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Guevara-Alvarez A, Valencia-Ramon EA, Bothorel H, Collin P, Zbinden J, Guizzi A, Lädermann A. Traumatic and Atraumatic Rotator Cuff Tears Have the Same Rates of Healing. Arthrosc Sports Med Rehabil 2024; 6:100867. [PMID: 38379596 PMCID: PMC10877195 DOI: 10.1016/j.asmr.2023.100867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/15/2023] [Indexed: 02/22/2024] Open
Abstract
Background To examine whether traumatic rotator cuff repairs (RCRs) differ in postoperative rotator cuff tendon integrity and functional outcomes from degenerative RCRs. Methods RCRs performed by a single surgeon were retrospectively identified. The inclusion criteria were repairable Goutallier grades 0 to 2 full-thickness rotator cuff tears. Demographic and clinical data as well as radiological results were compared. A multivariate logistic regression of the of patient acceptable symptom state for American Shoulder and Elbow Surgeons (ASES) score was performed to evaluate whether the origin of tear led to a different relative risk (RR) independently from tear and surgical characteristics. Results A total of 616 consecutive shoulders (304 traumatic and 312 degenerative) were finally included. Traumatic ruptures presented a greater distribution of male (72% vs 51%, P < .001) and younger patients (53 vs 57 years, P < .001), as well as earlier onset of symptoms (3 vs 15 months, P < .001), reduced range of motion in preoperative assessment for forward elevation (130° vs 150°, P < .001), and slightly greater preoperative ASES (46.5 ± 19.7 vs 50.0 ± 18.0, P = .022) and Constant (47.0 ± 20.2 vs 52.0 ± 18.9, P = .001) scores. Degenerative tears presented a lower proportion of grade 3 tendon coronal retraction (11% vs 18%, P = .031). Postoperative tendon integrity at 6 months was comparable for both groups, predominantly Sugaya types 1 and 2 (91% traumatic; 92% degenerative, P = .371). Both groups exhibited favorable outcomes in range of motion and postoperative functional scores at last follow-up. The multivariate regression confirmed that the tear origin was not significantly associated with patient acceptable symptom state achievement (P = .201) but rather with greater preoperative ASES score (RR, 1.01), men (RR, 1.16) and workers' compensation (RR, 0.65) (P < .05). Conclusions Traumatic cases were frequent, involved younger patients, more frequently affected the anterior rotator cuff, and were associated with more severe tendon retraction. Traumatic and degenerative RCRs lead to comparable clinical and radiologic results. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
| | | | - Hugo Bothorel
- Research Department, La Tour Hospital, Meyrin, Switzerland
| | | | - Jeanni Zbinden
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alberto Guizzi
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia (BS), Italy
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Nyffeler RW, Lustenberger A, Bissig P. [Can a fall onto the shoulder (direct impact) cause a rotator cuff tear?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:195-200. [PMID: 38374440 PMCID: PMC10896884 DOI: 10.1007/s00132-024-04474-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 02/21/2024]
Abstract
The question of whether a fall directly onto the shoulder can cause a rotator cuff tear has occupied doctors (and courts) for many years. Experts who rely on the medical insurance literature usually reject the causality of the incident. There are no scientific studies on this. The report below describes a typical case in which a fall directly onto the shoulder caused a massive rotator cuff tear.
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Affiliation(s)
- Richard W Nyffeler
- Orthopädie Sonnenhof KLG, Salvisbergstrasse 4, 3006, Bern, Schweiz.
- Campus Stiftung Lindenhof Bern (Campus SLB), Salvisbergstrasse 4, 3006, Bern, Schweiz.
