Does reaching the back reflect the actual internal rotation of the shoulder?

Improved joint function when reaching behind the back is associated with patient reported outcomes in individuals with rotator cuff tears following exercise therapy

BACKGROUND

Reaching behind the back is painful for individuals with rotator cuff tears. The objectives of the study were to determine changes in glenohumeral kinematics when reaching behind the back, passive range of motion (RoM), patient reported outcomes and the relationships between kinematics and patient reported outcomes following exercise therapy.

METHODS

Eighty-four individuals with symptomatic isolated supraspinatus tears were recruited for this prospective observational study. Glenohumeral kinematics were measured using biplane radiography during a reaching behind the back movement. Passive glenohumeral internal rotation and patient reported outcome measures were collected. Depending on data normality, appropriate tests were utilized to determine changes in variables. Spearman's correlations were utilized for associations, and Stuart-Maxwell tests for changes in distributions.

FINDINGS

Maximum active glenohumeral internal rotation increased by 3.2° (P = 0.001), contact path length decreased by 5.5% glenoid size (P = 0.022), passive glenohumeral internal rotation RoM increased by 4.9° (P = 0.001), and Western Ontario Rotator Cuff Index and American Shoulder and Elbow Surgeons scores increased by 29.8 and 21.1 (P = 0.001), respectively. Changes in Western Ontario Rotator Cuff Index scores positively associated with changes in maximum active glenohumeral internal rotation and negatively associated with changes in contact path lengths (P = 0.008 and P = 0.006, respectively).

INTERPRETATION

The reaching behind the back movement was useful in elucidating in-vivo mechanistic changes associated with patient reported outcomes. Glenohumeral joint function and patient reported outcomes improved, where changes in Western Ontario Rotator Cuff Index scores were associated with kinematics. These findings inform clinicians of functional changes following exercise therapy and new targetable treatment factors.

Incidence and risk factors for early postoperative stiffness after arthroscopic rotator cuff repair in patients without preoperative stiffness

The purpose of this study was to investigate the incidence and risk factors of early postoperative stiffness in patients without preoperative stiffness undergoing isolated arthroscopic rotator cuff repair (ARCR). Two hundred seventy-four patients who underwent primary ARCR were included. At 3 months after surgery, criteria for shoulder stiffness was set as follows: (1) passive forward flexion < 120˚, or (2) external rotation at side < 30˚. Patients with preoperative stiffness or who underwent additional procedures were excluded. Patients-related, radiological (muscle atrophy and fatty infiltration), and intraoperative (tear size, repair techniques, number of anchors used, and synovitis scores) risk factors were analyzed. Univariate and multivariate analyses were used to identify risk factors for postoperative stiffness. Thirty-nine of 274 patients (14.2%) who underwent ARCR developed postoperative stiffness. Univariate analyses revealed that early postoperative stiffness was significantly associated with diabetes mellitus (p = 0.030). However, radiological and intraoperative factors did not affect postoperative shoulder stiffness (all p > 0.05). Multivariate analyses revealed early postoperative stiffness was significantly associated with diabetes mellitus and timing of rehabilitation (p = 0.024, p = 0.033, respectively). The overall incidence of early postoperative stiffness following isolated ARCR in patients without preoperative stiffness was 14.2%. Diabetes mellitus and timing of rehabilitation were independent risk factors for early postoperative stiffness following ARCR.

Thumb to spinous process is a false metric for glenohumeral internal rotation

Background

The measurement of internal rotation by noting the maximal vertebral level reached by the patient's thumb behind their back is an established physical examination technique, as outlined in the American Shoulder and Elbow Surgeons Shoulder Assessment Form.7 The purpose of the present study is to correlate real-time glenohumeral internal rotation with thumb to spinous process movement to determine the accuracy of the technique.

Methods

Healthy volunteers with no previous history of shoulder injury or symptoms were recruited from the local medical school population. Ultrasound probe was placed over the anterolateral shoulder, and relevant anatomy was identified. Internal rotation was evaluated by measuring displacement of the peak of the medial aspect of the bicipital groove relative to the anterior glenoid rim with the arm held in defined positions of progressively increasing internal rotation. The difference in displacement between arm positions was calculated and recorded.

