Longo, Umile Giuseppe; Rizzello, Giacomo; Berton, Alessandra; Maltese, Ludovica; Fumo, Caterina; Khan, Wasim S; Denaro, Vincenzo
Rotator cuff tear causes a high rate of morbidity. After surgical repair, the presence of a scar tissue reduces tendon biomechanical properties. Emerging strategies for enhancing tendon healing are growth factors, cytokines, gene therapy and tissue engineering. However their efficacy has to be proved. Growth factors help the process of tendon healing by aiding cells chemotaxis, differentiation and proliferation. Numerous growth factors, including the bone morphogenetic proteins and platelet-derived growth factor can be found during the early healing process of a rotator cuff repair. Growth factors are delivered to the repair site using tissue-engineered scaffolding, coated sutures, or dissolved in a fibrin sealant. Platelet-rich plasma is an autologous concentration of platelets and contains an high density of growth factors. There is some evidence that platelet-rich plasma may improve pain and recovery of function in a short time period, but it does not improve healing rates in rotator cuff. Thus the routine use of platelet-rich plasma in rotator cuff repair is not recommended. The addition of mesenchymal stem cells to scaffolds can lead to the production of a better quality healing tissue. Gene therapy is a gene transfer from a cell into another, in order to over-express the gene required. In this way, cultures of stem cells can over-express growth factors. Better understanding of the mechanisms of physiological tendon healing can promote the correct use of these new biological therapies for a better healing tissue.
Zumstein, M-A; Lädermann, A; Raniga, S; Schär, M-O
Despite advances in surgical reconstruction of chronic rotator cuff (RC) tears leading to improved clinical outcomes, failure rates of 13-94% have been reported. Reasons for this rather high failure rate include compromised healing at the bone-tendon interface, as well as the musculo-tendinous changes that occur after RC tears, namely retraction and muscle atrophy, as well as fatty infiltration. Significant research efforts have focused on gaining a better understanding of these pathological changes in order to design effective therapeutic solutions. Biological augmentation, including the application of different growth factors, platelet concentrates, cells, scaffolds and various drugs, or a combination of the above have been studied. It is important to note that instead of a physiological enthesis, an abundance of scar tissue is formed. Even though cytokines have demonstrated the potential to improve rotator cuff healing in animal models, there is little information about the correct concentration and timing of the more than 1500 cytokines that interact during the healing process. There is only minimal evidence that platelet concentrates may lead to improvement in radiographic, but not clinical outcome. Using stem cells to biologically augment the reconstruction of the tears might have a great potential since these cells can differentiate into various cell types that are integral for healing. However, further studies are necessary to understand how to enhance the potential of these stem cells in a safe and efficient way. This article intends to give an overview of the biological augmentation options found in the literature.
Background In vivo studies showing the effects of biologic healing-promoting factors on tendon-to-bone healing after rotator cuff repair have focused only on biologic healing-promoting factors and have not taken into consideration the effect of the carrier vehicle. Moreover, most studies have evaluated the healing process using different carrier vehicles, each of which may have specific effects on tendon healing. This may explain the large variability seen in outcomes in research studies. In this study, we investigated the effects of Poloxamer 407 as a carrier vehicle on rotator cuff healing at the repair site and compared it with those of a collagen sponge, which is a commonly used carrier vehicle. Methods Fifty-seven adult male Sprague–Dawley rats underwent detachment and immediate repair of the bilateral supraspinatus tendons. Rats were randomly assigned to three groups: repair only, repair with collagen sponge, and repair with Poloxamer 407. The repairs were evaluated at 1, 2, 4, and 8 weeks after surgery with histological analysis and biomechanical testing. Results At 4 weeks, more cellular organization, a greater number of collagen fibers, and increased maturity of collagen fibers were observed in the repair with Poloxamer 407 group than in the other groups. The repair with collagen sponge group had delayed development and collagen fiber maturation. Significant differences in the biomechanical properties were found between groups at 4 weeks. Stiffness in the case of the repair with Poloxamer 407 group was significantly higher than that in the repair with collagen sponge group. The modulus was significantly lower in the repair with collagen sponge group than in the repair only group. However, the use of Poloxamer 407 versus the collagen sponge did not significantly affect the biomechanical properties of the repaired tendons at 8 weeks. Conclusions Carrier vehicles may have differing effects at the early stages of rotator cuff healing. The use of
... cuff are common. They include tendinitis, bursitis, and injuries such as tears. Rotator cuff tendons can become ... cuff depends on age, health, how severe the injury is, and how long you've had the ...
... to these tendons may result in: Rotator cuff tendinitis, which is irritation and swelling of these tendons ... Brien MJ, Leggin BG, Williams GR. Rotator cuff tendinopathies and tears: surgery and therapy. In: Skirven TM, ...
Ye, Chenyi; Zhang, Wei; Wang, Shengdong; Jiang, Shuai; Yu, Yuanbin; Chen, Erman; Xue, Deting; Chen, Jianzhong; He, Rongxin
To investigate whether the systematic administration of icariin (ICA) promotes tendon-bone healing after rotator cuff reconstruction in vivo, a total of 64 male Sprague Dawley rats were used in a rotator cuff injury model and underwent rotator cuff reconstruction (bone tunnel suture fixation). Rats from the ICA group (n = 32) were gavage-fed daily with ICA at 0.125 mg/g, while rats in the control group (n = 32) received saline only. Micro-computed tomography, biomechanical tests, serum ELISA (calcium; Ca, alkaline phosphatase; AP, osteocalcin; OCN) and histological examinations (Safranin O and Fast Green staining, type I, II and III collagen (Col1, Col2, and Col3), CD31, and vascular endothelial growth factor (VEGF)) were analyzed two and four weeks after surgery. In the ICA group, the serum levels of AP and OCN were higher than in the control group. More Col1-, Col2-, CD31-, and VEGF-positive cells, together with a greater degree of osteogenesis, were detected in the ICA group compared with the control group. During mechanical testing, the ICA group showed a significantly higher ultimate failure load than the control group at both two and four weeks. Our results indicate that the systematic administration of ICA could promote angiogenesis and tendon-bone healing after rotator cuff reconstruction, with superior mechanical strength compared with the controls. Treatment for rotator cuff injury using systematically-administered ICA could be a promising strategy. PMID:27792147
Ye, Chenyi; Zhang, Wei; Wang, Shengdong; Jiang, Shuai; Yu, Yuanbin; Chen, Erman; Xue, Deting; Chen, Jianzhong; He, Rongxin
To investigate whether the systematic administration of icariin (ICA) promotes tendon-bone healing after rotator cuff reconstruction in vivo, a total of 64 male Sprague Dawley rats were used in a rotator cuff injury model and underwent rotator cuff reconstruction (bone tunnel suture fixation). Rats from the ICA group (n = 32) were gavage-fed daily with ICA at 0.125 mg/g, while rats in the control group (n = 32) received saline only. Micro-computed tomography, biomechanical tests, serum ELISA (calcium; Ca, alkaline phosphatase; AP, osteocalcin; OCN) and histological examinations (Safranin O and Fast Green staining, type I, II and III collagen (Col1, Col2, and Col3), CD31, and vascular endothelial growth factor (VEGF)) were analyzed two and four weeks after surgery. In the ICA group, the serum levels of AP and OCN were higher than in the control group. More Col1-, Col2-, CD31-, and VEGF-positive cells, together with a greater degree of osteogenesis, were detected in the ICA group compared with the control group. During mechanical testing, the ICA group showed a significantly higher ultimate failure load than the control group at both two and four weeks. Our results indicate that the systematic administration of ICA could promote angiogenesis and tendon-bone healing after rotator cuff reconstruction, with superior mechanical strength compared with the controls. Treatment for rotator cuff injury using systematically-administered ICA could be a promising strategy.
Ono, Yohei; Dávalos Herrera, Diego Alejandro; Woodmass, Jarret M.; Boorman, Richard S.; Thornton, Gail M.; Lo, Ian K. Y.
Background: Arthroscopic repair of large to massive rotator cuff tears commonly retear. To improve healing rates, a number of different approaches have been utilized, including the use of grafts, which may enhance the biomechanical and biologic aspects of the repair construct. However, the outcomes after the use of grafts are diverse. Purpose: To systematically review the literature for large to massive rotator cuff tears to determine whether the use of grafts generally provides superior tendon healing and clinical outcomes to the repairs without grafts. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic review of the literature was performed. Clinical studies comparing the repairs with (graft group) and without grafts (control group) were included and analyzed. The primary outcome was tendon healing on either magnetic resonance imaging or ultrasound. The secondary outcome measures included visual analog scale for pain, University of California at Los Angles (UCLA) score, and forward elevation range. Differences between groups in all outcome measures were statistically analyzed. Results: Six comparative studies (level of evidence 2 or 3) with 13 study groups were included. A total of 242 repairs in the graft group (mean age, 62.5 ± 4.6 years) and 185 repairs in the control group (mean age, 62.5 ± 5.0 years) were analyzed. The graft types utilized included autograft (fascia lata) in 1 study, allograft (human dermis) in 2 studies, xenograft (bovine pericardium, porcine small intestine submucosa) in 2 studies, synthetic graft (polypropylene) in 1 study, and a combination of autograft (the long head of biceps) and synthetic graft (polypropylene) in 1 study. The overall mean follow-up time was 28.4 ± 9.0 months. When 1 or 2 studies/study groups were excluded due to practical or statistical reasons, the graft group demonstrated significantly improved healing (odds ratio, 2.48; 95% CI, 1.58-3.90; P < .0001) and all clinical outcome measures at
Nikolaidou, Ourania; Migkou, Stefania; Karampalis, Christos
Background: Rotator cuff tears are a very common condition that is often incapacitating. Whether non-surgical or surgical, successful management of rotator cuff disease is dependent on appropriate rehabilitation. If conservative management is insufficient, surgical repair is often indicated. Postsurgical outcomes for patients having had rotator cuff repair can be quite good. A successful outcome is much dependent on surgical technique as it is on rehabilitation. Numerous rehabilitation protocols for the management of rotator cuff disease are based primarily on clinical experience and expert opinion. This article describes the different rehabilitation protocols that aim to protect the repair in the immediate postoperative period, minimize postoperative stiffness and muscle atrophy. Methods: A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair was performed to illustrate the available evidence behind various postoperative treatment modalities. Results: There were no statistically significant differences between a conservative and an accelerated rehabilitation protocol . Early passive range of motion (ROM) following arthroscopic cuff repair is thought to decrease postoperative stiffness and improve functionality. However, early aggressive rehabilitation may compromise repair integrity. Conclusion: The currently available literature did not identify any significant differences in functional outcomes and relative risks of re-tears between delayed and early motion in patients undergoing arthroscopic rotator cuff repairs. A gentle rehabilitation protocol with limits in range of motion and exercise times after arthroscopic rotator cuff repair would be better for tendon healing without taking any substantial risks. A close communication between the surgeon, the patient and the physical therapy team is important and should continue throughout the whole recovery process.
Miller RH III, Azar FM, Throckmorton TW. Shoulder and elbow injuries. In: Canale ST, Beaty JH, eds. ... Krishnan SG. Rotator cuff and impingement lesions. In: Miller MD, Thompson SR, eds. DeLee and Drez's Orthopaedic ...
... presentations/100229.htm Rotator cuff repair - series—Normal anatomy To use the sharing features on this page, ... Bethesda, MD 20894 U.S. Department of Health and Human Services National Institutes of Health Page last updated: ...
Crusher, R H
Different types of rotator cuff injuries frequently present to Accident and Emergency departments and minor injury units but can be difficult to differentiate clinically. This brief case study describes the examination and diagnosis of related shoulder injuries, specifically rotator cuff tears/disruption and calcifying supraspinatus tendinitis. The relevant anatomy and current therapies for these injuries is also discussed to enable the emergency nurse practitioner to have a greater understanding of the theory surrounding their diagnosis and treatments.
Connors, G. Patrick
Many baseball players suffer from shoulder injuries related to the rotator cuff muscles. These injuries may be classified as muscular strain, tendonitis or tenosynovitis, and impingement syndrome. Treatment varies from simple rest to surgery, so it is important to be seen by a physician as soon as possible. In order to prevent these injuries, the…
Del Buono, Angelo; Oliva, Francesco; Longo, Umile Giuseppe; Rodeo, Scott A; Orchard, John; Denaro, Vincenzo; Maffulli, Nicola
The molecular changes occurring in rotator cuff tears are still unknown, but much attention has been paid to better understand the role of matrix metalloproteinases (MMP) in the development of tendinopathy. These are potent enzymes that, once activated, can completely degrade all components of the connective tissue, modify the extracellular matrix (ECM), and mediatethe development of painful tendinopathy and tendon rupture. To control the local activity of activated proteinases, the same cells produce tissue inhibitors of metalloproteinases (TIMP) that bind to the enzymes and prevent degradation. The balance between the activities of MMPs and TIMPs regulates tendon remodeling, whereas an imbalance produces a collagen dis-regulation and disturbances intendons. ADAMs (a disintegrin and metalloproteinase) are cell membrane-linked enzymes with proteolytic and cell signaling functions. ADAMTSs (ADAM with thrombospondin motifs) are secreted into the circulation, and constitute a heterogenous family of proteases with both anabolic and catabolic functions. Biologic modulation of endogenous MMP activity to basal levels may reduce pathologic tissue degradation and favorably influence healing after rotator cuff repair. Further studies are needed to better define the mechanism of action, and whether these new strategies are safe and effective in larger models.
A histologically normal insertion site does not regenerate following rotator cuff tendon-to-bone repair, which is likely due to abnormal or insufficient gene expression and/or cell differentiation at the repair site. Techniques to manipulate the biologic events following tendon repair may improve healing. We used a sheep infraspinatus repair model to evaluate the effect of osteoinductive growth factors and BMP-12 on tendon-to-bone healing. Magnetic resonance imaging and histology showed increased formation of new bone and fibrocartilage at the healing tendon attachment site in the treated animals, and biomechanical testing showed improved load-to-failure. Other techniques with potential to augment repair site biology include use of platelets isolated from autologous blood to deliver growth factors to a tendon repair site. Modalities that improve local vascularity, such as pulsed ultrasound, have the potential to augment rotator cuff healing. Important information about the biology of tendon healing can also be gained from studies of substances that inhibit healing, such as nicotine and antiinflammatory medications. Future approaches may include the use of stem cells and transcription factors to induce formation of the native tendon-bone insertion site after rotator cuff repair surgery. PMID:18264850
Randelli, Pietro; Ragone, Vincenza; Menon, Alessandra; Cabitza, Paolo; Banfi, Giuseppe
Rotator cuff injuries are a common source of shoulder pathology and result in an important decrease in quality of patient life. Given the frequency of these injuries, as well as the relatively poor result of surgical intervention, it is not surprising that new and innovative strategies like tissue engineering have become more appealing. Tissue-engineering strategies involve the use of cells and/or bioactive factors to promote tendon regeneration via natural processes. The ability of numerous growth factors to affect tendon healing has been extensively analyzed in vitro and in animal models, showing promising results. Platelet-rich plasma (PRP) is a whole blood fraction which contains several growth factors. Controlled clinical studies using different autologous PRP formulations have provided controversial results. However, favourable structural healing rates have been observed for surgical repair of small and medium rotator cuff tears. Cell-based approaches have also been suggested to enhance tendon healing. Bone marrow is a well known source of mesenchymal stem cells (MSCs). Recently, ex vivo human studies have isolated and cultured distinct populations of MSCs from rotator cuff tendons, long head of the biceps tendon, subacromial bursa, and glenohumeral synovia. Stem cells therapies represent a novel frontier in the management of rotator cuff disease that required further basic and clinical research. PMID:25184132
Mei-Dan, Omer; Carmont, Michael R
We review the management of rotator cuff tears, the mechanism of action of autologous blood products, principally platelet-rich plasma, and the current evidence for effective use of platelet-rich plasma, particularly in relation to the shoulder and chronic rotator cuff tears, for biological augmentation of rotator cuff repair.
Bokor, Desmond John; Sonnabend, David; Deady, Luke; Cass, Ben; Young, Allan; Van Kampen, Craig; Arnoczky, Steven
Summary Background partial-thickness rotator cuff tears frequently enlarge due to increased local strain and often progress to full-thickness tears. Studies suggest the addition of new tendinous tissue to injured cuff tendons would significantly decrease peak strain, possibly protecting against tear progression. The aim of this study was to assess the ability of a highly-porous collagen implant to induce new tissue formation and limit tear progression when placed on the bursal surface of partial-thickness cuff tears. Methods following arthroscopic subacromial decompression, the implant was attached to the bursal surface of the supraspinatus tendon in a prospective series of 13 consecutive patients with intermediate – (3–6 mm) to high-grade (>6 mm) partial – thickness cuff tears (5 articular, 3 bursal, 5 intra-substance). Tendon thickness, defect size, and tendon quality were evaluated using magnetic resonance imaging (MRI) preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical outcomes were assessed using the Constant and American Shoulder and Elbow Society scores at the same preoperative and follow-up times. All 13 patients completed all follow-up exams (mean length of follow-up 27.0 months, range 23.3–32.0); no patients were lost to follow-up. Results the implant induced significant new tissue formation in all patients by 3 months (mean increase in tendon thickness 2.2 ± 0.26 mm). This tissue matured over time and became radiologically indistinguishable from the underlying tendon. The partial-thickness cuff tears showed consistent filling of the defects, with complete healing in 7 patients at 12 months, and a progressive improvement in tendon quality in the remaining patients. No tear progression was observed by MRI in any of the patients at 24 months. All clinical scores improved significantly over time. At 24 months, 12 of 13 patients (92%) had satisfactory or better results. Conclusions the results of this clinical study demonstrated
Virk, Mandeep S; Cole, Brian J
The long head of biceps tendon (LHBT) is frequently involved in rotator cuff tears and can cause anterior shoulder pain. Tendon hypertrophy, hourglass contracture, delamination, tears, and tendon instability in the bicipital groove are common macroscopic pathologic findings affecting the LHBT in the presence of rotator cuff tears. Failure to address LHBT disorders in the setting of rotator cuff tear can result in persistent shoulder pain and poor satisfaction after rotator cuff repair. Tenotomy or tenodesis of the LHBT are effective options for relieving pain arising from the LHBT in the setting of reparable and selected irreparable rotator cuff tears.
Bytomski, Jeffrey R; Black, Douglass
Across all ages and activity levels, rotator cuff injuries are one of the most common causes of shoulder pain. The anatomy and biomechanics of the shoulder guide the history and physical exam toward the appropriate treatment of rotator cuff injuries. Rotator cuff tears are rare under the age of 40 unless accompanied by acute trauma. Throwing athletes are prone to rotator cuff injury from various causes of impingement (subacromial, internal, or secondary) and flexibility deficits, strength deficits, or both along the kinetic chain. Most rotator cuff injuries may be treated conservatively by using regimens of nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, and functional rehabilitation therapy. Injury prevention programs are essential for the long-term care of patients with rotator cuff disease, for primary prevention, and for prevention of recurrent injuries, unless a traumatically torn rotator cuff is present. Surgical management is reserved for refractory cases that have exhausted conservative measures.
Wu, Yang; Dong, Yu; Chen, Shiyi; Li, Yunxia
To test the hypothesis that a platelet-rich plasma (PRP) plus bioactive glass (BG) mixture could shorten the tendon-bone healing process in rotator cuff tendon repair, thirty mature male New Zealand white rabbits were randomly divided into three groups, Control, PRP, and PRP + BG. All groups underwent a surgical procedure to establish a rotator cuff tendon healing model. Mechanical examinations and histological assays were taken to verify the adhesion of the tendon-bone. Real-time PCR was adopted to analyze Bone Morphogenetic Protein-2 (BMP-2). The maximum load-to-failure value in mechanical examinations was significantly higher in the PRP + BG group than that in the control group after six weeks (Control 38.73 ± 8.58, PRP 54.49 ± 8.72, PRP + BG 79.15 ± 7.62, p < 0.001), but it was not significantly different at 12 weeks (PRP 74.27 ± 7.74, PRP + BG 82.57 ± 6.63, p = 0.145). In histological assays, H&E (hematoxylin-eosin) staining showed that the interface between the tendon-bone integration was much sturdier in the PRP + BG group compared to the other two groups at each time point, and more ordered arranged tendon fibers can be seen at 12 weeks. At six weeks, the mRNA expression levels of BMP-2 in the PRP + BG group were higher than those in the other groups (PRP + BG 0.65 ± 0.11, PRP 2.284 ± 0.07, Control 0.12 ± 0.05, p < 0.05). However, there was no significant difference in the mRNA expression levels of BMP-2 among the three groups at 12 weeks (p = 0.922, 0.067, 0.056). BMP-2 levels in PRP and PRP+BG groups were significantly lower at 12 weeks compared to six weeks (p = 0.006, <0.001).We found that the PRP + BG mixture could enhance tendon-bone healing in rotator cuff tendon repair.
Lansdown, Drew A; Feeley, Brian T
Rotator cuff injuries are common problems and a frequent reason for patients to present to primary care physicians. These injuries are seen more frequently now with the aging population. These muscles allow for movement of the arm in overhead activities and controlled movements through space. A thorough physical examination can lead to the diagnosis of rotator cuff pathology. Radiographic imaging may offer some insight into the underlying pathology, and magnetic resonance imaging provides for excellent visualization of the rotator cuff. Many rotator cuff tears, especially partial tears, will symptomatically improve with conservative management. Surgical treatment may offer improved pain relief and function in those patients for whom nonoperative care is insufficient. In cases in which rotator cuff repair is not possible, the reverse total shoulder arthroplasty is a possibility. New technologies are also under investigation that allow for biological augmentation of rotator cuff tears.
Hsu, Jason E; Horneff, John G; Gee, Albert O
Recurrent tears after rotator cuff repair are common. Postoperative rehabilitation after rotator cuff repair is a modifiable factor controlled by the surgeon that can affect re-tear rates. Some surgeons prefer early mobilization after rotator cuff repair, whereas others prefer a period of immobilization to protect the repair site. The tendon-healing process incorporates biochemical and biomechanical responses to mechanical loading. Healing can be optimized with controlled loading. Complete load removal and chronic overload can be deleterious to the process. Several randomized clinical studies have also characterized the role of postoperative mobilization after rotator cuff repair.
Matthewson, Graeme; Beach, Cara J.; Nelson, Atiba A.; Woodmass, Jarret M.; Ono, Yohei; Boorman, Richard S.; Lo, Ian K. Y.; Thornton, Gail M.
Partial thickness rotator cuff tears are a common cause of pain in the adult shoulder. Despite their high prevalence, the diagnosis and treatment of partial thickness rotator cuff tears remains controversial. While recent studies have helped to elucidate the anatomy and natural history of disease progression, the optimal treatment, both nonoperative and operative, is unclear. Although the advent of arthroscopy has improved the accuracy of the diagnosis of partial thickness rotator cuff tears, the number of surgical techniques used to repair these tears has also increased. While multiple repair techniques have been described, there is currently no significant clinical evidence supporting more complex surgical techniques over standard rotator cuff repair. Further research is required to determine the clinical indications for surgical and nonsurgical management, when formal rotator cuff repair is specifically indicated and when biologic adjunctive therapy may be utilized. PMID:26171251
Heers, H; Heers, G
Rotator cuff defects are common disorders of the shoulder. Although the outcome of surgical treatment of rotator cuff tears is well documented in the literature, less is known about the efficacy of physical therapy for symptomatic rotator cuff tears. Clear therapeutic standards are still missing. This article presents the nonoperative treatment options as well as a literature review. The results of most studies show that patients with rotator cuff defects do benefit from both physical therapy and simple home exercises independent from the size of the defect. However, due to the heterogeneity of outcome measures used, it is difficult to compare the results published. There is still a need for well-planned randomised controlled studies investigating the efficacy of exercise in the management of rotator cuff tears.
Greenspoon, Joshua A.; Moulton, Samuel G.; Millett, Peter J.; Petri, Maximilian
Background: Surgical treatment of rotator cuff tears has consistently demonstrated good clinical and functional outcomes. However, in some cases, the rotator cuff fails to heal. While improvements in rotator cuff constructs and biomechanics have been made, the role of biologics to aid healing is currently being investigated. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: Biologic augmentation of rotator cuff repairs can for example be performed wtableith platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Clinical results on PRP application have been controversial. Application of MSCs has shown promise in animal studies, but clinical data on its effectiveness is presently lacking. The role of Matrix Metalloproteinase (MMP) inhibitors is another interesting field for potential targeted drug therapy after rotator cuff repair. Conclusions: Large randomized clinical studies need to confirm the benefit of these approaches, in order to eventually lower retear rates and improve clinical outcomes after rotator cuff repair. PMID:27708732
Osborne, Jeffrey D; Gowda, Ashok L; Wiater, Brett; Wiater, J Michael
A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.
Thès, André; Hardy, Philippe; Bak, Klaus
Treatment of massive rotator cuff tears has developed over many years ranging from conservative treatment to open and arthroscopic repair, muscle transfers and reversed arthroplasty. The evolution of more advanced techniques in arthroscopic repair has changed the treatment approach and improved the prognosis for functional outcome despite low healing rates. Due to this rapid development, our evidence-based knowledge today is mainly founded in Level 3 and Level 4 studies. Based on the literature, the current knowledge on treatment of symptomatic massive rotator cuff tears is proposed in an algorithm. Level of evidence V.
Ficklscherer, A; Scharf, M; Hartl, T K; Schröder, C; Milz, S; Roßbach, B P; Gülecyüz, M F; Pietschmann, M F; Müller, P E
We hypothesized that botulinumneurotoxin A (BoNtA) positively influences tissue characteristics at the re-insertion site when used as an adjuvant prior to rotator cuff repair. One hundred and sixty Sprague-Dawley rats were randomly assigned to either a BoNtA or saline-injected control group. BoNtA or saline solution was injected into the supraspinatus muscle one week prior to repair of an artificially created supraspinatus tendon defect. Post-operatively, one subgroup was immobilized using a cast on the operated shoulder while the other had immediate mobilization. Histologically, the fibrocartilage transition zone was more prominent and better organized in the BoNtA groups when compared to the saline control group. In the immediately mobilized BoNtA groups significantly more collagen 2 at the insertion was detected than in the control groups (p<0.05). Fiber orientation of all BoNtA groups was better organized and more perpendicular to the epiphysis compared with control groups. Tendon stiffness differed significantly (p<0.05) between casted BoNtA and casted saline groups. Tendon viscoelasticity was significantly higher (p<0.05) in the immobilized saline groups no matter if repaired with increased or normal repair load. The results of this study suggest that reduction of load at the healing tendon-to-bone interface leads to improved repair tissue properties.
Brand, Jefferson C
Results from a recent investigation into the practice of greater tuberosity decortication before rotator cuff repair showed that decortication significantly reduced the ultimate failure load. Although the potential of greater tuberosity treatment for solving the rotator cuff healing quandary still exists, the biomechanics are clear, one should not decorticate the greater tuberosity to cancellous bone.
Garofalo, Raffaele; Cesari, Eugenio
A massive rotator cuff tear is not necessarily irreparable. Number of tendons involved, muscle-tendon unit quality, and decreased acromionhumeral distance (AHD) are as important as tear size in determining reparability of lesion. Massive and irreparable rotator cuff tears cannot be anatomically repaired to the bone and are a common source of pain and disability even in middle-aged patients. In these patients when conservative management has failed, it is possible to perform different surgical techniques. A functional repair can help to restore the horizontal force couple of the cuff on the humeral head and to increase the AHD. Debridement of irreparable tears and biceps tenotomy or tenodesis can have a role in low functional demand patients but results deteriorate over time. Recently, several commercially available tissue-engineered biological and synthetic scaffolds have been developed to augment rotator cuff repairs. The aim is to provide a mechanical improvement in case of poor quality tissue at time zero and give a support to have a better cuff healing. In selected cases, the scaffold can be used also to bridge tendon defect. Patients who not have pseudoparalysis, cuff tear arthropathy and with intact deltoid function can benefit from tendon transfers with satisfactory outcomes. These different procedures should be chosen for each patient with selected criteria and after a satisfactory explanation about the really possible expectation after surgery. PMID:27582930
Dougherty, Kaitlin A; Dilisio, Matthew F; Agrawal, Devendra K
Tendon-to-bone healing after rotator cuff repair surgery has a failure rate of 20%–94%. There has been a recent interest to determine the factors that act as determinants between successful and unsuccessful rotator cuff repair. Vitamin D level in patients is one of the factors that have been linked to bone and muscle proliferation and healing, and it may have an effect on tendon-to-bone healing. The purpose of this article is to critically review relevant published research that relates to the effect of vitamin D on rotator cuff tears and subsequent healing. A review of the literature was conducted to identify all studies that investigate the relationship between vitamin D and tendon healing, in addition to its mechanism of action. The data were then analyzed in order to summarize what is currently known about vitamin D, rotator cuff pathology, and tendon-to-bone healing. The activated metabolite of vitamin D, 1α,25-dihydroxyvitamin D3, affects osteoblast proliferation and differentiation. Likewise, vitamin D plays a significant role in the tendon-to-bone healing process by increasing the bone mineral density and strengthening the skeletal muscles. The 1α,25-dihydroxyvitamin D3 binds to vitamin D receptors on myocytes to stimulate growth and proliferation. The form of vitamin D produced by the liver, calcifediol, is a key initiator of the myocyte healing process by moving phosphate into myocytes, which improves function and metabolism. Investigation into the effect of vitamin D on tendons has been sparse, but limited studies have been promising. Matrix metalloproteinases play an active role in remodeling the extracellular matrix (ECM) of tendons, particularly deleterious remodeling of the collagen fibers. Also, the levels of transforming growth factor-β3 positively influence the success of the surgery for rotator cuff repair. In the tendon-to-bone healing process, vitamin D has been shown to successfully influence bone and muscle healing, but more research is
Pedowitz, Robert A; Yamaguchi, Ken; Ahmad, Christopher S; Burks, Robert T; Flatow, Evan L; Green, Andrew; Iannotti, Joseph P; Miller, Bruce S; Tashjian, Robert Z; Watters, William C; Weber, Kristy; Turkelson, Charles M; Wies, Janet L; Anderson, Sara; St Andre, Justin; Boyer, Kevin; Raymond, Laura; Sluka, Patrick; McGowan, Richard
Of the 31 recommendations made by the work group, 19 were determined to be inconclusive because of the absence of definitive evidence. Of the remaining recommendations, four were classified as moderate grade, six as weak, and two as consensus statements of expert opinion. The four moderate-grade recommendations include suggestions that exercise and nonsteroidal anti-inflammatory drugs be used to manage rotator cuff symptoms in the absence of a full-thickness tear, that routine acromioplasty is not required at the time of rotator cuff repair, that non-cross-linked, porcine small intestine submucosal xenograft patches not be used to manage rotator cuff tears, and that surgeons can advise patients that workers' compensation status correlates with less favorable outcomes after rotator cuff surgery.
Dau, Leonardo; Abagge, Marcelo; Fruehling, Vagner Messias; Sola Junior, Wilson; Lavrador, José Marcos; da Cunha, Luiz Antônio Munhoz
Objective to compare healing strength of the infraspinatus tendon of rats with corticoid inoculation, regarding maximum tension, maximum force and rupture force, after injury and experimental repair. Methods a total of 60 Wistar rats were subjected to tenotomy of the infraspinatus tendon, which was then sutured. Before the surgery, they were divided into a control group (C) inoculated with serum and a study group (S) inoculated with corticoids over the tendon. After repair, the rats were sacrificed in groups of 10 individuals in the control group and 10 in the study group at the times of one week (C1 and S1), three weeks (C3 and S3) and five weeks (C5 and S5). The rats were dissected, separating out the infraspinatus tendon with the humerus. The study specimens were subjected to a traction test, with evaluation of the maximum tension (kgf/cm2), maximum force (kgf) and rupture force (kgf), comparing the study group with the respective control groups. Results among the rats sacrificed one week after the procedure, we observed greater maximum tension in group C1 than in group S1. The variables of maximum force (kgf) and rupture force did not differ statistically between the groups investigated. In the same way, among the rats sacrificed three weeks after the procedure, group C3 only showed greater maximum tension than group S3 (p = 0.007), and the other variables did not present differences. Among the rats sacrificed five weeks after the procedure (C5 and S5), none of the parameters studied presented statistical differences. Conclusion we concluded that corticoid diminished the resistance to maximum tension in the groups sacrificed one and three weeks after the procedure, in comparison with the respective control groups. The other parameters did not show differences between the study and control groups. PMID:26229831
Geary, Michael B.
Rotator cuff tears (RCT) are a common clinical problem in the geriatric population, and debate exists over how to best provide pain relief and restore shoulder function. Treatment options can be broadly divided into nonsurgical and surgical, with the majority of patients initially placed on a trial of conservative therapy. For those with irreparable RCT, low functional demand, or interest in nonoperative management, there are a number of nonsurgical treatments to consider, including rehabilitation and injections of corticosteroids, hyaluronate, and platelet-rich plasma. Surgical treatment is increasingly common, as geriatric patients remain active with high functional demands. Studies in elderly populations have demonstrated satisfactory healing and clinical results following surgical repair. Predictors of poor outcome after repair are large tear size as well as higher stages of fatty infiltration. Decompression is a less invasive surgical option that has been shown to provide short-term pain relief, though the lasting effects may deteriorate over time. A number of factors must be weighed when considering which patients are likely to benefit from surgical intervention. PMID:26328240
Lawton, Cindy M.; Weaver, Amelia M.; Chan, Martha Kwan Yi; Cournoyer, Michael Edward
Gloveboxes are essential to the pharmaceutical, semi-conductor, nuclear, and biochemical industries. While gloveboxes serve as effective containment systems, they are often difficult to work in and present a number of ergonomic hazards. One such hazard is injury to the rotator cuff, a group of tendons and muscles in the shoulder, connecting the upper arm to the shoulder blade. Rotator cuff integrity is critical to shoulder health. This study compared the rotator cuff muscle strength ratios of glovebox workers to the healthy norm. Descriptive statistics were collected using a short questionnaire. Handheld dynamometry was used to quantify the ratio of forces produced for shoulder internal and external rotation. Results showed this population to have shoulder strength ratios significantly different from the healthy norm. Strength ratios were found to be a sound predictor of symptom incidence. The deviation from the normal ratio demonstrates the need for solutions designed to reduce the workload on the rotator cuff musculature in order to improve health and safety. Assessment of strength ratios can be used to screen for risk of symptom development. As a result, this increases technical knowledge and augments operational safety.
Lawton, Cindy M.; Weaver, Amelia M.; Chan, Martha Kwan Yi; ...
Gloveboxes are essential to the pharmaceutical, semi-conductor, nuclear, and biochemical industries. While gloveboxes serve as effective containment systems, they are often difficult to work in and present a number of ergonomic hazards. One such hazard is injury to the rotator cuff, a group of tendons and muscles in the shoulder, connecting the upper arm to the shoulder blade. Rotator cuff integrity is critical to shoulder health. This study compared the rotator cuff muscle strength ratios of glovebox workers to the healthy norm. Descriptive statistics were collected using a short questionnaire. Handheld dynamometry was used to quantify the ratio of forcesmore » produced for shoulder internal and external rotation. Results showed this population to have shoulder strength ratios significantly different from the healthy norm. Strength ratios were found to be a sound predictor of symptom incidence. The deviation from the normal ratio demonstrates the need for solutions designed to reduce the workload on the rotator cuff musculature in order to improve health and safety. Assessment of strength ratios can be used to screen for risk of symptom development. As a result, this increases technical knowledge and augments operational safety.« less
Westgard, Paul; Chandler, Zachary; Gaskill, Trevor R.; Kokmeyer, Dirk; Millett, Peter J.
Purpose: To provide an overview of the characteristics and timing of rotator cuff healing and provide an update on treatments used in rehabilitation of rotator cuff repairs. The authors' protocol of choice, used within a large sports medicine rehabilitation center, is presented and the rationale behind its implementation is discussed. Background: If initial nonsurgical treatment of a rotator cuff tear fails, surgical repair is often the next line of treatment. It is evident that a successful outcome after surgical rotator cuff repair is as much dependent on surgical technique as it is on rehabilitation. To this end, rehabilitation protocols have proven challenging to both the orthopaedic surgeon and the involved physical therapist. Instead of being based on scientific rationale, traditionally most rehabilitation protocols are solely based on clinical experience and expert opinion. Methods: A review of currently available literature on rehabilitation after arthroscopic rotator cuff tear repair on PUBMED / MEDLINE and EMBASE databases was performed to illustrate the available evidence behind various postoperative treatment modalities. Results: There is little high-level scientific evidence available to support or contest current postoperative rotator cuff rehabilitation protocols. Most existing protocols are based on clinical experience with modest incorporation of scientific data. Conclusion: Little scientific evidence is available to guide the timing of postsurgical rotator cuff rehabilitation. To this end, expert opinion and clinical experience remains a large facet of rehabilitation protocols. This review describes a rotator cuff rehabilitation protocol that incorporates currently available scientific literature guiding rehabilitation. PMID:22530194
Laudicina, Laurence; D'Ambrosia, Robert
Glenohumeral arthritis with irreparable rotator cuff tears remain a difficult entity to treat. Varied causes include rotator cuff tear arthropathy, osteoarthritis, or rheumatoid arthritis with irreparable cuff tear. Common symptoms are progressive pain and dysfunction. Physical examination may reveal pain, crepitance, rotator cuff weakness, and loss of motion and function. Radiographs may reveal varying degrees of osteophyte formation, sclerotic bone, superior humeral head migration, and bony erosion. Additional imaging modalities may reveal cuff tear size, retraction, atrophy, and fatty infiltration. Failure of nonoperative management may lead to operative intervention. Rotator cuff repair or reconstruction may help prevent progression of tears and future arthritic changes. In patients with moderate to severe glenohumeral arthritis and irreparable rotator cuff tears, hemiarthroplasty is currently the procedure of choice. For patients with severe cuff dysfunction or loss of coracoacromial arch, or for patients who require revision, the reverse shoulder prosthesis may offer a treatment option. Future management continues to be defined with additional study.
Rui, Yongjun; Pan, Feng; Mi, Jingyi
The rat is a suitable model to study human rotator cuff pathology owing to the similarities in morphological anatomy structure. However, few studies have reported the composition muscle fiber types of rotator cuff muscles in the rat. In this study, the myosin heavy chain (MyHC) isoforms were stained by immunofluorescence to show the muscle fiber types composition and distribution in rotator cuff muscles of the rat. It was found that rotator cuff muscles in the rat were of mixed fiber type composition. The majority of rotator cuff fibers labeled positively for MyHCII. Moreover, the rat rotator cuff muscles contained hybrid fibers. So, compared with human rotator cuff muscles composed partly of slow-twitch fibers, the majority of fast-twitch fibers in rat rotator cuff muscles should be considered when the rat model study focus on the pathological process of rotator cuff muscles after injury. Gaining greater insight into muscle fiber types in rotator cuff muscles of the rat may contribute to elucidate the mechanism of pathological change in rotator cuff muscles-related diseases. Anat Rec, 299:1397-1401, 2016. © 2016 Wiley Periodicals, Inc.
Flanagin, Brody A.; Garofalo, Raffaele; Lo, Eddie Y.; Feher, LeeAnne; Castagna, Alessandro; Qin, Huanying; Krishnan, Sumant G.
statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair. Level of Evidence: Level IV PMID:26980983
Lädermann, Alexandre; Denard, Patrick J.; Kolo, Frank C.
Purpose: The purpose of this report is to describe a new full-thickness tear pattern of the posterosuperior rotator cuff with reversal healing. We describe the specific radiologic signs associated with this tear pattern and the arthroscopic rotator cuff repair technique. Materials and Methods: A prospective radiologic and clinical study collected all patients with a magnetic resonance imaging arthrogram that underwent an arthroscopic rotator cuff repair over a 1 year period. Results: Among 97 patients, five demonstrated a tear of the posterosuperior rotator cuff with reversal healing. Characteristic radiographic findings included a thicker tendon than normal, the presence of a stump and accumulation of liquid in the superior-medial part of the subacromial bursa, and adhesions between the supraspinatus tendon and the wall of the subacromial bursa. Conclusion: Avulsion of the posterosuperior rotator cuff with reversal healing on its bursal-side is a less common condition. This type of lesion and distinct radiographic signs that can be recognized to facilitate anatomic repair of the rotator cuff. Level of evidence: Level IV. PMID:25709239
Agnollitto, Paulo Moraes; Chu, Marcio Wen King; Lorenzato, Mario Muller; Zatiti, Salomão Chade Assan; Nogueira-Barbosa, Marcello Henrique
The present report describes a case where typical findings of traumatic glenohumeral interposition of rotator cuff stumps were surgically confirmed. This condition is a rare complication of shoulder trauma. Generally, it occurs in high-energy trauma, frequently in association with glenohumeral joint dislocation. Radiography demonstrated increased joint space, internal rotation of the humerus and coracoid process fracture. In addition to the mentioned findings, magnetic resonance imaging showed massive rotator cuff tear with interposition of the supraspinatus, infraspinatus and subscapularis stumps within the glenohumeral joint. Surgical treatment was performed confirming the injury and the rotator cuff stumps interposition. It is important that radiologists and orthopedic surgeons become familiar with this entity which, because of its rarity, might be neglected in cases of shoulder trauma.
Consigliere, Paolo; Polyzois, Ioannis; Sarkhel, Tanaya; Gupta, Rohit; Levy, Ofer; Narvani, A. Ali
Background: Recurrence rate of rotator cuff tears is still high despite the improvements of surgical techniques, materials used and a better knowledge of the healing process of the rotator cuff tendons. Large to massive rotator cuff tears are particularly associated with a high failure rate, especially in elderly. Augmentation of rotator cuff repairs with extracellular matrix or synthetic patches has gained popularity in recent years with the aim of reducing failure. The aim of this study was to investigate the outcome of rotator cuff repairs augmented with denatured extracellular matrix in a series of patients who underwent arthroscopic rotator cuff repair for large to massive tears. Methods: Ten consecutive patients, undergoing arthroscopic rotator cuff repair with extracellular matrix augment for large and massive tears, were prospectively enrolled into this single surgeon study. All repairs were performed arthroscopically with a double row technique augmented with extracellular matrix. Oxford Shoulder Score, Constant Score and pain visual analogue scale (VAS) were used to monitor the shoulder function and outcome pre-operatively and at three, six and 12-month follow-up. Minimum follow up was three months. Mean follow up was 7 months. Results: Mean Constant score improved from 53 (SD=4) pre-operatively to 75 (SD=11) at final follow up. Mean Oxford score also increased from 30 (SD=8) pre-operatively to 47 (SD=10) at the final follow up. The visual analogue scale (VAS) improved from seven out of 10 (SD=2) preoperatively to 0.6 (SD=0.8) at final follow up. Additionally, there was significant improvement at three months mark in Constant score. Conclusion: Arthroscopic repair and augmentation of large and massive rotator cuff tears with extracellular matrix patch has good early outcome. PMID:28271082
Jarrett, Claudius D; Schmidt, Christopher C
The goal of this article is to summarize the current concepts on rotator cuff disease with an emphasis on arthroscopic treatment. Most rotator cuff tears are the result of an ongoing attritional process. Once present, a tear is likely to gradually increase in size. Partial-thickness and subscapularis tears can both be successfully treated arthroscopically if conservative management fails. Partial tears involving greater than 50% of tendon thickness should be repaired. Articular-sided partial tears involving less than 50% of the rotator cuff can reliably be treated with debridement. A more aggressive approach should be considered for low-grade tears (<50%) if they occur on the bursal side. Biomechanical and anatomic studies have shown clear superiority with dual-row fixation compared with single-row techniques. However, current studies have yet to show clear clinical advantage with dual-row over single-row repairs. Biceps tenotomy or tenodesis can reliably provide symptomatic improvement in patients with irreparable massive tears. True pseudoparalysis of the shoulder is a contraindication to this procedure alone and other alternatives should be considered.
Holzer, Nicolas; Cunningham, Gregory; Duthon, Victoria; Graf, Véronique; Ziltener, Jean-Luc; Hoffmeyer, Pierre
Rehabilitation post surgical repair of the rotator cuff is an important determinant of the quality of the healing process, and of the clinical and functional results. Techniques used have been reported to favor certain of those parameters at the expense of others. Several approaches have been proposed; none has reached a consensus yet. The level of evidence in the literature does not allow for definitive recommendations and elaborating a protocol relies on clinical experience as well as expert opinion, incorporating scientific data. An initial period of rest with limited passive motion emerges though as an approach suited to the treatment of most clinical situations.
Skoff, Hillel D
Revision rotator cuff reconstruction for large tears with retraction results in a high rate of recurrent cuff tearing. To try to obtain more consistent results, I conducted a study of a technique that addresses the potential factors involved. Ten patients (7 men, 3 women) were enrolled. Mean age was 58 years. Mean follow-up was 24 months. Mean time between primary and revision cuff surgery was 36 months. The cardinal inclusion criterion was a symptomatic, full-thickness rotator cuff tear with at least 3 cm of retraction in a shoulder that previously underwent rotator cuff repair. Ultrasound was used for postoperative radiographic assessment of cuff integrity. Validated Constant, American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) shoulder scoring systems were used. Surgical technique included mini-open incision, adequate débridement and mobilization of remaining cuff, reconstitution of cuff defect with autogenous biceps tendon incubated in concentrated autologous bone marrow, and sewing under zero tissue tension. Constant, ASES, and UCLA scores improved significantly (standard error at .001). Ultrasound revealed 0% incidence of full-thickness rotator cuff retearing. In patients with large recurrent retracted rotator cuff tears the technique presented in the current study consistently yields satisfactory clinical results and promotes rotator cuff tissue healing without full-thickness retearing.
Vopat, Bryan G; Murali, Jothi; Gowda, Ashok L; Kaback, Lee; Blaine, Theodore
Most arthroscopic rotator cuff repairs utilize suture passing devices placed through arthroscopic cannulas. These devices are limited by the size of the passing device where the suture is passed through the tendon. An alternative technique has been used in the senior author's practice for the past ten years, where sutures are placed through the rotator cuff tendon using percutaneous passing devices. This technique, dubbed the global percutaneous shuttling technique of rotator cuff repair, affords the placement of sutures from nearly any angle and location in the shoulder, and has the potential advantage of larger suture bites through the tendon edge. These advantages may increase the area of tendon available to compress to the rotator cuff footprint and improve tendon healing and outcomes. The aim of this study is to describe the global percutaneous shuttling (GPS) technique and report our results using this method. The GPS technique can be used for any full thickness rotator cuff tear and is particularly useful for massive cuff tears with poor tissue quality. We recently followed up 22 patients with an average follow up of 32 months to validate its usefulness. American Shoulder and Elbow Surgeons scores improved significantly from 37 preoperatively to 90 postoperatively (P<0.0001). This data supports the use of the GPS technique for arthroscopic rotator cuff repair. Further biomechanical studies are currently being performed to assess the improvements in tendon footprint area with this technique.
Al-Hakim, Wisam; Noorani, Ali
Tears of the rotator cuff are common and becoming an increasingly frequent problem. There is a vast amount of literature on the merits and limitations of the various methods of clinical and radiological assessment of rotator cuff tears. This is also the case with regard to treatment strategies. Certain popular beliefs and principles practiced widely and the basis upon which they are derived may be prone to inaccuracy. We provide an overview of the historical management of rotator cuff tears, as well as an explanation for how and why rotator cuff tears should be managed, and propose a structured methodology for their assessment and treatment. PMID:27582960
Neri, Brian R; Chan, Keith W; Kwon, Young W
Massive rotator cuff tears pose a distinct clinical challenge for the orthopaedist. In this review, we will discuss the classification, diagnosis, and evaluation of massive rotator cuff tears before discussing various treatment options for this problem. Nonoperative treatment has had inconsistent results and proven unsuccessful for chronic symptoms while operative treatment including debridement and partial and complete repairs have had varying degrees of success. For rotator cuff tears that are deemed irreparable, treatment options are limited. The use of tendon transfers in younger patients to reconstruct rotator cuff function and restore shoulder kinematics can be useful in salvaging this difficult problem.
Papatheodorou, Athanasios; Ellinas, Panagiotis; Takis, Fotios; Tsanis, Antonios; Maris, Ioannis; Batakis, Nikolaos
Ultrasonography (US) has been shown to be an effective imaging modality in the evaluation of both rotator cuff and non-rotator cuff disorders, usually serving in a complementary role to magnetic resonance imaging of the shoulder. US technique for shoulder examination depends on patient positioning, scanning protocol for every tendon and anatomic part, and dynamic imaging. The primary US signs for rotator cuff supraspinatus tendon tears are tendon nonvisualization for complete tears, focal tendon defect for full-thickness tears, a hypoechoic defect of the articular side of the tendon for an articular-side partial-thickness tear, and flattening of the bursal surface of the tendon for a bursal-side partial-thickness tear. Secondary US signs such as cortical irregularity of the greater tuberosity and joint and subacromial-subdeltoid bursal fluid are helpful when correlated with the primary signs. Tendon degeneration, tendinosis, and intrasubstance tear are demonstrated as internal heterogeneity. Long-head biceps tendon abnormalities include instability, acute or chronic tear, and tendinosis. The acromioclavicular joint is assessed for dislocation, fluid collection, cysts, and bone erosions. Other non-rotator cuff disorders include synovial disorders such as adhesive capsulitis and synovial osteochondromatosis; degenerative disorders such as osteoarthritis, amyloid arthropathy, hemarthrosis, and chondrocalcinosis; infectious disorders such as septic arthritis and bursitis; and space-occupying lesions.
Maffulli, Nicola; Longo, Umile Giuseppe; Loppini, Mattia; Berton, Alessandra; Spiezia, Filippo; Denaro, Vincenzo
The purpose of this systematic review was to address the treatment of rotator cuff tears by applying tissue engineering approaches to improve tendon healing, specifically platelet rich plasma (PRP) augmentation, stem cells, and scaffolds. Our systematic search was performed using the combination of the following terms: “rotator cuff”, “shoulder”, “PRP”, “platelet rich plasma”, “stemcells”, “scaffold”, “growth factors”, and “tissue engineering”. No level I or II studies were found on the use of scaffolds and stem cells for rotator cuff repair. Three studies compared rotator cuff repair with or without PRP augmentation. All authors performed arthroscopic rotator cuff repair with different techniques of suture anchor fixation and different PRP augmentation. The three studies found no difference in clinical rating scales and functional outcomes between PRP and control groups. Only one study showed clinical statistically significant difference between the two groups at the 3-month follow up. Any statistically significant difference in the rates of tendon rerupture between the control group and the PRP group was found using the magnetic resonance imaging. The current literature on tissue engineering application for rotator cuff repair is scanty. Comparative studies included in this review suggest that PRP augmented repair of a rotator cuff does not yield improved functional and clinical outcome compared with non-augmented repair at a medium and long-term followup. PMID:25098365
Gilotra, Mohit N; Christian, Matthew W; Lovering, Richard M
The patient was a 21-year-old collegiate running back who was tackled during a football game and sustained a posterior glenohumeral dislocation. He was referred to an orthopaedist and presented 3 weeks after the injury, and, following examination, further imaging was ordered by the orthopaedist due to rotator cuff weakness. Magnetic resonance imaging showed a complete tear of the supraspinatus and infraspinatus, as well as a posterior Bankart lesion, a subscapularis tear, and a dislocation of the biceps long head tendon into the reverse Hill-Sachs lesion. J Orthop Sports Phys Ther 2016;46(8):708. doi:10.2519/jospt.2016.0413.
The objective of this study was to investigate the national trends in rotator cuff surgery in Korea and analyze hospital type-specific trends. We analyzed a nationwide database acquired from the Korean Health Insurance Review and Assessment Service (HIRA) from 2007 to 2015. International Classification of Diseases, 10th revision (ICD-10) codes, procedure codes, and arthroscopic device code were used to identify patients who underwent surgical treatment for rotator cuff disease. A total of 383,719 cases of rotator cuff surgeries were performed from 2007 to 2015. The mean annual percentage change in the age-adjusted rate of rotator cuff surgery per population of 100,000 persons rapidly increased from 2007 to 2012 (53.3%, P < 0.001), while that between 2012 to 2015 remained steady (2.3%, P = 0.34). The proportion of arthroscopic surgery among all rotator cuff surgeries steadily rose from 89.9% in 2007 to 96.8% in 2015 (P < 0.001). In terms of hospital types, the rate of rotator cuff surgery increased to the greatest degree in hospitals with 30–100 inpatient beds, and isolated acromioplasty procedure accounted for a larger proportion of the rotator cuff surgeries in small hospitals and clinics compared to large hospitals. Overall, our findings indicate that cases of rotator cuff surgery have increased rapidly recently in Korea, of which arthroscopic surgeries account for the greatest proportion. While rotator cuff surgery is a popular procedure that is commonly performed even in small hospitals, there was a difference in the component ratio of the procedure code in accordance with hospital type. PMID:28049250
Nash, Heyward L.
Sports medicine specialists are beginning to reexamine the causes and treatments of rotator cuff problems, questioning the role of primary impingement in a deficient or torn cuff and trying new surgical procedures as alternatives to the traditional open acromioplasty. (Author/CB)
Gellhorn, Alfred C; Gillenwater, Cody; Mourad, Pierre D
The objective of this preliminary study was to evaluate the ability of individual 0.1-s long pulses of intense focused ultrasound (iFU) emitted with a carrier frequency of 2 MHz to evoke diagnostic sensations when applied to patients whose shoulders have rotator cuff tears or tendinopathy. Patients were adults with painful shoulders and clinical and imaging findings consistent with rotator cuff disease. iFU stimulation of the shoulder was performed using B-mode ultrasound coupled with a focused ultrasound transducer that allowed image-guided delivery of precisely localized pulses of energy to different anatomic areas around the rotator cuff. The main outcome measure was iFU spatial average-temporal average intensity (I_SATA), and location required to elicit sensation. In control patients, iFU produced no sensation throughout the range of stimulation intensities (≤2000 W/cm(2) I_SATA). In patients with rotator cuff disease, iFU was able to induce sensation in the tendons of the rotator cuff, the subacromial bursa, and the subchondral bone in patients with chronic shoulder pain and rotator cuff disease, with an average ± standard deviation intensity equaling 680 ± 281 W/cm(2) I_SATA. This result suggests a primary role for these tissues in the pathogenesis of shoulder pain related to rotator cuff tendinopathy.
Sambandam, Senthil Nathan; Khanna, Vishesh; Gul, Arif; Mounasamy, Varatharaj
Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and
Chung, Seok Won; Kim, Sae Hoon; Tae, Suk-Kee; Yoon, Jong Pil; Choi, Jung-Ah
Background Atrophy of rotator cuff muscles has been considered an irreversible phenomenon. The purpose of this study is to evaluate whether atrophy is truly irreversible after rotator cuff repair. Methods We measured supraspinatus muscle atrophy of 191 patients with full-thickness rotator cuff tears on preoperative magnetic resonance imaging and postoperative multidetector computed tomography images, taken at least 1 year after operation. The occupation ratio was calculated using Photoshop CS3 software. We compared the change between pre- and postoperative occupation ratios after modifying the preoperative occupation ratio. In addition, possible relationship between various clinical factors and the change of atrophy, and between the change of atrophy and cuff integrity after surgical repair were evaluated. Results The mean occupation ratio was significantly increased postoperatively from 0.44 ± 0.17 to 0.52 ± 0.17 (p < 0.001). Among 191 patients, 81 (42.4%) showed improvement of atrophy (more than a 10% increase in occupation ratio) and 33 (17.3%) worsening (more than a 10% decrease). Various clinical factors such as age tear size, or initial degree of atrophy did not affect the change of atrophy. However, the change of atrophy was related to repair integrity: cuff healing failure rate of 48.5% (16 of 33) in worsened atrophy; and 22.2% (18 of 81) in improved atrophy (p = 0.007). Conclusions The supraspinatus muscle atrophy as measured by occupation ratio could be improved postoperatively in case of successful cuff repair. PMID:23467404
Chaudhury, Salma; Holland, Christopher; Porter, David; Tirlapur, Uday K; Vollrath, Fritz; Carr, Andrew J
The cause of the high failure rates often observed following rotator cuff tendon repairs, particularly massive tears, is not fully understood. Collagen structural changes have been shown to alter tendon thermal and mechanical properties. This study aimed to form a quantitative rather than qualitative assessment, of whether differences in collagen structure and integrity existed between small biopsies of normal, small, and massive rotator cuff tears using differential scanning calorimetry. Thermal properties were measured for 28 human biopsies taken intra-operatively from normal, small, and massive rotator cuff tendon tears in this powered study. Denaturation temperatures are represented by T(onset) (°C) and T(peak) (°C). The T(onset) is proposed to represent water-amide hydrogen bond breakage and resulting protein backbone mobility. T(peak) reportedly corresponds to the temperature at which the majority of proteins fall out of solution. Denaturation enthalpy (ΔH) should correlate with the amount of triple helical structure that is denatured. Fluorescence and confocal microscopy allowed quantitative validation. Small and massive rotator cuff tears had significantly higher T(onset), T(peak), and ΔH compared to controls. Polarized light microscopy of torn tendons confirmed greater collagen structural disruption compared to controls. These novel findings suggest greater quantifiable collagen structural disruption in rotator cuff tears, compared to controls. This study offers insight into possible mechanisms for the reduced strength of torn tendons and may explain why repaired tendons fail to heal.
Pillai, Anup; Hall, Brittany N.; Thigpen, Charles A.; Kwartowitz, David M.
Rotator cuff disease impacts over 50% of the population over 60, with reports of incidence being as high as 90% within this population, causing pain and possible loss of function. The rotator cuff is composed of muscles and tendons that work in tandem to support the shoulder. Heavy use of these muscles can lead to rotator cuff tear, with the most common causes is age-related degeneration or sport injuries, both being a function of overuse. Tears ranges in severity from partial thickness tear to total rupture. Diagnostic techniques are based on physical assessment, detailed patient history, and medical imaging; primarily X-ray, MRI and ultrasonography are the chosen modalities for assessment. The final treatment technique and imaging modality; however, is chosen by the clinician is at their discretion. Ultrasound has been shown to have good accuracy for identification and measurement of full-thickness and partial-thickness rotator cuff tears. In this study, we report on the progress and improvement of our method of transduction and analysis of in situ measurement of rotator cuff biomechanics. We have improved the ability of the clinician to apply a uniform force to the underlying musculotendentious tissues while simultaneously obtaining the ultrasound image. This measurement protocol combined with region of interest (ROI) based image processing will help in developing a predictive diagnostic model for treatment of rotator cuff disease and help the clinicians choose the best treatment technique.
Mollison, Scott; Shin, Jason J.; Glogau, Alexander; Beavis, R. Cole
Background: Postoperative rehabilitation after arthroscopic rotator cuff repair (ARCR) remains controversial and suffers from limited high-quality evidence. Therefore, appropriate use criteria must partially depend on expert opinion. Hypothesis/Purpose: The purpose of the study was to determine and report on the standard and modified rehabilitation protocols after ARCR used by member orthopaedic surgeons of the American Orthopaedic Society for Sports Medicine (AOSSM) and the Arthroscopy Association of North America (AANA). We hypothesized that there will exist a high degree of variability among rehabilitation protocols. We also predict that surgeons will be prescribing accelerated rehabilitation. Study Design: Cross-sectional study; Level of evidence, 4. Methods: A 29-question survey in English language was sent to all 3106 associate and active members of the AOSSM and the AANA. The questionnaire consisted of 4 categories: standard postoperative protocol, modification to postoperative rehabilitation, operative technique, and surgeon demographic data. Via email, the survey was sent on September 4, 2013. Results: The average response rate per question was 22.7%, representing an average of 704 total responses per question. The most common immobilization device was an abduction pillow sling with the arm in neutral or slight internal rotation (70%). Surgeons tended toward later unrestricted passive shoulder range of motion at 6 to 7 weeks (35%). Strengthening exercises were most commonly prescribed between 6 weeks and 3 months (56%). Unrestricted return to activities was most commonly allowed at 5 to 6 months. The majority of the respondents agreed that they would change their protocol based on differences expressed in this survey. Conclusion: There is tremendous variability in postoperative rehabilitation protocols after ARCR. Five of 10 questions regarding standard rehabilitation reached a consensus statement. Contrary to our hypothesis, there was a trend toward later
Caro, Adam C; Tucker, Jennica J; Yannascoli, Sarah M; Dunkman, Andrew A; Thomas, Stephen J; Soslowsky, Louis J
Although relief of postoperative pain is an imperative aspect of animal welfare, analgesics that do not interfere with the scientific goals of the study must be used. Here we compared the efficacy of different analgesic agents by using an established rat model of supraspinatus tendon healing and a novel gait-analysis system. We hypothesized that different analgesic agents would all provide pain relief in this model but would cause differences in tendon-to-bone healing and gait parameters. Buprenorphine, ibuprofen, tramadol-gabapentin, and acetaminophen were compared with a no-analgesia control group. Gait measures (stride length and vertical force) on the operative forelimb differed between the control group and both the buprenorphine (2 and 4 d postsurgery) and ibuprofen (2 d postsurgery) groups. Step length was different in the control group as compared with the tramadol-gabapentin (2 d after surgery), buprenorphine (2 and 4 d after surgery), and ibuprofen (2 d after surgery) groups. Regarding tendon-to-bone healing, the ibuprofen group showed less stiffness at the insertion site; no other differences in tendon-to-bone healing were detected. In summary, the analgesics evaluated were associated with differences in both animal gait and tendon-to-bone healing. This information will be useful for improving the management of postsurgical pain without adversely affecting tissue healing. Given its ability to improve gait without impeding healing, we recommend use of buprenorphine for postsurgical pain management in rats. In addition, our gait-analysis system can be used to evaluate new analgesics.
Koh, Kyoung Hwan; Kim, Jong Ho; Yoo, Jae Chul
In combined stiffness with rotator cuff tear, the brisement manipulation with or without capsular release has been more common procedure prior to the rotator cuff repair. It is known to be relatively safe and easy procedure with rare complications. However, the present authors found the iatrogenic fracture of anteroinferior portion of glenoid after brisement manipulation during the arthroscopic rotator cuff repair. The patient was followed up with the routine postoperative protocol for rotator cuff repair, which was composed of 4 weeks of protection with abduction brace, passive and active assisted range of motion exercise afterward, and progressive strengthening exercise. Two years after surgery, the patient showed improved clinical score and healing of fracture fragment. However, iatrogenic glenoid fracture should be kept in mind when the brisement manipulation is performed during arthroscopic surgery.
Nam, Denis; Maak, Travis G; Raphael, Bradley S; Kepler, Christopher K; Cross, Michael B; Warren, Russell F
Rotator cuff tear arthropathy encompasses a broad spectrum of pathology, but it involves at least three critical features: rotator cuff insufficiency, degenerative changes of the glenohumeral joint, and superior migration of the humeral head. Although many patients possess altered biomechanics of the glenohumeral joint secondary to rotator cuff pathology, not all patients develop rotator cuff tear arthropathy, and thus the exact etiology of rotator cuff tear arthropathy remains unclear. The objectives of this manuscript are to (1) review the biomechanical properties of the rotator cuff and the glenohumeral joint, (2) discuss the proposed causes of rotator cuff tear arthropathy, (3) provide a brief review of the historically used surgical options to treat rotator cuff tear arthropathy, and (4) present a treatment algorithm for rotator cuff tear arthropathy based on a patient's clinical presentation, functional goals, and anatomic integrity.
ElShewy, Mohamed Taha
Calcific tendinitis within the rotator cuff tendon is a common shoulder disorder that should be differentiated from dystrophic calcification as the pathogenesis and natural history of both is totally different. Calcific tendinitis usually occurs in the fifth and sixth decades of life among sedentary workers. It is classified into formative and resorptive phases. The chronic formative phase results from transient hypoxia that is commonly associated with repeated microtrauma causing calcium deposition into the matrix vesicles within the chondrocytes forming bone foci that later coalesce. This phase may extend from 1 to 6 years, and is usually asymptomatic. The resorptive phase extends from 3 wk up to 6 mo with vascularization at the periphery of the calcium deposits causing macrophage and mononuclear giant cell infiltration, together with fibroblast formation leading to an aggressive inflammatory reaction with inflammatory cell accumulation, excessive edema and rise of the intra-tendineous pressure. This results in a severely painful shoulder. Radiological investigations confirm the diagnosis and suggest the phase of the condition and are used to follow its progression. Although routine conventional X-ray allows detection of the deposits, magnetic resonance imaging studies allow better evaluation of any coexisting pathology. Various methods of treatment have been suggested. The appropriate method should be individualized for each patient. Conservative treatment includes pain killers and physiotherapy, or “minimally invasive” techniques as needling or puncture and aspiration. It is almost always successful since the natural history of the condition ends with resorption of the deposits and complete relief of pain. Due to the intolerable pain of the acute and severely painful resorptive stage, the patient often demands any sort of operative intervention. In such case arthroscopic removal is the best option as complete removal of the deposits is unnecessary. PMID
Black, Eric M.; Lin, Albert; Srikumaran, Uma; Jain, Nitin; Freehill, Michael T.
