Arthroscopic Palliative Resection of the Rotator Cuff in Patients with Unreconstructible Lesions

PURPOSE OF THE STUDYTo evaluate the results of arthroscopic capsular release for the treatment of severe frozen shoulder syndrome. Between 2006 and 2008, 27 patients with severe frozen shoulder syndrome were treated by arthroscopic capsular release. The average age of the patients was 54 years (range, 34 to 75), 15 were men and 12 were women. The right shoulder was operated on more frequently (16 patients). The average pre-operative flexion was 73 degrees (range, 10° to 150°) and pre-operative abduction was 56 degrees (10° to 140°). The average Constant score was 35 points. MATERIAL METHODSWith the patient in a lateral recumbent position, arthroscopic release of the joint capsule is performed with the Mitek VAPR 3 radiofrequency system, using a hook or an LPS electrode. The rotator interval, coracohumeral ligament, superior and middle glenohumeral ligaments and anterior part of the inferior glenohumeral ligament are gradually released, as well as the anterior glenohumeral joint capsule along its full width at the anterior rim of the labrum.To avoid damage to the axillary nerve, the axillary part of the joint capsule is released along the edge of the glenoid cavity. When internal rotation in abduction still remains restricted, release is extended to the posterior glenohumeral joint capsule. The procedure also involves exploration of the subacromial space and, if necessary, subacromial bursectomy or acromioplasty. Subsequently, the range of motion after release is tested and, when necessary, the remaining fibres of the joint capsule are disintegrated by careful manipulation (redress). The surgery is followed by analgesic and rehabilitation therapy. RESULTSAll treated patients reported an improved range of motion. The average post-operative flexion and abduction extended to 160 degrees and 155 degrees, respectively, and 23 patients gained the motion range necessary for normal shoulder function.The average Constant score was 80.3 points and the University of California at Los Angeles (UCLA) score was 28.6 points. When using the school marking system, the average result evaluation was 1.75. All patients were satisfied with the outcome and were willing to undergo surgery on the other side if need be. No complications were recorded. DISCUSSIONTherapy for frozen shoulder can be conservative or surgical. Most of the cases can be managed by correct conservative treatment. In accordance with the current literature data, we are using arthroscopic capsular release in resistant cases. This technique allows us to release contracted structures without the risk of iatrogenic injury and offers possibilities for the treatment of co-existing lesions. In the majority of patients this procedure can remedy their complaints, although the affected shoulder joint rarely remains asymptomatic. The aim of this approach is to accelerate the treatment of this disability; the long-term results are similar to those of conservative therapy. CONCLUSIONSArthroscopic capsular release is the method of choice for the treatment of frozen shoulder synd...

Arthroscopic Capsular Release in Frozen Shoulder Syndrome

Musil¹,

Sadovský²,

Stehlík³

et al. 2009

Calcareous Tendinitis of the Shoulder. Treatment by Needling

Lubojacký¹

2009

PURPOSE OF THE STUDYCalcareous tendinitis (calcifying tendinitis) of the shoulder is a disease characterized by the formation of macroscopic deposits of hydroxyapatite (a crystalline calcium phosphate) in any tendon of the rotator cuff. It presents clinically as sudden intense pain flares resembling gout. It can be treated most effectively by invasive methods such as surgery or needling. The latter is associated with lower risks and fewer organizational and financial demands. The aim of this study is to promote the use of needling in orthopaedic outpatient departments where ultrasonography is available for diagnosis and guided intervention. MATERIALIn the period from 2000 to 2006, a total of 38 shoulders (36 patients) with calcareous tendinitis were treated. In one patient both shoulders were effected five years apart, and one patient experienced recurrence in the same shoulder after 2 years. Needling was performed in 36 shoulders, two cases were treated arthroscopically. METHODSNeedling as the primary therapy was indicated immediately after the diagnosis had been established usually on the first patient's visit, and was carried out under local anaesthesia as an outpatient procedure. The tendon with calcareous deposits was perforated with a needle under sonographic guidance and, in the majority of cases, this calcareous material was aspirated. When signs of subacromial bursitis were present, Depomedrol was administered during or following the procedure. RESULTSThe outcome was evaluated at an average follow-up of 23.4 months (range, 5 to 89). All outcomes were from excellent to satisfactory, with no poor result. Five patients underwent further treatment for impingement syndrome which two of them had already had before the needling procedure. One patient reported slightly restricted range of motion due to subsequent adhesive capsulitis. However, she was not limited in her daily activities and therefore did not require any further therapy. Five patients with occasional unspecific complaints, usually in relation to wheather changes or exercise, did not ask for any further treatment either. CONCLUSIONSNeedling is an effective method to treat calcareous tendinitis and provides results comparable with those of arthroscopy, but without operative risks. It is much less expensive (10-to 20-times) with no additional demands for either the patient or the institution. Today, the majority of orthopaedic outpatient departments in the Czech Republic have the necessary facilities and should include needling in the procedures routinely performed.

Central Motor Deficits of the Deltoid Muscle in Patients with Chronic Rotator Cuff Tears

Berth¹,

Pap²,

Awiszus³

et al. 2009

PURPOSE OF THE STUDYPrevious surface EMG studies have shown that chronic rotator cuff tears (RCT) may be associated with a altered activation of adjacent shoulder muscles. The effect of RCT on central neuromuscular control mechanisms of the shoulder girdle muscles such as the deltoideus muscle (MD), a key muscle of shoulder function, has as yet not been studied in detail. This study investigated the cortico-spinal excitability of the MD to assess the effects of RCT on the central neuromuscular function of upper limb muscles. MATERIAL AND METHODSThe motor evoked potentials (MEP) in response to transcranial magnetic stimulation of MD and first dorsal interosseus muscle (FDI) on both sides were obtained of six right-handed men with chronic, symptomatic, full-thickness RCT on the dominant sides. Stimulus response curves at four different levels were measured at two tasks (MD at rest and during activity). RESULTSDifferent interactions were found between stimulus intensity, task and side for MEP of the MD (F = 3.9, P = 0.03), indicating that MD excitability on the affected side were lower when compared with the non-affected side. No correlation was found between the correspondent MEP amplitudes of MD and FDI at rest (r = 0.1, P = 0.44) and MD activation (r = 0.3, P = 0.05) on the affected side whereas a correlation existed on the non-affected side at rest (r = 0.5, P = 0.007) and during activation (r = 0.8, P < 0.001). CONCLUSIONSThese decreased cortico-motoneuronal excitability of the MD on the affected side seems to related to adaptive changes in motor cortex as a consequence of chronic RCT. The data suggest an involvement of central mechanisms and seem to precede severe changes of osteoarthritis of the shoulder.