| | | | - Philipp Bissig
- Orthomed, Orthopädische Chirurgie Biel-Seeland, Bifangweg 1, 3270, Aarberg, Schweiz
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Furrer PR, Borbas P, Egli RJ, Zindel C, Wieser K, Bouaicha S. MRI findings of traumatic and degenerative rotator cuff tears and introduction of the "cobra sign". JSES Int 2023; 7:550-554. [PMID: 37426911 PMCID: PMC10328769 DOI: 10.1016/j.jseint.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023] Open
Abstract
Background A rotator cuff tear (RCT) is a common shoulder diagnosis and its etiology may be acute, traumatic, or chronic degenerative. Differentiation between the 2 etiologies may be important for multiple reasons, but remains difficult based on imaging. Further knowledge about radiographic and magnetic resonance findings to distinguish traumatic from degenerative RCT is needed. Methods We analyzed magnetic resonance arthrograms (MRAs) of 96 patients with traumatic or degenerative superior RCT, which were matched according their age and the affected rotator cuff muscle into the 2 groups. Patients older than 66 years of age were excluded from the study to avoid including cases with pre-existing degeneration. In the case of traumatic RCT, the time between the trauma and MRA had to be less than 3 months. Various parameters of the supraspinatus (SSP) muscle-tendon unit were assessed (tendon thickness, presence of a remaining tendon stump at the greater tubercle, magnitude of retraction, layer appearance). The retraction of the 2 SSP layers were individually measured to determine the difference of retraction. Additionally, edema of the tendon and muscle, the tangent- and kinking-sign as well as the newly introduced Cobra-sign (bulging of the distal part of the ruptured tendon with slim configuration of the medial part of the tendon) were analyzed. Results Edema within the SSP muscle (sensitivity 13%, specificity 100%, P = .011) or the tendon (sensitivity 86%, specificity 36%, P = .014) are more frequent in traumatic RCT. The same association was found for the kinking-sign (sensitivity 53%, specificity 71%, P = .018) and the Cobra sign (sensitivity 47%, specificity 84%, P = .001). Even though not statistically significant, tendencies were observed toward thicker tendon stumps in traumatic RCT, and greater difference in retraction between the 2 SSP layers in the degenerative group. The cohorts had no difference in the presence of a tendon stump at the greater tuberosity. Conclusion Muscle and tendon edema, as well as tendon kinking appearance and the newly introduced cobra-sign are suitable MRA parameters to distinguish between traumatic and degenerative etiology of a superior RTC.
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Affiliation(s)
- Pascal R. Furrer
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paul Borbas
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Rainer J. Egli
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Zindel
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Samy Bouaicha
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Wang S, Lädermann A, Chiu J, Nabergoj M, Ho SWL, Brigitte VR, Bothorel H, Lädermann L, Kolo F. Muscle Edema of Retraction and Pseudo-Fatty Infiltration After Traumatic Rotator Cuff Tears: An Experimental Model in Sheep. Orthop J Sports Med 2023; 11:23259671231154275. [PMID: 36874052 PMCID: PMC9982832 DOI: 10.1177/23259671231154275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/21/2022] [Indexed: 03/04/2023] Open
Abstract
Background Traumatic rotator cuff tears can result in retraction of the tendon and may be associated with muscle edema, which may be confused with fatty infiltration as seen on magnetic resonance imaging (MRI). Purpose To describe the characteristics of a type of edema associated with acute retraction of the rotator cuff tendon (termed "edema of retraction") and to highlight the risk of mistaking it with pseudo-fatty infiltration of the rotator cuff muscle. Study Design Descriptive laboratory study. Methods A total of 12 alpine sheep were used for analysis. On the right shoulder, osteotomy of the greater tuberosity was performed to release the infraspinatus tendon; the contralateral limb acted as the control. MRI was performed immediately after surgery (time zero) and at 2 and 4 weeks postoperatively. T1-weighted, T2-weighted, and Dixon pure-fat sequences were reviewed for hyperintense signals. Results Edema of retraction resulted in hyperintense signals around or within the retracted rotator cuff muscle on both T1- and T2-weighted imaging, but there was an absence of hyperintense signals on Dixon pure-fat imaging. This represented pseudo-fatty infiltration. Edema of retraction created a characteristic "ground glass" appearance of the muscle on T1-weighted sequences and was often found in either the perimuscular or intramuscular location of the rotator cuff muscle. Compared to time zero values, a decrease in the percentage of fatty infiltration was observed at 4 weeks postoperatively (16.5% ± 4.0% vs 13.8% ± 2.9%, respectively; P < .005). Conclusion The location of edema of retraction was often peri- or intramuscular. Edema of retraction presented as a characteristic "ground glass" appearance of the muscle on T1-weighted sequences and led to a decrease in the fat percentage because of a dilution effect. Clinical Relevance Physicians should be aware that this edema can result in a form of pseudo-fatty infiltration, as it is associated with hyperintense signals on both T1- and T2-weighted sequences, and it can be mistaken for fatty infiltration.