The goal of this study was to review the authors’ initial experience with arthroscopic transosseous rotator cuff repair. Thirty-one patients with full-thickness rotator cuff tears underwent arthroscopic transosseous rotator cuff repair over a 15-month period. Preoperatively, demographics and subjective scores were recorded. Postoperatively, pain levels, subjective shoulder values, satisfaction scores, American Shoulder and Elbow Surgeons (ASES) scores, complications, and reoperations were noted with a minimum 2-year follow-up. The relationships between pre- and intraoperative variables and outcome scores were determined with univariate analysis. Average patient age was 56 years, and 23 patients (74%) were men. Twenty patients (65%) underwent primary rotator cuff repair, and 11 patients (35%) underwent revision repair. Average time to follow-up was 26 months. Average preoperative pain level and subjective shoulder value were 5.1 of 10 and 35%, respectively. Average postoperative scores included pain level of 0.9 of 10, subjective shoulder value of 84%, satisfaction score of 90.6 of 100, and ASES score of 86.3 of 100. There were 3 (9.7%) major and 2 (6%) minor complications. Patients undergoing revision rotator cuff repair had significantly worse outcomes (pain level, subjective shoulder value, ASES score; P<.05) compared with those undergoing primary repair, and cortical augmentation did not significantly affect outcome. Overall, outcomes after arthroscopic transosseous rotator cuff repair are good, although patients undergoing revision repair do not have the same outcomes as those undergoing primary cuff repair. The procedure is not without complications (9.7% major, 6% minor complications). Cortical augmentation may be used to supplement fixation, although it does not necessarily affect outcomes. Patients without such augmentation may be at increased risk for suture cutout through the bone. PMID:25970360
Moulton, Samuel G.; Greenspoon, Joshua A.; Millett, Peter J.; Petri, Maximilian
Background: It is important to appreciate the risk factors for the development of rotator cuff tears and specific physical examination maneuvers. Methods: A selective literature search was performed. Results: Numerous well-designed studies have demonstrated that common risk factors include age, occupation, and anatomic considerations such as the critical shoulder angle. Recently, research has also reported a genetic component as well. The rotator cuff axially compresses the humeral head in the glenohumeral joint and provides rotational motion and abduction. Forces are grouped into coronal and axial force couples. Rotator cuff tears are thought to occur when the force couples become imbalanced. Conclusion: Physical examination is essential to determining whether a patient has an anterosuperior or posterosuperior tear. Diagnostic accuracy increases when combining a series of examination maneuvers. PMID:27708731
Greenspoon, Joshua A.; Millett, Peter J.; Moulton, Samuel G.; Petri, Maximilian
Background: Tendon transfers can be a surgical treatment option in managing younger, active patients with massive irreparable rotator cuff tears. The purpose of this article is to provide an overview of the use of tendon transfers to treat massive irreparable rotator cuff tears and to summarize clinical outcomes. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: Latissimus dorsi transfers have been used for many years in the management of posterosuperior rotator cuff tears with good reported clinical outcomes. It can be transferred without or with the teres major (L’Episcopo technique). Many surgical techniques have been described for latissimus dorsi transfer including single incision, double incision, and arthroscopically assisted transfer. Transfer of the pectoralis major tendon is the most common tendon transfer procedure performed for anterosuperior rotator cuff deficiencies. Several surgical techniques have been described, however transfer of the pectoralis major beneath the coracoid process has been found to most closely replicate the force vector that is normally provided by the intact subscapularis. Conclusion: Tendon transfers can be used successfully in the management of younger patients with massive irreparable rotator cuff tears and minimal glenohumeral arthritis. Improvements in clinical outcomes scores and range of motion have been demonstrated. This can delay arthroplasty, which is of particular importance for younger patients with high functional demands. PMID:27708730
Popowitz, Richard L; Zvijac, John E; Uribe, John W; Hechtman, Keith S; Schürhoff, Matthias R; Green, Jeremy B
Previous studies on the treatment of rotator cuff tears in wheelchair-bound patients have concentrated on nonsurgical management. We conducted a retrospective review to determine the effectiveness of surgical repair of rotator cuff tears in spinal cord-injured patients. Five male patients with rotator cuff tears confirmed by physical examination and magnetic resonance imaging underwent rotator cuff repair. Two of eight shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved in 6 of 8 shoulders. Strength was increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other spinal cord injury patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Surgery for spinal cord injury patients with rotator cuff tears can improve their functional capability and autonomy while reducing their pain. Compliance with the demanding postoperative rehabilitation is essential; therefore proper patient selection is crucial for optimal results.
Camargo, Paula R; Alburquerque-Sendín, Francisco; Salvini, Tania F
Excessive mechanical loading is considered the major cause of rotator cuff tendinopathy. Although tendon problems are very common, they are not always easy to treat. Eccentric training has been proposed as an effective conservative treatment for the Achilles and patellar tendinopathies, but less evidence exists about its effectiveness for the rotator cuff tendinopathy. The mechanotransduction process associated with an adequate dose of mechanical load might explain the beneficial results of applying the eccentric training to the tendons. An adequate load increases healing and an inadequate (over or underuse) load can deteriorate the tendon structure. Different eccentric training protocols have been used in the few studies conducted for people with rotator cuff tendinopathy. Further, the effects of the eccentric training for rotator cuff tendinopathy were only evaluated on pain, function and strength. Future studies should assess the effects of the eccentric training also on shoulder kinematics and muscle activity. Individualization of the exercise prescription, comprehension and motivation of the patients, and the establishment of specific goals, practice and efforts should all be considered when prescribing the eccentric training. In conclusion, eccentric training should be used aiming improvement of the tendon degeneration, but more evidence is necessary to establish the adequate dose-response and to determine long-term follow-up effects. PMID:25405092
Oh, Joo Han; Kim, Woo; Kim, Jung Youn
Background Rehabilitation and overuse of the shoulder after rotator cuff repair are a concern in patients with comorbid disability in other extremities. Improvement of outcomes can be hampered in this situation. This study was to describe the clinical outcomes of rotator cuff repair in patients with comorbid disability in other extremities. Methods In two tertiary institutions, 16 patients with comorbid disability (9 men and 7 women; mean age of 57.1 years [range, 45 to 71 years]; 14 dominant arms; mean follow-up of 18 months [range, 12 to 38 months]) underwent rotator cuff repair. There were 5 massive tears, 1 large tear, 9 medium tears, and 1 small tear. Open repair was performed in 3 patients and arthroscopic repair in 13. The most common comorbid condition was paralysis (n = 7). Eight patients walked with crutches preoperatively. Anatomical outcome was investigated in 12 patients using either magnetic resonance imaging or ultrasonography at least 6 months postoperatively. Results Range of motion, visual analogue scale for pain and satisfaction, and all functional scores improved significantly. Healing failure occurred in 4 patients (2 large-to-massive and 2 medium size tears), but none required revision surgery. All 4 retears involved the dominant side, and 3 patients were crutch users. Conclusions The current data suggested favorable outcome of rotator cuff repair in patients with comorbid disability. Careful surgical planning and rehabilitation is particularly important for crutch users and in the case of dominant arm involvement in disabled patients. PMID:28261431
Audigé, Laurent; Blum, Raphael; Müller, Andreas M.; Flury, Matthias; Durchholz, Holger
Background Valid comparison of outcomes after surgical procedures requires consensus on which instruments and parameters should be used, including the recording and evaluation of surgical complications. An international standard outlining the terminology and definitions of surgical complications in orthopaedics is lacking. Purpose This study systematically reviewed the literature for terms and definitions related to the occurrence of negative events or complications after arthroscopic rotator cuff repair (ARCR) with specific focus on shoulder stiffness. Study Design Systematic review; Level of evidence, 4. Methods PubMed, EMBASE, Cochrane Library, and Scopus databases were searched for reviews, clinical studies, and case reports of complications associated with ARCR. Reference lists of selected articles were also screened. The terminology of complications and their definitions were extracted from all relevant original articles by a single reviewer and verified by a second reviewer. Definitions of shoulder stiffness or equivalent terms were tabulated. Results Of 654 references published after 2007 and obtained from the search, 233 full-text papers (44 reviews, 155 studies, 31 case reports, and 3 surgical technique presentations) were reviewed. Twenty-two additional references cited for a definition were checked. One report defined the term surgical complication. There were 242 different terms used to describe local events and 64 to describe nonlocal events. Furthermore, 16 definitions of terms such as frozen shoulder, shoulder stiffness, or stiff painful shoulder were identified. Diagnosis criteria for shoulder stiffness differed widely; 12 various definitions for restriction in range of motion were noted. One definition included a gradation of stiffness severity, whereas another considered the patient’s subjective assessment of motion. Conclusion The literature does not consistently report on complications after ARCR, making valid comparison of the incidence of
Rotator cuff tear is one of the most common shoulder diseases. It is interesting that some rotator cuff tears are symptomatic, whereas others are asymptomatic. Pain is the most common symptom of patients with a tear. Even in patients with an asymptomatic tear, it may become symptomatic with an increase in tear size. Physical examination is extremely important to evaluate the presence, location, and extent of a tear. It also helps us to understand the mechanism of pain. Conservative treatment often works. Patients with well-preserved function of the supraspinatus and infraspinatus are the best candidates for conservative treatment. After a successful conservative treatment, the symptom once disappeared may come back again. This recurrence of symptoms is related to tear expansion. Those with high risk of tear expansion and those with less functional rotator cuff muscles are less likely to respond to conservative treatment. They may need a surgical treatment.
Greis, Ari C; Derrington, Stephen M; McAuliffe, Matthew
Rotator cuff calcific tendinopathy is a common finding that accounts for about 7% of patients with shoulder pain. There are numerous theories on the pathogenesis of rotator cuff calcific tendinopathy. The diagnosis is confirmed with radiography, MRI or ultrasound. There are numerous conservative treatment options available and most patients can be managed successfully without surgical intervention. Nonsteroidal anti-inflammatory drugs and multiple modalities are often used to manage pain and inflammation; physical therapy can help improve scapular mechanics and decrease dynamic impingement; ultrasound-guided needle aspiration and lavage techniques can provide long-term improvement in pain and function in these patients.
De Baere, Tom; Dubuc, Jean-Emile; Joris, Daniel; Delloye, Christian
The influence of acromioplasty in long standing rotator cuff deficiency with intractable pain was retrospectively evaluated in a consecutive series of 13 patients who were followed for a mean period of 19 months (range, 12 to 42 months) after arthroscopic acromioplasty. The Constant score improved from 59.3 (range, 39.9 to 90.3) preoperatively to 98.7 (69.1 to 122.7) postoperatively. Pain and motion improved significantly whereas strength did not improve. Arthroscopic acromioplasty in painful chronic rotator cuff avulsion was found to be an effective means to control pain and improve motion; it can be recommended when conservative treatment has failed.
Kim, Chang-Wan; Kim, Dong-Gyun
Background We evaluated the factors that affect pain pattern after arthroscopic rotator cuff repair. Methods From June 2009 to October 2010, 210 patients underwent arthroscopic rotator cuff repair operations. Of them, 84 patients were enrolled as subjects of the present study. The evaluation of postoperative pain was conducted by visual analog scale (VAS) scores during postoperative outpatient interviews at 6 weeks, 3 months, 6 months, and 12 months. The factors that were thought to affect postoperative pain were evaluated by dividing into three categories: preoperative, operative, and postoperative. Results Pain after arthroscopic rotator cuff repair surgery showed a strictly decreasing pain pattern. In single analysis and multiple regression tests for factors influencing the strictly decreasing pain pattern, initial VAS and pain onset were shown to be statistically significant factors (p = 0.012, 0.012, 0.044 and 0.028, respectively). With regard to the factors influencing lower than average intensity pain pattern for each period, the stiffness of internal rotation at 3 months postoperatively was shown to be a statistically significant factor in single and multiple regression tests (p = 0.017 and p = 0.004, respectively). Conclusions High initial VAS scores and the acute onset of pain affected the strictly decreasing postoperative pain pattern. Additionally, stiffness of internal rotation at postoperative 3 months affected the higher than average intensity pain pattern for each period after arthroscopic rotator cuff repair. PMID:25436062
Atoun, Ehud; Funk, Lennard; Copland, Stephen A; Even, Tirtza; Levy, Ofer; Rath, Ehud
The use of shoulder manipulation in the treatment of frozen shoulder remains controversial. Humeral fractures and neurological damage are the risks associated with the procedure. A concern of causing a rotator cuff tear exists but the incidence of iatrogenic rotator cuff tears is not reported. The purpose of this study was to assess the effect of shoulder manipulation for frozen shoulder on the integrity of the rotator cuff. In a prospective study, 32 consecutive patients (33 shoulders) with the diagnosis of frozen shoulder underwent manipulation of the shoulder under anaesthesia (MUA), 18 female and 15 males with mean age at manipulation of 503 years (range: 42-63). The average duration of symptoms before treatment was 6.2 months (range: 2-18 months). The patients were examined prior to the manipulation and at follow-up for combined shoulder range of motion, external and internal rotation and strength. All patients had an ultrasound assessment of the rotator cuff before and at 3 weeks after manipulation of the shoulder. Mean time between manipulation and last follow-up was 133 weeks. None of the patients had ultrasound findings of a rotator cuff tear, prior to the manipulation. In all patients the rotator cuff remained undamaged on ultrasound examination at 3 weeks after the procedure. The mean improvement in motion was 81.2 degrees (from 933 degrees pre-op to 174.5 degrees at last follow-up) for forward flexion; 102.6 degrees (from 68.8 degrees pre-op to 171.4 degrees at last follow-up) for abduction, 49.4 degrees (from 8.8 degrees pre-op to 58.2 degrees at last follow-up) for external rotation and 3.5 levels of internal rotation (range: 2 to 5 levels). These gains in motion were all highly significant (p < 0.0001). No fractures, dislocations or nerve palsies were observed. In this study, manipulation of the shoulder has not been associated with rotator cuff tears. If done properly the procedure appeared to be safe and to result in a marked improvement of range
The incidence of rotator cuff tear increases with age. Degenerative rotator cuff tears are commonly seen in athletes above 40 years. These athletes are commonly involved in overhead activities. Repetitive microtrauma is a more important factor in rotator cuff degeneration than acute trauma. Conservative treatment is the mainstay treatment for these injuries. A case report of an elderly athlete who sailed competitively is presented. The clinical and radiographic presentations, management and rehabilitation of degenerative rotator cuff tears are discussed. ImagesFigure 1
Kelly, Brian A; Proffen, Benedikt L; Haslauer, Carla M; Murray, Martha M
The addition of platelet-rich plasma (PRP) to rotator cuff repair has not translated into improved outcomes after surgery. However, recent work stimulating ligament healing has demonstrated improved outcomes when PRP or whole blood is combined with an extracellular matrix carrier. The objective of this study was to evaluate the effect of three components of blood (plasma, platelets, and macrophages) on the in vitro activity of ovine rotator cuff cells cultured in an extracellular matrix environment. Tenocytes were obtained from six ovine infraspinatus tendons and cultured over 14 days in an extracellular matrix scaffold with the following additives: (1) plasma (PPP), (2) plasma and platelets (PAP), (3) plasma and macrophages (PPPM), (4) plasma, platelets and macrophages (PAPM), (5) phosphate buffered saline (PBS), and (6) PBS with macrophages (PBSM). Assays measuring cellular metabolism (AlamarBlue), proliferation (Quantitative DNA assay), synthesis of collagen and cytokines (SIRCOL, TNF-α and IL-10 ELISA, and MMP assay), and collagen gene expression (qPCR) were performed over the duration of the experiment, as well as histology at the conclusion. Plasma was found to stimulate cell attachment and spreading on the scaffold, as well as cellular proliferation. Platelets also stimulated cell proliferation, cellular metabolism, transition of cells to a myofibroblast phenotype, and contraction of the scaffolds. The addition of macrophages did not have any significant effect on the sheep rotator cuff cells in vitro. In vivo studies are needed to determine whether these changes in cellular function will translate into improved tendon healing.
Casser, H R; Sulimma, H; Straub, A; Paus, R
Sonography of the shoulder joint has developed into an established examination technique in the diagnosis of periarticular lesions of the shoulder. Sonographic diagnosis of the rotator cuff in particular contains a multitude of possible errors, which are gone into by this study by means of 149 clinically, radiologically and sonographically examined shoulder patients with an average age of 50.5 years. Besides errors made by wrong examination technique such of the transducer as incorrect adjustment of the equipment, insufficient contact of the transducer with the skin and unsuitable choice of the examination plane, there are sources of errors in the interpretation of the sonogram caused by lack of knowledge about physically caused artifacts and sonoanatomical qualities of the shoulder joint. Calcification inside the rotator cuff and the so-called "sonographic inhomogeneity of the rotator cuff" are numbered among the sources of error particular to the shoulder joint. Most errors in sonographic diagnosis of the rotator cuff can be avoided by careful examination of both shoulder joints with an exactly tuned ultrasound device, taking into account the sonoanatomical and ultrasonic qualities. Radiological examination of the affected shoulder joint cannot be replaced by ultrasound.
Choo, Alexander; McCarthy, Meagan; Pichika, Rajeswari; Sato, Eugene J.; Lieber, Richard L.; Schenk, Simon; Lane, John G.; Ward, Samuel R.
Background: Rotator cuff pathology is a common source of shoulder pain with variable etiology and pathoanatomical characteristics. Pathological processes of fatty infiltration, muscle atrophy, and fibrosis have all been invoked as causes for poor outcomes after rotator cuff tear repair. The aims of this study were to measure the expression of key genes associated with adipogenesis, myogenesis, and fibrosis in human rotator cuff muscle after injury and to compare the expression among groups of patients with varied severities of rotator cuff pathology. Methods: Biopsies of the supraspinatus muscle were obtained arthroscopically from twenty-seven patients in the following operative groups: bursitis (n = 10), tendinopathy (n = 7), full-thickness rotator cuff tear (n = 8), and massive rotator cuff tear (n = 2). Quantitative polymerase chain reaction (qPCR) was performed to characterize gene expression pathways involved in myogenesis, adipogenesis, and fibrosis. Results: Patients with a massive tear demonstrated downregulation of the fibrogenic, adipogenic, and myogenic genes, indicating that the muscle was not in a state of active change and may have difficulty responding to stimuli. Patients with a full-thickness tear showed upregulation of fibrotic and adipogenic genes; at the tissue level, these correspond to the pathologies most detrimental to outcomes of surgical repair. Patients with bursitis or tendinopathy still expressed myogenic genes, indicating that the muscle may be attempting to accommodate the mechanical deficiencies induced by the tendon tear. Conclusions: Gene expression in human rotator cuff muscles varied according to tendon injury severity. Patients with bursitis and tendinopathy appeared to be expressing pro-myogenic genes, whereas patients with a full-thickness tear were expressing genes associated with fatty atrophy and fibrosis. In contrast, patients with a massive tear appeared to have downregulation of all gene programs except inhibition of
Ross, David; Maerz, Tristan; Lynch, Jamie; Norris, Sarah; Baker, Kevin; Anderson, Kyle
Physical rehabilitation following arthroscopic rotator cuff repair has conventionally involved a 4- to 6-week period of immobilization; there are two schools of thought regarding activity level during this period. Some authors encourage early, more aggressive rehabilitation along with the use of a continuous passive motion device; others propose later, more conservative rehabilitation. Although some studies report trends in improved early range of motion, pain relief, and outcomes scores with aggressive rehabilitation following rotator cuff repair, no definitive consensus exists supporting a clinical difference resulting from rehabilitation timing in the early stages of healing. Rehabilitation timing does not affect outcomes after 6 to 12 months postoperatively. Given the lack of information regarding which patient groups benefit from aggressive rehabilitation, individualized patient care is warranted.
Kraeutler, Matthew J; Freedman, Kevin B; MacLeod, Robert A; Schrock, John B; Tjoumakaris, Fotios P; McCarty, Eric C
Analysis of the number of citations within a given specialty provides information on the classic publications of that specialty. The goals of this study were to identify the 50 most cited articles on rotator cuff repair and to analyze various characteristics of these articles. The ISI Web of Science (Thomson Reuters, Philadelphia, Pennsylvania) was used to conduct a search for the term rotator cuff repair. The 50 most cited articles were retrieved, and the following objective characteristics of each article were recorded: number of times cited, citation density, journal, country of origin, and language. The following subjective characteristics of each article were also recorded: article type (clinical vs basic science), article subtype, and level of evidence for clinical articles. Of the 50 most cited articles on rotator cuff repair, the number of citations ranged from 138 to 677 (mean, 232±133 citations) and citation density ranged from 3.8 to 53.5 citations per year (mean, 16.9±9.2 citations per year). The articles were published between 1974 and 2011, with most of the articles published in the 2000s (29 articles), followed by the 1990s (16 articles). The articles originated from 8 countries, with the United States accounting for 30 articles (60%). Overall, 66% of the articles were clinical and 34% were basic science. The most common article subtype was the clinical case series (48%). Of the 33 clinical articles, 24 (73%) were level IV. Among the 50 most cited articles on rotator cuff repair, the case series was the most common article subtype, showing the effect that publication of preliminary outcomes and new surgical techniques has had on surgeons performing rotator cuff repair. [Orthopedics. 2016; 39(6):e1045-e1051.].
Terhune, E. Bailey; Cannamela, Peter C.; Johnson, Jared S.; Saad, Charles D.; Barnes, John; Silbernagel, Janette; Faciszewski, Thomas; Shea, Kevin G.
Background: As value becomes a larger component of heath care decision making, cost data can be evaluated for regional and physician variation. Value is determined by outcome divided by cost, and reducing cost increases value for patients. “Third-party spend” items are individual selections by surgeons used to perform procedures. Cost data for third-party spend items provide surgeons and hospitals with important information regarding care value, potential cost-saving opportunities, and the total cost of ownership of specific clinical decisions. Purpose: To perform a cost review of isolated rotator cuff repair within a regional 7-hospital system and to document procedure cost variation among operating surgeons. Study Design: Economic and decision analysis; Level of evidence, 4. Methods: Current Procedural Terminology (CPT) codes were used to retrospectively identify subjects who received an isolated rotator cuff repair within a 7-hospital system. Cost data were collected for clinically sensitive third-party spend items and divided into 4 cost groups: (1) suture anchors, (2) suture-passing devices and needles, (3) sutures used for cuff repair, and (4) disposable tools or instruments. Results: A total of 62 isolated rotator cuff repairs were performed by 17 surgeons over a 13-month period. The total cost per case for clinically sensitive third-party spend items (in 2015 US dollars) ranged from $293 to $3752 (mean, $1826). Four surgeons had a mean procedure cost that was higher than the data set mean procedure cost. The cost of an individual suture anchor ranged from $75 to $1775 (mean, $403). One disposable suture passer was used, which cost $140. The cost of passing needles ranged from $140 to $995 (mean, $468). The cost per repair suture (used to repair cuff tears) varied from $18 to $298 (mean, $61). The mean suture (used to close wounds) cost per case was $81 (range, $0-$454). A total of 316 tools or disposable instruments were used, costing $1 to $1573 per
Valencia Mora, Maria; Ruiz Ibán, Miguel A; Díaz Heredia, Jorge; Barco Laakso, Raul; Cuéllar, Ricardo; García Arranz, Mariano
Rotator cuff tears are frequent shoulder problems that are usually dealt with surgical repair. Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon. It is essential to understand the molecular mechanisms that determine this failure. The study of the molecular environment during embryogenesis and during normal healing after injury is key in devising strategies to get a successful repair. Mesenchymal stem cells (MSC) can differentiate into different mesodermal tissues and have a strong paracrine, anti-inflammatory, immunoregulatory and angiogenic potential. Stem cell therapy is thus a potentially effective therapy to enhance rotator cuff healing. Promising results have been reported with the use of autologous MSC of different origins in animal studies: they have shown to have better healing properties, increasing the amount of fibrocartilage formation and improving the orientation of fibrocartilage fibers with less immunologic response and reduced lymphocyte infiltration. All these changes lead to an increase in biomechanical strength. However, animal research is still inconclusive and more experimental studies are needed before human application. Future directions include expanded stem cell therapy in combination with growth factors or different scaffolds as well as new stem cell types and gene therapy.
Mora, Maria Valencia; Ibán, Miguel A Ruiz; Heredia, Jorge Díaz; Laakso, Raul Barco; Cuéllar, Ricardo; Arranz, Mariano García
Rotator cuff tears are frequent shoulder problems that are usually dealt with surgical repair. Despite improved surgical techniques, the tendon-to-bone healing rate is unsatisfactory due to difficulties in restoring the delicate transitional tissue between bone and tendon. It is essential to understand the molecular mechanisms that determine this failure. The study of the molecular environment during embryogenesis and during normal healing after injury is key in devising strategies to get a successful repair. Mesenchymal stem cells (MSC) can differentiate into different mesodermal tissues and have a strong paracrine, anti-inflammatory, immunoregulatory and angiogenic potential. Stem cell therapy is thus a potentially effective therapy to enhance rotator cuff healing. Promising results have been reported with the use of autologous MSC of different origins in animal studies: they have shown to have better healing properties, increasing the amount of fibrocartilage formation and improving the orientation of fibrocartilage fibers with less immunologic response and reduced lymphocyte infiltration. All these changes lead to an increase in biomechanical strength. However, animal research is still inconclusive and more experimental studies are needed before human application. Future directions include expanded stem cell therapy in combination with growth factors or different scaffolds as well as new stem cell types and gene therapy. PMID:26029341
Miyazaki, Alberto Naoki; Fregoneze, Marcelo; Santos, Pedro Doneux; Silva, Luciana Andrade; Eduardo, Cesar Moreira Mariz Pinto Rodrigo Tormin Ortiz; Checchia, Sergio Luiz
To assess the outcomes of the surgical treatment of extensive rotator cuff injuries through arthroscopy. Methods: Between June 1998 and October 2006, 61 patients with extensive rotator cuff injuries and submitted to surgical arthroscopy technique by the Shoulder and Elbow Group of the Department of Orthopaedics and Traumatology, Santa Casa de Misericórdia Medical School were reassessed. The study included all patients with at least two tendons affected or with retraction at least on two tendons up to the glenoidal cavity edge and with at least 12 months of follow-up. Results: According to UCLA's evaluation criteria, 54 (89%) patients showed excellent or good outcomes; no fair outcome in none of the patients; and seven (11%) poor outcomes. A satisfaction rate of 92% was reported. Postoperative joint motion went from a mean lifting value of 93° to 141°, the mean lateral rotation went from 32° to 48° and the mean medial rotation went from L1 to T10. These differences were regarded as statistically significant. Conclusion: The arthroscopic repair of extensive rotator cuff injuries leads to satisfactory outcomes for most of the patients, with a high satisfaction degree. PMID:26998466
Meyer, Gretchen A; Farris, Ashley L; Sato, Eugene; Gibbons, Michael; Lane, John G; Ward, Samuel R; Engler, Adam J
Chronic rotator cuff (RC) tears affect a large portion of the population and result in substantial upper extremity impairment, shoulder weakness, pain, and limited range of motion. Regardless of surgical or conservative treatment, persistent atrophic muscle changes limit functional restoration and may contribute to surgical failure. We hypothesized that deficits in the skeletal muscle progenitor (SMP) cell pool could contribute to poor muscle recovery following tendon repair. Biopsies were obtained from patients undergoing arthroscopic RC surgery. The SMP population was quantified, isolated, and assayed in culture for its ability to proliferate and fuse in vitro and in vivo. The SMP population was larger in muscles from cuffs with partial tears compared with no tears or full thickness tears. However, SMPs from muscles in the partial tear group also exhibited reduced proliferative ability. Cells from all cuff states were able to fuse robustly in culture and engraft when injected into injured mouse muscle, suggesting that when given the correct signals, SMPs are capable of contributing to muscle hypertrophy and regeneration regardless of tear severity. The fact that this does not appear to happen in vivo helps focus future therapeutic targets for promoting muscle recovery following rotator cuff repairs and may help improve clinical outcomes.
Simone, J P; Streubel, P H; Sperling, J W; Schleck, C D; Cofield, R H; Athwal, G S
We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture. Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears.
Kokmeyer, Dirk; Dube, Eric; Millett,, Peter J.
Background: Rehabilitation after rotator cuff repair surgery has been the focus of several clinical trials in the past decade. Many illuminate new evidence with regard to the prognosis of structural and functional success after surgery. Methods: A selective literature search was performed and personal physiotherapeutic and surgical experiences are reported. Results: Post-operative rehabilitation parameters, namely the decision to delay or allow early range of motion after surgery, play a large role in the overall success after surgery. Using a prognosis driven rehabilitation program offers clinicians a means of prescribing optimal rehabilitation parameters while ensuring structural and functional success. This commentary aims to synthesize the evidence in a spectrum of prognostic factors to guide post-operative rehabilitation. Conclusion: The optimal rehabilitation program after rotator cuff repair surgery is debatable; therefore, we suggest using a spectrum of prognostic factors to determine a rehabilitation program suited to ensure structural and functional success, quickly and safely. PMID:27708736
Oliva, Francesco; Piccirilli, Eleonora; Bossa, Michela; Via, Alessio Giai; Colombo, Alessandra; Chillemi, Claudio; Gasparre, Giuseppe; Pellicciari, Leonardo; Franceschetti, Edoardo; Rugiero, Clelia; Scialdoni, Alessandro; Vittadini, Filippo; Brancaccio, Paola; Creta, Domenico; Buono, Angelo Del; Garofalo, Raffaele; Franceschi, Francesco; Frizziero, Antonio; Mahmoud, Asmaa; Merolla, Giovanni; Nicoletti, Simone; Spoliti, Marco; Osti, Leonardo; Padulo, Johnny; Portinaro, Nicola; Tajana, Gianfranco; Castagna, Alex; Foti, Calogero; Masiero, Stefano; Porcellini, Giuseppe; Tarantino, Umberto; Maffulli, Nicola
Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources. PMID:26958532
Nérot, C; Jully, J L; Gérard, Y
Among the all rotator cuff tears, the subscapularis lesions are quite rare. But a careful analysis leads to recognize them specially in case of antero-medial impingement between the coracoid process and the head of the humerus. This study of 25 observations where the rupture of the subscapularis was the predominant lesion, allows to emphasize some characteristics of them. The patients are often younger than for the other ruptures, a traumatic experience is not rare at the beginning of the history, the pain is usually the first symptom before the functional disability, the alterations of the rotator-interval and of the biceps tendon are very frequent, the arthroscanner is a very good help for the diagnosis and satisfying stitches are possible in case of early diagnoses. Lastly, the prognosis of these limited lesions is quite different than the one of very large cuff tears including the suscapularis tendon.
Singaraju, Vamsi M; Kang, Richard W; Yanke, Adam B; McNickle, Allison G; Lewis, Paul B; Wang, Vincent M; Williams, James M; Chubinskaya, Susan; Romeo, Anthony A; Cole, Brian J
Patients with chronic rotator cuff tears frequently have anterior shoulder pain attributed to the long head of the biceps brachii (LHBB) tendon. In this study, tenodesis or tenotomy samples and cadaveric controls were assessed by use of immunohistochemical and histologic methods to quantify inflammation, vascularity, and neuronal plasticity. Patients had moderate pain and positive results on at least 1 clinical test of shoulder function. The number of axons in the distal LHBB was significantly less in patients with biceps tendinitis. Calcitonin gene-related peptide and substance P immunostaining was predominantly within nerve roots and blood vessels. A moderate correlation (R = 0.5) was identified between LHBB vascularity and pain scores. On the basis of these results, we conclude that, in the context of rotator cuff disease, the etiology of anterior shoulder pain with macroscopic changes in the biceps tendon is related to the complex interaction of the tendon and surrounding soft tissues, rather than a single entity.
Franceschi, J P; Curvale, G; Acquaviva, P; Lafforgue, P; Mattei, J P; Roux, H
This study analyses the results of 30 surgical repairs of the rotator cuff. The basic problem was degenerative pathology in which medical treatment had been tried previously in all cases. The type of treatment was based upon preoperative evaluation and arthro-CT scan in particular. Results were invariably good, with regression of pain and recovery of activity. Muscle power was significantly correlated with the value of the tendon repaired, this being reflected overall by incomplete recovery.
Lawson, Kevin A; Codella, Stephen; Ciccotti, Michael G; Kane, Patrick W; Duncan, Ian C; Cohen, Steven B
The content and quality of Internet websites are not governed or regulated. Therefore, patients who consult the Internet may receive outdated or incorrect medical information. Researchers have analyzed the quality of web information about various orthopedic surgeries, but no such analysis has been performed on websites covering rotator cuff repair. We conducted a study to evaluate and analyze rotator cuff repair information available to the general public through the Internet; to assess changes in the quality of information over time; to determine if sites sponsored by academic institutions offered higher-quality information; and to assess whether the readability of the material varied according to DISCERN scores. Two Internet searches were conducted, in 2011 and 2014. The 3 most commonly used search engines were used to search for rotator cuff repair. The first 50 websites from each search engine were evaluated for authorship and content. The DISCERN instrument was used to analyze the quality of each website's health information. The 2011 search revealed 21% of websites were associated with an academic institution, 38% were authored by a hospital or physician group, and 11.5% were industry-sponsored. The 2014 search revealed a similar distribution of contributors. The highest DISCERN scores were given to academic institution websites (51.6) and public education websites (49). There was no correlation between readability and DISCERN scores. Websites associated with academic institutions produced the highest-quality medical information. Over the past few years, authorship and content have changed little with respect to Internet information about rotator cuff repair.
... Rest. Your doctor may suggest rest and activity modiﬁcation, such as avoiding overhead activities. Non-steroidal anti- ... on a strengthening program for the rotator cuﬀ muscles. Steroid injection. If rest, medications, and physical therapy ...
Petri, M.; Ettinger, M.; Brand, S.; Stuebig, T.; Krettek, C.; Omar, M.
Background: The role of nonoperative management for rotator cuff tears remains a matter of debate. Clinical results reported in the literature mainly consist of level IV studies, oftentimes combining a mixed bag of tear sizes and configurations, and are contradictory to some extent. Methods: A selective literature search was performed and personal surgical experiences are reported. Results: Most studies show an overall success rate of around 75% for nonoperative treatment. However, the majority of studies also present a progression of tear size and fatty muscle infiltration over time, with however debatable clinical relevance for the patient. Suggested factors associated with progression of a rotator cuff tear are an age of 60 years or older, full-thickness tears, and fatty infiltration of the rotator cuff muscles at the time of initial diagnosis. Conclusion: Non-operative management is indicated for patients with lower functional demands and moderate symptoms, and/or of course for those refusing to have surgery. Close routinely monitoring regarding development of tear size should be performed, especially in patients that remain symptomatic during nonoperative treatment. To ensure judicious patient counseling, it has to be taken into account that 1) tears that are initially graded as reparable may become irreparable over time, and 2) results after secondary surgical therapy after failed nonoperative treatment are usually reported to be inferior to those who underwent primary tendon repair. PMID:27708737
Murray, Iain R; LaPrade, Robert F; Musahl, Volker; Geeslin, Andrew G; Zlotnicki, Jason P; Mann, Barton J; Petrigliano, Frank A
Rotator cuff tears are common and result in considerable morbidity. Tears within the tendon substance or at its insertion into the humeral head represent a considerable clinical challenge because of the hostile local environment that precludes healing. Tears often progress without intervention, and current surgical treatments are inadequate. Although surgical implants, instrumentation, and techniques have improved, healing rates have not improved, and a high failure rate remains for large and massive rotator cuff tears. The use of biologic adjuvants that contribute to a regenerative microenvironment have great potential for improving healing rates and function after surgery. This article presents a review of current and emerging biologic approaches to augment rotator cuff tendon and muscle regeneration focusing on the scientific rationale, preclinical, and clinical evidence for efficacy, areas for future research, and current barriers to advancement and implementation.
Anastasopoulos, Panagiotis P.; Alexiadis, George; Spyridonos, Sarantis; Fandridis, Emmanouil
Background: Massive rotator cuff tears pose a difficult and complex challenge even for the experienced surgeon; inability to repair these tears by conventional means designates them as irreparable, while management becomes quite taxing. Several operative options have been suggested for the management of such lesions with varying degrees of success, while it is imperative to match patient demands and expectations to the predicted outcome. Methods: Research articles are examined and key concepts are discussed, in order to provide an evidence based review of the available literature. The anatomy and pathomechanics along with the indications, contraindications and surgical techniques are reported. Results: Transfer of the Latissimus dorsi has been used with success to restore shoulder function in deficits of the posterior rotator cuff. Although it can be used in a variety of settings, the ideal patient for a Latissimus dorsi tendon transfer is a young and active individual, with no glenohumeral osteoarthritis that has a severe disability and weakness related to an irreparable posterior cuff tear. Conclusion: Tendon transfers have proved to be a successful treatment option in salvaging this difficult problem, providing pain relief and restoring shoulder function. Despite the excellent functional outcomes and pain suppression following operation, a variety of factors may affect the outcome; thus making indications and preoperative assessment a valuable component.
Godinho, Glaydson Gomes; França, Flávio de Oliveira; Freitas, José Márcio Alves; Santos, Flávio Márcio Lago; Prandini, Alexandre; Godinho, André Couto; Costa, Rafael Patrocínio de Paula
Objectives To evaluate function among patients with postoperative recurrence of rotator cuff injuries that was treated arthroscopically (case series) and compare this with function in patients without recurrence (control group); and to compare function among patients with recurrence of rotator cuff injuries that were greater than and smaller than 3 cm. Methods This was a retrospective evaluation of patients who underwent arthroscopic revision of rotator cuff injuries using the ASES, Constant & Murley and UCLA scores and a visual analog pain scale, in comparison with patients in a control group who underwent primary rotator cuff repair. Results The size of the rotator cuff injury recurrence had a statistically significant influence on the result from the arthroscopic surgical treatment. The functional scores showed worse results than those from the first procedure. Conclusion Arthroscopic surgical treatment of renewed tearing of rotator cuff injuries showed worse functional scores than those from primary repair of the injury. PMID:26229900
Kelly, James D
Rotator cuff failure by suture-bone or suture anchor pull-out, suture breakage, knot slippage, and tendon pull-out are well described. I report a case of early disintegration of a bioabsorbable suture anchor. A 77-year-old woman underwent arthroscopic rotator cuff repair. On suspecting failure, the repair was repeated 40 days later. Arthroscopy revealed disintegration of the suture loop from the anchor. Open rotator cuff repair was then performed with transosseous suture and metallic anchors.
Yadav, Pankaj K; Shah, Bhavin; Shende, Amol; Rajesh, S
The objective of this study was to evaluate the role of biceps tendon sheath effusion detected on ultrasound as a diagnostic clue to rotator cuff pathology. Despite being the most common cause of shoulder pain in adults early sonographic changes of rotator cuff tendinopathy are easy to miss. A total of 31 patients out of whom 27 had unilateral shoulder pain and 4 had bilateral complaints under- went ultrasonographic examination of shoulder joint using high frequency linear array transducer. Any fluid surrounding the long head of biceps tendon was noted followed by a careful search for any associated sonographic abnormality involving the rotator cuff. Eighteen out of the 35 had presence of fluid in their biceps tendon sheath. Twelve had presence of both biceps tendon sheath effusion and rotator cuff pathologies. Among 17 patients, who had no fluid in their biceps tendon sheath, only 2 had rotator cuff involvement whereas rest 15 had neither biceps tendon sheath fluid nor rotator cuff pathologies. A significant association was found between presence of fluid in long head of biceps tendon sheath and rotator cuff pathologies. Thus the most common finding observed in association with the presence of fluid around the long head of biceps tendon sheath in this study was tendinosis of rotator cuff. On ultrasonography simple presence of fluid around the long head of biceps tendon sheath demands careful examination of rotator cuff.
Cho, Edward; Zhang, Yue; Pruznak, Anne; Kim, H Mike
Fatty degeneration of the rotator cuff muscles is an irreversible change resulting from chronic rotator cuff tear and is associated with poor clinical outcomes following rotator cuff repair. We evaluated the effect of Tamoxifen, a competitive estrogen receptor inhibitor, on fatty degeneration using a mouse model for chronic rotator cuff tear. Sixteen adult mice were divided into two diet groups (Tamoxifen vs. Regular) and subjected to surgical creation of a large rotator cuff tear and suprascapular nerve transection in their left shoulder with the right shoulder serving as a control. The rotator cuff muscles were harvested at 16 weeks and subjected to histology and RT-PCR for adipogenic and myogenic markers. Histology showed substantially decreased atrophy and endomysial inflammation in Tamoxifen group, but no significant differences in the amount of intramuscular adipocytes and lipid droplets compared to the Regular group. With RT-PCR, the operated shoulders showed significant upregulation of myogenin and PPAR-γ, and downregulation of myostatin compared to the nonsurgical shoulder. No significant differences of gene expression were found between the two diet groups. Our study demonstrated that tamoxifen diet leads to decreased muscle atrophy and inflammatory changes following chronic rotator cuff tear, but has no apparent effect on adipogenesis.
Passaretti, Daniele; Candela, Vittorio; Venditto, Teresa; Giannicola, Giuseppe; Gumina, Stefano
Background and purpose — Long-term alcohol intake is associated with various negative effects on capillary microcirculation and tissue perfusion. We hypothesized that alcohol consumption might be a risk factor for both the occurrence and the severity of rotator cuff tears (RCTs). Patients and methods — A case-control study was performed. We studied 249 consecutive patients (139 men and 110 women; mean age 64 (54–78) years) who underwent arthroscopic rotator cuff repair. Tear size was determined intraoperatively. The control group had 356 subjects (186 men and 170 women; mean age 66 (58–82) years) with no RCT. All participants were questioned about their alcohol intake. Participants were divided into: (1) non-drinkers if they consumed less than 0.01 g of ethanol per day, and (2) moderate drinkers and (3) excessive drinkers if women (men) consumed > 24 g (36 g) per day for at least 2 years. Results — Total alcohol consumption, wine consumption, and duration of alcohol intake were higher in both men and women with RCT than in both men and women in the control group. Excessive alcohol consumption was found to be a risk factor for the occurrence of RCT in both sexes (men: OR = 1.7, 95% CI: 1.2–3.9; women: OR = 1.9, 95% CI: 0.94–4.1). Massive tears were associated with a higher intake of alcohol (especially wine) than smaller lesions. Interpretation — Long-term alcohol intake is a significant risk factor for the occurrence and severity of rotator cuff tear in both sexes. PMID:26610042
It is now over a decade since the features defining a contractile dysfunction of the shoulder were first reported. Since this time, some progress has been made to better understand this mechanical syndrome. In response to these developments, this narrative review will explore current understanding in relation to pathology, diagnosis, treatment, and prognosis of this syndrome with reference to literature specifically relating to contractile dysfunction but also literature relating to rotator cuff tendinopathy where necessary. The review not only identifies the strengths of the mechanical diagnosis and therapy approach with reference to a contractile dysfunction of the shoulder but also identifies where further progress needs to be made.
Dilisio, Matthew F.; Neyton, Lionel
The comma sign was described as an arthroscopic landmark to identify the torn subscapularis stump to mobilize and repair the tendon in anterosuperior rotator cuff tears. It was hypothesized that it is composed of the humeral attachments of the superior glenohumeral and coracohumeral ligaments. This arthroscopic finding has since become accepted orthopaedic nomenclature pathognomonic for subscapularis tears and a key component of subscapularis tear classification. We propose an alternative theory of the pathoanatomy of the comma sign in anterosuperior rotator cuff tears and present the technique of comma sign–directed repairs of combined subscapularis and supraspinatus lesions. After appropriate releases, tendon-to-tendon repair of the distal-superior aspect of the comma sign to the upper border of the remnant subscapularis results in anatomic re-creation of the intra-articular portion of the torn subscapularis with concomitant reduction of the anterior leading edge of the supraspinatus and reconstitution of the rotator cable complex. A tension-free, single-anchor subscapularis repair is then performed to secure the tendon to the lesser tuberosity. After subscapularis repair, the supraspinatus that was previously retracted to the glenoid rim takes the appearance of a crescent-type tear that is easily approximated to its anatomic insertion. PMID:25685676
Gibbons, Michael C; Sato, Eugene J; Bachasson, Damien; Cheng, Timothy; Azimi, Hassan; Schenk, Simon; Engler, Adam J; Singh, Anshuman; Ward, Samuel R
Rotator cuff (RC) tendon tears lead to negative structural and functional changes in the associated musculature. The structural features of muscle that predict function are termed "muscle architecture." Although the architectural features of "normal" rotator cuff muscles are known, they are poorly understood in the context of cuff pathology. The purpose of this study was to investigate the effects of tear and repair on RC muscle architecture. To this end thirty cadaveric shoulders were grouped into one of four categories based on tear magnitude: Intact, Full-thickness tear (FTT), Massive tear (MT), or Intervention if sutures or hardware were present, and key parameters of muscle architecture were measured. We found that muscle mass and fiber length decreased proportionally with tear size, with significant differences between all groups. Conversely, sarcomere number was reduced in both FTT and MT with no significant difference between these two groups, in large part because sarcomere length was significantly reduced in MT but not FTT. The loss of muscle mass in FTT is due, in part, to subtraction of serial sarcomeres, which may help preserve sarcomere length. This indicates that function in FTT may be impaired, but there is some remaining mechanical loading to maintain "normal" sarcomere length-tension relationships. However, the changes resulting from MT suggest more severe limitations in force-generating capacity because sarcomere length-tension relationships are no longer normal. The architectural deficits observed in MT muscles may indicate deeper deficiencies in muscle adaptability to length change, which could negatively impact RC function despite successful anatomical repair. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2089-2095, 2016.
Cortez, Paulo José Oliveira; Tomazini, José Elias
OBJECTIVE: To compare the strength generated by the rotator muscles of the shoulder joint between the right upper limb and left upper limb among healthy individuals. METHODS: To evaluate the muscle strength of upper limbs from isometric contractions in the horizontal direction (rotation) an isometric dynamometer was used, equipped with transducers, signal conditioning, a data acquisition board, and finally, a computer. Study participants were 22 male military subjects, aged between 18 and 19 years old, body mass between 57.7 and 93.0 kg (71.8 ± 9.45 kg) and height between 1.67 and 1.90 m (1.75 ± 0.06 m), healthy and without clinical diseases or any type of orthopedic injury in the muscle skeletal system. RESULTS: The internal rotation in the right upper limb (RUL) was higher than the average strength of internal rotation in the left upper limb (LUL) (p = 0.723). The external rotation strength in RUL was lower than the average strength of external rotation in the LUL (p=0.788). No statistical difference was observed by comparing the strength values of all isometric strength tests. CONCLUSION: For the sample and methodology used to assess muscle strength, there was no statistical difference between the strength generated by the muscles of the rotator cuff of the right and left upper limbs. Experimental Study. PMID:26207091
Pécora, José Otávio Reggi; Malavolta, Eduardo Angeli; Assunção, Jorge Henrique; Gracitelli, Mauro Emílio Conforto; Martins, João Paulo Sobreiro; Ferreira, Arnaldo Amado
OBJECTIVE: To identify prognostic factors of postoperative functional outcomes. METHODS: Retrospective case series evaluating patients undergoing rotator cuff repair, analyzed by the UCLA score (pre and 12-month postoperative) and Magnetic Resonance Imaging (preoperative). Patients' intrinsic variables related to the injury and intervention were evaluated. Multivariate linear regression analysis was performed to determine variables impact on postoperative functional assessment. RESULTS: 131 patients were included. The mean UCLA score increased from 13.17 ± 3.77 to 28.73 ± 6.09 (p<0,001). We obtained 65.7% of good and excellent results. Age (r= 0.232, p= 0.004) and reparability of posterosuperior injuries (r= 0.151, p= 0.043) correlated with the functional assessment at 12 months. After multivariate linear regression analysis, only age was associated (p = 0.008). CONCLUSIONS: The surgical treatment of rotator cuff tears lead to good and excellent results in 65.6% of patients. Age was an independent predictor factor with better clinical outcomes by UCLA score in older patients. Level of Evidence IV, Case Series. PMID:26207092
Meschino, G. J.; Comas, D. S.; González, M. A.; Capiel, C.; Ballarin, V. L.
Evaluation and diagnosis of diseases of the muscles within the rotator cuff can be done using different modalities, being the Magnetic Resonance the method more widely used. There are criteria to evaluate the degree of fat infiltration and muscle atrophy, but these have low accuracy and show great variability inter and intra observer. In this paper, an analysis of the texture features of the rotator cuff muscles is performed to classify them and other tissues. A general supervised classification approach was used, combining forward-search as feature selection method with kNN as classification rule. Sections of Magnetic Resonance Images of the tissues of interest were selected by specialist doctors and they were considered as Gold Standard. Accuracies obtained were of 93% for T1-weighted images and 92% for T2-weighted images. As an immediate future work, the combination of both sequences of images will be considered, expecting to improve the results, as well as the use of other sequences of Magnetic Resonance Images. This work represents an initial point for the classification and quantification of fat infiltration and muscle atrophy degree. From this initial point, it is expected to make an accurate and objective system which will result in benefits for future research and for patients’ health.
Pill, Stephan G; Walch, Gilles; Hawkins, Richard J; Kissenberth, Michael J
Tendinopathy of the long head of the biceps (LHB) tendon commonly occurs in patients with rotator cuff tears, and the inflammation of one head tends to lead to inflammation of the other. Many theories have been proposed regarding the function of the LHB tendon; however, its exact purpose is poorly understood. It has been described as an important stabilizer of the glenohumeral joint, a depressor of the humeral head, and as a vestigial structure. The LHB tendon can be a significant source of pain in patients with rotator cuff tears. The appropriate treatment depends on the patient's age, comorbidities, activity level, extent of disability, the presence of rotator cuff arthropathy, and the quality of the rotator cuff tissue. Conservative treatment is usually attempted first, with modalities such as nonsteroidal anti-inflammatory drugs, corticosteroid injections, physical therapy, and activity modification. If symptoms persist, biceps tenotomy or tenodesis may be combined with rotator cuff repair, depending on the quality of the rotator cuff tissue, the severity of rotator cuff arthropathy, and the willingness of the patient to comply with postoperative immobilization and rehabilitation. Even when rotator cuff repair is not possible, isolated tenotomy or tenodesis of the LHB tendon can provide substantial pain relief.
Brand, Jefferson C
In "Risk Factors for Infection After Rotator Cuff Repair," B. G. Vopat et al. report a lower rate of postoperative infection with an arthroscopic rotator cuff repair than with an open or mini-open approach. Although there were only 14 infections (infection rate of 0.77%), the reason for the preponderance of male patients, 13 of the 14 infections, needs further research to determine effective preventive strategies.
Davies, Michael R; Ravishankar, Bharat; Laron, Dominique; Kim, Hubert T; Liu, Xuhui; Feeley, Brian T
Rotator cuff tears (RCTs) are among the most common musculoskeletal injuries seen by orthopaedic surgeons. Clinically, massive cuff tears lead to unique pathophysiological changes in rotator cuff muscle, including atrophy, and massive fatty infiltration, which are rarely seen in other skeletal muscles. Studies in a rodent model for RCT have demonstrated that these histologic findings are accompanied by activation of the Akt/mammalian target of rapamycin (mTOR) and transforming growth factor-β (TGF-β) pathways following combined tendon-nerve injury. The purpose of this study was to compare the histologic and molecular features of rotator cuff muscle and gastrocnemius muscle--a major hindlimb muscle, following combined tendon-nerve injury. Six weeks after injury, the rat gastrocnemius did not exhibit notable fatty infiltration compared to the rotator cuff. Likewise, the adipogenic markers SREBP-1 and PPARγ as well as the TGF-β canonical pathway were upregulated in the rotator cuff, but not the gastrocnemius. Our study suggests that the rat rotator cuff and hindlimb muscles differ significantly in their response to a combined tendon-nerve injury. Clinically, these findings highlight the unique response of the rotator cuff to injury, and may begin to explain the poor outcomes of massive RCTs compared to other muscle-tendon injuries.
Riley, G P; Harrall, R L; Constant, C R; Chard, M D; Cawston, T E; Hazleman, B L
OBJECTIVES--To analyse the collagen composition of normal adult human supraspinatus tendon and to compare with: (1) a flexor tendon (the common biceps tendon) which is rarely involved in any degenerative pathology; (2) degenerate tendons from patients with chronic rotator cuff tendinitis. METHODS--Total collagen content, collagen solubility and collagen type were investigated by hydroxyproline analysis, acetic acid and pepsin digestion, cyanogen bromide peptide analysis, SDS-PAGE and Western blotting. RESULTS--The collagen content of the normal cadaver supraspinatus tendons (n = 60) was 96.3 micrograms HYPRO/mg dry weight (range 79.3-113.3) and there was no significant change across the age range 11 to 95 years. There was no significant difference from the common biceps tendon [93.3 (13.5) micrograms HYPRO/mg dry weight, n = 24]. Although extremely insoluble in both acetic acid and pepsin, much of the collagen was soluble after cyanogen bromide digestion [mean 47.9% (29.8)]. Seventeen per cent (10/60) of the 'normal' cadaver supraspinatus tendon sample contained more than 5% type III collagen, although none of the common biceps tendons had significant amounts. Degenerate supraspinatus and subscapularis tendons had a reduced collagen content [83.8 (13.9) micrograms/mg dry weight and 76.9 (16.8) micrograms/mg dry wt respectively) and were more soluble in acetic acid, pepsin and cyanogen bromide (p < 0.001). Eighty two per cent (14/17) of supraspinatus tendons and 100% (8/8) of subscapularis tendons from patients with tendinitis contained more than 5% type III collagen. CONCLUSIONS--The changes in collagen composition in rotator cuff tendinitis are consistent with new matrix synthesis, tissue remodelling and wound healing, in an attempt to repair the tendon defect, even in old and degenerate tendons. An increase in type III collagen in some 'normal' cadaver supraspinatus tendons is evidence that changes in collagen synthesis and turnover may precede tendon rupture
Park, Jung Gwan; Cho, Nam Su; Song, Jong Hoon; Baek, Jong Hun; Jeong, Ho Yeon
Background Some studies have shown significant functional improvement after rotator cuff (RC) repair in elderly patients. However, few studies have reported the healing potential of RC tears in elderly patients. Methods Twenty-five patients aged ≥ 75 years who underwent RC repair were enrolled. The mean age at the time of surgery was 78.3 years (range, 75 to 88 years) while the mean follow-up was 36.3 months (range, 18 to 114 months). We evaluated clinical and structural outcomes after RC repair in the retear and healed groups. Results Of 25 patients, 16 (64%) had healed RC lesions and 9 (36%) had retorn cuff lesions. The retear rate increased significantly with increasing initial tear size (small to medium, 13%; large, 60%; massive, 80%; p = 0.024) but not with increasing age (p = 0.072). The mean visual analog scale (VAS), University of California Los Angeles (UCLA), and Constant scores significantly improved from 5.2, 15.8, and 49.3 preoperatively to 1.4, 31.1, and 71.9 in the healed group and from 6.0, 14.4, and 39.5 preoperatively to 2.4, 28.3, and 63.6 in the retear group at the final follow-up (p < 0.05, respectively). There were no significant differences in clinical outcomes between the 2 groups at the final follow-up. Retear was significantly correlated with initial tear size (p = 0.001; odds ratio [OR], 2.771; 95% confidence interval [CI], 1.394 to 5.509 for large to massive tears) (p = 0.001; OR, 0.183; 95% CI, 0.048 to 0.692 for small to medium tears). Conclusions There were significant improvements in clinical outcomes after RC repair in patients ≥ 75 years. Structural integrity after cuff repair did not affect the final clinical outcome. Even in elderly patients aged ≥ 75 years, healing of repaired RC can be expected in cases of small to medium tears. Although the retear rate was relatively high for large to massive tears, clinical outcomes still showed significant improvement. PMID:27904725
Nissan, J; Zenziper, E; Rosner, O; Kolerman, R; Chaushu, L; Chaushu, G
Soft tissue shrinkage during the course of restoring dental implants may result in biological and prosthodontic difficulties. This study was conducted to measure the continuous shrinkage of the mucosal cuff around dental implants following the removal of the healing abutment up to 60 s. Individuals treated with implant-supported fixed partial dentures were included. Implant data--location, type, length, diameter and healing abutments' dimensions--were recorded. Mucosal cuff shrinkage, following removal of the healing abutments, was measured in bucco-lingual direction at four time points--immediately after 20, 40 and 60 s. anova was used to for statistical analysis. Eighty-seven patients (49 women and 38 men) with a total of 311 implants were evaluated (120 maxilla; 191 mandible; 291 posterior segments; 20 anterior segments). Two-hundred and five (66%) implants displayed thick and 106 (34%) thin gingival biotype. Time was the sole statistically significant parameter affecting mucosal cuff shrinkage around dental implants (P < 0.001). From time 0 to 20, 40 and 60 s, the mean diameter changed from 4.1 to 4.07, 3.4 and 2.81 mm, respectively. The shrinkage was 1%, 17% and 31%, respectively. The gingival biotype had no statistically significant influence on mucosal cuff shrinkage (P = 0.672). Time required replacing a healing abutment with a prosthetic element should be minimised (up to 20/40 s), to avoid pain, discomfort and misfit.
Nakamura, Hidehiro; Gotoh, Masafumi; Kanazawa, Tomonoshin; Ohta, Keisuke; Nakamura, Keiichirou; Honda, Hirokazu; Ohzono, Hiroki; Shimokobe, Hisao; Mitsui, Yasuhiro; Shirachi, Isao; Okawa, Takahiro; Higuchi, Fujio; Shirahama, Masahiro; Shiba, Naoto; Matsueda, Satoko
Corticosteroids (CS) or hyaluronic acid (HA) is used in subacromial injection for the conservative treatment of rotator cuff tears (RCT); this study addresses the question of how CS and HA affect the tendon tissue and fibroblasts in vitro and in rats. Cell proliferation assays were performed in human tendon fibroblasts from RCT. Rats underwent surgery to create RCT, and the surgical sites were injected with CS or HA. The rotator cuff tendons were subjected to biomechanical testing, microscopic and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA), and ultrastructural analysis. Cell proliferation was significantly decreased with CS in vitro (p < 0.05). Maximal load of CS-treated tendons was significantly decreased compared with that of HA-treated tendons (p < 0.05), as well as PCNA(+) cells at 2 weeks (p < 0.05). Ultrastructural observations of the CS-treated rats detected apoptosis of tendon fibroblasts 24 h after surgery. Histological and biomechanical data 4 weeks after surgery were not significant among the three groups. Unlike HA, CS caused cell death, and inhibition of the proliferation of tendon fibroblasts, leading to a delay of tendon healing involved and a subsequent decrease of biomechanical strength at the surgical site.
Carvalho, Cassiano Diniz; Andreoli, Carlos Vicente; Pochini, Alberto de Castro; Ejnisman, Benno
ABSTRACT Objective To evaluate the clinical and functional behavior of patients undergoing cuff tear arthroplasty at different stages of the disease. Methods Cuff tear arthroplasty hemiarthroplasties were performed in 34 patients with rotator cuff arthropathy and associated comorbidities, classified according to Seebauer. The mean age was 76.3 years, and the sample comprised 23 females (67.6%) and 11 males (32.4%). The mean follow-up period was 21.7 months, and evaluations were performed using the Visual Analog Scale for pain and the Constant scale. Results There were no statistically significant differences in the mean reduction in the Visual Analog Scale or in the Constant scale increase between the female and male groups. The variation between the pre- and postoperative Visual Analog Scale and Constant scale evaluations was significant. There was also no statistically significant difference between the Seebauer classification groups regarding the mean Visual Analog Scale reduction, or the mean Constant scale increase. Conclusion Cuff tear arthroplasty shoulder hemiarthroplasty is a good option for rotator cuff arthropathy in patients with comorbidities. PMID:28076600
Wang, Allan W; Bauer, Stefan; Goonatillake, Matthew; Breidahl, William; Zheng, Ming-Hao
Tendinopathy and small partial-thickness tears of the rotator cuff tendon are common presentations in sports medicine. No promising treatment has yet been established. Corticosteroid injections may improve symptoms in the short term but do not primarily treat the tendon pathology. Ultrasound-guided autologous tenocyte implantation (ATI) is a novel bioengineered treatment approach for treating tendinopathy. We report the first clinical case of ATI in a 20-year-old elite gymnast with a rotator cuff tendon injury. The patient presented with 12 months of increasing pain during gymnastics being unable to perform most skills. At 1 year after ATI the patient reported substantial improvement of clinical symptoms. Pretreatment and follow-up MRIs were reported and scored independently by two experienced musculoskeletal radiologists. Tendinopathy was improved and the partial-thickness tear healed on 3 T MRI. The patient was able to return to national-level competition.
Wang, Allan W; Bauer, Stefan; Goonatillake, Matthew; Breidahl, William; Zheng, Ming-Hao
Tendinopathy and small partial-thickness tears of the rotator cuff tendon are common presentations in sports medicine. No promising treatment has yet been established. Corticosteroid injections may improve symptoms in the short term but do not primarily treat the tendon pathology. Ultrasound-guided autologous tenocyte implantation (ATI) is a novel bioengineered treatment approach for treating tendinopathy. We report the first clinical case of ATI in a 20-year-old elite gymnast with a rotator cuff tendon injury. The patient presented with 12 months of increasing pain during gymnastics being unable to perform most skills. At 1 year after ATI the patient reported substantial improvement of clinical symptoms. Pretreatment and follow-up MRIs were reported and scored independently by two experienced musculoskeletal radiologists. Tendinopathy was improved and the partial-thickness tear healed on 3 T MRI. The patient was able to return to national-level competition. PMID:23314880
Mulligan, Edward P; Devanna, Raymond R; Huang, Mu; Middleton, Emily F; Khazzam, Michael
Multiple factors influence rehabilitation strategies after rotator cuff repair. These variables may also impact the overall success of the surgical intervention. Physicians and rehabilitation specialists should be aware of prognostic indicators that can provide therapeutic guidance and offer insights into eventual clinical outcomes. The success of surgical and rehabilitative interventions is often evaluated in terms of patient-reported outcome measures, return to activity, and pain. Although these factors are somewhat interdependent, each of them independently influences the final result. This article presents a comprehensive overview of the recent literature in this area to provide insight as to the short- and long-term outcomes that patients should expect based on their unique presentations. This article examines both intrinsic and extrinsic patient factors to help therapists develop customized rehabilitation programs that optimize surgical outcomes.
Carbonel, Ignacio; Martínez, Angel A; Aldea, Elisa; Ripalda, Jorge; Herrera, Antonio
Purpose. The purpose of this study was to evaluate the functional outcome and the tendon healing after arthroscopic double row rotator cuff repair of large and massive rotator cuff tears. Methods. 82 patients with a full-thickness large and massive rotator cuff tear underwent arthroscopic repair with double row technique. Results were evaluated by use of the UCLA, ASES, and Constant questionnaires, the Shoulder Strength Index (SSI), and range of motion. Follow-up time was 2 years. Magnetic resonance imaging (MRI) studies were performed on each shoulder preoperatively and 2 years after repair. Results. 100% of the patients were followed up. UCLA, ASES, and Constant questionnaires showed significant improvement compared with preoperatively (P < 0.001). Range of motion and SSI in flexion, abduction, and internal and external rotation also showed significant improvement (P < 0.001). MRI studies showed 24 cases of tear after repair (29%). Only 8 cases were a full-thickness tear. Conclusions. At two years of followup, in large and massive rotator cuff tears, an arthroscopic double row rotator cuff repair technique produces an excellent functional outcome and structural integrity.
Carbonel, Ignacio; Martínez, Angel A.; Aldea, Elisa; Ripalda, Jorge
Purpose. The purpose of this study was to evaluate the functional outcome and the tendon healing after arthroscopic double row rotator cuff repair of large and massive rotator cuff tears. Methods. 82 patients with a full-thickness large and massive rotator cuff tear underwent arthroscopic repair with double row technique. Results were evaluated by use of the UCLA, ASES, and Constant questionnaires, the Shoulder Strength Index (SSI), and range of motion. Follow-up time was 2 years. Magnetic resonance imaging (MRI) studies were performed on each shoulder preoperatively and 2 years after repair. Results. 100% of the patients were followed up. UCLA, ASES, and Constant questionnaires showed significant improvement compared with preoperatively (P < 0.001). Range of motion and SSI in flexion, abduction, and internal and external rotation also showed significant improvement (P < 0.001). MRI studies showed 24 cases of tear after repair (29%). Only 8 cases were a full-thickness tear. Conclusions. At two years of followup, in large and massive rotator cuff tears, an arthroscopic double row rotator cuff repair technique produces an excellent functional outcome and structural integrity. PMID:23533788
Perry, Stephanie M; Getz, Charles L; Soslowsky, Louis J
Although presumed, damage in the remaining (intact) rotator cuff tendons in the presence of an isolated supraspinatus tendon tear or multiple tendon tear has not been well studied. This study used an animal model of multiple rotator cuff tendon tears to investigate alterations in the remaining (intact) tendon mechanical properties at 4 and 8 weeks after injury. Twenty-four rats served as uninjured controls, whereas 72 were divided among 3 tendon detachment groups: supraspinatus tendon detachment, supraspinatus + infraspinatus tendon detachment, and supraspinatus + subscapularis tendon detachment. The remaining (intact) rotator cuff tendons had decreased mechanical properties in the presence of rotator cuff tears. The remaining (intact) subscapularis and infraspinatus tendon cross-sectional areas increased, whereas tendon modulus decreased after tears of both 1 and 2 tendons. The remaining (intact) tendon cross-sectional areas continued to increase with time after injury. These alterations could potentially lead to further tendon damage and tear progression.
