Akiyoshi Handa

Vascular endothelial growth factor (VEGF) expression in the subacromial bursa is increased in patients with impingement syndrome

Vascular endothelial growth factor (VEGF), which is known to be an angiogenetic factor, plays an important role in the inflammation of synovial tissue. To investigate the relationships between VEGF and clinical symptoms in rotator cuff disease, VEGF expression was examined using RT‐‐PCR and immunohistochemical analysis in 50 patients with this disease (26 with full‐thickness cuff tear, 12 with partial‐thickness tear, and 12 with subacromial bursitis). VEGF mRNA expression was detected in 40 out of 50 patients by RT—PCR. VEGF mRNA expression was found more frequently in the patients with motion pain (39 out of 41) than in those without motion pain (1 out of 9) with statistical significance (Fishers test, P < 0.001). Thirty‐one out of 33 patients with synovial proliferation showed VEGF mRNA expression, whereas the expression of this transcript was found in 9 out of 17 patients without synovial proliferation. This association with synovial proliferation was also significant (Fishers test, P = 0.0013). Thirty out of 41 patients with motion pain had synovial proliferation but 3 out of 9 patients without motion pain had synovial proliferation. In all these 30 patients with both motion pain and synovial proliferation, VEGF mRNA expression was detected. This association between motion pain and synovial proliferation was also significant (Fishers test, P < 0.05). The mean vessel count and area in subacromial bursa expressing VEGF was significantly higher than in those without VEGF (Mann‐Whitneys U test, P < 0.01). These results suggested that VEGF expression is associated with vascularity, synovial proliferation and shoulder motion pain in the rotator cuff disease.

Vascular endothelial growth factor 121 and 165 in the subacromial bursa are involved in shoulder joint contracture in type II diabetics with rotator cuff disease

Vascular endothelial growth factor (VEGF) is a glycoprotein that plays an important role in neovascularization and increases vascular permeability. We reported that VEGF is involved in motion pain of patients with rotator cuff disease by causing synovial proliferation in the subacromial bursa (SAB). The present study investigates whether VEGF is also involved in the development of shoulder contracture in diabetics with rotator cuff disease. We examined 67 patients with rotator cuff disease, including 36 with complete cuff tears, 20 with incomplete tears, and 11 without apparent tears (subacromial bursitis). The patients were into groups according to the presence or absence of diabetes (14 type II diabetics and 53 non‐diabetics). Specimens of the synovium of the SAB were obtained from all patients during surgery. Expression of the VEGF gene in the synovium of the subacromial bursa was evaluated by using the reverse transcriptase polymerase chain reaction. The VEGF protein was localized by immunohistochemistry, and the number of vessels was evaluated based on CD34 immunoreactivity. The results showed that VEGF mRNA was expressed in significantly more diabetics (100%, 14/14) than in non‐diabetics (70%, 37/53) (P = 0.0159, Fishers test). Investigation of VEGF isoform expression revealed VEGF121 in all 14 diabetics and in 37 of the 53 non‐diabetics, VEGF 165 in 12 of the 14 diabetics and in 21 of the 53 non‐diabetics, and VEGF 189 in 1 of the 14 diabetics and in 2 of the 53 non‐diabetics. No VEGF206 was expressed in either group. VEGF protein was localized in both vascular endothelial cells and synovial lining cells. The mean number of VEGF‐positive vessels and the vessel area were also significantly greater in the diabetics (p < 0.015, Mann‐Whitney U test). Synovial proliferation and shoulder joint contracture were more common in the diabetics (P = 0.0329 and P = 0.073, respectively; Fishers test). The mean preoperative range of shoulder motion significantly differed in terms of elevation between two groups: 103.8° in diabetics and 124.9° in no diabetics (p = 0.0039 Mann–Whitney U test). In contrast, external rotation did not significantly differ: 44° in diabetics and 49° in non‐diabetics (p ° 0.4957, Mann–Whitney U test). These results suggest that VEGF121 and VEGF165 expression in the SAB is responsible for the development of shoulder joint contracture, especially in elevation, among type II diabetic patients with rotator cuff disease.

