Robert J. Neviaser

The frozen shoulder. Diagnosis and management.

The differentiation between the stiff and painful shoulder without any joint capsule involvement and with capsule involvement (true adhesive capsulitis) must be established before a rational treatment can be prescribed. Arthrography establishes the correct diagnosis of adhesive capsulitis. Treatment of the stiff and painful shoulder is through prevention and exercise. The treatment of adhesive capsulitis includes prevention, exercises, manipulation, and capsulotomy. Each treatment method is determined by specific criteria. Arthroscopy is not useful for either diagnosis or treatment of adhesive capsulitis but may be useful for recognition of the four stages of the disease.

The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff.

In sixteen patients with massive tears of the rotator cuff of the shoulder, bridging of the defect with a freeze-dried graft of a rotator cuff from a cadaver produced a satisfactory repair in all cases. A good or excellent functional result was obtained in all but two patients, with a definite decrease or absence of nocturnal pain in all sixteen. The operative technique includes avoidance of a complete acromionectomy and an adequate suture of the deltoid muscle to the acromion after an acromioplasty.

Concurrent rupture of the rotator cuff and anterior dislocation of the shoulder in the older patient.

Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. All of the patients were more than thirty-five years old. Twenty-nine of them were initially presumed to have had an injury to the axillary nerve, although this injury was confirmed in only four of the twenty patients who had electrodiagnostic studies. In eight patients, the subscapularis tendon and anterior part of the capsule had ruptured from the lesser tuberosity. Recurrent instability developed in all eight patients, and repair of these structures alone was successful in restoring stability. The association between primary anterior dislocation of the glenohumeral joint and rupture of the rotator cuff in the older patient who cannot abduct the arm after reduction is poorly appreciated, as it is often missed. In our series of such patients, the incidence of injury to the axillary nerve was 7.8 per cent, as compared with 100 per cent for rupture of the rotator cuff. However, the comparative rates of occurrence of these two entities in older patients who have an anterior dislocation have not been determined.

Glenohumeral motion in patients with rotator cuff tears: A comparison of asymptomatic and symptomatic shoulders

The purpose of this study was to determine whether there was a relationship between altered scapular plane glenohumeral kinematics end shoulder pain. Subjects were divided into 3 groups: normal volunteers (n = 10), patients with symptomatic rotator cuff tears severe enough to warrant surgery (n = 10), and subjects with no symptoms who had tears documented on magnetic resonance imaging and normal examination (n = 10). Humeral kinematics were observed with a computer-enhanced modification of the Poppen and Walker technique. Scapular plane x-ray films were obtained at 0 degree, 30 degrees, 60 degrees, 90 degrees, 120 degrees, and 150 degrees of elevation. Measurements were made by 3 independent observers blinded to the diagnosis, and data interpretation was performed based on mean values for independent observers. Results showed a high degree of interobserver and intraobserver reliability (coefficients = 0.96 and 0.95, respectively). The symptomatic and asymptomatic groups showed progressive superior translation of the humeral head on the glenoid with increasing arm elevation. The normal group, in contrast, maintained a constant center of rotation along the geometric center of the glenoid. Symptomatic and asymptomatic rotator cuff tear groups showed superior head migration from 30 degrees to 150 degrees, which was significantly different from those seen in the normal group. No significant difference between the symptomatic and asymptomatic groups was demonstrated with the small numbers used in this study. The presence of a rotator cuff tear was associated in a disruption of normal glenohumeral kinematics in the scapular plane. Because significant superior migration of the humeral head was seen in both the asymptomatic and symptomatic rotator cuff groups, painless and normal shoulder motion is possible in the presence of abnormal glenohumeral kinematics. Abnormal glenohumeral kinematics alone was not an independent factor, which could explain the occurrence of symptoms.