Tempelaere, Christine; Pierrart, Jérome; Lefèvre-Colau, Marie-Martine; Vuillemin, Valérie; Cuénod, Charles-André; Hansen, Ulrich; Mir, Olivier; Skalli, Wafa; Gregory, Thomas
Background MRI is the standard methodology in diagnosis of rotator cuff diseases. However, many patients continue to have pain despite treatment, and MRI of a static unloaded shoulder seems insufficient for best diagnosis and treatment. This study evaluated if Dynamic MRI provides novel kinematic data that can be used to improve the understanding, diagnosis and best treatment of rotator cuff diseases. Methods Dynamic MRI provided real-time 3D image series and was used to measure changes in the width of subacromial space, superior-inferior translation and anterior-posterior translation of the humeral head relative to the glenoid during active abduction. These measures were investigated for consistency with the rotator cuff diseases classifications from standard MRI. Results The study included: 4 shoulders with massive rotator cuff tears, 5 shoulders with an isolated full-thickness supraspinatus tear, 5 shoulders with tendinopathy and 6 normal shoulders. A change in the width of subacromial space greater than 4mm differentiated between rotator cuff diseases with tendon tears (massive cuff tears and supraspinatus tear) and without tears (tendinopathy) (p = 0.012). The range of the superior-inferior translation was higher in the massive cuff tears group (6.4mm) than in normals (3.4mm) (p = 0.02). The range of the anterior-posterior translation was higher in the massive cuff tears (9.2 mm) and supraspinatus tear (9.3 mm) shoulders compared to normals (3.5mm) and tendinopathy (4.8mm) shoulders (p = 0.05). Conclusion The Dynamic MRI enabled a novel measure; ‘Looseness’, i.e. the translation of the humeral head on the glenoid during an abduction cycle. Looseness was better able at differentiating different forms of rotator cuff disease than a simple static measure of relative glenohumeral position. PMID:27434235
Galanopoulos, Ilias; Ilias, Aslanidis; Karliaftis, Konstantinos; Papadopoulos, Dimitrios; Ashwood, Neil
Background: It is generally accepted that rotator cuff repair gives satisfactory results in the long term, although most studies have so far shown a fairly high rate of structural failure or re-tear. The purpose of this review study is to assess whether failure of the repaired cuff to heal could negatively affect the functional outcome. Methods: This article includes an extensive Internet PubMed based research in the current English-language literature including level I to level V studies as well as systematic reviews. Results: According to this extended study research, the results are mixed; certain reports show that patients with a healed rotator cuff repair have improved function and strength compared to those with structural failure, whereas other studies support the generally perceived concept that tendon re-tear does not lead to inferior clinical outcome. Conclusion: Further high-level prospective studies with larger numbers of patients and longer follow up are needed to overcome the current debate over function between healed and failed rotator cuff repairs.
Holtby, Richard; Christakis, Monique; Maman, Eran; MacDermid, Joy C.; Dwyer, Tim; Athwal, George S.; Faber, Kenneth; Theodoropoulos, John; Woodhouse, Linda J.; Razmjou, Helen
Background: Increased interest in using platelet-rich plasma (PRP) as an augment to rotator cuff repair warrants further investigation, particularly in smaller rotator cuff tears. Purpose: To examine the effectiveness of PRP application in improving perioperative pain and function and promoting healing at 6 months after arthroscopic repair of small- or medium-sized rotator cuff tears. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a double-blinded randomized controlled trial of patients undergoing arthroscopic repair of partial- or full-thickness rotator cuff tears of up to 3 cm who were observed for 6 months. Patients were randomized to either repair and PRP application (study group) or repair only (control group) groups. The patient-oriented outcome measures utilized were the visual analog scale (VAS), the Short Western Ontario Rotator Cuff Index (ShortWORC), the American Shoulder and Elbow Surgeons (ASES) form, and the Constant-Murley Score (CMS). Range of motion (ROM) and inflammatory and coagulation markers were measured before and after surgery. Magnetic resonance imaging was used at 6 months to assess retear and fatty infiltration rate. Results: Eighty-two patients (41 males) with a mean age of 59 ± 8 years were enrolled; 41 patients were included in each group. Both the PRP and control groups showed a significant improvement in their pain level based on the VAS within the first 30 days (P < .0001), with the PRP group reporting less pain than the control group (P = .012), which was clinically significantly different from days 8 through 11. The PRP group reported taking less painkillers (P = .026) than the control group within the first 30 days. All outcome measure scores and ROM improved significantly after surgery (P < .0001), with no between-group differences. No differences were observed between groups in inflammatory or coagulation marker test results (P > .05), retear (14% vs 18% full retear; P = .44), or fatty
Conti, Marco; Garofalo, Raffaele; Delle Rose, Giacomo; Massazza, Giuseppe; Vinci, Enzo; Randelli, Mario; Castagna, Alessandro
Today advances in techniques and materials for rotator cuff surgery allow the repair of a large variety of types or extensions of cuff lesions in patients from a wide range of age groups who have different kinds of jobs and participate in different kinds of sports, and who have widely different expectations in terms of recovery of functions and pain relief. A large number of factors must be taken into account before implementing a rehabilitation protocol after rotator cuff surgery. These mainly include the technique (materials and procedure) used by the surgeon. Moreover, tissue quality, retraction, fatty infiltration and time from rupture are important biological factors while the patient's work or sport or daily activities after surgery and expectations of recovery must also be assessed. A rehabilitation protocol should also take into account the timing of biological healing of bone to tendon or tendon to tendon interface, depending on the type of rupture and repair. This timing should direct the therapist's choice of correct passive or assisted exercise and mobilisation manoeuvres and the teaching of correct active mobilisation movements the patient has to do. Following accepted knowledge about the time of biological tissue healing, surgical technique and focused rehabilitation exercise, a conceptual protocol in four phases could be applied, tailoring the protocol for each patient. It starts with sling rest with passive small self-assisted arm motion in phase one, to prevent post-op stiffness. In phase two passive mobilisation by the patient dry or in water, integrated with scapular mobilisation and stabiliser reinforcement, are done. Phase three consists of progressive active arm mobilisation dry or in water integrated with proprioceptive exercise and "core" stabilisation. In phase four full strength recovery integrated with the recovery of work or sports movements will complete the protocol. Because of the multi-factorial aspects of the problem, the best
ultimate load (56%-76%) of rotator cuff repairs in a human cadaver model.20 X-Repair augmentation also altered the mode of repair failure: failure by...amore clinically relevant repair and loading conditions in a human cadaver model: full-thickness supraspinatus tendon repairs (with and without...Andreychik D, Ahmad S. Determinants of outcome in the treatment of rotator cuff disease . Clin Orthop Rel Res 1994;308:90-7. 6. Bishop J, Klepps S, Lo IK
Redler, Lauren H.; Byram, Ian R.; Luchetti, Timothy J.; Tsui, Ying Lai; Moen, Todd C.; Gardner, Thomas R.; Ahmad, Christopher S.
Background: Redundancies in the rotator cuff tissue, commonly referred to as “dog ear” deformities, are frequently encountered during rotator cuff repair. Knowledge of how these deformities are created and their impact on rotator cuff footprint restoration is limited. Purpose: The goals of this study were to assess the impact of tear size and repair method on the creation and management of dog ear deformities in a human cadaveric model. Study Design: Controlled laboratory study. Methods: Crescent-shaped tears were systematically created in the supraspinatus tendon of 7 cadaveric shoulders with increasing medial to lateral widths (0.5, 1.0, and 1.5 cm). Repair of the 1.5-cm tear was performed on each shoulder with 3 methods in a randomized order: suture bridge, double-row repair with 2-mm fiber tape, and fiber tape with peripheral No. 2 nonabsorbable looped sutures. Resulting dog ear deformities were injected with an acrylic resin mixture, digitized 3-dimensionally (3D), and photographed perpendicular to the footprint with calibration. The volume, height, and width of the rotator cuff tissue not in contact with the greater tuberosity footprint were calculated using the volume injected, 3D reconstructions, and calibrated photographs. Comparisons were made between tear size, dog ear measurement technique, and repair method utilizing 2-way analysis of variance and Student-Newman-Keuls multiple-comparison tests. Results: Utilizing 3D digitized and injection-derived volumes and dimensions, anterior dog ear volume, height, and width were significantly smaller for rotator cuff repair with peripheral looped sutures compared with a suture bridge (P < .05) or double-row repair with 2-mm fiber tape alone (P < .05). Similarly, posterior height and width were significantly smaller for repair with looped peripheral sutures compared with a suture bridge (P < .05). Dog ear volumes and heights trended larger for the 1.5-cm tear, but this was not statistically significant
Rotator cuff tears are a common cause of shoulder pain that may lead to severe impairment of shoulder function with significant limitation of the quality of life. Furthermore, they are associated with high direct and indirect costs.Conservative therapy and various surgical procedures for rotator cuff repair are all possible treatment options. Therefore, the correct treatment for a symptomatic rotator cuff tear is important.The conservative therapy may be considered as an alternative treatment option for a symptomatic rotator cuff tear in patients with small or incomplete tears with no fatty atrophy or tendon retraction, with only slight pain, and in older patients with few functional demands. Surgical treatment is recommended after failed conservative treatment lasting 3-6 months, with the corresponding psychological strain. Moreover, surgical treatment should be considered as a primary treatment option for a symptomatic rotator cuff tear in young patients with high functional demands, patients with a high level of physical strain in their jobs, large tears, and tears where there is already significant muscle atrophy or tendon retraction.Arthroscopic treatment is considered to be the gold standard because of the better cosmetic results and treatment of concomitant pathological conditions, the lower levels of postoperative pain, the potentially lower risk of shoulder stiffness, and more focused adhesiolysis. However, arthroscopy does not improve clinical results. Because of the current financial situation, however, open rotator cuff repair is still a viable alternative.
Trent, Erika A.; Bailey, Lane; Mefleh, Fuad N.; Raikar, Vipul P.; Shanley, Ellen; Thigpen, Charles A.; Dean, Delphine; Kwartowitz, David M.
Rotator cuff disease is a degenerative disorder that is a common, costly, and often debilitating, ranging in severity from partial thickness tear, which may cause pain, to total rupture, leading to loss in function. Currently, clinical diagnosis and determination of disease extent relies primarily on subjective assessment of pain, range of motion, and possibly X-ray or ultrasound images. The final treatment plan however is at the discretion of the clinician, who often bases their decision on personal experiences, and not quantitative standards. The use of ultrasound for the assessment of tissue biomechanics is established, such as in ultrasound elastography, where soft tissue biomechanics are measured. Few studies have investigated the use of ultrasound elastography in the characterization of musculoskeletal biomechanics. To assess tissue biomechanics we have developed a device, which measures the force applied to the underlying musculotendentious tissue while simultaneously obtaining the related ultrasound images. In this work, the musculotendinous region of the infraspinatus of twenty asymptomatic male organized baseball players was examined to access the variability in tissue properties within a single patient and across a normal population. Elastic moduli at percent strains less than 15 were significantly different than those above 15 percent strain within the normal population. No significant difference in tissue properties was demonstrated within a single patient. This analysis demonstrated elastic moduli are variable across individuals and incidence. Therefore threshold elastic moduli will likely be a function of variation in local-tissue moduli as opposed to a specific global value.
Neto, Arnaldo Amado Ferreira; Trevizani, Cassio Silva; Benegas, Eduardo; Malavolta, Eduardo Angeli; Gracitelli, Mauro Emílio Conforto; Bitar, Alexandre Carneiro; Neto, Francisco José dos Santos
To evaluate the clinical and radiographic results from arthroscopic surgical treatment of the rotator cuff in patients with calcifying tendinitis. Method: A retrospective study was conducted on twenty patients who underwent arthroscopic treatment for calcifying tendinitis of the shoulder between March 1999 and November 2005. Six patients were excluded due to loss of follow-up. The average follow-up period was 41.4 months. Eight patients (57%) were female and six (43%) were male. The right side was affected in 10 cases (71%) and the left in four cases (29%). Nine cases (64%) had calcification in the supraspinatus tendon, two (14%) in the infraspinatus tendon, and three (21%) in both tendons. Results: In all cases, resection of the calcium deposits was performed by means of a needle (Jelco® No. 14) in combination with curettage (mini-curette). Two shoulders (14%) underwent subacromial decompression, and one (7%) underwent excision of the distal clavicle. A tendon-tendon suture was performed in three shoulders (21%). None of the patients underwent tendon-bone reinsertion. The mean score obtained on the UCLA scale was 33 points (26-35), thus indicating that a majority of patients had good results. In the final radiographic evaluation, none of the patients showed signs of calcification. Conclusion: Arthroscopic treatment of calcifying tendinitis of the shoulder safely allows excision of the calcification, leading to good results in relation to shoulder pain and function. PMID:27022591
Lewis, Jeremy; McCreesh, Karen; Roy, Jean-Sébastien; Ginn, Karen
Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patient's response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge
Chen, Xiaobin; Giambini, Hugo; Ben-Abraham, Ephraim; An, Kai-Nan; Nassr, Ahmad; Zhao, Chunfeng
Introduction An increased bone mineral density (BMD) in the proximity to tendon insertion can improve rotator cuff repair and healing. However, how a decrease of BMD in the humeral head affects the biomechanical properties of the rotator cuff tendon is still unclear. Previous studies have demonstrated ovariectomy in animals to lead to osteoporosis and decreased BMD, and Teriparatide (PTH) administration to improve BMD and strength of bone. This study aimed to explore the correlation between humeral head BMD and infraspinatus (ISP) tendon insertion strength, and if an increase in bone quantity of the humeral head can improve the strength of the rotator cuff. Materials and Methods Eighteen New England white rabbits were divided into the 3 groups: Control, Ovariectomy-Saline (OVX-Saline), and Ovariectomy-PTH (OVX-PTH). The OVX-Saline group and the OVX-PTH were administered daily saline and Teriparatide injections for 8 weeks starting at 17 weeks of OVX. BMD of the humeral head was measured, the ISP tendon failure load was tested and the failure stress was calculated. One specimen from each group was used for histological analysis. Linear regression analysis was used to derive equations for the BMD and failure stress. Results Significant differences were observed in the measured humeral head BMD of the Control and OVX-PTH groups compared to the OVX-Saline group (P = 0.0004 and P = 0.0024, respectively). No significant difference was found in failure stress among the three groups, but an expected trend with the control group and OVX-PTH group presenting higher failure strength compared to the OVX-Saline group. BMD at the humeral head showed a positive linear correlation with stress (r2 = 0.54). Histology results showed the superiority in OVX-PTH group ISP enthesis compared to the OVX-Saline group. Conclusion Bone loss of the humeral head leads to decreased tendon/bone insertion strength of the infraspinatus tendon enthesis. Teriparatide administration can increase bone
Levy, David M.; Abrams, Geoffrey D.; Harris, Joshua D.; Bach, Bernard R.; Nicholson, Gregory P.; Romeo, Anthony A.
Rotator cuff tears have been reported to be uncommon following total shoulder arthroplasty (TSA). Postoperative rotator cuff tears can lead to pain, proximal humeral migration, and glenoid component loosening. The purpose of this paper was to evaluate the incidence of post-TSA rotator cuff tears or dysfunction in osteoarthritic patients. A systematic review of multiple databases was performed using preferred reporting items for systematic reviews and meta-analyses guidelines. Levels I-IV evidence clinical studies of patients with primary osteoarthritis with a minimum 2-year follow-up were included. Fifteen studies with 1259 patients (1338 shoulders) were selected. Student's t-tests were used with a significant alpha value of 0.05. All patients demonstrated significant improvements in motion and validated clinical outcome scores (P < 0.001). Radiographic humeral head migration was the most commonly reported data point for extrapolation of rotator cuff integrity. After 6.6 ± 3.1 years, 29.9 ± 20.7% of shoulders demonstrated superior humeral head migration and 17.9 ± 14.3% migrated a distance more than 25% of the head. This was associated with an 11.3 ± 7.9% incidence of postoperative superior cuff tears. The incidence of radiographic anterior humeral head migration was 11.9 ± 15.9%, corresponding to a 3.0 ± 13.6% rate of subscapularis tears. We found an overall 1.2 ± 4.5% rate of reoperation for cuff injury. Nearly all studies reported indirect markers of rotator cuff dysfunction, such as radiographic humeral head migration and clinical exam findings. This systematic review suggests that rotator cuff dysfunction following TSA may be more common than previously reported. IV, systematic review of Levels I-IV studies. PMID:27186060
Kanazawa, Tomonoshin; Gotoh, Masafumi; Ohta, Keisuke; Honda, Hirokazu; Ohzono, Hiroki; Shimokobe, Hisao; Shiba, Naoto; Nakamura, Kei-ichiro
Successful rotator cuff repair requires biological anchoring of the repaired tendon to the bone. However, the histological structure of the repaired tendon-bone interface differs from that of a normal tendon insertion. We analysed differences between the normal tendon insertion and the repaired tendon-bone interface after surgery in the mechanical properties, histomorphometric analysis, and 3-dimensional ultrastructure of the cells using a rat rotator cuff repair model. Twenty-four adult Sprague-Dawley (SD) rats underwent complete cuff tear and subsequent repair of the supraspinatus tendon. The repaired tendon-bone interface was evaluated at 4, 8, and 12 weeks after surgery. At each time point, shoulders underwent micro-computed tomography scanning and biomechanical testing (N = 6), conventional histology and histomorphometric analysis (N = 6), and ultrastructural analysis with focused ion beam/scanning electron microscope (FIB/SEM) tomography (N = 4). We demonstrated that the cellular distribution between the repaired tendon and bone at 12 weeks after surgery bore similarities to the normal tendon insertion. However, the ultrastructure of the cells at any time point had a different morphology than those of the normal tendon insertion. These morphological differences affect the healing process, partly contributing to re-tearing at the repair site. These results may facilitate future studies of the regeneration of a normal tendon insertion. PMID:27647121
Background Rotator-cuff pathology is the most common cause of pain and disability in the shoulder. Examining the combined effect of biological and societal factors on disability would potentially identify existing differences between men and women with rotator cuff pathology which would help to provide suggestions for better models of care. Purpose of this study was to determine the overall differences in disability between men and women and to examine the relationship between factors that represent sex (biological factors) and gender (non-biological factors) with disability and satisfaction with surgical outcome 6 months after rotator cuff surgery. Methods Patients with impingement syndrome and/or rotator cuff tear who underwent rotator cuff surgery completed the Western Ontario Rotator Cuff (WORC) index, the American Shoulder & Elbow Surgeons (ASES) assessment form, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measures prior to surgery and 6 months post-operatively. They also rated their satisfaction with surgery at their follow-up appointment. Results and Discussion One hundred and seventy patients entered into the study (85 men and 85 women). One hundred and sixty patients (94%) completed the 6-month assessment. Women reported more disability both prior to and after surgery. Disability at 6 months was associated with pain-limited range of motion, participation limitation, age and strength. Satisfaction with surgery was associated with level of reported disability, expectations for improved pain, pain-limited range of motion and strength. Conclusions The results of this study indicate that women with rotator cuff pathology suffer from higher levels of pre- and post-operative disability and sex and gender qualities contribute to these differences. Gender-sensitive approach will help to identify existing differences between men and women which will help to promote more effective and tailored care by health professionals. PMID
Park, Gi-Young; Lee, Sang Chul
Rotator cuff tendon tear is one of the most common causes of chronic shoulder pain and disability. In this study, we investigated the therapeutic effects of ultrasound-guided human umbilical cord blood (UCB)-derived mesenchymal stem cell (MSC) injection to regenerate a full-thickness subscapularis tendon tear in a rabbit model by evaluating the gross morphology and histology of the injected tendon and motion analysis of the rabbit’s activity. At 4 weeks after ultrasound-guided UCB-derived MSC injection, 7 of the 10 full-thickness subscapularis tendon tears were only partial-thickness tears, and 3 remained full-thickness tendon tears. The tendon tear size and walking capacity at 4 weeks after UCB-derived MSC injection under ultrasound guidance were significantly improved compared with the same parameters immediately after tendon tear. UCB-derived MSC injection under ultrasound guidance without surgical repair or bioscaffold resulted in the partial healing of full-thickness rotator cuff tendon tears in a rabbit model. Histology revealed that UCB-derived MSCs induced regeneration of rotator cuff tendon tear and that the regenerated tissue was predominantly composed of type I collagens. In this study, ultrasound-guided injection of human UCB-derived MSCs contributed to regeneration of the full-thickness rotator cuff tendon tear without surgical repair. The results demonstrate the effectiveness of local injection of MSCs into the rotator cuff tendon. Significance The results of this study suggest that ultrasound-guided umbilical cord blood-derived mesenchymal stem cell injection may be a useful conservative treatment for full-thickness rotator cuff tendon tear repair. PMID:26371340
Baumer, Timothy G.; Chan, Derek; Mende, Veronica; Dischler, Jack; Zauel, Roger; van Holsbeeck, Marnix; Siegal, Daniel S.; Divine, George; Moutzouros, Vasilios; Bey, Michael J.
Background: Physical therapy (PT) is often prescribed for patients with rotator cuff tears. The extent to which PT influences strength, range of motion (ROM), and patient-reported outcomes has been studied extensively, but the effect of PT on in vivo joint kinematics is not well understood. Purpose: To assess the influence of symptomatic rotator cuff pathology and the effects of PT on shoulder motion, strength, and patient-reported outcomes. Study Design: Controlled laboratory study. Methods: Twenty-five patients with a symptomatic rotator cuff tear and 25 age-matched asymptomatic control subjects were recruited. Shoulder motion was measured using a biplane radiography imaging system, strength was assessed with a Biodex dynamometer, and patient-reported outcomes were assessed using the Western Ontario Rotator Cuff Index and visual analog scale (VAS) pain scores. Data were acquired from the patients before and after 8 weeks of physical therapy. Data were acquired at 1 time point for the control subjects. Results: Compared with the control subjects, patients with a symptomatic rotator cuff tear had significantly worse pain/function scores (P < .01); less ROM (P < .01); lower abduction (ABD), external rotation (ER), and internal rotation (IR) strength (P < .01); less scapulothoracic posterior tilt (P = .05); and lower glenohumeral joint elevation (P < .01). Physical therapy resulted in improved pain/function scores (P < .01), increased ROM (P < .02), increased scapulothoracic posterior tilt (P = .05), increased glenohumeral joint elevation (P = .01), and decreased acromiohumeral distance (AHD) (P = .02). Conclusion: Compared with age-matched controls, patients had worse pain/function scores, less ROM, and lower ABD, ER, and IR strength. Patients also had less scapulothoracic anteroposterior tilt, less glenohumeral joint elevation, and an altered glenohumeral joint contact path. PT resulted in improved pain/function scores, increased ROM, greater posterior
Anley, Cameron M; Chan, Samuel KL; Snow, Martyn
The management of patients with irreparable rotator cuff tears remains a challenge for orthopaedic surgeons with the final treatment option in many algorithms being either a reverse shoulder arthroplasty or a tendon transfer. The long term results of these procedures are however still widely debated, especially in younger patients. A variety of arthroscopic treatment options have been proposed for patients with an irreparable rotator cuff tear without the presence of arthritis of the glenohumeral joint. These include a simple debridement with or without a biceps tenotomy, partial rotator cuff repair with or without an interval slide, tuberplasty, graft interposition of the rotator cuff, suprascapular nerve ablation, superior capsule reconstruction and insertion of a biodegradable spacer (Inspace) to depress the humeral head. These options should be considered as part of the treatment algorithm in patients with an irreparable rotator cuff and could be used as either as an interim procedure, delaying the need for more invasive surgery in the physiologically young and active, or as potential definitive procedures in the medically unfit. The aim of this review is to highlight and summarise arthroscopic procedures and the results thereof currently utilised in the management of these challenging patients. PMID:25405083
Osti, Leonardo; Buda, Matteo; Buono, Angelo Del; Osti, Raffaella; Massari, Leo
Summary Purpose the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears. Methods a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words “hyaluronic acid”, “rotator cuff tear”, “hyaluronate”, “shoulder”, “viscosupplementation”, with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported. Results a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed. Conclusion intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction. Level of evidence Level I. PMID:26958534
Akyol, Engin; Hindocha, Sandip; Khan, Wasim S
In this review, we analysed the role of stem cell and growth factor therapy on rotator cuff tendon repair. The injury to the rotator cuff tendons can be sustained in numerous ways and generally causes significant pain and disability to the affected individual. Following surgical repair of ruptured rotator cuff tendons re-rupture rates can be as high as 20-60%. In order to augment this repair process and to decrease the re-rupture rates tissue engineering methods can be used. These include the use of stem cells and growth factors. Mesenchymal stem cells are stem cells which can differentiate into a variety of connective tissue cell types and can therefore be utilised in repairing tendons. So far there has only been one human study using stem cells in rotator cuff tendon repair. This study has produced a positive result but consisted of only 14 patients and lacks a control group for comparison. Similar work has also been done using growth factors. Both individual and combination growth factor therapy have been used to improve rotator cuff tendon repair. However, the results so far have been disappointing with growth factors. For the purpose of future studies better techniques should be explored with regards to the delivery of stem cells and growth factors as well as the possibility of combining growth factor and stem cell therapy to improve repair rates.
Griffiths, Stephanie; Yohannes, A M
Selecting the most appropriate patients to refer for surgery is crucial for high-quality and efficient clinical care. However, there are no specific referral criteria to guide the referral of appropriate patients for rotator cuff repair surgery. The aim of the present study was to design robust surgical referral criteria for patients with degenerative rotator cuff tears using consensus methodology. A two-round Delphi questionnaire was undertaken with a nationally representative sample of 41 specialist shoulder surgeons experienced in rotator cuff repair. Surgical referral criteria for degenerative rotator cuff tear were developed where consensus of at least 70% agreement was achieved. The initial questionnaire consisted of 24 items. Consensus was reached on 14 items, including: severity of pain, functional limitation, the identification of fat atrophy, agreement that a course of physiotherapy should be attempted before surgical referral, and exclusion for those with an active frozen shoulder. However, there was no consensus with regard to the dimensions of the tear. The surgical referral criteria developed were novel and promising for patients with degenerative rotator cuff tears, and further research is required to examine their efficacy.
Kim, Kyeongwon; Kim, Hong Geum; Song, Daeheon; Yoon, Jung Yoon; Chung, Myung Eun
In evaluating patients complaining of shoulder pain, ultrasonography is an emerging imaging tool due to convenience, low cost, high sensitivity and specificity. However, normative values of ultrasound dimensions of the shoulder to be compared with pathologic findings in Korean adults are not provided yet. We evaluated the ultrasound dimensions of the rotator cuff, long head of biceps tendon, deltoid muscle and acromioclavicular joint in Korean healthy adults. Shoulder ultrasonography was performed on 200 shoulders from 100 healthy adults. The dimensions of the thickness of rotator cuff (supraspinatus, infraspinatus, subscapularis tendon), deltoid muscle, long head of biceps tendon, subacromial subdeltoid bursa, and acromioclavicular joint interval were measured in a standardized manner. Differences in measurements among sex, age, and dominant arms were compared. The thickness of rotator cuff tendons (supraspinatus, infraspinatus, subscapularis) and deltoid muscle were significantly different between men and women. The thickness of subacromial subdeltoid bursa was significantly different between men and women for non-dominant side. In rotator cuff tendon measurements, the differences between dominant and non-dominant shoulders were not significant, which means the asymptomatic contralateral shoulder can be used to estimate the normal reference values. When stratified by age divided by 10 years, the measurements of supraspinatus, subscapularis and deltoid thickness showed tendency of increase with the age. The acromioclavicular joint interval, on the other hand, revealed decreasing tendency. This report suggests normative values of ultrasound dimensions of healthy Korean population with varying age, and can be useful as reference values in evaluating shoulder pathology, especially in rotator cuff tendon pathology.
Zhao, Song; Zhao, Jingwen; Dong, Shikui; Huangfu, Xiaoqiao; Li, Bin; Yang, Huilin; Zhao, Jinzhong; Cui, Wenguo
Clinically, rotator cuff tear (RCT) is among the most common shoulder pathologies. Despite significant advances in surgical techniques, the re-tear rate after rotator cuff (RC) repair remains high. Insufficient healing capacity is likely the main factor for reconstruction failure. This study reports on a basic fibroblast growth factor (bFGF)-loaded electrospun poly(lactide-co-glycolide) (PLGA) fibrous membrane for repairing RCT. Implantable biodegradable bFGF–PLGA fibrous membranes were successfully fabricated using emulsion electrospinning technology and then characterized and evaluated with in vitro and in vivo cell proliferation assays and repairs of rat chronic RCTs. Emulsion electrospinning fabricated ultrafine fibers with a core-sheath structure which secured the bioactivity of bFGF in a sustained manner for 3 weeks. Histological observations showed that electrospun fibrous membranes have excellent biocompatibility and biodegradability. At 2, 4, and 8 weeks after in vivo RCT repair surgery, electrospun fibrous membranes significantly increased the area of glycosaminoglycan staining at the tendon–bone interface compared with the control group, and bFGF–PLGA significantly improved collagen organization, as measured by birefringence under polarized light at the healing enthesis compared with the control and PLGA groups. Biomechanical testing showed that the electrospun fibrous membrane groups had a greater ultimate load-to-failure and stiffness than the control group at 4 and 8 weeks. The bFGF–PLGA membranes had the highest ultimate load-to-failure, stiffness, and stress of the healing enthesis, and their superiority compared to PLGA alone was significant. These results demonstrated that electrospun fibrous membranes aid in cell attachment and proliferation, as well as accelerating tendon–bone remodeling, and bFGF-loaded PLGA fibrous membranes have a more pronounced effect on tendon–bone healing. Therefore, augmentation using bFGF–PLGA electrospun
Davis, Max E; Korn, Michael A; Gumucio, Jonathan P; Harning, Julie A; Saripalli, Anjali L; Bedi, Asheesh; Mendias, Christopher L
Background Chronic rotator cuff tears are a common source of shoulder pain and disability, and patients with chronic cuff tears often have substantial weakness, fibrosis, inflammation and fat accumulation. Identifying therapies to prevent the development of these pathologies will likely have a positive impact on clinical outcomes. Simvastatin is a drug with demonstrated anti-inflammatory and anti-fibrotic effects in many tissues, but had not previously been studied in the context of rotator cuff tears. We hypothesized that following the induction of a massive supraspinatus tear, simvastatin would protect muscles from a loss of force production and fibrosis. Methods We measured changes in muscle fiber contractility, histology and biochemical markers of fibrosis and fatty infiltration in rats that received a full-thickness supraspinatus tear and were treated with either carrier alone or simvastatin. Results Compared to vehicle treated controls, simvastatin did not have an appreciable effect on muscle fiber size, but treatment did increase muscle fiber specific force by 20%. Simvastatin also reduced collagen accumulation by 50%, but did not effect triglyceride content of muscles. Several favorable changes in the expression of genes and other markers of inflammation, fibrosis and regeneration were also observed. Conclusions Simvastatin partially protected muscles from the weakness that occurs as a result of chronic rotator cuff tear. Fibrosis was also markedly reduced in simvastatin treated animals. While further studies are necessary, statin medication could potentially help to improve outcomes for patients with rotator cuff tears. PMID:25213828
Merolla, Giovanni; Chillemi, Claudio; Franceschini, Vincenzo; Cerciello, Simone; Ippolito, Giorgio; Paladini, Paolo; Porcellini, Giuseppe
Summary Background: treatment of symptomatic irreparable rotator cuff tears is extremely challenging because, at present, there are no ideal solutions to this problem. Many patients respond favorably to nonsurgical treatment. However, when conservative measures fail to improve the patient’s pain and disability, surgery should be considered. Methods: different surgical techniques are available and the choice of the most appropriate procedure depends on the presenting symptoms, age of the patient, functional demand, medical comorbidities, joint stability and presence of arthritic changes. The transposition of the surrounding muscles to replace the rotator cuff function represents a viable option in the treatment of younger patients without glenohumeral osteoarthritis and with severe functional limitation. Purpose: aim of this study is to give an overview of the currently available evidence regarding tendon transfer procedures for irreparable rotator cuff tears. PMID:25767779
El-Tawil, Sherif; Prinja, Aditya; Stanton, Jeremy
We describe the first reported case of a tumour deposit within the rotator cuff presenting as a bizarre, progressive, and fixed external rotation deformity of the shoulder. It is also the first reported case to our knowledge of an oesophageal primary metastasising to the rotator cuff. PMID:26543658
El-Tawil, Sherif; Prinja, Aditya; Stanton, Jeremy
We describe the first reported case of a tumour deposit within the rotator cuff presenting as a bizarre, progressive, and fixed external rotation deformity of the shoulder. It is also the first reported case to our knowledge of an oesophageal primary metastasising to the rotator cuff.
Leong, Hio Teng; Hug, François; Fu, Siu Ngor
Although excessive tension of the upper trapezius (UT) is thought to contribute to rotator cuff tendinopathy, no study examined UT tension in athletes with and without rotator cuff tendinopathy. Here we used UT shear modulus measured using ultrasound shear wave elastography as an index of muscle stiffness/tension. The aims of this study were twofold: 1) to determine whether the UT muscle shear modulus is altered in athletes with rotator cuff tendinopathy compared to asymptomatic athletes, and 2) to detect optimal cut-off points of UT shear modulus in identifying athletes with rotator cuff tendinopathy. Forty-three male volleyball players (17 asymptomatic and 26 with rotator cuff tendinopathy, mean age = 22.9±3.5 years) participated in the study. UT shear modulus was quantified during active arm holding at 30° and 60° of shoulder abduction and passive arm positioning at 0°, 30° and 60° of shoulder abduction. During the active tasks, the UT shear modulus was higher in athletes with rotator cuff tendinopathy than the asymptomatic athletes (p = 0.002), regardless the arm position. During the passive tasks, athletes with rotator cuff tendinopathy exhibited a higher UT shear modulus than asymptomatic athletes only at 0° of shoulder abduction (13.0±2.5 kPa vs 10.2±1.8 kPa, p = 0.001). When considering the active task, an optimal cut-off shear modulus of 12.0 kPa at 30° of shoulder abduction (sensitivity = 0.84, specificity = 0.57, AUC = 0.757, p = 0.008) and 9.5 kPa at 60° of shoulder abduction (sensitivity = 0.88, specificity = 0.67, AUC = 0.816, p = 0.002) was detected. When considering the passive task at 0° of shoulder abduction, a cut-off of 12.2 kPa was found (sensitivity = 0.73, AUC = 0.817, p = 0.001). Findings from the present study show that monitoring passive and active UT muscle shear modulus may provide important information for the prevention/rehabilitation of rotator cuff tendinopathy. PMID:27159276
Merolla, Giovanni; Singh, Sanjay; Paladini, Paolo; Porcellini, Giuseppe
Calcific tendinitis is a painful shoulder disorder characterised by either single or multiple deposits in the rotator cuff tendon. Although the disease subsides spontaneously in most cases, a subpopulation of patients continue to complain of pain and shoulder dysfunction and the deposits do not show any signs of resolution. Although several treatment options have been proposed, clinical results are controversial and often the indication for a given therapy remains a matter of clinician choice. Herein, we report on the current state of the art in the pathogenesis, diagnosis and treatment of calcific tendinitis of the rotator cuff.
Klatte-Schulz, Franka; Pauly, Stephan; Scheibel, Markus; Greiner, Stefan; Gerhardt, Christian; Hartwig, Jelka; Schmidmaier, Gerhard; Wildemann, Britt
Tendon bone healing of the rotator cuff is often associated with non-healing or recurrent defects, which seems to be influenced by the patient's age and sex. The present study aims to examine cellular biological characteristics of tenocyte-like cells that may contribute to this impaired rotator cuff healing. Moreover, a therapeutic approach using growth factors could possibly stimulate tendon bone healing. Therefore, our second aim was to identify patient groups who would particularly benefit from growth factor stimulation. Tenocyte-like cells isolated from supraspinatus tendons of female donors younger and older than 65 years of age were characterized with respect to different cellular biological parameters, such as cell density, cell count, marker expression, collagen-I protein synthesis, and stem cell potential. Furthermore, cells of the donor groups were stimulated with BMP-2 and BMP-7 (200 and 1000 ng/ml) in 3D-culture and analyzed for cell count, marker expression and collagen-I protein synthesis. Female donors older than 65 years of age showed significantly decreased cell count and collagen-I protein synthesis compared to cells from donors younger than 65 years. Cellular biological parameters including cell count, collagen-I and -III expression, and collagen-I protein synthesis of cells from both donor groups were stimulated with BMP-2 and BMP-7. The cells from donors older than 65 years revealed a decreased stimulation potential for cell count compared to the younger group. Cells from female donors older than 65 years of age showed inferior cellular biological characteristics. This may be one reason for a weaker healing potential observed in older female patients and should be taken into consideration for tendon bone healing of the rotator cuff.
De Roo, Pieter-Jan; Muermans, Stijn; Maroy, Mathieu; Linden, Patrick; Van den Daelen, Luc
This prospective randomized study compares the clinical results of immediate passive mobilization versus delayed mobilization in the rehabilitation of rotator cuff repair during the early postoperative period. The mobilization group (79 patients) received immediate daily passive mobilization. The immobilization group (51 patients) was immobilized for 4 weeks until physiotherapy was started. Passive range of motion was noted preoperatively, at 6 weeks and 4 months. Strength was measured preoperatively and at 4 months. Constant-Murley, Simple Shoulder Test, SPADI and UCLA scores were noted at baseline and at 4 months. Ultrasonography was performed at 6 weeks to exclude early failures of repair. We noted no significant difference between the two groups regarding range of motion at 6 weeks and range of motion, strength and functional outcome scores at 4 months. Ultrasound didn't show a difference in healing at 6 w in either of both groups. Both rehabilitation protocols seem applicable as well as safe in the early post-operative phase.
Tanaka, Suguru; Gotoh, Masafumi; Mitsui, Yasuhiro; Shirachi, Isao; Okawa, Takahiro; Higuchi, Fujio; Shiba, Naoto
We report a case of subcutaneous ganglion adjacent to the acromioclavicular joint with massive rotator cuff tear [1-7]. An 81-year-old woman presented with a ganglion adjacent to the acromioclavicular joint that had first been identified 9 months earlier. The ganglion had recurred after having been aspirated by her local physician, so she was referred to our hospital. The puncture fluid was yellowish, clear and viscous. Magnetic resonance imaging identified a massive rotator cuff tear with multi- lobular cystic lesions continuous to the acromioclavicular joint, presenting the "geyser sign". During arthroscopy, distal clavicular resection and excision of the ganglion were performed together with joint debridement. At present, the ganglion has not recurred and the patient has returned to normal daily activity. In this case, the ganglion may have developed subsequent to the concomitant massive cuff tear, due to subcutaneous fluid flow through the damaged acromioclavicular joint.
Peach, M. Sean; Ramos, Daisy M.; Morozowich, Nicole L.; Mazzocca, Augustus D.; Doty, Steven B.; Allcock, Harry R.; Kumbar, Sangamesh G.; Laurencin, Cato T.
Rotator cuff (RC) tears represent a large proportion of musculoskeletal injuries attended to at the clinic and thereby make RC repair surgeries one of the most widely performed musculoskeletal procedures. Despite the high incidence rate of RC tears, operative treatments have provided minimal functional gains and suffer from high re-tear rates. The hypocellular nature of tendon tissue poses a limited capacity for regeneration. In recent years, great strides have been made in the area of tendonogenesis and differentiation towards tendon cells due to a greater understanding of the tendon stem cell niche, development of advanced materials, improved scaffold fabrication techniques, and delineation of the phenotype development process. Though in vitro models for tendonogenesis have shown promising results, in vivo models have been less successful. The present work investigates structured matrices mimicking the tendon microenvironment as cell delivery vehicles in a rat RC tear model. RC injuries augmented with a matrix delivering rat mesenchymal stem cells (rMSCs) showed enhanced regeneration over suture repair alone or repair with augmentation, at 6 and 12-weeks post-surgery. The local delivery of rMSCs led to increased mechanical properties and improved tissue morphology. We hypothesize that the mesenchymal stem cells function to modulate the local immune and bioactivity environment through autocrine/paracrine and/or cell homing mechanisms. This study provides evidence for improved tendon healing with biomimetic matrices and delivered MSCs with the potential for translation to larger, clinical animal models. The enhanced regenerative healing response with stem cell delivering biomimetic matrices may represent a new treatment paradigm for massive RC tendon tears. PMID:28369135
Littlewood, Chris; Malliaras, Peter; Chance-Larsen, Ken
Exercise is widely regarded as an effective intervention for symptomatic rotator cuff tendinopathy but the prescription is diverse and the important components of such programmes are not well understood. The objective of this study was to systematically review the contextual factors and prescription parameters of published exercise programmes for rotator cuff tendinopathy, to generate recommendations based on current evidence. An electronic search of AMED, CiNAHL, CENTRAL, MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to June 2014 and supplemented by hand searching. Eligible studies included randomized controlled trials evaluating the effectiveness of exercise in participants with rotator cuff tendinopathy. Included studies were appraised using the Cochrane risk of bias tool and synthesized narratively. Fourteen studies were included, and suggested that exercise programmes are widely applicable and can be successfully designed by physiotherapists with varying experience; whether the exercise is completed at home or within a clinic setting does not appear to matter and neither does pain production or pain avoidance during exercise; inclusion of some level of resistance does seem to matter although the optimal level is unclear, the optimal number of repetitions is also unclear but higher repetitions might confer superior outcomes; three sets of exercise are preferable to two or one set but the optimal frequency is unknown; most programmes should demonstrate clinically significant outcomes by 12 weeks. This systematic review has offered preliminary guidance in relation to contextual factors and prescription parameters to aid development and application of exercise programmes for rotator cuff tendinopathy.
Wang, EnZhi; Wang, Liang; Gao, Peng; Li, ZhongJi; Zhou, Xiao; Wang, SongGang
Background It is a challenge for orthopaedic surgeons to treat massive rotator cuff tears. The optimal management of massive rotator cuff tears remains controversial. Therefore, the goal of this study was to compare arthroscopic single- versus double-row rotator cuff repair with a larger sample size. Material/Methods Of the subjects with massive rotator cuff tears, 146 were treated using single-row repair, and 102 were treated using double-row repair. Pre- and postoperative functional outcomes and radiographic images were collected. The clinical outcomes were evaluated for a minimum of 2 years. Results No significant differences were shown between the groups in terms of functional outcomes. Regarding the integrity of the tendon, a lower rate of post-treatment retear was observed in patients who underwent double-row repair compared with single-row repair. Conclusions The results suggest that double-row repair is relatively superior in shoulder ROM and the strength of tendon compared with single-row repair. Future studies involving more patients in better-designed randomized controlled trials will be required. PMID:26017641
RANDELLI, PIETRO; RANDELLI, FILIPPO; COMPAGNONI, RICCARDO; CABITZA, PAOLO; RAGONE, VINCENZA; PULICI, LUCA; BANFI, GIUSEPPE
Purpose the aim of this systematic literature review is to report clinical outcomes of reverse shoulder arthroplasty (RSA) used as a revision surgery following failure of the primary implant due to rotator cuff insufficiency. Methods a systematic review was performed using the following key words: revision, shoulder, rotator cuff deficiency, outcome assessment, treatment outcome, complications. Studies eligible for inclusion in the review were clinical trials investigating patients in whom a primary shoulder arthroplasty implant with an incompetent rotator cuff was replaced with a reverse shoulder prosthesis. Results nine articles were identified and further reviewed. The results refer to a total of 226 shoulders that were treated with RSA as revision surgery. The patients in the studies had a mean age ranging from 64 to 72 years and the longest follow-up was 3.8 years. Improvements in function and reduction of pain were shown by many studies, but the mean Constant score ranged from 44.2 to 56. High complication rates (of up to 62%) were recorded, and a mean reoperation rate of 27.5%. Conclusions RSA as revision surgery for patients with rotator cuff deficiency is a valid option, and often the only solution available, but it should be limited to elderly patients with poor function and severe pain. Level of evidence level IV, systematic review of level I–IV studies. PMID:26151037
Frey, Eric; Regenfelder, Felix; Sussmann, Patrick; Zumstein, Matthias; Gerber, Christian; Born, Walter; Fuchs, Bruno
Chronic rotator cuff tendon tears lead to fatty infiltration and muscle atrophy with impaired physiological functions of the affected muscles. However, the cellular and molecular mechanisms of corresponding pathophysiological processes remain unknown. The purpose of this study was to characterize the expression pattern of adipogenic (PPARgamma, C/EBPbeta) and myogenic (myostatin, myogenin, Myf-5) transcription factors in infraspinatus muscle of sheep after tenotomy, implantation of a tension device, refixation of the tendon, and rehabilitation, reflecting a model of chronic rotator cuff tears. In contrast to human patients, the presented sheep model allows a temporal evaluation of the expression of a given marker in the same individual over time. Semiquantitative RT/PCR analysis of PPARgammaã, myostatin, myogenin, Myf-5, and C/EBPbeta transcript levels was carried out with sheep muscle biopsy-derived total RNA. We found a significantly increased expression of Myf-5 and PPARgamma after tenotomy and a significant change for Myf-5 and C/EBPbeta after continuous traction and refixation. This experimental sheep model allows the molecular analysis of pathomechanisms of muscular changes after rotator cuff tear. The results point to a crucial role of the transcription factors PPARgamma, C/EBPbeta, and Myf-5 in impairment and regeneration of rotator cuff muscles after tendon tears in sheep.
Didden, Karolien; Leirs, Geert; Aerts, Peter
We retrospectively assessed time off work after rotator cuff repair, in relation with the compensation system and the shoulder loading demand at work. The Belgian insurance system distinghuises three main financial compensation systems for time off work. Patients with a work-related accident receive the highest compensation. A second group includes employees suffering a private accident or a chronic rotator cuff tear. Self-employed workers receive the lowest compensation. Work-demand on the shoulder was graded level I to IV according to the Iannotti classification. From a series of 201 young patients who underwent rotator cuff tear surgery, 93 were selected based on specific inclusion criteria; of these 93 patients, 73 could be thoroughly investigated. We found a significantly longer postoperative time off work in the highest compensation group (7 months versus 2.5 months for the lowest compensation group). We found a significantly longer postoperative time to return to work in the higher stages of the Iannoti classification. Based on the results of this study, the probable postoperative absence from work can be roughly estimated for each patient after rotator cuff surgery in relation with the particular compensation system and particular occupational demand level.
Itoigawa, Yoshiaki; Kishimoto, Koshi N; Sano, Hirotaka; Kaneko, Kazuo; Itoi, Eiji
Fatty degeneration often occurs in rotator cuff muscle with tendon rupture. However, the molecular mechanism underlying this change has not been fully clarified yet. We investigated the gene expression of Wnt10b and adipogenic marker gene, PPARγ and C/EBPα in C2C12 myogenic cell line under inhibition of Wnt10b by adipogenic induction medium, isobutylmethylxanthine, dexamethasone, and insulin (MDI). The role of Wnt-signal was confirmed by adding Lithium chloride (LiCl), which mimics Wnt signaling to the cultured cell with MDI. We also assessed the expression profiles of same genes in the rat rotator cuff tear model in vivo. MDI induced Oil red-O staining positive adipocytes and upregulated PPARγ and C/EBPα expression. LiCl inhibited adipogenic induction of MDI. Rotator cuff muscle with tendon rupture showed positive staining for Oil red-O. Real-time polymerase chain reaction analyses revealed decreased expression of Wnt10b followed by increased PPARγ and C/EBPα gene expression in the supraspinatus muscle. Fatty degeneration and its molecular events were remarkably seen in the distal one-third of the detached supraspinatus muscle versus control. Wnt signaling may regulate adipogenic differentiation both in the myoblasts in vitro and the muscle in vivo. Our results indicate that the reduction of Wnt10b in muscle with a rotator cuff tear is a key signal in fatty degeneration of the muscle.
Thakkar, Dipti; Grant, Tyler M; Hakimi, Osnat; Carr, Andrew J
There is increasing evidence for a progressive extracellular matrix change in rotator cuff disease progression. Directly surrounding the cell is the pericellular matrix, where assembly of matrix aggregates typically occurs making it critical in the response of tendon cells to pathological conditions. Studies in animal models have identified type VI collagen, fibrillin-1 and elastin to be located in the pericellular matrix of tendon and contribute in maintaining the structural and biomechanical integrity of tendon. However, there have been no reports on the localization of these proteins in human tendon biopsies. This study aimed to characterize the distribution of these ECM components in human rotator cuffs and gain greater insight into the relationship of pathology to tear size by analyzing the distribution and expression profiles of these ECM components. Confocal microscopy confirmed the localization of these structural molecules in the pericellular matrix of the human rotator cuff. Tendon degeneration led to an increased visibility of these components with a significant disorganization in the distribution of type VI collagen. At the genetic level, an increase in tear size was linked to an increased transcription of type VI collagen and fibrillin-1 with no significant alteration in the elastin levels. This is the first study to confirm the localization of type VI collagen, elastin and fibrillin-1 in the pericellular region of human supraspinatus tendon and assesses the effect of tendon degeneration on these structures, thus providing a useful insight into the composition of human rotator cuff tears which can be instrumental in predicting disease prognosis.
Ghellioni, Gustavo Vinícius; da Silva, Lucas Souto; Piovezan, Anna Paula; Martins, Rafael Olívio
Objective To evaluate the influence of treatment with different doses of methylprednisolone on the mechanical resistance and possible histological alterations of the rotator cuff tendon in rats. Methods Male Wistar rats were divided randomly into four treatment groups: sham, vehicle or 0.6 mg/kg or 6.0 mg/kg of methylprednisolone. Changes to mechanical resistance (in N) and histological parameters (fibrillar appearance, presence of collagen, edema and vascular proliferation) of the rotator cuff tendon were evaluated. The analyses were conducted after administration of one treatment (24 h afterwards), two treatments (7 days afterward) or three treatments (14 days afterwards), into the subacromial space. Results Seven and fourteen days after the treatments were started, it was found that in a dose-dependent manner, methylprednisolone reduced the mechanical resistance of the rotator cuff tendon (p < 0.05 in relation to the vehicle group). Modifications to the histological parameters were observed on the 7th and 14th days after the first infiltration, especially regarding the presence of collagen and vascular proliferation, for the dose of 0.6 mg/kg of methylprednisolone, and also regarding the presence of collagen, edema and vascular proliferation for the dose of 6.0 mg/kg of corticoid. Conclusion The results obtained demonstrated a relationship between methylprednisolone use through infiltration into the subacromial space and reduction of the mechanical resistance of and histological modifications to the rotator cuff tendon in rats. PMID:26229927
MacDermid, Joy C; Ramos, Joanne; Drosdowech, Darren; Faber, Ken; Patterson, Stuart
The purposes of this study were to determine the reliability of strength and self-reporting measures, the relationship of different strength measures to function, and the impact of rotator cuff pathology on patients' quality of life. Patients with nonoperated rotator cuff pathology (n = 36) and unaffected control subjects (n = 48) were assessed by use of the LIDO dynamometer to determine isometric and isokinetic (concentric and eccentric) strength of the shoulder rotators. The Shoulder Pain and Disability Index and Short Form-36 were self-reported by patients. Intraclass correlation coefficients (ICCs) were used to assess reliability, and Pearson correlations and multiple linear regression were used to determine the relationship between strength and function. The findings of this study include the following: (1) measures of self-reported physical disability had high reliability (ICC = 0.89); (2) the LIDO dynamometer reliably measured internal and external shoulder rotation strength in both concentric and isometric modes of testing (ICC = 0.78-0.94), whereas eccentric muscle actions had lower reliability; (3) all shoulder rotation strength measures were predictive of disability, with isometric external rotation strength being the most predictive (r = 0.56); and (4) the presence of rotator cuff pathology was highly predictive of impaired physical health quality of life (R(2) = 0.71, P < .001).
Merolla, Giovanni; Paladini, Paolo; Saporito, Marco; Porcellini, Giuseppe
Summary Rotator cuff tears are a common cause of pain and shoulder dysfunction. The prevalence of the rotator cuff tears increases with the age reaching the 80% in patients aged more than 80 year. Symptomatic shoulders usually are initially treated conservatively and then, in case of poor outcomes, with surgery. Different parameters are still used to decide between the conservative or surgical treatment in patients with rotator cuff tears. Aim of the current study is to characterize the various features used in decision making and to validate a “Prediction Score” that let us know which patients could have a good and stable outcome with non operative treatment. We enrolled 60 patients (mean age 52 years) with symptomatic rotator cuff tears who were assigned to conservative treatment and were evaluated at 6,9 and 12 months follow-up. We developed a score based on 18 clinical and radiographic parameters. 27 patients (“non conservative”) (45%) with a mean prediction score of 16.1 ± 1.7 interrupted the conservative treatment, while 33 patients (“conservative”) (55%) with an average prediction score of 11.3 ± 1.8 remained conservatively treated at last follow-up. The conservative patients were 14 years older than non conservative patients. According to the results of this study we identified a value of 13 points as a “cut-off” score to predict good results by conservative management of rotator cuff tear. These outcomes support the assumption that a predictive prognostic score may guarantee a rational approach in the management of subjects with RC tears, especially in elderly who continue to have the higher rate of recurrence and therefore could be well treated with standard conservative therapies. PMID:23738239
Narvy, Steven J.; Didinger, Tracey C.; Lehoang, David; Vangsness, C. Thomas; Tibone, James E.; Hatch, George F. Rick; Omid, Reza; Osorno, Felipe; Gamradt, Seth C.
Background: Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments. Hypothesis: The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients. Study Design: Cohort study; Level of evidence, 3. Methods: Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared. Results: There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients. Conclusion: Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery. PMID:27826595
Zheng, Zefeng; Ran, Jisheng; Chen, Weishan; Hu, Yejun; Zhu, Ting; Chen, Xiao; Yin, Zi; Heng, Boon Chin; Feng, Gang; Le, Huihui; Tang, Chenqi; Huang, Jiayun; Chen, Yangwu; Zhou, Yiting; Dominique, Pioletti; Shen, Weiliang; Ouyang, Hong-Wei
Rotator cuff tear is one of the most common types of shoulder injuries, often resulting in pain and physical debilitation. Allogeneic tendon-derived decellularized matrices do not have appropriate pore size and porosity to facilitate cell infiltration, while commercially-available synthetic scaffolds are often inadequate at inducing tenogenic differentiation. The aim of this study is to develop an advanced 3D aligned collagen/silk scaffold (ACS) and investigate its efficacy in a rabbit massive rotator cuff tear model. ACS has similar 3D alignment of collagen fibers as natural tendon with superior mechanical characteristics. Based on ectopic transplantation studies, the optimal collagen concentration (10mg/ml), pore diameter (108.43±7.25μm) and porosity (97.94±0.08%) required for sustaining a stable macro-structure conducive for cellular infiltration was determined. Within in vitro culture, tendon stem/progenitor cells (TSPCs) displayed spindle-shaped morphology, and were well-aligned on ACS as early as 24h. TSPCs formed intercellular contacts and deposited extracellular matrix after 7days. With the in vivo rotator cuff repair model, the regenerative tendon of the ACS group displayed more conspicuous native microstructures with larger diameter collagen fibrils (48.72±3.75 vs. 44.26±5.03nm) that had better alignment and mechanical properties (139.85±49.36vs. 99.09±33.98N) at 12weeks post-implantation. In conclusion, these findings demonstrate the positive efficacy of the macroporous 3D aligned scaffold in facilitating rotator cuff tendon regeneration, and its practical applications for rotator cuff tendon tissue engineering.
In evaluating patients complaining of shoulder pain, ultrasonography is an emerging imaging tool due to convenience, low cost, high sensitivity and specificity. However, normative values of ultrasound dimensions of the shoulder to be compared with pathologic findings in Korean adults are not provided yet. We evaluated the ultrasound dimensions of the rotator cuff, long head of biceps tendon, deltoid muscle and acromioclavicular joint in Korean healthy adults. Shoulder ultrasonography was performed on 200 shoulders from 100 healthy adults. The dimensions of the thickness of rotator cuff (supraspinatus, infraspinatus, subscapularis tendon), deltoid muscle, long head of biceps tendon, subacromial subdeltoid bursa, and acromioclavicular joint interval were measured in a standardized manner. Differences in measurements among sex, age, and dominant arms were compared. The thickness of rotator cuff tendons (supraspinatus, infraspinatus, subscapularis) and deltoid muscle were significantly different between men and women. The thickness of subacromial subdeltoid bursa was significantly different between men and women for non-dominant side. In rotator cuff tendon measurements, the differences between dominant and non-dominant shoulders were not significant, which means the asymptomatic contralateral shoulder can be used to estimate the normal reference values. When stratified by age divided by 10 years, the measurements of supraspinatus, subscapularis and deltoid thickness showed tendency of increase with the age. The acromioclavicular joint interval, on the other hand, revealed decreasing tendency. This report suggests normative values of ultrasound dimensions of healthy Korean population with varying age, and can be useful as reference values in evaluating shoulder pathology, especially in rotator cuff tendon pathology. PMID:27510393
Lin, Yin-Liang; Karduna, Andrew
Rotator cuff and scapular muscle strengthening exercises are an essential part of shoulder rehabilitation and sports training. Although the effect of exercise training on pain and function have been widely investigated, few studies have focused on the changes in shoulder kinematics and muscle activity after exercise training. Therefore, the purpose of the present study was to investigate the effect of rotator cuff and scapular strengthening exercises on shoulder kinematics and the activation of rotator cuff and scapular muscles in healthy subjects. Thirty-six healthy subjects were recruited and randomly assigned into either a training or control group. Subjects in the training group were trained with rotator cuff and scapular strengthening exercises for four weeks. Scapular kinematics and shoulder muscle activity during arm elevation were measured before and after exercise training. After the four-week training protocol, there was an increase in strength and a decrease in upper trapezius activation in the training group, which is consistent with previous studies. However, no difference was found in scapular kinematics and activation of rotator cuff muscles between the control and training groups after the training protocol. Although the exercise protocol resulted in strength gains for the rotator cuff, these gains did not transfer to an increase in muscle activation during motion. These results demonstrate the difficulty in changing activation patterns of the rotator cuff muscles. PMID:26996811
Zvijac, J E; Levy, H J; Lemak, L J
Arthroscopic subacromial decompression has become an accepted treatment for patients with impingement syndrome; however, its use for full thickness rotator cuff tears continues to be controversial. The purpose of this study is to determine if the results of arthroscopic subacromial decompression alone for full thickness rotator cuff tears deteriorate at long-term follow-up. We reevaluated all 25 patients with full thickness rotator cuff tears who underwent arthroscopic subacromial decompression from our original study group. Based on the University of California at Los Angeles shoulder rating, 68% of patients were rated as excellent or good at the present mean follow-up of 45.8 months (range 36-72 months). This represents a significant decrease from our initial report of 84% satisfactory results at a mean follow-up of 24.6 months. There was a significant decrease in ratings with regard to pain and function; however, no significant deterioration was noted with regard to motion and strength. Two additional patients required open rotator cuff repair since the time of initial follow-up for a total of six. Large and massive rotator cuff tears fared worse over time as compared with small and moderate size tears. Although 1- to 3-year results of arthroscopic subacromial decompression and rotator cuff debridement were favorable, the long-term follow-up demonstrates deterioration of results. We therefore cannot support the use of decompression and debridement alone in the treatment of repairable full thickness rotator cuff tears.
Shishido, Hiroaki; Kikuchi, Shinichi; Otoshi, Kenichi; Konno, Shinichi
Some patients with rotator cuff tear have shoulder stiffness preoperatively. Concomitant preoperative shoulder stiffness may affect postoperative outcomes of arthroscopic subacromial decompression (ASD) for rotator cuff tear. The purpose of this study was to compare postoperative outcomes for ASD between rotator cuff tear patients with and without preoperative shoulder stiffness and to analyze the serial change in functional scores, range of motion (ROM), and pain intensity of the 2 groups after operation. 60 shoulders of 58 patients who underwent ASD for rotator cuff tear were studied. Arthroscopic release was performed for the stiffness group. The results were assessed before surgery and 1, 3, 6, 12 and 24 months after surgery, and the results in the stiffness group and non-stiffness group were compared. No differences in serial changes for postoperative outcomes of ASD were seen in terms of the Japanese Orthopaedic Association shoulder scoring system (JOA scores) and the visual analog scale (VAS scores) for pain at night and pain during motion between the stiffness group and non-stiffness group. However, compared to the non-stiffness group, forward flexion and abduction angles were significantly smaller for the stiffness group at 1 and 3 months after surgery. External rotation and internal rotation angles were significantly smaller at 1 month after surgery for the stiffness group than for the non-stiffness group. Preoperative shoulder stiffness does not affect improvement of postoperative JOA scores and VAS scores of ASD. When measured 6 months after surgery, ROM in the stiffness group and the non-stiffness group was similar.
Katthagen, Jan Christoph; Millett, Peter J.; Espinoza-Ervin, Christopher; Horan, Marilee P.; Ho, Charles P.; Warth, Ryan J.; Dornan, Grant
Objectives: The purpose of this study was to analyze predictors of clinical outcomes of knotted versus knotless double-row self-reinforcing rotator cuff repairs of full-thickness rotator cuff tears with propensity score matching. Methods: Patients with arthroscopic repair of full-thickness rotator cuff tears involving the supraspinatus tendon using either a knotted or knotless linked, self-reinforcing double-row technique were included in the study. Preoperative subjective evaluation was performed using the ASES and SF-12 PCS scores. After a minimum two-year follow-up period, ASES and SF-12 PCS scores were collected again along with the SANE score, the QuickDASH score, and patient satisfaction. All data were collected prospectively and retrospectively reviewed. Postoperative ASES and SF-12 PCS scores were then modeled using inverse propensity score weighting in a multiple linear regression model (MLR) with multiple imputations. Age, sex, baseline ASES score, length of follow-up, number of anchors, worker’s compensation, previous cuff repair, and double-row repair technique (knotted or knotless) were the covariates used in this model. Results: 155 shoulders in 151 patients (109 men, 42 women; mean age at time of surgery 59±10 years) were eligible for inclusion. Outcomes data were available for 130 of 148 shoulders (87.8%) after exclusion of seven shoulders (4.5%) that underwent revision rotator cuff repair before final follow up (n=33/39 in the knotted group [84.6%]; n=97/109 [88.9%] in the knotless group).The mean follow-up was 2.9 years (range, 2.0-5.4 years). Overall, postoperative outcomes scores were significantly improved when compared to preoperative baselines (p<0.05), with a median postoperative ASES score of 97 for the entire cohort. Our model showed that previous rotator cuff repair had a significant negative effect on postoperative ASES (β = -12.7, p<0.001) and SF-12 PCS scores (β = -5.0, p = 0.036). A workers’ compensation claim (β = -10.6, p
Cooper, H John; Milillo, Ralph; Klein, Devon A; DiFelice, Gregory S
We present the case of a 71-year-old man with a large acromioclavicular (AC) joint cyst successfully managed with surgical excision. AC joint cysts are soft tissue masses generally signifying underlying rotator cuff pathology. Traditionally, these cysts were identified with shoulder arthrography as a "geyser" of fluid escaping through the AC joint. Magnetic resonance imaging (MRI) is today's preferred imaging modality; we describe the MRI equivalent of the "geyser sign," signifying synovial fluid escaping through the cuff defect, across the subacromial bursa, and decompressing superiorly through a degenerated AC joint. Surgical management is preferred for symptomatic cysts. Based on a review of limited retrospective case series, recommendations for management of these lesions are as follows. Repair of the rotator cuff is preferable whenever possible. In the case of an irreparable defect, good results can be achieved through excisional AC joint arthroplasty and resection of the cyst base. Aspiration of these cysts should not be attempted, due to the high recurrence rate and potential for a draining sinus. Hemiarthroplasty also may be effective in indirectly decompressing these cysts; but given the invasive nature of this procedure, it should be reserved for patients who are also symptomatic from cuff arthropathy.
Huisstede, Bionka M A; Koes, Bart W; Gebremariam, Lukas; Keijsers, Ellen; Verhaar, Jan A N
In this systematic review we assessed effectiveness of non-surgical and (post)surgical interventions for symptomatic rotator cuff tears (RotCuffTear). The Cochrane Library, PubMed, Embase, Cinahl, and Pedro were searched for relevant systematic reviews and randomized controlled trials (RCTs). Two reviewers independently selected relevant studies, extracted data and assessed the methodological quality. Three Cochrane reviews (7 RCTs) and 14 RCTs were included (3 non-surgery, 10 surgery, 8 post-surgery). For small or medium RotCufftears, moderate evidence was found in favour of surgery versus physiotherapy in mid- and long-term. In surgery, tendon-to-bone fixation with one metal suture anchor loaded with double sutures (TB) was more effective (moderate evidence) than a side-to-side repair with permanent sutures (SS) in the mid- and long-term; limited evidence for effectiveness was found in favour of debridement versus anchor replacement and suture repair of the type II SLAP tear in the long-term. Further, no evidence was found in favour of any non-surgical, surgical or post-surgical intervention. In conclusion, although surgery seems to give better results compared to non-surgery and TB is more effective than SS in rotator cuff repair (RCR), it remains hard to draw firm evidence-based conclusions for effectiveness of non-surgical or (post)surgical interventions to treat RotCuffTears. More research is clearly needed.
