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Imaging of calcific tendinopathy around the shoulder: usual and unusual presentations and common pitfalls.
Albano, D, Coppola, A, Gitto, S, Rapisarda, S, Messina, C, Sconfienza, LM
La Radiologia medica. 2021;(4):608-619
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Abstract
Rotator cuff calcific tendinopathy (RCCT) is a very common condition, characterized by calcium deposition over fibrocartilaginous metaplasia of tenocytes, mainly occurring in the supraspinatus tendon. RCCT has a typical imaging presentation: in most cases, calcific deposits appear as a dense opacity around the humeral head on conventional radiography, as hyperechoic foci with or without acoustic shadow at ultrasound and as a signal void at magnetic resonance imaging. However, radiologists have to keep in mind the possible unusual presentations of RCCT and the key imaging features to correctly differentiate RCCT from other RC conditions, such as calcific enthesopathy or RC tears. Other presentations of RCCT to be considered are intrabursal, intraosseous, and intramuscular migration of calcific deposits that may mimic infectious processes or malignancies. While intrabursal and intraosseous migration are quite common, intramuscular migration is an unusual evolution of RCCT. It is important also to know atypical regions affected by calcific tendinopathy as biceps brachii, pectoralis major, and deltoid tendons. Unusual presentations of RCCT may lead to diagnostic challenge and mistakes. The aim of this review is to illustrate the usual and unusual imaging findings of RCCT that radiologists should know to reach the correct diagnosis and to exclude other entities with the purpose of preventing further unnecessary imaging examinations or interventional procedures.
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Biomechanical Analysis of Medial-Row All-Suture Suture Anchor Fixation for Rotator Cuff Repair in a Pair-Matched Cadaveric Model.
Bernardoni, ED, Frank, RM, Veera, SS, Waterman, BR, Griffin, JW, Shewman, EF, Cole, BJ, Romeo, AA, Verma, NN
Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2019;(5):1370-1376
Abstract
PURPOSE To compare the biomechanical properties of all-suture suture anchors (ASSAs) with conventional suture anchors (CSAs) for double-row rotator cuff repair (RCR). METHODS Fourteen fresh-frozen human cadaveric shoulders were randomized into 2 RCR treatment groups: ASSA and CSA. All constructs received a double-row repair, with the lateral-row implants consisting of two 5.5-mm PEEK (polyether ether ketone) Footprint anchors. Each construct was loaded to a 10-N preload for 2 minutes, followed by cyclic loading from 10 to 160 N at a rate of 100 N/s for 100 cycles. Load-to-failure testing was performed immediately after cyclic loading testing at 1 mm/s from the zero position until failure. Cyclic creep, elongation amplitude, maximum load, stiffness, energy, and failure mode were recorded. RESULTS No significant difference in cyclic creep (P = .117) or elongation amplitude (P = .428) was found between the ASSA and CSA groups during cyclic testing. Three specimens in each group (43% in each) failed by the suture tearing through the tendon. The remaining specimens in each group failed by the anchor pulling out of the humeral head. The mean maximum load was 617.73 ± 177.77 N and 545.13 ± 212.98 N for the ASSA and CSA groups, respectively (P = .339). Maximum elongation before failure was not different between groups (P = .122). Mean energy and stiffness were not statistically different between the ASSA and CSA groups (P = .629 and P = .973, respectively). CONCLUSIONS In this cadaveric analysis with a simplified unidirectional experimental setup, failure mechanics and maximum load between the ASSA and CSA constructs were similar, with no difference in energy and stiffness. Although the ASSA group showed slightly larger elongation than the CSA group, these differences may not be clinically relevant. CLINICAL RELEVANCE This study provides a biomechanical head-to-head comparison of ASSAs and CSAs, indicating that ASSAs may be clinically equivalent to CSAs for use in an RCR.
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Arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomised controlled trial at a minimum follow-up of ten years.