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Affiliation(s)
- Sidi Wang
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland.,Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Joe Chiu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Taoyuan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Taoyuan
| | - Marko Nabergoj
- Valdoltra Orthopedic Hospital, Ankaran, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Sean W L Ho
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore
| | - von Rechenberg Brigitte
- Musculoskeletal Research Unit, University of Zurich, Zurich, Switzerland.,Competence Center for Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich, Switzerland
| | - Hugo Bothorel
- Research Department, La Tour Hospital, Meyrin, Switzerland
| | - Léo Lädermann
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Frank Kolo
- Rive Droite Radiology Center, Geneva, Switzerland
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Zhao J, Luo M, Liang G, Pan J, Han Y, Zeng L, Yang W, Liu J. What Factors Are Associated with Symptomatic Rotator Cuff Tears: A Meta-analysis. Clin Orthop Relat Res 2022; 480:96-105. [PMID: 34424222 PMCID: PMC8673964 DOI: 10.1097/corr.0000000000001949] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/02/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tears are common. A previous systematic review reported on factors associated with rotator cuff tears; however, it included relatively few studies and few variables, and in addition, it had considerable heterogeneity. To identify the factors associated with symptomatic rotator cuff tears and to help guide clinicians to potentially modifiable factors, we felt a broader and more inclusive meta-analysis would be useful. QUESTIONS/PURPOSES In this systematic review and meta-analysis, we asked what (1) demographic, (2) disease, and (3) imaging factors are associated with symptomatic rotator cuff tears? METHODS PubMed, Embase, and Web of Science were searched, and the search period were from the inception of each database through February 2021. The keywords included "risk factor," "rotator cuff injury," "rotator cuff tears," and "rotator cuff tendinitis." All comparative studies on symptomatic rotator cuff tears were included. We considered that the diagnosis of rotator cuff tear could be made by any imaging tool (MRI or ultrasound). We considered either partial- or full-thickness tears to be a rotator cuff tear. No language restrictions were applied. Twenty-six articles from 14 countries involving 9809 individuals, consisting of 3164 patients and 6645 controls, were included. The Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality (AHRQ) scale were used to evaluate the risk of bias of the included studies, and the highest scores were 9 and 11, respectively. The Newcastle-Ottawa Scale was used for retrospective comparative studies, and the AHRQ was used to evaluate prospective comparative studies. The eight retrospective comparative studies we included were scored from 4 to 9. The quality score of the 18 prospective comparative studies ranged from 6 to 9. Publication bias was explored using the Egger test. Heterogeneity was estimated using the I2 value. If there was no heterogeneity (I2 ≤ 50%), a fixed-effects model was used to determine the overall effect size; if there was heterogeneity (I2 > 50%), a random-effects model was used to merge the effect values. A meta-analysis was performed with RevMan 5.3, and the risk ratio (RR) and weighted mean difference of related factors were calculated. RESULTS Our meta-analysis identified the following demographic factors associated with an increased risk of rotator cuff tears: older age (mean difference 3.1 [95% CI 1.4 to 4.8]; p < 0.001), greater BMI (mean difference 0.77 [95% CI 0.37 to 1.17]; p < 0.001), smoking (RR 1.32 [95% CI 1.17 to 1.49]; p < 0.001), dominant arm (RR 1.15 [95% CI 1.06 to 1.24]; p < 0.001), greater height (mean difference 0.9 [95% CI 0.4 to 1.4]; p < 0.001), and heavier weight (mean difference 2.24 [95% CI 0.82 to 3.66]; p = 0.002). Regarding disease factors, we found that traumatic events (RR 1.91 [95% CI 1.40 to 2.54]; p < 0.001) and hypertension (RR 1.50 [95% CI 1.32 to 1.70]; p < 0.001) were associated with symptomatic rotator cuff tears. Regarding imaging factors, we found that the following three factors were associated with symptomatic rotator cuff tears: greater acromion index (mean difference 0.11 [95% CI 0.06 to 0.16]; p < 0.001), greater critical shoulder angle (mean difference 1.9 [95% CI 1.5 to 2.3]; p < 0.001), and smaller glenoid version angle (mean difference -1.3 [95% CI -1.9 to -0.8]; p < 0.001). We found no association between the patient's sex or the presence or absence of thyroid disease and the likelihood of a rotator cuff tear being present. CONCLUSION This study identified several factors associated with symptomatic rotator cuff tears, including blood glucose, blood pressure, weight, and smoking. Clinicians may seek to modify these factors, possibly in patients with symptomatic rotator cuff tears, but also in symptomatic patients who have not yet been diagnosed with rotator cuff tears because there would be no harm or risk associated with modifying any of the factors we identified. Future research should further study whether addressing these factors can delay the progression and size of rotator cuff tears.Level of Evidence Level III, prognostic study.