Analan, Pınar Doruk; Leblebici, Berrin; Adam, Mehmet
[Purpose] The aim of this prospective, double-blind, randomized, placebo-controlled study was to evaluate the effects of therapeutic continuous ultrasound (US) on patients with rotator cuff disease. [Subjects and Methods] Twenty-two patients were treated with a standard physiotherapy program consisting of a hot-pack, transcutaneous electrical nerve stimulation (TENS), exercises, and US that was supervised by the same physiotherapist. The patients were randomly assigned to either a group that received true US (n=11) or one that received sham US (n=11). [Results] There were significant differences between the pre- and post-intervention UCLA Shoulder Rating Scale and Constant-Murley Shoulder Outcome scores, VAS, and external rotation (ER) peak torque 60°/second values for both the true and sham US groups. However, the between-group differences were not statistically significant. [Conclusion] In patients with rotator cuff disease, physiotherapy interventions effectively treat the pain, improve the clinical status, and increase the muscle strength of the shoulder ER at a low constant angular velocity, with functional improvement being seen immediately after treatment. However, at the end of the intervention, the US had yielded no additional efficacy to the physiotherapy treatment regimen of the patients with rotator cuff disease. PMID:26644656
Kuhn, John E
Magnetic resonance imaging (MRI) findings are common in patients and athletes with shoulder pain. Historically these anatomic derangements have been thought to be the source of the patient's symptoms, and approaches have been focused on restoring the anatomy. This manuscript will address three objectives: (1) suggest that the approach to rotator cuff disease should be based on the patient's history and physical examination, and not necessarily on the anatomic disorders apparent on imaging; (2) review the data that supports the contention that rotator cuff disease is not the source of pain in the symptomatic shoulder, and (3) describe the concept of adaptive pathology. The findings on the MRI in the thrower's painful shoulder may be adaptive, and these alterations may be required to allow performance at high levels in sport.
Savarese, Eugenio; Romeo, Rocco
Massive, irreparable rotator cuff tears are a source of pain and disability. Although most rotator cuff tears can be completely repaired, a significant number are considered massive and irreparable. Numerous operative techniques have been described for the treatment of these kinds of tears including arthroscopic debridement, biceps tenotomy, tendon transfer, grafting, and reverse arthroplasty. We describe a surgical technique using a biodegradable subacromial balloon spacer (InSpace; OrthoSpace, Kfar Saba, Israel) implanted between the humeral head and acromion that permits smooth, frictionless gliding, restoring the shoulder biomechanics. The technique is easy to perform and is less invasive than the conventional surgical techniques available, and it may potentially serve as a bridging option in patients with massive, irreparable tears who are normally candidates for reverse arthroplasty. PMID:23766979
Posada, A; Uribe, J W; Hechtman, K S; Tjin-A-Tsoi, E W; Zvijac, J E
To determine whether the results of arthroscopically assisted rotator cuff repair deteriorate with time, 60 shoulders were evaluated on 2 separate occasions. There were 7 small, 16 medium, 20 large, and 17 massive tears. Patients were evaluated with a detailed questionnaire that included the UCLA shoulder scale and physical examination. Average initial follow-up was at 21 months (range, 12 to 68 months), and the second follow-up was at an average of 62 months (range, 24 to 103 months); only 4 patients had a change of more than 3 points on the UCLA scoring scale. No statistically significant difference was found in pain, function, range of motion, strength score, satisfactory results (80% on both occasions), and UCLA score (30.8 v 31.4) at second follow-up. The results of our study indicate that there is no significant deterioration over time of results of rotator cuff repair using the mini-deltoid splitting technique.
Mathewson, Margie A; Kwan, Alan; Eng, Carolyn M; Lieber, Richard L; Ward, Samuel R
In this study, we compare rotator cuff muscle architecture of typically used animal models with that of humans and quantify the scaling relationships of these muscles across mammals. The four muscles that correspond to the human rotator cuff - supraspinatus, infraspinatus, subscapularis and teres minor - of 10 commonly studied animals were excised and subjected to a series of comparative measurements. When body mass among animals was regressed against physiological cross-sectional area, muscle mass and normalized fiber length, the confidence intervals suggested geometric scaling but did not exclude other scaling relationships. Based on the architectural difference index (ADI), a combined measure of fiber length-to-moment arm ratio, fiber length-to-muscle length ratio and the fraction of the total rotator cuff physiological cross-sectional area contributed by each muscle, chimpanzees were found to be the most similar to humans (ADI=2.15), followed closely by capuchins (ADI=2.16). Interestingly, of the eight non-primates studied, smaller mammals such as mice, rats and dogs were more similar to humans in architectural parameters compared with larger mammals such as sheep, pigs or cows. The force production versus velocity trade-off (indicated by fiber length-to-moment arm ratio) and the excursion ability (indicated by fiber length-to-muscle length ratio) of humans were also most similar to those of primates, followed by the small mammals. Overall, primates provide the best architectural representation of human muscle architecture. However, based on the muscle architectural parameters of non-primates, smaller rather than larger mammals may be better models for studying muscles related to the human rotator cuff.
Hatta, Taku; Giambini, Hugo; Uehara, Kosuke; Okamoto, Seiji; Chen, Shigao; Sperling, John W; Itoi, Eiji; An, Kai-Nan
Ultrasound imaging has been used to evaluate various shoulder pathologies, whereas, quantification of the rotator cuff muscle stiffness using shear wave elastography (SWE) has not been verified. The purpose of this study was to investigate the reliability and feasibility of SWE measurements for the quantification of supraspinatus (SSP) muscle elasticity. Thirty cadaveric shoulders (18 intact and 12 with torn rotator cuff) were used. Intra- and inter-observer reliability was evaluated on an established SWE technique for measuring the SSP muscle elasticity. To assess the effect of overlying soft tissues above the SSP muscle, SWE values were measured with the transducer placed on the skin, on the subcutaneous fat after removing the skin, on the trapezius muscle after removing the subcutaneous fat, and directly on the SSP muscle. In addition, SWE measurements on 4 shoulder positions (0°, 30°, 60°, and 90° abduction) were compared in those with/without rotator cuff tears. Intra- and inter-observer reliability of SWE measurements were excellent for all regions in SSP muscle. Also, removing the overlying soft tissue showed no significant difference on SWE values measured in the SSP muscle. The SSP muscle with 0° abduction showed large SWE values, whereas, shoulders with large-massive tear showed smaller variation throughout the adduction-abduction positions. SWE is a reliable and feasible tool for quantitatively assessing the SSP muscle elasticity. This study also presented SWE measurements on the SSP muscle under various shoulder abduction positions which might help characterize patterns in accordance to the size of rotator cuff tears.
Hartzler, Robert U.; Sperling, John W.; Schleck, Cathy D.; Cofield, Robert H.
Purpose: Historically, results of open revision of rotator cuff repair have been mixed and often poor. We reviewed the outcomes of revision rotator cuff repair with a detailed analysis of clinical and radiographic risk factors in order to improve patient selection for this type of surgery. Materials and Methods: Thirty-six patients (37 shoulders) underwent first-time, open revision rotator cuff repair between 1995 and 2005. Average follow-up was 7.0 years (range 1-14.9 years). The tear size was small in 1 shoulder, medium in 8, large in 22 and massive in 6. Associations of 29 clinical and radiographic factors with the outcomes of pain, motion, and function were assessed. Results: Satisfactory outcome occurred in 22 shoulders (59%): An excellent result in 2, a good result in 7, and a fair result in 13. Unsatisfactory, poor results occurred in 15. Pain was substantially reduced in 25 (68%). Median pain scores decreased to five from a pre-operative eight (P = 0.002). Median motion did not change from pre-operative to post-operative. The chance of a satisfactory outcome and improved post-operative motion were associated with males, greater pre-operative motion, increased acromial humeral distance, the absence of glenohumeral arthritis, or a degenerative re-tear. Conclusions: Revision rotator cuff repair, although a safe operation, with a low re-operative rate, has very mixed overall results. By knowing the factors associated with success, surgeons can better counsel patients and with this increased knowledge, consider alternative treatment choices. PMID:23960361
Littlewood, Chris; Malliaras, Peter; Mawson, Sue; May, Stephen; Walters, Stephen
This paper describes a self-managed loaded exercise programme which has been designed to address the pain and disability associated with rotator cuff tendinopathy. The intervention has been developed with reference to current self-management theory and with reference to the emerging benefit of loaded exercise for tendinopathy. This self-managed loaded exercise programme is being evaluated within the mixed methods SELF study (ISRCTN 84709751) which includes a pragmatic randomised controlled trial conducted within the UK National Health Service.
Imam, Mohamed Abdelnabi; Abdelkafy, Ashraf
Background: The transosseous-equivalent cross bridge double row (TESBDR) rotator cuff (RC) repair technique has been developed to optimize healing biology at a repaired RC tendon insertion. It has been shown in the laboratory to improve pressurized contact area and mean foot print pressure when compared with a double row anchor technique. Pressure has been shown to influence healing between tendon and bone, and the tendon compression vector provided by the transosseous-equivalent suture bridges may enhance healing. The purpose was to prospectively evaluate the outcomes of arthroscopic TESBDR RC repair. Methods: Single center prospective case series study. Sixty-nine patients were selected to undergo arthroscopic TESBDR RC repair and were included in the current study. Primary outcome measures included the Oxford Shoulder Score (OSS), the University of California, Los Angeles (UCLA) score, the Constant-Murley (CM) Score and Range of motion (ROM). Secondary outcome measures included a Visual Analogue Scale (VAS) for pain, another VAS for patient satisfaction from the operative procedure, EuroQoL 5-Dimensions Questionnaire (EQ-5D) for quality of life assessment. Results: At 24 months post-operative, average OSS score was 44, average UCLA score was 31, average CM score was 88, average forward flexion was 145°, average internal rotation was 35°, average external rotation was 79°, average abduction was 150°, average EQ-5D score was 0.73, average VAS for pain was 2.3, and average VAS for patient satisfaction was 9.2. Conclusion: Arthroscopic TESBDR RC repair is a procedure with good post-operative functional outcome and low re-tear rate based on a short term follow-up. PMID:27163096
Edwards, Peter; Ebert, Jay; Joss, Brendan; Bhabra, Gev; Ackland, Tim; Wang, Allan
The incidence of rotator cuff tears increases with age, with full-thickness rotator cuff tears present in approximately 25% of individuals in their sixties, and more than 50% of those in their eighties. While surgery is considered an effective treatment, recurrent tears at the insertion site are common, especially with degenerative tears, which are frequent in the older population. More recently, there has been increasing interest in exercise rehabilitation and physical therapy as a means to manage partial and full thickness tears of the rotator cuff by addressing weakness and functional deficits. Recent studies have suggested that patients opting for physical therapy have demonstrated high satisfaction, an improvement in function, and success in avoiding surgery. When considering the increasing rate of shoulder surgery and the associated economic and social burden rotator cuff surgery places on both the patient and the health care system, non-surgical management such as physical therapy and exercise may, in selected cases, be a treatment alternative to surgical repair. The purpose of this clinical commentary is to provide an overview of rotator cuff pathology and pathogenesis, and to present an evidence-based case for the role of conservative rehabilitation in the management of rotator cuff injuries. Level of Evidence Level 5 PMID:27104061
Filho, Rômulo Brasil; Ribeiro, Fabiano Rebouças; Tenor, Antonio Carlos; Filho, Cantidio Salvador Filardi; da Costa, Guilherme Barbieri Leme; Storti, Thiago Medeiros; da Costa Garcia, André; Lutfi, Hilton Vargas
Objective: To assess results of CTA® partial shoulder arthroplasty for treatment of degenerative arthropathy of the rotator cuff. Methods: Between December 2006 and June 2009, 23 shoulders of 23 patients were submitted to CTA® type partial shoulder arthroplasty for treatment of arthropathy secondary to rotator cuff injury. Post-operative follow up time ranged from 6 to 35 months. Mean age was 74.1 years. Patients were predominantly female, representing 78.3% of cases. The right limb was affected in 18 patients. All patients had undergone at least 6 months of physiotherapy without improvement of the algetic picture, and being submitted to surgery by the same surgical team. None of the patients had history of surgery on the affected shoulder. The method elected for assessing patients during post-operative follow up was based on UCLA scoring criteria. Results: Improvement in pain was observed in all patients after arthroplasty. Mean UCLA pain score was 9.22 (ranging from 10 to 8). Mean function was 6 (10 to 2). Active frontal flexion was 2.39 (highest score 4 and lowest 0). Mean frontal flexion force was 4.09, maximum was 5 and minimum 3. Mean score on the UCLA was 26.52. 95% were satisfied with the surgery. Conclusion: CTA® type partial shoulder arthroplasty produced satisfactory results in the treatment of degenerative arthropathy of the rotator cuff and had a low rate of complications. PMID:27028431
Miyazaki, Alberto Naoki; Fregoneze, Marcelo; Santos, Pedro Doneux; da Silva, Luciana Andrade; do Val Sella, Guilherme; Santos, Ruy Mesquita Maranhão; de Souza, Adriano; Estelles, José Renato Depari; Checchia, Sérgio Luiz
Objectives: To assess the results from open or arthroscopic surgical treatment on patients with symptomatic recurrence of rotator cuff injuries. Methods: Between December 1990 and July 2007, 30 patients were assessed and underwent reoperation performed by the Shoulder and Elbow Surgery Group of the Department of Orthopedics and Traumatology, Fernandinho Simonsen Wing, Santa Casa de São Paulo, because of dehiscence of the rotator cuff suture. The study included patients with symptomatic recurrence of the injury and with at least 24 months of postoperative follow-up. Results: According to the UCLA evaluation criteria, 21 patients (70%) showed excellent or good outcomes; and nine patients (30%) showed fair or poor outcomes. Conclusion: Open or arthroscopic surgical treatment of recurrent rotator cuff injuries tended to present worse results than from the primary repair. In this study, we found that 70% of the results were excellent and good. The presence of extensive injuries in the reoperation tended to evolve with larger numbers of unsatisfactory results. In our study, we obtained better results from arthroscopic surgery than from open surgery. PMID:27026985
El-Kouba, Gabriel; Andreas Huber, Thomas; Freitas, José Renato Wilke; Steglich, Valdir; Ayzemberg, Henrique; Santos, Adriano M.
The aim of this study was to evaluate the accuracy of simple radiography, ultrasound and magnetic resonance imaging (MRI) in diagnosing rotator cuff injuries, comparing their findings with open or arthroscopic surgery findings. Methods: Protocols of the Shoulder and Elbow Surgery Service for patients undergoing surgical treatment for rotator cuff injuries diagnosed by means of radiography, ultrasound and/or MRI between 2002 and 2007 were evaluated. Based on the data gathered, we analyzed the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of these complementary examinations, compared with the findings during the surgical procedures. Results: This study included 147 patients with a mean age of 46.09 years. All the patients had undergone a radiography examination, 101 had undergone ultrasound examination and 72 had undergone MRI. We found sensitivity of 13.8%, specificity of 2.6% and accuracy of 30% with radiography; sensitivity of 57.6%, specificity of 29.6% and accuracy of 51.4% with ultrasound; and sensitivity of 86.6%, specificity of 22.2% and accuracy of 63.3% with MRI. Conclusion: Radiography was found to be a specific examination when the mirror sign was present. MRI and ultrasound were shown to be reliable methods with high accuracy for diagnosing rotator cuff injuries. PMID:27022589
Meira, Erik P.; En Gilpin, Hui; Brunette, Meredith
Background and Purpose: Golf is a popular sport played by hundreds of thousands of individuals of all ages and of varying skill levels. An orthopedic or sports-related injury and/or surgery may limit an individual's sport participation, require him/her to complete a course of rehabilitation, and initiate (or resume) a sport-specific training program. Unlike the availability of evidence to guide postsurgical rehabilitation and sport-specific training of athletes from sports other than golf, there have only been two reports describing outcomes after surgery and for golfers. The purpose of this case report is to present a post-rehabilitation return to sport-training program for a recreational golfer 11-months after a rotator cuff repair. Case Description: The subject, a 67-year old female, injured her right shoulder requiring a rotator cuff repair 11-months prior to her participation in a golf fitness training program. The subject participated in six training sessions over seven week period consisting of general strengthening exercises (including exercises for the rotator cuff), exercises for the core, plyometrics, and power exercises. Outcomes: The subject made improvements in power and muscular endurance of the core. She was able to resume golf at the completion of the training program. Discussion: The subject was able to make functional improvements and return to golf after participation in a comprehensive strength program. Additional studies are necessary to improve program design for golfers who wish to return to sport after shoulder surgery. PMID:22163096
Gayton, J Christopher; Rubino, L Joseph; Rich, Mark M; Stouffer, Mark H; Wang, Qingbo; Boivin, Gregory P
Rotator cuff tears are a major cause of morbidity. Following rotator cuff tears, muscle atrophy and fatty infiltration begin in the tissue, limiting repair potential and leading to a higher re-tear rate and a worse functional outcome. We evaluated whether fatty degeneration resulting from a complete supraspinatus tear with retraction is associated with an injury to the suprascapular nerve. Four skeletally mature New Zealand white rabbits were randomized to receive an index procedure on either their right or left shoulder with the opposite shoulder serving as a control. At the index procedure, the supraspinatus tendon was transected at its insertion and allowed to retract. At 3 months, the rabbits were euthanized, and both supraspinatus muscles were harvested. The specimens were then examined with confocal microscopy and histology. Atrophy was grossly visible in all four test muscles, and fatty infiltration was confirmed with osmium tetroxide staining. In all four rabbits, the degree of denervation (p = 0.71) and partial denervation (p = 0.91) was not significantly different between control and experimental muscle. Rotator cuff tear does not affect the motor endplate or innervation status of the supraspinatus. Fatty infiltration occurs independent of denervation of the supraspinatus.
Hayes, Kimberley; Ginn, Karen A; Walton, Judie R; Szomor, Zoltan L; Murrell, George A C
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.
Ji, Jong-Hun; Shafi, Mohamed; Moon, Chang-Yun; Park, Sang-Eun; Kim, Yeon-Jun; Kim, Sung-Eun
Arthroscopic removal, now the main treatment option, has almost replaced open surgery for treatment of resistant calcific tendinitis. In some cases of chronic calcific tendinitis of the shoulder, the calcific materials are hard and adherent to the tendon. Removal of these materials can cause significant intratendinous tears between the superficial and deep layers of the degenerated rotator cuff. Thus far, there are no established surgical techniques for removing the calcific materials while ensuring cuff integrity. Good clinical results for rotator cuff repair were achieved by using an arthroscopic suture bridge technique in patients with long-standing calcific tendinitis. Intact rotator cuff integrity and recovery of signal change on follow-up magnetic resonance imaging scans were confirmed. This is a technical note about a surgical technique and its clinical results with a review of relevant published reports.
Kim, Moon-Hwan; Oh, Jae-Seop
[Purpose] The purpose of this study was to examine the effects of humeral head compression taping (HHCT) on the strength of the shoulder external rotator muscle in patients with rotator cuff tendinitis. [Subjects and Methods] Twenty patients with rotator cuff tendinitis were recruited. The shoulder external rotator strength was measured using a Biodex isokinetic dynamometer system. A paired t-test was performed to evaluate within-group differences in the strength of the shoulder external rotator muscle. [Results] Significantly higher shoulder external rotator peak torque and peak torque per body weight were found in the HHCT condition than in the no-taping condition. [Conclusion] HHCT may effectively increase the shoulder external rotator muscle strength in patients with rotator cuff tendinitis. PMID:25642053
Rittmeister, M; Kerschbaumer, F
This study was undertaken to determine whether patients with severe rheumatoid arthritis and irreparable rotator cuff rupture can be treated successfully with the Grammont shoulder arthroplasty. Seven patients with rheumatoid arthritis (8 shoulders) with nonreconstructible rotator cuff lesions and Larsen stage-V radiographic changes of the glenoid and the humeral head underwent a Grammont reverse shoulder arthroplasty. The Constant score improved from a mean of 17 points (range 4 to 25) preoperatively to a mean of 63 points (range 41 to 79) at a mean of 54 months (range 48 to 73) after shoulder arthroplasty. The mean strength at 90 degrees of abduction measured 3.6 kg (range 1 to 6). Shoulder instability was not observed. Complications included septic implant loosening (1 shoulder), aseptic glenoid loosening (2), and failed acromion osteosynthesis following the transacromial approach (3). These data of Grammont arthroplasty are encouraging with respect to restoration of stability and satisfactory function in rheumatoid, cuff-deficient shoulders. However, glenoid loosening remained a serious problem, and transacromial approaches were complicated by failure of acromial fixation.
Tenor Júnior, Antônio Carlos; de Lima, José Alano Benevides; de Vasconcelos, Iúri Tomaz; da Costa, Miguel Pereira; Filho, Rômulo Brasil; Ribeiro, Fabiano Rebouças
Objective To evaluate the evolution of the functional results from CTA® hemiarthroplasty for surgically treating degenerative arthroplathy of the rotator cuff, with a mean follow-up of 5.4 years. Methods Eighteen patients who underwent CTA® partial arthroplasty to treat degenerative arthroplathy of the rotator cuff between April 2007 and June 2009 were reevaluated, with minimum and mean follow-ups of 4.6 years and 5.4 years, respectively. Pre and postoperative parameters for functionality and patient satisfaction were used (functional scale of the University of California in Los Angeles, UCLA). All the patients underwent prior conservative treatment for 6 months and underwent surgical treatment because of the absence of satisfactory results. Patients were excluded if they presented any of the following: previous shoulder surgery; pseudoparalysis; insufficiency of the coracoacromial arch (type 2 B in Seebauer's classification); neurological lesions; or insufficiency of the deltoid muscle and the subscapularis muscle. Results With a mean follow-up of 5.4 years, 14 patients considered that they were satisfied with the surgery (78%); the mean range of joint motion for active elevation improved from 55.8° before the operation to 82.0° after the operation; the mean external rotation improved from 18.9° before the operation to 27.3° after the operation; and the mean medial rotation remained at the level of the third lumbar vertebra. The mean UCLA score after the mean follow-up of 5.4 years was 23.94 and this was an improvement in comparison with the preoperative mean and the mean 1 year after the operation. Conclusion The functional results from CTA® hemiarthroplasty for treating rotator cuff arthroplasty in selected patients remained satisfactory after a mean follow-up of 5.4 years. PMID:26229938
Godinho, Glaydson Gomes; Freitas, José Márcio Alves; de Oliveira França, Flávio; Santos, Flávio Márcio Lago; de Simoni, Leandro Furtado; Godinho, Pedro Couto
Objective To evaluate the clinical outcome of arthroscopic rotator cuff fixation and, when present, simultaneous repair of the Bankart lesion caused by traumatic dislocation; and to assess whether the size of the rotator cuff injury caused by traumatic dislocation has any influence on the postoperative clinical outcomes. Methods Thirty-three patients with traumatic shoulder dislocation and complete rotator cuff injury, with at least two years of follow up, were retrospectively evaluated. For analysis purposes, the patients were divided into groups: presence of fixed Bankart lesion or absence of this lesion, and rotator cuff lesions smaller than 3.0 cm (group A) or greater than or equal to 3.0 cm (group B). All the patients underwent arthroscopic repair of the lesions and were evaluated postoperatively by means of the UCLA (University of California at Los Angeles) score and strength measurements. Results The group with Bankart lesion repair had a postoperative UCLA score of 33.96, while the score of the group without Bankart lesion was 33.7, without statistical significance (p = 0.743). Group A had a postoperative UCLA score of 34.35 and group B, 33.15, without statistical significance (p = 0.416). Conclusion The functional outcomes of the patients who only presented complete rotator cuff tearing after traumatic shoulder dislocation, which underwent arthroscopic repair, were similar to the outcomes of those who presented an associated with a Bankart lesion that was corrected simultaneously with the rotator cuff injury. The extent of the original rotator cuff injury did not alter the functional results in the postoperative evaluation. PMID:27069884
Nicholas, Stephen J.; Lee, Steven J.; Mullaney, Michael J.; Tyler, Timothy F.; Fukunaga, Takumi; Johnson, Christopher D.; McHugh, Malachy P.
Background: The functional benefits of double-row (DR) versus single-row (SR) rotator cuff repair are not clearly established. Purpose: To examine the effect of DR versus SR rotator cuff repair on functional outcomes and strength recovery in patients with full-thickness tears. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Forty-nine patients were randomized to DR or SR repairs; 36 patients (13 women, 23 men; mean age, 62 ± 7 years; 20 SR, 16 DR) were assessed at a mean 2.2 ± 1.6 years after surgery (range, 1-7 years; tear size: 17 medium, 13 large, 9 massive). The following data were recorded prior to surgery and at follow-up: Penn shoulder score, American Shoulder and Elbow Surgeons (ASES), and Simple Shoulder Test (SST) results; range of motion (ROM) for shoulder flexion, external rotation (ER) at 0° and 90° of abduction, and internal rotation (IR) at 90° of abduction; and shoulder strength (Lafayette manual muscle tester) in empty- and full-can tests, abduction, and ER at 0° of abduction. Treatment (SR vs DR) × time (pre- vs postoperative) mixed-model analysis of variance was used to assess the effect of rotator cuff repair. Results: Rotator cuff repair markedly improved Penn, ASES, and SST scores (P < .001), with similar improvement between SR and DR repairs (treatment × time, P = .38-.10) and excellent scores at follow-up (DR vs SR: Penn, 91 ± 11 vs 92 ± 11 [P = .73]; ASES, 87 ± 12 vs 92 ± 12 [P = .21]; SST, 11.4 ± 1.0 vs 11.3 ± 1.0 [P = .76]). Patients with DR repairs lost ER ROM at 0° of abduction (preoperative to final follow-up, 7° ± 10° loss [P = .013]). ER ROM did not significantly change with SR repair (5° ± 14° gain, P = .16; treatment by time, P = .008). This effect was not apparent for ER ROM at 90° of abduction (treatment × time, P = .26). IR ROM improved from preoperative to final follow-up (P < .01; SR, 17° ± 27°; DR, 7° ± 21°; treatment × time, P = .23). Rotator cuff repair markedly
Miyazaki, Alberto Naoki; Fregoneze, Marcelo; Santos, Pedro Doneux; da Silva, Luciana Andrade; do Val Sella, Guilherme; Neto, Douglas Lobato Lopes; Muchiuti Junior, Melvis; Checchia, Sergio Luiz
Objective to evaluate the functional result from arthroscopic repair of rotator cuff injuries in patients with pseudoparalysis, defined as incapacity to actively raise the arm above 90°, while complete passive elevation was possible. Methods we reevaluated 38 patients with a mean follow-up of 51 months (minimum of 24). We analyzed the pseudoparalysis reversion rate and the functional result obtained. Results according to the assessment criteria of the University of California in Los Angeles (UCLA), 31 (82%) patients had good and excellent results, two (5%) had fair results and five (13%) had poor results. The mean active elevation went from 39° before the operation to 139° after the operation (p < 0.05); the mean active lateral rotation went from 30° to 48° (p < 0.05) and the mean active medial rotation went from level L3 to T12 (p < 0.05). Conclusion arthroscopic repair of rotator cuff injuries produced good and excellent results in 82% of the cases and a statistically significant improvement of active range of motion, with reversion of the pseudoparalysis in 97.4% of the cases. It is therefore a good treatment option. PMID:26229796
Abdul-Wahab, Taiceer A.; Betancourt, Jean P.; Hassan, Fadi; Thani, Saeed Al.; Choueiri, Hened; Jain, Nitin B.; Malanga, Gerard A.; Murrell, William D.; Prasad, Anil; Verborgt, Olivier
Summary Background rotator cuff tear affects many people. Natural history, and evidence for non-operative treatment remains limited. Our objective is to assess evidence available for the efficacy and morbidity of commonly used systemic medications, physiotherapy, and injections alongside evaluating any negative long-term effects. Methods a systematic search was performed of PubMed, Cochrane, EMBASE and CINAHL dates (1 January 1960 – 1 December 2014), search terms: ‘rotator cuff tear’, ‘natural history’, ‘atraumatic’, ‘injection’, ‘physiotherapy’ or ‘physical therapy’, ‘injection’, ‘corticosteroid’, ‘PRP‘, ‘MSC’, risk of conservative treatment’, and ‘surgical indication’. Results eleven studies were included. The mean Coleman Methodology Score modified for conservative therapy is 69.21 (range 88–44) (SD 12.31). This included 2 RCTs, 7 prospective, and 2 retrospective studies. Evidence suggests it is safe to monitor symptomatic rotator cuff tears, as tear size and symptoms are not correlated with pain, function, and/or ultimate outcome. Conclusions complete rotator cuff tears may be effectively treated with injections, exercise in the short and intermediate terms respectively. Negative effect of corticosteroids on rotator cuff tissue has not been demonstrated. Timing to end conservative treatment is unknown, but likely indicated when a patient demonstrates increased weakness and loss of function not recoverable by physiotherapy. PMID:27331030
Pai Raikar, Vipul; Kwartowitz, David M.
Degradation and injury of the rotator cuff is one of the most common diseases of the shoulder among the general population. In orthopedic injuries, rotator cuff disease is only second to back pain in terms of overall reduced quality of life for patients. Clinically, this disease is managed via pain and activity assessment and diagnostic imaging using ultrasound and MRI. Ultrasound has been shown to have good accuracy for identification and measurement of rotator cuff tears. In our previous work, we have developed novel, real-time techniques to biomechanically assess the condition of the rotator cuff based on Musculoskeletal Ultrasound. Of the rotator cuff tissues, supraspinatus is the first that sees degradation and is the most commonly affected. In our work, one of the challenges lies in effectively segmenting and characterizing the supraspinatus. We are exploring the possibility of using curvelet transform for improving techniques to segment tissue in ultrasound. Curvelets have been shown to give optimal multi-scale representation of edges in images. They are designed to represent edges and singularities along curves in images which makes them an attractive proposition for use in ultrasound segmentation. In this work, we present a novel approach to the possibility of using curvelet transforms for automatic edge and feature extraction for the supraspinatus.
de Castro Veado, Marco Antônio; Castilho, Rodrigo Simões; Maia, Philipe Eduardo Carvalho; Rodrigues, Alessandro Ulhôa
Objective: To prospectively assess the surgical results from patients undergoing repairs to rotator cuff injuries via open and arthroscopic procedures, with regard to functional and clinical features, and by means of ultrasound examinations, and to compare occurrences of renewed tearing. Methods: Sixty patients underwent operations performed by the same surgeon (29 via open surgery and 31 via arthroscopy), to repair complete rotator cuff tears. The procedures were performed at Hospital Governor Israel Pinheiro (HGIP) and Mater Dei Hospital in Belo Horizonte, Minas Gerais, between August 2007 and February 2009. The patients were assessed functionally by means of the UCLA score before and after the operation, and magnetic resonance imaging was done before the operation. All the patients were reassessed at least 12 months after the operation, and an ultrasound examination was also performed at this time. Results: Out of the 29 patients who underwent open surgery, 27 (93.1%) presented good or excellent results, with a mean UCLA score of 32 after the operation. Their mean follow-up was 14 months. Three patients presented renewed tearing on ultrasound, of whom one remained asymptomatic. Out of the 31 patients who underwent arthroscopic procedures, 29 (93.5%) presented good or excellent results, with a mean UCLA score of 33 after the operation. Their mean follow-up was 19 months. Two patients presented renewed tearing, of whom one remained asymptomatic and one evolved with loosening of an anchor, with an unsatisfactory result. Conclusion: The repairs on rotator cuff injuries presented good results by means of both open surgery and arthroscopy, with similar functional results in the two groups and similar rates of renewed tearing. PMID:27027052
Zargar, N.; Smith, R. D. J.; Carr, A. J.
Objectives All-suture anchors are increasingly used in rotator cuff repair procedures. Potential benefits include decreased bone damage. However, there is limited published evidence for the relative strength of fixation for all-suture anchors compared with traditional anchors. Materials and Methods A total of four commercially available all-suture anchors, the ‘Y-Knot’ (ConMed), Q-FIX (Smith & Nephew), ICONIX (Stryker) and JuggerKnot (Zimmer Biomet) and a traditional anchor control TWINFIX Ultra PK Suture Anchor (Smith & Nephew) were tested in cadaveric human humeral head rotator cuff repair models (n = 24). This construct underwent cyclic loading applied by a mechanical testing rig (Zwick/Roell). Ultimate load to failure, gap formation at 50, 100, 150 and 200 cycles, and failure mechanism were recorded. Significance was set at p < 0.05. Results Overall, mean maximum tensile strength values were significantly higher for the traditional anchor (181.0 N, standard error (se) 17.6) compared with the all-suture anchors (mean 133.1 N se 16.7) (p = 0.04). The JuggerKnot anchor had greatest displacement at 50, 100 and 150 cycles, and at failure, reaching statistical significance over the control at 100 and 150 cycles (22.6 mm se 2.5 versus 12.5 mm se 0.3; and 29.6 mm se 4.8 versus 17.0 mm se 0.7). Every all-suture anchor tested showed substantial (> 5 mm) displacement between 50 and 100 cycles (6.2 to 14.3). All-suture anchors predominantly failed due to anchor pull-out (95% versus 25% of traditional anchors), whereas a higher proportion of traditional anchors failed secondary to suture breakage. Conclusion We demonstrate decreased failure load, increased total displacement, and variable failure mechanisms in all-suture anchors, compared with traditional anchors designed for rotator cuff repair. These findings will aid the surgeon’s choice of implant, in the context of the clinical scenario. Cite this article: N. S. Nagra, N. Zargar, R. D. J. Smith, A. J. Carr
Sconfienza, Luca Maria; Randelli, Filippo; Sdao, Silvana; Sardanelli, Francesco; Randelli, Pietro
Calcific tendinopathy of the rotator cuff is a common condition. Ultrasound-guided percutaneous aspiration is one of several options to treat this condition. The main advantages of this procedure are short duration, good outcome, and low cost. Furthermore, only minor complications have been reported in the literature, namely, vagal reactions during the procedure and mild postprocedural pain. We report the first case of septic bursitis after ultrasound-guided percutaneous treatment of calcific tendinopathy. Although this is generally considered a very safe procedure, a risk of infection should be taken into account.
Spigno, F; Galli, R; Casali, C; Lagattolla, N; De Lucchi, M
The authors have gone through the complaints concerning all the cases of shoulder accidents at work filed by the Genoa office of the Italian Workers' National compensation Agency (INAIL) during the two years' period 2006-2007, reviewing in particular those somehow affecting rotator components. The aim of this paper is to assess the real role played by the occupational trauma in the rotator cuff tear. The data gathered so far have shown, on the one hand, a high prevalence of pre-existing inflammatory and degenerative diseases and, on the other, a rather modest influence of the trauma which, for this reason, has usually borne, as an immediate medico-legal consequence, the rejection of a cause-effect relationship between the accident and the rotator cuff lesion, without taking into any account whether the worker was likely to be affected by an occupational disease (ex table Ministerial Decree n. 81 April 9th 2008- item 78). In such cases a systematic and in-depth investigation of the occupational case history is suggested, in order to highlight the possible pre-existence of a former biomechanical overload of the upper limbs, so as to allow the physician to detect a pathology often misdiagnosed.
Muiño, José María Silberberg; Gimenez, Martín Alejandro; Salvucci, Mauro Gabriel Maroa; Ferro, Diego; Rullan, Ramón Muiña
Objective: To evaluate subjective and functional mid term results of patients treated by a lattisimus dorsi tendón transfer arthroscopically assisted for massive irreparable posterolateral injuries of the Rotator Cuff. Methods: Between 2009 and 2012, 17 Lattisimus Dorsi transfers (Paribelli technique) for irreparable posterolateral rotator cuff tears were performed. Distribution by sex: 12 men and 5 women with a mean age of 53 years old (range, 40-63). Thirteen right shoulders and 4 left shoulders. Average duration of symptoms prior to surgery was 8 months (range, 6-13 months). Mean follow-up was 28 months (range, 18-44). Patients were evaluated by the VAS, satisfaction rate, the Constant Modified Scale, postoperative range of motion and strength. Postoperative radiological studies included simple AP radiographs and MRI in order to measure AC distance and asses the integrity of the plasty. Results: Postoperative Constant Modified score averaged 63.54 points. (average increase of 13 points compared to preoperative score. (P ..05)). Active Mobility: a) Mean elevation: 142° postop vs. 119° preop (p <.001). b) Mean abduction: 138.24º postop vs. 112.35º preop (p <.001). c) Mean external rotation 40° postop vs. 20.29º preop (p <.004). Insert text. Conclusion: Lattisimus Dorsi transfer in patients with posterolateral massive irreparable injuries of the RC, is a highly demanding and palliative procedure for those cases with loss of active mobility, especially lifting and shoulder abduction.
Gumucio, J. P.; Flood, M. D.; Bedi, A.; Kramer, H. F.; Russell, A. J.
Objectives Rotator cuff tears are among the most frequent upper extremity injuries. Current treatment strategies do not address the poor quality of the muscle and tendon following chronic rotator cuff tears. Hypoxia-inducible factor-1 alpha (HIF-1α) is a transcription factor that activates many genes that are important in skeletal muscle regeneration. HIF-1α is inhibited under normal physiological conditions by the HIF prolyl 4-hydroxylases (PHDs). In this study, we used a pharmacological PHD inhibitor, GSK1120360A, to enhance the activity of HIF-1α following the repair of a chronic cuff tear, and measured muscle fibre contractility, fibrosis, gene expression, and enthesis mechanics. Methods Chronic supraspinatus tears were induced in adult rats, and repaired 28 days later. Rats received 0 mg/kg, 3 mg/kg, or 10 mg/kg GSK1120360A daily. Collagen content, contractility, fibre type distribution and size, the expression of genes involved in fibrosis, lipid accumulation, atrophy and inflammation, and the mechanical properties of the enthesis were then assessed two weeks following surgical repair. Results At two weeks following repair, treatment groups showed increased muscle mass but there was a 15% decrease in force production in the 10 mg/kg group from controls, and no difference between the 0 mg/kg and the 3 mg/kg groups. There was a decrease in the expression of several gene transcripts related to matrix accumulation and fibrosis, and a 50% decrease in collagen content in both treated groups compared with controls. Additionally, the expression of inflammatory genes was reduced in the treated groups compared with controls. Finally, PHD inhibition improved the maximum stress and displacement to failure in repaired tendons. Conclusions GSK1120360A resulted in improved enthesis mechanics with variable effects on muscle function. PHD inhibition may be beneficial for connective tissue injuries in which muscle atrophy has not occurred. Cite this article: J. P. Gumucio
Shirasawa, Hideyuki; Matsumura, Noboru; Shimoda, Masayuki; Oki, Satoshi; Yoda, Masaki; Tohmonda, Takahide; Kanai, Yae; Matsumoto, Morio; Nakamura, Masaya; Horiuchi, Keisuke
Fatty infiltration in muscle is often observed in patients with sizable rotator cuff tear (RCT) and is thought to be an irreversible event that significantly compromises muscle plasticity and contraction strength. These changes in the mechanical properties of the affected muscle render surgical repair of RCT highly formidable. Therefore, it is important to learn more about the pathology of fatty infiltration to prevent this undesired condition. In the present study, we aimed to generate a mouse model that can reliably recapitulate some of the important characteristics of muscular fatty infiltration after RCT in humans. We found that fatty infiltration can be efficiently induced by a combination of the following procedures: denervation of the suprascapular nerve, transection of the rotator cuff tendon, and resection of the humeral head. Using this model, we found that platelet-derived growth factor receptor-α (PDGFRα)-positive mesenchymal stem cells are induced after this intervention and that inhibition of PDGFR signaling by imatinib treatment can significantly suppress fatty infiltration. Taken together, the present study presents a reliable fatty infiltration mouse model and suggests a key role for PDGFRα-positive mesenchymal stem cells in the process of fatty infiltration after RCT in humans.
Shirasawa, Hideyuki; Matsumura, Noboru; Shimoda, Masayuki; Oki, Satoshi; Yoda, Masaki; Tohmonda, Takahide; Kanai, Yae; Matsumoto, Morio; Nakamura, Masaya; Horiuchi, Keisuke
Fatty infiltration in muscle is often observed in patients with sizable rotator cuff tear (RCT) and is thought to be an irreversible event that significantly compromises muscle plasticity and contraction strength. These changes in the mechanical properties of the affected muscle render surgical repair of RCT highly formidable. Therefore, it is important to learn more about the pathology of fatty infiltration to prevent this undesired condition. In the present study, we aimed to generate a mouse model that can reliably recapitulate some of the important characteristics of muscular fatty infiltration after RCT in humans. We found that fatty infiltration can be efficiently induced by a combination of the following procedures: denervation of the suprascapular nerve, transection of the rotator cuff tendon, and resection of the humeral head. Using this model, we found that platelet-derived growth factor receptor-α (PDGFRα)-positive mesenchymal stem cells are induced after this intervention and that inhibition of PDGFR signaling by imatinib treatment can significantly suppress fatty infiltration. Taken together, the present study presents a reliable fatty infiltration mouse model and suggests a key role for PDGFRα-positive mesenchymal stem cells in the process of fatty infiltration after RCT in humans. PMID:28139720
Thigpen, Charles A; Shaffer, Michael A; Kissenberth, Michael J
Rotator cuff repairs have increased. Although clinical trials have examined the effect of immobilization and timing of passive range of motion (ROM) on patient outcomes and structural integrity, there is controversy as to the timing and progression for therapy. Primary goals are restoring function while maintaining the structural integrity of the repair. We advocate for a protocol of 4 to 6 weeks of immobilization, followed by protected passive ROM, which is followed by a gradual progression to active ROM and then appropriate resistance exercise program for most all rotator cuff repairs. The rate of progression should be adjusted individually.
Miyazaki, Alberto Naoki; Fregoneze, Marcelo; Santos, Pedro Doneux; da Silva, Luciana Andrade; do Val Sella, Guilherme; Santos, Ruy Mesquita Maranhão; de Souza, Adriano; Checchia, Sérgio Luiz
Objective: To assess the results from arthroscopic surgical treatment of rotator cuff injuries among patients under 50 years of age. Methods: Sixty-three patients with rotator cuff injuries who underwent arthroscopic surgical treatment performed by the Shoulder and Elbow Group of the Department of Orthopedics and Traumatology, in the Fernandinho Simonsen wing of Santa Casa Medical School, São Paulo, between August 1998 and December 2007, were reassessed. The study included all patients with rotator cuff injuries who were under 50 years of age and had been followed up postoperatively for at least 24 months. Results: According to the UCLA evaluation criteria, 59 patients (92%) showed excellent and good results; five (8%) showed fair results; and none showed poor results. The postoperative evaluation showed that the mean range of motion was 145° for elevation, 47° for lateral rotation and T10 for medial rotation. Unsatisfactory results were associated with prolonged duration of the injury, with a statistically significant relationship. Conclusion: Arthroscopic repair of rotator cuff injuries in young patients produces excellent or good results for most patients. PMID:27047819
Wei, Anthony S.; Callaci, John J.; Juknelis, Dainius; Marra, Guido; Tonino, Pietro; Freedman, Kevin B.; Wezeman, Frederick H.
Background Subacromial corticosteroid injections are commonly used in the nonoperative management of rotator cuff disease. The effects of corticosteroid injection on injured rotator cuff tendons have not been studied. Our aims were to characterize the acute response of rotator cuff tendons to injury through the analysis of the type-III to type-I collagen expression ratio, a tendon injury marker, and to examine the effects of corticosteroid on this response. Methods Sixty Sprague-Dawley rats were randomly assigned to four groups: control, tendon injury, steroid treatment, and tendon injury and steroid treatment. Six rats served as sham controls. Unilateral tendon injuries were created with full-thickness defects across 50% of the total width of the infraspinatus tendon, 5 mm from its humeral insertion. Steroid treatment with a single dose of methylprednisolone (0.6 mg/kg), equivalent to that given to humans, was injected into the subacromial space under direct visualization. Steroid treatment followed the creation of an injury in the rats in the injury and steroid treatment group. At one, three, and five weeks after the injury, the total RNA isolated from tendons was quantified with real-time polymerase chain reaction with use of primers for type-I and type-III collagen and ribosomal 18s RNA. Results The type-III to type-I collagen expression ratio remained at baseline at all time-points in the control and sham groups. At one week, the type-III to type-I collagen expression ratio increased more than fourfold above the control level in the tendon injury group (p = 0.017) and the tendon injury and steroid treatment group (p = 0.003). The ratio remained greater than twofold above the control at three weeks in both groups (p = 0.003 and p = 0.037) and returned to baseline at five weeks. Interestingly, the group that had steroid treatment only showed an increase of >4.5-fold (p = 0.001) in the type-III to type-I collagen expression ratio, without structural injury to the
Franceschi, Francesco; Papalia, Rocco; Palumbo, Alessio; Del Buono, Angelo; Maffulli, Nicola; Denaro, Vincenzo
Repair of rotator cuff tears (RCT) is challenging. In RC tears, a partial (PTRCTs) or full (RCTs) discontinuation of one or more of the muscles or tendons and may occur as a result of traumatic injury or degeneration over a period of years. Many factors seem to contribute to the final outcome and a considerable number of variations during the decision-making process of patients with RCTs exist. Accurate diagnosis is fundamental to guide correct management, and the tear pattern should be carefully evaluated to plan the appropriate repair. Both non-operative and operative treatments are used to relieve pain and restore movement and function of the shoulder. Different surgical options are available. The present review describes the current evidence about diagnosis and management of partial and complete rotator tears.
Larson, Susan G
Scapular shape variation among primates is widely viewed as being strongly related to locomotor differences. The relative importance of overhead forelimb elevation in the locomotor repertoire of a species, as reflected in muscular leverage for scapular rotation or in the sizes of attachment areas for muscles involved in glenohumeral elevation, has proven to be a useful organizing principle for understanding this variation. While generally successful in sorting primate scapulae into functional groups, the scapulae of some species do not entirely match predictions based on the perceived importance of forelimb elevation. A recent study has shown that scapular fossa sizes in apes are not as accurate predictors of the sizes of the muscles arising from them as has been assumed. To further explore the degree of correspondence between actual and predicted muscle size based on the perceived importance of forelimb elevation, the current study examines the relative sizes of the rotator cuff muscles in a wider sample of primate taxa using published data on muscle mass and cross-sectional area. The results do not support some of the accepted generalizations about the relative sizes of members of the rotator cuff based on measurements of the sizes of scapular fossae. For example, orthograde apes do not display enlarged supraspinatus muscles compared to pronograde monkeys. Differences in assessments of relative muscle size based on mass compared to those based on cross-sectional area suggest that poor correspondence between muscle size predicted from scapular fossa size and actual muscle size may be related to constraints on scapular form associated with muscular leverage for scapular rotation and with scapular position on the thorax.
Ebaugh, David; Spinelli, Bryan; Schmitz, Kathryn H
Over 2.6 million breast cancer survivors currently reside in the United States. While improvements in the medical management of women diagnosed with breast cancer have resulted in a 5-year survival rate of 89%, curative treatments are associated with a high prevalence of shoulder and arm morbidity, which, in turn, can negatively impact a woman's quality of life. Breast cancer survivors frequently experience shoulder and arm pain, decreased range of motion, muscle weakness, and lymphedema. These symptoms can lead to difficulties with daily activities ranging from overhead reaching and carrying objects to caring for family and returning to work. Despite health care professionals awareness of these problems, a significant number of breast cancer survivors are confronted with long-term, restricted use of their affected shoulder and upper extremity. This problem may partially be explained by: (1) an incomplete understanding of relevant impairments and diagnoses associated with shoulder/arm pain and limited upper extremity use, and (2) the limited effectiveness of current rehabilitation interventions for managing shoulder pain and decreased upper extremity function in breast cancer survivors. Because breast cancer treatment directly involves the neuromusculoskeletal tissues of the shoulder girdle, it is understandable why breast cancer survivors are likely to develop shoulder girdle muscle weakness and fatigue, decreased shoulder motion, altered shoulder girdle alignment, and lymphedema. These impairments can be associated with diagnoses such as post-mastectomy syndrome, adhesive capsulitis, myofascial dysfunction, and brachial plexopathy, all of which have been reported among breast cancer survivors. It is our belief that these impairments also put women at risk for developing symptomatic rotator cuff disease. In this paper we set forth the rationale for our belief that breast cancer treatments and subsequent impairments of shoulder girdle neuromusculoskeletal tissues
Yamaguchi, Takeshi; Ochiai, Nobuyasu; Sasaki, Yu; Kijima, Takehiro; Hashimoto, Eiko; Sasaki, Yasuhito; Kenmoku, Tomonori; Yamazaki, Hironori; Miyagi, Masayuki; Ohtori, Seiji; Takahashi, Kazuhisa
This study evaluated dorsal root ganglia from C3-C7, analyzed gait, and compared the expression of calcitonin gene-related peptide (CGRP) which was a marker of inflammatory pain in a rat rotator cuff tear model in which the supraspinatus and infraspinatus tendons were detached; comparisons were made to a sham group in which only the tendons were exposed. Fluorogold was injected into the glenohumeral joint 21 days after surgery in both groups, and saline, steroids, or hyaluronic acid was injected into the glenohumeral joint in the rotator cuff tear group 26 days after surgery. The proportions of CGRP-immunoreactive neurons were higher and the gait parameters were impaired in the rotator cuff tear group compared to in the sham group. However, the CGRP expression was reduced and the gait was improved with steroid or hyaluronic acid injection compared to saline, suggesting that both hyaluronic acid and steroid injections suppressed of inflammation which thought to be provided pain relief. While there were no significant differences, the suppression of CGRP expression and the improved gait after hyaluronic acid and steroid injections suggested that both methods were effective for rat rotator cuff tear model.
Becciolini, Marco; Bonacchi, Giovanni; Galletti, Stefano
Calcific tendinopathy of the shoulder is a common condition caused by calcium hydroxyapatite crystals, affecting the tendons of the rotator cuff. Among uncommon complication, one is the migration of the calcium in the subacromion-subdeltoid bursa. More rare is the intraosseous migration. We present four cases of an even more rare condition, not well described in literature yet, the intramuscular migration of calcium.
Shoulder pain is a common reason for a patient to see their primary care physician. This article focuses on the evaluation and management of 3 common shoulder disorders; rotator cuff disorders, acromioclavicular joint arthritis, and glenohumeral joint arthritis. The typical history and physical examination findings for each of these entities are highlighted, in addition to treatment options.
Neuwirth, Jana; Fuhrmann, Renée AE; Veit, Amanda; Aurich, Matthias; Stonâns, Ilmars; Trommer, Tilo; Hortschansky, Peter; Chubinskaya, Susanna; Mollenhauer, Juergen A
Degeneration of the rotator cuff is often associated with inflammation of the subacromial bursa and focal mineralization of the supraspinatus tendon. Portions of the supraspinatus tendon distant from the insertion site could transform into fibrous cartilage, causing rotator-cuff tears owing to mechanical instability. Indirect evidence is presented to link this pathology to ectopic production and secretion of bioactive bone morphogenetic proteins (BMPs) from sites within the subacromial bursa. Surgically removed specimens of subacromial bursa tissue from patients with chronic tears of the rotator cuff were analyzed by immunohistochemistry and reverse transcription-PCR. Bioactive BMP was detected in bursa extracts by a bioassay based on induction of alkaline phosphatase in the osteogenic/myogenic cell line C2C12. Topical and differential expression of BMP-2/4 and BMP-7 mRNA and protein was found in bursa tissue. The bioassay of C2C12 cells revealed amounts of active BMP high enough to induce osteogenic cell types, and blocking BMP with specific antibodies or soluble BMP receptors Alk-3 and Alk-6 abolished the inductive properties of the extract. Sufficient information was gathered to explain how ectopic expression of BMP might induce tissue transformation into ectopic bone/cartilage and, therefore, promote structural degeneration of the rotator cuff. Early surgical removal of the subacromial bursa might present an option to interrupt disease progression. PMID:16719933
Miyazaki, Alberto Naoki; Santos, Pedro Doneux; da Silva, Luciana Andrade; do Val Sella, Guilherme; Checchia, Sérgio Luiz; Yonamine, Alexandre Maris
Objective To evaluate whether the good and excellent functional results from arthroscopic repair of massive rotator cuff tears are maintained over the long term. Methods From the sample of the study conducted by our group in 2006, in which we evaluated the functional results from arthroscopic repair of massive rotator cuff tears, 35 patients were reassessed, 8 years after the first evaluation. The inclusion criteria were that these patients with massive rotator cuff tears operated by means of an arthroscopic technique, who participated in the previous study and achieved good or excellent outcomes according to the UCLA criteria. Patients whose results were not good or excellent in the first evaluation according to the UCLA criteria were excluded. Results Among the 35 patients reassessed, 91% of them continued to present good and excellent results (40% excellent and 51% good), while 3% presented fair results and 6% poor results. The time interval between the first and second evaluations was 8 years and the minimum length of follow-up since the immediate postoperative period was 9 years (range: 9–17 years), with an average of 11.4 years. Conclusion The good and excellent results from arthroscopic repair of massive rotator cuff tears were mostly maintained (91%), with the same level of function and satisfaction, even though 8 years had passed since the first assessment, with a follow-up period averaging 11.4 years. PMID:26962491
GIGANTE, ANTONIO; BOTTEGONI, CARLO; MILANO, GIUSEPPE; RICCIO, MICHELE; DEI GIUDICI, LUCA
Massive rotator cuff tears are difficult to treat surgically due to retraction, degeneration and fraying of the ends of torn tendons, severe fatty infiltration and atrophy of the respective muscles. Procedures developed to close the gap between the rotator cuff and the greater tuberosity of the humerus, such as soft tissue release may be inadequate for large tears. Human or porcine dermal allografts still have uncertain benefits, and tendon transfers seem to be associated with poor outcomes, donor site morbidity and altered mechanics. Reverse total shoulder arthroplasty has limited durability and is not indicated in young patients with high functional demands. We developed a new technique for repairing massive rotator cuff tears by semitendinosus and gracilis myotendinous grafting. This novel therapeutic option allows massive rotator cuff tears to be repaired using autologous material that is adequate and adaptable, making it possible to cover any width of defect. The technique is low-invasive and not technically demanding, with minimal donor site morbidity. PMID:27900313
De Los Ríos, F. A.; Paluszny, M.
We consider some methods to extract information about the rotator cuff based on magnetic resonance images; the study aims to define an alternative method of display that might facilitate the detection of partial tears in the supraspinatus tendon. Specifically, we are going to use families of ellipsoidal triangular patches to cover the humerus head near the affected area. These patches are going to be textured and displayed with the information of the magnetic resonance images using the trilinear interpolation technique. For the generation of points to texture each patch, we propose a new method that guarantees the uniform distribution of its points using a random statistical method. Its computational cost, defined as the average computing time to generate a fixed number of points, is significantly lower as compared with deterministic and other standard statistical techniques. PMID:25650281
Veiersted, K B; Goffeng, L O; Tynes, T
This article describes the symptomatology of three patients following electrical accidents. The flow of the current was from hand to hand, voltage was 220/380 V, and duration was at least a few seconds for all patients. The development of symptoms was the same, and may be explained as a thermal effect of electricity on the tissue. Initially the patients experienced transient confusion, followed by stiff muscles after 1 to 3 days, and then pain in the muscle attachments and joints close to path of the current. This pain increased slowly during the first two weeks. Recovery was gradual, but often incomplete. The case notes showed that electrical accidents may be followed by chronic rotator cuff tendinitis. The clinical examination also revealed a hearing loss at about 2,000 Hz and above 4,000 Hz. The neuropsychological testing indicated a diffuse impaired function in only one patient.
Ribinik, P; Calmels, P; Barrois, B; Le Moine, F; Yelnik, A P
This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after rotator cuff tear surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients' needs, in accordance with the International Classification of Functioning (ICF) (WHO).
Sejersen, Maria Hee Jung; Frost, Poul; Hansen, Torben Bæk; Deutch, Søren Rasmussen; Svendsen, Susanne Wulff
Background Rotator cuff tendinopathy including tears is a cause of significant morbidity. The molecular pathogenesis of the disorder is largely unknown. This review aimed to present an overview of the literature on gene expression and protein composition in human rotator cuff tendinopathy and other tendinopathies, and to evaluate perspectives of proteomics – the comprehensive study of protein composition - in tendon research. Materials and Methods We conducted a systematic search of the literature published between 1 January 1990 and 18 December 2012 in PubMed, Embase, and Web of Science. We included studies on objectively quantified differential gene expression and/or protein composition in human rotator cuff tendinopathy and other tendinopathies as compared to control tissue. Results We identified 2199 studies, of which 54 were included; 25 studies focussed on rotator cuff or biceps tendinopathy. Most of the included studies quantified prespecified mRNA molecules and proteins using polymerase chain reactions and immunoassays, respectively. There was a tendency towards an increase of collagen I (11 of 15 studies) and III (13 of 14), metalloproteinase (MMP)-1 (6 of 12), -9 (7 of 7), -13 (4 of 7), tissue inhibitor of metalloproteinase (TIMP)-1 (4 of 7), and vascular endothelial growth factor (4 of 7), and a decrease in MMP-3 (10 of 12). Fourteen proteomics studies of tendon tissues/cells failed inclusion, mostly because they were conducted in animals or in vitro. Conclusions Based on methods, which only allowed simultaneous quantification of a limited number of prespecified mRNA molecules or proteins, several proteins appeared to be differentially expressed/represented in rotator cuff tendinopathy and other tendinopathies. No proteomics studies fulfilled our inclusion criteria, although proteomics technologies may be a way to identify protein profiles (including non-prespecified proteins) that characterise specific tendon disorders or stages of tendinopathy. Thus
Al-Hadithy, Nawfal; Furness, Nicholas; Patel, Ronak; Jonas, Sam; Jobbagy, Attila; Lowdon, Ian
Background Cementless surface replacement hemiarthroplasty (CSRHA) is an established treatment for glenohumeral osteoarthritis; however, studies evaluating its role in arthritis with rotator cuff deficiency are limited. This study reviews the outcomes of CSRHA for glenohumeral osteoarthritis with and without rotator cuff tears. Methods 41 CSRHA (Mark III Copeland prosthesis) were performed for glenohumeral osteoarthritis with intact rotator cuffs (n = 21) and cuff-deficient shoulders (n = 20). Patients were assessed using Oxford and Constant questionnaires, patient satisfaction, range of motion measurements and by radiography. Results Mean age and follow-up were 75 years and 5.1 years, respectively. Functional gains were significantly higher in patients with intact rotator cuffs compared to cuff-deficient shoulders, with Oxford Shoulder Score improving from 18 to 37.5 and 15 to 27 and forward flexion improved from 60° to 126° and 44° to 77° in each group, respectively. Two patients with deficient cuffs had deficient subscapularis tendons; one of which was dislocated anteriorly. Conclusions CSRHA provides significant improvements in pain and function in patients with glenohumeral osteoarthritis. In patients with deficient cuffs, functional gains are limited, and should be considered in low-demand patients where pain is the primary problem. Caution should be taken in patients with a deficient subscapularis as a result of the risk of dislocation. PMID:27582984
Littlewood, Chris; Malliaras, Peter; Bateman, Marcus; Stace, Richmond; May, Stephen; Walters, Stephen
Tendinopathy is a term used to describe a painful tendon disorder but despite being a well-recognised clinical presentation, a definitive understanding of the pathoaetiology of rotator cuff tendinopathy remains elusive. Current explanatory models, which relate to peripherally driven nocioceptive mechanisms secondary to structural abnormality, or failed healing, appear inadequate on their own in the context of current literature. In light of these limitations this paper presents an extension to current models that incorporates the integral role of the central nervous system in the pain experience. The role of the central nervous system (CNS) is described and justified along with a potential rationale to explain the favourable response to loaded therapeutic exercises demonstrated by previous studies. This additional consideration has the potential to offer a useful way to explain pain to patients, for clinicians to prescribe appropriate therapeutic management strategies and for researchers to advance knowledge in relation to this clinically challenging problem.
Kirsch, Jacob Matthew; Nathani, Amit; Robbins, Christopher; Gagnier, Joel Joseph; Bedi, Asheesh; Miller, Bruce S.
Objectives: Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCT). Current theories suggest a morphologic predisposition for altered shoulder biomechanics favoring the development of RCTs. The critical shoulder angle (CSA) is a radiographic measure that accounts for both glenoid inclination and lateral extension of the acromion, and angles >35 degrees are reported to be correlated with the development of degenerative RCTs. The impact of the CSA on outcomes following rotator cuff repair (RCR) has not previously been investigated. The purpose of this study was to investigate the relationship between the CSA and clinical outcomes after rotator cuff repair. Methods: As part of a prospective observational cohort study we obtained CSA measurements for 144 patients with documented full-thickness RCTs who were followed up for a minimum of 48 weeks. Patients were then stratified based on RCT etiology and treatment. Demographic data as well as The Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score and Visual Analog Scale (VAS) for pain were collected at baseline, four, eight, 16, 32 and 48 weeks. The CSA for all of the patients was measured retrospectively, with all assessors being blinded to the data and we calculated interclass correlation coefficients (ICC) to measure agreement. The statistical analysis included longitudinal multilevel regression modeling to investigate the association of the CSA and the WORC, ASES and VAS for pain. Results: Controlling for demographic and clinical characteristics, patients with CSAs less than 38 degrees reported better outcome scores over time compared to those with CSAs greater than 38 degrees (WORC: B=-106.6, p=0.025, ASES: B=4.83, p=0.0001, VAS: B=-12.99, p=0.0001). Interobserver and intraobserver reliability for CSA measurements resulted in an ICC of 0.969 and 0.982 respectively, indicating excellent agreement. Conclusion: We found
Zhou, Jiaojiao; Yuan, Chaoqun; Chen, Kai; Cheng, Biao
Background The single-row and double-row fixation techniques have been widely used for rotator cuff tears. However, whether the double-row technique produces superior clinical or anatomic outcomes is still considered controversial. This study aims to use meta-analysis to compare the clinical and anatomical outcomes between the two techniques. Methods The Pubmed, Embase, and Cochrane library databases were searched for relevant studies published before November 1, 2012. Studies clearly reporting a comparison of the single-row and double-row techniques were selected. The Constant, ASES, and UCLA scale systems and the rotator cuff integrity rate were evaluated. The weighted mean differences and relative risks were calculated using a fixed-effects or random-effects model. Results Eight studies were included in this meta-analysis. The weighted mean differences of the ASES (−0.84; P = 0.04; I2 = 0%) and UCLA (−0.75; P = 0.007; I2 = 0%) scales were significantly low in the single-row group for full-thickness rotator cuff tears. For tear sizes smaller than 3 cm, no significant difference was found between the groups no matter in Constant (P = 0.95; I2 = 0%), ASES (P = 0.77; I2 = 0%), or UCLA (P = 0.24; I2 = 13%) scales. For tear sizes larger than 3 cm, the ASES (−1.95; P = 0.001; I2 = 49%) and UCLA (−1.17; P = 0.006; I2 = 0%) scales were markedly lower in the single-row group. The integrity of the rotator cuff (0.81; P = 0.0004; I2 = 10%) was greater and the partial thickness retear rate (1.93; P = 0.007; I2 = 10%) was less in the double-row group. Full-thickness retears showed no difference between the groups (P = 0.15; I2 = 0%). Conclusion The meta-analysis suggests that the double-row fixation technique increases post-operative rotator cuff integrity and improves the clinical outcomes, especially for full-thickness rotator cuff tears larger than 3 cm. For tear sizes smaller than 3 cm
Amaral, Marcus Vinicius Galvão; de Faria, José Leonardo Rocha; Siqueira, Gláucio; Cohen, Marcio; Brandão, Bruno; Moraes, Rickson; Monteiro, Martim; Motta, Geraldo
Objective to present a retrospective analysis on the clinical-functional results and complications among patients with rotator cuff arthropathy (RCA) who underwent reverse arthroplasty of the shoulder. Methods patients with a diagnosis of RCA associated with pseudoparalysis of anterior elevation who underwent reverse arthroplasty of the shoulder with a minimum follow-up of one year were selected. Results preoperative information was gathered from our shoulder and elbow arthroplasty register, comprising age, sex, laterality, history of previous procedures, Constant's functional scores and the preoperative range of motion as described in the protocol of the American Academy of Shoulder and Elbow Surgery (ASES). After a mean follow-up of 44 months, 17 patients (94%) were satisfied with the result from the procedure. Conclusion reverse arthroplasty for treating RCA in patients with pseudoparalysis of the shoulder was shown to be effective in achieving a statistically significant improvement in range of motion regarding anterior flexion and abduction. However, in this series, there was no improvement in range of motion regarding external and internal rotation. Reverse arthroplasty is a procedure that reestablishes shoulder joint function in patients who previously did not present any therapeutic possibilities. PMID:26229813
de Castro Veado, Marco Antonio; Prata, Eric Fontes; Gomes, David Correia
Objective To retrospectively evaluate the results from patients who underwent arthroscopic treatment for rotator cuff injuries, among those aged over 65 years, observing integrity, function and strength. Methods Thirty-five shoulders were operated between July 2005 and July 2010, and 28 shoulders were re-evaluated regarding elevation strength and external rotation, using a digital dynamometer. Integrity was evaluated by means of ultrasound examinations. The patients, whose mean age was 70.54 years (ranging from 65 to 82 years), were followed up for a minimum of 26 months and mean of 51.18 months (ranging from 26 to 82 months). To evaluate function, the UCLA score, the Simple Shoulder Test (SST) and a visual analog scale (VAS) for pain were used. Results In analyzing the ultrasound scans, it was observed that the integrity of the rotator cuff was maintained in 75% of the cases at the end of the follow-up, along with the improvement in the UCLA score, which evolved from 17.46 to 32.39, i.e. excellent and good results in 89.28%. The mean SST and VAS indices were 9.86 and 1.5 respectively. Conclusion Arthroscopic surgery to repair rotator cuff injuries in patients over the age of 65 years leads to improved function and pain relief, with maintenance of the integrity of the repair. The data on muscle strength were inconclusive. PMID:26229937
Kim, Hyeyoung; Lee, Youngsun; Shin, Insik; Kim, Kitae; Moon, Jeheon
[Purpose] For maximum efficiency and to prevent injury during javelin throwing, it is critical to maintain muscle balance and coordination of the rotator cuff and the glenohumeral joint. In this study, we investigated the change in the rotator cuff muscle strength, throw distance and technique of javelin throwers after they had performed a specific physical training that combined elements of weight training, function movement screen training, and core training. [Subjects] Ten javelin throwers participated in this study: six university athletes in the experimental group and four national-level athletes in the control group. [Methods] The experimental group performed 8 weeks of the specific physical training. To evaluate the effects of the training, measurements were performed before and after the training for the experimental group. Measurements comprised anthropometry, isokinetic muscle strength measurements, the function movement screen test, and movement analysis. [Results] After the specific physical training, the function movement screen score and external and internal rotator muscle strength showed statistically significant increases. Among kinematic factors, only pull distance showed improvement after training. [Conclusion] Eight weeks of specific physical training for dynamic stabilizer muscles enhanced the rotator cuff muscle strength, core stability, throw distance, and flexibility of javelin throwers. These results suggest that specific physical training can be useful for preventing shoulder injuries and improving the performance for javelin throwers. PMID:25364111
García-Coiradas, J; Lópiz, Y; Marco, F
Scapular spine stress fractures have been scarcely reported in the literature. Their pathomechanics, clinical course and treatment are not well established. We review 3 cases in 2 patients that were associated with cuff dysfunction. On follow-up, none of these fractures progressed to healing. Two of them needed osteosynthesis and bone grafting, and the third one became a painless non-union. The authors propose the combination of 3 factors as a reason for this lesion: a functionally impaired cuff, a greater activation of the muscles with origin and insertion in the spine-acromion and a fragile bone. As we believe that these fractures are unstable, and non-union would be expected, their surgical management is recommended.