Results

A total of 20 participants (11 women/9 men, aged 22-42 years) were recruited for measurement. A mixed-model repeated-measures analysis of variance was used. The most significant differences in displacement, and therefore internal rotation, were observed between the neutral and anterior superior iliac spine (0.21 ± 0.39 mm, P= .0269) and between the anterior superior iliac spine and peak iliac crest (0.26 ± 0.44 mm, P= .0163). After the peak iliac crest, there was no further statistically significant change in rotation.

Conclusion

The present study suggests that most glenohumeral internal rotation occurs before reaching the arm behind the back. Although not directly studied, this supports the notion that the maximal vertebral level reached involves an interplay of various joint motions. While the thumb to spinous process maneuver remains a functional evaluation, our results suggest a different examination technique be used to more accurately test glenohumeral internal rotation.

How internal rotation is measured in reverse total shoulder arthroplasty: a systematic review of the literature

Background

Reverse total shoulder arthroplasty (RTSA) can lead to limited postoperative internal rotation (IR). We assessed how IR is measured and reported in the RTSA literature and examined the relationships between these measures and patient-reported ability to perform activities of daily living.

Methods

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for articles published in English from January 2000 through September 2018 that reported clinical outcomes after RTSA (minimum 12-month follow-up). We included studies reporting IR range of motion (ROM) and/or patient-reported functional outcomes related to IR. We identified 255 studies, 35% of which were excluded because they reported no IR outcome measures, leaving 165 studies for analysis.

Results

Studies reported 3 methods of measuring IR ROM: (1) vertebral level (VL) method (ie, the most proximal VL reached by the extended thumb with the arm behind the back), (2) degrees of IR with the arm abducted to 90°, and (3) degrees of IR with the arm in a neutral position. The VL measurement was reported in 89% of studies, but the methods of reporting this measure varied. Only 9% of studies reported functional outcomes related to IR. No study correlated clinical measurements of IR ROM with functional outcomes.

Conclusions

Measures and reporting of shoulder IR after RTSA varied widely. This variability makes it difficult to assess associations between postoperativce IR limitation and functional abilities. Standardization of IR measures and reporting is needed to allow meta-analysis of data related to this important outcome.

An Intra-articular Steroid Injection at 6 Weeks Postoperatively for Shoulder Stiffness After Arthroscopic Rotator Cuff Repair Does Not Affect Repair Integrity

BACKGROUND

Shoulder stiffness is a common complication after arthroscopic rotator cuff repair. However, there is no consensus on the treatment of stiffness after repair. Although one treatment option is an intra-articular steroid injection, it may negatively affect repair integrity, and there is a paucity of literature regarding the timing of intra-articular injections for stiffness after repair and its effect on repair integrity.

PURPOSE

To compare repair integrity and clinical outcomes after an intra-articular steroid injection administered at 6 weeks and 12 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 (6-week group) and 12 weeks (12-week group) postoperatively. The control group had rotator cuff tears but neither stiffness nor injections. Shoulder range of motion (ROM), the Korean Shoulder Scoring System (KSS) score, and the University of California, Los Angeles (UCLA) shoulder score were assessed preoperatively with a minimum of 2-year follow-up. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively.

RESULTS

Seventy-four of 209 patients (35.4%) who underwent arthroscopic rotator cuff repair developed stiffness. There were no significant differences in retear rates among the 6-week (5.7%, 2/35 patients), 12-week (10.3%, 4/39 patients), and control groups (14.1%, 19/135 patients) ( P = .374). Both the 6- and 12-week groups showed significant improvement in ROM (both P < .001), KSS scores (both P < .001), and UCLA scores (both P < .001) at the final follow-up. The 6-week group showed significantly better ROM ( P < .001), KSS scores ( P < .001), and UCLA scores ( P < .001) than the 12-week group at 3 months postoperatively. However, both the 6- and 12-week groups showed significantly lower KSS (81.3 ± 12.0 [ P = .004] and 83.4 ± 8.6 [ P = .035], respectively) and UCLA (29.3 ± 4.6 [ P = .006] and 30.0 ± 3.3 [ P = .042], respectively) scores than the control group (90.4 ± 13.6 and 32.3 ± 4.7, respectively) at the last follow-up.

CONCLUSION

An intra-articular steroid injection administered at 6 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair may be effective for reducing patients' pain and improving shoulder ROM at 3 months postoperatively without compromising repair integrity.

