Pieter Bas de Witte

Calcific tendinitis of the rotator cuff: a randomized controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids.

Background: Calcific tendinitis of the rotator cuff (RCCT) is frequently diagnosed in patients with shoulder pain, but there is no consensus on its treatment. Purpose: To compare 2 regularly applied RCCT treatments: ultrasound (US)–guided needling and lavage (barbotage) combined with a US-guided corticosteroid injection in the subacromial bursa (subacromial bursa injection [SAI]) (group 1) versus an isolated SAI (group 2). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were randomly assigned to the 2 groups. Shoulder function was assessed before treatment and at regular follow-up intervals (6 weeks and 3, 6, and 12 months) using the Constant shoulder score (CS, primary outcome), the Western Ontario Rotator Cuff Index (WORC), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Additionally, calcification location, size, and Gärtner classification were assessed on radiographs. Results were analyzed using the t test, linear regression, and a mixed model for repeated measures. Results: This study included 48 patients (25 female, 52.1%; mean age, 52.0 ± 7.3 years; 23 patients in group 1) with a mean baseline CS of 68.7 ± 11.9. No patients were lost to follow-up. Four patients in group 1 and 11 in group 2 (P = .06) had an additional barbotage procedure or surgery during the follow-up period because of persisting symptoms and no resorption. At 1-year follow-up, the mean CS in group 1 was 86.0 (95% CI, 80.3-91.6) versus 73.9 (95% CI, 67.7-80.1) in group 2 (P = .005). The mean calcification size decreased by 11.6 ± 6.4 mm in group 1 and 5.1 ± 5.7 mm in group 2 (P = .001). There was total resorption in 13 patients in group 1 and 6 patients in group 2 (P = .07). With regression analyses, correcting for baseline CS and Gärtner type, the mean treatment effect was 20.5 points (P = .05) in favor of barbotage. Follow-up scores were significantly influenced by baseline scores. Results for the DASH and WORC were similar. Conclusion: On average, there was improvement at 1-year follow-up in both treatment groups, but clinical and radiographic results were significantly better in the barbotage group.

The Western Ontario Rotator Cuff Index in Rotator Cuff Disease Patients A Comprehensive Reliability and Responsiveness Validation Study

Background: The Western Ontario Rotator Cuff Index (WORC) is an increasingly applied condition-specific outcome measure for rotator cuff (RC) conditions. However, in most WORC validation studies, only a limited number of psychometric properties are studied in indistinct patient groups. Purpose: To assess psychometric properties of the WORC according to the Scientific Advisory Committee quality criteria for health questionnaires in 3 patient groups with distinct RC conditions. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The WORC (range, 0-100; 21 items, 5 domains) was administered twice (T1, T2) in 92 patients (35 RC tears, 35 calcific tendinitis, 22 impingement). Additionally, the Constant score (CS) and the Disabilities of the Arm, Shoulder and Hand score (DASH) were recorded. Calcific tendinitis patients were reassessed 6 weeks after treatment with needling and lavage or a subacromial injection with corticosteroids (T3). We assessed floor and ceiling effects, internal consistency, test-retest reliability, precision, construct validity, minimally detectable change, and responsiveness in the diagnostic subgroups and the total group. Results: Mean age was 55.0 ± 8.7 years, and 49 of 92 (53%) patients were female. Mean baseline WORC was 46.8 ± 20.4, CS was 63.9 ± 15.4, and DASH was 40.9 ± 18.6. Significant differences were found for the CS and DASH between RC tear patients (severe symptoms) and the other patients, but not for the WORC. There were no floor and ceiling effects. Internal consistency was high: the Cronbach alpha coefficient was .95. The intraclass correlation coefficient of .89 and standard error of measurement of 6.9 indicated high reproducibility. Pearson correlations of the WORC with the CS and DASH were .56 and –.65, respectively (both P < .001). At T3, total WORC improved significantly (mean change, 18.8; 95% confidence interval, 11.3-26.2). Correlations of the WORC change scores with CS and DASH changes were .61 and –.84, respectively (both P < .001). Effect size was 0.96, with a standardized response mean of 0.91, indicating good responsiveness. Conclusion: Applied to a variety of RC patients, the WORC had high internal consistency, moderate to good construct validity, high test-retest reliability, and good responsiveness. These findings support the use of the WORC as a condition-specific self-reported outcome measure in RC patients, but its validity in patients with severe symptoms needs further investigation.