Ranalletta, Maximiliano; Rossi, Luciano A.; Sirio, Adrian; Bruchmann, Guillermina; Maignon, Gastón D.; Bongiovanni, Santiago L.
Background: Arthroscopic treatment of calcific deposits of rotator cuff tears has been described with successful results in the general population. However, despite the high frequency of this condition, there is no information in the literature regarding arthroscopic treatment of rotator cuff calcifications in athletes. Purpose: To analyze the time to return to sport, clinical outcomes, and complications of complete arthroscopic removal of intratendinous calcific deposits and repair of the tendon lesion without acromioplasty in athletes. Study Design: Case series; Level of evidence, 4. Methods: This study retrospectively evaluated 24 consecutive patients with a mean age of 36.2 years. The mean follow-up was 59 months (range, 24-108 months). Patients completed a questionnaire focused on the time to return to sport and treatment course. Pre- and postoperative functional assessment was performed using the Constant score and University of California Los Angeles (UCLA) score. Pain was assessed by visual analog scale (VAS). Radiographs and magnetic resonance imaging (MRI) were performed to evaluate the recurrence of calcifications and the indemnity of the supraspinatus tendon repair. Results: Of the 24 patients, 23 (95.8%) were able to return to sports; 91.3% returned to the same level. The mean time to return to play was 5.3 months (range, 3-9 months): 26% of patients (6/23) returned to sports in less than 4 months, 61% (14/24) returned between 4 and 6 months, and 13% (3/24) returned after the sixth month. The mean Constant score increased from 26.9 preoperatively to 89.7 postoperatively (P < .001), and the UCLA score increased from 17.3 preoperatively to 33.2 postoperatively (P < .001). Significant improvement was obtained for pain (mean VAS, 8.4 [before surgery] vs 0.6 [after]; P < .001). The overall majority (91.6%) of patients were satisfied with their result. MRI examination at last follow-up (79% of patients) showed no tendon tears. Conclusion: In athletes with
Veado, Marco Antônio de Castro; Rodrigues, Alessandro Ulhôa
To evaluate the results from patients who underwent arthroscopic debridement of extensive irreparable rotator cuff injuries. Methods: 27 patients were operated between 2003 and 2007, and 22 of them were evaluated. The surgical procedure consisted of arthroscopic debridement of the stumps of the tendons involved, bursectomy, removal of acromial osteophytes and, possibly, biceps tenotomy and tuberoplasty. Results: All the patients showed involvement of the supraspinatus and infraspinatus tendons at the preoperative stage. In the postoperative evaluation, 14 patients had a complete teres minor muscle, and three had partial tears of the subscapularis tendon. There was an improvement in the UCLA criteria, from 15 preoperatively to 31 postoperatively. There was no improvement in muscle strength, but there was a reduction in the pain. Conclusion: Arthroscopic debridement is a recommended procedure for elderly patients with irreparable rotator cuff tears, good range of motion and low functional demand, when the main objective is to diminish pain. PMID:27022590
Narvani, A Ali; Consigliere, Paolo; Polyzois, Ioannis; Sarkhel, Tanaya; Gupta, Rohit; Levy, Ofer
Despite the vast improvement in techniques and technology for arthroscopic rotator cuff surgery, repairs of massive and large tears remain challenging because they are associated with significantly high failure rates. In recent years, patch augmentation has gained popularity as a technique to decrease these high failure rates. Arthroscopic patch augmentation of rotator cuff repair, however, is technically difficult. The purpose of this report is to describe a simple and reproducible technique for all-arthroscopic extracellular matrix graft augmentation. With this technique, which we refer to as the "owl" technique because the prepared extracellular augment resembles an owl, there are relatively few suture ends involved; therefore, augment introduction is straightforward with a reduced risk of suture ends becoming tangled. In addition, the way in which our augmentation is prepared helps to prevent it from becoming bunched up when being secured.
Kuhn, John E
A systematic review of the literature was performed to evaluate the role of exercise in treating rotator cuff impingement and to synthesize a standard evidence-based rehabilitation protocol. Eleven randomized, controlled trials (level 1 and 2) evaluating the effect of exercise in the treatment of impingement were identified. Data regarding demographics, methodology, and outcomes of pain, range of motion, strength, and function were recorded. Individual components of each rehabilitation program were catalogued. Effectiveness was determined by statistical and clinical significance. Although many articles had methodologic concerns, the data demonstrate that exercise has statistically and clinically significant effects on pain reduction and improving function, but not on range of motion or strength. Manual therapy augments the effects of exercise, yet supervised exercise was not different than home exercise programs. Information regarding specific components of the exercise programs was synthesized into a gold standard rehabilitation protocol for future studies on the nonoperative treatment of rotator cuff impingement.
Dines, Joshua S; Jones, Kristofer; Maher, Patrick; Altchek, David
Clinical outcomes of surgical management of full-thickness rotator cuff tears in professional baseball players have been uniformly poor. We conducted a study to investigate return-to-play data and functional performance using a novel arthroscopic repair technique. We hypothesized that arthroscopic rotator cuff repair would result in a high rate of return to professional pitching and favorable functional outcomes. We identified 6 consecutive Major League Baseball (MLB) pitchers who underwent surgical repair of full-thickness rotator cuff injuries using the lateralized footprint repair technique. At most recent follow-up, patients were evaluated to determine their ability to return to athletic activity. Functional outcomes were also assessed using player performance statistics. By mean follow-up of 66.7 months (range, 23.2-94.6 months), 5 (83%) of the 6 pitchers had returned to their preinjury level of competition for at least 1 full season. Despite the high rate of return to MLB play, few pitchers resumed pitching productivity at their preoperative level; mean number of innings pitched decreased from 1806.5 to 183.7. A slight performance reduction was also found in a comparison of preoperative and postoperative pitching statistics. Of note, the return rate was higher for players over age 30 years than for those under 30 years. Overhead athletes require a delicate balance of shoulder mobility and stability to meet functional demands. Anatomical adaptations at the glenohumeral joint should be considered when performing rotator cuff repair in these patients in order to preserve peak functional performance. This novel repair technique affords a high rate of return to MLB play, though elite overhead throwers should be counseled that pitching productivity might decrease after surgery.
Nogueira-Barbosa, Marcello H.; Gregio-Junior, Everaldo; Lorenzato, Mario Muller
Objective The present study was aimed at investigating bone involvement secondary to rotator cuff calcific tendonitis at ultrasonography. Materials and Methods Retrospective study of a case series. The authors reviewed shoulder ultrasonography reports of 141 patients diagnosed with rotator cuff calcific tendonitis, collected from the computer-based data records of their institution over a four-year period. Imaging findings were retrospectively and consensually analyzed by two experienced musculoskeletal radiologists looking for bone involvement associated with calcific tendonitis. Only the cases confirmed by computed tomography were considered for descriptive analysis. Results Sonographic findings of calcific tendinopathy with bone involvement were observed in 7/141 (~ 5%) patients (mean age, 50.9 years; age range, 42-58 years; 42% female). Cortical bone erosion adjacent to tendon calcification was the most common finding, observed in 7/7 cases. Signs of intraosseous migration were found in 3/7 cases, and subcortical cysts in 2/7 cases. The findings were confirmed by computed tomography. Calcifications associated with bone abnormalities showed no acoustic shadowing at ultrasonography, favoring the hypothesis of resorption phase of the disease. Conclusion Preliminary results of the present study suggest that ultrasonography can identify bone abnormalities secondary to rotator cuff calcific tendinopathy, particularly the presence of cortical bone erosion. PMID:26811551
Carroll, Michael J; More, Kristie D; Sohmer, Stephen; Nelson, Atiba A; Sciore, Paul; Boorman, Richard; Hollinshead, Robert; Lo, Ian K Y
Purpose. The purpose of this study was to compare the accuracy of the conventional method for determining the percentage of partial thickness rotator cuff tears to a method using an intra-articular depth guide. The clinical utility of the intra-articular depth guide was also examined. Methods. Partial rotator cuff tears were created in cadaveric shoulders. Exposed footprint, total tendon thickness, and percentage of tendon thickness torn were determined using both techniques. The results from the conventional and intra-articular depth guide methods were correlated with the true anatomic measurements. Thirty-two patients were evaluated in the clinical study. Results. Estimates of total tendon thickness (r = 0.41, P = 0.31) or percentage of thickness tears (r = 0.67, P = 0.07) using the conventional method did not correlate well with true tendon thickness. Using the intra-articular depth guide, estimates of exposed footprint (r = 0.92, P = 0.001), total tendon thickness (r = 0.96, P = 0.0001), and percentage of tendon thickness torn (r = 0.88, P = 0.004) correlated with true anatomic measurements. Seven of 32 patients had their treatment plan altered based on the measurements made by the intra-articular depth guide. Conclusions. The intra-articular depth guide appeared to better correlate with true anatomic measurements. It may be useful during the evaluation and development of treatment plans for partial thickness articular surface rotator cuff tears.
Almeida, Alexandre; Atti, Vinícius; Agostini, Daniel Cecconi; Valin, Márcio Rangel; de Almeida, Nayvaldo Couto; Agostini, Ana Paula
Objective To analyze the results from arthroscopic suturing of large and extensive rotator cuff injuries, according to the patient's degree of osteopenia. Method 138 patients who underwent arthroscopic suturing of large and extensive rotator cuff injuries between 2003 and 2011 were analyzed. Those operated from October 2008 onwards formed a prospective cohort, while the remainder formed a retrospective cohort. Also from October 2008 onwards, bone densitometry evaluation was requested at the time of the surgical treatment. For the patients operated before this date, densitometry examinations performed up to two years before or after the surgical treatment were investigated. The patients were divided into three groups. Those with osteoporosis formed group 1 (n = 16); those with osteopenia, group 2 (n = 33); and normal individuals, group 3 (n = 55). Results In analyzing the University of California at Los Angeles (UCLA) scores of group 3 and comparing them with group 2, no statistically significant difference was seen (p = 0.070). Analysis on group 3 in comparison with group 1 showed a statistically significant difference (p = 0.027). Conclusion The results from arthroscopic suturing of large and extensive rotator cuff injuries seem to be influenced by the patient's bone mineral density, as assessed using bone densitometry. PMID:26229899
Júnior, Sérgio Correa Pinto; Luciano, Lessandro Gesser; Zotto, Crischiman Dal; Vieira, Felipe Fantozzi; Klassen, Ralf; Rodrigues, Airton; Neto, Francisco José dos Santos
Objective: To evaluate the influence of smoking on the results from surgical repair of Snyder type C1 and C2 complete lesions of the rotator cuff. Methods: We evaluated 166 patients who had undergone surgical treatment for Snyder type C1 and C2 complete lesions of the rotator cuff, between June 2002 and December 2006. The inclusion criteria were a minimum follow-up period of 24 months and the absence of previous surgery on the affected shoulder. Patients with other associated injuries were excluded. We evaluated smoking and nonsmoking patients in accordance with the criteria of the World Health Organization (WHO). Female patients (119) predominated over male patients (47), and the mean age was 57 years (38 to 78). Out of the 166 patients evaluated, 21 were classified as smokers and 145 as nonsmokers. The final results were evaluated using the UCLA (University of California at Los Angeles) criteria and statistical analysis was performed using the Epi Info® software. Results: According to the UCLA criteria, smokers had a final average of 32.6 points, while non-smokers had 33.8. Postoperative statistical analysis revealed a difference between the two groups, such that non-smoking patients had a better outcome. Conclusion: Smoking interferes with the final results from repairs of small and medium-sized lesions of the rotator cuff. PMID:27026963
Bachasson, Damien; Singh, Anshuman; Shah, Sameer; Lane, John G.; Ward, Samuel R.
Rotator cuff (RC) disease is an extremely common condition associated with shoulder pain, reduced functional capacities and impaired quality of life. It primarily involves alterations in tendon health and mechanical properties that can ultimately lead to tendon failure. RC tendon tears induce progressive muscular changes that negatively impact surgical reparability of the RC tendons and clinical outcomes. At the same time, a significant base of clinical data suggests a relatively weak relationship between RC integrity and clinical presentation, emphasizing the multifactorial aspects of RC disease. This review aims to summarize the potential contribution of peripheral, spinal and supraspinal neural factors that may: (i) exacerbate structural and functional muscle changes induced by tendon tear, (ii) compromise the reversal of these changes during surgery and rehabilitation, (iii) contribute to pain generation and persistence of pain, iv) impair shoulder function through reduced proprioception, kinematics and muscle recruitment, and iv) help to explain interindividual differences and response to treatment. Given the current clinical and scientific interest in peripheral nerve injury in the context of RC disease and surgery, we carefully reviewed this body of literature with a particular emphasis for suprascapular neuropathy that has generated a large number of studies in the past decade. Within this process, we highlight the gaps in current knowledge and suggest research avenues for scientists and clinicians. PMID:26189809
Mangone, Giuseppe; Veliaj, Altin; Postiglione, Marco; Viliani, Tamara; Pasquetti, Pietro
The objective of the study is to evaluate the effectiveness of Radial Extracorporeal Shock-wave Therapy (RESWT) compared with High Power LASER Therapy (HPLT) for the treatment of patients with Rotator Cuff Calcific Tendinosis (RCCT). RCCT is widely diffused, it is painful and invalidating. It is an important public health problem with social and economic implications. The most common therapeutic approach is a physiotherapic one. Both HPLT and RESWT give positive results. There is a debate on which is to be preferred. Therefore there is need to obtain scientific evidence to support either case. An observational study was carried out in the period between October 2008 and September 2009 in our outpatient clinic with 62 patients, divided into 3 groups: group A 36 patients treated only with RESWT, group B 26 patients treated only with HPLT and group C 16 patients with only short term improvement with HPLT retreated with RESWT. Patients were evaluated with Constant-Murley scale before and after treatment (immediately, 1 month and 3 months) for mean constant score, pain and range of movement. Data were examined statistically with SPSS. Criteria for inclusion and exclusion were defined. Patients treated with HPLT have shown good clinical results but have returned to original syndrome 1 month after treatment. RESWT has given improvement after treatment extended in time (3 months) in terms of pain and recover of functionality with a limited number of applications. The evidence collected indicates that RESWT is the method of choice. PMID:22460011
Tahririan, Mohammad Ali; Moezi, Mehdi; Motififard, Mahdi; Nemati, Mahdi; Nemati, Amin
Background: Degenerative changes and inflammation in the rotator cuff (RC) are the most important causes of shoulder pain. The aim of the present study was to determine the effectiveness of platelet-rich plasma (PRP) in patients with chronic RC tendinopathy. Materials and Methods: This study was an open-label study performed at Kashani Hospital between April 2012 and June 2014. Patients with a <1 cm partial tearing of the bursal side of RC with no or little response to conservative management were included. PRP injection was done using ultrasonography guide via posterior subacromial approach. Demographic data were obtained in all patient before the study, and shoulder function was evaluated using Constant shoulder score (CSS) before and 3 months after PRP injection. Results: A total number of 17 patients were enrolled. The mean of CSS before and after intervention was 37.05 ± 11.03 and 61.76 ± 14.75, respectively (P < 0.001). There was no statistically significant correlation between the pain score before the study and the improvement in CSS (P = 0.45, r = 0.03). Significant relation was observed between the individuals’ age and improvement of CSS (P = 0.02, r = −0.49). There was no significant difference in CSS improvement between genders (P = 0.23). Conclusion: Single injection of PRP is effective to reduce pain and improve range of motion in patients with bursal side partial tearing of RC who failed to respond to conservative treatments. PMID:28217638
Ichiseki, Toru; Ueda, Shusuke; Matsumoto, Tadami
Coexistence of septic arthritis and gouty arthritis is rare. In particular, no reports have described the development of both gouty and septic arthritis after arthroscopic shoulder surgery. The patient was an 83-year-old man who underwent arthroscopic rotator cuff repair. He had a history of diabetes mellitus (HbA1c: 7.4%), but not of gout, and the GFR was decreased (GFR=46). During the postoperative course fever suddenly developed and joint fluid retention was found. Uric acid crystals were detected when the joint fluid was aspirated, after which when the culture results became available sepsis due to methicillin sensitive Staphylococcus aureus (MSSA) was diagnosed. On the 2(nd) day after fever onset, lavage and debridement were performed under arthroscopy, with the subsequent course uneventful with no recurrence of the infection or gouty arthritis and no joint destruction. When uric acid crystals are found in aspirated joint fluid, gouty arthritis tends to be diagnosed, but like in the present case if infection also supervenes, joint destruction and a poor general state may result if appropriate intervention is not initiated swiftly. Accordingly, even if uric acid crystals are found, the possibility of coexistence of septic arthritis and gouty arthritis should be kept in mind.
Bachasson, Damien; Singh, Anshuman; Shah, Sameer B; Lane, John G; Ward, Samuel R
Rotator cuff (RC) disease is an extremely common condition associated with shoulder pain, reduced functional capacities, and impaired quality of life. It primarily involves alterations in tendon health and mechanical properties that can ultimately lead to tendon failure. RC tendon tears induce progressive muscle changes that have a negative impact on surgical reparability of the RC tendons and clinical outcomes. At the same time, a significant base of clinical data suggests a relatively weak relationship between RC integrity and clinical presentation, emphasizing the multifactorial aspects of RC disease. This review aims to summarize the potential contribution of peripheral, spinal, and supraspinal neural factors that may (1) exacerbate structural and functional muscle changes induced by tendon tear, (2) compromise the reversal of these changes during surgery and rehabilitation, (3) contribute to pain generation and persistence of pain, (4) impair shoulder function through reduced proprioception, kinematics, and muscle recruitment, and (5) help explain interindividual differences and response to treatment. Given the current clinical and scientific interest in peripheral nerve injury in the context of RC disease and surgery, we carefully reviewed this body of literature with a particular emphasis on suprascapular neuropathy that has generated a large number of studies in the past decade. Within this process, we highlight the gaps in current knowledge and suggest research avenues for scientists and clinicians.
Malliou, P; Giannakopoulos, K; Beneka, A; Gioftsidou, A; Godolias, G
Background: Many studies have compared different training methods for improving muscular performance, but more investigations need to be directed to the restoration of muscular imbalances. Objective: To determine the most effective training for altering strength ratios in the shoulder rotator cuff. Methods: Forty eight physical education students were randomly assigned to four groups (12 per group): (a) experimental group who carried out multijoint dynamic resistance training for shoulder internal and external rotation movement (pull ups or lat pull downs, overhead press, reverse pull ups, push ups) (MJDR group); (b) experimental group who exercised the same muscle group using dumbbells weighing 2 kg (isolated group); (c) experimental group who followed an isokinetic strengthening programme for the rotator cuff muscle group (isokinetic group); (d) control group who had no strength training. Testing was performed in the supine position with the glenohumeral joint in 90° of abduction in the coronal plane, with a range of motion of 0–90° of external rotation and 0–65° of internal rotation at angular velocities of 60, 120, and 180°/s. The test procedure was performed before and after the exercise period of six weeks. Results: One way analysis of variance found no differences between the groups for the initial tests. Analysis of variance with repeated measures showed that the strength ratios in all the experimental groups had altered after the exercise period, with the isokinetic group showing the most significant improvement. Conclusions: Isokinetic strengthening is the most effective method of altering strength ratios of the rotator cuff muscle. PMID:15562178
Tashjian, Robert Z.; Farnham, James M.; Granger, Erin K.; Teerlink, Craig C.; Cannon-Albright, Lisa A.
Background: Rotator cuff tearing has been found to be clinically associated with other tendinopathies and compression neuropathies; a significant excess of these phenotypes has been seen in patients with rotator cuff tears. It is unclear if the association is secondary to environmental or genetic influences. Purpose: To examine population-based data for comorbid association of rotator cuff tearing and tendinopathies and compression neuropathies and to determine whether the association extends to relatives of patients with rotator cuff tears, which could suggest a genetic contribution. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The Utah Population Database (UPDB) contains health and genealogical data on over 2 million Utah residents. Current Procedural Terminology, Fourth Revision, codes (CPT 4) and International Classification of Diseases, Ninth Revision, codes (ICD-9) entered in patient records were used to identify patients with rotator cuff tearing and with comorbid tendinopathies and compression neuropathies. We tested the hypothesis of excess familial clustering of these other phenotypes with rotator cuff tearing using a well-established method (estimation of relative risks) in the overall study group of rotator cuff patients (N = 1889). Results: Significantly elevated risk for elbow, hand/wrist, foot/ankle, knee, and hip tendinopathies, as well as for all tendinopathies and compression neuropathies, was observed in rotator cuff tear cases themselves (P < 2.8e–13), in their spouses (P < .02), and in their first-degree relatives (P < 5.5e–4). A significant excess of elbow (P = .01), foot/ankle (P = .04), and all tendinopathies (P = 3.1e–3) was also observed in second-degree relatives, and a significant excess of compression neuropathies (P = .03) was observed in third-degree relatives. Conclusion: The current study shows strong evidence of familial clustering of rotator cuff tearing with other tendinopathies and with compression
Zumstein, Matthias A.; Raniga, Sumit; Labrinidis, Agatha; Eng, Kevin; Bain, Gregory I.; Moor, Beat K.
Background: The optimal placement of suture anchors in transosseous-equivalent (TOE) double-row rotator cuff repair remains controversial. Purpose: A 3-dimensional (3D) high-resolution micro–computed tomography (micro-CT) histomorphometric analysis of cadaveric proximal humeral greater tuberosities (GTs) was performed to guide optimal positioning of lateral row anchors in posterior-superior (infraspinatus and supraspinatus) TOE rotator cuff repair. Study Design: Descriptive laboratory study. Methods: Thirteen fresh-frozen human cadaveric proximal humeri underwent micro-CT analysis. The histomorphometric parameters analyzed in the standardized volumes of interest included cortical thickness, bone volume, and trabecular properties. Results: Analysis of the cortical thickness of the lateral rows demonstrated that the entire inferior-most lateral row, 15 to 21 mm from the summit of the GT, had the thickest cortical bone (mean, 0.79 mm; P = .0001), with the anterior-most part of the GT, 15 to 21 mm below its summit, having the greatest cortical thickness of 1.02 mm (P = .008). There was a significantly greater bone volume (BV; posterior, 74.5 ± 27.4 mm3; middle, 55.8 ± 24.9 mm3; anterior, 56.9 ± 20.7 mm3; P = .001) and BV as a percentage of total tissue volume (BV/TV; posterior, 7.3% ± 2.7%, middle, 5.5% ± 2.4%; anterior, 5.6% ± 2.0%; P = .001) in the posterior third of the GT than in intermediate or anterior thirds. In terms of both BV and BV/TV, the juxta-articular medial row had the greatest value (BV, 87.3 ± 25.1 mm3; BV/TV, 8.6% ± 2.5%; P = .0001 for both) followed by the inferior-most lateral row 15 to 21 mm from the summit of the GT (BV, 62.0 ± 22.7 mm3; BV/TV, 6.1% ± 2.2%; P = .0001 for both). The juxta-articular medial row had the greatest value for both trabecular number (0.3 ± 0.06 mm–1; P = .0001) and thickness (0.3 ± 0.08 μm; P = .0001) with the lowest degree of trabecular separation (1.3 ± 0.4 μm; P = .0001). The structure model index
Aliprandi, Alberto; Messina, Carmelo; Arrigoni, Paolo; Bandirali, Michele; Di Leo, Giovanni; Longo, Stefano; Magnani, Sandro; Mattiuz, Chiara; Randelli, Filippo; Sdao, Silvana; Sardanelli, Francesco; Sconfienza, Luca Maria; Randelli, Pietro
AIM To determine diagnostic performance of magnetic resonance arthrography (MRA) in evaluating rotator cuff tears (RCTs) using Snyder’s classification for reporting. METHODS One hundred and twenty-six patients (64 males, 62 females; median age 55 years) underwent shoulder MRA and arthroscopy, which represented our reference standard. Surgical arthroscopic reports were reviewed and the reported Snyder’s classification was recorded. MRA examinations were evaluated by two independent radiologists (14 and 5 years’ experience) using Snyder’s classification system, blinded to arthroscopy. Agreement between arthroscopy and MRA on partial- and full-thickness tears was calculated, first regardless of their extent. Then, analysis took into account also the extent of the tear. Interobserver agreement was also calculated the quadratically-weighted Cohen kappa statistics. RESULTS On arthroscopy, 71/126 patients (56%) had a full-thickness RCT. The remaining 55/126 patients (44%) had a partial-thickness RCT. Regardless of tear extent, out of 71 patients with arthroscopically-confirmed full-thickness RCTs, 66 (93%) were correctly scored by both readers. All 55 patients with arthroscopic diagnosis of partial-thickness RCT were correctly assigned as having a partial-thickness RCT at MRA by both readers. Interobserver reproducibility analysis showed total agreement between the two readers in distinguishing partial-thickness from full-thickness RCTs, regardless of tear extent (k = 1.000). With regard to tear extent, in patients in whom a complete tear was correctly diagnosed, correct tear extent was detected in 61/66 cases (92%); in the remaining 5/66 cases (8%), tear extent was underestimated. Agreement was k = 0.955. Interobserver agreement was total (k = 1.000). CONCLUSION MRA shows high diagnostic accuracy and reproducibility in evaluating RCTs using the Snyder’s classification for reporting. Snyder’s classification may be adopted for routine reporting of MRA.
Fávaro, Rodrigo Caldonazzo; Abdulahad, Michel; Filho, Salim Mussi; Valério, Rafael; Superti, Mauro José
Objective To evaluate the functional results from reverse arthroplasty and its complications and relationships with types of injury. Methods Twenty-seven shoulders (26 women and one man) were treated. The patients were assessed using the UCLA functional scale. The implant used was the Delta Xtend Depuy® model. The injuries were classified using the Seebauer method for the degree of arthroplasty and the Nerot method for notching. Result The mean age was 77.4 years (range: 67–89) and the follow-up was 25.8 months (range: 6–51). The preoperative UCLA score was 10.1 (range: 6–15) and the postoperative UCLA score was 29.8 (range: 22–35), which was a statistically significant improvement (p < 0.001). According to the Seebauer classification, five patients were 1B, 19 were 2A and three were 2B. Fifteen cases presented complications (55.5%) and notching was the commonest of these, occurring in 14 patients (nine with grade 1 and five with grade 2), but this did not cause instability in any of them. Only one patient (3.7%) had a major complication, consisting of dislocation in the immediate postoperative period. Two patients (7.4%) said that they would undergo the procedure again. One patient (3.7%) underwent a revision procedure. Conclusion Reverse arthroplasty was shown to be an excellent option for treating patients with rotator cuff arthropathy, with a low rate of major complications. Notching was a frequent complication, but in the majority of the cases, it did not present clinical repercussions. PMID:26535197
Desmeules, François; Boudreault, Jennifer; Dionne, Clermont E.; Frémont, Pierre; Lowry, Véronique; MacDermid, Joy C.; Roy, Jean-Sébastien
Objective: To perform a systematic review of randomized controlled trials (RCTs) on the efficacy of therapeutic exercises for workers suffering from rotator cuff (RC) tendinopathy. Methods: A literature search in four bibliographical databases (Pubmed, CINAHL, EMBASE, and PEDro) was conducted from inception up to February 2015. RCTs were included if participants were workers suffering from RC tendinopathy, the outcome measures included work-related outcomes, and at least one of the interventions under study included exercises. The methodological quality of the studies was evaluated with the Cochrane Risk of Bias Assessment tool. Results: The mean methodological score of the ten included studies was 54.4%±17.2%. Types of workers included were often not defined, and work-related outcome measures were heterogeneous and often not validated. Three RCTs of moderate methodological quality concluded that exercises were superior to a placebo or no intervention in terms of function and return-to-work outcomes. No significant difference was found between surgery and exercises based on the results of two studies of low to moderate methodological quality. One study of low methodological quality, comparing a workplace-based exercise program focusing on the participants' work demands to an exercise program delivered in a clinical setting, concluded that the work-based intervention was superior in terms of function and return-to-work outcomes. Conclusion: There is low to moderate-grade evidence that therapeutic exercises provided in a clinical setting are an effective modality to treat workers suffering from RC tendinopathy and to promote return-to-work. Further high quality studies comparing different rehabilitation programs including exercises in different settings with defined workers populations are needed to draw firm conclusions on the optimal program to treat workers. PMID:27488037
Tomlinson, Daniel P.; Vanadurongwan, Bavornrat; Lenhoff, Mark W.; Cordasco, Frank A.; Chehab, Eric L.; Adler, Ronald S.; Henn, R. Frank; Hillstrom, Howard J.
Electromyography (EMG) of the shoulder girdle is commonly performed; however, EMG spectral properties of shoulder muscles have not been clearly defined. The purpose of this study was to determine the maximum power frequency, Nyquist rate, and minimum sampling rate for indwelling and surface EMG of the normal shoulder girdle musculature. EMG signals were recorded using indwelling electrodes for the rotator cuff muscles and surface electrodes for ten additional shoulder muscles in ten healthy volunteers. A fast Fourier transform was performed on the raw EMG signal collected during maximal isometric contractions to derive the power spectral density. The 95% power frequency was calculated during the ramp and plateau subphase of each contraction. Data were analyzed with analysis of variance (ANOVA) and paired t tests. Indwelling EMG signals had more than twice the frequency content of surface EMG signals (p < .001). Mean 95% power frequencies ranged from 495 to 560 Hz for indwelling electrodes and from 152 to 260 Hz for surface electrodes. Significant differences in the mean 95% power frequencies existed among muscles monitored with surface electrodes (p = .002), but not among muscles monitored with indwelling electrodes (p = .961). No significant differences in the 95% power frequencies existed among contraction subphases for any of the muscle–electrode combinations. Maximum Nyquist rate was 893 Hz for surface electrodes and 1,764 Hz for indwelling electrodes. Our results suggest that when recording EMG of shoulder muscles, the minimum sampling frequency is 1,340 Hz for surface electrodes and 2,650 Hz for indwelling electrodes. The minimum sampling recommendations are higher than the 1,000 Hz reported in many studies involving EMG of the shoulder. PMID:22294954
Lumsdaine, William; Smith, Adam; Walker, Rowan G; Benz, Daniel; Mohammed, Khalid D; Stewart, Fiona
In shoulder surgery, a precise understanding of anatomical relationships is required for accurate reconstruction. Reports in recent literature have challenged the traditional definitions of the humeral footprints of the supraspinatus and infraspinatus tendons. This study aims to precisely delineate these footprints. The rotator cuffs of 54 shoulders from 27 Australian Caucasoid donor cadavers were examined. The tendinous portions were dissected down to their region/footprint of attachment upon the humerus. Measurements of those footprints, upon the greater and lesser tuberosities, were made. Those measurements were statistically analyzed for any association with age, sex, height, or side. Twenty-seven cadavers had an average age at death of 74.9 (± 12.8), 56% were male, average height was 168 (± 8.6) cm. Due to premorbid fracture, or degeneration, 11 shoulders were excluded. The footprint of the supraspinatus was triangular, with a medial, anteroposterior length of 20.4 ± 4.2 mm. Its lateral anteroposterior length was 6.3 ± 1.6 mm and its maximal mediolateral width was 6.6 ± 2.7 mm. Its calculated area was 122.0 ± 66.6 mm(2). The footprint of the infraspinatus was trapezoidal, with a medial anteroposterior length 22.6 ± 3.0 mm. Its lateral anteroposterior length was 25.4 ± 3.3mm and its maximal mediolateral width was 12.0 ± 2.7 mm. Its calculated area was 294.9 ± 74.1 mm(2). There was no statistical correlation between size of the footprint and age, sex, side, or height. The humeral footprints of the supraspinatus and infraspinatus tendons upon the greater tuberosity were distinct. The lateral border of the infraspinatus' humeral attachment extended much farther anteriorly upon the highest facet of the greater tuberosity than in traditional descriptions.
Vosloo, M; Keough, N; De Beer, M A
The rotator cuff (RC) insertions according to most anatomical texts are described as being separate from one another. However, clear fusion of the RC tendon fibres exists with prior studies showing this interdigitation forming a common, continuous insertion onto and around the lesser and greater tubercles (LT and GT) of the humerus. Current surgical repair methods (especially arthroscopic techniques) rarely mention or consider these connections during repair and suture anchor implantation. The general principles of RC surgery remain a controversial subject, due to various available techniques, surgeon experience and preference, and the contradicting success rates. This results from old-fashioned knowledge of the anatomy of the RC complex and its functional aspects. Therefore, the purpose of this project was to visualise and define the RC footprint and extension insertions with the aim of enhancing and improving knowledge of the basic anatomy in the hopes that this will be considered during orthopaedic repair. Twenty shoulders (16 cadaveric and 4 fresh) were used in the study. The fresh shoulders were received from the National Tissue Bank, and ethical clearance was obtained (239/2015). Reverse dissection was performed to better visualise the RC unit exposing the interdigitated rotator hood (extension insertions), as well as the complete RC unit (tendons + internal capsule) separated from the scapula and humerus. Once the insertions were exposed and documented, the RC muscle footprint (articular surface area) was measured and recorded, using AutoCAD 2016. No statistical significant difference between left and right (p = 0.424) was noted, but a significant difference between males and females (p = 0.000) was. Collectively, these findings indicate and strengthen evidence towards the notion that the RC muscles/tendons and the internal capsule are one complete and inseparable unit/complex. The fact that the RC unit is more complex in its structure and attachment
Mueller, Maike; Hoy, Gregory; Branson, Ruben
Introduction Professional sports injuries are usually all dealt with at one single operation to return the player to the sport after appropriate rehabilitation. We questioned the assumption that rotator cuff tears must be repaired concurrently with instability syndromes, and aimed to allow a professional rugby league player to achieve career goals by NOT correcting all pathology at one surgery. Case Presentation A professional rugby league player presented with acute shoulder instability on a setting of a chronic full thickness rotator cuff tear. We performed an “in season” arthroscopic stabilization on an elite rugby league player, leaving a previously diagnosed large full thickness rotator cuff tear untreated. This allowed aggressive rehabilitation and return to contact competition at 12 weeks post-surgery. The player achieved a long held career goal of winning a premiership ring before undertaking rotator cuff repair at the end of the season. Latest follow up at seven years (still at elite level) demonstrated an asymptomatic shoulder. Conclusions The assumption that all pathology found at surgical exploration requires correction to play at elite level is not universally correct. We postulate that whilst rotator cuff deficiency has severe long-term sequelae, it is shoulder instability alone that prevents high level contact sports participation. Career goal management is an important part of managing elite level athletes. We have demonstrated that by careful management of the specific pathology preventing participation can allow elite athletes to achieve career goals without compromising long-term health. PMID:27217928
Merolla, Giovanni; Dave, Arpit C; Paladini, Paolo; Campi, Fabrizio; Porcellini, Giuseppe
Ossifying tendinitis (OT) is a type of heterotopic ossification, characterized by deposition of hydroxyapatite crystals in a histologic pattern of mature lamellar bone. It is usually associated with surgical intervention or trauma and is more commonly seen in Achilles or distal biceps tendons, and also in the gluteus maximus tendon. To our knowledge, there is no description of OT as a complication of calcifying tendinitis of the rotator cuff. In this report, we describe two cases in which the patients developed an OT of the supraspinatus after arthroscopic removal of calcium deposits. The related literature is reviewed.
Pearsall, Albert W; Ibrahim, Khalid A; Madanagopal, Sudhakar G
Background To prospectively evaluate patients who underwent a "mini-open" repair versus a completely arthroscopic technique for small to large size rotator cuff tears. Methods Fifty-two patients underwent "mini-open" or all arthroscopic repair of a full thickness tear of the rotator cuff. Patients who complained of shoulder pain and/or weakness and who had failed a minimum of 6 weeks of physical therapy and had at least one sub-acromial injection were surgical candidates. Pre and post-operative clinical evaluations included the following: 1) demographics; 2) Simple Shoulder Test (SST); 3) University of California, Los Angeles (UCLA) rating scale; 4) visual analog pain assessment (VAS); and 5) pre-op SF12 assessment. Descriptive analysis was performed for patient demographics and for all variables. Pre and post outcome scores, range of motion and pain scale were compared using paired t-tests. Analysis of variance (ANOVA) was used to evaluate any effect between dependent and independent variables. Significance was set at p is less than or equal to 0.05. Results There were 31 females and 21 males. The average follow-up was 50.6 months (27 – 84 months). The average age was similar between the two groups [arthroscopic x = 55 years/mini-open x = 58 years, p = 0.7]. Twenty-seven patients underwent arthroscopic repair and 25 underwent repair with a mini-open incision. The average rotator cuff tear size was 3.1 cm (range: 1–5 centimeters). There was no significant difference in tear size between the two groups (arthroscopic group = 2.9 cm/mini-open group = 3.2 cm, p = 0.3). Overall, there was a significant improvement from pre-operative status in shoulder pain, shoulder function as measured on the Simple Shoulder test and UCLA Shoulder Form. Visual analog pain improved, on average, 4.4 points and the most recent Short Shoulder Form and UCLA scores were 8 and 26 respectively. Both active and passive glenohumeral joint range of motion improved significantly from pre
Craig, E V
The geyser radiographic sign on shoulder arthrogram is characterized by leakage of dye from the glenohumeral joint into the subdeltoid bursa. The dye outlines the acromioclavicular joint. It is usually an indication of a full-thickness cuff tear of long duration. The clinical occurrence and pathomechanics of this finding indicate that repair is generally difficult.
Wu, ZiYing; Zhang, Chong; Zhang, Peng; Chen, TianWu; Chen, ShiYi; Chen, JiWu
Purpose. To compare the biomechanical properties of 3 suture-bridge techniques for rotator cuff repair. Methods. Twelve pair-matched fresh-frozen shoulder specimens were randomized to 3 groups of different repair types: the medially Knotted Suture Bridge (KSB), the medially Untied Suture Bridge (USB), and the Modified Suture Bridge (MSB). Cyclic loading and load-to-failure test were performed. Parameters of elongation, stiffness, load at failure, and mode of failure were recorded. Results. The MSB technique had the significantly greatest load to failure (515.6 ± 78.0 N, P = 0.04 for KSB group; P < 0.001 for USB group), stiffness (58.0 ± 10.7 N/mm, P = 0.005 for KSB group; P < 0.001 for USB group), and lowest elongation (1.49 ± 0.39 mm, P = 0.009 for KSB group; P = 0.001 for USB group) among 3 groups. The KSB repair had significantly higher ultimate load (443.5 ± 65.0 N) than USB repair (363.5 ± 52.3 N, P = 0.024). However, there was no statistical difference in stiffness and elongation between KSB and USB technique (P = 0.396 for stiffness and P = 0.242 for elongation, resp.). The failure mode for all specimens was suture pulling through the cuff tendon. Conclusions. Our modified suture bridge technique (MSB) may provide enhanced biomechanical properties when compared with medially knotted or knotless repair. Clinical Relevance. Our modified technique may represent a promising alternative in arthroscopic rotator cuff repair.
Zhang, Peng; Chen, TianWu; Chen, ShiYi
Purpose. To compare the biomechanical properties of 3 suture-bridge techniques for rotator cuff repair. Methods. Twelve pair-matched fresh-frozen shoulder specimens were randomized to 3 groups of different repair types: the medially Knotted Suture Bridge (KSB), the medially Untied Suture Bridge (USB), and the Modified Suture Bridge (MSB). Cyclic loading and load-to-failure test were performed. Parameters of elongation, stiffness, load at failure, and mode of failure were recorded. Results. The MSB technique had the significantly greatest load to failure (515.6 ± 78.0 N, P = 0.04 for KSB group; P < 0.001 for USB group), stiffness (58.0 ± 10.7 N/mm, P = 0.005 for KSB group; P < 0.001 for USB group), and lowest elongation (1.49 ± 0.39 mm, P = 0.009 for KSB group; P = 0.001 for USB group) among 3 groups. The KSB repair had significantly higher ultimate load (443.5 ± 65.0 N) than USB repair (363.5 ± 52.3 N, P = 0.024). However, there was no statistical difference in stiffness and elongation between KSB and USB technique (P = 0.396 for stiffness and P = 0.242 for elongation, resp.). The failure mode for all specimens was suture pulling through the cuff tendon. Conclusions. Our modified suture bridge technique (MSB) may provide enhanced biomechanical properties when compared with medially knotted or knotless repair. Clinical Relevance. Our modified technique may represent a promising alternative in arthroscopic rotator cuff repair. PMID:27975065
Saadat, Fatemeh; Deymier, Alix C; Birman, Victor; Thomopoulos, Stavros; Genin, Guy M
The tendon-to-bone attachment site integrates two distinct tissues via a gradual transition in composition, mechanical properties, and structure. Outcomes of surgical repair are poor, in part because surgical repair does not recreate the natural attachment, and in part because the mechanical features that are most critical to mechanical and physiological functions have not been identified. We employed allometric analysis to resolve a paradox about how the architecture of the rotator cuff contributes to load transfer: whereas published data suggest that the mean muscle stresses expected at the tendon-to-bone attachment are conserved across species, data also show that the relative dimensions of key anatomical features vary dramatically, suggesting that the amplification of stresses at the interface between tendon and bone should also vary widely. However, a mechanical model that enabled a sensitivity analysis revealed that the degree of stress concentration was in fact highly conserved across species: the factors that most affected stress amplification were most highly conserved across species, while those that had a lower effect showed broad variation across a range of relative insensitivity. Results highlight how micromechanical factors can influence structure-function relationships and cross-species scaling over several orders of magnitude in animal size, and provide guidance on physiological features to emphasize in surgical and tissue engineered repair of the rotator cuff.
Meyer, Gretchen A.
Persistent muscle atrophy in the chronically torn rotator cuff is a significant obstacle for treatment and recovery. Large atrophic changes are predictive of poor surgical and nonsurgical outcomes and frequently fail to resolve even following functional restoration of loading and rehabilitation. New insights into the processes of muscle atrophy and recovery gained through studies in developmental biology combined with the novel tools and strategies emerging in regenerative medicine provide new avenues to combat the vexing problem of muscle atrophy in the rotator cuff. Moving these treatment strategies forward likely will involve the combination of surgery, biologic/cellular agents, and physical interventions, as increasing experimental evidence points to the beneficial interaction between biologic therapies and physiologic stresses. Thus, the physical therapy profession is poised to play a significant role in defining the success of these combinatorial therapies. This perspective article will provide an overview of the developmental biology and regenerative medicine strategies currently under investigation to combat muscle atrophy and how they may integrate into the current and future practice of physical therapy. PMID:26847008
Sato, Eugene J.; Killian, Megan L.; Choi, Anthony J.; Lin, Evie; Choo, Alexander D.; Rodriguez-Soto, Ana E.; Lim, Chanteak T.; Thomopoulos, Stavros; Galatz, Leesa M.; Ward, Samuel R.
Background: Injury to the rotator cuff can cause irreversible changes to the structure and function of the associated muscles and bones. The temporal progression and pathomechanisms associated with these adaptations are unclear. The purpose of this study was to investigate the time course of structural muscle and osseous changes in a rat model of a massive rotator cuff tear. Methods: Supraspinatus and infraspinatus muscle architecture and biochemistry and humeral and scapular morphological parameters were measured three days, eight weeks, and sixteen weeks after dual tenotomy with and without chemical paralysis via botulinum toxin A (BTX). Results: Muscle mass and physiological cross-sectional area increased over time in the age-matched control animals, decreased over time in the tenotomy+BTX group, and remained nearly the same in the tenotomy-alone group. Tenotomy+BTX led to increased extracellular collagen in the muscle. Changes in scapular bone morphology were observed in both experimental groups, consistent with reductions in load transmission across the joint. Conclusions: These data suggest that tenotomy alone interferes with normal age-related muscle growth. The addition of chemical paralysis yielded profound structural changes to the muscle and bone, potentially leading to impaired muscle function, increased muscle stiffness, and decreased bone strength. Clinical Relevance: Structural musculoskeletal changes occur after tendon injury, and these changes are severely exacerbated with the addition of neuromuscular compromise. PMID:25834081
Fuchs, Bruno; Zumstein, Matthias; Regenfelder, Felix; Steinmann, Patrick; Fuchs, Thomas; Husmann, Knut; Hellermann, Jens; Jost, Bernhard; Hodler, Jürg; Born, Walter; Gerber, C
Impaired function of shoulder muscles, resulting from rotator cuff tears, is associated with abnormal deposition of fat in muscle tissue, but corresponding cellular and molecular mechanisms, likely reflected by altered gene expression profiles, are largely unknown. Here, an analysis of muscle gene expression was carried out by semiquantitative RT-PCR in total RNA extracts of supraspinatus biopsies collected from 60 patients prior to shoulder surgery. A significant increase of alpha-skeletal muscle actin (p = 0.0115) and of myosin heavy polypeptide 1 (p = 0.0147) gene transcripts was observed in parallel with progressive fat deposition in the muscle, assessed on parasagittal T1-weighted turbo-spin-echo magnetic resonance images according to Goutallier. Upregulation of alpha-skeletal muscle actin and of myosin heavy polypeptide-1 has been reported to be associated with increased muscle tissue metabolism and oxidative stress. The findings of the present study, therefore, challenge the hypothesis that increased fat deposition in rotator cuff muscle after injury reflects muscle degeneration.
Kang, Jeong-Il; Moon, Young-Jun; Choi, Hyun; Jeong, Dae-Keun; Kwon, Hye-Min; Park, Jun-Su
[Purpose] This study investigated the effect on activities, shoulder muscle fatigue, upper limb disability of two exercise types performed by patients in the post- immobilization period of rotator cuff repair. [Subjects and Methods] The intervention program was performed by 20 patients from 6 weeks after rotator cuff repair. Ten subjects each were randomly allocated to a group performing open kinetic chain exercise and a group preforming closed kinetic chain exercise. Muscle activity and median frequency were measured by using sEMG and the Upper Extremity Function Assessment before and after conducting the intervention and changes in the results were compared. [Results] There was a significant within group increases in the activities of the shoulder muscles, except for the posterior deltoid. The median power frequencies (MFD) of the supraspinatus, infraspinatus and anterior deltoid significantly increased in the open kinetic chain exercise group, but that of the posterior deltoid decreased. There were significant differences in the changes in the upper limb disability scores of the two groups, in the shoulder muscle activities, except for that of the posterior deltoid, in the comparison of the change in the muscle activities of the two groups, and in the MDFs of all shoulder muscles. [Conclusion] The Median power frequencies of all these muscles after closed kinetic chain exercise increased indicating that muscle fatigue decreased. Therefore, research into exercise programs using closed kinetic chain exercises will be needed to establish exercise methods for reducing muscle fatigue. PMID:27821933
Massive irreparable rotator cuff tears can be reconstructed with latissimus dorsi tendon transfers (LDTT). Although uncommon, the natural length of the latissimus dorsi tendon (LDT) could be insufficient for transfer even after adequate soft tissue releases. Descriptions of cases where grafts were needed to lengthen the LDT are therefore rare. We located only two reports of the use of an acellular dermal matrix to increase effective tendon length in tendon transfers about the shoulder: (1) GraftJacket patch for a pectoralis major tendon reconstruction and (2) ArthroFlex® patch for LDTT. Both of these brands of allograft patches are obtained from human cadavers. These products are usually used to cover soft tissue repairs and offer supplemental support rather than for increasing tendon length. Extending the LDTT with GraftJacket to achieve adequate length, to our knowledge, has not been reported in the literature. We report the case of a 50-year-old male who had a massive, irreparable left shoulder rotator cuff tear that was reconstructed with a LDTT. The natural length of his LDT was insufficient for transfer. This unexpected situation was rectified by sewing two patches of GraftJacket to the LDT. The patient had greatly improved shoulder function at two-year follow-up. PMID:28194290
Kimura, A; Aoki, M; Fukushima, S; Ishii, S; Yamakoshi, K
We reconstructed defects in the infraspinatus tendon u sing polytetrafluoroethylene (PTFE) felt grafts in 31 beagle dogs and examined the mechanical responses and histocompatibility. Except for one infected specimen, all the reconstructed infraspinatus tendons healed. We examined eight specimens each immediately after surgery and at six and 12 weeks. The ultimate tensile strength of the reconstructed tendons was 60.84 N, 172.88 N, and 306.51 N immediately after surgery and at six and 12 weeks, respectively. The stiffness of the specimens at the PTFE felt-bone interface was 9.61 kN/m, 64.67 kN/m, and 135.09 kN/m immediately after surgery and at six and 12 weeks, respectively. Six tendons were examined histologically at three, six, 12 and 24 weeks. Histological analysis showed that there was ingrowth of fibrous tissue between the PTFE fibres. Foreign-body reactionswere found at the margin of the PTFE-bone interface between 12 and 24 weeks. The mechanical recovery and tissue affinity of PTFE felt to bone and to tendon support its use for reconstruction of the rotator cuff. The possible development of a foreign-body reaction should be borne in mind.
Peltz, Cathryn D; Sarver, Joseph J; Dourte, Leann M; Würgler-Hauri, Carola C; Williams, Gerald R; Soslowsky, Louis J
Rotator cuff tears are a common clinical problem that can result in pain and disability. Previous studies in a rat model showed enhanced tendon to bone healing with postoperative immobilization. The objective of this study was to determine the effect of postimmobilization activity level on insertion site properties and joint mechanics in a rat model. Our hypothesis was that exercise following a short period of immobilization will cause detrimental changes in insertion site properties compared to cage activity following the same period of immobilization, but that passive shoulder mechanics will not be affected. We detached and repaired the supraspinatus tendon of 22 Sprague-Dawley rats, and the injured shoulder was immobilized postoperatively for 2 weeks. Following immobilization, rats were prescribed cage activity or exercise for 12 weeks. Passive shoulder mechanics were determined, and following euthanasia, tendon cross-sectional area and mechanical properties were measured. Exercise following immobilization resulted in significant decreases compared to cage activity in range of motion, tendon stiffness, modulus, percent relaxation, and several parameters from both a structurally based elastic model and a quasi-linear viscoelastic model. Therefore, we conclude that after a short period of immobilization, increased activity is detrimental to both tendon mechanical properties and shoulder joint mechanics, presumably due to increased scar production.
Liu, Jin; Fan, Lin; Zhu, Yingbo; Yu, Haotong; Xu, Tianyang; Li, Guodong
Abstract Background: The aim of the study was to compare the clinical outcomes of patients undergoing all-arthroscopic (AA) or mini-open (MO) rotator cuff repair. Methods: The present study evaluated 50 patients who had undergone AA repair and 50 patients who had undergone MO repair with a minimum 1-year follow-up. Every patient was asked to complete the Disabilities of the Arm, Shoulder and Hand (DASH) and visual analog scale (VAS) questionnaires. Constant–Murley score (CMS) and active ranges, forward flexion and external rotation, were also evaluated and documented. One year after surgery, ultrasound evaluation was done to determine the integrity of the rotator cuff for each patient. Results: The average age of enrolled patients at the time of surgery was 53.0 years (range, 40–59 years), and average follow-up was 16.6 months (range, 12–24 months). At 2 weeks, the range of forward flexion in the AA group was larger than that in the MO group (136.5 ± 10.2 vs 132.5 ± 7.7, P = 0.03). On postoperative day 1, the VAS in the MO group was significantly higher than that in the AA group (6.5 ± 0.6 vs 6.1 ± 0.6, P < 0.01). At 1 month, the difference in VAS between both groups reappeared (2.9 ± 0.6 vs 2.6 ± 0.6, P = 0.03). At 1 month, the CMS score of patients in the AA group was higher than that in the MO group (52.8 ± 3.6 vs 50.9 ± 5.0, P = 0.03). At 3 and 6 months, the DASH score of patients in the AA group was lower than that in the MO group (43.8 ± 8.2 vs 47.8 ± 4.4, P < 0.01 and 38.6 ± 4.3 vs 42.7 ± 9.9, P < 0.01, respectively). Mean operative time was longer in the AA group compared with that in the MO group (71.9 ± 17.6 vs 64.7 ± 12.7 minutes, P < 0.01). Five patients (10.0%) in the AA group and 4 patients (8.2%) in the MO group had rotator cuff retear, and 6 patients (12.0%) in the AA group and 8 patients (16.3%) in the MO group had adhesive capsulitis by the end
Kokubu, T.; Mifune, Y.; Inui, A.; Sakata, R.; Harada, Y.; Takase, F.; Kurosaka, M.
Objectives Triamcinolone acetonide (TA) is widely used for the treatment of rotator cuff injury because of its anti-inflammatory properties. However, TA can also produce deleterious effects such as tendon degeneration or rupture. These harmful effects could be prevented by the addition of platelet-rich plasma (PRP), however, the anti-inflammatory and anti-degenerative effects of the combined use of TA and PRP have not yet been made clear. The objective of this study was to determine how the combination of TA and PRP might influence the inflammation and degeneration of the rotator cuff by examining rotator cuff-derived cells induced by interleukin (IL)-1ß. Methods Rotator cuff-derived cells were seeded under inflammatory stimulation conditions (with serum-free medium with 1 ng/ml IL-1ß for three hours), and then cultured in different media: serum-free (control group), serum-free + TA (0.1mg/ml) (TA group), serum-free + 10% PRP (PRP group), and serum-free + TA (0.1mg/ml) + 10% PRP (TA+PRP group). Cell morphology, cell viability, and expression of inflammatory and degenerative mediators were assessed. Results Exposure to TA significantly decreased cell viability and changed the cell morphology; these effects were prevented by the simultaneous administration of PRP. Compared with the control group, expression levels of inflammatory genes and reactive oxygen species production were reduced in the TA, PRP, and TA+PRP groups. PRP significantly decreased the expression levels of degenerative marker genes. Conclusions The combination of TA plus PRP exerts anti-inflammatory and anti-degenerative effects on rotator cuff-derived cells stimulated by IL-1ß. This combination has the potential to relieve the symptoms of rotator cuff injury. Cite this article: T. Muto, T. Kokubu, Y. Mifune, A. Inui, R. Sakata, Y. Harada, F. Takase, M. Kurosaka. Effects of platelet-rich plasma and triamcinolone acetonide on interleukin-1ß-stimulated human rotator cuff-derived cells. Bone Joint
Bateman, Marcus; Davies-Jones, Gareth; Tambe, Amol; Clark, David I
Shoulder problems account for 2.4% of GP consultations in the United Kingdom and of those 70% are related to the rotator cuff. Many rotator cuff tears are of a degenerate nature but they can occur as a result of trauma in 8% of cases. Evidence suggests that patients with traumatic rotator cuff tears gain a better outcome in terms of pain and function if the tear is repaired early after injury. A specialist shoulder soft tissue injury clinic was set up in a large UK NHS teaching hospital with the primary purpose in the first year to halve the length of time patients with traumatic rotator cuff tears had to wait to consult a specialist and double the number of patients undergoing surgical repair within three months. The secondary purpose was to ensure that the new clinic was utilised to capacity by the end of the first year. The clinic was later expanded to manage patients with acute glenohumeral joint (GHJ) or acromioclavicular joint (ACJ) dislocations and identify those patients requiring surgical stabilisation. The new service involved referral of all patients presenting to the Accident & Emergency department with recent shoulder trauma and either an inability to raise the arm over shoulder height with a normal set of radiographs, or a confirmed GHJ or ACJ dislocation; to a specialist clinic run by an experienced upper limb physiotherapist. Patients were reassessed and referred for further imaging if required. Those patients found to have traumatic rotator cuff tears or structural instability lesions were listed for expedited surgery. The clinic ran alongside a consultant-led fracture clinic giving fast access to surgical decision-making. The service was reviewed after 3, 6, and 12 months and findings compared to a sample of 30 consecutive patients having undergone rotator cuff repair surgery via the previous pathway. 144 patients were referred to the clinic in the first year: 62 with rotator cuff symptoms, 38 with GHJ instability, 13 with ACJ instability, and 33
Vidt, Meghan E; Santago, Anthony C; Marsh, Anthony P; Hegedus, Eric J; Tuohy, Christopher J; Poehling, Gary G; Freehill, Michael T; Miller, Michael E; Saul, Katherine R
Rotator cuff tears (RCT) in older individuals may compound age-associated physiological changes and impact their ability to perform daily functional tasks. Our objective was to quantify thoracohumeral kinematics for functional tasks in 18 older adults (mean age=63.3±2.2), and compare findings from nine with a RCT to nine matched controls. Motion capture was used to record kinematics for 7 tasks (axilla wash, forward reach, functional pull, hair comb, perineal care, upward reach to 90°, upward reach to 105°) spanning the upper limb workspace. Maximum and minimum joint angles and motion excursion for the three thoracohumeral degrees of freedom (elevation plane, elevation, axial rotation) were identified for each task and compared between groups. The RCT group used greater minimum elevation angles for axilla wash and functional pull (p≤0.0124) and a smaller motion excursion for functional pull (p=0.0032) compared to the control group. The RCT group also used a more internally rotated maximum axial rotation angle than controls for functional reach, functional pull, hair comb, and upward reach to 105° (p≤0.0494). The most differences between groups were observed for axial rotation, with the RCT group using greater internal rotation to complete functional tasks, and significant differences between groups were identified for all three thoracohumeral degrees of freedom for functional pull. We conclude that older adults with RCT used more internal rotation to perform functional tasks than controls. The kinematic differences identified in this study may have consequences for progression of shoulder damage and further functional impairment in older adults with RCT.
Andreoli, Carlos Vicente; Esteves, Leonardo Roure; Figueiredo, Eduardo; Belangero, Paulo Santoro; de Castro Pochini, Alberto; Ejnisman, Benno
Anatomical variations at the origin of the biceps tendon have been described by several authors, but occurrences of an origin in the supraspinatus are rare. It is unclear whether this variation might contribute toward pathological conditions of the shoulder. Our objective here was to describe a case of an anatomical variation in the origin of the tendon of the long head of the biceps. The clinical information, preoperative images and arthroscopic images relating to a patient with an aberrant origin of the long head of the biceps, which was observed during shoulder arthroscopy, were reviewed. In this case study, the origin of the biceps was found in the rotator cuff, without any origin from the supraglenoid tubercle or upper labrum. This variant did not seem to contribute toward the pathological condition of the shoulder, and standard treatment for the concomitant condition was sufficient for treating it.
Werner, Clément M L; Ruckstuhl, Thomas; Müller, Roland; Zanetti, Marco; Gerber, Christian
This investigation was performed to analyze the influence of innervation and psychomotor skills on the outcome of latissimus dorsi transfer. Patients with the 10 best and 10 worst results after latissimus dorsi transfer for irreparable rotator cuff tears were selected. All patients meeting the inclusion criteria (n = 12) were subject to a psychomotor test battery (Motorische Leistungsserie) and electromyographic innervation assessment. There was no statistical difference between the 2 groups preoperatively in terms of the commonly tested factors known to influence the results of this procedure adversely. There was a significant difference in both the pattern and selectivity of innervation in the group that had better clinical results. The psychomotor findings were negatively correlated with the range of motion and the strength of the operative shoulder. Function of the operative shoulder could also be predicted by psychomotor function of the uninjured contralateral side. Psychomotor skills testing appears to be a new, potential method by which to predict the outcome of latissimus dorsi transfer.
Inklebarger, James; Gyer, Giles; Parkunan, Anand; Galanis, Nikiforos; Michael, Jimmy
Down-sloped or hooked acromion morphologies may cause bony encroachment on the soft tissues of the subacromial space, predisposing to shoulder impingement syndrome. Of the latter, a hooked or Type III acromion (T3A) has also been linked to rotator cuff (RC) pathology. However, as bony acromial impingement is typically thought to occur over the age of 40, its occurrence in younger shoulder athletes presenting with shoulder pain, impingement and RC pathology may be overlooked. This case serves to illustrate the occurrence of T3A in a younger shoulder athlete, and the importance of early imaging in achieving diagnostic accuracy. Appropriate surgical referrals are patients with subacromial impingement syndrome refractory to 3–6 months of appropriate conservative treatment. Surgery may be particularly beneficial in patients with a T3A. PMID:28096319
Del Castillo-González, Federico; Ramos-Álvarez, Juan José; Rodríguez-Fabián, Guillermo; González-Pérez, José; Calderón-Montero, Javier
Summary Purpose: to evaluate the short and long term effectiveness of ultrasonography (US)-guided percutaneous needle lavage in calcific tendinopathy of the rotator cuff. To study the evolution of the size of calcifications and pain in the two years after treatment. Methods: a 2 year longitudinal prospective study is carried out after applying the UGPL technique on a number of patients diagnosed with calcific tendinitis of the rotator cuff. Clinical, ultrasound and radiology follow-up controls were performed, 3 months, 6 months, one year and two years after the treatment. The Visual Analog Scale (VAS) was used to assess the pain. The degree and point of pain is selected on a 10cm line, arranged horizontally or vertically. The “0” represents no pain and “10” represents worst pain. The population studied was made up of 121 patients that required our service as a result of suffering from a painful shoulder. Results: the pain (VAS) and the size of the calcification significantly decreased with the application of the technique (p< 0,001 in both cases) and regardless of the sex (p: 0.384 for pain and p: 0.578 for the size of the calcification). This occurred from the first check-up (3 months) and was maintained for two year. Conclusion: we consider this technique to be a valid alternative as a first-choice treatment of calcific tendinitis of the shoulder. The intervention is simple, cost-effective, does not require hospitalization, involves no complications, rehabilitation treatment is not required and it shows very few side effects without sequelae, significantly reducing the size of the calcification and pain in the majority of patients. PMID:25767776
Miyazaki, Alberto Naoki; da Silva, Luciana Andrade; Santos, Pedro Doenux; Checchia, Sergio Luiz; Cohen, Carina; Giora, Taís Stedile Busin
Objectives To evaluate the results from arthroscopic surgical treatment of rotator cuff injuries in patients aged 65 years and over. Methods Between 1998 and 2009, 168 patients underwent operations. Five cases were excluded. The remaining 163 patients were stratified according to their age group: 65–69 years (49.1%), 70–74 (26.4%) and 75 years and over (24.5%). Their mean age was 71 years (range: 65–83). There were 63 male patients (38.7%). The mean length of time with pain, from the onset of symptoms to the surgery, was 23 months (range: 2 days to 240 months). Sixty-two patients (38%) reported histories of trauma and 26 (16%) reported that their pain worsened through exertion. Results From the UCLA criteria, 80.4% of the results were excellent, 16% good, 1.8% fair and 1.8% poor. Complications occurred in 11%. The final clinical result did not show any correlation with age progression, injury size or tendons affected. However, there was a significant association (p < 0.001) between the presence of trauma and larger injuries. The length of time between the onset of symptoms and the surgical procedure had a significant relationship (p < 0.027) with the postoperative results: the longer this time was, the worse the results were. Conclusion Arthroscopic treatment of rotator cuff injuries in patients aged 65 years and over presented excellent and good results in 96.4% of the cases, according to the UCLA assessment, with a low complication rate. Advanced age did not show any influence on the postoperative clinical evolution, but the earlier the surgical treatment was instituted, the better the results were. PMID:26229935
Eslamian, Fariba; Shakouri, Seyyed Kazem; Ghojazadeh, Morteza; Nobari, Ozra Eslampanah; Eftekharsadat, Bina
Rotator cuff tendinitis is one of the main causes of shoulder pain. The objective of this study was to evaluate the possible additive effects of low-power laser treatment in combination with conventional physiotherapy endeavors in these patients. A total of 50 patients who were referred to the Physical Medicine and Rehabilitation Clinic with shoulder pain and rotator cuff disorders were selected. Pain severity measured with visual analogue scale (VAS), abduction, and external rotation range of motion in shoulder joint was measured by goniometry, and evaluation of daily functional abilities of patients was measured by shoulder disability questionnaire. Twenty-five of the above patients were randomly assigned into the control group and received only routine physiotherapy. The other 25 patients were assigned into the experimental group and received conventional therapy plus low-level laser therapy (4 J/cm(2) at each point over a maximum of ten painful points of shoulder region for total 5 min duration). The above measurements were assessed at the end of the third week of therapy in each group and the results were analyzed statistically. In both groups, statistically significant improvement was detected in all outcome measures compared to baseline (p < 0.05). Comparison between two different groups revealed better results for control of pain (reduction in VAS average) and shoulder disability problems in the experimental group versus the control (3.1 ± 2.2 vs. 5 ± 2.6, p = 0.029 and 4.4 ± 3.1 vs. 8.5 ± 5.1, p = 0.031, respectively ) after intervention. Positive objective signs also had better results in the experimental group, but the mean range of active abduction (144.92 ± 31.6 vs. 132.80 ± 31.3) and external rotation (78.0 ± 19.5 vs. 76.3 ± 19.1) had no significant difference between the two groups (p = 0.20 and 0.77, respectively). As one of physical modalities, gallium-arsenide low-power laser combined with
Choi, Eunkyung; Park, Yongmin; Jeon, Younghoon
Abstract Background: Positional change affects the cuff pressure of an endotracheal tube (ETT) in treacheally intubated patients. We compared the cuff pressure of a TaperGuard ETT and a cylindrical ETT after lateral rotation of head during middle ear surgery. Methods: Fifty-two patients aged 18–70 years underwent a tympanomastoidectomy under general anesthesia were randomly allocated to receive endotracheal intubation with cylindrical (group C, n = 26) or TaperGuard ETTs (group T, n = 26). After endotracheal intubation, the ETT cuff pressure was set at 22 cmH2O in the neutral position of head. After lateral rotation of head, the cuff pressure was measured again and readjusted to 22 cmH2O. In addition, the change of distance from the carina to the tip of the ETT was measured before and after the positional change. The incidence of cough, sore throat, and hoarseness was assessed at 30 minutes, 6 hours, and 24 hours after surgery. Results: There was no difference in demographic data between groups. After lateral rotation of head, the cuff pressure significantly increased in group T (11.9 ± 2.3 cmH2O) compared with group C (6.0 ± 1.9 cmH2O) (P < 0.001). The incidence of a cuff pressure >30 cmH2O was higher in group T (96.2%) than in group C (30.8%) (P < 0.001). In addition, the degree of displacement of an ETT was greater in group T (11.0 ± 1.7 mm) than in group C (7.2 ± 2.6 mm) (P < 0.001). The overall incidences of postoperative sore throat, hoarseness, and cough at 30 minutes, 6 hours, and 24 hours after surgery were comparable between two groups. Conclusion: The cuff pressure was higher in the TaperGuard ETT than in the cylindrical ETT after positional change of head from neutral to lateral rotation. In addition, after a positional change, the extent of displacement of ETT was greater in the TaperGuard ETT than in the cylindrical ETT. PMID:28272230
Batalha, Nuno M; Raimundo, Armando M; Tomas-Carus, Pablo; Marques, Mário A C; Silva, António J
Imbalance in shoulder rotator muscles is a well-documented problem in swimmers, and it is important to implement land-based strength training programs. Meanwhile, the effects of a detraining period on swimmers' shoulder rotator muscles are unknown. The purpose of this study was to analyze the effects of a strength training program and detraining on the strength and balance of shoulder rotator cuff muscles in young swimmers, despite the continuity of usual water training. An experimental group (n = 20) and a control group (n = 20) of young male swimmers with the same characteristics (age, body mass, height, training volume, and maturational state) were evaluated. In both groups, the peak torques of shoulder internal (IR) and external (ER) rotators were assessed during preseason, midseason (16 weeks), and postseason (32 weeks). The experimental group underwent a strength training regimen from baseline to 16 weeks and a detraining period from 16 to 32 weeks. Concentric action at 60°·s-1 and 180°·s-1 was measured using an isokinetic dynamometer. The ER/IR strength ratios were obtained. At 60°·s-1, there were significant increments in IR strength and the ER/IR ratio in both shoulders. This trend was the same throughout the competitive season. The tendency was the same at 180°·s-1 because training effects were noted primarily in IR and ER/IR ratios. Moreover, the absence of land-based strength training, from 16 to 32 weeks, revealed a reduction in the ER/IR ratio values in both shoulders. Our findings suggest that young swimmers' coaches should use dry-land strength training protocols, and that it is recommended that these should be conducted on a regular basis (during the whole season).
