• Clinics in Shoulder and Elbow
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• v.22 no.1
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• pp.9-15
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• 2019

Background: Latissimus dorsi (LD) tendon transfer is used as a treatment option for massive irreparable posterosuperior rotator cuff tears, and recently, an arthroscopic-assisted technique was introduced. This study was undertaken to evaluate the clinical and radiological outcomes of arthroscopic-assisted LD tendon transfer for the management of irreparable rotator cuff tears in active middle-aged patients. Methods: The records of five patients (two males) with irreparable tears involving the supraspinatus and infraspinatus tendons managed by arthroscopic-assisted LD tendon transfer were retrospectively reviewed. Clinical outcomes were assessed using the visual analogue scale (VAS) pain scale, American Shoulder and Elbow Surgeon's (ASES) scores, the University of California Los Angeles (UCLA) scale, and ranges of motion. Postoperative integrities of transferred tendon were evaluated by magnetic resonance imaging in 4 patients and by ultrasound in one. Results: Mean patient age was 55 years (range, 48-61 years), and mean follow-up period was 20 months (range, 12.0-27.2 months). Mean VAS score significantly improved from $6.6{\pm}2.6$ preoperatively to $1.8{\pm}2.5$ postoperatively (p=0.009), mean ASES score increased from $67.6{\pm}9.2$ to $84.6{\pm}15.1$, and mean UCLA score from $18.0{\pm}1.4$ to $28.8{\pm}8.5$ (all p<0.001). Postoperative imaging of the transferred LD tendon showed intact repair in 4 patients. The remaining patient experienced LD transfer rupture and a poor outcome. Conclusions: Arthroscopic-assisted LD tendon transfer improved shoulder pain and function in patients with massive, irreparable rotator cuff tears, and may be an option for this condition, especially in physically active patients.

• Clinics in Shoulder and Elbow
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• v.22 no.3
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• pp.139-145
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• 2019

Background: The present study was undertaken to evaluate the relationship between location of the rotator cuff tear and shape of the subacromial spur. Methods: Totally, 80 consecutive patients who underwent arthroscopic repair for partial thickness rotator cuff tear were enrolled for the study. Bigliani's type of the acromion, type of subacromial spur, and location of partial thickness tear of the rotator cuff were evaluated using plain X-ray and magnetic resonance imaging. We then compared the groups of no spur with spur, and heel with traction spur. Results: Of the 80 cases, 25 cases comprised the no spur group, and 55 cases comprised the spur group. There was a significant difference in type of tear (p=0.0004) between these two groups. Bursal side tears were significantly greater (odds ratio=6.000, p=0.0007) in the spur group. Subjects belonging to the spur group were further divided into heel (38 cases) and traction spur (17 cases). Comparing these two groups revealed significant differences only in the type of tear (p=0.0001). Furthermore, the heel spur had significantly greater bursal side tear (odds ratio=29.521, p=0.0005) as compared to traction spur. Conclusions: The heel spur is more associated to bursal side tear than the traction spur, whereas the traction spur associates greater to the articular side tear.

• Clinics in Shoulder and Elbow
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• v.22 no.4
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• pp.195-202
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• 2019

Background: This study investigates the effects of neuromuscular electrical stimulation (NMES) in preventing deltoid atrophy during the first 12 weeks after arthroscopic rotator cuff repair. Methods: Eighteen patients undergoing arthroscopic repair of a medium-sized rotator cuff tear by a single surgeon, were randomized into two groups: NMES and transcutaneous electrical nerve stimulation (TENS). Each group used the respective device for 6 weeks after surgery. Pain was measured at baseline, 6, and 12 weeks postoperatively, using the visual analogue scale (VAS); range of motion (ROM), abduction strength and functional scores were measured at baseline and 12 weeks postoperatively. Deltoid thickness and cross-sectional areas were measured using magnetic resonance imaging at 12 weeks postoperatively. Results: At 12 weeks post-surgery, no statistically significant difference was observed between the NMES and TENS groups in the pain VAS, the Disabilities of the Arm, Shoulder and Hand score, ROM, and abduction strength. Postoperative decrease in the thickness of the anterior, middle, and posterior deltoid, at the level just below the coracoid, was -2.5%, -0.7%, and -6.8%, respectively, in the NMES group, and -14.0%, -2.6%, and -8.2%, respectively, in the TENS group (p=0.016, p=0.677, and p=0.791, respectively). At the level of the inferior glenoid tubercle, postoperative decrease in area of the deltoid was -5.4% in the NMES group and -14.0% in the TENS group, which was significantly different (p=0.045). Conclusions: NMES has the potential for reducing deltoid atrophy after arthroscopic rotator cuff repair, suggesting that NMES might help minimize postoperative atrophy after various shoulder surgeries.