Anterior Dislocation of the Shoulder and Rotator Cuff Rupture

Thirty-seven patients older than 40 years of age were seen after sustaining primary anterior dislocations of the shoulder. An associated rupture of the rotator cuff in each patient had been missed, often being mistaken for an axillary neuropathy. Eleven of these patients developed recurrent anterior instability that was due to rupture of the subscapularis and anterior capsule from the lesser tuberosity. In no patient was there a Bankart lesion. Repair of the capsule and subscapularis restored stability in all of the patients with recurrence.

Painful conditions affecting the shoulder.

Many painful conditions affect the shoulder. They can be divided into those extrinsic or intrinsic to the shoulder. The extrinsic conditions include disorders of the cervical spine and thoracic outlet, as well as postural conditions. Intrinsic lesions include acute and chronic calcific tendinitis, bicipital tenosynovitis, arthritis, and adhesive capsulitis. Each disorder has a characteristic clinical pathologic set of diagnostic features, arthrographic picture, and treatment requirements.

Rupture of the Ulnar Collateral Ligament of the Thumb (gamekeeper's Thumb): Correction By Dynamic Repair

1. The pathology of rupture of the ulnar collateral ligament of the thumb (gamekeepers thumb) has been presented. 2. A new procedure which provides dynamic stabilization of the metacarpophalangeal joint of the thumb in the function of pinch by advancement of the insertion of the adductor pollicis has been described. 3. It has been emphasized that arthrodesis rather than adductor advancement is indicated in the presence of arthrosis.

The four-in-one arthroplasty for the painful arc syndrome.

The painful arc syndrome of the shoulder is a manifestation of rotator cuff tendinitis associated with tenosynovitis of the long head of the biceps under and just distal to the transverse humeral ligament. Eighty-nine patients with clinical signs of the painful arc syndrome were proven to have an associated biceps tenosynovitis by arthrography and at surgical treatment. The four-in-one arthroplasty consists of: (1) excision of the coracoacromial ligament; (2) acromioclavicular arthroplasty; (3) excision of the anterior inferior area of the acromion process; and (4) transfer and tenodesis of the long head of the biceps. The operation decompresses the acromial arch and also eliminates the biceps tenosynovitis by tenodesis. Almost invariably, there was relief of pain within four to five months of postoperative rehabilitation, and at an average follow-up of two to eight years.

Adhesive capsulitis of the shoulder.

&NA; Adhesive capsulitis is characterized by painful, gradual loss of active and passive shoulder motion resulting from fibrosis and contracture of the joint capsule. Other shoulder pathology can produce a similar clinical picture, however, and must be considered. Management is based on the underlying cause of pain and stiffness, and determination of the etiology is essential. Subtle clues in the history and physical examination can help differentiate adhesive capsulitis from other conditions that cause a stiff, painful shoulder. The natural history of adhesive capsulitis is a matter of controversy. Management of true capsular restriction of motion (ie, true adhesive capsulitis) begins with gentle, progressive stretching exercises. Most patients improve with nonsurgical treatment. Indications for surgery should be individualized. Failure to obtain symptomatic improvement and continued functional disability following ≥6 months of physical therapy is a general guideline for surgical intervention. Diligent postoperative therapy to maintain motion is required to minimize recurrence of adhesive capsulitis.

Outcome of latissimus dorsi transfer as a salvage procedure for failed rotator cuff repair with loss of elevation

Eighteen patients, referred from an outside institution with massive, irreparable rotator cuff tears and loss of elevation, were treated with a latissimus dorsi tendon transfer as a salvage procedure for failed, prior, attempted rotator cuff repair. Clinical outcomes were measured by the American Shoulder and Elbow Surgeons (ASES) score, pain level, and active range of motion. The average postoperative ASES score was 61, an increase from 43 pre-operatively (P = .05). Active elevation improved to an average of 137 degrees compared to 56 degrees pre-operatively (P < .001). The average post-operative pain level was 22 mm, down from 59 (P = .001), and the average post-operative active external rotation at the side was 45 degrees, improved from 31 degrees (P < .001). We conclude that latissimus transfer, as a salvage procedure for failed rotator cuff repair with loss of elevation, allows for significant return of active elevation and function with minimal post-operative pain.