Can patients manage toileting after reverse total shoulder arthroplasty? A systematic review

PURPOSE

A major concern for patients undergoing reverse total shoulder arthroplasty (RTSA) is managing toileting after surgery. The goals of this systematic review of RTSA studies were to determine the following: (1) the percentage of patients who can manage toileting, (2) their degree of difficulty with toileting, and (3) the percentage of patients who can manage toileting after bilateral versus unilateral RTSA.

METHODS

Medline, EMBASE, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched for studies reporting the ability to manage toileting after RTSA. Six studies with at least 12 months of follow-up were included, yielding 183 patients (105 unilateral RTSA, 78 bilateral RTSA). We pooled patient data and calculated the weighted mean proportion of patients able to manage toileting, those who reported difficulty, and those able to manage toileting after unilateral versus bilateral RTSA. Statistical significance was set at P < 0.05.

RESULTS

Most patients (92%; 95% confidence interval, 87-95%) were able to manage toileting after RTSA. Some degree of difficulty with toileting was reported for 20% of all shoulders. Almost all patients with bilateral RTSA were able to manage toileting with at least one arm (weighted mean proportion 97%; 95% confidence interval, 88-99%). There was no significant difference in the proportion of patients able to manage toileting after unilateral versus bilateral RTSA (P = 0.08). Only 3% of all papers published on the clinical results of RTSA by June 2017 reported upon toileting after the procedure.

CONCLUSIONS

With the available evidence, most patients were able to manage toileting after RTSA, although one-fifth reported some degree of difficulty. Ability to manage toileting was similar after unilateral versus bilateral RTSA. In the future, this variable should be a standard question after shoulder arthroplasty.

LEVEL OF EVIDENCE

IV.

Validity of an Alternate Hand Behind Back Shoulder Range of Motion Measurement in Patients With Shoulder Pain and Movement Dysfunction

OBJECTIVES

The purpose of this study was to determine the criterion-related validity of a novel method of measuring hand behind back (HBB) shoulder range of motion (ROM) for evaluating pain and disability in people with shoulder pain and movement impairment.

METHODS

This cross-sectional study design evaluated shoulder ROM, pain, fear-avoidance beliefs, and disability in 60 people (aged 35-70 years, 31 male) with chronic unilateral shoulder dysfunction (mean duration 15.73 weeks). Shoulder HBB ROM was measured with a bubble inclinometer in a manner that did not require the patient to disrobe. Correlations were sought between HBB ROM and other shoulder movements, as well as scores recorded on the Shoulder Pain and Disability Index (SPADI), visual analogue scale for pain, Fear Avoidance Beliefs Questionnaire (FABQ), and duration of symptoms.

RESULTS

Restriction of HBB movement was significantly correlated with SPADI total disability score (r = 0.39, P < .01), flexion ROM (r = 0.30, P < .05), abduction ROM (r = 0.39, P < .01), and external rotation ROM (r = 0.60, P < .01). Other variables were not significantly correlated with HBB ROM. Multiple linear regression analysis indicated that the variance in HBB ROM was explained by the SPADI disability subscore (P = .01) but not by visual analogue scale score (P = .05), FABQ score (P = .65), or duration of symptoms (P = .73). The FABQ score was not explained by limitation in HBB ROM and shoulder movements.

CONCLUSION

These findings suggest that this novel method of measuring HBB ROM could be used as a functional outcome measure in the evaluation of patients with shoulder disorders. This method could be considered as an additional or alternative where there are challenges in measuring HBB because of restrictions in undressing a patient, such as for cultural reasons.

Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: a comparative study

[Purpose] This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. [Subjects and Methods] Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. Pain was measured with a visual analog scale, abduction and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. [Results] Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. [Conclusion] This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.

Agreement between patient self-assessment and physician assessment of shoulder range of motion

BACKGROUND

Shoulder outcome scores that include range of motion (ROM) and apprehension signs are limited by the need for direct involvement of the physician. Patient-reported outcome measures are patient centered and self-administered, and they can help physicians track the patient's progress between office visits and for long-term follow-up once the patient has been discharged.

METHODS

Thirty consecutive patients completed a form before their 6-month follow-up after surgery on the labrum or capsule as a result of instability or pain related to instability. The form included bilateral ROM, apprehension, and instability episodes. The same parameters were measured by the physician during the visit. The patient's and physician's responses were compared. The primary outcome was the percentage agreement with exact and approximate agreement.

