Janne T. Lehtinen

Anchor Design and Bone Mineral Density Affect the Pull-out Strength of Suture Anchors in Rotator Cuff Repair Which Anchors Are Best to Use in Patients With Low Bone Quality?

Background Different metal and biodegradable suture anchors are available for rotator cuff repair. Poor bone quality may result in anchor loosening and tendon rerupture. Hypotheses Higher bone mineral density is associated with higher pull-out strength of suture anchors. Depending on anchor placement, pull-out strengths of anchors are different within the greater tuberosity. Study Design Cadaveric biomechanical study. Methods Trabecular and cortical bone mineral densities were determined for different regions within the greater tuberosity. Metal screw-type and biodegradable hook-type anchors were cyclically loaded. Results Mean failure load of metal and biodegradable anchors was 273 N and 162 N, respectively, for the proximal part (P < .01) and 184 N and 112 N, respectively, for the distal part (P < .01). Both types of anchors showed higher failure loads in the proximal-anterior and -middle parts of the greater tuberosity than in the distal part (P < .01). A significant positive correlation was found between cortical bone mineral density and failure load of metal anchors (P < .01). Conclusion Bone quality, anchor type, and anchor placement have a significant impact on anchor failure loads. Clinical Relevance Suture anchors should be placed in the proximal-anterior and -middle parts of the greater tuberosity. In the distal parts, biodegradable hook-like anchors should be used with caution.

Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome?: A TWO-YEAR RANDOMISED CONTROLLED TRIAL

We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.

Magnetic resonance imaging in quantitative analysis of rotator cuff muscle volume.

Tears of the rotator cuff are accompanied by muscle atrophy, which has direct implications on patient outcome after rotator cuff surgery. However, no reliable method exists to determine muscle volumes in situ. The current authors evaluated the reliability of magnetic resonance imaging in assessing rotator cuff muscle volumes. Muscle volumes were determined in 10 shoulders from cadavers using two methods: (1) oblique sagittal shoulder scans were obtained, the contours of the supraspinatus, infraspinatus and teres minor, and subscapularis muscles were traced, and muscle volumes were calculated using image analysis software; and (2) rotator cuff muscles were dissected and muscle volumes were measured by water displacement. The average magnetic resonance imaging volume of the supraspinatus, infraspinatus and teres minor, and subscapularis muscles were 36 ± 12, 96 ± 41, and 99 ± 33 mL, respectively. There was a significant correlation between magnetic resonance imaging and water displacement measurements. The intraobserver and interobserver variabilities were less than 4%. The results indicate the magnetic resonance imaging is a reliable method to determine rotator cuff muscle volumes with good intraobserver and interobserver variability. This method may prove valuable preoperative assessment of rotator cuff muscles and prediction of outcome after rotator cuff repair.

Treatment of non-traumatic rotator cuff tears A randomised controlled trial with one-year clinical results

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.

The painful scapulothoracic articulation: Surgical management

To clarify the indications and effectiveness of surgical decompression for scapulothoracic bursitis, 16 patients were evaluated, who during a 5-year period, had surgical treatment of refractory pain and snapping in the scapulothoracic region. Twelve women and four men with a mean age of 41 years had one of five methods of surgical decompression of the scapulothoracic articulation. Six patients had an open resection of the scapulothoracic bursa with excision of the superomedial portion of the scapula, two had this procedure using an arthroscopic method, and six had a combined approach with arthroscopic scapulothoracic bursectomy and open resection of the superomedial scapula through a small incision. One patient had an arthroscopic and one an open scapulothoracic bursectomy only. At final followup of an average of 36 months (range, 24–69 months), 81% of patients reported satisfaction with the procedure and indicated they would have it again based on the relief they obtained from pain. The Simple Shoulder Test was 9.8 (range, 2–12). Although there was no statistical difference in the success using any given technique, we thought that the combined open and arthroscopic approach was the most effective, and surgical treatment is an acceptable method for treatment of refractory painful scapulothoracic bursitis.

Treatment of Nontraumatic Rotator Cuff Tears: A Randomized Controlled Trial with Two Years of Clinical and Imaging Follow-up.

