Joo Han Oh

Factors Affecting Rotator Cuff Healing After Arthroscopic Repair Osteoporosis as One of the Independent Risk Factors

Background: The prognostic factors associated with structural outcome after arthroscopic rotator cuff repair have not yet been fully determined. Hypothesis: The hypothesis of this study was that bone mineral density (BMD) is an important prognostic factor affecting rotator cuff healing after arthroscopic cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: Among 408 patients who underwent arthroscopic repair for full-thickness rotator cuff tear between January 2004 and July 2008, 272 patients were included whose postoperative cuff integrity was verified by computed tomography arthrography (CTA) or ultrasonography (USG) and simultaneously who were evaluated by various functional outcome instruments. The mean age at the time of operation was 59.5 ± 7.9 years. Postoperative CTA or USG was performed at a mean 13.0 ± 5.1 months after surgery, and the mean follow-up period was 37.2 ± 10.0 months (range, 24-65 months). The clinical, structural, and surgery-related factors affecting cuff integrity including BMD were analyzed using both univariate and multivariate analysis. Evaluation of postoperative cuff integrity was performed by musculoskeletal radiologists who were unaware of the present study. Results: The failure rate of rotator cuff healing was 22.8% (62 of 272). The failure rate was significantly higher in patients with lower BMD (P < .001); older age (P < .001); female gender (P = .03); larger tear size (P < .001); higher grade of fatty infiltration (FI) of the supraspinatus, infraspinatus, and subscapularis (all P < .001); diabetes mellitus (P = .02); shorter acromiohumeral distance (P < .001); and associated biceps procedure (P < .001). However, in the multivariate analysis, only BMD (P = .001), FI of the infraspinatus (P = .01), and the amount of retraction (P = .03) showed a significant relationship with cuff healing failure following arthroscopic rotator cuff repair. Conclusion: Bone mineral density, as well as FI of the infraspinatus and amount of retraction, was an independent determining factor affecting postoperative rotator cuff healing. Further studies with prospective, randomized, and controlled design are needed to confirm the relationship between BMD and postoperative rotator cuff healing.

Arthroscopic Repair of Massive Rotator Cuff Tears Outcome and Analysis of Factors Associated With Healing Failure or Poor Postoperative Function

Background: Many patients with an unhealed cuff after repair show functional improvement. Purpose: To evaluate outcomes of arthroscopically repaired massive rotator cuff tears and to identify prognostic factors affecting rotator cuff healing and functional outcome, especially in patients with failed rotator cuff healing. Study Design: Case series; Level of evidence, 4. Methods: Among 173 patients who underwent arthroscopic repair of a massive rotator cuff tear, 108 patients with a mean age of 63.7 years were included. Outcome evaluation was completed both anatomically (CT arthrography or ultrasonography) and functionally at a minimum of 1 year postoperatively; mean follow-up period was 31.68 ± 15.81 months. Various factors affecting cuff healing were analyzed, and factors affecting functional outcome were evaluated in patients with failed repairs using both univariate and multivariate analyses. Results: The anatomic failure rate was 39.8% in arthroscopically repaired massive rotator cuff tears; however, functional status significantly improved regardless of cuff healing (P < .05). Several factors were associated with failure of cuff healing in the univariate analysis, but only fatty infiltration (FI) of the infraspinatus was significantly related to healing failure in the multivariate analysis (P = .04). Among patients with failed rotator cuff healing, only reduced postoperative acromiohumeral distance (AHD) was related to poor functional outcome in the multivariate analysis (P = .01), with a cutoff value of 4.1 mm. Conclusion: Despite a high rate of healing failures, arthroscopic repair can be recommended in patients with massive rotator cuff tears because of the functional gain at midterm follow-up. Higher FI of the infraspinatus was the single most important factor negatively affecting cuff healing. In cases of failed massive rotator cuff repair, no preoperative factor was able to predict poor functional outcome; reduced postoperative AHD was the only relevant functional determinant in the patients’ eventual functional outcome and should be considered when ascertaining a prognosis and planning further treatment strategies.

