle atrophy on a 4-point scale. Fatty infiltration and muscle atrophy correlated positively with tear size (p < 0.0001, r = 0.712). Moreover, American Shoulder and Elbow Surgeons (ASES) and Constant scores as well as strength measurements correlated inversely with fatty infiltration and muscle atrophy (p < 0.03). Repeat tear was associated with fatty infiltration of the supraspinatus and weakness in forward flexion, and external rotation was most strongly associated with fatty infiltration of the in-fraspinatus. However, pain relief was independent of the de-grees of fatty infiltration and muscle atrophy.

Cohen reported on the inhibitory effects of traditional nonsteroidal anti-inflammatory drugs and cyclooxygenase-2- selective inhibitors on rotator cuff tendon-healing in a rat model. Following rotator cuff detachment and repair, 180 rats were randomly assigned to receive celecoxib, indomethacin, or no drug. Groups of animals were killed at two, four, and eight weeks postoperatively, and the tendons were subjected to bio-mechanical and histologic evaluation. The author found that load to failure was significantly lower in the indomethacin and celecoxib groups compared with the control group at two, four, and eight weeks. In contrast to both treatment groups, the control group exhibited improved collagen maturity and organization at the tendon-insertion site. The results demon-strate that both traditional nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors significantly impair tendon-to-bone healing in the rat rotator cuff.

Tingart evaluated the effect of suture anchor design and bone density on the pullout strength of suture anchors used for rotator cuff repair. The trabecular and cortical bone min-eral density was determined for six regions within the greater tuberosity. Metal screw-type and biodegradable hook-type su-ture anchors were inserted into each region and were cyclically loaded until failure. Metal anchors failed at an average 66% higher load than bioabsorbable anchors did (p < 0.01). For both anchor types, failure loads correlated with bone-mineral density and were significantly higher in the proximal tuberos-ity (p < 0.01).

1-Feb-05 11:00 AM

Development of a Flexilevel Scale for use with computer adaptive testing for assessing shoulder function

randy sarinas — Tue, 01 Feb 2005 14:45:00 GMT

In a 5-year study, a self-report measure of shoulder function—the Flexilevel Scale of Shoulder Function (FLEX-SF)—was developed by use of item response the-ory. A large pool of candidate items (N 68) was developed. A questionnaire that included the 68 items, another scale of shoulder function, and clinical and demographic questions were administered to 400 per-sons with shoulder complaints. Patients’ responses to the 68 items were calibrated by use of Andrich’s rat-ing scale model. Thirty-three items were selected from the pool and subdivided into three overlapping testlets targeting low, medium, and high shoulder function. A table translates raw scores on testlets to a common mathematical metric. The validity and reliability of the FLEX-SF was evaluated in a longitudinal study of 199 patients. The FLEX-SF scores were highly reliable and exhibited excellent validity (including responsiveness). We report on a simulation of a computer-adaptive test of shoulder function. This simulation is based on the developmental items we tested for use in the FLEX-SF. The results indicate that greater measurement effi-ciency can be achieved with a computer-adaptive test format. (J Shoulder Elbow Surg 2005;14:90S-94S.)

1-Feb-05 8:45 AM

Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: A prospective, randomized study of one-year outcomes

Dr. Gary Gartsman — Tue, 31 Aug 2004 14:00:00 GMT

All other aspects of the surgical and postsurgical treatment were identical. We included patients with full-thickness tears limited to the supraspinatus tendon and a type 2 acromion. We excluded patients with prior surgery, those with larger tears involving two or more tendons, those with a type 1 or 3 acromion, those with workers’ compensation claims, and those who had concomitant procedures (labral repair, acromioclavicular joint resection) There were 47 patients in group 1 and 46 in group 2. Minimum follow-up was 1 year (mean, 15.6 3.3 months). We recorded the American Shoulder and Elbow Surgeons (ASES) shoulder scores preoperatively and postoperatively. There was no statistical difference in postoperative ASES scores between group 1 (91.5 10.3) and group 2 (89.2 15.1) (P .392). The change in ASES score over time did not differ between the two groups (61.1 vs 60.2, P .363). In conclusion, within the parameters described above, arthroscopic subacromial decompression does not appear to change the functional outcome after arthroscopic repair of the rotator cuff. (J Shoulder Elbow Surg 2004;13:424–6.)... (download full pdf article)