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Affiliation(s)
- Jinlong Zhao
- The Second School of Clinical Medical Sciences, Guangzhou University of Chinese Medicine, Guagnzhou, China
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
| | - Minghui Luo
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Guihong Liang
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Jianke Pan
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Yanhong Han
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Lingfeng Zeng
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Weiyi Yang
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
| | - Jun Liu
- Research Team on Bone and Joint Degeneration and Injury, Guangdong Academy of Traditional Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital, Guangzhou University of Chinese Medicine (Guangdong Province Hospital of Traditional Chinese Medicine), Guangzhou, China
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Porschke F, Loew M, Schnetzke M. Traumatische vs. degenerative Rotatorenmanschettenläsion. ARTHROSKOPIE 2021. [DOI: 10.1007/s00142-021-00438-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pogorzelski J, Erber B, Themessl A, Rupp MC, Feucht MJ, Imhoff AB, Degenhardt H, Irger M. Definition of the terms "acute" and "traumatic" in rotator cuff injuries: a systematic review and call for standardization in nomenclature. Arch Orthop Trauma Surg 2021; 141:75-91. [PMID: 33130936 PMCID: PMC7815591 DOI: 10.1007/s00402-020-03656-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/15/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although of high relevance for clinical decision making, there exists no consensus throughout the literature of the terms "acute" and "traumatic" used in the classification of rotator cuff tears. With differing definitions, the comparability of outcome studies may be limited. The aim was to provide a detailed systematic review of the definitions used in the literature and present a suggestion for a standardization in nomenclature based on the findings. METHODS Four different internet databases were searched in February 2020 using the terms ("acute" OR "traumatic" OR "trauma" OR "athlete" OR "young") AND ("rotator cuff tears" OR "rotator cuff tear" OR "rotator cuff" OR "rotator cuff rupture" OR "supraspinatus" OR "infraspinatus" OR "subscapularis" OR "teres minor"). Prospective, retrospective, cohort and case-control studies as well as case series were included. Systematic reviews, cadaveric or laboratory studies and studies on non-traumatic or non-acute rotator cuff tears were excluded. RESULTS The literature search conducted 10,349 articles of which 10,151 were excluded based on the title, 119 based on the abstract and 33 based on the manuscript. A total of 46 studies were finally included for review and subsequently analyzed. Overall, there exists no consensus neither on the term "acute" nor on "traumatic" in the context of rotator cuff tears in the literature. The time span for acute injuries ranged between 2 weeks and 6 months. For traumatic injuries, only 20% of the selected studies described a specific and adequate injury mechanism in combination with adequate imaging. CONCLUSION The term "acute" should be reserved for RCT showing muscle edema, wavelike appearance of the central part of the torn tendon and joint effusion, which typically requires adequate imaging within 2 weeks from trauma. Repair of acute tears should occur within 8 weeks from trauma to benefit from possibly superior biological healing capacities. The term "traumatic" should be used for a sudden onset of symptoms in a previously asymptomatic patient, triggered by an adequate trauma, e.g., a fall on the retroverted arm with an axial cranioventral force or a traumatic shoulder dislocation.
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Affiliation(s)
- Jonas Pogorzelski
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany.
| | - Bernd Erber
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Alexander Themessl
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Marco-Christopher Rupp
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Matthias J Feucht
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
- Department of Orthopaedics and Trauma Surgery, Medical Center, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Andreas B Imhoff
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Hannes Degenhardt
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
| | - Markus Irger
- Department of Orthopedic Sports Medicine, Hospital Rechts Der Isar, Technical University of Munich, Ismaninger Street 22, 81675, Munich, Germany
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Böhm E, Gleich J, Siebenbürger G, Böcker W, Ockert B. [Rotator cuff tear : Indications and pathology-specific reconstructive procedures]. Unfallchirurg 2020; 124:108-116. [PMID: 33346861 DOI: 10.1007/s00113-020-00940-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2020] [Indexed: 11/26/2022]
Abstract
Rotator cuff (RC) tears comprise a broad spectrum of lesions ranging from partial to full thickness tears of a single tendon and massive cuff tears. Both glenohumeral trauma as well as degenerative processes can result in tearing of the RC. Treatment therefore requires a meticulous diagnosis as well as a differentiated approach by careful consideration of morphological and patient-specific factors. The pathogenesis, tear morphology, clinical symptoms and functional demands of the patient determine the therapeutic approach. Despite pathological and individual patient-related factors, early surgical repair is generally recommended for traumatic RC tears in young patients and in patients with high functional demands due to the high risk of tear progression. The results of RC repair are negatively correlated with the size of the lesion, the number of tendons involved, the degree of tendon retraction, muscular alteration and patient age. This article provides an overview of the various pathogenesis, indications and surgical repair of RC tears with respect to modern pathology-specific reconstructive procedures.
