Gregory Cunningham

Shoulder Apprehension Impacts Large-Scale Functional Brain Networks

BACKROUND AND PURPOSE: Shoulder apprehension is defined as anxiety and resistance in patients with a history of anterior glenohumeral instability. It remains unclear whether shoulder apprehension is the result of true recurrent instability or a memorized subjective sensation. We tested whether visual presentation of apprehension videos modifies functional brain networks associated with motor resistance and anxiety. MATERIALS AND METHODS: This prospective study includes 15 consecutive right-handed male patients with shoulder apprehension (9 with right shoulder apprehension, 6 with left shoulder apprehension; 27.5 ± 6.4 years) and 10 healthy male right-handed age-matched control participants (29.0 ± 4.7 years). Multimodal MR imaging included 1) functional connectivity tensorial independent component analysis, 2) task-related general linear model analysis during visual stimulation of movies showing typical apprehension movements vs control videos, 3) voxel-based morphometry analysis of GM, and 4) tract-based spatial statistics analysis of WM. RESULTS: Patients with shoulder apprehension had significant (P < .05 corrected) increase in task-correlated functional connectivity, notably in the bilateral primary sensory-motor area and dorsolateral prefrontal cortex and, to a lesser degree, the bilateral dorsomedial prefrontal cortex, anterior insula, and dorsal anterior cingulate cortex (+148% right, +144% left). Anticorrelated functional connectivity decreased in the higher-level visual and parietal areas (−185%). There were no potentially confounding structural changes in GM or WM. CONCLUSIONS: Shoulder apprehension induces specific reorganization in apprehension-related functional connectivity of the primary sensory-motor areas (motor resistance), dorsolateral prefrontal cortex (cognitive control of motor behavior), and the dorsal anterior cingulate cortex/dorsomedial prefrontal cortex and anterior insula (anxiety and emotional regulation).

Correlation Between American Shoulder and Elbow Surgeons and Single Assessment Numerical Evaluation Score After Rotator Cuff or SLAP Repair

PURPOSE To compare the American Shoulder and Elbow Surgeons (ASES) and the Single Assessment Numerical Evaluation (SANE) scores after rotator cuff repair, rotator cuff revision, and SLAP repair. METHODS This study was a retrospective review of a prospectively filled database of 262 patients who underwent arthroscopic surgery for rotator cuff tears or SLAP lesions between 1999 and 2007. All patients were operated on by the same surgeon, with a minimum follow-up of 2 years. The patient database included preoperative and outcome measures, such as pain, range of motion, and notably postoperative ASES and SANE scores. Any patient with incomplete data was removed from the study. RESULTS Three groups were identified: primary rotator cuff repair (n = 135), rotator cuff revision (n = 73), and SLAP repair (n = 54). The overall mean ASES and SANE scores after surgery were 82.7 (± 20.2) and 83.3 (± 19.6), respectively. The Pearson correlation coefficient (r) between both scores was 0.8 (P < .001), demonstrating a very good correlation. In subgroup analysis, the correlation was highest in the cuff revision group (r = 0.88; P < .001) followed by the SLAP group (r = 0.78; P < .001) and primary cuff group (r = 0.75; P < .001). CONCLUSIONS This study shows that there is a significant correlation between postoperative SANE and ASES rating methods in rotator cuff and SLAP repairs. We recommend the SANE score as a reliable outcome indicator for iterative follow-up, which can then be combined with a more clinically informative score such as the ASES or other process-based scores for preoperative and final workup. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Injury to the axillary nerve after reverse shoulder arthroplasty: An anatomical study

BACKGROUND Subclinical neurological lesions after reverse shoulder arthroplasty are frequent, mainly those involving the axillary nerve. One of the major reported risk factors is postoperative lengthening of the arm. The purpose of this study was to evaluate the anatomical relationship between the axillary nerve and prosthetic components after reverse shoulder arthroplasty. The study hypothesis was that inferior overhang of the glenosphere relative to glenoid could put this nerve at risk. MATERIAL AND METHODS Eleven fresh frozen shoulder specimens were dissected after having undergone reverse shoulder arthroplasty using a classic deltopectoral approach. RESULTS The mean distance from the inferior border of the glenoid to the inferior edge of the glenosphere was 6.0±4.3mm (range, 1.0 to 16.2mm). The axillary nerve was never closer than 15mm to the glenosphere. The main anterior branch of the axillary nerve was in close contact with the posterior metaphysis or humeral prosthetic implant. The mean distance between the nerve and the humeral implants was 5.2±2.1mm (range, 2.0 to 8.1mm). CONCLUSIONS The proximity of the axillary nerve to the posterior metaphysis or humeral implants may be a risk factor for axillary nerve injury after reverse shoulder arthroplasty. CLINICAL RELEVANCE This study quantifies the proximity of the axillary nerve to the implant after reverse shoulder arthroplasty. LEVEL OF EVIDENCE Basic science study, cadaver study.