Recurrent anterior shoulder instability: accuracy of estimations of glenoid bone loss with computed tomography is insufficient for therapeutic decision-making

ObjectiveTo evaluate the reliability of glenoid bone loss estimations based on either axial computed tomography (CT) series or single sagittal (“en face” to glenoid) CT reconstructions, and to assess their accuracy by comparing with actual CT-based bone loss measurements, in patients with anterior glenohumeral instability.Materials and methodsIn two separate series of patients diagnosed with recurrent anterior glenohumeral instability, glenoid bone loss was estimated on axial CT series and on the most lateral sagittal (en face) glenoid view by two blinded radiologists. Additionally, in the second series of patients, glenoid defects were measured on sagittal CT reconstructions by an independent observer.ResultsIn both series, larger defects were estimated when based on sagittal CT images compared to axial views. In the second series, mean measured bone loss was 11.5% (SD = 6.0) of the total original glenoid area, with estimations of 9.6% (SD = 7.2) and 7.8% (SD = 4.2) for sagittal and axial views, respectively. Correlations of defect estimations with actual measurements were fair to poor; glenoid defects tended to be underestimated, especially when based on axial views.ConclusionCT-based estimations of glenoid bone defects are inaccurate. Especially for axial views, there is a high chance of glenoid defect underestimation. When using glenoid bone loss quantification in therapeutic decision-making, measuring the defect instead of estimating is strongly advised.

Communication breakdown: clinicians disagree on subacromial impingement

Abstract“Subacromial impingement syndrome (SIS)” is often used as a diagnostic label, but has become more controversial as such in the literature. We assessed views on SIS in clinical practice using a survey with 63 0–10 VAS items among orthopedic surgeons and physical therapists from the United States and the Netherlands. Multivariate regression and cluster analyses were applied to identify consensus items and to study profession and/or nationality effects on item ratings. Most items received neutral or highly variable ratings. Twenty-nine were considered associated with SIS, including worsening of pain with overhead activities, painful arc and a positive Neer’s test. Seven items were regarded pleading against SIS, including loss of passive motion. Activity modifications and physical therapy are the most important treatments according to therapists, who highly valued motion-related etiologic mechanisms. Surgeons, with higher ratings for intrinsic and anatomic etiologies, appreciated the use of subacromial corticosteroids and surgery. Clinicians from different professional backgrounds have different views on what SIS is, and even within professional groups, variations are substantial. This has to be taken into account when communicating about SIS symptoms, for example, in intercollegial consultation or scientific research. The authors suggest cautious use of (subacromial) impingement syndrome as a diagnostic label.

Posttraumatic midshaft clavicular shortening does not result in relevant functional outcome changes.

Background and purpose — Shoulder function may be changed after healing of a nonoperatively treated clavicular fracture, especially in cases of clavicular shortening or mal-union. We investigated scapular orientations and functional outcome in healed clavicular fractures with and without clavicular shortening. Patients and methods — 32 participants with a healed nonoperatively treated midshaft clavicular fracture were investigated. Motions of the thorax, arm, and shoulder were recorded by standardized electromagnetic 3D motion tracking. The DASH score and Constant-Murley score were used to evaluate functional outcome. Orientation of the scapula and humerus at rest and during standardized tasks, and strength and function of the affected shoulders were compared with corresponding values for the uninjured contralateral shoulders. Results — Mean clavicular shortening was 25 mm (SD 16). Scapula protraction had increased by mean 4.4° in rest position in the affected shoulders. During abduction, slightly more protraction, slightly more lateral rotation, and slightly less backward tilt was found for the affected shoulders. For anteflexion, the scapular orientations of the affected shoulders also showed slightly increased protraction, slightly increased lateral rotation, and slightly reduced backward tilt. Scapulohumeral kinematics, maximum humerus angles, and strength were not associated with the degree of clavicular shortening. All participants had excellent performance on the Constant-Murley score and DASH score. Interpretation — Scapulohumeral kinematics in shoulders with a healed clavicular fracture differ from those in uninjured shoulders, but these changes are small, do not result in clinically relevant changes in outcome, and do not relate to the amount of clavicular shortening. These findings do not support routine operative reduction and fixation of shortened midshaft clavicular fractures based on the argument of functional outcome.

Surgical site infection in orthopaedic oncology.