RESULTS

Exact agreement was moderate for forward elevation at 56.6%; fair for abduction and external rotation at 90° at 24.5% and 34%, respectively; and poor for internal rotation at 90° and external rotation with the arm at the side at 2.6% and 12%, respectively. Approximate agreement within a range of positive or negative 20° range was very good for forward elevation (94%), abduction (92%), and external rotation at 90° (87%); moderate for external rotation with the arm at the side; and fair for internal rotation at 90°. There was 70% agreement regarding apprehension, 93% regarding subluxation events, and 100% regarding redislocation events.

CONCLUSION

Some measures of shoulder ROM showed a moderate to high level of agreement between patient-reported measurements and the physician's measurements. This method for short- and long-term follow-up could potentially replace routine clinic visits.

Passive range of motion in patients with adhesive shoulder capsulitis, an intertester reliability study over eight weeks

BACKGROUND

Measuring range of motion (ROM) in the shoulder joint is important for the diagnosis and monitoring of change over time. To what degree passive ROM can be trusted as a reliable outcome measure was examined as part of an on-going randomized controlled trial for patients with shoulder capsulitis. The aim of this study was to examine intertester reliability of passive ROM in the shoulder joint over a period of eight weeks in patients with adhesive capsulitis stage II.

METHODS

Fifty patients with a clinical diagnosis of adhesive shoulder capsulitis were examined by two independent testers. A predefined protocol was used for measuring passive range of motion with an inclinometer, a plurimeter, in both affected and non-affected shoulders three times; at the start of the study and after 4 and 8 weeks.

RESULTS

Very good to excellent intertester agreements were found for most parameters for the affected arm at all three test points. The intraclass correlation coefficient (ICC 2.1) values ranged from 0.76 to 0.98, i.e. from very reliable to excellent. The measurement error was in general small for the affected arm (5°-7°). ICCs were slightly lower for the non-affected arm at 8 weeks, but with acceptable measurement errors.

CONCLUSIONS

Intertester reliability between two testers was very good at three visits over a time period of eight weeks using a plurimeter to measure passive range of motion in patients with adhesive shoulder capsulitis. This method can reliably determine passive range of motion in this patient population and be a reliable outcome measure.

Accuracy and reliability testing of two methods to measure internal rotation of the glenohumeral joint

BACKGROUND

We compared accuracy and reliability of a traditional method of measurement (most cephalad vertebral spinous process that can be reached by a patient with the extended thumb) to estimates made with the shoulder in abduction to determine if there were differences between the two methods.

METHODS

Six physicians with fellowship training in sports medicine or shoulder surgery estimated measurements in 48 healthy volunteers. Three were randomly chosen to make estimates of both internal rotation measurements for each volunteer. An independent observer made objective measurements on lateral scoliosis films (spinous process method) or with a goniometer (abduction method). Examiners were blinded to objective measurements as well as to previous estimates.

RESULTS

Intraclass coefficients for interobserver reliability for the traditional method averaged 0.75, indicating good agreement among observers. The difference in vertebral level estimated by the examiner and the actual radiographic level averaged 1.8 levels. The intraclass coefficient for interobserver reliability for the abduction method averaged 0.81 for all examiners, indicating near-perfect agreement. Confidence intervals indicated that estimates were an average of 8° different from the objective goniometer measurements. Pearson correlation coefficients of intraobserver reliability for the abduction method averaged 0.94, indicating near-perfect agreement within observers. Confidence intervals demonstrated repeated estimates between 5° and 10° of the original.

CONCLUSIONS

Internal rotation estimates made with the shoulder abducted demonstrated interobserver reliability superior to that of spinous process estimates, and reproducibility was high. On the basis of this finding, we now take glenohumeral internal rotation measurements with the shoulder in abduction and use a goniometer to maximize accuracy and objectivity.

Effect of capsular release in the treatment of shoulder stiffness concomitant with rotator cuff repair: diabetes as a predisposing factor associated with treatment outcome

BACKGROUND

In spite of the high prevalence of shoulder stiffness during rotator cuff repair, optimal management remains unclear.