Neural Correlates of Clinical Scores in Patients with Anterior Shoulder Apprehension

INTRODUCTION Anterior shoulder apprehension is a commonly reported complaint in anterior shoulder instability, which may lead to patient morbidity and impede shoulder function. It is the result of a cognitively complex mechanism, which includes anxiety, salience, fear, and anticipation. PURPOSE The aim of this prospective case-control study was to correlate five clinically established scores using functional magnetic resonance imaging to assess brain activation patterns in patients with apprehension related to anterior shoulder instability. METHODS This study includes 28 consecutive male right-handed patients (mean ± SEM, 26.8 ± 1.2 yr) with positive shoulder apprehension test and 10 healthy matched control participants without apprehension or a history of instability. Task-related and functional connectivity functional magnetic resonance imaging activation patterns occurring during apprehension video cue stimulation were correlated with five clinical tests and scores: Visual Analog Scale (VAS), Rowe score for instability, Simple Shoulder Test, Subjective Shoulder Value (SSV), and Western Ontario Shoulder Instability (WOSI). RESULTS Rowe, pain VAS, and WOSI scores correlated with prefrontal cortex, dorsolateral prefrontal cortex, dorsomedial prefrontal cortex, somatosensory area, and parieto-occipital and temporal areas (default mode network). Rowe score additionally correlated with frontal pole, anterior midcingulate cortex, and visual areas. Moreover, SSV correlated with task-related brain activity in the bilateral precentral gyrus, bilateral postcentral gyrus, and bilateral superior parietal lobe. CONCLUSIONS Overall, Rowe score provides the strongest link between shoulder apprehension and brain level alterations as it correlates with the highest number of independent components involving areas responsible for both motor and cognitive functions, whereas pain VAS and WOSI occupy an intermediately strong link recruiting less brain networks. Finally, Simple Shoulder Test and SSV have the weakest link at the brain level.

Does surgery for instability of the shoulder truly stabilize the glenohumeral joint?: A prospective comparative cohort study.

Abstract Despite the fact that surgery is commonly used to treat glenohumeral instability, there is no evidence that such treatment effectively corrects glenohumeral translation. The purpose of this prospective clinical study was to analyze the effect of surgical stabilization on glenohumeral translation. Glenohumeral translation was assessed in 11 patients preoperatively and 1 year postoperatively following surgical stabilization for anterior shoulder instability. Translation was measured using optical motion capture and computed tomography. Preoperatively, anterior translation of the affected shoulder was bigger in comparison to the normal contralateral side. Differences were significant for flexion and abduction movements (P < 0.001). Postoperatively, no patients demonstrated apprehension and all functional scores were improved. Despite absence of apprehension, postoperative anterior translation for the surgically stabilized shoulders was not significantly different from the preoperative values. While surgical treatment for anterior instability limits the chance of dislocation, it does not seem to restore glenohumeral translation during functional range of motion. Such persistent microinstability may explain residual pain, apprehension, inability to return to activity and even emergence of dislocation arthropathy that is seen in some patients. Further research is necessary to better understand the causes, effects, and treatment of residual microinstability following surgical stabilization of the shoulder.

Brain activity in the right-frontal pole and lateral occipital cortex predicts successful post-operatory outcome after surgery for anterior glenoumeral instability

Shoulder apprehension is more complex than a pure mechanical problem of the shoulder, creating a scar at the brain level that prevents the performance of specific movements. Surgery corrects for shoulder instability at the physical level, but a re-dislocation within the first year is rather common. Predicting which patient will be likely to have re-dislocation is therefore crucial. We hypothesized that the assessment of neural activity at baseline and follow-up is the key factor to predict the post-operatory outcome. 13 patients with shoulder apprehension (30.03 ± 7.64 years) underwent clinical and fMRI examination before and one year after surgery for shoulder dislocation contrasting apprehension cue videos and control videos. Data analyses included task-related general linear model (GLM) and correlations imaging results with clinical scores. Clinical examination showed decreased pain and increased shoulder functions for post-op vs. pre-op. Coherently, GLM results show decreased activation of the left pre-motor cortex for post-surgery vs. pre-surgery. Right-frontal pole and right-occipital cortex activity predicts good recovery of shoulder function measured by STT. Our findings demonstrate that beside physical changes, changes at the brain level also occur one year after surgery. In particular, decreased activity in pre-motor and orbito-frontal cortex is key factor for a successful post-operatory outcome.