MacDermid, Joy C; Holtby, Richard; Razmjou, Helen; Bryant, Dianne
Background Rotator cuff tears are the most common source of shoulder pain and disability. Only poor quality studies have compared mini-open to arthroscopic repair, leaving surgeons with inadequate evidence to support optimal, minimally-invasive repair. Methods/Design This randomized, multi-centre, national trial will determine whether an arthroscopic or mini-open repair provides better quality of life for patients with small or moderate-sized rotator cuff tears. A national consensus meeting of investigators in the Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS Canada) identified this question as the top priority for shoulder surgeons across Canada. The primary outcome measure is a valid quality-of-life scale (Western Ontario Rotator Cuff (WORC)) that addresses 5 domains of health affected by rotator cuff disease. Secondary outcomes will assess rotator cuff functionality (ROM, strength, Constant score), secondary dimensions of health (general health status (SF-12) and work limitations), and repair integrity (MRI). Outcomes are measured at baseline, at 6 weeks, 3, 6, 12, and 24 months post-operatively by blinded research assistants and musculoskeletal radiologists. Patients (n = 250) with small or medium-sized cuff tears identified by clinical examination and MRI who meet eligibility criteria will be recruited. This sample size will provide 80% power to statistically detect a clinically important difference of 20% in WORC scores between procedures after controlling for baseline WORC score (α = 0.05). A central methods centre will manage randomization, data management, and monitoring under supervision of experienced epidemiologists. Surgeons will participate in either conventional or expertise-based designs according to defined criteria to avoid biases from differential surgeon expertise. Mini-open or all-arthroscopic repair procedures will be performed according to a standardized protocol. Central Adjudication (of cases), Trial Oversight
Medium- to long-term results of a randomized controlled trial to assess the efficacy of arthoscopic-subacromial decompression versus mini-open repair for the treatment of medium-sized rotator cuff tears
Birch, Ann; Temperley, David; Odak, Saurabh; Walton, Michael J; Haines, John F; Trail, Ian
Background We report on the medium- to long-term results of a randomized controlled trial (RCT) aiming to determine whether rotator cuff repair confers any advantage over arthroscopic sub-acromial decompression (ASAD) alone in the management of medium-sized rotator cuff tears. Methods Ethical approval was sought to follow-up patients previously enrolled in a completed and previously published RCT comparing the outcome of ASAD with mini-open cuff repair for the treatment of rotator cuff tear. Forty-two patients were enrolled in the original study, with a mean of 64 years (range 54 years to 77 years). Results Fifteen of the original 17 patients randomized to ASAD alone and 18 of the original 25 patients randomized to cuff repair were available for follow-up. Each patient underwent American Shoulder and Elbow Surgeons (ASES), Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scoring, and clinical and ultrasound examination. Mean duration of follow-up was 7 years (range 5 years to 11 years). There was no statistically significant difference in terms of ASES, DASH and Constant scores at follow-up between the two groups. Some 33% of patients in the cuff-repair group had a proven re-rupture on ultrasound. This patient subgroup had significantly worse Constant scores compared to patients where the repair remained intact. None of the patients from either group developed cuff-tear arthropathy requiring arthroplasty surgery. Conclusions In this medium- to longer-term study, there is no demonstrable significant benefit of cuff repair over decompression alone for the treatment of medium-sized rotator cuff tears, in terms of ASES, DASH and Constant scores for pain, function and strength modules. The presence of cuff tear does not necessitate surgical repair. This conclusion should drive surgical strategies and shared decision-making between patients and surgeons. PMID:27583006
Huber, W; Hofstaetter, J G; Hanslik-Schnabel, B; Posch, M; Wurnig, C
The evaluation of quality of life is an established criterion for evaluation of therapeutic measures. Starting from the English-speaking area a great number of different patient-based outcomes measures were developed to specifically question disorders of the musculoskeletal system and the results of treatment. Because of the lack of a German measurement tool for patients with rotator cuff disease the translation and the psychometric testing following international guidelines of the 34-item, multidimensional, English Rotator Cuff Quality-of-Life Measure (RC-QOL) was undertaken. Reliability (test-retest reliability, internal consistency), validity, practicability and acceptance of the German version of the RC-QOL were tested by 102 patients with an impingement syndrome after translation and cross-culture adaptation of the English original questionnaire. In addition, the SF-36, the Constant and UCLA scores were evaluated. Between the evaluations there was no significant difference; the Pearson correlation coefficient was 0.89 for the test-retest reliability. The internal consistency showed a high homogeneity with a Cronbach Alpha-coefficient of 0.98. A Pearson correlation coefficient between 0.67-0.76 registered a high correlation with the physical subscales of the SF-36, the Constant and the UCLA scores. The mean time required for completing the RC-QOL was 12 minutes; mean time required for evaluation was 10 minutes. The questionnaire was incompletely answered by 16 patients (15.6%). A total of 120 items (3.5%) were left unanswered. After successful translation and psychometric testing of the German version of the Rotator Cuff Quality-of-Life Measure (RC-QOL) a multidimensional measurement tool for evaluating the quality of life of German-speaking patients with pathology of the rotator cuff is available.
Chauhan, Narvir Singh; Ahluwalia, Ajay; Sharma, Yash Paul; Thakur, Lokesh
Summary Background To evaluate the accuracy of high resolution ultrasound (USG) and MRI in the diagnosis of rotator cuff tears (RCT) and to determine if high resolution USG compares favorably in sensitivity and specificity to MRI in the diagnosis of rotator cuff injury. Material/Methods In this prospective comparative study, 40 patients with clinically suspected rotator cuff tears underwent both ultrasound and MRI of the shoulder. Out of these 40 patients, 31 patients who had positive findings for rotator cuff tears on ultrasound and/or MRI were finally included in the study while the remaining 9 patients with negative or unrelated findings were excluded. The USG and MRI were interpreted by two radiologists experienced in musculoskeletal radiology and blinded to findings of each other. Comparison was done using MRI as a standard reference. Results The agreement between USG and MRI for diagnosis of RCTs was statistically excellent; USG showed a sensitivity of 86.7% and a specificity of 100% for full-thickness tears, and a sensitivity of 89.7% and a specificity of 98.8% for partial-thickness tears; observed accuracy for full thickness tears was 98.4% and 95.9% for partial thickness tears. The Kappa coefficient of association was 0.91 for full thickness tears and 0.90 for partial thickness tears. Conclusions Considering the comparable diagnostic accuracy of USG and MRI, the former modality can be used as a first-line investigation for diagnosis of RCT. MRI should be used secondarily as a problem-solving tool either following an equivocal shoulder USG or for delineation of anatomy in cases where surgical correction is needed. PMID:27800039
Suh, Mi Ri; Chang, Won Hyuk; Choi, Hyo Seon
Objective To assess the efficacy of trigger point injection into brachialis muscle for rotator cuff disease patients with upper arm pain. Methods A prospective, randomized, and single-blinded clinical pilot trial was performed at university rehabilitation hospital. Twenty-one patients clinically diagnosed with rotator cuff disease suspected of having brachialis myofascial pain syndrome (MPS) were randomly allocated into two groups. Effect of ultrasound (US)-guided trigger point injection (n=11) and oral non-steroidal anti-inflammatory drug (NSAID) (n=10) was compared by visual analog scale (VAS). Results US-guided trigger point injection of brachialis muscle resulted in excellent outcome compared to the oral NSAID group. Mean VAS scores decreased significantly after 2 weeks of treatment compared to the baseline in both groups (7.3 vs. 4.5 in the injection group and 7.4 vs. 5.9 in the oral group). The decrease of the VAS score caused by injection (ДVAS=-2.8) was significantly larger than caused by oral NSAID (ДVAS=-1.5) (p<0.05). Conclusion In patients with rotator cuff disease, US-guided trigger point injection of the brachialis muscle is safe and effective for both diagnosis and treatment when the cause of pain is suspected to be originated from the muscle. PMID:25379497
Kim, Jae-Woon; Kim, Yong-Nam; Lee, Dong-Kyu
[Purpose] The purpose of this research was to determine the effect of combined exercise with slings and a Flexi-Bar on muscle activity and pain in rotator cuff repair patients. [Subjects and Methods] This research evaluated 20 rotator cuff repair patients divided randomly into groups of 10 as the control group and the experimental group. The experimental group performed combined exercise with slings and a Flexi-Bar. Both the experimental and control groups were treated with a transcutaneous electrical nerve stimulator and continuous passive motion. Muscle activity was measured with surface electromyography. Pain was measured with the visual analogue scale. The paired t-test was used to compare groups before and after the experiment. The independent t-test was used to assess the differences in the degree of change between the two groups before and after the experiment. [Results] Subjects of both the experimental group and control group showed significant differences in muscle activity and pain. However, as compared with the control group, there was significant differences in the muscle activity and pain in the experimental group. [Conclusion] These results indicate that combined exercise with slings and a Flexi-Bar is effective in improving muscle activity and decreasing pain in rotator cuff repair patients. PMID:27821956
Garofalo, Raffaele; Conti, Marco; Notarnicola, Angela; Maradei, Leonardo; Giardella, Antonio; Castagna, Alessandro
The study included 100 patients who underwent an arthroscopic rotator cuff repair. All patients suffered about a rotator cuff tear that was repaired arthroscopically with a suture anchor technique. Immediately postoperatively, patients were randomly allocated to one of two different postoperative physiotherapy regimens: passive self-assisted range of motion exercise (controls: 46 patients) versus passive self-assisted range of motion exercise associated with use of continuous passive motion (CPM) for a total of 2 h per day (experimental group: 54 patients), for 4 weeks. After this time, all the patients of both groups underwent the same physical therapy protocol. An independent examiner assessed the patients at 2.5, 6 and 12 months particularly about pain with the VAS scale (0-10) and the range of motion (ROM). Our findings show that postoperative treatment of an arthroscopic rotator cuff repair with passive self-assisted exercises associated with 2-h CPM a day provides a significant advantage in terms of ROM improvement and pain relief when compared to passive self-assisted exercise alone, at the short-term follow-up. No significant differences between the two groups were observed at 1 year postoperatively.
Palma Fogazza, Bianca; da Silva Carvalho, Carolina; Godoy Penteado, Sergio; Meneses, Cláudio S.; Abrahão Martin, Airton; da Silva Martinho, Herculano
FT-Raman spectroscopy was employed to access the biochemical alterations occurring on the degenerative process of the rotator cuff supraspinatus tendons. The spectral characteristic variations in the 351 spectra of samples of 39 patients were identified with the help of Principal Components Analysis. The main variations occurred in the 840-911; 1022- 1218; 1257; 1270; 1300; 1452; 1663; and 1751 cm -1 regions corresponding to the vibrational bands of proline, hydroxiproline, lipids, nucleic acids, carbohydrates, collagen, and elastin. These alterations are compatible with the pathology alterations reported on the literature. Scattering plots of PC 4 vs PC 2 and PC 3 vs PC 2 contrasted with histopathological analysis has enabled the spectral classification of the data into normal and degenerated groups of tendons. By depicting empiric lines the estimated sensibility and specificity were 39,6 % and 97,8 %, respectively for PC 4 vs PC 2 and 36,0 % and 100 %, respectively for PC 3 vs PC 2. These results indicate that Raman spectroscopy can be used to probe the general tendon quality and could be applied as co adjuvant element in the usual arthroscopy surgery apparatus to guide the procedure and possibly infer about the probability of rerupture.
Objective To propose and evaluate the effectiveness of a telerehabilitation platform designed for patients with rotator cuff (RC) tears. Methods During the first study phase, a virtual service platform that included information on RC tear pathology, joint care, and a series of instructions regarding therapeutic exercise was designed and created. Subsequently, in the clinical phase, a quasi-experimental study was performed. The platform was tested on patients and evaluated at baseline and at 1, 2, 3, and 6 months with respect to their pain levels and functionality on the Constant-Murley (CM) scale. Results Eleven patients were included, 5 women and 6 men, with a median age of 55 years (range, 42–68 years). Pain diminished from a baseline value of 64 mm (range, 40–80 mm) to 16 mm (range, 0–30 mm) at 6 months (p<0.001). Points on the CM scale rose from a baseline value of 54 points (range, 51–66 points) to 85 points (range, 70–100 points) at 6 months (p=0.001). Functionality in daily living and work activities, movement, and strength exhibited significant changes at 6 months (p<0.05). Conclusion Significant changes were observed in pain and functionality in this group of participants who used a telerehabilitation platform. To the best of our knowledge, this is the first study that included a specific program for RC tears. PMID:27606278
Skedros, John G.; Kiser, Casey J.; Hill, Bryce B.
This report describes a patient who had an open repair of a small supraspinatus tendon tear performed 6 months after an arthroscopic acromioplasty with debridement had failed to provide pain relief. Three months prior to the tendon repair, he had a two-level cervical spine discectomy and fusion (C4–5, C5–6) that improved his neck pain. Florid suprascapular neuropathy was detected 10 weeks after the open rotator cuff repair. Evidence of some nerve recovery resulted in a long period of observation. But unsatisfactory improvement warranted decompression of the suprascapular notch, which was found to be very stenotic. At surgery, there was no evidence of neuroma, cyst, or other compressing lesion or tissue. Therefore, it was ultimately hypothesized that there was an exacerbation of a preexisting, but clinically unrecognized, entrapment of the suprascapular nerve in the suprascapular notch in the setting of cervical radiculopathy (primarily C5). Retrospectively it was also concluded that had this compressive etiology been recognized, it would have favored prompt decompression rather than the long observation period. Three years was required to achieve a good result following suprascapular notch decompression. The underlying C5 radiculopathy may have created a “double crush syndrome” that contributed to the propensity for injury and the prolonged recovery. There should be heightened awareness of this problem in patients who do not have satisfactory improvement in shoulder pain from previous shoulder and neck surgery. PMID:27917243
Morris, Brent J; Haigler, Richard E; Cochran, John M; Laughlin, Mitzi S; Elkousy, Hussein A; Gartsman, Gary M; Edwards, T Bradley
The potential adverse effect of body mass index (BMI) on shoulder function scores after reverse shoulder arthroplasty (RSA) has not been investigated. We conducted a study to examine outcomes of RSA performed for rotator cuff tear arthropathy (RCTA) across BMI categories (normal weight, overweight, obese). We hypothesized that, compared with normal-weight patients, obese patients would have worse shoulder function scores, worse mobility, and more complications. Using a prospective shoulder arthroplasty registry, we identified 77 primary RSAs performed for RCTA with minimum 2-year follow-up. Thirty-four patients had normal weight (BMI <25 kg/m2), 21 were overweight (BMI 25-30 kg/m2), and 22 were obese (BMI >30 kg/m2). Shoulder function scores, mobility, and satisfaction were evaluated before surgery and at final follow-up. The 3 BMI groups were not significantly different on demographic factors, preoperative shoulder function scores, or preoperative mobility (P > .05). For each group, shoulder function scores and mobility significantly improved between the preoperative and final follow-up assessments (P < .001). Patient satisfaction was similar between groups (P = .967). Improved shoulder function scores, mobility, and patient satisfaction can be expected after RSA for RCTA in patients regardless of BMI.
Miller, Bruce S.; Robbins, Christopher; Gagnier, Joel Joseph
Objectives: The minimally important difference (MID) is the smallest change in an outcome measure that is perceived by patients as beneficial. The MIDs for the ASES and WORC scores have not been established in a homogenous population of patients with rotator cuff tears. The objective of the present study was to establish the MIDs for patients with known cuff tears who were treated both surgically and non-surgically, and to compare the MIDs over time. Methods: We included 209 subjects with known full-thickness rotator cuff tears who were followed prospectively for two years. The WORC and ASES scores were collected at baseline, 4, 8, 16, 32, and 48 weeks, 1 year and 2 years. At the final follow-up point patients filled out an end-of-study form which included questions regarding change in their condition after treatment. Results: For those that indicated being minimally better, the change from baseline for the ASES score was -20.57 (-2.94 to -38.20) and for the WORC was 418.60 (70.39 to 766.81); both indicated improvement in outcomes. When converted to the percentage change score the WORC change represented 19.93%. The plots of these new MID values for the ASES and WORC indicate that not only does the operative group improve more than the non-operative group but it does so to an extent that is greater than the MID. The non-operative group also improved across time, but the magnitude did not exceed the MID for either the WORC or the ASES. Conclusion: We found that the ASES and the WORC MIDs in patients with rotator cuff tears is different from that previously reported, and that the operative group change was greater than the non-operative group change. This information will directly improve our ability to: (1) Determine when patients with RCTs are changing in a meaningful manner; (2) Accurately power clinical studies using these outcome measures; (3) Make more informed choices of treatments in these patients. This is the first study to report MIDs for the ASES and WORC
Gigliotti, Deanna; Leiter, Jeff R S; Macek, Bryce; Davidson, Michael J; MacDonald, Peter B; Anderson, Judy E
The high frequency of poor outcome and chronic pain after surgical repair of shoulder rotator-cuff injury (RCI) prompted this study to explore the potential to amplify muscle regeneration using nitric oxide (NO)-based treatment. After preoperative magnetic resonance imaging (MRI), biopsies of supraspinatus and ipsilateral deltoid (as a control) were collected during reparative surgery for RCI. Muscle fiber diameter, the pattern of neuromuscular junctions observed with alpha-bungarotoxin staining, and the γ:ε subunit ratio of acetylcholine receptors in Western blots were examined in tandem with experiments to determine the in vitro responsiveness of muscle satellite cells to activation (indicated by uptake of bromodeoxyuridine, BrdU) by the NO-donor drug, isosorbide dinitrate (ISDN). Consistent with MRI findings of supraspinatus atrophy (reduced occupation ratio and tangent sign), fiber diameter was lower in supraspinatus than in deltoid. ISDN induced a significant increase over baseline (up to 1.8-fold), in the proportion of BrdU+ (activated) Pax7+ satellite cells in supraspinatus, but not in deltoid, after 40 h in culture. The novel application of denervation indices revealed a trend for supraspinatus muscle to have a higher γ:ε subunit ratio than deltoid (P = 0.13); this ratio inversely with both occupancy ratio (P < 0.05) and the proportion of clusters at neuromuscular junctions (P = 0.05). Results implicate possible supraspinatus denervation in RCI and suggest NO-donor treatment has potential to promote growth in atrophic supraspinatus muscle after RCI and improve functional outcome.
Ikemoto, Roberto Yukio; Pileggi, Paulo Eduardo; Murachovsky, Joel; Nascimento, Luís Gustavo Prata; Serpone, Rogerio Bueno; Strose, Eric; Oliveira, Luiz Henrique Almeida
Objective: To compare the functional results among patients undergoing tenotomy with or without tenodesis of the long head of the biceps associated with arthroscopic repair of rotator cuff injuries, with a minimum two-year follow-up. Method: This was a retrospective non-randomized trial with evidence level III, in which the medical files of 77 patients with lesions of the long head of the biceps were reviewed and clinically reassessed. Among these, 55 patients underwent tenotomy without tenodesis and 22 underwent tenotomy with tenodesis, with outpatient follow-up for at least two years. The age, dominant side, operated side, lesion size using the Gartsman classification, pre and postoperative range of motion, presence or absence of the Popeye sign, pain in the bicipital groove and assessments using the University of California at Los Angeles (UCLA) score and the elbow strength index. Results: The mean UCLA score of the sample went from 16.92 (range: 8 to 25) to 31.45 (range: 13 to 35) (p < 0.001). Comparison of the pre and postoperative UCLA scores in the two groups showed that the difference in the group with tenotomy and tenodesis was 15.95 and in the group with tenotomy alone, 14.62 (p = 0.023). However, there was no statistical significance in comparing the groups regarding pain in the bicipital groove, Popeye sign or elbow strength index. Conclusion: This study showed that the difference in UCLA scores was statistically significant. The group with tenotomy and tenodesis of the long head of the biceps presented better functional results. PMID:27047893
Kukkonen, J; Joukainen, A; Lehtinen, J; Mattila, K T; Tuominen, E K J; Kauko, T; Aärimaa, V
We have compared three different methods of treating symptomatic non-traumatic tears of the supraspinatus tendon in patients above 55 years of age. A total of 180 shoulders (173 patients) with supraspinatus tendon tears were randomly allocated into one of three groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and physiotherapy (group 2) and rotator cuff repair, acromioplasty and physiotherapy (group 3). The Constant score was assessed and followed up by an independent observer pre-operatively and at three, six and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one year (follow-up rate of 92.8%). There were 55 shoulders in group 1 (24 in males and 31 in females, mean age 65 years (55 to 79)), 57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79)) and 55 shoulders in group 3 (26 male and 29 female, mean age 65 years (55 to 81)). There were no between-group differences in the Constant score at final follow-up: 74.1 (sd 14.2), 77.2 (sd 13.0) and 77.9 (sd 12.1) in groups 1, 2 and 3, respectively (p = 0.34). The mean change in the Constant score was 17.0, 17.5, and 19.8, respectively (p = 0.34). These results suggest that at one-year follow-up, operative treatment is no better than conservative treatment with regard to non-traumatic supraspinatus tears, and that conservative treatment should be considered as the primary method of treatment for this condition.
Swanson, Brian T.; Holst, Brian; Infante, John; Poenitzsch, James; Ortiz, Alexis
Objectives The objectives of this pilot study were to investigate rotator cuff activity that may be present during grade III distraction and posterior glide mobilization of the glenohumeral (GH) joint, as well as to examine any differences in response between painful and non-painful shoulders utilizing these techniques. Methods EMG data were collected using Delsys EMGworks® software and Trigno® mini-wireless electrodes for the supraspinatus, infraspinatus and upper trapezius musculature during grade III GH distraction and posterior glide mobilization. A total of 20 shoulders (10 painful, 10 non-painful) were recruited from a sample of convenience. Submaximal voluntary dynamic contraction against gravity was used as reference for each of the three selected muscles. Participants underwent two trials of each mobilization, and the mean results for each group were assessed using descriptive statistics (mean, standard deviation) and effect size. Results Both the painful and non-painful groups exhibited considerable levels of rotator cuff activity during each test parameter, with the painful group consistently generating higher supraspinatus and infraspinatus RMS and peak force activity. Analysis of the peak combined rotator cuff activity during distraction (d = 0.58) and posterior glides (d = 0.64) suggests moderate-to-high practical significance of the results. Discussion GH distraction and posterior glide mobilizations have traditionally been thought of as passive treatment procedures. The results of this pilot study indicate that the supraspinatus and infraspinatus are significantly active during these techniques. Findings suggest that during these techniques, the total infra/supraspinatus EMG activity approaches the level produced while raising the arm against gravity. Level of evidence: 2b PMID:27252577
Savoie, Felix H; Zunkiewicz, Mark; Field, Larry D; Replogle, William H; O’Brien, Michael J
Purpose This study was designed to compare functional outcomes in patients undergoing revision repair of massive rotator cuff tears (retracted medial to the glenoid) with Goutallier Grade 4 atrophy and concomitant release of the suprascapular nerve to a similar group of patients with Grade 3 atrophy undergoing revision rotator cuff repair (RTCR) without nerve release. We hypothesized that patients undergoing nerve release would have more favorable functional outcomes as measured by the Modified University of California at Los Angeles shoulder rating scale (UCLA). Patients and methods Twenty-two patients underwent revision repair of massive rotator cuff tears with release of the suprascapular nerve at the suprascapular notch. We compared total preoperative, postoperative, and change in UCLA score in these patients to a similar group of 22 patients undergoing revision RTCR without suprascapular nerve release. Additionally, UCLA subscores between the two groups were compared preoperatively and at final follow-up. Results The average preoperative UCLA score in the nerve-release group was 7.91, and final follow-up average was 27.86; average 3.05 grades of strength were recovered. In the comparison group, average preoperative UCLA score was 11.77, and final follow-up average was 29.09; average 1.32 grades of strength were recovered. The average preoperative UCLA score was significantly worse in the nerve-release group (P=0.007). The average postoperative UCLA score was not significantly different (P=0.590) between the groups, indicating a better improvement in the nerve-release group with significantly greater improvement in active forward flexion, strength, and pain relief. Conclusion Patients who underwent concomitant release of the suprascapular nerve during revision RTCR had greater overall improvement as noted in pain relief, active forward flexion, and strength, than a comparable group without nerve release. PMID:27799834
Pelotti, Patrizia; Serraino, Salvatore; Battaglia, Milva; Bettelli, Graziano; Fusaro, Isabella; Guglielmi, Giuseppe; Rotini, Roberto; Albisinni, Ugo
Objective: Rotator cuff calcific tendinitis (RCCT) is a common cause of shoulder pain in adults and typically presents as activity-related shoulder pain. Between non-surgical and surgical treatment options, today a few minimal invasive techniques are available to remove the calcific deposit, and they represent a cornerstone in the management of this painful clinical condition. The aim of the work was a retrospective evaluation of double-needle ultrasound-guided percutaneous fragmentation and lavage (DNL), focused on understanding the factors which are of major importance in determining a quick and good response at 1 month. Methods: A series of 147 patients affected by RCCT and suitable for DNL were evaluated. A systematic review of anamnestic, clinical and imaging data was performed in 144 shoulders treated in a single-centre setting. Clinical reports and imaging examinations were revisited. The inclusion criteria were submission to DNL, therefore fitness for the percutaneous procedure, and following 1-month follow-up. There was no exclusion owing to risk of bias. The treatment was defined as successful for constant shoulder modified score (CSS) improvement of >50% at 1 month. Results: In 70% of shoulders, the treatment resulted in a quick and significant reduction of symptoms (successful). On the whole, CSS increase at 1 month was estimated at 91.5 ± 69.1%. CSS variations were significantly related to age of patients (better results between 30 and 40 years old), calcification size (more relevant improvement for middle-sized calcifications, 12–17 mm), sonographic and radiographic features of calcific deposits (softer calcifications) and thickening of subacromial/subdeltoid bursa walls. In the final model of stepwise regression for CSS variation, ultrasound score pre-treatment and post-treatment, the distance between bursa and calcification before treatment and the size of post-treatment calcification area were shown to be independently correlated to
... protect your shoulder and keep it still. • Activity modiﬁcation. Avoid activities that cause shoulder pain. • Non-steroidal ... improve ﬂexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and ...
... Diet Plans Nutrients and Nutritional Info Sugar and Sugar Substitutes Exercise and Fitness Exercise Basics Sports Safety Injury Rehabilitation ... Diet Plans Nutrients and Nutritional Info Sugar and Sugar Substitutes Exercise and Fitness Exercise Basics Sports Safety Injury Rehabilitation ...
DeBerardino TM, Scordino L. Shoulder arthroscopy. In: Miller MD, Thompson SR, eds. DeLee and Drez's Orthopaedic Sports Medicine: Principles and Practice. 4th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 45. Miller ...
Kolk, A; Yang, K G Auw; Tamminga, R; van der Hoeven, H
The aim of this study was to determine the effect of radial extracorporeal shock-wave therapy (rESWT) on patients with chronic tendinitis of the rotator cuff. This was a randomised controlled trial in which 82 patients (mean age 47 years (24 to 67)) with chronic tendinitis diagnosed clinically were randomly allocated to a treatment group who received low-dose rESWT (three sessions at an interval 10 to 14 days, 2000 pulses, 0.11 mJ/mm(2), 8 Hz) or to a placebo group, with a follow-up of six months. The patients and the treating orthopaedic surgeon, who were both blinded to the treatment, evaluated the results. A total of 44 patients were allocated to the rESWT group and 38 patients to the placebo group. A visual analogue scale (VAS) score for pain, a Constant-Murley (CMS) score and a simple shoulder test (SST) score significantly improved in both groups at three and six months compared with baseline (all p ≤ 0.012). The mean VAS was similar in both groups at three (p = 0.43) and six months (p = 0.262). Also, the mean CMS and SST scores were similar in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or improve function in patients chronic rotator cuff tendinitis compared with placebo treatment.
Karataglis, D; Papadopoulos, P; Boutsiadis, A; Fotiadou, A; Ditsios, K; Hatzokos, I; Christodoulou, A
This study evaluates the position of the long head of biceps tendon using ultrasound following simple tenotomy, in patients with arthroscopically repaired rotator cuff tears. In total, 52 patients with a mean age of 60.7 years (45 to 75) underwent arthroscopic repair of the rotator cuff and simple tenotomy of the long head of biceps tendon. At two years post-operatively, ultrasound revealed that the tendon was inside the bicipital groove in 43 patients (82.7%) and outside in nine (17.3%); in six of these it was lying just outside the groove and in the remaining three (5.8%) it was in a remote position with a positive Popeye Sign. A dynamic ultrasound scan revealed that the tenotomised tendons had adhered to the surrounding tissues (autotenodesis).The initial condition of the tendon influenced its final position (p < 0.0005). The presence of a Popeye sign was statistically influenced by the pre-operative co-existence of supraspinatus and subscapularis tears (p < 0.0001). It appears that the natural history of the tenotomised long head of biceps tendon is to tenodese itself inside or just outside the bicipital groove, while its pre-operative condition and coexistent subscapularis tears play a significant role in the occurrence of a Popeye sign.
Sousa, Catarina de Oliveira; Camargo, Paula Rezende; Ribeiro, Ivana Leão; Reiff, Rodrigo Bezerra de Menezes; Michener, Lori Ann; Salvini, Tania Fátima
This study described the three-dimensional shoulder motion during the arm elevation in individuals with isolated acromioclavicular osteoarthritis (ACO) and ACO associated with rotator cuff disease (RCD), as compared to controls. Seventy-four participants (ACO=23, ACO+RCD=25, Controls=26) took part of this study. Disability was assessed with the DASH, three-dimensional kinematics were collected during arm elevation in the sagittal and scapular planes, and pain was assessed with the 11-point numeric pain rating scale. For each kinematic variable and demographic variables, separate linear mixed-model 2-way ANOVAs were performed to compare groups. Both ACO groups had higher DASH and pain scores. At the scapulothoracic joint, the isolated ACO group had greater internal rotation than control, and the ACO+RCD group had greater upward rotation than both other groups. At the sternoclavicular joint, both groups with ACO had less retraction, and the isolated ACO group had less elevation and posterior rotation. At the acromioclavicular joint, the isolated ACO group had greater upward rotation, and both ACO groups had greater posterior tilting. Patients with ACO had altered shoulder kinematics, which may represent compensatory responses to reduce pain and facilitate arm motion during arm elevation and lowering.
Godinho, Glaydson Gomes; França, Flavio de Oliveira; Alves, Freitas José Marcio; Watanabe, Fábio Nagato; Nobre, Leonardo Oliveira; De Almeida Neto, Manoel Augusto; Mendes Da Silva, Marcos André
Objective: To evaluate the functional and anatomical results from surgical treatment via arthroscopy in cases of complete rupture of the rotator cuff, using ultrasound images and the Constant and Murley functional index to investigate the correlation between them. Methods: 100 patients (110 shoulders) were evaluated. The mean follow-up was 48.8 ± 33.28 months (12 to 141 months). The mean age was 60.25 ± 10.09 (36 to 81 years). Rupture of the supraspinal tendon alone occurred in 85 cases (77%), and in association with the infraspinatus in 20 cases (18%) and subscapularis in four shoulders (4%). An association of supraspinatus, infraspinatus and subscapularis lesions was found in one shoulder (1%). The lesions were classified according to DeOrio and Cofield scores as small/medium in 85 shoulders (77%) and large/extensive in 25 (23%). The clinical results were assessed in accordance with the Constant and Murley criteria. The ultrasound results relate to reports issued by different radiologists. Statistical analysis was carried out using the chi-square test, Fisher's exact test, Student's t test, Pearson's correlation, Kruskal-Wallis correlation and logistic regression (significance: p < 0.05). Results: The mean Constant evaluation was 85.3 ± 10.06 in the normal shoulders and 83.96 ± 8.67 in the operated shoulders (p = 0.224). Excellent and good results were found in 74 shoulders (67%), satisfactory and moderate results in 32 (29%) and poor results in four (4%). The ultrasound evaluation showed 38 shoulders with re-rupture (35%) and absence of rupture in 71 (65%). Among the 74 shoulders (67%) with excellent/good results, 22 (30%) presented re-rupture in the ultrasound report (p = 0.294). Among the four shoulders (4%) with poor results, two (50%) presented reports of intact tendons (p = 0.294). Conclusion: There was no statistically valid correlation between the ultrasound diagnosis and the clinical evaluation of results among the patients who underwent arthroscopic
Park, Jin-Young; Lee, Jae-Hyung; Oh, Kyung-Soo; Chung, Seok-Won; Bang, Jin-Young; Noh, Young-Min
Tendinopathy of the long head of the biceps is often found as an intra-articular pathology in the glenohumeral joint. Because long head of the biceps lesions are common, surgical intervention to properly manage the long head of the biceps has become an important issue. Both tenodesis and tenotomy have been shown to provide benefits in biceps long head tendinopathy. But because of concerns about muscle power reduction, cramping, and "Popeye's deformity," which may result from biceps tenotomy, biceps tenodesis is a good option for treating biceps lesions. Here, we describe a time-saving, simple, and secure biceps tenodesis method during rotator cuff repairs, which is a combination of an adjacent soft-tissue tenodesis and a bony suprapectoral tenodesis, by performing a combined tenodesis (soft + bony), and we believe that the shoulder joint will gain more strength and loosening complications will be reduced.
Vidt, Meghan E; Santago, Anthony C; Hegedus, Eric J; Marsh, Anthony P; Tuohy, Christopher J; Poehling, Gary G; Freehill, Michael T; Miller, Michael E; Saul, Katherine R
Rotator cuff tears (RCT) are prevalent in older individuals and may compound age-associated functional declines. Our purpose was to determine whether self-report measures of perceived functional ability are valid for older patients with RCT. Twenty five subjects participated (12M/13F; age=63.9±3.0years); 13 with RCT and 12 controls (CON). Participants completed self-report measures of shoulder function (SST, ASES, WORC) and health-related quality of life (SF-36). Isometric joint moment and range of motion (ROM) were measured at the shoulder. Relationships among functional self-reports, and between these measures and joint moment and ROM were assessed; group differences for total and subcategory scores were evaluated. There were significant correlations among self-reports (rs=0.62-0.71, p⩽0.02). For RCT subjects, ASES was associated with all joint moments except adduction (p⩽0.02); SST, ASES, and WORC were associated with abduction and external rotation ROM (p⩽0.04). For RCT subjects, SST and WORC were associated with SF-36 physical function subcategory scores (p⩽0.05). The RCT group scored worse than CON on all functional self-reports (p<0.01) and WORC and ASES subcategories (p<0.01). In conclusion, SST, ASES, and WORC demonstrate utility and discriminant validity for older individuals by distinguishing those with RCT, but this work suggests prioritizing ASES given its stronger association with functional group strength.
Romana-Souza, Bruna; Otranto, Marcela; Vieira, Andreza M; Filgueiras, Cláudio C; Fierro, Iolanda M; Monte-Alto-Costa, Andréa
Stress impairs wound healing of cutaneous lesions; however, the mechanism is still unclear. The aim of this study was to evaluate the effects of rotational stress on cutaneous wound healing in mice and propose a mechanism. Male mice were spun at 45 rpm for 15 min every hour beginning 3 days before wounding until euthanasia. Control animals were not subjected to stress. To confirm that catecholamines participate in stress-induced delay of wound healing, mice were treated daily with propranolol. An excisional lesion was created and measured. Seven and 14 days later, animals were killed and lesions collected. Sections were stained with hematoxylin-eosin and immunostained for alpha-smooth muscle actin and proliferating cell nuclear antigen. Matrix metalloproteinase (MMP)-2 and -9 activity, nitrite levels, and tumor necrosis factor-alpha (TNF-alpha) expression were measured in the wounds. In addition, murine skin fibroblast cultures were treated with high levels of epinephrine and fibroblast activity was evaluated. Stressed mice exhibited reduced locomotor activity and increased normetanephrine plasma levels. Rotational stress was associated with decreased wound contraction, reduced re-epithelialization, reduced MMP-2 and MMP-9 activation, but with strongly increased nitrite levels. Furthermore, inflammatory cell infiltration, TNF-alpha expression, myofibroblastic differentiation, and angiogenesis were all delayed in the stress group. Propranolol administration reversed the deleterious effects of stress on wound contraction and re-epithelialization. High epinephrine concentrations increased murine skin fibroblast proliferation and nitric oxide synthesis, and strongly inhibited skin fibroblast migration and both pro- and active MMP-2. In conclusion, rotational stress impairs cutaneous wound healing due to epinephrine increased levels.
Huisstede, Bionka M A; Gebremariam, Lukas; van der Sande, Renske; Hay, Elaine M; Koes, Bart W
Extracorporeal shock-wave therapy (ESWT) is suggested as a treatment alternative for calcific and non-calcific rotator cuff tendinosis (RC-tendinosis), which may decrease the need for surgery. In this study we assessed the evidence for effectiveness of ESWT for these disorders. The Cochrane Library, PubMed, Embase, Pedro, and Cinahl were searched for relevant systematic reviews and RCTs. Two reviewers independently extracted data and assessed the methodological quality. Seventeen RCTs (11 calcific, 6 non-calcific) were included. For calcific RC-tendinosis, strong evidence was found for effectiveness in favour of high-ESWT versus low-ESWT in short-term. Moderate evidence was found in favour of high-ESWT versus placebo in short-, mid- and long-term and versus low-ESWT in mid- and long-term. Moreover, high-ESWT was more effective (moderate evidence) with focus on calcific deposit versus focus on tuberculum major in short- and long-term. RSWT was more effective (moderate evidence) than placebo in mid-term. For non-calcific RC-tendinosis, no strong or moderate evidence was found in favour of low-, mid- or high-ESWT versus placebo, each other, or other treatments. This review shows that only high-ESWT is effective for treating calcific RC-tendinosis. No evidence was found for the effectiveness of ESWT to treat non-calcific RC-tendinosis.
Muiño, José María Silberberg; Gimenez, Martín Alejandro; Salvucci, Mauro Gabriel Maroa; Ferro, Diego; Rullan, Ramón Muiña; Blanchero, Pablo
Objectives: To compare clinical and radiological results of two types of rotator cuff (RC) repairs: the double row and double row-suture bridge. Methods: Forty-two patients with a complete tear (medium and large size) of the RC were repaired by a double row arthroscopic technique. Minimum follow-up was 19 months (range, 19-28 months). Clinical outcomes were assessed by the Modified Constant Scale and satisfaction rate by an independent observer; VAS, UCLA and ASES. Radiological results were assed by a postoperative MRI by a musculoskeletal radiologist. Results: Series of 22 patients in the double row technique (Group A) and 20 patients in the double-row suture bridge (Gruop B). Statistically there was a significant improvement in the Constant Scale, satisfaction rate, muscle assessment, VAS, UCLA and ASES in both groups after the surgical procedure. There were no significant clinical differences between both groups at any time after the surgical procedure. According to MRI postop, 19/22 shoulders in Group A and 18/20 in Group B remained intact, with no significant differences between the two groups. Conclusion: RC repairs with double row and double-row-suture bridge techniques provide clinical and radiological good and excelent results. In our retrospective, mid-size study, we have found no differences between these two repair techniques.
Sousa, Catarina de Oliveira; Michener, Lori Ann; Ribeiro, Ivana Leão; Reiff, Rodrigo Bezerra de Menezes; Camargo, Paula Rezende; Salvini, Tania Fátima
This study aimed to compare muscle activity in individuals with isolated acromioclavicular osteoarthritis (ACO), ACO associated with rotator cuff disease (ACO+RCD), and controls. Seventy-four participants (23 isolated ACO, 25 ACO+RCD, 26 controls) took part in this study. Disability was assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Muscle activity of the upper trapezius (UT), lower trapezius (LT), serratus anterior (SA), and anterior deltoid (AD) was collected during arm elevation in the sagittal and scapular planes. Pain during motion was assessed with the numerical pain rating scale. Analysis of the DASH, pain and kinematics were reported in part 1 of this study. For each muscle, separate 2-way linear mixed-model ANOVAs were performed to compare groups. ACO+RCD group had more UT and AD activity than the the isolated ACO and control other groups, more AD activity than the isolated ACO group during the ascending phase, and more AD activity than the ACO and control groups during the descending phase in both planes. Isolated ACO group had less SA activity than the control group only in the sagittal plane. Alterations in shoulder muscle activity are present in individuals with isolated ACO and with ACO+RCD and should be considered in rehabilitation.
Watanabe, Tsuneo; Terabayashi, Nobuo; Fukuoka, Daisuke; Murakami, Hiroki; Ito, Hiroyasu; Matsuoka, Toshio; Seishima, Mitsuru
The aim of this study was to quantitatively assess the echo intensity of the supraspinatus muscle and compare magnetic resonance imaging and ultrasound findings for 27 patients (12 women, 15 men, 65.8 ± 11.5 y). Tear size and fatty infiltration were determined by magnetic resonance imaging; five stages were assigned based on Goutallier's classification. Gray-scale histogram analysis was used for ultrasound assessment, which was performed in both subcutaneous fat and supraspinatus muscle in three different regions; the echo intensity ratio was the ratio of echo intensity in subcutaneous fat to that in the supraspinatus muscle. Sonograms of 27 shoulders revealed 3 shoulders with a partial tear, and 4 with a small tear, 6 with a medium tear, 6 with a large tear and 4 with a massive tear; 4 shoulders had no tear. Supraspinatus muscle echo intensity and echo intensity ratio were significantly lower in the stage 0 and 1 than in stages 2-4. Our study suggests that ultrasound can quantitatively and objectively assess fatty infiltration in the rotator cuff muscle.
Batalha, Nuno; Raimundo, Armando; Tomas-Carus, Pablo; Paulo, João; Simão, Roberto; Silva, António J
During the repeated execution of the swimming strokes, the shoulder adductor and internal rotator muscles have a tendency to become proportionally stronger when compared to their antagonist group. This can lead to muscle imbalances. The aim of this study was to examine the effects of a compensatory training programme on the strength and balance of shoulder rotator muscles in young swimmers. A randomized controlled trial design was used. Forty male swimmers took part in the study and were randomly divided into two groups: an experimental group (n = 20) and a training group (n = 20). A control group (n = 16) of young sedentary male students was also evaluated. The experimental group subjects participated in a 16-week shoulder-strength programme with Thera-Band® elastic bands; the training group was restricted to aquatic training. Peak torque of shoulder internal rotator and external rotator (ER) was measured at baseline and after 16 weeks. Concentric action at 1.04 rad s(-1) (3 reps) and 3.14 rad s(-1) (20 reps) was measured using an isokinetic dynamometer. The strength-training programme led to an improvement of the ER strength and shoulder rotator balance in the experimental group (data from both shoulders at 1.04 rad s(-1)). Moreover, concentric action at 3.14 rad s(-1) presented significant differences only for the dominant shoulder. Findings suggest that the prescribed shoulder-strengthening exercises could be a useful training option for young competitive swimmers. They can produce an increase in absolute strength values and greater muscle balance in shoulder rotators.
Ventres, William B.
My personal ethos of healing is an expression of the belief that I can and do act to heal patients while I attend to the traditional goals of medicine. The 7 supporting principles that inform my ethos are dignity, authenticity, integrity, transparency, solidarity, generosity, and resiliency. I invite others, including medical students, residents, and practicing physicians, to reflect and discover their own ethos of healing and the principles that guide their professional growth. A short digital documentary accompanies this essay for use as a reflective prompt to encourage personal and professional development. PMID:26755787
WOPENKA, BRIGITTE; KENT, ALISTAIR; PASTERIS, JILL D.; YOON, YOUNG; THOMOPOULOS, STAVROS
We applied Raman spectroscopy to monitor the distribution of minerals and the degree of mineralization across the tendon–bone insertion site in the shoulders of five rats. We acquired Raman spectra from 100 to 4000 Δcm-1 on individual 1 μm points across the 120 μm wide transition zone of each tissue sample and identified all the peaks detected in pure tendon and in pure bone, as well as in the transition zone. The intensity of the 960 Δcm-1 P–O stretch for apatite (normalized to either the 2940 Δcm-1 C–H stretch or the 1003 Δcm-1 C–C stretch for collagen) was used as an indicator of the abundance of mineral. We relate the observed histological morphology in the tissue thin section with the observed Raman peaks for both the organic component (mostly collagen) and the inorganic component (a carbonated form of the mineral apatite) and discuss spectroscopic issues related to peak deconvolution and quantification of overlapping Raman peaks. We show that the mineral-to-collagen ratio at the insertion site increases linearly (R2 = 0.8 for five samples) over the distance of 120 μm from tendon to bone, rather than abruptly, as previously inferred from histological observations. In addition, narrowing of the 960 Δcm-1 band across the traverse indicates that the crystalline ordering within the apatite increases concomitantly with the degree of mineralization. This finding of mineral gradation has important clinical implications and may explain why the uninjured tendon-to-bone connection of the rotator cuff can sustain very high stress concentrations without failure. Our finding is also consistent with recent mechanical models and calculations developed to better understand the materials properties of this unusually strong interface. PMID:19094386
ABSTRACT Background and Purpose Rotator cuff tendinopathy (RTCT) is regularly treated by the physical therapist. Multiple etiologies for RTCT exist, leading an individual to seek treatment from their provider of choice. Strengthening exercises (SE) have been reported to be effective in the treatment of RTCT, but there is limited evidence on the effectiveness of dry needing (DN) for this condition. The purpose of this retrospective case series was to investigate DN to various non-trigger point-based anatomical locations coupled with strengthening exercises (SE) as a treatment strategy to decrease pain and increase function in healthy patients with chronic RTC pathology. Case Descriptions Eight patients with RTCT were treated 1-2 times per week for up to eight weeks, and no more than sixteen total treatment sessions of SE and DN. Outcomes were tested at baseline and upon completion of therapy. A long-term outcome measure follow up averaging 8.75 months (range 3 to 20 months) was also performed. The outcome measures included the Visual Analog Scale (VAS) and the Quick Dash (QD). Outcomes Clinically meaningful improvements in disability and pain in the short term and upon long-term follow up were demonstrated for each patient. The mean VAS was broken down into best (VASB), current (VASC), and worst (VASW) rated pain levels and the mean was calculated for the eight patients. The mean VASB improved from 22.5 mm at the initial assessment to 2.36 mm upon completion of the intervention duration. The mean VASC improved from 28.36 mm to 5.0 mm, and the mean VASW improved from 68.88 mm to 13.25 mm. At the long-term follow up (average 8.75 months), The mean VASB, VASC, and VASW scores were 0.36 mm, 4.88 mm, and 17.88 mm respectively. The QDmean for the eight patients improved from 43.09 at baseline to 16.04 at the completion of treatment. At long-term follow-up, the QDmean was 6.59. Conclusion Clinically meaningful improvements in pain and disability were
... you to strengthen your shoulder muscles. Returning to Sports It is best to avoid playing sports until you have no pain during rest or ... your shoulder joint and shoulder blade Returning to sports and other activity should be gradual. Ask your ...
Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint?: A radiological study of the critical shoulder angle.
Moor, B K; Bouaicha, S; Rothenfluh, D A; Sukthankar, A; Gerber, C
We hypothesised that a large acromial cover with an upwardly tilted glenoid fossa would be associated with degenerative rotator cuff tears (RCTs), and conversely, that a short acromion with an inferiorly inclined glenoid would be associated with glenohumeral osteoarthritis (OA). This hypothesis was tested using a new radiological parameter, the critical shoulder angle (CSA), which combines the measurements of inclination of the glenoid and the lateral extension of the acromion (the acromion index). The CSA was measured on standardised radiographs of three groups: 1) a control group of 94 asymptomatic shoulders with normal rotator cuffs and no OA; 2) a group of 102 shoulders with MRI-documented full-thickness RCTs without OA; and 3) a group of 102 shoulders with primary OA and no RCTs noted during total shoulder replacement. The mean CSA was 33.1° (26.8° to 38.6°) in the control group, 38.0° (29.5° to 43.5°) in the RCT group and 28.1° (18.6° to 35.8°) in the OA group. Of patients with a CSA > 35°, 84% were in the RCT group and of those with a CSA < 30°, 93% were in the OA group. We therefore concluded that primary glenohumeral OA is associated with significantly smaller degenerative RCTs with significantly larger CSAs than asymptomatic shoulders without these pathologies. These findings suggest that individual quantitative anatomy may imply biomechanics that are likely to induce specific types of degenerative joint disorders.
Lakhotia, Devendra; Swaminathan, Siva; Oh, Jong Keon; Moon, Jun Gyu; Dwivedi, Chirayu; Hong, Suk Joo
Background Transtrochanteric rotational osteotomy (TRO) is a controversial hip-preserving procedure with a variable success rate. The healing process of femoral head osteonecrosis after TRO has been poorly explained till now. This study aimed to evaluate the healing process of previously transposed necrotic lesion after a TRO for nontraumatic osteonecrosis of the femoral head using computed tomography (CT). Methods Among 52 patients (58 hips) who had preserved original femoral head after TRO, we retrospectively reviewed 27 patients (28 hips) who had undergone sequential CT scans and had no major complication following TRO. The average age was 34 years (range, 18 to 59 years). The mean follow-up period was 9.1 years. We evaluated the reparative process of the transposed osteonecrotic lesion with CT scans. Results Plain radiographs of the osteonecrotic lesion revealed sclerotic and lucent changes in 14 hips (50%) and normal bony architecture in the other 14 hips (50%) at the final follow-up. CT scans of the osteonecrotic lesions showed cystic changes with heterogeneous sclerosis in 13 hips (46%), normal trabecular bone with or without small cysts in 9 hips (32%), and fragmentation of the necrotic lesion in 6 hips (22%). Seventeen hips (60%) showed minimal (13 hips) to mild (4 hips) nonprogressive collapse of the transposed osteonecrotic area. The collapse of the transposed osteonecrotic area on the CT scan was significantly associated with the healing pattern (p = 0.009), as all 6 patients (6 hips) with fragmentation of the necrotic lesion had minimal (5 hips) to mild (1 hip) collapse. Furthermore, a significant association was found between the collapse of the transposed osteonecrotic area on the CT scan of 17 hips (60%) and postoperative Harris hip score (p = 0.021). We observed no differences among the healing patterns on CT scans with regard to age, gender, etiology, staging, preoperative lesion type, preoperative intact area, percentage of necrotic area
Background This study evaluates the preoperative conventional anteroposterior radiography and clinical testing in non-operated patients with cuff tear arthropathy. It analyses the radiological findings in relation to the status of the rotator cuff and clinical status as also the clinical testing in relation to the rotator cuff quality. The aim of the study is to define the usefulness of radiography and clinical examination in cuff tear arthropathy. Methods This study analyses the preoperative radiological (AP-view, (Artro-)CT-scan or MRI-scan) and clinical characteristics (Constant-Murley-score plus active and passive mobility testing) and the peroperative findings in a cohort of 307 patients. These patients were part of a multicenter, retrospective, consecutive study of the French Orthopaedic Society (SOFCOT-2006). All patients had no surgical antecedents and were all treated with prosthetic shoulder surgery for a painful irreparable cuff tear arthropathy (reverse-(84%) or hemi-(8%) or double cup-bipolar prosthesis (8%)). Results A positive significancy could be found for the relationship between clinical testing and the rotator cuff quality; between acromiohumeral distance and posterior rotator cuff quality; between femoralization and posterior rotator cuff quality. Conclusion A conventional antero-posterior radiograph can not provide any predictive information on the clinical status of the patient. The subscapular muscle can be well tested by the press belly test and the teres minor muscle can be well tested by the hornblower' sign and by the exorotation lag signs. The upward migration index and the presence of femoralization are good indicators for the evaluation of the posterior rotator cuff. An inferior coracoid tip positioning suggests rotator cuff disease. PMID:21208449
The impact of rotator cuff deficiency on structure, mechanical properties, and gene expression profiles of the long head of the biceps tendon (LHBT): Implications for management of the LHBT during primary shoulder arthroplasty.
Kurdziel, Michael D; Moravek, James E; Wiater, Brett P; Davidson, Abigail; Seta, Joseph; Maerz, Tristan; Baker, Kevin C; Wiater, J Michael
The long head of the biceps tendon (LHBT) occupies a unique proximal intra-articular and distal extra-articular position within the human shoulder. In the presence of a rotator cuff (RC) tear, the LHBT is recruited into an accelerated role undergoing potential mechanical and biochemical degeneration. Intra-articular sections of the LHBT were harvested during primary shoulder arthroplasty from patients with an intact or deficient RC. LHBTs were stained (H&E, Alcian Blue) and subjected to histologic analysis using the semiquantitative Bonar scale and measurement of collagen orientation. LHBTs (n = 12 per group) were also subjected to gene-expression analyses via an RT(2) -PCR Profiler Array quantifying 84 genes associated with cell-cell and cell-matrix interactions. LHBTs (n = 18 per group) were biomechanically tested with both stress-relaxation and load-to-failure protocols and subsequently modeled with the Quasilinear Viscoelastic (QLV) and Structural-Based Elastic (SBE) models. While no histologic differences were observed, significant differences in mechanical testing, and viscoelastic modeling parameters were found. PCR arrays identified five genes that were differentially expressed between RC-intact and RC-deficient LHBT groups. LHBTs display signs of pathology regardless of RC status in the arthroplasty population, which may be secondary to both glenohumeral joint arthritis and the additional mechanical role of the LHBT in this population.
Moosmayer, S; Lund, G; Seljom, U; Svege, I; Hennig, T; Tariq, R; Smith, H-J
In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005).
Baker, J. T.
A mechanical occlusive cuff controller suitable for blood flow experiments in space shuttle flights is described. The device requires 115 volt ac power and a pressurized gas source. Two occluding cuff pressures (30 and 50 mmHg) are selectable by a switch on the front panel. A screw driver adjustment allows accurate cuff pressurization levels for under or oversized limbs. Two pressurization cycles (20 second and 2 minutes) can be selected by a front panel switch. Adjustment of the timing cycles is also available through the front panel. A pushbutton hand switch allows remote start of the cuff inflation cycle. A stop/reset switch permits early termination of the cycle and disabling of the controller to prevent inadvertent reactivation. Pressure in the cuff is monitored by a differential aneroid barometer. In addition, an electrocardiogram trigger circuit permits the initiation of the pressurization cycle by an externally supplied ECG cycle.
Lambert, Donald R.
A flexible connector apparatus used to join two stiff non-deformable members, such as piping. The apparatus is provided with one or more flexible sections or assemblies each utilizing a bellows of a rolling cuff type connected between two ridge members, with the bellows being supported by a back-up ring, such that only the curved end sections of the bellows are unsupported. Thus, the bellows can be considered as being of a tube-shaped configuration and thus have high pressure resistance. The components of the flexible apparatus are sealed or welded one to another such that it is fluid tight.
Komasawa, Nobuyasu; Mihara, Ryosuke; Imagawa, Kentaro; Hattori, Kazuo; Minami, Toshiaki
The present study compared changes in cuff pressure by head and neck position between high-volume low-pressure (HVLP) and taper-shaped (taper) cuffs in a prospective randomized clinical trial. Methods. Forty patients were intubated using tracheal tubes with either HVLP (n = 20; HVLP group) or taper-shaped (n = 20; Taper group) cuffs. Initial cuff pressure was adjusted to 15, 20, or 25 cmH2O in the neutral position. Cuff pressure was evaluated after changing the head and neck positions to flexion, extension, and rotation. Results. Cuff pressure significantly increased with flexion in both HVLP and Taper groups at all initial cuff pressures. It significantly increased with extension in the HVLP group, but not in the Taper group. Cuff pressure did not significantly differ with rotation in either group and was significantly smaller in the Taper group during flexion and extension than in the HVLP group, regardless of initial cuff pressure. Conclusion. Cuff pressure changes with head and neck flexion and extension were smaller in the Taper group than in the HVLP group. Our results highlight the potential for taper cuffs to prevent excessive cuff pressure increases with positional changes in the head and neck. This trial is registered with UMIN000016119.
Yang, Chi; Io, Chong-Wai; I, Lin
The cooperative motion induced structural evolution of the liquid with microheterogeneity is investigated in quasi-2D dusty plasma liquids, through direct optical visualization. A novel bond-dynamics analysis is used to further classify the robust cooperative 2D clusters into static, rotating, and drifting patches, beyond the earlier findings of the cooperative hopping strings and bands. The relative motion between two adjacent clusters causes the formation of a fractal network with narrow shear strips along the cluster interface. The rotation of the large ordered patch through rupturing into multiple rotating patches followed by the healing process, and the growth to a larger ordered patch by aligning the different lattice orientations of the adjacent ordered domains through patch rupturing, rotation, drifting, and merging are the key processes for the microstructural evolution.
... relieve shoulder pain and prevent further injury. Flexibility: Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness ...
... three repair methods the same for pain relief, strength improvement, and overall satisfaction. Open Repair A traditional ... physical therapy program will help you regain shoulder strength and motion. Immobilization A er surgery, therapy progresses ...
Ligaments and tendons are dense connective tissues that are important in transmitting forces and facilitate joint articulation in the musculoskeletal system. Their injury frequency is high especially for those that are functional important, like the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) of the knee as well as the glenohumeral ligaments and the rotator cuff tendons of the shoulder. Because the healing responses are different in these ligaments and tendons after injury, the consequences and treatments are tissue- and site-specific. In this review, we will elaborate on the injuries of the knee ligaments as well as using functional tissue engineering (FTE) approaches to improve their healing. Specifically, the ACL of knee has limited capability to heal, and results of non-surgical management of its midsubstance rupture have been poor. Consequently, surgical reconstruction of the ACL is regularly performed to gain knee stability. However, the long-term results are not satisfactory besides the numerous complications accompanied with the surgeries. With the rapid development of FTE, there is a renewed interest in revisiting ACL healing. Approaches such as using growth factors, stem cells and scaffolds have been widely investigated. In this article, the biology of normal and healing ligaments is first reviewed, followed by a discussion on the issues related to the treatment of ACL injuries. Afterwards, current promising FTE methods are presented for the treatment of ligament injuries, including the use of growth factors, gene delivery, and cell therapy with a particular emphasis on the use of ECM bioscaffolds. The challenging areas are listed in the future direction that suggests where collection of energy could be placed in order to restore the injured ligaments and tendons structurally and functionally. PMID:20492676
inflated ETT cuff. This method may lead to erroneous cuff pressures. Fernandez, Blanch, Mancebo, Bonsoms, and Artigas studied the accuracy of...Laryngologica, 345, suppl: 1-71. 10. Fernandez, R., Blanch, L., Mancebo, J., Bonsoms, N., Artigas , A. (1990). Endotracheal tube cuff pressure assessment
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Cuff spreader. 868.5760 Section 868.5760 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5760 Cuff spreader. (a) Identification. A cuff spreader is...
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Cuff spreader. 868.5760 Section 868.5760 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5760 Cuff spreader. (a) Identification. A cuff spreader is...
Fletcher, Matt D A
Massive rotator cuff tears may not be primarily repairable with salvage options not necessarily providing acceptable results. Extrinsic tendon transfer is a significant undertaking with prolonged rehabilitation and variable outcome. A novel technique for the reconstruction of massive tears, not amenable to primary repair, by performing a transfer of the intrinsic posterior rotator cuff onto an intact, tenodesed long head of biceps tendon acting as a scaffold for the intrinsic transfer is described. The clinical results at short to medium term in 17 initial patients are presented. Encouraging results from this study suggest that this is a viable option for the management of massive rotator cuff tears with an intact posterior cuff with results equal or superior to other reconstructive techniques.
adults Fixed wing/3,000 Cuff pressure 45 cm H2O at 3,000 ft Mann  ETTs LMA Air filled Diameter Bench top Rotor wing/10,000 Cuff diameter...increased by 4.5 mm at 10,000 ft Wilson  LMA Air filled Pressure Adult & infant mannequin Fixed wing/6,000 Rotor wing/2,200 Cuff pressure...120 cm H2O at 5,000 ft Miyashiro  ETTs LMA Air filled Pressure Tracheal model Ground ascent/ 7,874 Cuff pressure > 80 cm H2O at 8,000
Kesterson, Joshua; Davies, Matthew; Green, Janis; Penezic, Lindsey; Vargas, Roberto; Harkins, Gerald
Background and Objectives: The aim of our study is to evaluate the role of electrosurgery and vaginal closure technique in the development of postoperative vaginal cuff dehiscence. Methods: From prospective surgical databases, we identified 463 patients who underwent total laparoscopic hysterectomy (TLH) for benign disease and 147 patients who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. All TLHs and LAVHs were performed entirely by use of electrosurgery, including colpotomy. Colpotomy in the TLH group was performed with Harmonic Ace Curved Shears (Ethicon Endo-Surgery, Cincinnati, OH, USA), and in the LAVH group, it was performed with a monopolar electrosurgical pencil. The main surgical difference was vaginal cuff closure—laparoscopically in the TLH group and vaginally in the LAVH group. Results: Although patients in the LAVH group were at increased risk for poor healing (significantly older, higher body mass index, more medical comorbidities, higher blood loss, and longer operative time), there were no vaginal cuff dehiscences in the LAVH group compared with 17 vaginal cuff dehiscences (4%) in the TLH group (P = .02). Conclusion: It does not appear that the increased vaginal cuff dehiscence rate associated with TLH is due to electrosurgery; rather, it is due to the vaginal closure technique. PMID:24018078
Reuther, Katherine E.; Tucker, Jennica J.; Thomas, Stephen J.; Vafa, Rameen P.; Liu, Stephen S.; Gordon, Joshua A.; Caro, Adam C.; Yannascoli, Sarah M.; Kuntz, Andrew F.; Soslowsky, Louis J.