BACKGROUND The optimal treatment for symptomatic, nontraumatic rotator cuff tear is unknown. The purpose of this trial was to compare the effectiveness of physiotherapy, acromioplasty, and rotator cuff repair for this condition. We hypothesized that rotator cuff repair yields superior results compared with other treatment modalities. METHODS One hundred and eighty shoulders with symptomatic, nontraumatic, supraspinatus tears were randomized into one of three cumulatively designed intervention groups: the physiotherapy-only group (denoted as Group 1), the acromioplasty and physiotherapy group (denoted as Group 2), and the rotator cuff repair, acromioplasty, and physiotherapy group (denoted as Group 3). The Constant score was the primary outcome measure. Secondary outcome measures were visual analog scale for pain, patient satisfaction, rotator cuff integrity in a control imaging investigation, and cost of treatment. RESULTS One hundred and sixty-seven shoulders (160 patients) were available for analysis at two years. There were no significant differences (p = 0.38) in the mean change of Constant score: 18.4 points (95% confidence interval, 14.2 to 22.6 points) in Group 1, 20.5 points (95% confidence interval, 16.4 to 24.6 points) in Group 2, and 22.6 points (95% confidence interval, 18.4 to 26.8 points) in Group 3. There were no significant differences in visual analog scale for pain scores (p = 0.45) and patient satisfaction (p = 0.28) between the groups. At two years, the mean sagittal size of the tendon tear was significantly smaller (p < 0.01) in Group 3 (4.2 mm) compared with Groups 1 and 2 (11.0 mm). Rotator cuff repair and acromioplasty were significantly more expensive than physiotherapy only (p < 0.01). CONCLUSIONS There was no significant difference in clinical outcome between the three interventions at the two-year follow-up. The potential progression of the rotator cuff tear, especially in the non-repaired treatment groups, warrants further follow-up. On the basis of our findings, conservative treatment is a reasonable option for the primary initial treatment for isolated, symptomatic, nontraumatic, supraspinatus tears in older patients. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Bone destruction, upward migration, and medialisation of rheumatoid shoulder: a 15 year follow up study

OBJECTIVE To evaluate bone destruction, upward migration, and medialisation of the glenohumeral (GH) joint in a cohort of 74 patients with seropositive and erosive rheumatoid arthritis followed up prospectively. METHODS At the 15 year follow up 148 shoulders were radiographed by a standard method. Bone destruction in the GH joint was examined from the radiographs by four methods, of which three measured the migration and one the remodelling of the humeral head. The distances from the greater tuberosity of the humeral head to the coracoid process (medialisation distance (MD)) and to the articular surface of the humeral head (GA) have been previously developed to evaluate the preoperative offsets of the arthritic GH joint. Medial displacement index (MI) and upward migration index (UI) have been recently developed to evaluate the destructive pattern of the rheumatoid GH joint. Destruction of the GH joints was assessed by the Larsen method on a scale of 0 to 5. The relation between the measurements and the grade of destruction of the GH joints was examined. UI was compared with our previous measurements of the subacromial space. RESULTS Both the MI and the UI had a negative correlation with the GH joint destruction (Larsen grade), r=−0.49 (95% CI −0.36 to −0.60) and r=−0.58 (95% CI −0.46 to −0.68). The UI correlated significantly with the subacromial space, r=0.90 (95% CI 0.86 to 0.93). The mean MI and UI measurements of the non-affected joints were within the reported normal variation. The mean MD collapsed between Larsen grades 4 (83.0 mm) and 5 (65.5 mm). The morphology of the humeral head began to flatten and erode from the grade 3 onwards and medial head destruction was detected at grade 5. CONCLUSIONS Medialisation seems to be preceded by upward migration of the humeral head, indicating rotator cuff damage. Symptomatic Larsen grade 3 shoulders should be intensively followed up by clinical and radiological means. If a total shoulder arthroplasty is considered, an orthopaedic consultation is worthwhile at a sufficiently early stage (Larsen 3 and 4), when soft tissue structures responsible for function are still in proper condition and timing of the operative procedure can be well planned.

Practical assessment of rotator cuff muscle volumes using shoulder MRI.