PURPOSE

To identify the effect of capsular release during rotator cuff repair on the outcomes of patients with both shoulder stiffness and a rotator cuff tear, based on subgroup analyses.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Forty-nine consecutive patients (mean age, 61.5 ± 8.3 years) were enrolled who underwent arthroscopic repair of a small- to large-sized full-thickness rotator cuff tear and manipulation for concomitant shoulder stiffness (passive forward flexion ≤120°, external rotation at the side ≤45°). The first 21 consecutive patients underwent manipulation alone to treat stiffness; the second 28 consecutive patients underwent capsular release with manipulation. Among the 49 patients, 25 showed severe stiffness (forward flexion ≤100°, external rotation at the side ≤30°; 11 in the first series and 14 in the second series), and 15 had diabetes mellitus (30.6%; 6 in the first series and 9 in the second series). Shoulder range of motion was measured 6 weeks, 3 months, 6 months, and 1 year postoperatively and at final follow-up visit. Simultaneously, functional outcome was evaluated by visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and muscle strength ratio (involved/uninvolved), and cuff integrity was assessed ultrasonographically at least 1 year postoperatively.

RESULTS

All range of motion measurements, functional scores, and muscle strength ratios significantly improved postoperatively regardless of the treatment method of stiffness. No outcome measure differed significantly between patients who did and did not undergo capsular release, regardless of the severity of stiffness, except for a temporary improvement in external rotation at side 3 months postoperatively in favor of those who underwent capsular release in cases with severe stiffness. Among patients with diabetes mellitus however, those who underwent capsular release showed greater improvement in forward flexion after 3 months and 1 year and in external rotation at the side for all time points (all P < .05), except for 6 weeks postoperatively; these patients also had a significantly higher final American Shoulder and Elbow Surgeons score (P = .03). Of 21 patients who underwent manipulation alone and of 28 who underwent capsular release and manipulation, 2 and 1 developed retears, respectively.

CONCLUSION

Both manipulation and capsular release with manipulation significantly improved range of motion and produced satisfactory functional outcomes. The outcomes did not differ between treatment methods for stiffness regardless of the severity of stiffness. In patients with diabetes mellitus however, capsular release at the time of rotator cuff repair seems to be beneficial, especially for external rotation and final postoperative function.

Defining functional shoulder range of motion for activities of daily living

INTRODUCTION

The range of motion (ROM) in the wrist and elbow required for daily activities has been reported to be less than the normal anatomic ROM. This functional ROM has not been defined for the shoulder. Many shoulder outcome assessment tools use specific functional tasks of daily living to score functional results of treatment. This study quantified the total shoulder ROM required to perform the functional tasks of the American Shoulder and Elbow Surgeon (ASES), Simple Shoulder Test (SST), and University of Pennsylvania (U-Penn) Shoulder Score (PSS).

MATERIALS AND METHODS

The FASTRAK electromagnetic tracking system (Colchester, VT, USA) was used to test 40 shoulders in 20 volunteers with no shoulder pathology found on physical examination. Three sensors were used: 1 each on the T3 spinous process, the scapular spine, and the arm over the distal humerus. Subjects performed each functional task of the ASES, SST, and PSS while flexion, extension, abduction, adduction, external rotation, and internal rotation were recorded.

RESULTS

Average shoulder motions required to perform the 10 functional tasks were flexion, 121° ± 6.7°; extension, 46° ± 5.3°; abduction, 128° ± 7.9°; cross-body adduction, 116° ± 9.1°; external rotation with the arm 90° abducted, 59° ± 10°; and internal rotation with the arm at the side, 102° ± 7.7°.

CONCLUSION

Although attaining full motion is a reasonable goal of all shoulder treatment, our results indicate that less ROM is required to perform the functional tasks used in common outcome tools.

ANALYSIS ON THE VARIATION OF MEDIAL ROTATION VALUES ACCORDING TO THE POSITION OF THE HUMERAL DIAPHYSIS

OBJECTIVE

To analyze the validity of measurements of medial rotation (MR) of the shoulder, using vertebral levels, according to the variation in the position of the humeral diaphysis, and to test the bi-goniometer as a new measuring instrument.

METHODS

140 shoulders (70 patients) were prospectively evaluated in cases presenting unilateral shoulder MR limitation. The vertebral level was evaluated by means of a visual scale and was correlated with the angle obtained according to the position of the humeral diaphysis, using the bi-goniometer developed with the Department of Mechanical Engineering of Mackenzie University.