Is Early Passive Motion Exercise Necessary After Arthroscopic Rotator Cuff Repair

Background: Early passive motion exercise has been the standard rehabilitation protocol after rotator cuff repair for preventing postoperative stiffness. However, recent approaches show that longer immobilization may enhance tendon healing and quality. Purpose: To elucidate whether early passive motion exercise affects functional outcome and tendon healing after arthroscopic rotator cuff repair. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: One hundred five consecutive patients who underwent arthroscopic repair for small to medium-sized full-thickness rotator cuff tears were included. Patients with large to massive tears and concomitant stiffness or labral lesions were excluded. Patients were instructed to wear an abduction brace for 4 to 5 weeks after surgery and to start active-assisted shoulder exercise after brace weaning. Fifty-six patients were randomly allocated into group 1: early passive motion exercises were conducted 3 to 4 times per day during the abduction brace-wearing period. Forty-nine patients were allocated into group 2: no passive motion was allowed during the same period. Range of motion (ROM) and visual analog scale (VAS) for pain were measured preoperatively and 3, 6, and 12 months postoperatively. Functional evaluations, including Constant score, Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons (ASES) score, were also evaluated at 6 and 12 months postoperatively. Ultrasonography, magnetic resonance imaging, or computed tomography arthrography was utilized to evaluate postoperative cuff healing. Results: There were no statistical differences between the 2 groups in ROM or VAS for pain at each time point. Functional evaluations were not statistically different between the 2 groups either. The final functional scores assessed at 12 months for groups 1 and 2 were as follows: Constant score, 69.81 ± 3.43 versus 69.83 ± 6.24 (P = .854); SST, 9.00 ± 2.12 versus 9.00 ± 2.59 (P = .631); and ASES score, 73.29 ± 18.48 versus 82.90 ± 12.35 (P = .216). Detachment of the repaired cuff was identified in 12% of group 1 and 18% of group 2 (P = .429). Conclusion: Early passive motion exercise after arthroscopic cuff repair did not guarantee early gain of ROM or pain relief but also did not negatively affect cuff healing. We suggest that early passive motion exercise is not mandatory after arthroscopic repair of small to medium-sized full-thickness rotator cuff tears, and postoperative rehabilitation can be modified to ensure patient compliance.

Reliability of the Grading System for Fatty Degeneration of Rotator Cuff Muscles

Fatty degeneration of the rotator cuff muscles is considered one of the most important factors for the outcomes of cuff repair. However, the reliability of the grading system is not well validated. Two specialists in musculoskeletal radiology and three shoulder fellowship-trained orthopaedic surgeons reviewed the fatty degeneration grades of each cuff muscle of consecutive 75 full-thickness cuff tears. Fatty degeneration grades were assessed according to the systems of Goutallier et al. and Fuchs et al. using preoperative MR and postoperative CT arthrographies. The interclass correlation coefficient was analyzed to assess interobserver and intraobserver reliabilities. For interobserver reliability using the system of Goutallier et al. the interclass correlation coefficient was higher in MR arthrography (0.6–0.72) than in CT arthrography (0.43–0.6) and higher for radiologists (0.58–0.78) than for orthopaedic surgeons (0.32–0.68). There was no difference between the systems of Goutallier et al. and Fuchs et al. Intraobserver reliabilities showed a similar pattern (0.26–0.81), but the level of experience should be considered. Although the system of Goutallier et al. is most widely used in orthopaedics, reported data should be interpreted carefully because of the relatively low reliability.Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Effect of Age on Functional and Structural Outcome after Rotator Cuff Repair

Background There are numerous reports on the outcome of rotator cuff repair according to age. However, the results are conflicting and driven by univariate analysis, which is not free of confounding factors. Hypothesis Age does not affect the anatomical and functional outcomes of rotator cuff repair. Study design Case series; Level of evidence, 4. Materials and Methods Eighty-one men and 96 women underwent rotator cuff repair at one institution and received computed tomography arthrography and functional evaluations at least 1 year after surgery. Various structural and clinical features according to age were evaluated. The correlation was assessed between age and outcomes, with adjustment for the preoperative score. Results Patient mean age was 60.0 ± 8.7 years. The mean ages were higher in women, nonsmokers, and those with positive paradoxical abduction, lower level of sports activity, the presence of biceps injury, higher fatty degeneration in cuff muscles, inferior isokinetic muscle performance, bigger tear size, more retraction of tear, and symptomatic acromioclavicular arthritis. For the integrity of the repair, the mean age was higher in the retear group (31.1%) than in the intact group (68.9%)—that is, 63.7 ± 7.5 and 58.4 ± 8.7 years, respectively (P < .001). Only the Constant score exhibited a positive correlation with age after adjustment (P = .009). Univariate regression analysis revealed that a 0.313-point increment of Constant score could be expected for each year of age. Conclusion On univariate analysis, older age was related with poor postoperative integrity and better functional improvement in Constant score. Multivariate regression revealed that age was not an independent determinant for anatomical or functional outcome whereas the tear retraction and fatty degeneration of the infraspinatus were independent factors for the integrity of repair and the presence of the paradoxical abduction and abduction torque of the unaffected shoulder for the Constant score.

