Kazutoshi Hamada

Roentgenographic Findings in Massive Rotator Cuff Tears A Long-term Observation

It is difficult to determine the size and localization of rotator cuff tears preoperatively. But with the special arthrographic technique, a diagnosis with about 80% accuracy was possible in 65 surgically confirmed rotator cuff tears. With this technique, 22 massive cuff tears were found in conservatively treated patients. In these patients, the plain roentgenograms obtained at the initial examination were also analyzed. The roentgenographic findings included narrowing of the acromiohumeral interval and degenerative changes of the humeral head, the tuberosities, the acromion, the acromioclavicular joint, and the glenohumeral joint. Based on these data, five roentgenographic grades of massive cuff tears were identified. Of seven patients with massive tears, which had been treated conservatively and followed for more than eight years, the roentgenographic grades advanced in five. One shoulder progressed to cuff-tear arthropathy. Based on these observations, it is proposed that the following pathogenetic mechanisms are responsible for the progressive roentgenographic changes: (1) arm elevation in activities of daily living, (2) rupture of the long head of biceps tendon, (3) the abnormal fulcrum of the humeral head against the acromion and the coracoacromial ligament, and (4) the weakness of external rotation. A massive cuff tear will progress to cuff-tear arthropathy, with each step of progression accompanied by characteristic roentgenographic changes.

Pathology and pathogenesis of bursal-side rotator cuff tears viewed from en bloc histologic sections

Histologic sections from 12 en bloc surgical specimens were studied in order to clarify the pathogenesis of bursal-side rotator cuff tears (BSRCTs). The specimens consisted of the bony insertion, the partially torn area, and the musculotendinous junction of the supraspinatus tendon. There were eight men and four women, with an average age of 48.7 years. Trauma was noted in three instances. All patients exhibited clinical evidence of subacromial impingement, which was confirmed at surgery. Histologic sections were stained with azan or hematoxylin and eosin. All the tears developed from within 1 cm of the insertion. The depth of the tears varied from a superficial flap to a nearly full-thickness tear. Microscopically, the sections demonstrated several abnormalities in addition to degeneration. At the site of insertion and in the distal stump, local disruptions of the normal four layers of enthesis and areas of hypervascularity were observed in all sections. The proximal stumps were rounded, retracted, and avascular, with abundant chondrocytes. No active repair was noted in the proximal stumps. The pathogenesis of BSRCTs appears to be related to: (1) a combination of aging and precarious vascularity of the tendon, (2) repetitive movements of the arm at above-horizontal levels, (3) injury, and (4) especially subacromial-tendon impingement.

Pathology and pathogenesis of the intratendinous tearing of the rotator cuff viewed from en bloc histologic sections.

Histologic sections from 17 en bloc surgical specimens were studied to clarify the pathogenesis of intratendinous tears of the rotator cuff. The specimens consisted of the bony insertion, the partially torn area, and the musculotendinous junction of the supraspinatus tendon. An intratendinous tear alone was present in two patients, and was associated with bursal side cuff tears in seven patients and joint side cuff tears in eight. There were 13 men and 4 women, whose average age was 49.8 years. Trauma was noted in all intratendinous tears and combined intratendinous and joint side cuff tears and in two of the seven patients who had intratendinous plus bursal side tears. All patients exhibited clinical evidence of subacromial impingement. Histologic sections were stained with azan and hematoxylin and eosin. Microscopically, the sections demonstrated several abnormalities in addition to degeneration. The intratendinous tears was located in the midlayer of the tendon in 15 specimens and eccentrically in two, the axis of which were parallel to tendon fibers in all. The intratendinous tears continued to local disruptions of the enthesis in 11 cases. The inner surface of the tear appeared smooth in 16 specimens. Despite the presence of granulation tissue and vessel proliferation near the intratendinous tears, there was no evidence of closure of the defect in any specimen. Intratendinous tears develop between superficial and deep layers of the degenerated rotator cuff. Shear within the tendon appears to be responsible in pathogenesis. Concomitant subacromial bursitis is very common.

Partial-thickness tears of the rotator cuff

Summary. This review is based on 66 patients with partial-thickness tears of the rotator cuff, verified at operation. Their average age was 54 years, and all had symptoms of subacromial impingement. The duration of shoulder pain was for between 2 and 108 months (mean 11.4 months). Ultrasonography, arthrography and bursography were helpful in establishing the diagnosis. On exploration, tears were found in the supraspinatus tendon, with 9 extending into the infraspinatus. After anterior acromioplasty, excision of the diseased portion and tenorrhaphy were undertaken. Satisfactory results were obtained in 62 patients (94%) with an average follow-up of 32 months. Spontaneous repair at the torn site was never seen. In addition to Neer’s staging of impingement, we propose a new classification based on the integrity of the cuff tendon. We conclude that a partial-thickness cuff tear is an important cause of shoulder disability, which deserves much more clinical attention; misdiagnosis is common and leads to mismanagement. When conservative treatment fails, accurate diagnosis and proper surgical repair are essential.