31-Aug-04 9:00 AM

Outcome Expectancies, Functional Outcomes, and Expectancy Fulfillment for Patients With Shoulder Problems

Wed, 04 Feb 2004 14:00:00 GMT

Methods: Patients (n 199) treated for shoulder problems at one orthopedic surgeon's office completed a baseline survey comprised of measures of outcome expectancies, shoulder function, health status, and demographics. At 1 month, 2 months, and 3 months, patients completed a mailed follow-up survey comprised of all baseline measures except demographic variables. At 3 months, a measure of expectancy fulfillment was added. A general linear modeling approach was used to assess the significance and effect size of 1) outcome expectancies on changes in shoulder function; and (2) outcome expectancies, shoulder function changes, and their interaction on perceptions of expectancy fulfillment. Results: Outcome expectancies significantly predicted changes in shoulder function and accounted for 10% of the variance in functional improvement. The improvement difference between patients with high expectancies compared with those with low expectancies was clinically relevant (4.57 points), as it was greater than the minimal clinically important difference (3.02 points). Outcome... (download full pdf article)

4-Feb-04 8:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2004)

Sun, 04 Jan 2004 15:00:00 GMT

Shoulder Rotator Cuff Basic Science Kelly compared the muscle-firing patterns in both symptomatic and asymptomatic patients who had two-tendon rotator cuff tears. Asymptomatic patients demonstrated increased firing of the intact subscapularis, whereas symptomatic patients continued to rely on torn rotator cuff tendons and scapular muscle substitution, resulting in compromised function. Kalandiak compared the in vivo kinematics of painless shoulders that had massive rotator cuff tears with those of normal shoulders with use of cinefluoroscopy. Only one patient demonstrated normal "ball and socket" kinematics; most demonstrated increased scapulothoracic motion during initial forward elevation. The mean active forward elevation was 129° when performed against no resistance but only 86° when performed against resistance. Rubino studied the progression of fatty infiltration by harvesting the supraspinatus muscle bilaterally at various timeintervals following unilateral surgical detachment of that tendon in a rabbit model. A consistent decrease in muscle weight was noted when detached specimens were compared with intact specimens.

Fatty infiltration was evident as early as six weeks after detachment and increased over time as a percentage of muscle volume (p = 0.002). Schlegel compared the modified Mason-Allen stitch with a horizontal mattress stitch in a sheep model to determine the effect on tendon-healing to bone. Subsequent biomechanical and histological testing demonstrated similar stiffness and loads to failure and normal-appearing tendon-tobone insertions. St. Pierre compared three different suturerepair techniques in a human cadaver model. The modified Mason-Allen and double-mattress techniques had higher ultimate loads to failure than did the single-horizontal-mattress technique when used with suture anchors. Boswell compared bioabsorbable screw-and-washer fixation with various suture-anchor repairs for rotator cuff fixation in a bovine model. The study demonstrated that 5-mm gap formation occurred later in association with the bioabsorbable screw-and-washer method than it did in association with any suture-anchor repair method, including a technique involving the use of single-loaded anchors with modified Mason-Allen sutures. Tasto used a bovine model to demonstrate that the depth of insertion of suture anchors influences their ultimate load strength and mode of failure. Countersunk anchors had greater ultimate load strength to failure than did anchors that were placed proud or level with the cortical surface.

In addition, no sutures in the countersunk-sutureanchor group failed during cyclical loading. Hawkins compared the accuracy of physical examination alone with that of physical examination coupled with magnetic resonance imaging for the diagnosis of rotator cuff tears. Prospective data were collected on 299 patients who underwent rotator cuff surgery, 148 of whom had ancillary magnetic resonance imaging data. The positive predictive values for the diagnosis of a full-thickness tear on physical... (download full pdf article)

4-Jan-04 9:00 AM

Specialty Update: What’s New in Shoulder and Elbow Surgery (2003)

Fri, 03 Jan 2003 15:00:00 GMT

Shoulder Rotator Cuff Basic Science Several studies have employed sophisticated animal models to investigate rotator cuff repair and healing. Coleman reported on a chronic rotator cuff injury and repair model involving sheep. Infraspinatus contractile forces and histological findings were evaluated at various times following either immediate or delayed tendon repair. Longer delays to repair led to greater decreases in force and more modest recovery following repair. Muscle biopsies confirmed progressive fatty infiltration that was partially reversed after tendon repair in the group with a six-week delay before repair but not in the group with an eighteen-week delay before repair. This model has important implications regarding the recovery of strength following the repair of chronic rotator cuff tears. Rodeo presented a study on growth factor-enhanced rotator cuff tendon-bone healing in a sheep model.