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Affiliation(s)
- E Böhm
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - J Gleich
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - G Siebenbürger
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - W Böcker
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität, München, Deutschland
| | - B Ockert
- Sektion Schulter- und Ellenbogenchirurgie, Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum, Ludwig-Maximilians-Universität, München, Deutschland.
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9
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Buckup J, Smolen D, Hess F, Sternberg C, Leuzinger J. The arthroscopic triple-row modified suture bridge technique for rotator cuff repair: functional outcome and repair integrity. J Shoulder Elbow Surg 2020; 29:308-315. [PMID: 31451350 DOI: 10.1016/j.jse.2019.06.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/04/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The optimal technique for arthroscopic rotator cuff repair is still controversial. Large tears with a high grade of retraction have an especially high risk of retearing. This study reports the clinical and radiologic results of a triple-row modified suture bridge technique for the treatment of full-thickness rotator cuff tears with medium and high grades of retraction. METHODS A total of 101 shoulders in 100 patients underwent a triple-row modified suture bridge reconstruction for full-thickness rotator cuff tears with retraction grade II and grade III according to Patte; 81 patients were reached for follow-up 36.2 months after surgery. At follow-up, clinical outcome was assessed by the American Shoulder and Elbow Surgeons score, subjective shoulder value, visual analog scale score, University of California-Los Angeles shoulder score, and Constant score (CS). At follow-up, an ultrasound examination was performed to determine tendon integrity or retears in all patients. RESULTS The overall retear rate was 4.9% (4/81). The clinical outcome was good to excellent (American Shoulder and Elbow Surgeons score, 94 ± 11; subjective shoulder value, 92 ± 12; University of California-Los Angeles shoulder score, 33 ± 5; Constant score, 90 ± 9). In the radiologic follow-up, no retear was found in any of the follow-up patients after an average of 36.2 months. There was no significant difference in clinical outcome parameters between rotator cuff tears Patte II and Patte III (P > .05). CONCLUSION For tears with a high grade of retraction, surgical treatment using a triple-row modified suture bridge technique represents a good treatment option with a low rate of retearing and good to excellent clinical results.
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Affiliation(s)
- Johannes Buckup
- Center for Minimally Invasive Surgery, Etzelclinic, Pfäffikon, Switzerland; Department of Sport Traumatology, Knee, and Shoulder Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Frankfurt am Main, Germany.
| | - Daniel Smolen
- Center for Minimally Invasive Surgery, Etzelclinic, Pfäffikon, Switzerland
| | - Florian Hess
- Department of Orthopaedic Surgery and Traumatology, Cantonal Hospital Frauenfeld, Switzerland
| | | | - Jan Leuzinger
- Center for Minimally Invasive Surgery, Etzelclinic, Pfäffikon, Switzerland
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10
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Abechain JJK, Godinho GG, Matsunaga FT, Netto NA, Daou JP, Tamaoki MJS. Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair. World J Orthop 2017; 8:631-637. [PMID: 28875129 PMCID: PMC5565495 DOI: 10.5312/wjo.v8.i8.631] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/05/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair.
METHODS Eighty-seven patients with rotator cuff tears following arthroscopic treatment were divided into traumatic and non-traumatic tear groups. Postoperative muscle strength and outcomes using the modified University of California, Los Angeles score were evaluated. Sex, age, affected limb and dominant limb were correlated between groups. Muscle strength of the repaired and unaffected shoulders was compared. Rotator cuff injury size was measured.
RESULTS Of the 87 patients who underwent rotator cuff repairs, 35 had traumatic tears and 52 had non-traumatic tears. In patients with non-traumatic tears, the average age was 59 years, 74.5% were female, 96.1% were right-hand dominant and 92.3% had their dominant shoulder affected. Patients with traumatic tears were 59.5 years old on average, 51.4% were female, 91.4% were right-hand dominant and 88.5% had their dominant shoulder affected. No difference existed in the mean modified University of California, Los Angeles score between patients with traumatic tears (33.7) compared with those with non-traumatic tears (32.8). No strength differences were observed between groups: The strength difference between the non-affected and affected sides was 1.21 kg in the non-traumatic group and 1.39 kg in the traumatic group (P = 0.576), while the strength ratio between the non-affected/affected sides was 0.805 in the non-traumatic group and 0.729 in the traumatic group (P = 0.224).