RESULTS

The maximum vertebral level reached through MR on the unaffected side ranged from T3 to T12, and on the affected side, from T6 to the trochanter. Repositioning of the affected limb in MR according to the angular values on the normal side showed that 57.13% of the patients reached lower levels, between the sacrum, gluteus and trochanter. From analysis on the maximum vertebral level attained and the variation between the affected angle x (frontal plane: abduction and MR of the shoulder) and the unaffected angle x in MR, we observed that the greater the angle of the diaphyseal axis was, the lower the variation in the vertebral level attained was. From evaluating the linear correlation between the variables of difference in maximum vertebral level reached and variation in the affected angle y (extension and abduction of the shoulder) and the unaffected angle y in MR, we observed that there was no well-established linear relationship between these variables.

CONCLUSION

Measurement of MR using vertebral levels does not correspond to the real values, since it varies according to the positioning of the humeral diaphysis.

Analyzing glenohumeral torque-rotation response in vivo

BACKGROUND

Because the human shoulder has many degrees of freedom that allow redundant means of producing the same net humerothoracic motion, there are many impediments to objective, repeatable assessment of shoulder function in vivo. Devices designed to date have suffered from poor reliability. In this study we introduce a new device and methods to evaluate human shoulder kinematics and evaluate its reproducibility from subject to subject and from day to day.

METHODS

This was a controlled laboratory study. Using electromagnetic motion sensors to record the position and orientation of the thorax, scapula, and humerus, we quantified the kinematic response of twenty four normal shoulders in response to known internal-external torque application. A four-parameter logistic function was selected to characterize the strident features of the torque-rotation relationship.

FINDINGS

Our analysis in conjunction with the measurement technique described herein, allowed the passive glenohumeral internal-external range of motion to be differentiated from other motion components and was determined to within 9.6% of full scale over three repeated trials. Range of motion was the most reliable biomechanical outcome, more so than computed indices of glenohumeral flexibility and hysteresis. The exact profile of the torque-rotation response, and therefore the repeatability of the calculated outcomes, was unique from shoulder to shoulder.

INTERPRETATION

The development of the capacity for precise, non-invasive measurement of shoulder biomechanics over time is a requisite step towards optimizing treatment of shoulder injury and disease. Our current methods are superior to previous attempts at trying to non-invasively evaluate the biomechanics of the glenohumeral joint.

Moderate preoperative shoulder stiffness does not alter the clinical outcome of rotator cuff repair with arthroscopic release and manipulation

PURPOSE

The purpose of this study was to determine whether moderate preoperative shoulder stiffness affects the clinical outcome of rotator cuff repair, and to evaluate the serial change in range of motion (ROM), functional scores, pain, and satisfaction after rotator cuff repair.

METHODS

Rotator cuff repair was performed in 125 consecutive patients (127 shoulders). Thirty patients had concomitant moderate shoulder stiffness at the time of the repair. There were no statistical differences in sex ratio, age, the size and retraction of the tear, or the associated pathologies and repair procedure between the stiffness and nonstiffness groups. Arthroscopic capsular release and manipulation were added to the stiffness group, and the same rehabilitation protocol was applied according to the size of the tear. Clinical outcomes were evaluated using ROM, American Shoulder and Elbow Surgeon (ASES) score, Constant score, Simple Shoulder Test (SST), and short form 36. Pain and postoperative patient satisfaction were measured by a visual analog scale. All clinical parameters were prospectively recorded on the day before surgery, and at 3, 6, and 9 months postoperatively, and at their last follow-up visit.

RESULTS

Differences of ROM did not reach statistical significance after 6 months of operation. Other functional outcome instruments showed no statistical difference at any follow-up period. Postoperative cuff integrity after 1 year showed no statistical difference between 2 groups.

CONCLUSIONS

This study suggests that moderate preoperative shoulder stiffness does not affect clinical outcomes of rotator cuff repair if arthroscopic capsular release with manipulation is added to the index procedure. Arthroscopic capsular release with manipulation and a well programmed rehabilitation program can avoid any delay of surgery and limitation of motion after cuff repair in patients with concomitant moderate shoulder stiffness.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Assessment of shoulder range of motion: introduction of a novel patient self-assessment tool

PURPOSE

The goal of this study was to show that patient self-assessment of active shoulder range of motion (ROM) by use of a novel, diagram-based questionnaire is accurate when compared with physician-assessed shoulder ROM.