Histological analysis demonstrated greater new-bone and fibrovascular tissue formation in the treated animals. A substantial increase in attachment strength was noted in the treated animals at twelve weeks. The study demonstrates the ability of a growth factor to influence changes at the tendon-bone interface. MacGilivray evaluated the augmentation of rotator cuff repairs with a bioabsorbable scaffold in a goat model. Biomechanical testing showed no significant improvement in load to failure when a tendon defect was covered with a polylactic acid patch. The inability of the patch to enhance repair strength was thought to result from shielding of the patch from direct load by the repair. Halder used a cadaveric model to identify the characteristics of rotator cuff tears that were responsible for loss of strength. Detachment of one-third and two-thirds of the supraspinatus tendon affected force transmission by the rotator cuff only slightly, while detachment of the whole tendon resulted in greater reductions in force transmission.

Simulated muscle retraction also led to reductions in force transmission. Side-to-side repair of defects involving one third and two thirds of the tendon restored near-normal force transmission. These results echoed the clinical observation that patients with small rotator cuff tears may present without a loss of strength. Furthermore, side-to-side repair of otherwise irreparable defects may help to restore the integrity of the rotator cable. Chronic rotator cuff tears are often accompanied by muscle atrophy, fatty infiltration, and retraction, which may decrease overall muscle volume. Apreleva determined the reliability and validity of magnetic resonance imaging in the assessment of rotator cuff muscle volume in a study of cadaveric shoulders. Magnetic resonance imaging scans were made and the supraspinatus, infraspinatus-teres minor, and subscapularis muscle volumes were then computed with use of three-dimensional image-analysis software. Muscle volumes were confirmed with use of water displacement after dissection. The muscle volumes measured with use of the two methods were found to correlate highly, suggesting that magnetic resonance imaging may hold promise for the preoperative as... (download full pdf article)

3-Jan-03 9:00 AM

A Randomized Controlled Trial Comparing 2 Instructional Approaches to Home Exercise Instruction Following Arthroscopic Full-Thickness Rotator Cuff Repair Surgery

Sat, 09 Nov 2002 22:00:00 GMT

Background: Advances in orthopedic surgery and rehabilitation have placed increased emphasis on home exercise programs. Therefore, assessing the effectiveness of different methods of home program instruction is important. Methods and Measures: Patients who consented to undergo surgical repair were randomly assigned to either a videotape or personal instruction group. A self-reported compliance log categorized subjects as fully compliant, partially compliant, or noncompliant. The Shoulder Pain and Disability Index and the University of Pennsylvania Shoulder Scale scores were obtained from subjects preoperatively and at 12, 24, and 52 weeks postoperatively. The null hypotheses that neither group would have better outcomes as measured by 2 shoulder outcome scales at any level of compliance over 4 levels of time, were assessed by 2 separate 2×3×4 multiple analyses of variances (MANOVAs), 1 for each outcome measure ( = 0.025). Results: Neither MANOVA was significant and the null hypotheses were not rejected. The main effect of time (number of weeks postsurgery) was significant across all time intervals for both outcome measures (P0.0005). Conclusions: With a therapist available for questions, patients who utilized the videotape method for their home program instruction had self-reported outcomes equal to patients instructed in their home program personally by a physical therapist. Self-reported compliance with the rehabilitation program had little effect on the outcomes. J Orthop Sports Phys Ther 2002;32:548-559... (download full pdf article)

9-Nov-02 4:00 PM

Reliability by Surgical Status of Self-Reported Outcomes in Patients Who Have Shoulder Pathologies