Background Rotator cuff tears are common conditions that often require surgical repair to improve function and relieve pain. Unfortunately, repair failure remains a common problem following rotator cuff repair surgery. Several factors may contribute to repair failure including age, tear size, and time from injury. However, the mechanical mechanisms resulting in repair failure are not well understood making clinical management difficult. Specifically, altered scapular motion (termed scapular dyskinesis) may be one important and modifiable factor contributing to the risk of repair failure. Therefore, the objective of this study was to determine the effect of scapular dyskinesis on supraspinatus tendon healing following repair. Methods A rat model of scapular dyskinesis was used. 70 adult male Sprague-Dawley rats (400-450 grams) were randomized into two groups: nerve transection of the accessory and long-thoracic nerves (SD) or sham nerve transection (Sham Control). Following this procedure, all rats underwent unilateral detachment and repair of the supraspinatus tendon. All rats were sacrificed at 2, 4, and 8 weeks after surgery. Shoulder function, passive joint mechanics, and tendon properties (mechanical, histological, organizational, and compositional) were evaluated. Results Scapular dyskinesis alters joint function and may lead to compromised supraspinatus tendon properties. Specifically, diminished mechanical properties, altered histology, and decreased tendon organization was observed for some parameters. Conclusion This study identifies scapular dyskinesis as one underlying mechanism leading to compromise of supraspinatus healing following repair. Identifying modifiable factors that lead to compromised tendon healing will help improve clinical outcomes following repair. Level of evidence Basic Science, in-vivo Animal Study. PMID:25745826
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Nerve cuff. 882.5275 Section 882.5275 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Therapeutic Devices § 882.5275 Nerve cuff. (a) Identification. A nerve...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Nerve cuff. 882.5275 Section 882.5275 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Therapeutic Devices § 882.5275 Nerve cuff. (a) Identification. A nerve...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Nerve cuff. 882.5275 Section 882.5275 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Therapeutic Devices § 882.5275 Nerve cuff. (a) Identification. A nerve...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Nerve cuff. 882.5275 Section 882.5275 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Therapeutic Devices § 882.5275 Nerve cuff. (a) Identification. A nerve...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Nerve cuff. 882.5275 Section 882.5275 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES NEUROLOGICAL DEVICES Neurological Therapeutic Devices § 882.5275 Nerve cuff. (a) Identification. A nerve...
A flexible connector apparatus used to join two stiff non-deformable members, such as piping, is described. The apparatus is provided with one or more flexible sections or assemblies each utilizing a bellows of a rolling cuff type connected between two ridge members, with the bellows being supported by a back-up ring, such that only the curved end sections of the bellows are unsupported. Thus, the bellows can be considered as being of a tube-shaped configuration and thus have high pressure resistance. The components of the flexible apparatus are sealed or welded one to another such that it is fluid tight.
Bell, Rebecca; Taub, Peter; Cagle, Paul; Flatow, Evan L; Andarawis-Puri, Nelly
Supraspinatus (SS) tendon tears are common musculoskeletal injuries whose surgical repair exhibits the highest incidence of re-tear of any tendon. Development of therapeutics for improving SS tendon healing is impaired by the lack of a model that allows biological perturbations to identify mechanisms that underlie ineffective healing. The objective of this study was to develop a mouse model of supraspinatus insertion site healing by creating a reproducible SS tendon detachment and surgical repair which can be applied to a wide array of inbred mouse strains and genetic mutants. Anatomical and structural analyses confirmed that the rotator cuff of the mouse is similar to that of human, including the presence of a coracoacromial (CA) arch and an insertion site that exhibits a fibrocartilagenous transition zone. The surgical repair was successfully conducted on seven strains of mice that are commonly used in Orthopaedic Research suggesting that the procedure can be applied to most inbred strains and genetic mutants. The quality of the repair was confirmed with histology through 14 days after surgery in two mouse strains that represent the variation in mouse strains evaluated. The developed mouse model will allow us to investigate mechanisms involved in insertion site healing.
Norton, William E. (Inventor); Belcher, Jewell G., Jr. (Inventor); Carden, James R. (Inventor); West, Thomas W. (Inventor)
A prosthetic device has been developed for below-the-elbow amputees. The device consists of a cuff, a stem, a housing, two hook-like fingers, an elastic band for holding the fingers together, and a brace. The fingers are pivotally mounted on a housing that is secured to the amputee's upper arm with the brace. The stem, which also contains a cam, is rotationally mounted within the housing and is secured to the cuff, which fits over the amputee's stump. By rotating the cammed stem between the fingers with the lower arm, the amputee can open and close the fingers.
Lawlor, Megan L.; Rao, Rama; Manahan, Kelly J.
Background and Objectives: After being encouraged to change the technique for opening the vaginal cuff during robotic surgery, this study was performed to determine the correlation between vaginal cuff complications and electrosurgical techniques. Methods: The study group consisted of patients who had their vaginal cuffs opened with a cutting current compared to the group of patients having their vaginal cuff opened with a coagulation current. Data were collected on 150 women who underwent robotic surgery for endometrial cancer. All patients received preoperative antibiotics. Data, including operative time, type of electrosurgery used, estimated blood loss, transfusion rate, and complications, were collected from the patients' records. Results: Surgeries in 150 women and the associated complications were studied. The mean age of the patients was not significantly different between the groups (P = .63). The mean body mass index was 38 kg/m2 in the coagulation arm and 36 kg/m2 in the cutting arm (P = .03). Transfusion was not required. Estimated blood loss and operative time were not significantly different in the coagulation versus the cutting arms (P = .29 and .5; respectively). No patients in the cutting arm and 4 patients (with 5 complications) in the coagulation arm had cuff complications (P = .02). Conclusions: Complications involving the vaginal cuff appear to occur more frequently when the vagina is entered by using electrosurgery with coagulation versus cutting in this cohort of patients undergoing robot-assisted surgery for endometrial cancer.. PMID:26681912
Manning, Cionne N; Kim, H Mike; Sakiyama-Elbert, Shelly; Galatz, Leesa M; Havlioglu, Necat; Thomopoulos, Stavros
Despite advances in surgical technique, rotator cuff repairs are plagued by a high rate of failure. This failure rate is in part due to poor tendon-to-bone healing; rather than regeneration of a fibrocartilaginous attachment, the repair is filled with disorganized fibrovascular (scar) tissue. Transforming growth factor beta 3 (TGF-β3) has been implicated in fetal development and scarless fetal healing and, thus, exogenous addition of TGF-β3 may enhance tendon-to-bone healing. We hypothesized that: TGF-β3 could be released in a controlled manner using a heparin/fibrin-based delivery system (HBDS); and delivery of TGF-β3 at the healing tendon-to-bone insertion would lead to improvements in biomechanical properties compared to untreated controls. After demonstrating that the release kinetics of TGF-β3 could be controlled using a HBDS in vitro, matrices were incorporated at the repaired supraspinatus tendon-to-bone insertions of rats. Animals were sacrificed at 14-56 days. Repaired insertions were assessed using histology (for inflammation, vascularity, and cell proliferation) and biomechanics (for structural and mechanical properties). TGF-β3 treatment in vivo accelerated the healing process, with increases in inflammation, cellularity, vascularity, and cell proliferation at the early timepoints. Moreover, sustained delivery of TGF-β3 to the healing tendon-to-bone insertion led to significant improvements in structural properties at 28 days and in material properties at 56 days compared to controls. We concluded that TGF-β3 delivered at a sustained rate using a HBDS enhanced tendon-to-bone healing in a rat model.
Padilla, Sabino; Sanchez, Mikel; Padilla, Ione; Orive, Gorka; Anitua, Eduardo
Healing process might be considered as a byproduct of the mechanisms underlying the biological defense system consisting of hemostasis and clotting, the innate immune system, and fibrogenesis. But there is no biological process that does not potentially entail high costs through trade-offs with other life-history parameters and that might be seen as collateral damage. Depending on the balance among the robust and flexible modular defense system, which will be deployed in many different arrays, the structural outcome of the healing process will not resolve with a unitary outcome. Drawing on the regenerative potential of platelets, plasma biomolecules and fibrin matrix, several systems of producing autologous platelets-and plasma derived products (APPDPs) have been developed and aimed at enhancing the natural in vivo tissue regenerative capacity of damaged tissues. Despite the care with which the medical staff elaborate and apply autologous platelets-and plasma derived products, some pitfalls arise regarding the composition of autologous plasma-and platelet derived products, the modalities of their application, and the in vitro versus in vivo evaluations, all of which can deeply influence tissue healing - a process which is already unpredictable, without a unitary mechanism that might be deployed in many different structural and functional arrays which culminate in the tissue repair. A biological approach to the application of autologous platelets-and plasma derived products is crucial to obtaining optimum functional healing outcomes in addition to avoiding poor clinical results and reaching misleading conclusions.
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Blood pressure cuff. 870.1120 Section 870.1120...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Diagnostic Devices § 870.1120 Blood pressure cuff. (a) Identification. A blood pressure cuff is a device that has an inflatable bladder in an...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Blood pressure cuff. 870.1120 Section 870.1120...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Diagnostic Devices § 870.1120 Blood pressure cuff. (a) Identification. A blood pressure cuff is a device that has an inflatable bladder in an...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Blood pressure cuff. 870.1120 Section 870.1120...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Diagnostic Devices § 870.1120 Blood pressure cuff. (a) Identification. A blood pressure cuff is a device that has an inflatable bladder in an...
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Blood pressure cuff. 870.1120 Section 870.1120...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Diagnostic Devices § 870.1120 Blood pressure cuff. (a) Identification. A blood pressure cuff is a device that has an inflatable bladder in an...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Blood pressure cuff. 870.1120 Section 870.1120...) MEDICAL DEVICES CARDIOVASCULAR DEVICES Cardiovascular Diagnostic Devices § 870.1120 Blood pressure cuff. (a) Identification. A blood pressure cuff is a device that has an inflatable bladder in an...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false Inflatable tracheal tube cuff. 868.5750 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5750 Inflatable tracheal tube cuff. (a) Identification. An inflatable tracheal tube cuff is a device used to provide an airtight...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Tracheostomy tube and tube cuff. 868.5800 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5800 Tracheostomy tube and tube cuff. (a) Identification. A tracheostomy tube and tube cuff is a device intended to be placed into...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false Inflatable tracheal tube cuff. 868.5750 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5750 Inflatable tracheal tube cuff. (a) Identification. An inflatable tracheal tube cuff is a device used to provide an airtight...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Tracheostomy tube and tube cuff. 868.5800 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5800 Tracheostomy tube and tube cuff. (a) Identification. A tracheostomy tube and tube cuff is a device intended to be placed into...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Tracheostomy tube and tube cuff. 868.5800 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5800 Tracheostomy tube and tube cuff. (a) Identification. A tracheostomy tube and tube cuff is a device intended to be placed into...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false Inflatable tracheal tube cuff. 868.5750 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5750 Inflatable tracheal tube cuff. (a) Identification. An inflatable tracheal tube cuff is a device used to provide an airtight...
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false Inflatable tracheal tube cuff. 868.5750 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5750 Inflatable tracheal tube cuff. (a) Identification. An inflatable tracheal tube cuff is a device used to provide an airtight...
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false Inflatable tracheal tube cuff. 868.5750 Section... (CONTINUED) MEDICAL DEVICES ANESTHESIOLOGY DEVICES Therapeutic Devices § 868.5750 Inflatable tracheal tube cuff. (a) Identification. An inflatable tracheal tube cuff is a device used to provide an airtight...
Reinicke, Robert H. (Inventor)
A device for controlling flow of fluid to and from a resilient inflatable cuff implanted about the urethra to control flow of urine therethrough. The device comprises a flexible bulb reservoir and a control unit that includes a manually operated valve that opens automatically when the bulb is squeezed to force fluid into the cuff for closing the urethra. The control unit also includes a movable valve seat member having a relatively large area exposed to pressure of fluid in a chamber that is connected to the cuff and which moves to a position in which the valve member is unseated by an abutment when fluid pressure in the chamber exceeds a predetermined value to thereby relieve excess fluid pressure in the cuff. The arrangement is such that the valve element is held closed against the seat member by the full differential in fluid pressures acting on both sides of the valve element until the seat member is moved away from the valve element to thus insure positive closing of the valve element until the seat member is moved out of engagement with the valve element by excess pressure differential.
Carvalho, Cassiano Diniz; Cohen, Carina; Belangero, Paulo Santoro; Figueiredo, Eduardo Antônio; Monteiro, Gustavo Cará; de Castro Pochini, Alberto; Andreoli, Carlos Vicente; Ejnisman, Benno
O ombro doloroso é uma queixa muito comum entre os atletas, especialmente no caso dos arremessadores. As lesões parciais do manguito rotador podem ser muito dolorosas e causar limitação funcional importante na pratica esportiva do atleta. A incidência das lesões parciais do manguito é variável (13% a 37%). O diagnóstico clínico e radiológico é difícil e deve ser considerado em todo atleta que apresente sintomatologia da síndrome do manguito rotador, inclusive nos pacientes diagnosticados apenas com tendinopatia.
Hamming, David; Braman, Jonathan P; Phadke, Vandana; LaPrade, Robert F; Ludewig, Paula M
Conclusions about normal and pathologic shoulder motion are frequently made from studies using skin surface markers, yet accuracy of such sensors representing humeral motion is not well known. Nineteen subjects were investigated with flock of birds electromagnetic sensors attached to transcortical pins placed into the scapula and humerus, and a thermoplastic cuff secured on the arm. Subjects completed two repetitions of raising and lowering the arm in the sagittal, scapular and coronal planes, as well as shoulder internal and external rotation with the elbow at the side and abducted to 90°. Humeral motion was recorded simultaneously from surface and bone fixed sensors. The average magnitude of error was calculated for the surface and bone fixed measurements throughout the range of motion. ANOVA tested for differences across angles of elevation, raising and lowering, and differences in body mass index. For all five motions tested, the plane of elevation rotation average absolute error ranged from 0-2°, while the humeral elevation rotation average error ranged from 0-4°. The axial rotation average absolute error was much greater, ranging from 5° during elevation motions to approaching 30° at maximum excursion of internal/external rotation motions. Average absolute error was greater in subjects with body mass index greater than 25. Surface sensors are an accurate way of measuring humeral elevation rotations and plane of elevation rotations. Conversely, there is a large amount of average error for axial rotations when using a humeral cuff to measure glenohumeral internal/external rotation as the primary motion.
Saeed, N. P.; Robinson, T. G.
Arterial hypotension can be induced by sudden release of inflated thigh cuffs (THC), but its effects on the cerebral circulation have not been fully described. In nine healthy subjects [aged 59 (9) yr], bilateral cerebral blood flow velocity (CBFV) was recorded in the middle cerebral artery (MCA), noninvasive arterial blood pressure (BP) in the finger, and end-tidal CO2 (ETCO2) with nasal capnography. Three THC maneuvers were performed in each subject with cuff inflation 20 mmHg above systolic BP for 3 min before release. Beat-to-beat values were extracted for mean CBFV, BP, ETCO2, critical closing pressure (CrCP), resistance-area product (RAP), and heart rate (HR). Time-varying estimates of the autoregulation index [ARI(t)] were also obtained using an autoregressive-moving average model. Coherent averages synchronized by the instant of cuff release showed significant drops in mean BP, CBFV, and RAP with rapid return of CBFV to baseline. HR, ETCO2, and ARI(t) were transiently increased, but CrCP remained relatively constant. Mean values of ARI(t) for the 30 s following cuff release were not significantly different from the classical ARI [right MCA 5.9 (1.1) vs. 5.1 (1.6); left MCA 5.5 (1.4) vs. 4.9 (1.7)]. HR was strongly correlated with the ARI(t) peak after THC release (in 17/22 and 21/24 recordings), and ETCO2 was correlated with the subsequent drop in ARI(t) (19/22 and 20/24 recordings). These results suggest a complex cerebral autoregulatory response to the THC maneuver, dominated by myogenic mechanisms and influenced by concurrent changes in ETCO2 and possible involvement of the autonomic nervous system and baroreflex. PMID:25659488
Goutallier, D; Postel, J M; Van Driessche, S; Godefroy, D; Radier, C
Recurrent tears after rotator cuff repairs are frequent. These could be influenced by excessive tension on a degenerated tendinous stump and by fatty degeneration of the cuff muscles. The goal of this study was to evaluate the anatomic and functional results of tension-free cuff repairs with the excision of macroscopic tendon lesions in a series with limited muscular fatty degeneration of the infraspinatus and a global fatty degeneration index of rotator cuff muscles equal to or lower than 2. We studied 27 tears, comprising 13 cases involving both supraspinatus and infraspinatus tears, 13 cases with 3-tendon tears, and 1 case with only a supraspinatus tear. All shoulders were operated on through a transacromial approach easily repaired with 2 titanium screws with washers. To obtain a repair without tension, a single advancement was performed in 20 cases and a double advancement of both the supraspinatus and infraspinatus was done in 7 cases. The shoulders were evaluated clinically preoperatively and postoperatively with the non-weighted Constant score and anatomically with computed arthrotomography scans. The mean age at operation was 59.5 years, and the length of follow-up ranged from 1 to 4 years. Of the cuffs, 23 (85%) were watertight 1 year after surgery. No predictive factor of retear could be found. The functional improvement was statistically significant only for watertight cuffs, with an improvement of the Constant score from 57.8 to 75. The only predictive factor of functional outcome in this watertight group was the preoperative Constant score. Single and double advancements yielded similar functional results regardless of the extent of the initial tear, provided that the cuff was watertight at revision.
Khan, Mueen Ullah; Khokar, Rashid; Qureshi, Sadia; Al Zahrani, Tariq; Aqil, Mansoor; Shiraz, Motasim
Objective: To evaluate the conventional practice of endotracheal tube (ETT) cuff inflation and pressure measurement as compared to the instrumental method. Study Design: Prospective observational study. Place and Duration of Study: Department of Anaesthesia, King Saud University Hospital, Riyadh, Saudi Arabia (June 2014–July 2014). Methods: A total of 100 adult patients were observed according to the syringe size used Group-1 (10 ml) and Group-2 (20 ml) for ETT cuff inflation in general anesthesia. Patients with anticipated difficult intubation, risk for aspiration, known anatomical laryngotracheal abnormalities, and emergency cases were excluded. Trachea was intubated with size 8 or 8.5 mm and 7.0 or 7.5 mm ETT in male and female patients respectively. The ETT cuff was inflated with air by one of the anesthesia technician. Cuff pressures were measured using aneroid manometer. ETT cuff pressure of 20–30 cm of water was considered as standard. Results: In 69% of the patients, the cuff pressure measurements were above the standard. Age (P = 0.806), weight (P = 0.527), height (P = 0.850), and gender (P = 1.00) were comparable in both groups. The mean cuff pressure in Group-1 and Group-2 was 32.52 ± 6.39 and 38.90 ± 6.60 cm of water (P = 0.001). The cuff inflation with 20 ml syringe resulted in higher cuff pressure as compared to 10cc syringe 37.73 ± 4.23 versus 40.74 ± 5.01 (86% vs. 52%, P = 0.013). Conclusion: The conventional method for ETT cuff inflation and pressure measuring is unreliable. As a routine instrumental cuff pressure, monitoring is suggested. PMID:27833487
estimation of cuff pressure, with no effect of provider experience on accuracy (Fernandez, Blanch, Mancebo, Bonsoms, & Artigas , 1990). With the minimal...London: Oxford University Press. Fernandez, R., Blanch, L., Mancebo, J., Bonsoms, N., Artigas , A. (1990). Endotracheal tube cuff pressure assessment
Catan, Agustín; Vilaseca, Tomas; Arroquy, Damián; Carboni, Martín; Guiñazú, Jorge Eduardo; Orlowsky, Belén; Irigoitia, Nicolas; Chahla, Jorge
Objectives: The purpouse of this study was to evaluate MRI images of labral repair after one year, trying to stablish MRI images as a reliable tool for the diagnosis of labral healing. Methods: One hundred and sixty-two patients presenting with femoroacetabular impingement that underwent an arthroscopic surgery were treated between 2012 and 2015. Of these, 124 met the selection criteria and were included in this study. Only patients with 12 months of follow up and labral repair were included. Patients with previous hip surgery were excluded. Coronal, sagittal and axial MRI cuts were evaluated by three independent observers, an arthroscopic hip surgery, a fellow in hip arthroscopic surgery and a musculoeskeletal radiologist. Results: on regard of our statistics 68% of the patients had labral healing images, 16% had no healing signals and 16% unsatisfactory images. Just in the 47% the observers had a 100% of agreement. Interobserver variation was: intraobserver agreement was 94% ( arthroscopic surgeon), 72 % (radiologist), 67 % (fellow). Conclusion: The main finding of this study was that a high inter and intraobserver variability was found when analysing the healing status of hip repaired labrums. Assessment of labrum healing after an arthroscopic repair should not only rely on imaging methods and therefore should be concurrently performed with a comprehensive physical examination.
Eisenbrey, David; Eisenbrey, Arthur B; Pettengill, Patrick
Endotracheal tubes are intended to protect the airway and assist with mechanical ventilation in sedated patients. The blood vessels of the tracheal mucosa can be compressed by high tracheal tube cuff pressures (> 30 cm H2O), leading to reduced mucosal blood flow with resulting ischemia and morbidity. Previous research showed a direct correlation between aircraft pressure altitude and the pressure reading from the tracheal cuff, with resulting pressures > 80 cm H2O at 10,000 ft. Standard practice is to periodically remove air from the cuff during ascent based on assumed increased pressure on the adjacent tracheal mucosa. Using a vacuum chamber and a direct reading micropressure sensor in a 22-mm-diameter semirigid tube, we assessed the direct force applied by the tracheal cuff against the laryngeal tube analog. Standard tracheal cuffs showed direct force/pressure relationships when properly inflated to 20 cm H2O but much less than reported in the literature. Current literature reports values of 55 to 150 cm H2O at 5,000 ft, whereas we report 23 to 25 cm H2O. Our data indicate that a properly inflated cuff does not exceed the critical pressure of 30 cm H2O until the altitude exceeds 8,000 ft. Thus, the standard practice of deflating the laryngeal cuff on ascent should be reconsidered because it may be counterproductive to patient safety.
... care to prevent infection. Continue Reading Stages of Wound Healing Wounds heal in stages. The smaller the wound, ... How lacerations heal References Leong M, Phillips LG. Wound healing. In: Townsend CM, Beauchamp RD, Evers BM, Mattox ...
Frei, Regina; Serugendo, Giovanna Di Marzo
The following sections are included: * Introduction * Self-Awareness as an Aspect of Self-Healing * A Working Taxonomy for Software Self-Healing * Failures, errors and faults * Approaches to Software Self-Healing * Self-healing at code level * Self-healing through self-organisation * Self-healing based on policies * Architectures for self-healing * Model-based solutions for self-healing * Discussion and Conclusion
... surgical opening of the trachea to facilitate ventilation to the lungs. The cuff may be a separate or..., such as blood or vomit, or to provide a means for positive-pressure ventilation of the patient....
... surgical opening of the trachea to facilitate ventilation to the lungs. The cuff may be a separate or..., such as blood or vomit, or to provide a means for positive-pressure ventilation of the patient....
Naveed, M A; Kitson, J; Bunker, T D
The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.
Henry, F S; Küpper, C; Lewington, N P
Unnatural temporal and spatial distributions of wall shear stress in the anastomosis of distal bypass grafts have been identified as possible factors in the development of anastomotic intimal hyperplasia in these grafts. Distal bypass graft anastomoses with an autologus vein cuff (a Miller cuff) interposed between the graft and artery have been shown to alleviate the effects of intimal hyperplasia. In this study, pulsatile flow through models of a standard end-to-side anastomosis and a Miller cuff anastomosis are computed and the resulting wall shear stress and pressure distributions analysed. The results are inconclusive, and could be taken to suggest that the unnatural distributions of shear stress that do occur along the anastomosis floor may not be particularly important in the development of intimal hyperplasia. However, it seems more likely that the positive effects of the biological and material properties of the vein cuff, which are not considered in this study, somehow outweigh the negative effects of the shear stress distributions predicted to occur on the floor of the Miller-cuff graft.
Mahmoodpoor, Ata; Peyrovi-far, Ali; Hamishehkar, Hadi; Bakhtyiari, Zhaleh; Mirinezhad, Mir Mousa; Hamidi, Masoud; Golzari, Samad Eslam Jamal
Because microaspiration of contaminated supraglottic secretions past the endotracheal tube cuff is considered to be central in the pathogenesis of pneumonia, improved design of tracheal tubes with new cuff material and shape have reduced the size and number of folds, which together with the addition of suction ports above the cuff to drain pooled subglottic secretions leads to reduced aspiration of oropharyngeal secretions. So we conducted a study to compare the prophylactic effects of polyurethane-cylindrical or tapered cuff and polyvinyl chloride cuff endotracheal tubes (ETT) on ventilator-associated pneumonia. This randomized clinical trial was carried out in a 12 bed surgical intensive care unit. 96 patients expected to require mechanical ventilation more than 96 hours were randomly allocated to one of three following groups: Polyvinyl chloride cuff (PCV) ETT, Polyurethane (PU) cylindrical Sealguard ETT and PU Taperguard ETT. Cuff pressure monitored every three hours 3 days in all patients. Mean cuff pressure didn't have significant difference between three groups during 72 hours. Pneumonia was seen in 11 patients (34%) in group PVC, 8 (25%) in Sealguard and 7 (21%) in Taperguard group. Changes in mean cuff pressure between Sealguard and PVC tubes and also between Taperguard and PVC tubes did not show any significant difference. There was no significant difference in overinflation between three groups. The use of ETT with PU material results in reducing ventilator-associated pneumonia compared to ETT with PVC cuff. In PU tubes Taperguard has less incidence of ventilator-associated pneumonia compared to Sealguard tubes.
Lowe, Kevin; Alvarez, Diego F.; King, Judy A.; Stevens, Troy
Objective Lung inflammation causes perivascular fluid cuffs to form around extra-alveolar blood vessels; however, the physiologic consequences of such cuffs remain poorly understood. Herein, we tested the hypothesis that perivascular fluid cuffs, without concomitant alveolar edema, are sufficient to decrease lung compliance. Design Prospective, randomized, controlled study. Setting Research laboratory. Subjects One hundred twenty male CD40 rats. Interventions To test this hypothesis, the plant alkaloid thapsigargin was used to activate store-operated calcium entry and increase cytosolic calcium in endothelium. Thapsigargin was infused into a central venous catheter of intact, sedated, and mechanically ventilated rats. Measurements Static and dynamic lung mechanics and hemodynamics were measured continuously. Main Results Thapsigargin produced perivascular fluid cuffs along extra-alveolar vessels but did not cause alveolar flooding or blood gas abnormalities. Lung compliance dose-dependently decreased after thapsigargin infusion, attributable to an increase in tissue resistance that was attributed to increased tissue damping and tissue elastance. Airway resistance was not changed. Neither central venous pressure nor left ventricular end diastolic pressure was altered by thapsigargin. Heart rate did not change, although thapsigargin decreased pressure over time sufficient to reduce cardiac output by 50%. Infusion of the type 4 phosphodiesterase inhibitor, rolipram, prevented thapsigargin from inducing perivascular cuffs and decreasing lung compliance. Rolipram also normalized pressure over time and corrected the deficit in cardiac output. Conclusions Our findings resolve for the first time that perivascular cuff formation negatively impacts mechanical coupling between the bronchovascular bundle and the lung parenchyma, decreasing lung compliance without impacting central venous pressure. PMID:20400904
De Backer, Daniel
Stridor is one of the most frequent causes of early extubation failure. The cuff-leak test may help to identify patients at risk to develop post-extubation laryngeal edema. However the discrimination power of the cuff-leak test is highly variable and can be use, at best, to detect patients at risk to develop edema but should not be used to postpone extubation as tracheal extubation can still be successful in many patients with a positive test. In this editorial, the author discuss the factors influencing the leak and hence its predictive value.
Hilakivi, I; Peder, M; Elomaa, E; Johansson, G
Twenty-four-hour recordings of electrophysiological correlates of the sleep-waking cycle in the rat were performed during different stages of cuff pedestal treatment. It was found that rats adapted to live on pedestals with the cuff raised displayed undisturbed patterns of sleep and wakefulness. Lowering the cuff for three days resulted in virtually total disappearance of rapid eye movement sleep (REMs), while slow wave sleep (SWs) was only slightly reduced. Raising the cuff induced a prominent rebound increase of REMs. These results accord with data obtained by means of the conventional flowerpot procedure and corroborate the validity of the cuff pedestal technique.
Tekin, Murat; Kati, Ismail; Tomak, Yakup; Yuca, Koksal
This study aimed to evaluate the effects of different inflating gases used for ProSeal LMA (PLMA) cuff inflation on cuff pressure, oropharyngeal structure, and the incidence of sore throat. Eighty patients (American Society of Anesthesiologists; ASA I-II) were randomly divided into two groups. PLMA cuff inflation was achieved with appropriate volumes of 50% N2O + 50% O2 in group I and room air in group II, respectively. When the PLMA was removed, oropharyngeal examination was carried out immediately, using a rigid optical telescope. Patients were asked about sore throat symptoms postoperatively. Cuff pressures were significantly lower in group I, except at the initial pressure measurement. Cuff pressure was positively correlated with the length of the operation in group II, and negatively correlated in group I. PLMA cuff inflation with room air led to increased cuff pressure during the operation, possibly due to the diffusion of N2O into the cuff. We consider that a PLMA cuff inflated with an N2O-O2 mixture is convenient, especially in operations in which N2O has been used.
Fernández, M; Del Castillo, J L; Nieto, M J
The gown-glove interface is the weakest point in the barrier system of gown and glove protection for the surgeon. We are herein presenting an easy modification in the cuff of the gown that increases the security of the gown-glove interface.
pressure, with no effect of provider experience on accuracy (Fernandez, Blanch, Mancebo, Bonsoms, & Artigas , 1990). With the minimal leak technique...University Press. Fernandez, R., Blanch, L., Mancebo, J., Bonsoms, N., Artigas , A. (1990). Endotracheal tube cuff pressure assessment: pitfalls of finger
LIST OF FIGURES Page Figure 1. Intellicuff system software...Figure 3. The Cuff Sentry system .................................................................................................. 3 Figure 4...public release. Distribution is unlimited. Cleared, 88PA, Case # 2015-6230, 23 Dec 2015. 3.0 METHODS 3.1 Devices The Intellicuff system is
Ebert, Douglas; Garcia, Kathleen; Sargsyan, Ashot E.; Ham, David; Hamilton, Douglas; Dulchavsky, Scott A.
Introduction: Braslet-M is a set of special elasticized thigh cuffs used by the Russian space agency to reduce the effects of the head-ward fluid shift during early adaptation to microgravity by sequestering fluid in the lower extremities. Currently, no imaging modalities are used in the calibration of the device, and the pressure required to produce a predictable physiological response is unknown. This investigation intends to relate the pressure exerted by the cuffs to the extent of fluid redistribution and commensurate physiological effects. Materials and Methods: Ten healthy subjects with standardized fluid intake participated in the study. Data collection included femoral and internal jugular vein imaging in two orthogonal planes, pulsed Doppler of cervical and femoral vessels and middle cerebral artery, optic nerve imaging, and echocardiography. Braslet-M cuff pressure was monitored at the skin interface using pre-calibrated pressure sensors. Using 6 and 30 head-down tilt in two separate sessions, the effect of Braslet-M was assessed while incrementally tightening the cuffs. Cuffs were then simultaneously released to document the resulting hemodynamic change. Results: Preliminary analysis shows correlation between physical pressure exerted by the Braslet-M device and several parameters such as jugular and femoral vein cross-sections, resistivity of the lower extremity vascular bed, and others. A number of parameters reflect blood redistribution and will be used to determine the therapeutic range of the device and to prevent unsafe application. Conclusion: Braslet-M exerts a physical effect that can be measured and correlated with many changes in central and peripheral hemodynamics. Analysis of the full data set will be required to make definitive recommendations regarding the range of safe therapeutic application. Objective data and subjective responses suggest that a safer and equally effective use of Braslet can be achieved when compared with the current
ARRIGONI, PAOLO; ROSE, GIACOMO DELLE; D’AMBROSI, RICCARDO; ROTUNDO, GIORGIO; CAMPAGNA, VINCENZO; PIRANI, PIERGIORGIO; PANASCÌ, MANLIO; PETRICCIOLI, DARIO; BERTONE, CELESTE; GRASSO, ANDREA; LATTE, CARMINE; COSTA, ALBERTO; VIOLA, GINO; DE GIORGI, SILVANA; PANELLA, ANTONELLO; PADUA, ROBERTO; BECCARINI, ALESSANDRO; SALCHER, BARBARA; OLIVIERI, MATTEO; MUGNAINI, MARCO; PANNONE, ANTONELLO; CEOLDO, CHIARA; LONGO, UMILE GIUSEPPE; DENARO, VINCENZO; CERCIELLO, SIMONE; PANNI, ALFREDO SCHIAVONE; AVANZI, PAOLO; ZORZI, CLAUDIO; RAGONE, VINCENZA; CASTAGNA, ALESSANDRO; RANDELLI, PIETRO
Purpose the aim of this study was to investigate the relationship between positive painful forced internal rotation (FIR) and lateral pulley instability in the presence of a pre-diagnosed posterosuperior cuff tear. The same investigation was conducted for painful active internal rotation (AIR). Methods a multicenter prospective study was conducted in a series of patients scheduled to undergo arthroscopic posterosuperior cuff repair. Pain was assessed using a visual analog scale (VAS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) was administered. The VAS score at rest, DASH score, and presence/absence of pain on FIR and AIR were recorded and their relationships with lesions of the lateral pulley, cuff tear patterns and shape of lesions were analyzed. Results the study population consisted of 115 patients (mean age: 55.1 years) recruited from 12 centers. The dominant arm was affected in 72 cases (62.6%). The average anteroposterior extension of the lesion was 1.61 cm. The mean preoperative VAS and DASH scores were 6.1 and 41.8, respectively. FIR and AIR were positive in 94 (81.7%) and 85 (73.9%) cases, respectively. The lateral pulley was compromised in 50 cases (43.4%). Cuff tears were partial articular in 35 patients (30.4%), complete in 61 (53%), and partial bursal in 19 (16.5%). No statistical correlation between positive FIR or AIR and lateral pulley lesions was detected. Positive FIR and AIR were statistically associated with complete lesions. Negative FIR was associated with the presence of partial articular tears. Conclusions painful FIR in the presence of a postero-superior cuff tear does not indicate lateral pulley instability. When a cuff tear is suspected, positive FIR and AIR are suggestive of full-thickness tear patterns while a negative FIR suggests a partial articular lesion. Level of evidence: level I, validating cohort study with good reference standards. PMID:26151035
Sirveaux, F; Favard, L; Oudet, D; Huquet, D; Walch, G; Molé, D
We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73 degrees to 138 degrees. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted. This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients.
Solá, J; Proença, M; Chételat, O
The clinical demand for technologies to monitor Blood Pressure (BP) in ambulatory scenarios with minimal use of inflation cuffs is strong: new generation of BP monitors are expected to be not only accurate, but also non-occlusive. In this paper we review recent advances on the use of the so-called Pulse Wave Velocity (PWV) technologies to estimate BP in a beat-by-beat basis. After introducing the working principle and underlying methodological limitations, two implementation examples are provided. Pilot studies have demonstrated that novel PWV-based BP monitors depict accuracy scores falling within the limits of the British Hypertensive Society (BHS) Grade A standard. The reported techniques pave the way towards ambulatory-compliant, continuous and non-occlusive BP monitoring devices, where the use of inflation cuffs is drastically reduced.
Boileau, Pascal; Watkinson, Duncan; Hatzidakis, Armodios M; Hovorka, Istvan
This clinical study was performed to analyze the midterm results and potential complications of the reverse prosthesis in different diagnosis. Forty-five consecutive patients with Grammont prosthesis were evaluated clinically and radiographically with a mean follow-up of 40 months (range, 24-72 months). The indication was a massive and irreparable cuff tear associated with arthrosis (CTA) in 21 cases, fracture sequelae (FS) with arthritis in 5 cases, and failure of a revision arthroplasty (revision) in 19 cases. Fourteen complications occurred in 11 patients. 3 dislocations, 3 deep infections (all 3 in the revision group), 1 case of aseptic humeral loosening, 2 periprosthetic humeral fractures, 1 intraoperative glenoid fracture, 1 wound hematoma, 2 late acromial fractures, and 1 axillary nerve palsy. Of the patients, 10 (22%) required further surgery: 4 reoperations, 4 prosthesis revisions, and 2 prosthesis removals. Complications were higher in revision than in CTA (47% vs. 5%). All 3 groups showed a significant increase in active elevation (from 55 degrees preoperatively to 121 degrees postoperatively) and Constant score (from 17 to 58 points) but no significant change in active external rotation (from 7 degrees to 11 degrees ) or internal rotation (S1 preoperatively and postoperatively). Of the patients, 78% were satisfied or very satisfied with the result and 67% had no or slight pain. However, the postoperative Constant score, adjusted Constant score, and American Shoulder and Elbow Surgeons shoulder score were all significantly higher in the CTA group with as compared with the revision group (P = .01, .004, and .002, respectively). Scapular notching was seen in 24 cases (68%). No glenoid loosening was observed at current follow-up, even when the notch extended beyond the inferior screw (28% of cases). Atrophy of severe fatty infiltration of the teres minor was associated with lower external rotation (15 degrees vs 0 degrees , P = .02) and lower functional
... Loss Surgery? A Week of Healthy Breakfasts Shyness Wound Healing and Care KidsHealth > For Teens > Wound Healing and Care Print A A A What's in ... mouth, or sunken eyes. There's good news about wound healing when you're a teen: Age is on ...
Middleton, C; Uri, O; Phillips, S; Barmpagiannis, K; Higgs, D; Falworth, M; Bayley, I; Lambert, S
Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) and 9(°) (sd 15) respectively pre-operatively to 78(°) (sd 39) and 24(°) (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley-Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.
Dhall, Sandeep; Karim, Zubair A.; Khasawneh, Fadi T.; Martins-Green, Manuela
Objective: Impaired and chronic wounds occur due to defects in one or more of the overlapping stages of healing. However, problems related to the vascular system are critical for nonhealing, and chronic wounds in humans often show the presence of fibrin cuffs/clots. We hypothesized that these clots are due to alterations in platelet function; hence, we have investigated whether alterations in platelet function are present during impaired healing. Approach: Platelets were subjected to different agonists to determine the rate of aggregation and evaluate the molecules involved in adhesion and aggregation that could lead to faster thrombosis and potentially contribute to impaired wound healing. Results: We show that wounding of TNFSF14/LIGHT−/− mice, which have impaired healing, leads to an enhanced response in platelet aggregation and a faster time to blood vessel occlusion (thrombosis). In addition, after wounding, platelets from these mice have increased levels of P-selectin, integrin αIIbβ3, and phosphatidylserine, molecules that contribute to platelet adhesion. They also have more extensive open canalicular system than platelets of control mice, suggesting increased surface area for interactions upon activation. Innovation: These results show a novel function for TNFSF14/LIGHT during wound healing. Conclusion: The absence of TNFSF14/LIGHT from the cell surface of platelets causes rapid platelet aggregation and thrombus formation that may contribute to impaired healing by reducing the ability of the blood vessels to transport nutrients and oxygen and other molecules needed for proper healing. PMID:27785376
Dhall, Sandeep; Karim, Zubair A; Khasawneh, Fadi T; Martins-Green, Manuela
Objective: Impaired and chronic wounds occur due to defects in one or more of the overlapping stages of healing. However, problems related to the vascular system are critical for nonhealing, and chronic wounds in humans often show the presence of fibrin cuffs/clots. We hypothesized that these clots are due to alterations in platelet function; hence, we have investigated whether alterations in platelet function are present during impaired healing. Approach: Platelets were subjected to different agonists to determine the rate of aggregation and evaluate the molecules involved in adhesion and aggregation that could lead to faster thrombosis and potentially contribute to impaired wound healing. Results: We show that wounding of TNFSF14/LIGHT(-/-) mice, which have impaired healing, leads to an enhanced response in platelet aggregation and a faster time to blood vessel occlusion (thrombosis). In addition, after wounding, platelets from these mice have increased levels of P-selectin, integrin αIIbβ3, and phosphatidylserine, molecules that contribute to platelet adhesion. They also have more extensive open canalicular system than platelets of control mice, suggesting increased surface area for interactions upon activation. Innovation: These results show a novel function for TNFSF14/LIGHT during wound healing. Conclusion: The absence of TNFSF14/LIGHT from the cell surface of platelets causes rapid platelet aggregation and thrombus formation that may contribute to impaired healing by reducing the ability of the blood vessels to transport nutrients and oxygen and other molecules needed for proper healing.
... Energy Regulatory Commission Cuffs Run Pumped Storage, LLC; Notice of Preliminary Permit Application... 18, 2010, Cuffs Run Pumped Storage, LLC filed an application for a preliminary permit, pursuant to section 4(f) of the Federal Power Act, proposing to study the feasibility of the Cuffs Run Pumped...
Chen, Thomas S N; Chen, Peter S Y
The iconography of the healing Buddha embraces two healing traditions, symbolized by the healing stone lapis lazuli from Central Asia and by the myrobalan fruit from the ayurvedic medicine of ancient India. The first mention of the healing Buddha is in Buddhist texts of the first century BC, and the earliest extant icons date from the fourth century AD. This suggests the cult of the healing Buddha was a relatively late development in the history of Buddhism. Worshippers sought his help in alleviating spiritual, mental and physical suffering, as well as for medical cures. In China followers believed he was also a cosmic Buddha, to whom one appealed for longevity and protection from disasters. This form of faith-based healing remains vibrant in China, Japan and Tibet to this day.
Hager, Martin D; Greil, Peter; Leyens, Christoph; van der Zwaag, Sybrand; Schubert, Ulrich S
Self-healing materials are able to partially or completely heal damage inflicted on them, e.g., crack formation; it is anticipated that the original functionality can be restored. This article covers the design and generic principles of self-healing materials through a wide range of different material classes including metals, ceramics, concrete, and polymers. Recent key developments and future challenges in the field of self-healing materials are summarised, and generic, fundamental material-independent principles and mechanism are discussed and evaluated.
Efrati, Shai; Deutsch, Israel; Weksler, Nathan; Gurman, Gabriel M
Early detection of accidental endobronchial intubation (EBI) is still an unsolved problem in anesthesia and critical care daily practice. The aim of this study was to evaluate the ability of monitoring above cuff CO2 to detect EBI (the working hypothesis was that the origin of CO2 is from the unventilated, but still perfused, lung). Six goats were intubated under general anesthesia and the ETT positioning was verified by a flexible bronchoscope. The AnapnoGuard system, already successfully used to detect air leak around the ETT cuff, was used for continuous monitoring of above-the-cuff CO2 level. When the ETT distal tip was located in the trachea, with an average cuff pressure of 15 mmHg, absence of CO2 above the cuff was observed. The ETT was then deliberately advanced into one of the main bronchi under flexible bronchoscopic vision. In all six cases the immediate presence of CO2 above the cuff was identified. Further automatic inflation of the cuff, up to a level of 27 mmHg, did not affect the above-the-cuff measured CO2 level. Withdrawal of the ETT and repositioning of its distal tip in mid-trachea caused the disappearance of CO2 above the cuff in a maximum of 3 min, confirming the absence of air leak and the correct positioning of the ETT. Our results suggest that measurement of the above-the-cuff CO2 level could offer a reliable, on-line solution for early identification of accidental EBI. Further studies are planned to validate the efficacy of the method in a clinical setup.
Kofler, Markus; Ritschl, Paul; Oellinger, Robert; Aigner, Felix; Sucher, Robert; Schneeberger, Stefan; Pratschke, Johann; Brandacher, Gerald; Maglione, Manuel
Mouse models are of special interest in research since a wide variety of monoclonal antibodies and commercially defined inbred and knockout strains are available to perform mechanistic in vivo studies. While heart transplantation models using a suture technique were first successfully developed in rats, the translation into an equally widespread used murine equivalent was never achieved due the technical complexity of the microsurgical procedure. In contrast, non-suture cuff techniques, also developed initially in rats, were successfully adapted for use in mice1-3. This technique for revascularization involves two major steps I) everting the recipient vessel over a polyethylene cuff; II) pulling the donor vessel over the formerly everted recipient vessel and holding it in place with a circumferential tie. This ensures a continuity of the endothelial layer, short operating time and very high patency rates4. Using this technique for vascular anastomosis we performed more than 1,000 cervical heart transplants with an overall success rate of 95%. For arterial inflow the common carotid artery and the proximal aortic arch were anastomosed resulting in a retrograde perfusion of the transplanted heart. For venous drainage the pulmonary artery of the graft was anastomosed with the external jugular vein of the recipient5. Herein, we provide additional details of this technique to supplement the video. PMID:25350682
Background This clinical study evaluated the effect of a suctioning maneuver on aspiration past the cuff during mechanical ventilation. Methods Patients intubated for less than 48 hours with a PVC-cuffed tracheal tube, under mechanical ventilation with a PEEP ≥5 cm H2O and under continuous sedation, were included in the study. At baseline the cuff pressure was set at 30 cm H2O. Then 0.5ml of blue dye diluted with 3 ml of saline was instilled into the subglottic space just above the cuff. Tracheal suctioning was performed using a 16-French suction catheter with a suction pressure of – 400 mbar. A fiberoptic bronchoscopy was performed before and after the suctioning maneuver, looking for the presence of blue dye in the folds within the cuff wall or in the trachea under the cuff. The sealing of the cuff was defined by the absence of leakage of blue dye either in the cuff wall or in the trachea under the cuff. Results Twenty-five patients were included. The size of the tracheal tube was 7-mm ID for 5 patients, 7.5-mm ID for 16 patients, and 8-mm ID for four patients. Blue dye was never seen in the trachea under the cuff before suctioning and only in one patient (4%) after the suctioning maneuver. Blue dye was observed in the folds within the cuff wall in 6 of 25 patients before suctioning and 11 of 25 after (p = 0.063). Overall, the incidence of sealing of the cuff was 76% before suctioning and 56% after (p = 0.073). Conclusions In patients intubated with a PVC-cuffed tracheal tube and under mechanical ventilation with PEEP ≥5 cm H2O and a cuff pressure set at 30 cm H2O, a single tracheal suctioning maneuver did not increase the risk of aspiration in the trachea under the cuff. Trial registration ClinicalTrials.gov, number NCT01170156 PMID:23134813
We introduce the concept of self-healing in the field of complex networks modelling; in particular, self-healing capabilities are implemented through distributed communication protocols that exploit redundant links to recover the connectivity of the system. Self-healing is a crucial in implementing the next generation of smart grids allowing to ensure a high quality of service to the users. We then map our self-healing procedure in a percolation problem and analyse the interplay between redundancies and topology in improving the resilience of networked infrastructures to multiple failures. We find exact results both for planar lattices and for random lattices, hinting the role of duality in the design of resilient networks. Finally, we introduce a cavity method approach to study the recovery of connectivity after damage in self-healing networks. CNR-PNR National Project ``Crisis-Lab,'' EU HOME/2013/CIPS/AG/4000005013 project CI2C and EU FET project MULTIPLEX nr.317532.
An experiment was performed to compare the effects of stressors--cold, heat and noise--on primary wound activity (i.e., wound closure in the first 24 h after wound infliction) and on rate of healing in mice. A significant correlation was found between reduced primary wound activity and a faster rate of healing. Conversely, a correlation was found between relatively greater primary wound activity and a slower rate of healing. A possible explanation of this correlation is a compensatory mechanism inherent to the skin healing process. This mechanism is visualized as (1) stress exposure affecting the skin by (a) causing it to become thinner and tauter and (b) causing it to have less elastic recoil; therefore, (2) when a square wound is produced in stressed skin, (a) the wound does not recoil readily or gapes soon after cutting and (b) a longer wound perimeter results. Because there is evidence that rate of healing is governed by cells on the wound perimeter, the greater the perimeter, the greater the number of cells that will undergo rapid mitosis and the faster will be the rate of healing. Therefore, stressed skin will heal at a faster rate, compensating for the loss of elasticity and cellular depletion caused by stress. This study is of interest to anthropology because it deals with dynamic adaptation, trying to grasp the meaning of the elusive endocrine interface between environmental stimulation and a measurable physical entity like healing. This work may have revealed a functional complex that is common to the healing of all mammalian skin, whereby retarding effects of stress on the healing process are obviated.
Buckner, Samuel L; Dankel, Scott J; Counts, Brittany R; Jessee, Matthew B; Mouser, J Grant; Mattocks, Kevin T; Laurentino, Gilberto C; Abe, Takashi; Loenneke, Jeremy P
The purpose of this study was to examine the acute skeletal muscle and perceptual responses to blood flow restriction (BFR) exercise to failure between narrow nylon and elastic inflatable cuffs at rest and during exercise. Torque and muscle thickness was measured pre, post, and 5, 20, 40, and 60 min post-exercise with muscle activation being measured throughout exercise. Resting arterial occlusion pressure was different between the nylon [139 (14) mmHg] and elastic [246 (71) mmHg, p < 0.001] cuffs. However, when exercising at 40 % of each cuff's respective arterial occlusion pressure [nylon: 57 (7) vs. elastic: 106 (38) mmHg, p < 0.001], there were no differences in repetitions to failure, torque, muscle thickness, or muscle activation between the cuffs. Exercising with cuffs of different material but similar width resulted in the same acute muscular response when the cuffs were inflated to a pressure relative to each individual cuff.
Ordonez, Juan S; Pikov, Victor; Wiggins, Harvey; Patten, Craig; Stieglitz, Thomas; Rickert, J; Schuettler, Martin
A fabrication method for cuff electrodes to interface small nerves was developed. Medical grade silicone rubber conforms the body of the cuff and insulation of the wires, platinum was used as metal for the embedded wiring and contacts. Planar electrode arrays where fabricated using a picosecond laser and then positioned into a carrying tube to provide the third dimension with the desired inner diameter (Ø 0.3-0.5 mm). The post preparation of the cuffs after structuring allows the fabrication of a stable self-closing flap that insulates the opening slit of the cuff without the need of extra sutures. Basic for the success of the cuff is the laser-based local thinning of both the silicone rubber and the metal at defined sections. This is critical to permit the PDMS' body to dominate the mechanical properties. Finite element modeling was applied to optimize the displacement ability of the cuff, leading to design capable of withstanding multiple implantation procedures without wire damage. Furthermore, the contact's surface was roughened by laser patterning to increase the charge injection capacity of Pt to 285 μC/cm(2) measured by voltage transient detection during pulse testing. The cuff electrodes were placed on a small sympathetic nerve of an adult female Sprague-Dawley rat for recording of spontaneous and evoked neural activity in vivo.
Nakamura, S; Watanabe, T; Hiroi, E; Sasaki, T; Matsumoto, N; Hori, T
In our hospital, twenty-one cases of endotracheal tube cuff rupture during naso-tracheal intubation were noted in cases using 725 polyvinyl chloride (PVC) tracheal tubes. We analysed the causes of cuff troubles in these 21 samples of tubes. When the cuffs were inflated, they were not capable of containing the air in most cases. Some cuffs had small holes (described as pinholes), and the others had longer slits on scrape marks and burst. These scrape marks may have been caused by the object with sharp edges such as spina or crista of the nasal septum, or otherwise by the tip of intubation forceps. The cuff material appeared to be slightly hardened in some samples which may be due to the lubrication. We usually lubricated the tube with lidocaine spray or gel formulation and then sometimes placed it in hot water to soften it for avoiding naso-mucosal injury. It is not generally recommended to place tubes in hot water, as this procedure may soften the cuff and make it more suspectible to damage. The clarification is also needed on the use of lidocaine. Although the gel formulation is acceptable, but the spray formulation is known to react with cuff material and make it more susceptible to inducing blistering, pinholes and sudden rupture of PVC cuffs. We conclude that these cuff damages might have occurred from various causes. A main cause must be passing the tube through the narrow nasal turbinate with spina or crista. Other causes could not only be the use of Magill forceps but also lubrication of the tube with lidocaine spray and placing it in hot water.
Damm, Anders Aarup Munk; Bundgaard, Helle
During a percutaneous dilatation tracheotomy (PDT) performed at the intensive care unit of a regional hospital, subsequent to completion of the PDT a small segment of the cuff from the oro-tracheal tube was found missing, once the oro-tracheal tube was removed. The oto-rhino-laryngologist was called upon to carry out a flexible bronchoscopy and laryngoscopic examination of the patient. After deflation, the missing piece was located at the level of the tracheal tube cuff and removed successfully. We recommend examining the condition of the oro-tracheal tube cuff upon completion of the PDT procedure.
Hermann, B; Steiner, D
The basic arterial supply of the shoulder is well known, some details for example the supply of the m. supraspinatus are not studied yet. Preparation of shoulder-specimens after injection of silicone-caoutchouc are done to examine the vascular system. The arterial supply of the shoulder is described as a system of four rings. The results are discussed in combination with the literature.
Baker, Joseph F; Mullet, Hannan
The Heimlich manoeuvre is well recognised worldwide as an emergency technique to clear an obstructed airway. The potential for serious injury to the choking victim is also well reported. We report the first case of significant musculoskeletal injury suffered by a rescuer performing the Heimlich manoeuvre. He eventually made a full recovery from his injury. However, we need to be aware of the possibility of injury in the rescuer as well as the rescued.
Brassart, Nicolas; Sanghavi, Sanjay; Hansen, Ulrich N; Emery, Roger J; Amis, Andrew A
The purpose of this study was to examine the tendon-to-bone interface pressure, contact area, and force after reattaching a tendon to bone by use of a suture and suture anchor. Repairs were made in 8 ovine shoulders in vitro, by use of 3 suture types in each: Ethibond, polydioxanone, or Orthocord. A Tekscan pressure sensor was placed between the tendon and bone and monitored for 1 hour after the repair. The principal finding was a significant loss of approximately 60% of the contact parameters immediately after the suture was tied, followed by further significant loss over the next hour to a mean of only 14% of the initial readings. We concluded that pressure measurement systems that only record the initial maximum pressure would yield overly optimistic results for the actual repair pressure after the repair is completed. The Tekscan system, however, allowed us to monitor pressure reductions that occurred both during and after the repair.
Millions of the world's children are exposed to traumatic events and relationships every day. Whatever the cause, this overwhelming stress produces a host of unsettling symptoms and reactions. The author highlights six practical principles that undergird healing interventions.
Triantis, Iasonas F; Demosthenous, Andreas
Ideally, interference in neural measurements due to signals from nearby muscles can be completely eliminated with the use of tripolar cuffs, in combination with appropriate amplifier configurations, such as the quasi-tripole (QT) and the true-tripole (TT). The operation of these amplifiers, is based on the theoretical property of the nerve cuff to produce a linear relationship of potential versus distance along its length, internally, when external potentials appear between its ends. Thus, in principle, electroneurogram (ENG) recordings from an ideal tripolar cuff would be free from electromyogram (EMG) interference generated by nearby muscles. However, in practice the cuff exhibits non-ideal behaviour leading to "cuff imbalance". The main focus of this paper is to investigate the causes of cuff imbalance, to demonstrate that it should be incorporated as a main parameter in the theoretical ENG-recording cuff electrode model. In addition to cuff asymmetry and tissue growth, the proximity of the interference source to the cuff is shown to result in cuff imbalance. The influence of proximity imbalance on the performance of the QT and TT amplifiers is also considered. Proximity imbalance is studied using bioelectric field simulations and saline-bath experiments. Variation is observed with both distance (40 mm and 70 mm was examined) and orientation (0-180 degrees), with the latter causing a more severe effect especially when the source dipole and the cuff are vertical to each other. The simulations and measurements are in close agreement. Tissue growth imbalance and asymmetry imbalance are also investigated in vitro. Finally, the signal-to-interference ratio (SIR; ENG/EMG) of the QT and TT amplifiers is examined in the presence of cuff imbalance. It is shown that proximity imbalance results in their SIR to peak only at certain cuff orientation values. This important finding offers an insight as to why in practice ENG recordings using these amplifiers have been widely
therapy on wound repair have been amply demonstrated. Increased oxygen supply promotes wound healing whereas decreased oxygen supply retards repair...appmarn as early as 6 hms afte the a~ddton of DMF (Figl. 2). The increase was linea during the 24 hrs period of observaumoe in order toconfimn if the...Examine the effect of superoxide on collagen synthesis in vivo, * Examine the effect of increased superoxide levels on wound healing , and * Develop strategies to administer superoxide to wounds.
John, Gareth W; Narracott, Andrew J; Morris, Rhys J; Woodcock, John P; Lawford, Patricia V; Hose, D Rodney
Intermittent pneumatic compression (IPC) is widely used for deep vein thrombosis (DVT) prophylaxis. The technique involves periodic inflation of a compression cuff around a limb, which acts to simulate the muscle pump mechanism, encouraging venous blood flow. However, there is uncertainty regarding the relationship between compression, vascular effects and clinical outcomes. This study investigates calf compression provided by four IPC cuffs with different air bladder configurations. Interface pressure between the cuff and the skin surface is measured and magnetic resonance (MR) images are obtained showing the calf cross section before and during compression. The data will be used to inform numerical simulations of IPC, leading to increased understanding of the implications of cuff design in relation to IPC and DVT prophylaxis.
Tokunaga, Shigehiko; Cho, Tomoki; Izubuchi, Ryo; Masuda, Munetaka
Though the Carpentier Edwards PERIMOUNT Magna Ease valve is a bioprosthesis with documented excellent haemodynamics and easy implantability, this valve has a gap between the cobalt-chromium-nickel alloy stent and silicone sewing ring. This gap, which is widest just below each of the three commissural struts, lacks silicone and leaves the two-layer polytetrafluoroethylene fabric unsupported and unprotected. If the needle of a valve suture is placed in this structurally weak area of the sewing ring, the resultant fabric tear may result in a true cuff leakage, not the usual paravalvular leakage. We describe this pitfall in the context of a recent operation to alert surgeons everywhere that suture placement too close to the stent (missing the silicone sewing ring) can result in postoperative cuff leakage. We need to be very careful to include the silicone ring in each stitch to prevent injury to the valve cuff of this prosthesis and to avoid cuff leakage.
Astronomers combined 146 exposures taken by NASA's Hubble SpaceTelescope to make this 73-frame movie of the asteroid Vesta's rotation.Vesta completes a rotation every 5.34 hours.âº Asteroid and...
Caley, Matthew P.; Martins, Vera L.C.; O'Toole, Edel A.
Significance: Matrix metalloproteinases (MMPs) are present in both acute and chronic wounds. They play a pivotal role, with their inhibitors, in regulating extracellular matrix degradation and deposition that is essential for wound reepithelialization. The excess protease activity can lead to a chronic nonhealing wound. The timed expression and activation of MMPs in response to wounding are vital for successful wound healing. MMPs are grouped into eight families and display extensive homology within these families. This homology leads in part to the initial failure of MMP inhibitors in clinical trials and the development of alternative methods for modulating the MMP activity. MMP-knockout mouse models display altered wound healing responses, but these are often subtle phenotypic changes indicating the overlapping MMP substrate specificity and inter-MMP compensation. Recent Advances: Recent research has identified several new MMP modulators, including photodynamic therapy, protease-absorbing dressing, microRNA regulation, signaling molecules, and peptides. Critical Issues: Wound healing requires the controlled activity of MMPs at all stages of the wound healing process. The loss of MMP regulation is a characteristic of chronic wounds and contributes to the failure to heal. Future Directions: Further research into how MMPs are regulated should allow the development of novel treatments for wound healing. PMID:25945285
Tennyson, Joseph; Ford-Webb, Tucker; Weisberg, Stacy; LeBlanc, Donald
Introduction Endotracheal intubation is a common intervention in critical care patients undergoing helicopter emergency medical services (HEMS) transportation. Measurement of endotracheal tube (ETT) cuff pressures is not common practice in patients referred to our service. Animal studies have demonstrated an association between the pressure of the ETT cuff on the tracheal mucosa and decreased blood flow leading to mucosal ischemia and scarring. Cuff pressures greater than 30 cmH2O impede mucosal capillary blood flow. Multiple prior studies have recommended 30 cmH2O as the maximum safe cuff inflation pressure. This study sought to evaluate the inflation pressures in ETT cuffs of patients presenting to HEMS. Methods We enrolled a convenience sample of patients presenting to UMass Memorial LifeFlight who were intubated by the sending facility or emergency medical services (EMS) agency. Flight crews measured the ETT cuff pressures using a commercially available device. Those patients intubated by the flight crew were excluded from this analysis as the cuff was inflated with the manometer to a standardized pressure. Crews logged the results on a research form, and we analyzed the data using Microsoft Excel and an online statistical analysis tool. Results We analyzed data for 55 patients. There was a mean age of 57 years (range 18–90). The mean ETT cuff pressure was 70 (95% CI= [61–80]) cmH2O. The mean lies 40 cmH2O above the maximum accepted value of 30 cmH2O (p<0.0001). Eighty-four percent (84%) of patients encountered had pressures above the recommended maximum. The most frequently recorded pressure was >120 cmH2O, the maximum pressure on the analog gauge. Conclusion Patients presenting to HEMS after intubation by the referral agency (EMS or hospital) have ETT cuffs inflated to pressures that are, on average, more than double the recommended maximum. These patients are at risk for tracheal mucosal injury and scarring from decreased mucosal capillary blood flow
Ninan, Neethu; Thomas, Sabu; Grohens, Yves
Wound healing is a dynamic and complex phenomenon of replacing devitalized tissues in the body. Urethral healing takes place in four phases namely inflammation, proliferation, maturation and remodelling, similar to dermal healing. However, the duration of each phase of wound healing in urology is extended for a longer period when compared to that of dermatology. An ideal wound dressing material removes exudate, creates a moist environment, offers protection from foreign substances and promotes tissue regeneration. A single wound dressing material shall not be sufficient to treat all kinds of wounds as each wound is distinct. This review includes the recent attempts to explore the hidden potential of growth factors, stem cells, siRNA, miRNA and drugs for promoting wound healing in urology. The review also discusses the different technologies used in hospitals to treat wounds in urology, which make use of innovative biomaterials synthesised in regenerative medicines like hydrogels, hydrocolloids, foams, films etc., incorporated with growth factors, drug molecules or nanoparticles. These include surgical zippers, laser tissue welding, negative pressure wound therapy, and hyperbaric oxygen treatment.
Furman, J M
The natural stimulus for the semicircular canals is rotation of the head, which also might stimulate the otolith organs. Vestibular stimulation usually induces eye movements via the vestibulo-ocular reflex (VOR). The orientation of the subject with respect to the axis of rotation and the orientation of the axis of rotation with respect to gravity together determine which labyrinthine receptors are stimulated for particular motion trajectories. Rotational testing usually includes the measurement of eye movements via a video system but might use a subject's perception of motion. The most common types of rotational testing are whole-body computer-controlled sinusoidal or trapezoidal stimuli during earth-vertical axis rotation (EVAR), which stimulates primarily the horizontal semicircular canals bilaterally. Recently, manual impulsive rotations, known as head impulse testing (HIT), have been developed to assess individual horizontal semicircular canals. Most types of rotational stimuli are not used routinely in the clinical setting but may be used in selected research environments. This chapter will discuss clinically relevant rotational stimuli and several types of rotational testing that are used primarily in research settings.
Kasalický, M; Fried, M; Pesková, M
The gastric bandage is reliable method for long time control of weight loss in failed conservative cure of morbid obese patients. Since 1983 we have been concerned with bariatric surgery at the First Surgical Department of General Faculty Hospital of Charles University. 691 morbid obese patients (BMI 49.7 kg/m2, mean age of 38.1) underwent gastric banding (GB)--by laparotomy 58 obese patients and since 1993 by laparoscopy 633 obese patients. After 12 months the mean weight loss was 21.1 kg (14-32 kg) and after 24 month the mean weight loss was 38.7 kg (27-73 kg). In period of 1993-1998 the most frequent late complication in the group of 517 obese patients after laparoscopic nonadjustable gastric banding (LNGB) was in 5.1% dilatation of upper gastric pouch or slippage of anterior stomach wall above the band with vomiting and failure of gastric evacuation. In majority we removed GB laparoscopically. To prevent this complication we modified GB with fixing band with a cuff made from the anterior gastric wall. To test the effectiveness of this method we implemented in 1998-1999 a prospective randomized study. In the group of 80 morbid obese patients we created in 40 patients (n1-GB+C) LNGB with the cuff fixation and in 40 patients (n2-GB-C) without fixation. We followed-up of this patients after LNGB was in 6 weeks, 6 months and 12 months with measurement of pouch volume by endoscopy with calibrate endocannula. One year after GB in the group n1-GB+C the mean increase of the pouch volume was 14.6 ml, i.e. 124% of the original size, while in group n2-GB-C the mean increase of the pouch volume was 33.6 ml, i.e. 154.1% of the original size. The slippage or dilatation of the pouch was in group nl in one case while in group n2 in three cases (p < 0.001).
Buza, John A.; Einhorn, Thomas
Summary Delayed fracture healing and nonunion occurs in up to 5–10% of all fractures, and can present a challenging clinical scenario for the treating physician. Methods for the enhancement of skeletal repair may benefit patients that are at risk of, or have experienced, delayed healing or nonunion. These methods can be categorized into either physical stimulation therapies or biological therapies. Physical stimulation therapies include electrical stimulation, low-intensity pulsed ultrasonography, or extracorporeal shock wave therapy. Biological therapies can be further classified into local or systemic therapy based on the method of delivery. Local methods include autologous bone marrow, autologous bone graft, fibroblast growth factor-2, platelet-rich plasma, platelet-derived growth factor, and bone morphogenetic proteins. Systemic therapies include parathyroid hormone and bisphosphonates. This article reviews the current applications and supporting evidence for the use of these therapies in the enhancement of fracture healing. PMID:27920804
Diesendruck, Charles E; Sottos, Nancy R; Moore, Jeffrey S; White, Scott R
Self-healing is a natural process common to all living organisms which provides increased longevity and the ability to adapt to changes in the environment. Inspired by this fitness-enhancing functionality, which was tuned by billions of years of evolution, scientists and engineers have been incorporating self-healing capabilities into synthetic materials. By mimicking mechanically triggered chemistry as well as the storage and delivery of liquid reagents, new materials have been developed with extended longevity that are capable of restoring mechanical integrity and additional functions after being damaged. This Review describes the fundamental steps in this new field of science, which combines chemistry, physics, materials science, and mechanical engineering.