• Clinics in Shoulder and Elbow
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• v.22 no.4
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• pp.220-226
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• 2019

Background: This retrospective study was undertaken to evaluate mid-term clinical and radiological outcomes of lattisimus dorsi (LD) tendon transfer in patients with irreparable massive rotator cuff tears (MRCT). We hypothesize that LD tendon transfer would provide safe and satisfactory clinical outcomes at mid-term follow-up. Methods: From November 2008 to December 2016, 23 patients ($57.5{\pm}4.4years$; 20 male, 3 female) who underwent LD tendon transfer for massive tears, were enrolled. Inclusion criteria were irreparable MRCT. Exclusion criteria included full thickness subscapularis tear, rotator cuff arthropathy, anterosuperior rotator cuff tear, and osteoarthritis. Mean follow-up period was $4.7{\pm}4.0years$ (range, 2-12 years). Clinical assessment (American Shoulder and Elbow Surgeons [ASES], University of California, Los Angeles [UCLA], Simple Shoulder Test [SST]) and radiographic assessment (osteoarthritis [OA], acromiohumeral distance [AHI]) were evaluated. Results: ASES, UCLA and SST scores, and range of motion (ROM), except internal rotation, improved significantly at the last followup (p<0.05). Also, AHI was significantly improved at the last follow-up, from 6.6 mm to 8.2 mm (p=0.008). At the final follow-up, the radiologic stages of the glenohumeral osteoarthritis were determined as stage 1 in 9 patients, stage 2 in 10 patients, stage 3 in 2 patients, and stage 4 in 2 patients. Complications were observed in 21.7% cases: 3 re-tears and 2 infections were noted in our study. Conclusions: LD tendon transfer for irreparable MRCT provides satisfactory clinical outcomes at mid-term follow-up. Mild degenerative osteoarthritis (stage 1, 2) of the shoulder joint are common at the mid-term follow-up. Also, complications such as tear, infection should be considered.

• Clinics in Shoulder and Elbow
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• v.24 no.2
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• pp.88-92
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• 2021

Background: Patients who have rotator cuff arthropathy experience a limited range of motion (ROM) of the shoulder joint and experience problems in performing their daily activities; however, no evidence is available to suggest the exact ROM of the shoulder joint in this population. Therefore, this study sought to determine the degree of motion of the shoulder joint in three planes during different activities. Methods: Five subjects with rotator cuff injuries participated in this study. The motion of the shoulder joints on both the involved and normal sides was assessed by a motion analysis system while performing forward abduction (task 1), flexion (task 2), and forward flexion (task 3). The OpenSIM software program was used to determine the ROM of the shoulder joints on both sides. The difference between the ranges of motion was determined using a two-sample t-test. Results: The ROMs of the shoulder joint in task 1 were 93.5°±16.5°, 72.1°±2.6°, and 103.9°±25.7° for flexion, abduction, and rotation, respectively, on the normal side and 28°±19.8°, 31°±31.56°, and 48°±33.5° on the involved side (p<0.05). There was no significant difference between the flexion/extension and rotation movements of the shoulder joint when performing task 1. However, the difference between flexion and rotation movements of the shoulder joints for the second task was significant (p>0.05). Conclusions: Those with rotator cuff arthropathy have functional limitations due to muscle weakness and paralysis, especially during the vertical reaching task. However, although these individuals have decreased ROM for transverse reaching tasks, the reduction was not significant.