Ketola, S, Lehtinen, JT, Arnala, I
The bone & joint journal. 2017;(6):799-805
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Abstract
AIMS: Rotator cuff tendinopathy has a multifactorial origin. Rejecting the mechanistic theory has also led to abandoning operative treatment at initial presentation in the first line. Physiotherapy exercise programmes are the accepted first line treatment. The aim of this study was to assess the long-term additional benefits of subacromial decompression in the treatment of rotator cuff tendinopathy. PATIENTS AND METHODS This randomised controlled trial of 140 patients (52 men, 88 women, mean age 47.1 years; 18 to 60) with rotator cuff tendinopathy extended previous work up to a maximum of 13 years. The patients were randomised into two treatment groups: arthroscopic acromioplasty and a supervised exercise treatment and a similar supervised exercise treatment alone. Self-reported pain on a visual analogue scale (VAS) was the primary outcome measure. Secondary measures were disability, working ability, pain at night, Shoulder Disability Questionnaire score and the number of painful days during the three months preceding the final assessment. RESULTS A total of 90 patients (64%) returned questionnaires at a mean 12 years after randomisation. On an intention-to-treat basis, both treatment groups reached statistically significant improvement compared with the initial VAS for pain, but there was no significant difference between groups. The same was true in the secondary outcome measures. Due to group changes, the results were also analysed per protocol: operated or not. No significant differences between the groups were found. CONCLUSION The natural history of rotator cuff tendinopathy probably plays a significant role in the results in the long-term. Even though the patients who underwent operative treatment had a stronger belief in recovery, which is likely to be surgical and the effect of placebo, the exercise group obtained similar results. In the future, an optimum exercise regime should be searched for, as the most clinically and cost-effective conservative treatment for rotator cuff tendinopathy. Cite this article: Bone Joint J 2017;99-B:799-805.
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Compressive cryotherapy versus ice-a prospective, randomized study on postoperative pain in patients undergoing arthroscopic rotator cuff repair or subacromial decompression.
Kraeutler, MJ, Reynolds, KA, Long, C, McCarty, EC
Journal of shoulder and elbow surgery. 2015;(6):854-9
Abstract
BACKGROUND The purpose of this study was to compare the effect of compressive cryotherapy (CC) vs. ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. A commercial device was used for postoperative CC. A standard ice wrap (IW) was used for postoperative cryotherapy alone. METHODS Patients scheduled for rotator cuff repair or subacromial decompression were consented and randomized to 1 of 2 groups; patients were randomized to use either CC or a standard IW for the first postoperative week. All patients were asked to complete a "diary" each day, which included visual analog scale scores based on average daily pain and worst daily pain as well as total pain medication usage. Pain medications were then converted to a morphine equivalent dosage. RESULTS Forty-six patients completed the study and were available for analysis; 25 patients were randomized to CC and 21 patients were randomized to standard IW. No significant differences were found in average pain, worst pain, or morphine equivalent dosage on any day. CONCLUSION There does not appear to be a significant benefit to use of CC over standard IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. Further study is needed to determine if CC devices are a cost-effective option for postoperative pain management in this population of patients.
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Ossifying tendinitis of the rotator cuff after arthroscopic excision of calcium deposits: report of two cases and literature review.
Merolla, G, Dave, AC, Paladini, P, Campi, F, Porcellini, G
Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics and Traumatology. 2015;(1):67-73
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Abstract
Ossifying tendinitis (OT) is a type of heterotopic ossification, characterized by deposition of hydroxyapatite crystals in a histologic pattern of mature lamellar bone. It is usually associated with surgical intervention or trauma and is more commonly seen in Achilles or distal biceps tendons, and also in the gluteus maximus tendon. To our knowledge, there is no description of OT as a complication of calcifying tendinitis of the rotator cuff. In this report, we describe two cases in which the patients developed an OT of the supraspinatus after arthroscopic removal of calcium deposits. The related literature is reviewed.
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Does a water-training macrocycle really create imbalances in swimmers' shoulder rotator muscles?