Moderate Preoperative Shoulder Stiffness Does Not Alter the Clinical Outcome of Rotator Cuff Repair With Arthroscopic Release and Manipulation

PURPOSE The purpose of this study was to determine whether moderate preoperative shoulder stiffness affects the clinical outcome of rotator cuff repair, and to evaluate the serial change in range of motion (ROM), functional scores, pain, and satisfaction after rotator cuff repair. METHODS Rotator cuff repair was performed in 125 consecutive patients (127 shoulders). Thirty patients had concomitant moderate shoulder stiffness at the time of the repair. There were no statistical differences in sex ratio, age, the size and retraction of the tear, or the associated pathologies and repair procedure between the stiffness and nonstiffness groups. Arthroscopic capsular release and manipulation were added to the stiffness group, and the same rehabilitation protocol was applied according to the size of the tear. Clinical outcomes were evaluated using ROM, American Shoulder and Elbow Surgeon (ASES) score, Constant score, Simple Shoulder Test (SST), and short form 36. Pain and postoperative patient satisfaction were measured by a visual analog scale. All clinical parameters were prospectively recorded on the day before surgery, and at 3, 6, and 9 months postoperatively, and at their last follow-up visit. RESULTS Differences of ROM did not reach statistical significance after 6 months of operation. Other functional outcome instruments showed no statistical difference at any follow-up period. Postoperative cuff integrity after 1 year showed no statistical difference between 2 groups. CONCLUSIONS This study suggests that moderate preoperative shoulder stiffness does not affect clinical outcomes of rotator cuff repair if arthroscopic capsular release with manipulation is added to the index procedure. Arthroscopic capsular release with manipulation and a well programmed rehabilitation program can avoid any delay of surgery and limitation of motion after cuff repair in patients with concomitant moderate shoulder stiffness. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Effectiveness of multidetector computed tomography arthrography for the diagnosis of shoulder pathology: Comparison with magnetic resonance imaging with arthroscopic correlation

HYPOTHESIS This study evaluated the diagnostic efficacy of computed tomography arthrography (CTA) in the assessment of various shoulder pathologies with arthroscopic correlation. We hypothesized that CTA would be cost-effective and effectively comparable with magnetic resonance arthrography (MRA) for assessing labral detachments and full-thickness rotator cuff tears. MATERIALS AND METHODS A musculoskeletal radiologist interpreted CTAs for 78 patients and MRAs for 70 patients. Each imaging study was evaluated for the presence of bony (Hill-Sachs) or labral (Bankart or superior labrum anteroposterior [SLAP]) lesions, and rotator cuff disorder (full- or partial-thickness tears). All patients subsequently underwent arthroscopic surgery. Detailed arthroscopic findings were reported and compared with CTA and MRA findings. The sensitivity, specificity, kappa coefficients, and the area under the receiver operating characteristic (AUROC) curve were calculated. RESULTS The sensitivity, specificity, and agreement were comparable in each imaging study for Bankart, SLAP, and Hill-Sachs lesions, and full-thickness rotator cuff tears, but those of CTA were significantly lower than MRA for partial-thickness cuff tears. The AUROC curve for CTA and MRA were not significantly different for any of the pathologies, except partial-thickness cuff tears. CONCLUSIONS Our data suggest that CTA is a cost-effective, useful method in the preoperative evaluation of labral abnormalities, such as Bankart and SLAP lesions. It may also be useful for the detection of full-thickness rotator cuff tears. LEVEL OF EVIDENCE Level I; Diagnostic study.

Comparative evaluation of the measurement properties of various shoulder outcome instruments.