Structural white matter and functional connectivity alterations in patients with shoulder apprehension

Previous functional magnetic resonance imaging (fMRI) findings indicate that shoulder apprehension is more complex than a pure mechanical problem of the shoulder, showing a direct modification in functional brain networks associated with motor inhibition and emotional regulation. The current study extends these findings by investigating further structural alterations in patients with shoulder apprehension compared to controls. 14 aged patients with shoulder apprehension (27.3 ± 2.0 years) and 10 matched healthy controls (29.6 ± 1.3 years) underwent clinical and fMRI examination including fMRI and diffusion tensor imaging (DTI). Tract-based spatial statistics procedure was used to analyze white matter (WM) alterations. Functional images were analyzed investigating resting state network connectivity. DTI results were correlated with different shoulder clinical scores and functional connectivity networks. Fractional anisotropy (FA), representing white matter integrity, is increased in the left internal capsule and partially in the thalamus in patients compared to controls. Moreover, FA correlates negatively with simple shoulder test (SST) scores (p < .05) and positively with a functional connectivity network qualitatively replicating previous results (p < .01). This study extends previous findings, showing that in addition to functional changes, structural white matter changes are also present in patients with shoulder apprehension.

Redefining anterior shoulder impingement: a literature review

Many different types of impingements have been described in the shoulder. Inasmuch as the term ‘shoulder impingement’ usually refers to subacromial impingement, anterior impingement usually refers to subcoracoid impingement. However, there are many different subtypes of anterior impingements in the shoulder, and awareness of their existence is critical as they vary in their nature and treatment. Recent advances in biomechanical research and arthroscopic exploration of the anterior structures of the shoulder have brought new insights on the various potential impingements, warranting a revision and update of the current definitions of anterior shoulder impingement. The purpose of this article is to propose a comprehensive review and classification of all different subtypes of anterior impingement in the shoulder, including newly described entities.

Latarjet-Patte Triple-locking Procedure for Recurrent Anterior Instability

Indication to perform an anterior glenoid augmentation by means of a coracoid bone graft in the setting of anterior instability in particular subsets of patients emerges as a new standard of care. Surgical techniques originally described by Latarjet and Helfet were modified by Patte in 1980. The coracoid graft is lying in supine position held in place by a single screw. Systematic capsular retensioning adds a capsular lock to the classical bone block and sling effect of the Latarjet technique. We hypothesized that systematic capsular retensioning could reduce the recurrence rate of instability after surgical stabilization compared with other described techniques. A questionnaire as well as a radiologic workout was obtained from a consecutive series of patients who had undergone this procedure by the same operator between 1986 and 2006. Outcome was determined by the number of redislocations, number of reoperations, the Walch-Duplay score including pain score, and the index of satisfaction. A total of 148 patients responded (42 women and 106 men) with a mean age 28.4±8.7 years (range, 16 to 57 y). The mean follow-up was 14.6 years (range, 2.8 to 22.6 y). Thirty-two patients had hyperlaxity (21%). Three patients (2%) sustained a redislocation or resubluxation. However, none required further operation. Results of the Walch-Duplay score were excellent or good. Fifty-three percent of the patients were pain free, 34% presented occasional pain, 9% moderate pain, and 4% suffered from severe pain. Seventy-nine percent of patients were very satisfied, 18% were satisfied, and 3% were dissatisfied. Mid-term to long-term results of the modification of the Latarjet procedure according to Patte correlate with previous studies with respect to patient satisfaction and functional outcome. The recurrence rate is lower than in previously reported series and may reflect the beneficial effect of systemic capsular retensioning on a flap of coracoacromial ligament. Evidence level IV: Single-surgeon therapeutic case series.

Large paralabral cyst in the axilla.

Joint Bone Spine - In Press.Proof corrected by the author Available online since jeudi 26 juillet 2012