The etiology of rotator cuff disease is likely multifactorial, including age-related degeneration and microtrauma and macrotrauma. The incidence of rotator cuff tears increases with aging with more ...than half of individuals in their 80s having a rotator cuff tear. Smoking, hypercholesterolemia, and genetics have all been shown to influence the development of rotator cuff tearing. Substantial full-thickness rotator cuff tears, in general, progress and enlarge with time. Pain, or worsening pain, usually signals tear progression in both asymptomatic and symptomatic tears and should warrant further investigation if the tear is treated conservatively. Larger (>1-1.5 cm) symptomatic full-thickness cuff tears have a high rate of tear progression and, therefore, should be considered for earlier surgical repair in younger patients if the tear is reparable and there is limited muscle degeneration to avoid irreversible changes to the cuff, including tear enlargement and degenerative muscle changes. Smaller symptomatic full-thickness tears have been shown to have a slower rate of progression, similar to partial-thickness tears, and can be considered for initial nonoperative treatment due to the limited risk for rapid tear progression. In both small full-thickness tears and partial-thickness tears, increasing pain should alert physicians to obtain further imaging as it can signal tear progression. Natural history data, along with information on factors affecting healing after rotator cuff repair, can help guide surgeons in making appropriate decisions regarding the treatment of rotator cuff tears. The management of rotator cuff tears should be considered in the context of the risks and benefits of operative versus nonoperative treatment. Tear size and acuity, the presence of irreparable changes to the rotator cuff or glenohumeral joint, and patient age should all be considered in making this decision. Initial nonoperative care can be safely undertaken in older patients (>70 years old) with chronic tears; in patients with irreparable rotator cuff tears with irreversible changes, including significant atrophy and fatty infiltration, humeral head migration, and arthritis; in patients of any age with small (<1 cm) full-thickness tears; or in patients without a full-thickness tear. Early surgical treatment can be considered in significant (>1 cm-1.5 cm) acute tears or young patients with full-thickness tears who have a significant risk for the development of irreparable rotator cuff changes.
Background The MCID is the smallest difference in an outcome score which a patient perceives as beneficial. The PASS is the score below which patients consider themselves well. The purpose of this ...study was to determine the MCID and PASS for a visual analog scale (VAS) measuring pain in patients treated for rotator cuff disease. Material and methods 81 patients with rotator cuff disease were evaluated after 6 weeks of non-operative treatment with a VAS measuring pain and two transition questions utilized in determining the MCID and PASS. Results The MCID and PASS were estimated to be 1.4 cm ( P = .0255) and 3 cm (95% CI – 22.69, 37.31) on a 10 cm VAS measuring pain, respectively. Age ( P = .0492) and hand-dominance ( P = .0325) affected the MCID while age ( P = .0376) and duration of follow-up ( P = .0131) affected the PASS. Discussion The MCID and PASS estimates provide the basis to determine if statistically significant changes in VAS pain scores after treatment are clinically important and if the treatment allowed patients to achieve a satisfactory state. Level of evidence Level 3; Nonconsecutive series of patients, diagnostic study.
Background Minimal clinically important differences (MCIDs) for the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a visual analog scale (VAS) measuring pain ...have not been previously described using an anchor-based method after shoulder arthroplasty. The purpose of this study was to determine the MCIDs for these measures after shoulder arthroplasty for glenohumeral arthritis or advanced rotator cuff disease. Methods Primary anatomic total shoulder arthroplasty (TSA), primary reverse TSA, or hemiarthroplasty was performed in 326 patients by 1 of 5 shoulder and elbow surgeons. The SST score, ASES score, and VAS pain score were collected preoperatively and at a minimum of 2 years postoperatively (mean, 3.5 years). The MCIDs were calculated for the ASES score, SST score, and VAS pain score using an anchor-based method. Results The MCIDs for the ASES score, SST score, and VAS pain score were 20.9 ( P < .001), 2.4 ( P < .0001), and 1.4 ( P = .0158), respectively. Duration of follow-up and type of arthroplasty (anatomic TSA vs reverse TSA) did not have a significant effect on the MCIDs ( P > .1) except shorter follow-up correlated with a larger MCID for the ASES score ( P = .0081). Younger age correlated with larger MCIDs for all scores ( P < .024). Female sex correlated with larger MCIDs for the VAS pain score ( P = .123) and ASES score ( P = .05). Conclusions Patients treated with a shoulder arthroplasty require a 1.4-point improvement in the VAS pain score, a 2.4-point improvement in the SST score, and a 21-point improvement in the ASES score to achieve a minimal clinical importance difference from the procedure.
