Gary M. Gartsman

Arthroscopic repair of full-thickness tears of the rotator cuff.

We present the results of arthroscopic repair of full-thickness tears of the rotator cuff in seventy-three patients (thirty-nine men and thirty-four women). The average age of the patients at the time of the operation was 60.7 years (range, thirty-one to eighty-two years). All of the patients were followed for at least two years (average, thirty months; range, twenty-four to forty months). The shoulders were evaluated with the rating scale of the University of California at Los Angeles, the shoulder index of the American Shoulder and Elbow Surgeons, and the functional rating scale of Constant and Murley. In addition, the patients completed the Short-Form 36 Health Survey (SF-36) preoperatively and at the yearly follow-up evaluations. Eleven tears were small (less than one centimeter in length), forty-five were medium (one to three centimeters), eleven were large (more than three to five centimeters), and six were massive (more than five centimeters). The average length of the tear was twelve millimeters, and the average width was twenty-seven millimeters. Sixty-nine tendons were repaired anatomically, and four were repaired an average of three millimeters (range, two to eight millimeters) medial to the anatomical insertion of the tendon. An average of 2.3 (range, one to four) suture anchors were used in the repair. Sixty-three glenohumeral joints were normal, and ten had an intra-articular lesion. Seven patients had a concomitant resection of the acromioclavicular joint. The average duration of the operation was fifty-six minutes (range, thirty-five to ninety minutes). The active and passive ranges of motion improved significantly after the procedure (p = 0.0001). The strength of resisted elevation improved from 7.5 to 14.0 pounds (3.4 to 6.3 kilograms) (p = 0.0001). The average total score according to the rating scale of the University of California at Los Angeles improved from 12.4 to 31.1 points; the average total score according to the shoulder index of the American Shoulder and Elbow Surgeons, from 30.7 to 87.6 points; and the average absolute score according to the rating system of Constant and Murley, from 41.7 to 83.6 points (p = 0.0001 for all comparisons). The average score for the pain component of the rating scale of the University of California at Los Angeles improved from 2.4 to 8.6 points; fifty-seven (78 per cent) of the seventy-three patients rated the relief of pain as good or excellent on the visual-analog scale. The average score for satisfaction improved from 0.4 to 4.6 points; sixty-six patients (90 per cent) rated their satisfaction as good or excellent at the time of the most recent examination. None of the shoulders were rated as good or excellent before the operation, whereas sixty-one (84 per cent) were so rated at the most recent follow-up evaluation after the index procedure. In addition, significant improvements (p = 0.0015) were noted in the scales and summary measures of the SF-36. Arthroscopic repair of full-thickness tears of the rotator cuff produced satisfactory results with regard to traditional orthopaedic criteria as well as with regard to patient-assessed criteria such as satisfaction, pain relief, and general health. The arthroscopic method offers several advantages, including smaller incisions, access to the glenohumeral joint for the inspection and treatment of intra-articular lesions, no need for detachment of the deltoid, and less soft-tissue dissection. However, these advantages must be considered against the technical difficulty of the method, which limits its application to surgeons who are skilled in both open and arthroscopic procedures on the shoulder.

Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up.