Mon, 15 Jul 2002 14:00:00 GMT

Methods and Measures: A questionnaire containing self-report sections of 4 shoulder scales was administered to study participants twice with 1 week between administrations. The outcome measures examined were the: (1) University of California at Los Angeles (UCLA) Shoulder Score; (2) Constant-Murley Scale (CMS); (3) American Shoulder and Elbow Society (ASES) Shoulder Index; and (4) Shoulder Pain and Disability Index (SPADI). Intraclass correlation coefficients (ICC) were calculated to estimate the test-retest reliability of each of the scales and subscales. The interitem consistencies of the multi-item subscales were assessed using Cronbach's alpha. The effect of surgical status on shoulder outcome scale reliability was evaluated using a general linear models approach. Results: The interitem consistency estimates for the multi-item scales were high with both operative and nonoperative participants (0.88 to 0.96). With the exception of the satisfaction subscale of the UCLA Shoulder Score for the nonsurgical group, the estimated intraclass coefficients ranged from 0.51 to 0.91. The prediction of UCLA-satisfaction and ASES-disability, pain, and total retest scores was improved with the addition of surgical status into a regression model... (download full pdf article)

15-Jul-02 9:00 AM

Development and Psychometric Evaluation of the Flexilevel Scale of Shoulder Function

Sun, 20 Jan 2002 22:00:00 GMT

A more efficient approach is to use modern psychometric methods to construct an adaptive scale in which patients respond only to items that are targeted at their level of shoulder function. OBJECTIVES. We developed a Flexilevel Scale of Shoulder Function (FLEX-SF). This scale includes three testlets that target low, medium, and high shoulder function. Scores on the testlets were equated to a common mathematical metric. DESIGN AND SUBJECTS. We developed an initial pool of 68 items. This pool was administered to 400 patients, and responses were calibrated using a rating scale model. Subsets of items were identified for an easy, medium difficulty, and hard testlet. Properties of the scale were evaluated in a 3-month longitudinal study of 200 shoulder patients. RESULTS. The FLEX-SF exhibited high reliability at both the scale level (intraclass correlation coefficient [3,1] 0.90) and specific trait levels. The validity of the FLEX-SF was supported by its internal and external responsiveness (Guyatt responsiveness index 1.12) and the pattern of its associations with other health status measures. CONCLUSIONS. The FLEX-SF can be used as a primary endpoint in clinical trials even when there are relatively few people in each treatment group. The scale also has excellent properties for use in clinical settings tracking individual changes over time.... (download full pdf article)

20-Jan-02 4:00 PM

Specialty Update What’s New in Shoulder and Elbow Surgery (2002)

Fri, 04 Jan 2002 15:30:00 GMT

Shoulder Rotator Cuff Basic Science Uhthoff presented evidence that, in a rabbit model, the fatty infiltration that occurs in muscle after a rotator cuff tear is not reversed by a successful rotator cuff repair. This observation may prompt surgeons to reconsider rotator cuff repair for patients with this finding on magnetic resonance imaging. Altchek reported that a subscapularis tear increases external rotation and posterior translation and that this effect is not increased by the addition of an anterior capsular tear.

Impingement: The debate continues regarding the role of acromioplasty during the operative treatment of rotator cuff tears or impingement. Nirschl and Matsen advocated avoiding acromioplasty because of potential destabilization of the glenohumeral joint, harm to the deltoid origin, loss of the acromial lever, postoperative hemorrhage and adhesion, increased postoperative pain, and occasional acromial fracture.

Partial-Thickness: Tears Warren found that arthroscopic subacromial decompression was an effective treatment for partial-thickness tears of the rotator cuff followed for a mean of fifty-three months. However, the failure rate for partial-thickness tears of the bursal surface of the rotator cuff was 38%. This finding may suggest that a more aggressive approach to tears of the bursal surface is needed.

Full-Thickness: Tears Miniaci arthroscopically repaired mobile full-thickness tears of the rotator cuff with a bioabsorbable tack and found the procedure easier to perform than a repair with knot-tying techniques. His results were equivalent to those of previously reported arthroscopic repairs. Hawkins found that good results were possible when both a Bankart lesion and a rotator cuff tear were repaired at the same operation. Bigliani found superior results when a dislocated or subluxated biceps tendon was left in situ during the repair of a full-thickness rotator cuff tear. Relocation and stabilization of the tendon had the highest percentage of unsatisfactory results. Savoie found 88% excellent-to-good results with the arthroscopic treatment of large (3 to 5-cm) rotator cuff tears.