Background Accurate assessment of the critical shoulder angle (CSA) is important in clinical evaluation of degenerative rotator cuff tears. This study analyzed the influence of radiographic viewing ...perspective on the CSA, developed a classification system to identify malpositioned radiographs, and assessed the relationship between the CSA and demographic factors. Methods Glenoid height, width, and retroversion were measured on 3-dimensional computed tomography reconstructions of 68 cadaver scapulae. A digitally reconstructed radiograph was aligned perpendicular to the scapular plane, and retroversion was corrected to obtain a true anteroposterior (AP) view. In 10 scapulae, incremental anteversion/retroversion and flexion/extension views were generated. The CSA was measured, and a clinically applicable classification system was developed to detect views with >2° change in CSA vs. true AP view. Results The average CSA was 33° ± 4°. Intraobserver and interobserver reliability was high (intraclass correlation coefficient ≥ 0.81) but decreased with increasing viewing angle. Views beyond 5° anteversion, 8° retroversion, 15° flexion, and 26° extension resulted in >2° deviation of the CSA compared with the true AP view. The classification system was capable of detecting aberrant viewing perspectives with sensitivity of 95% and specificity of 53%. Correlations between glenoid size and CSA were small ( R ≤ 0.3), and CSA did not vary by gender ( P = .426) or side ( P = .821). Conclusions The CSA was most susceptible to malposition in anteversion/retroversion. Deviations as little as 5° in anteversion resulted in a CSA >2° from true AP view. A new classification system refines the ability to collect true AP radiographs of the scapula. The CSA was unaffected by demographic factors.
Background Lateral offset center of rotation (COR) reduces the incidence of scapular notching and potentially increases external rotation range of motion (ROM) after reverse total shoulder ...arthroplasty (rTSA). The purpose of this study was to determine the biomechanical effects of changing COR on abduction and external rotation ROM, deltoid abduction force, and joint stability. Materials and methods A biomechanical shoulder simulator tested cadaveric shoulders before and after rTSA. Spacers shifted the COR laterally from baseline rTSA by 5, 10, and 15 mm. Outcome measures of resting abduction and external rotation ROM, and abduction and dislocation (lateral and anterior) forces were recorded. Results Resting abduction increased 20° vs native shoulders and was unaffected by COR lateralization. External rotation decreased after rTSA and was unaffected by COR lateralization. The deltoid force required for abduction significantly decreased 25% from native to baseline rTSA. COR lateralization progressively eliminated this mechanical advantage. Lateral dislocation required significantly less force than anterior dislocation after rTSA, and both dislocation forces increased with lateralization of the COR. Conclusion COR lateralization had no influence on ROM (adduction or external rotation) but significantly increased abduction and dislocation forces. This suggests the lower incidence of scapular notching may not be related to the amount of adduction deficit after lateral offset rTSA but may arise from limited impingement of the humeral component on the lateral scapula due to a change in joint geometry. Lateralization provides the benefit of increased joint stability, but at the cost of increasing deltoid abduction forces.
Functional elbow range of motion for contemporary tasks Sardelli, Matthew; Tashjian, Robert Z; MacWilliams, Bruce A
Journal of bone and joint surgery. American volume,
2011-March-2, Letnik:
93, Številka:
5
Journal Article
Recenzirano
Elbow range of motion for functional tasks has been previously studied. Motion arcs necessary to complete contemporary tasks such as using a keyboard or cellular telephone have not been studied and ...could have implications on what is considered to be a functional arc of motion for these tasks. The purpose of this study was to determine elbow range of motion, including flexion-extension, pronation-supination, and varus-valgus angulation, with use of three-dimensional optical tracking technology for several previously described positional and functional tasks along with various contemporary tasks.
Twenty-five patients performed six positional and eleven functional tasks (both historical and contemporary). Elbow flexion-extension, varus-valgus, and forearm rotation (pronation and supination) ranges of motion were measured.