Surgical treatment of confirmed intratendinous rotator cuff tears: Retrospective analysis after an average of eight years of follow-up

HYPOTHESIS This study evaluated clinical features, diagnostic techniques, and summarized the results of open repair in a series of surgically confirmed cases of intratendinous rotator cuff tears. MATERIALS AND METHODS Between 1986 and 1999, 19 patients (17 men and 2 women) with intratendinous rotator cuff tears underwent surgery. Clinical findings, diagnostic results, and surgical findings were evaluated. The shoulder scores of the Japanese Orthopaedic Association (JOA) and the American Shoulder and Elbow Surgeons (ASES) were used to assess recovery at an average of 92 months (range, 31-231 months). RESULTS All patients had symptoms consistent with rotator cuff tendonitis. History of overt trauma was noted in 16 (84.2%). Neither ultrasound nor magnetic resonance imaging proved reliable for preoperative diagnosis. Surgery was performed if at least 6 months of conservative treatment, such as rest, heat, and physical therapies, failed. The definitive diagnosis was established intraoperatively with a longitudinal split along the fibers of the supraspinatus tendon. None of the intratendinous lesions had communication to the subacromial bursa or the glenohumeral joint. Excision of the intratendinous tear and repair resulted in improvement in pain and total scores of both JOA (66.8 vs 94.1) and ASES (37.1 vs 91.0). CONCLUSIONS Intratendinous rotator cuff tears were difficult to diagnose preoperatively. Our data suggest that conservative treatment failed, anterior acromioplasty and excision of the diseased portion of the tendon, followed by tenorrhaphy, proved effective. Satisfactory outcomes were achieved in 18 patients (94.7%) in this series.

Clinical results of a surgical technique using endobuttons for complete tendon tear of pectoralis major muscle: report of five cases

BackgroundWe herein describe a surgical technique for the repair of complete tear of the pectoralis major (PM) tendon using endobuttons to strengthen initial fixation.MethodsFive male patients (3 judo players, 1 martial arts player, and 1 body builder) were treated within 2 weeks of sustaining complete tear of the PM tendon. Average age at surgery and follow-up period were 28.4 years (range, 23-33) and 28.8 months (range, 24-36). A rectangular bone trough (about 1 × 4 cm) was created on the humerus at the insertion of the distal PM tendon. The tendon stump was introduced into this trough, and fixed to the reverse side of the humeral cortex using endobuttons and non-absorbable suture. Clinical assessment of re-tear was examined by MRI. Shoulder range of motion (ROM), outcome of treatment, and isometric power were measured at final follow-up.ResultsThere were no clinical re-tears, and MRI findings also showed continuity of the PM tendon in all cases at final follow-up. Average ROM did not differ significantly between the affected and unaffected shoulders. The clinical outcomes at final follow-up were excellent (4/5 cases) or good (1/5). In addition, postoperative isometric power in horizontal flexion of the affected shoulder showed complete recovery when compared with the unaffected side.ConclusionsSatisfactory outcomes could be obtained when surgery using the endobutton technique was performed within 2 weeks after complete tear of the PM tendon. Therefore, our new technique appears promising as a useful method to treat complete tear of the PM tendon.

Neer Modified Inferior Capsular Shift Procedure for Recurrent Anterior Instability of the Shoulder in Judokas

Background Little has been written about the operative repair of recurrent anterior instability of the shoulder in a single sport: in this case, Judo. Purpose The clinical efficacy of the Neer modified inferior capsular shift as an open procedure for injured judokas was investigated. Study Design Case series; Level of evidence, 4. Methods Fifty athletes (42 male and 8 female, 52 shoulders) took part in this study. The average age at surgery was 20 years (range, 14-38 years), and the mean follow-up period was 61 months (range, 24-172 months). The operation was performed on 29 tsurité (a lapel grip) shoulders and on 23 hikité (a sleeve grip) shoulders. The 2 grips are functionally and technically different from each other. Results Three cases of shoulder instability (5.8%) recurred after surgery. The average loss of external rotation was 9.6° with the arm at the side and 11.6° with the arm in 90° of abduction. The average Rowe and UCLA scores were 37.3 and 20.8 points preoperatively and 86.7 and 32.4 points at the final follow-up, respectively (P < .05). The return rate to the near-preinjury sports activity levels (>90% recovery: grades 1 and 2) was significantly lower in the tsurité shoulders (48.1%) than in the hikité shoulders (85.7%). Conclusion The overall recovery of more than 90% of preinjury activity levels in judo was 65% after modified inferior capsular shift for traumatic anterior instability of the shoulder. The tsurité shoulder should be treated with minimal restriction limitation in external rotation so that it is not limited postoperatively.