• Journal of Acupuncture Research
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• v.38 no.1
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• pp.20-31
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• 2021

The objective was to evaluate the effectiveness and safety of acupuncture for patients with rotator cuff diseases. There were 12 electronic databases and 3 trial registries searched up to November 30th, 2019. All randomized trials were eligible, regardless of language, date of publication, or settings. The primary outcomes were pain, shoulder function, and proportion of improved participants assessed within 12 weeks of randomization of the trial. The Cochrane risk of bias for the studies was assessed. Effects sizes were presented as a risk ratio, mean difference, or standardized mean difference with a 95% confidence intervals. Grading of Recommendations Assessment, Development and Evaluation approach was adopted to rate certainty of evidence. Of the 3,686 records screened, 28 randomized trials (2,216 participants) were included in this review. The types of acupuncture included manual acupuncture, dry needling, electroacupuncture, acupotomy, warm needle acupuncture, and fire needle acupuncture. All of the studies had an unclear or high risk of bias related to more than 1 domain. Significant benefits of acupuncture in terms of pain and shoulder function were observed in all comparisons, however, the proportion of improved participants was not described in 2 comparisons. There was substantial heterogeneity among meta-analyzed trials. No serious harm was observed. For primary outcomes, the overall certainty of evidence was very low. There was very low certainty of evidence for the benefits of acupuncture for patients with rotator cuff diseases. The safety of acupuncture remains unclear due to the incompleteness of reporting. Future well-designed randomized trials with transparent reporting are required.

• Clinics in Shoulder and Elbow
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• v.25 no.2
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• pp.101-105
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• 2022

Background: Rotator cuff tears cause pathologies of the long head of the biceps tendon (LHBT). One of the surgical treatments for such a tear is LHBT tenodesis to the humerus. This study aims to compare simultaneous rotator cuff repair and LHBT tenodesis with or without detachment of the proximal end of the LHBT (PELHBT) from its site of adhesion to the glenoid. Methods: This retrospective study involved patients affected by LHBT pathology with rotator cuff tear. The patients were divided into two groups, with or without PELHBT detachment from the glenoid. Therapeutic outcomes were investigated by evaluation of patient satisfaction, pain based on visual analog scale, shoulder function based on Constant score and simple shoulder test, and biceps muscle strength based on the manual muscle testing grading system before surgery, at 6 months, and at the final visit after surgery. Results: Groups 1 and 2 comprised 23 and 26 patients, respectively, who showed no significant differences in demographic characteristics (p>0.05). Shoulder function, biceps muscle strength, pain, and satisfaction rate improved over time (p<0.05) but were not significantly different between the two groups (p>0.05). No post-surgical complication was found in either group. Conclusions: There was no difference in final outcomes of tenodesis with or without detachment of the PELHBT from the supraglenoid tubercle. Such tendon detachment is not necessary.

• Clinics in Shoulder and Elbow
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• v.25 no.1
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• pp.22-27
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• 2022

Background: In some patients with rotator cuff tear (RCT), the axial view of magnetic resonance imaging (MRI) shows subtle posterior decentering (PD) of the humeral head from the glenoid fossa. This is considered to result from a loss of centralization that is typically produced by rotator cuff function. There are few reports on PD in RCT despite the common occurrence of posterior subluxation in degenerative joint disease. In this study, we investigated the effect of PD in arthroscopic rotator cuff repair (ARCR). Methods: We conducted a retrospective study of consecutive patients who underwent ARCR at our institute and were followed-up for at least 1 year. PD was identified as a 2-mm posterior shift of the humeral head relative to the glenoid fossa in the axial MRI view preoperatively. The tear size and fatty degeneration (FD, Goutallier classification) were also evaluated using preoperative MRI. Retears were evaluated through MRI at 1 year postoperatively. Results: We included 135 shoulders in this study. Ten instances of PD (including seven retears) were observed preoperatively. Fifteen retears (three and 12 retears in the small/medium and large/massive tear groups, respectively) were observed postoperatively. PD was significantly correlated with tear size, FD, and retear occurrence (p<0.01 each). The odds ratio for PD in retears was 34.1, which was greater than that for tear size ≥3 cm and FD grade ≥3. Conclusions: We concluded that large tear size and FD contribute to the occurrence of PD. Furthermore, PD could be a predictor of retear after ARCR.