METHODS

We designed a diagram-based self-assessment tool that enables patients to determine their own active shoulder ROM in 3 planes of motion: forward elevation, external rotation, and internal rotation. This questionnaire was administered to 100 consecutive English-speaking patients presenting to a university-based orthopaedic surgery practice for evaluation of a shoulder-related complaint. After completion of the questionnaire, the patients' actual shoulder ROM in each plane was measured by a single blinded investigator using a standard 12-inch goniometer. Direct comparison of patient and physician ROM assessments was performed, and logistic regression analysis was then applied to identify those factors affecting the patients' ability to accurately complete the questionnaire.

RESULTS

Patients were able to properly quantify motion 85% of the time; they were able to qualitatively assess motion as impaired or unimpaired 93% of the time. Patients who were more likely to make errors in self-assessment were significantly older than the error-free subjects and expressed significantly more dissatisfaction with shoulder function. In addition, there was a weak inverse relation between education level and accurate self-assessment. Gender, exposure to physical therapy, and involvement in litigation or Workers' Compensation cases were not significantly correlated with accurate ROM self-assessment. Patients were significantly less accurate in their assessment of internal rotation than in their assessment of both forward elevation and external rotation.

CONCLUSIONS

Using a diagram-based questionnaire, patients are able to accurately assess their own active shoulder ROM.

Natural history of complex fractures of the proximal humerus using a three-dimensional classification system

We studied the nonoperative treatment of proximal humeral fractures in severe injuries usually treated surgically. The natural history of 63 patients was followed prospectively for 2 to 9 years (mean, 42 months) with a nonrandomized protocol. A 3-dimensional classification system based on computed tomography scans was used to categorize the fractures. Assessment was made for range of motion, function via a validated testing instrument (Simple Shoulder Test), analog pain score, avascular necrosis (AVN), and fracture union. Magnetic resonance imaging for early signs of AVN was done in 16 cases. After conservative treatment of complex fractures of the shoulder, motion is considerably compromised but pain is minimal and functional status is acceptable to most individuals in this predominantly older patient population. Status comparable to a successful surgical shoulder fusion is achieved in most cases-Nature's fusion. Contrary to common belief, AVN, even in severely displaced injuries, is rare. Future randomized studies based on a 3-dimensional classification need to be done to compare these natural history results with various types of surgical interventions.

Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study

BACKGROUND

The retear rate following rotator cuff repair is variable. Recent biomechanical studies have demonstrated that double-row tendon-to-bone fixation excels in initial fixation strength and footprint coverage compared with the single-row or transosseous fixation methods. This study was designed to report the repair integrity and clinical outcome following arthroscopic double-row rotator cuff repair.

METHODS

A consecutive series of 106 patients with full-thickness rotator cuff tears underwent arthroscopic double-row rotator cuff repair with use of suture anchors and were followed prospectively. Twenty patients lacked complete follow-up data or were lost to follow-up. The eighty-six study subjects included fifty-two men and thirty-four women, with an average age of 60.5 years. There were twenty-six small, thirty medium, twenty-two large, and eight massive tears. Clinical outcomes were evaluated at an average of thirty-one months. Repair integrity was estimated with use of magnetic resonance imaging, which was performed, on the average, fourteen months postoperatively, and was classified into five categories, with type I indicating sufficient thickness with homogeneously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity; and type V, the presence of a major discontinuity.

RESULTS

The average clinical outcome scores all improved significantly at the time of the final follow-up (p < 0.01). At a mean of fourteen months postoperatively, magnetic resonance imaging revealed that thirty-seven shoulders had a type-I repair; twenty-one, a type-II repair; thirteen, a type-III repair; eight, a type-IV repair; and seven, a type-V repair. The overall rate of retears (types IV and V) was 17%. The retear rate was 5% for small-to-medium tears, while it was 40% for large and massive tears. The shoulders with a type-V repair demonstrated significantly inferior functional outcome in terms of overall scores and strength compared with the other types of repairs (p < 0.01).

CONCLUSIONS

Arthroscopic double-row repair can result in improved repair integrity compared with open or miniopen repair methods. However, the retear rate for shoulders with large and massive tears remains higher than that for smaller tears, and shoulders with large repair defects (type V) demonstrate significantly inferior functional outcomes.