Batalha, N, Marmeleira, J, Garrido, N, Silva, AJ
European journal of sport science. 2015;(2):167-72
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Abstract
The continuous execution of swimming techniques may cause muscle imbalances in shoulder rotators leading to injury. However, there is a lack of published research studies on this topic. The aim of this study was to analyze the influence of a competitive swim period on the shoulder rotator-cuff balance in young swimmers. A randomized controlled pretest-posttest design was used, with two measurements performed during the first macrocycle of the swimming season (baseline and 16 weeks). Twenty-seven young male swimmers (experimental group) and 22 male students who were not involved in swim training (control group) with the same characteristics were evaluated. Peak torque of shoulder internal and external rotators was assessed. Concentric action at 1.04 rad s(-1) (3 repetitions) and 3.14 rad s(-1) (20 repetitions) was measured using an isokinetic dynamometer (Biodex System 3). External/internal rotators strength ratios were also obtained. For both protocols, there were significant training effects on internal rotator strength and external/internal rotator ratios (p ≤ .05). This trend was the same for both shoulders. Within-group analysis showed significant changes from baseline to 16 weeks for internal rotators strength and unilateral ratios of the experimental group. Swimmers' internal rotator strength levels increased significantly. In contrast, a significant decrease of the unilateral ratios was observed. Findings suggest that a competitive swim macrocycle leads to an increase in muscular imbalances in the shoulder rotators of young competitive swimmers. Swimming coaches should consider implementing a compensatory strength-training program.
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Multimodal analgesia for arthroscopic rotator cuff repair: a randomized, placebo-controlled, double-blind trial.
Jo, CH, Shin, JS, Huh, J
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2014;(3):315-22
Abstract
BACKGROUND The aim of the study was to investigate whether a multimodal analgesia (MMA) protocol reduces postoperative pain and opioids consumption in patients undergoing arthroscopic rotator cuff repair. METHODS Fifty-four patients scheduled for arthroscopic rotator cuff repair were randomly assigned to either the MMA group or the control group. The primary outcome was visual analog scale (VAS) for pain. Secondary outcome measures included the time required for the VAS pain to reduce to that of a blood draw, (PCA) consumption, rescue morphine consumption, night awakening, and opioid-related side effects. RESULTS The MMA group showed significantly less postoperative pain at postoperative 5 h, and 9 a.m. and 5 p.m. at 4th postoperative day (P < 0.001, = 0.040, and 0.013, respectively). MMA also shortened the time for postoperative pain to reduce down to the blood draw pain level from 5 days in the control group to 2 days in the MMA group. MMA also significantly reduced PCA consumption for up to 24 h postoperatively (P = 0.038) and rescue morphine consumption during the first 6 h and between 48 and 60 h postoperatively (P = 0.036 and 0.044, respectively). No significant differences were observed between the MMA and control groups with respect to side effects. CONCLUSION The MMA protocol used in this study was found to reduce postoperative pain and opioid consumption during the acute postoperative period after arthroscopic rotator cuff repair without increasing side effects after arthroscopic rotator cuff repair.
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Double-needle ultrasound-guided percutaneous treatment of rotator cuff calcific tendinitis: tips & tricks.
Sconfienza, LM, Viganò, S, Martini, C, Aliprandi, A, Randelli, P, Serafini, G, Sardanelli, F
Skeletal radiology. 2013;(1):19-24
Abstract
Rotator cuff calcific tendinitis is a very common disease and may result in a very painful shoulder. Aetiology of this disease is still poorly understood. When symptoms are mild, this disease may be treated conservatively. Several treatment options have been proposed. Among them, ultrasound-guided procedures have been recently described. All procedures use one or two needles to inject a fluid, to dissolve calcium and to aspirate it. In the present article, we review some tips and tricks that may be useful to improve performance of an ultrasound-guided double-needle procedure.
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Tramadol and 0.5% levobupivacaine for single-shot interscalene block: effects on postoperative analgesia in patients undergoing shoulder arthroplasty.