A Radiographic Classification of Massive Rotator Cuff Tear Arthritis

BackgroundIn 1990, Hamada et al. radiographically classified massive rotator cuff tears into five grades. Walch et al. subsequently subdivided Grade 4 to reflect the presence/absence of subacromial arthritis and emphasize glenohumeral arthritis as a characteristic of Grade 4.Questions/purposesWe therefore determined (1) whether patient characteristics and MRI findings differed between the grades at initial examination and final followup; (2) which factors affected progression to a higher grade; (3) whether the retear rate of repaired tendons differed among the grades; and (4) whether the radiographic grades at final followup differed from those at initial examination among patients treated operatively.Patients and MethodsWe retrospectively reviewed 75 patients with massive rotator cuff tears. Thirty-four patients were treated nonoperatively and 41 operatively.ResultsPatients with Grade 3, 4, or 5 tears had a higher incidence of fatty muscle degeneration of the subscapularis muscle than patients with Grade 1 or 2 tears. In 26 patients with Grade 1 or 2 tears at initial examination, duration of followup was longer in patients who remained at Grade 1 or 2 than in those who progressed to Grade 3, 4, or 5 at final followup. The retear rate of repaired supraspinatus tendon was more frequent in Grade 2 than Grade 1 tears. In operated cases, radiographic grades at final followup did not develop to Grades 3 to 5.ConclusionsWe believe cuff repair should be performed before acromiohumeral interval narrowing. Our observations are consistent with the temporal concepts of massive cuff tear pathomechanics proposed by Burkhart and Hansen et al.Level of EvidenceLevel III, Therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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.

Biochemical markers in the synovial fluid of glenohumeral joints from patients with rotator cuff tear

It is known that rotator cuff tears are sometimes accompanied by joint destruction. Our purpose was to elucidate the pathology with this condition. Thirty‐two synovial fluid (SF) samples aspirated from the glenohumeral joints of patients with rotator cuff tears, including 7 with partial‐thickness and 25 with full‐thickness tears of the rotator cuff (10 massive and 15 isolated supraspinatus tendon (SSp) tears), were examined. Collagenase (MMP‐1), stromelysin 1 (MMP‐3), tissue inhibitor of metalloproteinases‐1 (TIMP‐1) and carboxy‐terminal type II procollagen peptide (pCOL II‐C) were measured in the SF using the respective sandwich enzyme immunoassays. Glycosaminoglycan (GAG) was also quantified with a cationic dye binding method using 1,9‐dimethylmethylene blue. Levels of any molecules except pCOL II‐C in the SF appeared to be higher in full‐thickness tears than those in partial‐thickness tears. Moreover, levels of MMP‐1, MMP‐3 and GAG in the SF were significantly higher in massive tears of the rotator cuff in comparison with those in isolated SSp tears. Such significance was not observed in the levels of TIMP‐1 or pCOL II C in the SF. We examined the relation of those levels with operative findings or clinical parameters from full‐thickness tears, and observed significant correlations of the tear size with the levels of MMP‐1, MMP‐3 and GAG in the SF. Although these marker molecules in SF do not always originate from cartilage, our results may indicate the potential for accelerated cartilage‐degrading activity in the glenohumeral joint in massive tears of the rotator cuff.

Interleukin-1-induced glenohumeral synovitis and shoulder pain in rotator cuff diseases.

Synovitis of the subacromial bursa has been identified as a main source of shoulder pain in rotator cuff diseases. Little interest, however, has been paid into the synovitis of glenohumeral joint. The mRNA expression levels of interleukin‐1β (IL‐1β) and interleukin‐1 receptor antagonists produced in the synovitis reflect the magnitude of inflammation. The present study was undertaken to determine the relationship between mRNA expression levels of IL‐1β and its receptor antagonists (secreted interleukin‐1 receptor antagonist (IL‐1ra) and intracellular IL‐1ra) in the synovium of the glenohumeral joint and shoulder pain in rotator cuff diseases, analyzing the synovial specimens by reverse transcriptase polymerase chain reaction. Thirty‐five patients with rotator cuff diseases were candidates. Based on the presence of cuff perforation, they were divided into two categories: 16 with non‐perforating tears and 19 with perforating tears. The degree of shoulder pain was evaluated by use of a visual analogue scale. The pain degree of non‐perforating tears was significantly greater than that of perforating tears (P < 0.01). In contrast, the expression levels of the cytokine‐mRNAs were constitutively greater in perforating tears than in non‐perforating tears (P < 0.01, respectively). The expression levels of the cytokine‐mRNAs were inversely correlated with the degree of pain (IL‐1β: r = 0.930; secreted IL‐1ra: r = 0.861: intracellular IL‐1ra: r = 0.932, P < 0.001 respectively). These results suggest that the expression levels of the cytokine‐mRNAs in the synovium of the glenohumeral joint contribute less to the generation of shoulder pain in rotator cuff diseases.

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.