Positional tasks required a minimum (mean and standard deviation) of 27° ± 7° of flexion and a maximum of 149° ± 5° of flexion. Forearm rotation ranged from 20.0° ± 18° of pronation to 104° ± 10° of supination. Varus and valgus angulations ranged between 2° ± 5° of varus to 9° ± 5° of valgus. For functional tasks, the maximum flexion arc was 130° ± 7°, with a minimum value recorded as 23° ± 6° and a maximum value recorded as 142° ± 3°. All of these were for the cellular telephone task. The maximum pronation-supination arc (103° ± 34°) was found with using a fork. Maximum pronation was found with typing on a keyboard (65° ± 8°). Maximum supination was found with opening a door (77° ± 13°). Maximum varus-valgus arc of motion was 11° ± 4°. Minimum valgus (0° ± 6°) was found with cutting with a knife, while maximum valgus (13° ± 6°) was found with opening a door.
Functional elbow range of motion necessary for activities of daily living may be greater than previously reported. Contemporary tasks, such as using a computer mouse and keyboard, appear to require greater pronation than other tasks, and using a cellular telephone usually requires greater flexion than other tasks.
Psychosocial factors including anxiety, depression, and poor mental health negatively influence the baseline clinical expression of rotator cuff tearing. The same factors may influence clinical ...outcomes after rotator cuff repair surgery. Counseling patients preoperatively about postoperative expectations of rotator cuff repair surgery has a substantial positive impact on postoperative functional outcomes. As surgeons, we need to take the time to not just be technicians but counsel our patients and consider the impact of distress, anxiety, and expectations on the success of our treatments for rotator cuff tears.
The minimal clinically important difference is the smallest difference in an outcome score that a patient perceives as beneficial. The purpose of this study was to determine the minimal clinically ...important difference in the American Shoulder and Elbow Surgeons (ASES) score and in the Simple Shoulder Test (SST) score for patients treated nonoperatively for rotator cuff disease.
Eighty-one patients with tendinitis or a tear of the rotator cuff were treated with nonoperative modalities. Evaluation with the ASES score and the SST was performed at baseline and at a minimum of six weeks after treatment. At the follow-up evaluation, the minimal clinically important difference was estimated for the two scores with use of an anchor-based approach involving fifteen-item (pain and function) and four-item improvement questions.
The fifteen-item function and four-item assessments indicated, respectively, that a 2.05-point (p = 0.02) and 2.33-point (p = 0.0009) change in the SST score from baseline represented a minimal clinically important difference. The fifteen-item function, fifteen-item pain, and four-item assessments indicated that a 12.01-point (p = 0.03), 16.92-point (p = 0.004), and 16.72-point (p < 0.0001) change in the ASES score from baseline represented a minimal clinically important difference. Age, sex, initial baseline scores, and hand dominance had no effect on the minimal clinically important differences (p > 0.05). A longer duration of follow-up after treatment was associated with a greater minimal clinically important difference in the ASES score (p < 0.05), although the duration of follow-up had no effect on the minimal clinically important difference in the SST score.
Patients with rotator cuff disease who are treated without surgery and have a 2-point change in the SST score or a 12 to 17-point change in the ASES score experience a clinically important change in self-assessed outcome. These minimal clinically important differences can provide the basis for determining if significant differences in outcomes after treatment are clinically relevant.
The purpose of this study was to determine whether preoperative skin preparation with hydrogen peroxide reduces intraoperative culture positivity for Cutibacterium acnes in shoulder arthroplasty.
...This was a prospective, controlled, parallel/noncrossover, nonrandomized, single-blinded trial registered at clinicaltrials.gov. We included a consecutive series of patients scheduled to undergo primary anatomic or reverse total shoulder arthroplasty. The first group of patients underwent a standard skin preparation and the second group underwent the same preparation with the addition of hydrogen peroxide. We then took skin, dermis, glenohumeral joint, and air (negative control) aerobic and anaerobic culture swabs. We blinded the laboratory analyzing the samples. An a priori power analysis determined that 56 patients would be needed to see a 50% reduction in culture positivity rates. We also conducted a post hoc gender-stratified analysis.
Between January 2017 and October 2018, the authors performed 124 primary shoulder arthroplasties, of which we included 65 and collected samples on 61. There were no demographic differences. There were fewer patients within the peroxide group with triple-positive cultures (skin, dermis, and joint) (0% vs. 19%, P = .024) and positive cultures from the joint (10% vs. 35%, P = .031). In our subgroup analysis, these differences were only significant in males. The vast majority of positive cultures were with C. acnes.
Although larger, randomized studies are needed, adding hydrogen peroxide to the preoperative skin preparation may be a low-cost, low-risk method to reduce deep tissue contamination with C. acnes, particularly within males.
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