Healing of full-thickness tears of avian supracoracoid tendons: in situ hybridization of α1(I) and α1(III) procollagen mRNA

Although clinically significant, much remains unknown about the healing of the torn rotator cuff tendon, because of unavailability of appropriate animal model. The human supraspinatus tendon faces the subacromial bursa superiorly, and the joint capsule inferiorly, while the digital flexor tendon is surrounded by the synovium. We hypothesized that the supraspinatus tendon heals by the process which is different from that observed with digital flexor tendons, in which epitenon cells migrate into the torn portion circumferentially. The avian supracoracoid tendon was adopted for this experiment because of its similarity to the human supraspinatus tendon. We developed a full‐thickness tendon laceration followed by primary suture. The objective of this study was to detect localization of the responsible cells for repair of the tendon. We examined the process using histology and in situ hybridization. Starting at week 1, the peritendon cells of the bursal side proliferated and migrated into the laceration site. At week 6, the tendon stumps were continuous with new connective tissue. High‐level expression of procollagen mRNA in the proliferating peritendon cells on the bursal side demonstrates to contribute to the reparative process, which progressed to the joint side. This mode of repair is different from that of the digital flexor tendon.

Comparison of three plain radiography methods for evaluating proximal humerus bone strength in women

BACKGROUND We assessed the correlation between three methods for measuring cortical thickness of the humerus on a plain radiograph and bone mineral density measured by dual-energy X-ray absorptiometry in order to establish a simple bone strength evaluation method in patients at risk of proximal humerus fragility fracture. METHODS In this retrospective study, 1732 patients underwent screening of the distal third radius, proximal femur, and lumbar spine by dual-energy X-ray absorptiometry. We identified 224 patients who also underwent anteroposterior shoulder radiography. Patients with fractures or who had undergone surgery in the region of interest were excluded. The study consisted of 80 women with a mean age of 76 years (range: 39-94 years). Cortical thickness, cortical index, and deltoid tuberosity index were determined to assess the proximal humerus. Correlation between bone mineral density measured by dual-energy X-ray absorptiometry and cortical thickness determined using these three methods was examined. We defined the osteoporosis group as patients satisfying both the World Health Organization criteria and the diagnostic criteria for primary osteoporosis (2012 revision) and compared values between the osteoporotic and non-osteoporotic groups. RESULTS BMD correlated positively with cortical thickness, cortical index, and deltoid tuberosity index values, but the strength of correlation differed. These values were significantly lower in the osteoporotic group than in the non-osteoporotic group. Receiver operating characteristic curve analysis revealed that only the distal third radius had an area under the curve of 0.7 or more for all methods. CONCLUSIONS All three methods yielded values that correlated with the dual-energy X-ray absorptiometry bone mineral density measured at the distal third radius, the proximal femur, and the lumbar spine. The correlation coefficient in the radius was high and differed significantly from those of weight-bearing bones (proximal femur, lumbar spine).

Open Bankart repair plus inferior capsular shift versus arthroscopic Bankart repair without augmentations for traumatic anterior shoulder instability: A prospective study:

Purpose: Arthroscopic treatment of shoulder instability has some advantages (including short surgical time, less morbidity, less postoperative pain, reduced hospitalization time, and decreased risk of complications) compared with open procedures. We performed a prospective study comparing open repair with arthroscopic repair for recurrent anterior shoulder instability. The aim was to clarify the relative effectiveness of open Bankart repair plus inferior capsular shift (OBRICS) and arthroscopic Bankart (AB) repair without augmentations with approximately 5 years of follow-up. Methods: We investigated 32 shoulders of 30 patients (24 men and 6 women) undergoing OBRICS (15 shoulders of 17 patients; two patients were bilateral) and AB (15 shoulders of 15 patients). The average follow-up was 5 years and 2.5 months (range: 60–66 months). The clinical evaluation included recurrent instability rate, range of motion, and postoperative rehabilitation. All patients were assessed using the scoring systems of Rowe and the University of California at Los Angeles (UCLA) preoperatively and during the final evaluation. Results: Recurrent instability rates were significantly different between the OBRICS (0%) and AB (26.6%) groups (p = 0.022). There were fewer limitations of external rotation (ER), ER at 90° abduction, and horizontal extension for AB than for OBRICS postoperatively (p < 0.05). The mean Rowe and UCLA scores for both methods were not significantly different at final follow-up. Conclusion: Our data suggest that OBRICS leads to a lower rate of recurrent instability. However, those with AB had fewer ER and horizontal extension limitations.