BACKGROUND This study addressed risk factors for surgical site infection in patients who had undergone orthopaedic oncology surgical procedures. METHODS We retrospectively reviewed data on 1521 orthopaedic oncologic surgical procedures in 1304 patients. We assessed patient demographics, updated Charlson comorbidity index, surgery-specific data, and treatment-related data and attempted to identify predictors of surgical site infection with bivariate and multivariable analysis. RESULTS Eight factors independently predicted surgical site infection: body mass index (odds ratio [OR]:, 1.03, 95% confidence interval [CI]: 1.00 to 1.07), age (OR: 1.18, 95% CI: 1.05 to 1.33), total number of preceding procedures (OR: 1.19, 95% CI: 1.07 to 1.34), preexisting implants (OR: 1.94, 95% CI: 1.17 to 3.21), infection at another site on the date of the surgery (OR: 4.13, 95% CI: 1.57 to 10.85), malignant disease (OR: 1.46, 95% CI: 0.94 to 2.26), hip region affected (OR: 1.96, 95% CI: 1.35 to 2.84), and duration of the procedure (OR: 1.16, 95% CI: 1.07 to 1.25). CONCLUSIONS These factors can inform patients and surgeons of the probability of surgical site infection after orthopaedic oncologic surgery. While most risk factors are unmodifiable or related to the complexity of the case, infection at another site on the date of the surgery is one factor amenable to intervention.

Three-dimensional shoulder kinematics normalize after rotator cuff repair

BACKGROUND Patients with a rotator cuff (RC) tear often exhibit scapular dyskinesia with increased scapular lateral rotation and decreased glenohumeral elevation with arm abduction. We hypothesized that in patients with an RC tear, scapular lateral rotation, and thus glenohumeral elevation, will be restored to normal after RC repair. METHODS Shoulder kinematics were quantitatively analyzed in 26 patients with an electromagnetic tracking device (Flock of Birds) before and 1 year after RC repair in this observational case series. We focused on humeral range of motion and scapular kinematics during abduction. The asymptomatic contralateral shoulder was used as the control. Changes in scapular kinematics were associated with the gain in range of motion. Shoulder kinematics were analyzed using a linear mixed model. RESULTS Mean arm abduction and forward flexion improved after surgery by 20° (95% confidence interval [CI], 2.7°-36.5°; P = .025) and 13° (95% CI, 1.2°-36.5°; P = .044), respectively. Kinematic analyses showed decreases in mean scapular protraction (ie, internal rotation) and lateral rotation (ie, upward rotation) during abduction by 3° (95% CI, 0.0°-5.2°; P = .046) and 4° (95% CI, 1.6°-8.4°; P = .042), respectively. Glenohumeral elevation increased by 5° (95% CI, 0.6°-9.7°; P = .028) at 80°. Humeral range of motion increased when scapular lateral rotation decreased and posterior tilt increased. CONCLUSIONS Scapular kinematics normalize after RC repair toward a symmetrical scapular motion pattern as observed in the asymptomatic contralateral shoulder. The observed changes in scapular kinematics are associated with an increased overall range of motion and suggest restored function of shoulder muscles.

Rotator Cuff Calcific Tendinitis: Ultrasound-Guided Needling and Lavage Versus Subacromial Corticosteroids: Five-Year Outcomes of a Randomized Controlled Trial:

Background: Barbotage (needling and lavage) is often applied in the treatment of calcific tendinitis of the rotator cuff (RCCT). In a previously published randomized controlled trial, we reported superior clinical and radiological 1-year outcomes for barbotage combined with a corticosteroid injection in the subacromial bursa (SAIC) compared with an isolated SAIC. There are no trials with a midterm or long-term follow-up of barbotage available. Purpose: To compare the 5-year results of 2 regularly applied treatments of RCCT: ultrasound (US)–guided barbotage combined with a SAIC (group 1) versus an isolated US-guided SAIC (group 2). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were randomly assigned to group 1 or 2 and evaluated before and after treatment at regular time points until 12 months and also at 5 years using the Constant score (CS), the Western Ontario Rotator Cuff Index (WORC), and the Disabilities of the Arm, Shoulder and Hand (DASH). The calcification location and size and Gärtner classification were assessed on radiographs. The rotator cuff condition was evaluated with US. Results were analyzed using t tests, linear regression, and a mixed model for repeated measures. Results: Forty-eight patients were included (mean age, 52.0 ± 7.3 years; 25 [52%] female) with a mean baseline CS of 68.7 ± 11.9. After a mean follow-up of 5.1 ± 0.5 years, the mean CS was 90 (95% CI, 83.0-95.9) in group 1 versus 87 (95% CI, 80.5-93.5) in group 2 (P = .58). The mean improvement in the CS in group 1 was 18 (95% CI, 12.3-23.0) versus 21 (95% CI, 16.2-26.2) in group 2 (P = .32). There was total resorption in 62% of group 1 and 73% of group 2 (P = .45). The US evaluation of the rotator cuff condition showed no significant differences between the groups. With the mixed model for repeated measures, taking into account the baseline CS and Gärtner classification, the mean treatment effect for barbotage was 6 (95% CI, –8.9 to 21.5), but without statistical significance. Follow-up scores were significantly associated with baseline scores and the duration of follow-up. Results for the DASH and WORC were similar. There were no significant complications, but 4 patients in group 1 and 16 in group 2 underwent additional treatment during the follow-up period (P < .001). Conclusion: No more significant differences were found in the clinical and radiological outcomes between barbotage combined with a SAIC versus an isolated SAIC after 5 years of follow-up. Registration: NTR2282 (Dutch Trial Registry).