The natural science base of modern medicine influences the way in which medicine is delivered and may ignore the spiritual factors associated with illness. The history of spirituality in healing presented here reflects the growth of scientific knowledge, demands for religious renewal, and the shift in the understanding of the concept of health within a broader cultural context. General practitioners have been willing to entertain the idea of spiritual healing and include it in their daily practice, or referral network. Recognizing patients' beliefs in the face of suffering is an important factor in health care practice. PMID:1777299
Ellegaard, M; Jørgensen, N R; Schwarz, P
Fracture healing is a complex process, and a significant number of fractures are complicated by impaired healing and non-union. Impaired healing is prevalent in certain risk groups, such as the elderly, osteoporotics, people with malnutrition, and women after menopause. Currently, no pharmacological treatments are available. There is therefore an unmet need for medications that can stimulate bone healing. Parathyroid hormone (PTH) is the first bone anabolic drug approved for the treatment of osteoporosis, and intriguingly a number of animal studies suggest that PTH could be beneficial in the treatment of fractures and could thus be a potentially new treatment option for induction of fracture healing in humans. Furthermore, fractures in animals with experimental conditions of impaired healing such as aging, estrogen withdrawal, and malnutrition can heal in an expedited manner after PTH treatment. Interestingly, fractures occurring at both cancellous and cortical sites can be treated successfully, indicating that both osteoporotic and nonosteoporotic fractures can be the target of PTH-induced healing. Finally, the data suggest that PTH partly prevents the delay in fracture healing caused by aging. Recently, the first randomized, controlled clinical trial investigating the effect of PTH on fracture healing was published, indicating a possible clinical benefit of PTH treatment in inducing fracture healing. The aim of this article is therefore to review the evidence for the potential of PTH in bone healing, including the underlying mechanisms for this, and to provide recommendations for the clinical testing and use of PTH in the treatment of impaired fracture healing in humans.
Jain, Monika; Kumar, Niranjan; Deb, Sujay
This paper presents a cuff-less hypertension pre-screening device that non-invasively monitors the Blood Pressure (BP) and Heart Rate (HR) continuously. The proposed device simultaneously records two clinically significant and highly correlated biomedical signals, viz., Electrocardiogram (ECG) and Photoplethysmogram (PPG). The device provides a common data acquisition platform that can interface with PC/laptop, Smart phone/tablet and Raspberry-pi etc. The hardware stores and processes the recorded ECG and PPG in order to extract the real-time BP and HR using kernel regression approach. The BP and HR estimation error is measured in terms of normalized mean square error, Error Standard Deviation (ESD) and Mean Absolute Error (MAE), with respect to a clinically proven digital BP monitor (OMRON HBP1300). The computed error falls under the maximum standard allowable error mentioned by Association for the Advancement of Medical Instrumentation; MAE <; 5 mmHg and ESD <; 8mmHg. The results are validated using two-tailed dependent sample t-test also. The proposed device is a portable low-cost home and clinic bases solution for continuous health monitoring.
On a tour of Cuba, Native scholars from North and South America reconnected with the "extinct" Taino people and shared their knowledge of traditional healing herbs. Western science is just beginning to validate the tremendous knowledge base that indigenous healers have developed--most indigenous medicinal knowledge is useful for finding…
Buchanan, Edward P; Longaker, Michael T; Lorenz, H Peter
The developing fetus has the ability to heal wounds by regenerating normal epidermis and dermis with restoration of the extracellular matrix (ECM) architecture, strength, and function. In contrast, adult wounds heal with fibrosis and scar. Scar tissue remains weaker than normal skin with an altered ECM composition. Despite extensive investigation, the mechanism of fetal wound healing remains largely unknown. We do know that early in gestation, fetal skin is developing at a rapid pace and the ECM is a loose network facilitating cellular migration. Wounding in this unique environment triggers a complex cascade of tightly controlled events culminating in a scarless wound phenotype of fine reticular collagen and abundant hyaluronic acid. Comparison between postnatal and fetal wound healing has revealed differences in inflammatory response, cellular mediators, cytokines, growth factors, and ECM modulators. Investigation into cell signaling pathways and transcription factors has demonstrated differences in secondary messenger phosphorylation patterns and homeobox gene expression. Further research may reveal novel genes essential to scarless repair that can be manipulated in the adult wound and thus ameliorate scar.
Portman, Tarrell A. A.; Garrett, Michael T.
Indigenous healing practices among Native Americans have been documented in the United States since colonisation. Cultural encapsulation has deterred the acknowledgement of Native American medicinal practices as a precursor to folk medicine and many herbal remedies, which have greatly influenced modern medicine. Understanding Native American…
... of collagen. So they're tougher and less flexible than the skin around them. Caring for Serious Wounds at Home Serious wounds don't heal overnight. It can take weeks for the body to build new tissue. So after you leave ...
Quisenberry, Nancy L., Ed.; McIntyre, D. John, Ed.
This book presents a collection of essays on racism and the role of teachers in healing racism. There are three sections with nine papers. After an "Introduction" (D. John McIntyre), Section 1, "Historical Perspectives," includes: (1) "Racism in Education" (Gwendolyn Duhon Boudreaux, Rose Duhon-Sells, Alice Duhon-Ross, and Halloway C. Sells); and…
Adams, Erica J.
As many as 9 in 10 justice-involved youth are affected by traumatic childhood experiences. According to "Healing Invisible Wounds: Why Investing in Trauma-Informed Care for Children Makes Sense," between 75 and 93 percent of youth currently incarcerated in the justice system have had at least one traumatic experience, including sexual…
I have tried to briefly review the evidence (summarized in Table II) indicating that fibronectin is important in cutaneous wound healing. Fibronectin appears to be an important factor throughout this process. It promotes the spreading of platelets at the site of injury, the adhesion and migration of neutrophils, monocytes, fibroblasts, and endothelial cells into the wound region, and the migration of epidermal cells through the granulation tissue. At the level of matrix synthesis, fibronectin appears to be involved both in the organization of the granulation tissue and basement membrane. In terms of tissue remodeling, fibronectin functions as a nonimmune opsonin for phagocytosis of debris by fibroblasts, keratinocytes, and under some circumstances, macrophages. Fibronectin also enhances the phagocytosis of immune-opsonized particles by monocytes, but whether this includes phagocytosis of bacteria remains to be determined. In general, phagocytosis of bacteria has not appeared to involve fibronectin. On the contrary, the presence of fibronectin in the wound bed may promote bacterial attachment and infection. Because of the ease of experimental manipulations, wound healing experiments have been carried out on skin more frequently than other tissues. As a result, the possible role of fibronectin has not been investigated thoroughly in the repair of internal organs and tissues. Nevertheless, it seems reasonable to speculate that fibronectin plays a central role in all wound healing situations. Finally, the wound healing problems of patients with severe factor XIII deficiencies may occur because of their inability to incorporate fibronectin into blood clots.
Thangapazham, Rajesh L.; Sharad, Shashwat; Maheshwari, Radha K.
Significance: Traditional therapies, including the use of dietary components for wound healing and skin regeneration, are very common in Asian countries such as China and India. The increasing evidence of health-protective benefits of phytochemicals, components derived from plants is generating a lot of interest, warranting further scientific evaluation and mechanistic studies. Recent Advances: Phytochemicals are non-nutritive substances present in plants, and some of them have the potential to provide better tissue remodeling when applied on wounds and to also act as proangiogenic agents during wound healing. Critical Issues: In this review, we briefly discuss the current understanding, important molecular targets, and mechanism of action(s) of some of the phytochemicals such as curcumin, picroliv, and arnebin-1. We also broadly review the multiple pathways that these phytochemicals regulate to enhance wound repair and skin regeneration. Future Directions: Recent experimental data on the effects of phytochemicals on wound healing and skin regeneration establish the potential clinical utility of plant-based compounds. Additional research in order to better understand the exact mechanism and potential targets of phytochemicals in skin regeneration is needed. Human studies a2nd clinical trials are pivotal to fully understand the benefits of phytochemicals in wound healing and skin regeneration. PMID:27134766
DiBiase, Miriam H., Ed.
This newly designed volume of "Healing Magazine" features practical, clinical information aimed at sharing current work in children's mental health. The first issue shares information on guiding children through times of trauma, particularly after the events of September 11th. Two articles provide information on debriefing after trauma…
Rutstein, Nathan, Ed.; Morgan, Michael, Ed.
The 16 essays in this collection address how to lessen the effects of racism through classroom education by emphasizing the oneness of humanity and the relatedness of all human beings. These selections offer advice about healing racism from the early grades through secondary education. The essays are: (1) "Racism as a Disease" (John Woodall); (2)…
Any free-particle wavepacket solution of Schrodinger's equation can be converted by differentiations to wavepackets rotating about the original direction of motion. The angular momentum component along the motion associated with this rotation is an integral multiple of [h-bar]. It is an "intrinsic" angular momentum: independent of origin and…
Hartbauer, Manfred; Krüger, Thilo B.; Stieglitz, Thomas
Recent advances in microsystems technology led to a miniaturization of cuff-electrodes, which suggests these electrodes not just for long-term neuronal recordings in mammalians, but also in medium-sized insects. In this study we investigated the possibilities offered by cuff-electrodes for neuroethology using insects as a model organism. The implantation in the neck of a tropical bushcricket resulted in high quality extracellular nerve recordings of different units responding to various acoustic, vibratory, optical and mechanical stimuli. In addition, multi-unit nerve activity related to leg movements was recorded in insects walking on a trackball. A drawback of bi-polar nerve recordings obtained during tethered flight was overlay of nerve activity with large amplitude muscle potentials. Interestingly, cuff-electrode recordings were robust to withstand walking and flight activity so that good quality nerve recordings were possible even three days after electrode implantation. Recording multi-unit nerve activity in intact insects required an elaborate spike sorting algorithm in order to discriminate neuronal units responding to external stimuli from background activity. In future, a combination of miniaturized cuff-electrodes and light-weight amplifiers equipped with a wireless transmitter will allow the investigation of neuronal processes underlying natural behavior in freely moving insects. By this means cuff-electrodes may contribute to the development of realistic neuronal models simulating neuronal processes underlying natural insect behavior, such like mate choice and predator avoidance. PMID:23576843
Kim, Jin Hwi; Byun, Seung Won; Song, Jae Yeon; Kim, Yeon Hee; Lee, Hee Joong; Park, Tae Chul; Lee, Keun Ho; Hur, Soo Young; Park, Jong Sup; Lee, Sung Jong
Abstract We compared results using unidirectional barbed sutures and conventional sutures for vaginal cuff closure during total laparoscopic hysterectomy (TLH).The electronic medical records and surgical videos of 170 patients who underwent TLH between January 2013 and March 2015 at Uijeong-bu St. Mary's Hospital of Catholic University of Korea were reviewed. Vaginal cuffs were closed using the 2-layer continuous running technique with unidirectional barbed sutures (V-Loc; Covidien, Mansfield, MA) in 64 patients and with polycolic acid Vicryl; Ethicon, Somerville, NJ sutures in 106 patients. Procedure time, clinical characteristics, and postoperative complications were compared between the 2 study groups. There were no differences in clinical characteristics (age, body mass index, and demographic data) between groups. The mean suturing time was significantly reduced in the barbed group (7.2 vs 12.2 minutes; P < 0.001), although the mean number of stitches was greater than in the Vicryl group (14.1 vs 12.3, P < 0.001). Perioperative complications, including episodes of vaginal bleeding, vaginal cuff cellulitis, and postoperative fever, did not differ between groups. There were no instances of vaginal cuff dehiscence in either group. Unidirectional barbed sutures can be used safely to reduce procedure time and surgical difficulty relative to conventional sutures in laparoscopic vaginal cuff closure. PMID:27684850
Peters, Alfred; Sten, Margaret S.
Objective. To review the vaginal cuff complications from a large series of total laparoscopic hysterectomies in which the laparoscopic culdotomy closure was highly standardized. Methods. Retrospective cohort study (Canadian Task Force Classification II-3) of consecutive total and radical laparoscopic hysterectomy patients with all culdotomy closures performed laparoscopically was conducted using three guidelines: placement of all sutures 5 mm deep from the vaginal edge with a 5 mm interval, incorporation of the uterosacral ligaments with the pubocervical fascia at each angle, and, whenever possible, suturing the bladder peritoneum over the vaginal cuff edge utilizing two suture types of comparable tensile strength. Four outcomes are reviewed: dehiscence, bleeding, infection, and adhesions. Results. Of 1924 patients undergoing total laparoscopic hysterectomy, 44 patients (2.29%) experienced a vaginal cuff complication, with 19 (0.99%) requiring reoperation. Five patients (0.26%) had dehiscence after sexual penetration on days 30–83, with 3 requiring reoperation. Thirteen patients (0.68%) developed bleeding, with 9 (0.47%) requiring reoperation. Twenty-three (1.20%) patients developed infections, with 4 (0.21%) requiring reoperation. Three patients (0.16%) developed obstructive small bowel adhesions to the cuff requiring laparoscopic lysis. Conclusion. A running 5 mm deep × 5 mm apart culdotomy closure that incorporates the uterosacral ligaments with the pubocervical fascia, with reperitonealization when possible, appears to be associated with few postoperative vaginal cuff complications. PMID:27579179
The idea of a connection between chastity and healing power is to be found as well in primitive cultures as in ethnomedicine and in the medicine of Antiquity. What is meant in the Hippocratic Oath, though, is not the sexual restraint of the physician himself, but moreover in the attitude towards his patient and all the people living in the same house with the patient. This is different, though, in ethnomedicine, where the healer is demanded to live sexually abstinent for a certain time and the persons assisting him are often expected to stay untouched, i.e. chaste. "Chastity", however, as conceived by the Ancient Greek and Roman meant the integrity of marital faith. The urine of women who were chaste in this sense was believed to have healing powers. Furthermore mention is made of an African tribe, of which it was said that its members originating definitely from this tribe only, were immune against the bite of snakes and therefore had a special capacity of healing bitten persons. Ethnomedicine, on the other side, attributes great power to those who lead an unchaste life as well as to illegitimately born children. We are here confronted with an ambiguity inherent in popular imagination of disease and healing. A figure of German poetry of the Middle Ages "Der Arme Heinrich" by Hartmann von Aue, f.i., is in search of the heartblood from a young, freeborn maiden which is to cure him from leprosy. In many cases objects used by virgins or unmarried men were believed to have healing powers. Especially the imagination of epilepsy and orgasm being related to each other, lead to the claim for sexual abstinence of the patient, yes, even for his castration. On the other hand, however, epileptics were recommended to have sexual intercourse. Fasting, sometimes together with sexual abstinence, was considered to be important for the healer and as well for the patient to be cured. Plants were given in order to lead to sexual abstinence. In primitive cultures the imagination of
Schou, Jesper; Beck, John G.
Simple convection models estimate the depth of supergranulation at approximately 15,000 km which suggests that supergranules should rotate at the rate of the plasma in the outer 2% of the Sun by radius. Previous measurements (Snodgrass & Ulrich, 1990; Beck & Schou, 2000) found that supergranules rotate significantly faster than this, with a size-dependent rotation rate. We expand on previous work and show that the torsional oscillation signal seen in the supergranules tracks that obtained for normal modes. We also find that the amplitudes and lifetimes of the supergranulation are size dependent.
Traditional African healing has been in existence for many centuries yet many people still seem not to understand how it relates to God and religion/spirituality. Some people seem to believe that traditional healers worship the ancestors and not God. It is therefore the aim of this paper to clarify this relationship by discussing a chain of communication between the worshipers and the Almighty God. Other aspects of traditional healing namely types of traditional healers, training of traditional healers as well as the role of traditional healers in their communities are discussed. In conclusion, the services of traditional healers go far beyond the uses of herbs for physical illnesses. Traditional healers serve many roles which include but not limited to custodians of the traditional African religion and customs, educators about culture, counselors, social workers and psychologists. PMID:26594664
Mattingly, Cheryl; Lawlor, Mary
This article explores a paradox—the simultaneous cultivation and suppression of “healing dramas” by pediatric rehabilitation therapists. Dramatic moments are defined as ones in which the routine exercises and treatment activities of therapeutic practice are transformed into narrative plots. These improvisational plots involve multiple characters, risks, suspense, and above all, a heightened sense that something is at stake. Experience itself becomes the focus of attention for the patient. Based upon ethnographic research in Chicago and Los Angeles, this article offers an anatomy of two such moments, investigating not only how healing dramas are constructed between patients and healers but how and why institutional discourses and practices invite their abandonment. PMID:20930950
Tsirogianni, Afrodite K; Moutsopoulos, Niki Maria; Moutsopoulos, Haralampos M
Wound healing is a complex biological process, comprised of a series of a sequential events aiming to repair injured tissue. The role of the immune system in this process is not only to recognise and combat the newly presented antigens at the site of injury, but also to participate in the debridement of the damaged area and to contribute to the process of healing. In this review, we discuss the molecules and cells of the immune system that participate in tissue repair. We describe the mechanisms of immune recognition during initial insult and the innate and adaptive immune responses to injury. Finally, we address the role of the immune system in regeneration and repair.
Tisi, Alessandra; Angelini, Riccardo
Copper amine oxidases (CuAO) and flavin-containing amine oxidases (PAO) are hydrogen peroxide (H2O2)-producing enzymes responsible for the oxidative de-amination of polyamines. Currently, a key role has been ascribed to apoplastic amine oxidases in plants, i.e., to behave as H2O2-delivering systems in the cell wall during cell growth and differentiation as well as in the context of host-pathogen interactions. Indeed, H2O2 is the co-substrate for the peroxidase-driven reactions during cell-wall maturation and a key signalling molecule in defence mechanisms. We recently demonstrated the involvement of an apoplastic PAO in the wound-healing process of the Zea mays mesocotyl. Experimental evidence indicated a similar role for an apoplastic PAO in Nicotiana tabacum. In this addendum we suggest that a CuAO activity is also involved in this healing event. PMID:19704660
Klein, Daniel J. (Inventor)
A three dimensional structure fabricated from a self-healing polymeric material, comprising poly(ester amides) obtained from ethylene glycol, azelaic acid and 1,1-aminoundecanoic acid, wherein polymeric material has a melt index above 2.5 g/10 min. as determined by ASTM D1238 at 190.degree. C. and 2.16kg, impact resistance and ductility sufficient to resist cracking and brittle fracture upon impact by a 9 mm bullet fired at a temperature of about 29.degree. C. at subsonic speed in a range from about 800 feet/sec to about 1000 feet/sec. It has been determined that the important factors necessary for self-healing behavior of polymers include sufficient impact strength, control of the degree of crystallinity, low melting point and the ability to instantly melt at impacted area.
Watson, S; Wenzel, R R; di Matteo, C; Meier, B; Lüscher, T F
Accurate measurement of arterial blood pressure is of great importance for the diagnosis and treatment of hypertension. Because of the chronic nature of antihypertensive drug therapy, the involvement of the patient in blood pressure control is desirable. Such an involvement, however, is only feasible if simple, user-friendly, and precise blood pressure measurement devices are available. In this study we tested a new wrist cuff oscillometric blood pressure measurement device in 100 consecutive patients undergoing cardiac catheterization. Blood pressures were simultaneously taken intraarterially (axillary artery) and with a mercury manometer and stethoscope or noninvasive measurement device (OMRON R3). Intraarterial measurements were directly compared with two measurements taken in random order with either an arm cuff mercury manometer or the wrist cuff device. Systolic and diastolic blood pressure as assessed with the mercury manometer was higher, especially when compared with the intraarterial and the wrist cuff values, which were comparable. Correlations of blood pressure values with intraarterial measurement were 0.86 systolic and 0.75 diastolic (P < .01) for the wrist cuff and 0.84 systolic (P < .01) and 0.59 diastolic (P < .05) for the mercury manometer measurements. Reproducibility of both measurements was good for the wrist cuff device ([systolic/diastolic]: r = 0.94/0.92; P < .01) and the mercury manometer (r = 0.97/0.88; P < .01). Both methods overestimated high diastolic values, whereas only the wrist cuff underestimated high systolic values. Thus, the new oscillometric wrist cuff blood pressure measurement device measures arterial blood pressure with great accuracy and reproducibility. As compared with intraarterial values, the wrist cuff device overestimated high diastolic and underestimated high systolic blood pressure values. Blood pressure values as measured by the mercury manometer were higher than intraarterial values and those of the wrist cuff
Demonstrates several objects rolling down a slope to explain the energy transition among potential energy, translational kinetic energy, and rotational kinetic energy. Contains a problem from Galileo's rolling ball experiment. (YP)
Sunspot observations made by Johannes Hevelius in 1642 - 1644 are the first ones providing significant information about the solar differential rotation. In modern astronomy the determination of the rotation rate is done in a routine way by measuring positions of various structures on the solar surface as well as by studying the Doppler shifts of spectral lines. In recent years a progress in helioseismology enabled determination of the rotation rate in the layers inaccessible for direct observations. There are still uncertainties concerning, especially, the temporal variations of the rotation rate and its behaviour in the radiative interior. We are far from understanding the observations. Theoretical works have not yet resulted in a satisfactory model for the angular momentum transport in the convective zone.
de Souza, Carolina Ramos; Santana, Vivian Taciana Simioni
Critically ill patients are intubated or tracheostomized because, in most cases, these individuals require invasive mechanical ventilation. The cannulae that are used include the cuff, which can act as a reservoir for oropharyngeal secretions, predisposing to ventilator-associated pneumonia. Studies have revealed that the suction of subglottic secretions through the dorsal suction lumen above the endotracheal tube cuff delays the onset and reduces the incidence of ventilator-associated pneumonia. The aim of this review is to assess published studies regarding the significance of using suction with a supra-cuff device for the prevention of ventilator-associated pneumonia in critically ill patients treated with orotracheal intubation or tracheostomy. Therefore, by searching national and international databases, a literature review was undertaken of studies published between the years 1986 and 2011. Few results were found relating the suction of subglottic secretions to decreased duration of mechanical ventilation and length of stay in the intensive care unit. The suction of subglottic secretions is ineffective in decreasing mortality but is effective in reducing the incidence of early-onset ventilator-associated pneumonia and hospital costs. Techniques involving continuous suction of subglottic secretions may be particularly efficient in removing secretions; however, intermittent suction appears to be the least harmful method. In conclusion, cannulae with a supra-cuff suction device enable the aspiration of subglottic secretions, providing benefits to critically ill patients by reducing the incidence of ventilator-associated pneumonia and, consequently, hospital costs - with no large-scale adverse effects. PMID:23917940
South Carolina State Dept. of Education, Columbia. Office of Vocational Education.
This module on making and setting cuffs, one in a series on the single needle lockstitch sewing machine for student self-study, contains three sections. Each section includes the following parts: an introduction, directions, an objective, learning activities, student information, student self-check, check-out activities, and an instructor's final…
Sacak, Bulent; Tosun, Ugur; Egemen, Onur; Sakiz, Damlanur; Ugurlu, Kemal
Conventional anastomosis with interrupted sutures can be time-consuming, can cause vessel narrowing, and can lead to thrombosis at the site of repair. The amount of suture material inside the lumen can impair the endothelium of the vessel, triggering thrombosis. In microsurgery, fibrin sealants have the potential beneficial effects of reducing anastomosis time and promoting accurate haemostasis at the anastomotic site. However, there has been a general reluctance to use fibrin glue for microvascular anastomoses because the fibrin polymer is highly thrombogenic and may not provide adequate strength. To overcome these problems, a novel technique was defined for microvascular anastomosis with fibrin glue and a venous cuff. Sixty-four rats in two groups are included in the study. In the experimental group (n = 32), end-to-end arterial anastomosis was performed with two stay sutures, fibrin glue, and a venous cuff. In the control group (n = 32), conventional end-to-end arterial anastomosis was performed. Fibrin glue assisted anastomosis with a venous cuff took less time, caused less bleeding at the anastomotic site, and achieved a patency rate comparable to that provided by the conventional technique. Fibrin sealant assisted microvascular anastomosis with venous cuff is a rapid, easy, and reliable technique compared to the end-to-end arterial anastomosis.
Dickey, Jean O.
The study of the Earth's rotation in space (encompassing Universal Time (UT1), length of day, polar motion, and the phenomena of precession and nutation) addresses the complex nature of Earth orientation changes, the mechanisms of excitation of these changes and their geophysical implications in a broad variety of areas. In the absence of internal sources of energy or interactions with astronomical objects, the Earth would move as a rigid body with its various parts (the crust, mantle, inner and outer cores, atmosphere and oceans) rotating together at a constant fixed rate. In reality, the world is considerably more complicated, as is schematically illustrated. The rotation rate of the Earth's crust is not constant, but exhibits complicated fluctuations in speed amounting to several parts in 10(exp 8) [corresponding to a variation of several milliseconds (ms) in the Length Of the Day (LOD) and about one part in 10(exp 6) in the orientation of the rotation axis relative to the solid Earth's axis of figure (polar motion). These changes occur over a broad spectrum of time scales, ranging from hours to centuries and longer, reflecting the fact that they are produced by a wide variety of geophysical and astronomical processes. Geodetic observations of Earth rotation changes thus provide insights into the geophysical processes illustrated, which are often difficult to obtain by other means. In addition, these measurements are required for engineering purposes. Theoretical studies of Earth rotation variations are based on the application of Euler's dynamical equations to the problem of finding the response of slightly deformable solid Earth to variety of surface and internal stresses.
Phadke, Ameya; Zhang, Chao; Arman, Bedri; Hsu, Cheng-Chih; Mashelkar, Raghunath A.; Lele, Ashish K.; Tauber, Michael J.; Arya, Gaurav; Varghese, Shyni
Synthetic materials that are capable of autonomous healing upon damage are being developed at a rapid pace because of their many potential applications. Despite these advancements, achieving self-healing in permanently cross-linked hydrogels has remained elusive because of the presence of water and irreversible cross-links. Here, we demonstrate that permanently cross-linked hydrogels can be engineered to exhibit self-healing in an aqueous environment. We achieve this feature by arming the hydrogel network with flexible-pendant side chains carrying an optimal balance of hydrophilic and hydrophobic moieties that allows the side chains to mediate hydrogen bonds across the hydrogel interfaces with minimal steric hindrance and hydrophobic collapse. The self-healing reported here is rapid, occurring within seconds of the insertion of a crack into the hydrogel or juxtaposition of two separate hydrogel pieces. The healing is reversible and can be switched on and off via changes in pH, allowing external control over the healing process. Moreover, the hydrogels can sustain multiple cycles of healing and separation without compromising their mechanical properties and healing kinetics. Beyond revealing how secondary interactions could be harnessed to introduce new functions to chemically cross-linked polymeric systems, we also demonstrate various potential applications of such easy-to-synthesize, smart, self-healing hydrogels. PMID:22392977
Seo, Jungmin; Hye Wee, Jee; Hoan Park, Jeong; Park, Pona; Kim, Jeong-Whun; Kim, Sung June
Objective. A novel nerve cuff electrode with embedded magnets was fabricated and developed. In this study, a pair of magnets was fully embedded and encapsulated in a liquid crystal polymer (LCP) substrate to utilize magnetic force in order to replace the conventional installing techniques of cuff electrodes. In vitro and in vivo experiments were conducted to evaluate the feasibility of the magnet-embedded nerve cuff electrode (MENCE). Lastly, several issues pertaining to the MENCE such as the cuff-to-nerve diameter ratio, the force of the magnets, and possible concerns were discussed in the discussion section. Approach. Electrochemical impedance spectrum and cyclic voltammetry assessments were conducted to measure the impedance and charge storage capacity of the cathodal phase (CSCc). The MENCE was installed onto the hypoglossal nerve (HN) of a rabbit and the movement of the genioglossus was recorded through C-arm fluoroscopy while the HN was stimulated by a pulsed current. Main results. The measured impedance was 0.638 ∠ -67.8° kΩ at 1 kHz and 5.27 ∠ -82.1° kΩ at 100 Hz. The average values of access resistance and cut-off frequency were 0.145 kΩ and 3.98 kHz, respectively. The CSCc of the electrode was measured as 1.69 mC cm-2 at the scan rate of 1 mV s-1. The movement of the genioglossus contraction was observed under a pulsed current with an amplitude level of 0.106 mA, a rate of 0.635 kHz, and a duration of 0.375 ms applied through the MENCE. Significance. A few methods to close and secure cuff electrodes have been researched, but they are associated with several drawbacks. To overcome these, we used magnetic force as a closing method of the cuff electrode. The MENCE can be precisely installed on a target nerve without any surgical techniques such as suturing or molding. Furthermore, it is convenient to remove the installed MENCE because it requires little force to detach one magnet from the other, enabling repeatable installation and removal. We
ELEMENT NUMBER 5d. PROJECT NUMBER 5e. TASK NUMBER 5f. WORK UNIT NUMBER 6. AUTHOR(S) 7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8...PERFORMING ORGANIZATION REPORT NUMBER 10. SPONSOR/MONITOR’S ACRONYM(S) 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 9. SPONSORING/MONITORING AGENCY...soundness; to cure (of a disease or wound).” Self-healing provides an important evolutionary advantage, since living organisms are affected both
de Albornoz, Pilar Martínez; Forriol, Francisco
Summary Meniscus is a difficult structure to repair and replace. An injured or degenerative meniscus promotes osteoarthritic joint changes that should be avoided. Research focused on promoting healing or replacement must cover three different working lines: biology, mechanics and surgical technique. Biology research line looks for specific factors able to develop a collagen tissue in a matrix with cells that joins the edges of the lesion and also looks for factors able to keep the elasticity and able to regenerate the damaged meniscus fibres. On the other side, scaffolds need the adequate viscoelasticity to allow the penetration of vessels and cells to avoid reabsorption. PMID:23738268
Innovation in medicine requires unique partnerships between academic research, biotech or pharmaceutical companies, and health-care providers. While innovation in medicine has greatly increased over the past 100 years, innovation in wound care has been slow, despite the fact that chronic wounds are a global health challenge where there is a need for technical, process and social innovation. While novel partnerships between research and the health-care system have been created, we still have much to learn about wound care and the wound-healing processes.
have shown experimentally and theoretically that Y - t°m° (24) YM ,. No (25) such that Y remains constant during healing and fracture. The number of...chains per unit volume, Nv., is Nv W (26) where p is the density and Na is Avogadros number. The strain energy density per chain, Uc, is therefore...force f = ol dl/dt, from the integral of fdl, as dlUp= I PoI(’i)dl (30) 4. where io is the monomer friction coefficient and dl/dt is a constant pull-out
Zheng, Yali; Poon, Carmen C Y; Yan, Bryan P; Lau, James Y W
Ambulatory blood pressure monitoring (ABPM) has become an essential tool in the diagnosis and management of hypertension. Current standard ABPM devices use an oscillometric cuff-based method which can cause physical discomfort to the patients with repeated inflations and deflations, especially during nighttime leading to sleep disturbance. The ability to measure ambulatory BP accurately and comfortably without a cuff would be attractive. This study validated the accuracy of a cuff-less approach for ABPM using pulse arrival time (PAT) measurements on both healthy and hypertensive subjects for potential use in hypertensive management, which is the first of its kind. The wearable cuff-less device was evaluated against a standard cuff-based device on 24 subjects of which 15 have known hypertension. BP measurements were taken from each subject over a 24-h period by the cuff-less and cuff-based devices every 15 to 30 minutes during daily activities. Mean BP of each subject during daytime, nighttime and over 24-h were calculated. Agreement between mean nighttime systolic BP (SBP) and diastolic (DBP) measured by the two devices evaluated using Bland-Altman plot were -1.4 ± 6.6 and 0.4 ± 6.7 mmHg, respectively. Receiver operator characteristics (ROC) statistics was used to assess the diagnostic accuracy of the cuff-less approach in the detection of BP above the hypertension threshold during nighttime (>120/70 mmHg). The area under ROC curves were 0.975/0.79 for nighttime. The results suggest that PAT-based approach is accurate and promising for ABPM without the issue of sleep disturbances associated with cuff-based devices.
A case is presented illustrating the potential effect of Brennan Healing Science on pain following hip arthroplasty for avascular necrosis. A 54-year-old woman experienced anterior groin pain, numbness at the bottom of her foot, and occasional grinding at her hip 22 years after right total hip arthroplasty secondary to avascular necrosis. X-ray films showed signs of osteolysis behind the acetabular cup and asymmetric decreased polyethylene thickness of the acetabular prosthetic. Her orthopedic surgeon advised the patient to follow up every 6-9 months to avoid catastrophic failure of the implant, with plans for surgical revision to be scheduled at the next appointment. The patient sought alternative treatment to avoid an invasive procedure. On presentation, the patient had difficulty walking up the stairs into the treatment room due to pain which she rated a 9/10. She found it painful to rotate, flex, extend her hip, or to sit. Hands-on healing techniques based on the Brennan Healing Science method were initiated, starting at the feet, balancing the energy, and working the way up the joints. Once the work at the hip was completed, the hands-on techniques continued up the centerline of the body and the healing was brought to a close. On completion of a 60-minute healing, the patient was able to stand freely and rated her pain as a 4/10. Flexion, extension, and rotation at the hip were no longer distressing. She was able to walk up and down stairs without distress and denied instability, bursitis, or trochanteric or iliopsoas pain or swelling. Repeat X-rays showed decrease in bone spurs and no hardware problem, and her orthopedic surgeon recommended follow-up after 2 years. It is suggested that Brennan Healing Science techniques could play an effective and cost-efficient role in the treatment of pain following hip arthroplasty.
Maltz, Jonathan S; Tison, Geoffrey H; Alley, Hugh F; Budinger, Thomas F; Owens, Christopher D; Olgin, Jeffrey
The integrity of endothelial function in major arteries (EFMA) is a powerful independent predictor of heart attack and stroke. Existing ultrasound-based non-invasive assessment methods are technically challenging and suitable only for laboratory settings. EFMA, like blood pressure (BP), is both acutely and chronically affected by factors such as lifestyle and medication. Consequently, lab-based measurements cannot fully gauge the effects of medical interventions on EFMA. EFMA and BP have, arguably, comparable (but complementary) value in the assessment of cardiovascular health. Widespread deployment of EFMA assessment is thus a desirable clinical goal. To this end, we propose a device based on modifying the measurement protocol of a standard electronic sphygmomanometer. Methods The protocol involves inflating the cuff to sub-diastolic levels to enable recording of the pulse waveform before and after vasodilatory stimulus. The mechanical unloading of the arterial wall provided by the cuff amplifies the distension that occurs with each pulse, which is measured as a pressure variation in the cuff. We show that the height of the rising edge of each pulse is proportional to the change in lumen area between diastole and systole. This allows the effect of vasodilatory stimuli on the artery to be measured with high sensitivity. We compare the proposed cuff flow-mediated dilation (cFMD) method to ultrasound FMD (uFMD). Results We find significant correlation (r=0.55, p = 0.003, N=27) between cFMD- and uFMD-based metrics obtained when the release of a 5-minute cuff occlusion is employed to induce endothelial stimulus via reactive hyperemia. cFMD is approximately proportional to the square of uFMD, representing a typical increase in sensitivity to vasodilation of 300–600%. Conclusion This study illustrates the potential for an individual to conveniently measure his/her EFMA by using a low-cost reprogrammed home sphygmomanometer. PMID:26393958
Cho, Sung-Hak; Baek, Il-Hun; Cheon, Ju Young; Cho, Min Jung; Choi, Mi Young; Jung, Da Hye
[Purpose] Although the Push-Up Plus is a useful exercise method for shoulder stabilization, few studies have examined its effects at different angles of shoulder rotation. Therefore, the present study investigated the most effective exercise method for shoulder stabilization by analyzing muscle activities of the rotator cuff muscles at different angles of shoulder rotation. [Subjects] Fifteen healthy university students in their 20s were the subjects of this study. [Methods] Changes in muscle EMG related to shoulder stabilization were analyzed by performing the Push-Up Plus in shoulder positions of neutral, internal and external rotation. [Results] The highest muscle activity was found in external rotation, and in internal rotation the pectoralis major and levator scapula showed significantly lower activities than the other positions. [Conclusion] Selectively changing the rotation angle of the shoulder for different purposes of the shoulder exercise would be an effective exercise method. PMID:25435689
Cho, Sung-Hak; Baek, Il-Hun; Cheon, Ju Young; Cho, Min Jung; Choi, Mi Young; Jung, Da Hye
[Purpose] Although the Push-Up Plus is a useful exercise method for shoulder stabilization, few studies have examined its effects at different angles of shoulder rotation. Therefore, the present study investigated the most effective exercise method for shoulder stabilization by analyzing muscle activities of the rotator cuff muscles at different angles of shoulder rotation. [Subjects] Fifteen healthy university students in their 20s were the subjects of this study. [Methods] Changes in muscle EMG related to shoulder stabilization were analyzed by performing the Push-Up Plus in shoulder positions of neutral, internal and external rotation. [Results] The highest muscle activity was found in external rotation, and in internal rotation the pectoralis major and levator scapula showed significantly lower activities than the other positions. [Conclusion] Selectively changing the rotation angle of the shoulder for different purposes of the shoulder exercise would be an effective exercise method.
Background Inappropriately cuffed tracheal tubes can lead to inadequate ventilation or silent aspiration, or to serious tracheal damage. Cuff pressures are of particular importance during aeromedical transport as they increase due to decreased atmospheric pressure at flight level. We hypothesised, that cuff pressures are frequently too high in emergency and critically ill patients but are dependent on providers’ professional background. Methods Tracheal cuff pressures in patients intubated before arrival of a helicopter-based rescue team were prospectively recorded during a 12-month period. Information about the method used for initial cuff pressure assessment, profession of provider and time since intubation was collected by interview during patient handover. Indications for helicopter missions were either Intensive Care Unit (ICU) transports or emergency transfers. ICU transports were between ICUs of two hospitals. Emergency transfers were either evacuation from the scene or transfer from an emergency department to a higher facility. Results This study included 101 patients scheduled for aeromedical transport. Median cuff pressure measured at handover was 45 (25.0/80.0) cmH2O; range, 8-120 cmH2O. There was no difference between patient characteristics and tracheal tube-size or whether anaesthesia personnel or non-anaesthesia personnel inflated the cuff (30 (24.8/70.0) cmH2O vs. 50 (28.0/90.0) cmH2O); p = 0.113. With regard to mission type (63 patients underwent an emergency transfer, 38 patients an ICU transport), median cuff pressure was different: 58 (30.0/100.0) cmH2O in emergency transfers vs. 30 (20.0/45.8) cmH2O in inter-ICU transports; p < 0.001. For cuff pressure assessment by the intubating team, a manometer had been applied in 2 of 59 emergency transfers and in 20 of 34 inter-ICU transports (method was unknown for 4 cases each). If a manometer was used, median cuff pressure was 27 (20.0/30.0) cmH2O, if not 70 (47.3/102.8) cmH2O; p < 0
Seaward, B L
In the past three decades the medical world has begun to take more serious notice of the healing power of humor and the positive emotions associated with it. Humor and laughter are currently being employed by psychotherapists and other care givers as tools to promote and maintain health, as well as intervention and rehabilitation tools for a host of maladies and illnesses related to stress and life-style. Although this empirical medical approach is relatively new, the study of humor has revealed a complex psychological phenomenon. Senses of humor have been categorized in types associated with personality. Humor has many styles and can be found in almost any situation, on any occasion. Theories of humor include the superiority theory, the incongruity theory, the release/relief theory, and the divinity theory. Laughter has many clinical benefits, promoting beneficial physiological changes and an overall sense of well-being. Humor even has long-term effects that strengthen the effectiveness of the immune system. In healthcare, humor therapy can help relieve stress associated with disease and illness. It serves as a diversionary tactic, a therapeutic tool for disorders such as depression, and a coping mechanism. It also is a natural healing component for care givers trying to cope with the stress and personal demands of their occupations.
Nurden, Alan T; Nurden, Paquita; Sanchez, Mikel; Andia, Isabel; Anitua, Eduardo
Platelets help prevent blood loss at sites of vascular injury. To do this, they adhere, aggregate and form a procoagulant surface favoring thrombin generation and fibrin formation. In addition, platelets express and release substances that promote tissue repair and influence processes such as angiogenesis, inflammation and the immune response. They contain large secretable pools of biologically active proteins, while newly synthesized active metabolites are also released. Although anucleate, activated platelets possess a spliceosome and can synthesize tissue factor and interleukin-1beta. The binding of secreted proteins within a developing fibrin mesh or to the extracellular matrix can create chemotactic gradients favoring the recruitment of stem cells, stimulating cell migration and differentiation, and promoting repair. The therapeutic use of platelets in a fibrin clot has a positive influence in clinical situations requiring rapid healing. Dental implant surgery, orthopaedic surgery, muscle and tendon repair, skin ulcers, hole repair in eye surgery and cardiac surgery are situations where the use of autologous platelets accelerates healing. We now review the ways in which platelets participate in these processes.
The Aboriginal people in Canada have been noted to have low self-esteem, subsequently increasing their risk of HIV. To this effect, two traditional healing practices are being used to help these people avoid HIV infection, and to live more healthily and positively if they are infected. The first method is the Medicine Wheel, which is a traditional model used to represent the complex interrelationship among all living things and show how their immune system is physically affected by their emotions and worries. Many Aboriginal AIDS Organizations, counselors and others are now using this AIDS teaching Wheel model. Meanwhile, the second method is the Sharing Circles, which provide an environment where people feel safe to talk about HIV and give participants a sense of support and a means for expression without stigma or judgement. As a result, many people who attend HIV circles begin to take better care of themselves and of others. Overall, it is emphasized that these traditional healing practices can be effectively adapted for use in HIV counseling and education.
... What Happens in the Operating Room? How Stitches Help Kids Heal KidsHealth > For Kids > How Stitches Help Kids Heal A A A What's in this ... the directions carefully with your mom's or dad's help. Different kinds of materials — sutures, glue, and butterflies — ...
Brochu, Alice B. W.; Craig, Stephen L.; Reichert, William M.
The goal of this review is to introduce the biomaterials community to the emerging field of self-healing materials, and also to suggest how one could utilize and modify self-healing approaches to develop new classes of biomaterials. A brief discussion of the in vivo mechanical loading and resultant failures experienced by biomedical implants is followed by presentation of the self-healing methods for combating mechanical failure. If conventional composite materials that retard failure may be considered zeroth generation self-healing materials, then taxonomically-speaking, first generation self-healing materials describe approaches that “halt” and “fill” damage, whereas second generation self-healing materials strive to “fully restore” the pre-failed material structure. In spite of limited commercial use to date, primarily because the technical details have not been suitably optimized, it is likely from a practical standpoint that first generation approaches will be the first to be employed commercially, whereas second generation approaches may take longer to implement. For self-healing biomaterials the optimization of technical considerations is further compounded by the additional constraints of toxicity and biocompatibility, necessitating inclusion of separate discussions of design criteria for self-healing biomaterials. PMID:21171168
Smith Anthos, Jeannette
This teacher believes that art has the power to heal, or at least aid in the healing process. After the terrorist attacks on 9/11, her students needed some way to express the injustice they felt. They discussed the attacks, and had some free drawing to release it from their system. They even did some patriotic-themed projects to boost their…
In this article, Robert Honour, Training and Staff Development Manager, at the Fairfax, Virginia, Department of Family Services (DFS), reports on the outcome of "Healing Racism" training at his organization. Participants in "Healing Racism Institutes" are transforming relationships and creating an organizational culture that…
You, Hi-Jin; Han, Seung-Kyu
In covering wounds, efforts should include utilization of the safest and least invasive methods with goals of achieving optimal functional and cosmetic outcome. The recent development of advanced wound healing technology has triggered the use of cells to improve wound healing conditions. The purpose of this review is to provide information on clinically available cell-based treatment options for healing of acute and chronic wounds. Compared with a variety of conventional methods, such as skin grafts and local flaps, the cell therapy technique is simple, less time-consuming, and reduces the surgical burden for patients in the repair of acute wounds. Cell therapy has also been developed for chronic wound healing. By transplanting cells with an excellent wound healing capacity profile to chronic wounds, in which wound healing cannot be achieved successfully, attempts are made to convert the wound bed into the environment where maximum wound healing can be achieved. Fibroblasts, keratinocytes, adipose-derived stromal vascular fraction cells, bone marrow stem cells, and platelets have been used for wound healing in clinical practice. Some formulations are commercially available. To establish the cell therapy as a standard treatment, however, further research is needed.
Beiermann, Brett A. (Inventor); Keller, Michael W. (Inventor); White, Scott R. (Inventor); Sottos, Nancy R. (Inventor)
A laminate material may include a first flexible layer, and a self-healing composite layer in contact with the first flexible layer. The composite layer includes an elastomer matrix, a plurality of first capsules including a polymerizer, and a corresponding activator for the polymerizer. The laminate material may self-heal when subjected to a puncture or a tear.
Given enough time, pressure, temperature fluctuation, and stress any material will fail. Currently, synthesized materials make up a large part of our everyday lives, and are used in a number of important applications such as; space travel, under water devices, precise instrumentation, transportation, and infrastructure. Structural failure of these material scan lead to expensive and dangerous consequences. In an attempt to prolong the life spans of specific materials and reduce efforts put into repairing them, biologically inspired, self-healing systems have been extensively investigated. The current review explores recent advances in three methods of synthesized self-healing: capsule based, vascular, and intrinsic. Ideally, self-healing materials require no human intervention to promote healing, are capable of surviving all the steps of polymer processing, and heal the same location repeatedly. Only the vascular method holds up to all of these idealities.
Hildebrand, K A; Frank, C B
Ligaments are highly organized, dense, fibrous connective-tissue structures that provide stability to joints and participate in joint proprioception. Injuries to ligaments induce a healing response that is characterized by the formation of a scar. The scar tissue is weaker, larger and creeps more than normal ligament and is associated with an increased amount of minor collagens (types III, V and VI), decreased collagen cross-links and an increased amount of glycosaminoglycans. Studies have shown that certain surgical variables alter the healing of ligaments. Such factors include the size of gap between the healing ligament, ends, the use of motion in a stable joint and the presence of multiple ligamentous injuries. Research on ligament healing includes studies on low-load and failure-load properties, alterations in the expression of matrix molecules, cytokine modulation of healing and gene therapy as a method to alter matrix protein and cytokine production.
Hinton, Devon E; Kirmayer, Laurence J
Theories of healing have attempted to identify general mechanisms that may work across different modalities. These include altering expectations, remoralization, and instilling hope. In this paper, we argue that many forms of healing and psychotherapy may work by inducing positive psychological states marked by flexibility or an enhanced ability to shift cognitive sets. Healing practices may induce these states of cognitive and emotional flexibility through specific symbolic interventions we term "flexibility primers" that can include images, metaphors, music, and other media. The flexibility hypothesis suggests that cognitive and emotional flexibility is represented, elicited, and enacted through multiple modalities in healing rituals. Identifying psychological processes and cultural forms that evoke and support cognitive and emotional flexibility provides a way to understand the cultural specificity and potential efficacy of particular healing practices and can guide the design of interventions that promote resilience and well-being.
Lemming, Dag; Börsbo, Björn; Sjörs, Anna; Lind, Eva-Britt; Arendt-Nielsen, Lars; Graven-Nielsen, Thomas; Gerdle, Björn
PURPOSE : The aim of this study was to evaluate pressure pain sensitivity on leg and arm in 98 healthy persons (50 women) using cuff algometry. Furthermore, associations with sex and physical activity level were investigated.
Struijk, J J
A model is presented for the calculation of single myelinated fiber action potentials in an unbounded homogeneous medium and in nerve cuff electrodes. The model consists of a fiber model, used to calculate the action currents at the nodes of Ranvier, and a cylindrically symmetrical volume conductor model in which the fiber's nodes are represented as point current sources. The extracellular action potentials were shown to remain unchanged if the fiber diameter and the volume conductor geometry are scaled by the same factor (principle of corresponding states), both in an unbounded homogeneous medium and in an inhomogeneous volume conductor. The influence of several cuff electrode parameters, among others, cuff length and cuff diameter, were studied, and the results were compared, where possible, with theoretical and experimental results as reported in the literature. Images FIGURE 2 PMID:9168022
Scherz, H C; Kaplan, G W; Boychuk, D I; Landa, H M; Haghighi, P
We studied urethral healing in New Zealand white rabbits by histological examination after insult (urethral catheter) or injury (urethrotomy) specifically for acute and chronic inflammation, fibrosis, fistulas, squamous metaplasia, foreign body giant cells and urethral dilatation. Urethral catheterization resulted in increased inflammation and fibrosis compared to noncatheterized animals. Skin closure techniques and materials resulted in an inflammatory response that may extend to and involve the urethra. Minor differences in suture size were not an important variable but the persistence of suture material may have a role in the degree of inflammation and the formation of foreign body giant cells. Transepithelial closure techniques drag epithelial cells into subcutaneous tissues and may predispose to fistula formation.
Dhall, Sandeep; Wijesinghe, Dayanjan Shanaka; Karim, Zubair A.; Castro, Anthony; Vemana, Hari Priya; Khasawneh, Fadi T.; Chalfant, Charles E.; Martins-Green, Manuela
Very little is known about lipid function during wound healing, and much less during impaired healing. Such understanding will help identify what roles lipid signaling plays in the development of impaired/chronic wounds. We took a lipidomics approach to study the alterations in lipid profile in the LIGHT−/− mouse model of impaired healing which has characteristics that resemble those of impaired/chronic wounds in humans, including high levels of oxidative stress, excess inflammation, increased extracellular matrix degradation and blood vessels with fibrin cuffs. The latter suggests excess coagulation and potentially increased platelet aggregation. We show here that in these impaired wounds there is an imbalance in the arachidonic acid (AA) derived eicosonoids that mediate or modulate inflammatory reactions and platelet aggregation. In the LIGHT−/− impaired wounds there is a significant increase in enzymatically derived breakdown products of AA. We found that early after injury there was a significant increase in the eicosanoids 11-, 12-, and 15-hydroxyeicosa-tetranoic acid, and the proinflammatory leukotrienes (LTD4 and LTE) and prostaglandins (PGE2 and PGF2α). Some of these eicosanoids also promote platelet aggregation. This led us to examine the levels of other eicosanoids known to be involved in the latter process. We found that thromboxane (TXA2/B2), and prostacyclins 6kPGF1α are elevated shortly after wounding and in some cases during healing. To determine whether they have an impact in platelet aggregation and hemostasis, we tested LIGHT−/− mouse wounds for these two parameters and found that, indeed, platelet aggregation and hemostasis are enhanced in these mice when compared with the control C57BL/6 mice. Understanding lipid signaling in impaired wounds can potentially lead to development of new therapeutics or in using existing nonsteroidal anti-inflammatory agents to help correct the course of healing. PMID:26135854
Background The abdominal insufflation and surgical positioning in the laparoscopic surgery have been reported to result in an increase of airway pressure. However, associated effects on changes of endotracheal tube cuff pressure are not well established. Methods 70 patients undergoing elective laparoscopic colorectal tumor resection (head-down position, n = 38) and laparoscopic cholecystecomy (head-up position, n = 32) were enrolled and were compared to 15 patients undergoing elective open abdominal surgery. Changes of cuff and airway pressures before and after abdominal insufflation in supine position and after head-down or head-up positioning were analysed and compared. Results There was no significant cuff and airway pressure changes during the first fifteen minutes in open abdominal surgery. After insufflation, the cuff pressure increased from 26 ± 3 to 32 ± 6 and 27 ± 3 to 33 ± 5 cmH2O in patients receiving laparoscopic cholecystecomy and laparoscopic colorectal tumor resection respectively (both p < 0.001). The head-down tilt further increased cuff pressure from 33 ± 5 to 35 ± 5 cmH2O (p < 0.001). There six patients undergoing colorectal tumor resection (18.8%) and eight patients undergoing cholecystecomy (21.1%) had a total increase of cuff pressure more than 10 cm H2O (18.8%). There was no significant correlation between increase of cuff pressure and either the patient's body mass index or the common range of intra-abdominal pressure (10-15 mmHg) used in laparoscopic surgery. Conclusions An increase of endotracheal tube cuff pressure may occur during laparoscopic surgery especially in the head-down position. PMID:25210501
Sheshadri, Veena; Tiwari, Akhilesh Kumar; Nagappa, Mahesh; Venkatraghavan, Lashmi
Context: Both invasive and noninvasive blood pressure (invasive arterial blood pressure [IABP] and noninvasive BP [NIBP]) monitors are used perioperatively; however, they often produce different values. The reason for this discrepancy is not clear, and it is possible that the act of cuff inflation itself might affect the IABP values, especially with the recurrent cycling of NIBP cuff. Aim: The aim of this study was to determine the effect of ipsilateral NIBP cuff inflation on the contralateral IABP values. Settings and Designs: Prospective, observational study. Materials and Methods: One hundred consecutive patients were studied. The NIBP device was set to cycle every 5 min for a total of 6 times. During each cuff inflation cycle, changes in IABP values from the arterial line in the contralateral arm were recorded. A total of 582 measurements were included for data analysis. Statistical Analysis: Chi-square, paired t-test, analysis of variance. Results: Mean (± standard deviation) changes in systolic BP (SBP), diastolic BP, and mean BP with cuff inflation were 6.7 ± 5.9, 2.6 ± 4.0, and 4.0 ± 3.9 mmHg, respectively. We observed an increase of 0–10 mmHg in SBP in majority (73.4%) of cuff inflations. The changes in IABP did not differ between the patients with or without hypertension or with the baseline SBP. Conclusions: This study showed that there is a transient reactive rise in IABP values with NIBP cuff inflation. This is important information in the perioperative and intensive care settings, where both these measurement techniques are routinely used. The exact mechanism for this effect is not known but may be attributed to the pain and discomfort from cuff inflation. PMID:28298779
This paper presents the main surgical techniques applied in the treatment of anterior recurrent shoulder dislocation, aiming the achievement of the normality of articulate movements. This was obtained by combining distinct surgical procedures, which allowed the recovery of a complete functional capacity of the shoulder, without jeopardizing the normality of movement, something that has not been recorded in the case of the tense sutures of the surgical procedures of Putti-Platt, Bankart, Latarjet, Dickson-O'Dell and others. The careful review of the methods applied supports the conclusion that recurrent shoulder dislocation can be cured, since cure has been obtained in 97% of the treated cases. However, some degree of limitation in the shoulder movement has been observed in most of the treated cases. Our main goal was to achieve a complete shoulder functional recovery, by treating simultaneously all of the anatomical-pathological lesions, without considering the so-called essential lesions. The period of post-operatory immobilization only last for the healing of soft parts; this takes place in a position of neutral shoulder rotation, since the use of vascular bone graft eliminates the need for long time immobilization, due to the shoulder stabilization provided by rigid fixation of the coracoid at the glenoid edge, as in the Latarjet's technique. Our procedure, used since 1959, comprises the association of several techniques, which has permitted shoulder healing without movement limitation. That was because of the tension reduction in the sutures of the subescapularis, capsule, and coracobraquialis muscles.
Lemieux, P O; Tétreault, P; Hagemeister, N; Nuño, N
This numerical study assesses the influence of an oversized humeral hemiprosthesis with a larger medial offset on the mechanics of the shoulder with cuff tear arthropathy (CTA). Shoulder elevation in the scapular plane is performed, and a Seebauer Type IIa CTA is simulated: a massive rotator cuff tear, a proximal and static migration of the humeral head, and two contacts with friction (glenohumeral and acromiohumeral). The CTA model without a prosthesis (friction coefficient 0.3) is evaluated first as a reference model. Then, three humeral head prosthetic geometries (friction coefficient 0.15) are evaluated: anatomical head, oversized head, and oversized head with a large medial offset. The function of the middle deltoid (i.e. moment arm, applied force, and strength), the contact forces, and the range of motion are studied. The anatomical head, which reduces friction by half, decreases the middle deltoid force (25%) and the contact forces (glenoid 7%; acromion 25%), and increases the range of motion from 41 to 54°. The oversized head increases the moment arm (15%) and the middle deltoid strength (13%), which further decreases the deltoid force (7%) and the contact forces (glenoid 7%; acromion 17%), and increases the range of motion from 54° to 69°. The oversized head with a large medial offset enhances these effects: the moment arm increases by another 3.1%, the deltoid force decreases by another 5% and the acromiohumeral contact force by another 12%, and the range of motion increases from 69° to 84°. These results suggest that increasing the medial offset and oversizing the hemiprosthetic head improve the function of the deltoid, reduce acromial solicitation, and restore elevation to almost 90°.
Ljubimov, Alexander V.; Saghizadeh, Mehrnoosh
Corneal wound healing is a complex process involving cell death, migration, proliferation, differentiation, and extracellular matrix remodeling. Many similarities are observed in the healing processes of corneal epithelial, stromal and endothelial cells, as well as cell-specific differences. Corneal epithelial healing largely depends on limbal stem cells and remodeling of the basement membrane. During stromal healing, keratocytes get transformed to motile and contractile myofibroblasts largely due to activation of transforming growth factor-β system. Endothelial cells heal mostly by migration and spreading, with cell proliferation playing a secondary role. In the last decade, many aspects of wound healing process in different parts of the cornea have been elucidated, and some new therapeutic approaches have emerged. The concept of limbal stem cells received rigorous experimental corroboration, with new markers uncovered and new treatment options including gene and microRNA therapy tested in experimental systems. Transplantation of limbal stem cell-enriched cultures for efficient re-epithelialization in stem cell deficiency and corneal injuries has become reality in clinical setting. Mediators and course of events during stromal healing have been detailed, and new treatment regimens including gene (decorin) and stem cell therapy for excessive healing have been designed. This is a very important advance given the popularity of various refractive surgeries entailing stromal wound healing. Successful surgical ways of replacing the diseased endothelium have been clinically tested, and new approaches to accelerate endothelial healing and suppress endothelial-mesenchymal transformation have been proposed including Rho kinase (ROCK) inhibitor eye drops and gene therapy to activate TGF-β inhibitor SMAD7. Promising new technologies with potential for corneal wound healing manipulation including microRNA, induced pluripotent stem cells to generate corneal epithelium, and
Butlin, Mark; Qasem, Ahmad; Avolio, Alberto P
There is increasing interest in non-invasive estimation of central aortic waveform parameters in the clinical setting. However, controversy has arisen around radial tonometric based systems due to the requirement of a trained operator or lack of ease of use, especially in the clinical environment. A recently developed device utilizes a novel algorithm for brachial cuff based assessment of aortic pressure values and waveform (SphygmoCor XCEL, AtCor Medical). The cuff was inflated to 10 mmHg below an individual's diastolic blood pressure and the brachial volume displacement waveform recorded. The aortic waveform was derived using proprietary digital signal processing and transfer function applied to the recorded waveform. The aortic waveform was also estimated using a validated technique (radial tonometry based assessment, SphygmoCor, AtCor Medical). Measurements were taken in triplicate with each device in 30 people (17 female) aged 22 to 79 years of age. An average for each device for each individual was calculated, and the results from the two devices were compared using regression and Bland-Altman analysis. A high correlation was found between the devices for measures of aortic systolic (R(2)=0.99) and diastolic (R(2)=0.98) pressure. Augmentation index and subendocardial viability ratio both had a between device R(2) value of 0.82. The difference between devices for measured aortic systolic pressure was 0.5±1.8 mmHg, and for augmentation index, 1.8±7.0%. The brachial cuff based approach, with an individualized sub-diastolic cuff pressure, provides an operator independent method of assessing not only systolic pressure, but also aortic waveform features, comparable to existing validated tonometric-based methods.
Huang, Alex S.; Balasubramanian, Siva; Tepelus, Tudor; Sadda, Jaya; Sadda, Srinivas; Stenger, Michael B.; Lee, Stuart M. C.; Laurie, Steve S.; Liu, John; Macias, Brandon R.
Changes in vision have been well documented among astronauts during and after long-duration space flight. One hypothesis is that the space flight induced headward fluid alters posterior ocular pressure and volume and may contribute to visual acuity decrements. Therefore, we evaluated venoconstrictive thigh cuffs as a potential countermeasure to the headward fluid shift-induced effects on intraocular pressure (IOP) and cephalic vascular pressure and volumes.
Brill, Natalie; Tyler, Dustin
A nerve cuff electrode is a viable technology for use in a neuroprostheses system to restore loss of function due to neurological injury. The Flat Interface Nerve Electrode (FINE) is a nerve cuff that gently reshapes the nerve to bring the axons closer to the stimulating contacts. The overall goal of this work is to optimize nerve cuff stimulation in upper extremity nerves. Recently, highly efficient and accurate linear models of neuronal activation have been developed in our lab. Using the fast calculations from the newly developed linear activation method, nerve stimulation parameters such as current pulse width and pulse amplitude at many electrode contacts can be explored by employing optimization algorithms. Finite element nerve models with high density electrodes were constructed based on upper extremity cadaveric nerve cross sections. An objective function was developed to target specific groups of nerve fascicles and minimize overlap amongst these groups. By changing the objective function and using a genetic search algorithm, stimulation parameters can be optimized for many contacts.
Van Tittelboom, K.; Adesanya, K.; Dubruel, P.; Van Puyvelde, P.; De Belie, N.
Different types of healing agents have already been tested on their efficiency for use in self-healing cementitious materials. Generally, commercial healing agents are used while their properties are adjusted for manual crack repair and not for autonomous crack healing. Consequently, the amount of regain in properties due to self-healing of cracks is limited. In this research, a methyl methacrylate (MMA)-based healing agent was developed specifically for use in self-healing cementitious materials. Various parameters were optimized including the viscosity, curing time, strength, etc. After the desired properties were obtained, the healing agent was encapsulated and screened for its self-healing efficiency. The decrease in water permeability due to autonomous crack healing using MMA as a healing agent was similar to the results obtained for manually healed cracks. First results seem promising: however, further research needs to be undertaken in order to obtain an optimal healing agent ready for use in practice.
Anderson, Caesar A.; Hare, Marc A.; Perdrizet, George A.
Significance: The demand for wound care therapies is increasing. New wound care products and devices are marketed at a dizzying rate. Practitioners must make informed decisions about the use of medical devices for wound healing therapy. This paper provides updated evidence and recommendations based on a review of recent publications. Recent Advances: The published literature on the use of medical devices for wound healing continues to support the use of hyperbaric oxygen therapy, negative pressure wound therapy, and most recently electrical stimulation. Critical Issue: To inform wound healing practitioners of the evidence for or against the use of medical devices for wound healing. This information will aid the practitioner in deciding which technology should be accepted or rejected for clinical use. Future Directions: To produce high quality, randomized controlled trials or acquire outcome-based registry databases to further test and improve the knowledge base as it relates to the use of medical devices in wound care. PMID:27076996
Hendrick, D A; Meyers, A
Compared with scalpel wounds, CO2 laser wounds show delays in inflammation, collagen production, reepithelialization, and tensile strength in the early stages of healing. Some of these delays are similar to those seen with electrocautery and burn wounds. Later stages compensate for these early deficiencies, because scalpel and laser wounds become more similar in epithelialization and wound strength over time. Healed CO2 laser wounds tend to have less scar contraction than scalpel wounds. Débridement of initial laser wound char, tissue cooling techniques during lasering, and pulsed modes of laser delivery all seem to result in more rapid, favorable healing. Similar wound healing trends have been seen with the CO2 laser in bone, with other lasers, and with laser vascular and neural anastomosis. Biostimulation with low-level laser energy is a complex subject of ongoing investigations.
Two milestones have revolutionised the management of wounds. First, the introduction of antibiotics, and second, the work carried out by Winter in 1962, introducing the concept that a warm moist environment encouraged healing.
Parrish, Clyde F. (Inventor)
A self-healing system for an insulation material initiates a self-repair process by rupturing a plurality of microcapsules disposed on the insulation material. When the plurality of microcapsules are ruptured, reactants within the plurality of microcapsules react to form a replacement polymer in a break of the insulation material. This self-healing system has the ability to repair multiple breaks in a length of insulation material without exhausting the repair properties of the material.
MacKay, Douglas; Miller, Alan L
Healing of wounds, whether from accidental injury or surgical intervention, involves the activity of an intricate network of blood cells, tissue types, cytokines, and growth factors. This results in increased cellular activity, which causes an intensified metabolic demand for nutrients. Nutritional deficiencies can impede wound healing, and several nutritional factors required for wound repair may improve healing time and wound outcome. Vitamin A is required for epithelial and bone formation, cellular differentiation, and immune function. Vitamin C is necessary for collagen formation, proper immune function, and as a tissue antioxidant. Vitamin E is the major lipid-soluble antioxidant in the skin; however, the effect of vitamin E on surgical wounds is inconclusive. Bromelain reduces edema, bruising, pain, and healing time following trauma and surgical procedures. Glucosamine appears to be the rate-limiting substrate for hyaluronic acid production in the wound. Adequate dietary protein is absolutely essential for proper wound healing, and tissue levels of the amino acids arginine and glutamine may influence wound repair and immune function. The botanical medicines Centella asiatica and Aloe vera have been used for decades, both topically and internally, to enhance wound repair, and scientific studies are now beginning to validate efficacy and explore mechanisms of action for these botanicals. To promote wound healing in the shortest time possible, with minimal pain, discomfort, and scarring to the patient, it is important to explore