CONCLUSION The functional results of traumatic rotator cuff repairs are similar to non-traumatic tears. Both outcomes are satisfactory.
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Comparison of outcomes with arthroscopic repair of acute-on-chronic within 6 months and chronic rotator cuff tears. J Shoulder Elbow Surg 2017; 26:648-655. [PMID: 27881294 DOI: 10.1016/j.jse.2016.09.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/25/2016] [Accepted: 09/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to define preoperative and intraoperative findings of acute-on-chronic rotator cuff tears (RCTs). This study also compared the functional and clinical outcomes with acute-on-chronic RCTs and chronic RCTs. METHODS This study was conducted between December 2007 and December 2013. An acute-on-chronic full-thickness RCT was diagnosed with preoperative and intraoperative findings on arthroscopy. The study group consisted of 36 patients with preoperative and intraoperative findings (surgery performed within 6 months of trauma) indicative of an acute-on-chronic RCT. Another 36 patients matched for age, sex, and tear size, who underwent arthroscopic rotator cuff repair after 6 months of onset of symptoms (chronic RCT group), were selected from our institution's database within the same time frame. Postoperative indirect magnetic resonance arthrogram was obtained 6 months after the repair, and rotator cuff integrity was graded according to the guidelines as described by Sugaya. Patients were evaluated using the visual analog scale for pain, American Shoulder and Elbow Surgeons Shoulder Assessment score, and Constant scores. Scores and measurements were obtained preoperatively and at 6, 12, and 24 months after surgery. RESULTS The clinical outcomes and range of motion recovery were better in the acute-on-chronic RCT group. Although statistically not significant, the acute-on-chronic RCT group's repair appeared closer to the complete repair and was associated with a lesser incidence of retear than the chronic RCT group. CONCLUSION Early repair of an acute-on-chronic full-thickness RCT results in a statistically and clinically superior improvement in outcomes compared with repairs of chronic RCTs.
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Balke M, Liem D, Greshake O, Hoeher J, Bouillon B, Banerjee M. Differences in acromial morphology of shoulders in patients with degenerative and traumatic supraspinatus tendon tears. Knee Surg Sports Traumatol Arthrosc 2016; 24:2200-5. [PMID: 25547273 DOI: 10.1007/s00167-014-3499-y] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 12/22/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Distinct characteristics of acromial morphology seem to be one factor for the development of degenerative supraspinatus tendon tears. Thus, it is questionable whether patients with traumatic tendon tears also present these parameters. The hypothesis of the present study was that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears. METHODS One hundred and thirty-six patients that were treated by arthroscopic rotator cuff repair from 2010 to 2013 were included in this study. Seventy-two patients had degenerative (group 1), and 64 had traumatic (group 2) supraspinatus tendon tears. On preoperative radiographs the Bigliani type, acromial slope, acromiohumeral (AH) distance, lateral acromial angle (LAA), acromion index (AI), and critical shoulder angle (CSA) were measured. Medians of these parameters as well as of age of both groups were compared using the t test. RESULTS The percentaged distribution of the Bigliani type differed (group 1 vs. 2: type 1: 18/38, type 2: 56/55, type 3: 26/8). All parameters showed significant differences between degenerative and traumatic tears. Slope: 21.2° (SD 7.6°) versus 19.2° (SD 7.9°, p = 0.026), AH distance: 8.4 mm (SD 2.3 mm) versus 9.9 mm (SD 1.9 mm, p = 0.0006), LAA: 77.0° (SD 4.0°) versus 82.5° (SD 4.7°, p < 0.0001), AI: 0.77 (SD 0.07) versus 0.73 (0.06, p = 0.0239), and CSA: 36.8° (SD 3.6°) versus 35.3° (SD 2.9°, p = 0.007). An LAA <70° or an AH distance of <5 mm only occurred in degenerative tears. Patients with degenerative tears were significantly older (60 vs. 54 years). CONCLUSIONS The hypothesis that the acromial morphology of patients with degenerative supraspinatus tendon tears differs from patients with traumatic tears was confirmed. Shoulders with degenerative tears show a narrower subacromial space and a larger lateral extension as well as a steeper angulation of the acromion than with traumatic tears. Thus, the results of this study support the theory of external impingement as a cause for degenerative rotator cuff tears. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Maurice Balke
- Sportsclinic Cologne, Cologne-Merheim Medical Center, University of Witten-Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany. .,Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany.