Background: Previous studies on arthroscopic treatment of anterior-inferior glenohumeral instability have focused on the repair of lesions of the anterior-inferior aspect of the labrum (Bankart lesions) and have demonstrated failure rates of as high as 50 percent. The current investigation supports the concept that anterior-inferior instability is associated with multiple lesions and that success rates can be increased by treating all of the lesions at the time of the operation. We present the results of arthroscopic treatment of anterior-inferior glenohumeral instability after a minimum duration of follow-up of two years. Methods: The study group consisted of fifty-three patients who had a mean age of thirty-two years (range, fifteen to fifty-eight years) at the time of the operation. There were forty-four male and nine female patients. The mean interval from the time of the operation to the final follow-up evaluation was thirty-three months (range, twenty-six to sixty-three months). The scores on the American Shoulder and Elbow Surgeons (ASES) Shoulder Index and the rating systems of Constant and Murley, Rowe et al., and the University of California at Los Angeles (UCLA) were recorded preoperatively and at the time of the final follow-up. Results: Preoperatively, none of the patients had an overall rating of good or excellent according to the system of Rowe et al.; however, 92 percent (forty-nine) of the fifty-three patients had a rating of good or excellent at the time of the final follow-up. The mean score improved from 45.5 points to 91.7 points on the ASES Shoulder Index, from 56.4 points to 91.8 points with the system of Constant and Murley, from 11.3 points to 91.9 points with the system of Rowe et al., and from 17.6 points to 32.0 points according to the UCLA Shoulder Score (p = 0.001 for all comparisons). The mean passive external rotation with the shoulder in 90 degrees of abduction measured 88.2 degrees. Thirty-four of thirty-eight patients returned to their desired level of sports activity following the operation. Four patients who had persistent instability were considered to have had a failure of the index operation, and one of them had a second operative procedure. Conclusions: The results of the present study suggest that our technique of arthroscopic treatment of anterior-inferior glenohumeral instability is better than previous arthroscopic techniques and is equivalent to open repair. We believe that the improved rate of success demonstrated in the present study was the result of repair not only of the anterior-inferior (Bankart) lesion but also (where necessary) of inferior and superior labral tears. Additionally, soft-tissue tension within the capsule and ligaments was corrected with use of a suture technique but was supplemented by laser thermal capsulorrhaphy in forty-eight of the fifty-three shoulders. Rotator interval repair was considered a critical factor in fourteen of the fifty-three shoulders.

Shoulder Arthroplasty with or without Resurfacing of the Glenoid in Patients Who Have Osteoarthritis

Background: The indications for resurfacing of the glenoid in patients who have osteoarthritis of the shoulder are not clearly defined; some investigators routinely perform hemiarthroplasty whereas others perform total shoulder arthroplasty. Methods: Forty-seven patients (fifty-one shoulders) who were scheduled to have a shoulder arthroplasty for the treatment of degenerative osteoarthritis were randomly assigned, according to a random-numbers table, to one of two groups: replacement of the humeral head with resurfacing of the glenoid with a polyethylene component with cement (total shoulder arthroplasty [twenty-seven shoulders]) or replacement of the humeral head without resurfacing of the glenoid (hemiarthroplasty [twenty-four shoulders]). All patients received the same type of humeral component, and all operations were performed by or under the direct supervision of the same surgeon. The patients were followed for a mean of thirty-five months (range, twenty-four to seventy-two months) postoperatively. Evaluation was performed with use of the scoring systems of the University of California at Los Angeles and the American Shoulder and Elbow Surgeons. Results: No difference was observed between the preoperative scores for the two groups of patients. Postoperatively, the mean scores with use of the University of California at Los Angeles system and the American Shoulder and Elbow Surgeons system were 23.2 points (range, 10 to 31 points) and 65.2 points (range, 15 to 94 points), respectively, after hemiarthroplasty and 27.4 points (range, 9 to 34 points) and 77.3 points (range, 3 to 100 points), respectively, after total shoulder arthroplasty. With the numbers available for study, no significant difference was found between the two operative groups with respect to the postoperative score. (Thirty-five subjects per group would be needed, assuming an effect size of 0.60 and a power of 0.80.) Total shoulder arthroplasty provided significantly greater pain relief (p = 0.002) and internal rotation (p = 0.003) than hemiarthroplasty did. Total shoulder arthroplasty also provided superior results in the specific areas of patient satisfaction, function, and strength, although none of these differences were found to be significant, with the numbers available. Total shoulder arthroplasty was associated with increased cost (

A Comparison Of Pain, Strength, Range Of Motion, And Functional Outcomes After Hemiarthroplasty And Total Shoulder Arthroplasty In Patients With Osteoarthritis Of The Shoulder: A Systematic Review And Meta-analysis

1177), operative time (thirty-five minutes), and blood loss (150 milliliters) per patient compared with hemiarthroplasty. To date, none of the total shoulder arthroplasties in the study group have been revised. Hemiarthroplasty yielded equivalent results for elevation and external rotation. Three of the twenty-five patients who had had a hemiarthroplasty needed a subsequent operation for resurfacing of the glenoid. The mean cost for the revision operations was

Massive, irreparable tears of the rotator cuff : Results of operative débridement and subacromial decompression

15,998. Conclusions: Total shoulder arthroplasty provided superior pain relief compared with hemiarthroplasty in patients who had glenohumeral osteoarthritis, but it was associated with an increased cost of

Self-assessment of general health status in patients with five common shoulder conditions****

1177 per patient.