Background Various shoulder outcome instruments have been used despite lack of information on their measurement properties; reliability, responsiveness, and validity; and correlation with health-related quality of life. Hypothesis Most shoulder outcome instruments have poor correlation with Short Form−36, a general measure of health-related quality of life, and with each other. Study Design Cohort study (diagnosis); Level of evidence, 2. Methods A consecutive group of 285 patients who had undergone shoulder surgery completed several shoulder outcome instruments—Short Form−36; University of California, Los Angeles shoulder score; American Shoulder and Elbow Surgeons shoulder evaluation form; Constant score; Simple Shoulder Test; Western Ontario Shoulder Instability Index; and the rating sheet for Bankart repair (Rowe score)—preoperatively and at 3, 6, 9, and 12 months postoperatively. Internal consistency, standardized response mean, effect size, and Pearson correlation were used to evaluate reliability, responsiveness, and validity. Results The American Shoulder and Elbow Surgeons form, Simple Shoulder Test, and Western Ontario Shoulder Instability Index displayed good internal consistency. The University of California, Los Angeles shoulder score and American Shoulder and Elbow Surgeons form exhibited good responsiveness, whereas Short Form−36 showed the least responsiveness. Pearson correlation coefficients between the shoulder outcome instruments and Short Form−36 were less than excellent (r < .60). Pearson correlation coefficients between the outcome instruments were generally low except for the Constant score and University of California, Los Angeles shoulder score (r = .673, P < .01). Conclusion There was no single shoulder outcome instrument that was superior to the others in terms of the measurement properties. Most of the tested shoulder outcome instruments did not reflect health-related quality of life well and poorly correlated with each other. This meant that the comparison of a given surgical result with different outcome instruments might be of little practical utility. Further prospective and serial studies should be conducted to develop better shoulder outcome instruments that have significant reliability, responsiveness, validity, and correlation with health-related quality of life. A careful combination of outcome instruments might be necessary to compensate the current evaluation systems.

Unicameral bone cysts

Open surgery is rarely justified for the initial treatment of a unicameral bone cyst, but there is some debate concerning the relative effectiveness of closed methods. This study compared the results of steroid injection with those of autologous bone marrow grafting for the treatment of unicameral bone cysts. Between 1990 and 2001, 30 patients were treated by steroid injection and 28 by grafting with autologous bone marrow. The overall success rates were 86.7% and 92.0%, respectively (p>0.05). The success rate after the initial procedure was 23.3% in the steroid group and 52.0% in those receiving autologous bone marrow (p<0.05), and the respective cumulative success rates after second injections were 63.3% and 80.0% (p>0.05). The mean number of procedures required was 2.19 (1 to 5) and 1.57 (1 to 3) (p<0.05), the mean interval to healing was 12.5 months (4 to 32) and 14.3 months (7 to 36) (p>0.05), and the rate of recurrence after the initial procedure was 41.7% and 13.3% in the steroid and in the autologous bone marrow groups, respectively (p<0.05). Although the overall rates of success of both methods were similar, the steroid group had higher recurrence after a single procedure and required more injections to achieve healing.

Effect of humeral component version on impingement in reverse total shoulder arthroplasty

HYPOTHESIS Reverse shoulder arthroplasty is growing in popularity for patients with deficient rotator cuffs; however, the phenomenon of scapular notching continues to be a concern. This study examined the effects of humeral component version in the Aequalis Reversed Shoulder Prosthesis (Tornier, Edina, MN) on impingement of the humeral prosthesis against the scapula to test the hypothesis that the mechanical contact of the humeral component with the scapular neck is influenced by the version of the humeral component. MATERIALS AND METHODS Seven shoulders from deceased donors were tested after the Aequalis Reversed Shoulder was implanted. The deltoid, pectoralis major, and latissimus dorsi were loaded based on physiologic cross-sectional area. The degree of internal and external rotation when impingement, subluxation, or dislocation occurred was measured at 0°, 30°, and 60° glenohumeral abduction in the scapular plane. Testing was performed with the humeral component placed in 20° of anteversion, neutral version, 20° of retroversion, and 40° of retroversion. RESULTS Maximum external rotation at 0° abduction was -1° ± 4° at 20° anteversion, 15° ± 3° at neutral, 28° ± 4° at 20° retroversion, and 44° ± 5° at 40° retroversion (P < .05). Maximum internal rotation at 0° abduction was 128° ± 9° at 20° anteversion, 112° ± 9° at neutral, 99° ± 8° at 20° retroversion, and 83° ± 8° at 40° retroversion (P < .05). Maximum external rotation at 30° abduction was 70° ± 6° at 20° anteversion, 84° ± 7° at neutral, 97° ± 6° at 20° retroversion, and 110° ± 5° at 40° retroversion (P < .05). There was no limitation to internal rotation at 30° abduction. No impingement occurred at 60° abduction. DISCUSSION Version of the humeral component plays a role in range of motion and impingement in reverse total shoulder arthroplasty. Anteversion can significantly decrease the amount of external rotation achievable after reverse total shoulder surgery. CONCLUSION Placing the Aequalis Reversed Shoulder humeral component at between 20° and 40° of retroversion more closely restores a functional arc of motion without impingement.