| | - Dennis Liem
- Department of Orthopaedic Surgery, University Hospital Muenster, Münster, Germany
| | - Oliver Greshake
- Sportsclinic Cologne, Cologne-Merheim Medical Center, University of Witten-Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Juergen Hoeher
- Sportsclinic Cologne, Cologne-Merheim Medical Center, University of Witten-Herdecke, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
| | - Marc Banerjee
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University of Witten-Herdecke, Cologne, Germany
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Loew M, Magosch P, Lichtenberg S, Habermeyer P, Porschke F. How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging. J Shoulder Elbow Surg 2015; 24:1685-93. [PMID: 26234668 DOI: 10.1016/j.jse.2015.06.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/14/2015] [Accepted: 06/01/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs. METHODS Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol. RESULTS No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups. CONCLUSION MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.
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Affiliation(s)
- Markus Loew
- Department of Shoulder and Elbow Surgery, ATOS Clinic, Heidelberg, Germany
| | - Petra Magosch
- Department of Shoulder and Elbow Surgery, ATOS Clinic, Heidelberg, Germany
| | - Sven Lichtenberg
- Department of Shoulder and Elbow Surgery, ATOS Clinic, Heidelberg, Germany
| | - Peter Habermeyer
- Department of Shoulder and Elbow Surgery, ATOS Clinic, Munich, Germany
| | - Felix Porschke
- BG Trauma Center Ludwigshafen at Heidelberg University Hospital, Ludwigshafen, Germany.
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Steinert AF, Kunz M, Prager P, Göbel S, Klein-Hitpass L, Ebert R, Nöth U, Jakob F, Gohlke F. Characterization of bursa subacromialis-derived mesenchymal stem cells. Stem Cell Res Ther 2015; 6:114. [PMID: 26036250 PMCID: PMC4479225 DOI: 10.1186/s13287-015-0104-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 08/15/2014] [Accepted: 05/21/2015] [Indexed: 12/31/2022] Open
Abstract
Introduction The bursa subacromialis (BS) provides the gliding mechanism of the shoulder and regenerates itself after surgical removal. Therefore, we explored the presence of mesenchymal stem cells (MSCs) within the human adult BS tissue and characterized the BS cells compared to MSCs from bone marrow (BMSCs) on a molecular level. Methods BS cells were isolated by collagenase digest from BS tissues derived from patients with degenerative rotator cuff tears, and BMSCs were recovered by adherent culture from bone-marrow of patients with osteoarthritis of the hip. BS cells and BMSCs were compared upon their potential to proliferate and differentiate along chondrogenic, osteogenic and adipogenic lineages under specific culture conditions. Expression profiles of markers associated with mesenchymal phenotypes were comparatively evaluated by flow cytometry, immunohistochemistry, and whole genome array analyses. Results BS cells and BMSCs appeared mainly fibroblastic and revealed almost similar surface antigen expression profiles, which was CD44+, CD73+, CD90+, CD105+, CD106+, STRO-1+, CD14−, CD31−, CD34−, CD45−, CD144−. Array analyses revealed 1969 genes upregulated and 1184 genes downregulated in BS cells vs. BMSCs, indicating a high level of transcriptome similarity. After 3 weeks of differentiation culture, BS cells and BMSCs showed a similar strong chondrogenic, adipogenic and osteogenic potential, as shown by histological, immunohistochemical and RT-PCR analyses in contrast to the respective negative controls. Conclusions Our in vitro characterizations show that BS cells fulfill all characteristics of mesenchymal stem cells, and therefore merit further attention for the development of improved therapies for various shoulder pathologies.
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Affiliation(s)
- Andre F Steinert
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Manuela Kunz
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Patrick Prager
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Sascha Göbel
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Ludger Klein-Hitpass
- University of Duisburg-Essen, Center for Medical Biotechnology, BioChip Laboratory, Essen, Germany.
| | - Regina Ebert
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Ulrich Nöth
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Franz Jakob
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany.
| | - Frank Gohlke
- Julius-Maximilians-University Würzburg, Department of Orthopaedic Surgery, König-Ludwig-Haus, Orthopaedic Center for Musculoskeletal Research, Julius-Maximilians-University Würzburg, Brettreichstr. 11, D - 97074, Würzburg, Germany. .,Present address: Klinik für Schulterchirurgie, Rhön Klinikum AG, Bad Neustadt/Saale, Germany.