Articular surface partial-thickness rotator cuff tears

BACKGROUNDnA systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder.nnnMETHODSnWe conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion.nnnRESULTSnA total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 +/- 0.3) compared with hemiarthroplasty (mean, 6.6 +/- 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I(2) = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13 degrees (95% confidence interval, 0.5 degrees to 26 degrees ) in favor of the total shoulder arthroplasty group (p = 0.008).nnnCONCLUSIONSnAt a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time.

Early Effectiveness of Arthroscopic Repair for Full-Thickness Tears of the Rotator Cuff. An Outcome Analysis*

Thirty-three consecutive patients in whom an irreparable tear of the rotator cuff had been treated with operative débridement and subacromial decompression were evaluated both preoperatively and postoperatively with regard to pain, ability to perform activities of daily living, range of motion, strength, and satisfaction. The assessments were performed with the Shoulder Score Index of the American Shoulder and Elbow Surgeons and the scoring systems of the University of California at Los Angeles and Constant and Murley. At the time of follow-up, twenty-six patients thought that the condition of the shoulder was improved; three, that it was unchanged; and four, that it was worse after the operation. There was a significant decrease in pain (p = 0.001) and significant increases in the range of motion (p = 0.038) and the ability to perform activities of daily living (p = 0.016). However, these improvements were inferior to those in reported series in which torn rotator cuffs had been repaired. Strength with elevation was decreased after the operations in the present series (p = 0.0007).

Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty

The SF-36 Health Survey is a patient self-administered general health status evaluation designed to measure the impact of disease on an individuals perception of his or her health. Five hundred forty-four patients with five common shoulder conditions (anterior glenohumeral instability (149 patients), complete reparable rotator cuff tear (111 patients), adhesive capsulitis (100 patients), glenohumeral osteoarthritis (67 patients), and impingement (117 patients)) completed the SF-36 Health Survey before undergoing treatment. When compared with U.S. general population norms, the patients with each of these shoulder conditions had statistically significant decreases in their health for Physical Functioning, Role-Physical, Bodily Pain, Social Functioning, Role-Emotional, and the Physical Component Summary as measured by the SF-36 Health Survey. Comparison with published data demonstrated that these shoulder conditions rank in severity (in terms of affecting a patients perception of his or her general health) with five major medical conditions (hypertension, congestive heart failure, acute myocardial infarction, diabetes mellitus, and clinical depression). The data presented in this study should serve as a baseline to document the impact of shoulder musculoskeletal conditions and possibly to allow comparison among various methods of operative and nonoperative treatment.

The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears.

Between 1987 and 1992, one hundred eleven articular surface partial-thickness rotator cuff tears were diagnosed in 106 patients; 90 were men, and 16 were women. The average age was 42.5 years. Average follow-up was 32.3 months, ranging from 26 to 84 months. Patients were separated into three groups. Group 1 consisted of 85 shoulders in which impingement was believed to be the primary cause; these shoulders were treated with debridement of the tear and arthroscopic subacromial decompression. Group 2 consisted of 14 shoulders with instability treated with debridement of the partial tear and anterior reconstruction (n = 10) or debridement and rehabilitation (n = 4). Group 3 contained 12 shoulders with tearing caused by trauma that were managed with debridement and open repair, if necessary. In 98 of 111 cases (88%), the patients had a satisfactory result. Five patients required open rotator cuff repair at a later date because of continued symptoms. Complications included significant postoperative stiffness in four shoulders, which required open release.