Subscapularis: Tears Burkhart reported successful results with arthroscopic treatment of complete subscapularis tears. He also studied the subscapularis attachment footprint and found that the superior portion was the most substantial... (download full pdf article)

4-Jan-02 9:30 AM

The Measurement Level and Trait-Specific Reliability of 4 Scales of Shoulder Functioning: An Empiric Investigation

Fri, 23 Nov 2001 23:00:00 GMT

Setting: Office of private practice orthopedic surgeon with practice limited to the shoulder. Participants: One-hundred ninety-two shoulder patients. Interventions: Participants completed the American Shoulder and Elbow Surgeons Patient Self-Evaluation Form (function subscale, modified), the disability subscale of the Shoulder Pain and Disability Index, the Simple Shoulder Test, and the function subscale of the University of Pennsylvania Shoulder Scale. Main Outcome Measures: The patients' responses were calibrated by using a partial credit model. We calculated standard errors of measurement and plotted the 95% confidence interval for different levels of shoulder functioning. We compared scales' raw scores with their equal interval measures obtained in the Rasch calibration. Results: The scales did not measure all levels of shoulder functioning with equal precision, suggesting that commonly used reliability estimates misrepresent scale precision in certain subpopulations. Conclusions: The scales' raw scores were found to be not of equal interval, calling into question the scoring systems recommended by the developers of these scales and the use of the scores in some statistical procedures. Key Words: Rehabilitation; Shoulder. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation... (download full pdf article)

23-Nov-01 5:00 PM

Arthroscopic Treatment of Multidirectional Glenohumeral Instability: 2- to 5-Year Follow-up

Fri, 02 Mar 2001 23:00:00 GMT

The average age at the time of operation was 30 years (range, 15 to 56 years). The average interval from operation to final evaluation was 35 months (range 26 to 67 months). The American Shoulder and Elbow Surgeons (ASES) Shoulder Index, Constant, Rowe, and UCLA scores were recorded preoperatively and at final evaluation. Results: Preoperatively, no patients were rated overall as good to excellent according to the Rowe scale; at final follow-up 94% (44 of 47 patients) were rated as good to excellent. One patient was considered a failure of the index operation due to persistent instability and underwent a second operative procedure. One patient noted a loss of strength during sports, and 2 patients had pain that limited their throwing ability. The ASES Shoulder Index improved to 94.7 from 45.4 (P 5 .001). The absolute Constant score improved to 91.7 from 60 (P 5 .001). The Rowe score improved to 93.7 from 14.2 (P 5 .001). The UCLA total score improved to 33.1 from 17.4 (P 5 .001). Average passive external rotation at 90° abduction measured 88.2°. Twenty-two of 26 patients (85%) returned to their desired levels of sports following the operations. Conclusions: Patients with multidirectional glenohumeral instability have multiple lesions within the shoulder and the surgeon must individualize the operative treatment. Arthroscopic surgery produced successful results in 44 of 47 patients. Key Words: Arthroscopic multidirectional glenohumeral instability... (download full pdf article)

2-Mar-01 5:00 PM

Arthroscopic treatment of bidirectional glenohumeral instability: Two- to five-year follow-up

Mon, 29 Jan 2001 22:15:00 GMT

The American Shoulder and Elbow Surgeons' Shoulder Index and the Constant, Rowe, and University of California at Los Angeles scores were recorded preoperatively and at final evaluation. Preoperatively, no patients rated good to excellent overall (according to the Rowe Scale), whereas at final follow-up 91% (49 of 54 patients) rated good to excellent. The American Shoulder and Elbow Surgeons' Shoulder Index improved to 94 from 45.5 (P = .001). The absolute Constant score improved to 92 from 57 (P = .001). The Rowe score improved to 92 from 20.3 (P = .001). The University of California at Los Angeles total score improved to 32.7 from 18.6 (P = .001). Average passive external rotation at 90 degrees of abduction measured 89.5 degrees. Forty patients returned to sports, but 10 (25%) of these patients participated at a lower level. For each of 4 patients, the index operation was considered a failure because of persistent instability; 1 patient underwent a second operative procedure. Thermal capsulorraphy (with a Holmium laser) of the glenohumeral ligaments was used to supplement suture repair, but in no shoulder was thermal capsulorraphy used as the only treatment. The etiology of bidirectional glenohumeral instability is complex, and operative correction of multiple intraarticular lesions was necessary. (J Shoulder Elbow Surg 2001;10:28-36.)... (download full pdf article)