• Clinics in Shoulder and Elbow
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• v.25 no.1
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• pp.5-14
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• 2022

Background: The purpose of this study was to verify the effect of protocatechuic acid (PCA) on tendon healing and fatty degeneration in a chronic rotator cuff model. Methods: Twenty-eight Sprague-Dawley male rats were randomly allocated into two groups: Saline+repair (SR) and PCA+repair (PR). The right shoulder was used for experimental interventions, and the left served as a control. PCA (30 mg/kg/day) was administered intraperitoneally at the site of infraspinatus tendon detachment in rats in the PR group, and the same volume of saline was administered to the same site in the SR group. The torn tendon was repaired 4 weeks after infraspinatus detachment. Four weeks after repair, hematoxylin and eosin (H&E), S100, and CD68 stains were performed to evaluate the degree of fatty degeneration and H&E and Masson trichrome stains were performed to assess tendon healing. Superoxide dismutase (SOD) was measured to test the efficacy of PCA as an antioxidant. Results: Results from histological evaluation indicated that SOD and CD68 levels at the musculotendinous region and collagen fiber parallel to the orientation at the tendon-to-bone junction were not significantly different between the SR and PR groups. The mean load-to-failure of the PR group (20.32±9.37 N) was higher than that of the SR group (16.44±6.90 N), although this difference was not statistically significant (p=0.395). The SOD activity in the operative side infraspinatus muscle of the PR group was higher than that of the SR group, but the difference was not statistically significant (p=0.053). Conclusions: The use of PCA could improve tendon healing and decrease fatty degeneration after rotator cuff repair.

• Clinics in Shoulder and Elbow
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• v.24 no.4
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• pp.224-230
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• 2021

Background: Local anesthetics often are used in rotator cuff tears as therapeutic tools, although some cases have reported that they have detrimental effects. Neurotropin (NTP) is used widely in Japan as a treatment for various chronic pain conditions and is shown to have protective effects on cartilage and nerve cells. In this study, we investigated the protective effect of NTP against lidocaine-induced cytotoxicity. Methods: Tenocytes from rotator cuff tendons were incubated with lidocaine, NTP, lidocaine with NTP, and a control medium. Cell viability was evaluated using the WST-8 assay. Cell apoptosis was detected via annexin V staining using flow cytometry. The expression of BCL-2 and cytochrome c, which are involved in the intrinsic mitochondrial pathway of apoptosis, was evaluated via Western blotting and immunohistochemical staining. Results: In the cell viability assay, lidocaine decreased cell viability in a dose-dependent manner, and NTP did not affect cell viability. Moreover, NTP significantly inhibited the cytotoxic effect of lidocaine. The flow cytometry analysis showed that lidocaine significantly induced apoptosis in tenocytes, and NTP considerably inhibited this lidocaine-induced apoptosis. Western blotting experiments showed that lidocaine decreased the protein expression of BCL-2, and that NTP conserved the expression of BCL-2, even when used with lidocaine. Immunohistochemical staining for cytochrome c showed that 0.1% lidocaine increased cytochrome c-positive cells, and NTP suppressed lidocaine-induced cytochrome c expression. Conclusions: NTP suppresses lidocaine-induced apoptosis of tenocytes by inhibiting the mitochondrial apoptotic pathway. Intra-articular/bursal injection of NTP with lidocaine could protect tenocytes in rotator cuff tendons against lidocaine-induced apoptosis.