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[Open transosseous reconstruction of the rotator cuff: clinical outcome, influencing factors and complications]. Chirurg 2012; 83:1068-77. [PMID: 23149767 DOI: 10.1007/s00104-012-2399-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Open transosseous rotator cuff reconstruction (RCR) still plays a prominent role in current treatment of rotator cuff tears. This study aimed to examine mid-term and long-term results of clinical outcome, determine influencing factors and analyze complications. PATIENTS This retrospective cohort study included 104 Patients following standardized open transosseous RCR. After a mean follow-up period of 38.3 months (range 12-71 months) 88 Patients (89 shoulders) were available for examination. The mean age of Patients at surgery was 57.1 years (range 29-83 years). Standardized clinical examination included sonography and assessment of the absolute, relative and intra-individual constant scores (CS(abs), CS(rel), CS(intra)), Oxford shoulder score (OSS), American shoulder and elbow surgeons' score (ASESS) and single assessment numeric evaluation score (SANES). The level of significance for analysis of variance (ANOVA) was set at p < 0.05 (95% confidence interval). RESULTS Mean values and standard deviations (σ) were: CS(abs) = 71 points (σ: 20.3), CS(rel) = 76 points (σ: 20.7), CS(intra) = 86 % (σ: 19.5), OSS(mod) = 77 points (σ: 20.6), ASESS = 73 points (σ: 23.3) and SANES = 72 % (σ: 22.0). Clinical results were superior when the complaints were initiated by trauma (p < 0.05). Patients with massive tears showed inferior results relative to all outcome measures (p < 0.05). Concomitant pathologies even without surgical relevance were associated with inferior outcome (p < 0.05). The factors surgeon, suture material and acromioplasty did not exert a significant influence. Revision surgery was required in 12 out of 89 (13.5 %) cases and re-ruptures occurred in 19.1%. CONCLUSIONS Objective and subjective clinical results following open transosseous RCR were comparable to those of previously described open and arthroscopic techniques. Results were superior when the complaints were initiated by trauma. Massive tears and concomitant pathologies even without surgical relevance were associated with inferior clinical outcome. Open or arthroscopic acromioplasty did not add further benefits. A standardized operative procedure led to reproducible results irrespective of the factor surgeon.
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Hantes ME, Karidakis GK, Vlychou M, Varitimidis S, Dailiana Z, Malizos KN. A comparison of early versus delayed repair of traumatic rotator cuff tears. Knee Surg Sports Traumatol Arthrosc 2011; 19:1766-1770. [PMID: 21258779 DOI: 10.1007/s00167-011-1396-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Accepted: 01/02/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to compare the clinical and magnetic resonance imaging (MRI) results between early and delayed operative treatment in patients with traumatic rotator cuff tears (RCT). METHODS Thirty-five patients with a traumatic RCT who have been treated surgically during a 4-year period were included in the study. The results of early versus delayed repair of traumatic rotator RCT were assessed using the Constant and UCLA scores. In addition, all patients underwent a postoperative MRI to evaluate repair integrity. Early repair (within 3 weeks) was performed in 15 patients (group I) and delayed repair (after 3 weeks) in the rest 20 patients (group II). The time interval between injury and operation was 12 and 131 days on average for group I and II, respectively. RESULTS Follow-up time was 34 and 38 months for group I and II, respectively. Postoperatively, the UCLA score was 31 and 26 (P < 0.05) for group I and II, respectively. The Constant score was 82 and 70 (P < 0.05) for group I and II, respectively. Range of motion was significantly better in group I. According to MRI, 5 patients (33%) in the group I and 7 patients (35%) in the group II had a retear. CONCLUSIONS Early repair of a traumatic RCT provides better results in terms of shoulder function in comparison with a delayed repair. A delayed diagnosis of a traumatic RCT leads to difficulties in surgery and less good results. LEVEL OF EVIDENCE Level III, therapeutic, retrospective, comparative study.
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Affiliation(s)
- Michael E Hantes
- The Department of Orthopaedic Surgery, University Hospital of Larissa, School of Health Sciences, University of Thessalia, Mezourlo, 41110, Larissa, Greece.
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Traumatische Subskapularisläsion beim älteren Patienten. ARTHROSKOPIE 2010. [DOI: 10.1007/s00142-010-0606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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