29-Jan-01 4:15 PM

Specialty Update: What’s New in Shoulder Surgery (2001)

Wed, 03 Jan 2001 15:00:00 GMT

Arthroplasty Developments in the Design of Prosthetic Shoulder Arthroplasty Humerus Recent developments in the design of humeral head replacements have focused on enhancing the ability of the prosthesis to replicate normal anatomic relationships. These third-generation modular designs provide both variable neckshaft angles and multiple head offsets in three dimensions. M.L. Pearl performed a three-dimensional analysis in cadavers and demonstrated that the variable geometry of the third-generation prosthetic system allowed for significantly better replication of the three-dimensional position of the center of rotation and the articulation point with preservation of the articular surface arc compared with the secondgeneration prosthetic systems. The most troublesome feature of the second-generation modular systems was the gap that was created by the prosthetic collar and the Morse taper between the prosthetic head and the humeral osteotomy site. Some newer designs have eliminated this gap. J.J.P. Warner compared hemiarthroplasty with use of a second-generation design with hemiarthroplasty with use of a third-generation design. The head-to-tuberosity height was greater than that on the contralateral, normal side in patients who underwent hemiarthroplasty with a second-generation prosthesis. Moreover, these shoulders had a decreased radius of curvature of the articular surface and an increased lateral offset compared with these parameters in the uninvolved shoulder. In contrast, all radiographic parameters were reconstructed to 2 mm of normal or less in the patients who underwent hemiarthroplasty with a more adaptable design. Although these studies raise concerns about the long-term survival of the prosthesis, currently there is no evidence from any study that third-generation implants produce superior clinical outcomes, to our knowledge. In fact, R.J. Friedman found no correlation between various radiographic measurements and the functional score following total shoulder arthroplasty. He concluded that good surgical technique, including careful soft-tissue balancing, appears to compensate for changes in the anatomic relationships.

Glenoid Another area of controversy, regarding the glenoid component, concerns the advantage of a keeled implant over a pegged... (download full pdf article)

3-Jan-01 9:00 AM

Comparison of the University of California–Los Angeles Shoulder Scale and the Simple Shoulder Test With the Shoulder Pain and Disability Index: Single-Administration Reliability and Validity

Sat, 05 Aug 2000 21:00:00 GMT

Methods. Cronbach alpha values and standard errors of measurement (SEM) were calculated for each of the multi-item subscales. Validity was examined through calculation of correlation coefficients among the 3 scales. Factor analysis was completed to assess the underlying constructs of the SPADI and the SST. Results. Cronbach alpha values ranged from .85 to .95. The SEM values for the multi-item scales ranged from 4.75 to 11.65. Evidence for validity to reflect function was indicated by the correlation between the SST and the SPADI disability subscale. The factor analysis of the SPADI revealed loading on 1 factor, whereas the SST loaded on 2 factors. Conclusion and Discussion. All scales demonstrated good internal consistency, suggesting that all items for each scale measure the same construct. However, the SEMs for all scales were high. Factor loading was inconsistent, suggesting that patients may not distinguish between pain and function. [Roddey TS, Olson SL, Cook KF, et al. Comparison of the University of California-Los Angeles Shoulder Scale and the Simple Shoulder Test with the Shoulder Pain and Disability Index: single-administration reliability and validity. Phys Ther. 2000;80:759 -768.]... (download full pdf article)

5-Aug-00 4:00 PM

Arthroscopic Biceps Tenodesis: Operative Technique

Fri, 28 Jul 2000 21:00:00 GMT

Biceps tendinitis and partial tears are occasionally isolated causes of significant shoulder pain but are more commonly found in conjunction with subacromial impingement and rotator cuff tears.1-6 Although much has been described about arthroscopic subacromial decompression and rotator cuff repair, arthroscopic biceps tenodesis is rarely mentioned. Our most common indication for tenodesis is a partial-thickness tear greater than 50% diameter and the next most common indication is medial subluxation of the tendon in association with a rotator cuff tear. We present our technique for arthroscopic tenodesis of the long head of the biceps brachii... (download full pdf article)

28-Jul-00 4:00 PM