Measurement of clavicular length and shortening after a midshaft clavicular fracture: Spatial digitization versus planar roentgen photogrammetry

PURPOSE Clavicular shortening after fracture is deemed prognostic for clinical outcome and is therefore generally assessed on radiographs. It is used for clinical decision making regarding operative or non-operative treatment in the first 2weeks after trauma, although the reliability and accuracy of the measurements are unclear. This study aimed to assess the reliability of roentgen photogrammetry (2D) of clavicular length and shortening, and to compare these with 3D-spatial digitization measurements, obtained with an electromagnetic recording system (Flock of Birds). PATIENTS AND METHODS Thirty-two participants with a consolidated non-operatively treated two or multi-fragmented dislocated midshaft clavicular fracture were analysed. Two observers measured clavicular lengths and absolute and proportional clavicular shortening on radiographs taken before and after fracture consolidation. The clavicular lengths were also measured with spatial digitization. Inter-observer agreement on the radiographic measurements was assessed using the Intraclass Correlation Coefficient (ICC). Agreement between the radiographic and spatial digitization measurements was assessed using a Bland-Altman plot. RESULTS The inter-observer agreement on clavicular length, and absolute and proportional shortening on trauma radiographs was almost perfect (ICC>0.90), but moderate for absolute shortening after consolidation (ICC=0.45). The Bland-Altman plot compared measurements of length on AP panorama radiographs with spatial digitization and showed that planar roentgen photogrammetry resulted in up to 37mm longer and 34mm shorter measurements than spatial digitization. CONCLUSION Measurements of clavicular length on radiographs are highly reliable between observers, but may not reflect the actual length and shortening of the clavicle when compared to length measurements with spatial digitization. We recommend to use proportional shortening when measuring clavicular length or shortening on radiographs for clinical decision making.

Heterogeneous MR arthrography findings in patients with subacromial impingement syndrome – Diagnostic subgroups?

BACKGROUND Subacromial Impingement Syndrome (SIS) is frequently diagnosed, but treatment results vary greatly. It is increasingly reported that SIS symptoms are caused by various underlying mechanisms that need distinctive treatment strategies. We evaluated a set of specific MRI Arthrography (MRA) characteristics that have been related with underlying mechanisms for SIS in the literature, in patients with SIS. METHODS In 47 patients diagnosed with SIS, MRA characteristics were evaluated and categorized into categories of potential underlying mechanisms: (1) extrinsic: e.g. acromion shape; (2) intrinsic: e.g. tendinosis; (3) dynamic: e.g. signs of glenohumeral (micro-)instability. Control values were obtained from the literature. With cluster analysis, potential patient subgroups were assessed. RESULTS In 17 (36.2%) patients originally diagnosed with SIS, specific other conditions were found, including rotator cuff tears and labrum lesions. In the remaining 30, all had positive signs of at least one of the predefined underlying mechanisms. Patients could be categorized into 2 groups: predominantly findings corresponding with extrinsic/structural causes, or with dynamic/(micro)instability. CONCLUSIONS MRA characteristics in patients with SIS symptoms are heterogeneous and many patients have specific other shoulder conditions causing symptoms. Patients without specific other conditions have MRA characteristics associated with either extrinsic (structural), or dynamic (e.g. micro-instability) underlying mechanisms.