Reliable quantitative assessment of rotator cuff (RC) muscle volumes can be done by reconstructing multiple MRI images of the entire shoulder. However, an equally reliable, but less time-consuming, method is needed for clinical practice. We compared the only method reported for estimation of volume with a new simple MRI technique. Both methods were validated by multiple MRI image reconstruction. We performed MRI scans of 10 cadaver shoulders and determined the cross-sectional areas of RC muscles with two methods, using image analyzing software. In Method 1, the cross-sections were determined on a single image, previously described as a Y-shaped image. In Method 2, the cross-sections were calculated from two images: the Y-shaped and an image located medially, twice the distance from the glenoid articular surface compared to the Y-shaped image. We compared the results of these two methods with the volume of multiple MRI image reconstruction, which took into account all images consisting of RC cross-sections. Pearson correlations for Method 1 were 0.96, 0.94 and 0.75, and for Method 2, 0.96, 0.97 and 0.93 for the supraspinatus, infraspinatus/teres minor and subscapularis muscle volumes when compared with the volumes determined by the multiple image reconstruction method. The Bland-Altman method showed better agreement with multiple MRI image reconstruction, using Method 2, to determine supraspinatus, infraspinatus, and subscapularis muscle volumes (p<0.001 for each). The mean intra- and inter-observer variabilities of Method 1 was 3.9% and 2.9% and that of Method 2, 3.0% and 1.7%, respectively. Both methods can be used for quantitative assessment of RC muscle volumes. However, Method 2, using two easily reproducible MRI images is more accurate for the evaluation of the supraspinatus and infraspinatus/teres minor muscles and particularly for the subscapularis muscle.

Relationship of ankle joint involvement with subtalar destruction in patients with rheumatoid arthritis.A 20-year follow-up study

AIMS In the present study we evaluated radiographically involvement of the ankle joint and its relationship to destruction of the subtalar joint in rheumatoid arthritis (RA). METHODS An inception cohort of 103 patients with seropositive RA was followed over a period of 20 years. Follow-up examinations were conducted after onset, 1, 3, 8, 15, and 20 years from entry. A total of 83 patients attended the 15-year and 68 patients the 20-year follow-up. Radiographic evaluation was performed using a lateral weight-bearing ankle radiograph. A simplified grading was applied for the talocrural joint, in which the ankles (patients) were divided into three groups: no changes, minor changes and major changes. In the end-point analysis the last radiograph was assigned. Subtalar destruction was recorded (Larsen grade > or = 2). Severity of RA in different groups was evaluated using the Larsen score of 0-100 of hands and feet. Difference between patient groups was evaluated using Cuzicks test. RESULTS At the endpoint major changes of the ankles were detected in seven patients (7%) only, minor changes were observed in 17 patients (16%). The first minor involvement of the ankle was observed at the three-year follow-up in two patients. First major changes were detected at the 15-year follow-up in three ankles of two patients. Subtalar pathology preceded that of TC joint in all ankles with major changes. In 17 patients with minor changes, simultaneous subtalar pathology was observed in all but two ankles, while preceding subtalar involvement was radiographically manifest in 13 of 21 ankles. The means of Larsen scores of 0-100 were in the three ankle grading groups 40, 54 and 63, respectively. Cuzicks test for the trend was highly significant (P < 0.001). No reconstructive surgery was performed on the ankle joint during the follow-up, whereas the subtalar joint complex was fused cumulatively in 12 patients. CONCLUSIONS The ankle joint is involved in a late stage of RA and is usually affected only in the patients with severe disease. Subtalar pathology precedes the changes in the talocrural joint almost regularly.

Reoperation rate after elbow synovectomy in rheumatoid arthritis

The purpose of this study was to evaluate the reoperation rate of elbow synovectomy in patients with rheumatoid arthritis. A total of 103 synovectomies were performed in 88 patients (61 women) with rheumatoid factor-positive rheumatoid arthritis with a mean follow-up of 5.2 years (range, 1-8 years). The survival rate after elbow synovectomy (free from reoperation) was 77% (95% confidence interval, 66%-85%) at 5 years. Eight resynovectomies and fourteen total elbow replacements were performed during the follow-up. No significant improvement in range of motion was detected after synovectomy, but pain relief and patient satisfaction were favorable. Elbows were classified preoperatively (before primary synovectomy) with the Larsen system. All resynovectomies were performed for elbows of grade 0-2 destruction. A significant difference was found between early (Larsen grade 0-2) and late (Larsen grade 3) synovectomies in relation to elbow replacement (P =.002) during the follow-up. Late synovectomy yielded more temporary pain relief with a high rate of elbow arthroplasties.