Alemanno, F, Ghisi, D, Fanelli, A, Faliva, A, Pergolotti, B, Bizzarri, F, Fanelli, G
Minerva anestesiologica. 2012;(3):291-6
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy of tramadol as an adjuvant to the local anaesthetic solution in patients undergoing shoulder arthroscopy for rotator cuff tear after middle interscalene block (MIB). METHODS We enrolled 120 patients (ASA I-II), scheduled for arthroscopic surgery for rotator cuff tear. The patients were sedated with midazolam 0.02 mg/kg and haloperidol 2 mg i.v. before performing MIB. All subjects underwent a MIB with 0.4 mL/kg of 0.5% levobupivacaine. After computerized randomization, all patients were allocated in 1 of 3 groups, each including 40 subjects. Group Placebo (Group P) received 0.4 mL/kg of 0.5% levobupivacaine plus isotonic sodium chloride for MIB and isotonic sodium chloride i.m. Group "Perineural Tramadol" (Group TPN) received 0.4 ml/Kg of 0.5% levobupivacaine plus 1.5 mg/kg of tramadol perineurally and isotonic sodium chloride i.m. Group "Intramuscular Tramadol" (Group TIM) received 0.4 ml/Kg of 0.5% levobupivacaine plus isotonic sodium chloride perineurally and 1.5 mg/kg of tramadol i.m. RESULTS The MIB onset times were not statistically different in the three groups. The duration of analgesia was significantly longer in Groups TPN and TIM, where tramadol was administered, either i.m. or perineurally, compared with the placebo group. A significant statistical difference was found in the duration of analgesia between the group TPN and TIM. CONCLUSION The addition of tramadol to the local anaesthetic solution administered for MIB provided a longer duration of analgesia compared with placebo and i.m tramadol administration in patients undergoing arthroscopic surgery for rotator cuff tear.
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Extracorporeal shock-wave therapy for supraspinatus calcifying tendinitis: a randomized clinical trial comparing two different energy levels.
Ioppolo, F, Tattoli, M, Di Sante, L, Attanasi, C, Venditto, T, Servidio, M, Cacchio, A, Santilli, V
Physical therapy. 2012;(11):1376-85
Abstract
BACKGROUND Extracorporeal shock-wave therapy (ESWT) represents a valid intervention in the treatment of people with supraspinatus calcifying tendinitis (SCT), but there is limited evidence for the useful range of ESWT doses. OBJECTIVE The aim of this study was to compare 2 different ranges of energy flux density in treatment of SCT with ESWT. DESIGN This study was designed as a single-blind randomized clinical trial. SETTING This study was performed in a university hospital. PATIENTS Forty-six patients with SCT were randomly assigned to 2 groups that received different therapeutic energy doses of ESWT (1) group A received ESWT at an energy level of 0.20 mJ/mm², and (2) group B received ESWT at an energy level of 0.10 mJ/mm². INTERVENTION The treatment protocol consisted of 4 sessions performed once a week. MEASUREMENTS The change in mean Constant Murley Scale (CMS) scores at 3 and 6 months was the primary endpoint. The change in the mean visual analog scale (VAS) scores from baseline to 3 and 6 months after the intervention and radiographic change in size of calcium deposits were evaluated as secondary endpoints. At 12 months, pain relief was assessed using a numeric rating scale. RESULTS Significant clinical improvement based on mean CMS scores was observed after 6 months in group A (X=79.43, SD=10.33) compared with group B (X=57.91, SD=6.53). Likewise, after 6 months, a significant decrease in VAS scores was found in group A (X=2.09, SD=1.54) compared with group B (X=5.36, SD=0.78). Calcific deposits disappeared in the same percentage of patients in both groups. LIMITATIONS The small sample size and lack of a control group were limitations of the study. CONCLUSIONS In ESWT for SCT, an energy level of 0.20 mJ/mm² appears to be more effective than an energy level of 0.10 mJ/mm² in pain relief and functional improvement.