JBJS 100: Shoulder Impingement and Distraction Osteogenesis
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
Anterior Acromioplasty for Chronic Impingement Syndrome in the Shoulder
C S Neer: JBJS, 1972 January; 54 (1): 41
For many years after its publication, this 1972 JBJS article changed the treatment approach for patients with shoulder disability. But more recently, arthroscopy and magnetic resonance imaging arthrography have identified other painful non-impingement shoulder conditions. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete rotator cuff tear, and performing aggressive rehabilitation prior to corrective surgery.
Use of the Ilizarov Technique for Treatment of Non-union of the Tibia Associated with Infection
G K Dendrinos, S Kontos, E Lyritsis: JBJS, 1995 June; 77 (6): 835
This case series described a technique of bone transport with bridging achieved by distraction osteogenesis. The defects averaged 6 cm, the mean duration of treatment was 10 months, and the mean time to union was 6 months. More recent research has focused on augmenting the osteogenic potential of tissues in the distraction gap with substances such as bone morphogenetic protein, platelet-rich plasma, and mesenchymal stem cells.
What’s New in Shoulder and Elbow Surgery
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, Aaron Chamberlain, MD, MSc, a co-author of the October 19, 2016 Specialty Update on Shoulder and Elbow Surgery, selected the five most clinically compelling findings from among the more than 40 studies summarized in the Specialty Update.
Reverse Shoulder Arthroplasty
Optimizing reverse shoulder arthroplasty implant design continues to be a research focus. There is significant variation among different implants with regard to the amount of lateralization of the center of rotation, and how lateralization affects clinical outcomes is of particular interest. Authors randomized patients to undergo reverse shoulder arthroplasty with a center of rotation at the native glenoid face or with lateralization.1 Postoperative functional results at a mean follow-up of 22 months were similar between groups overall. However, when the analysis excluded patients with teres minor muscle degeneration, patients with a more lateralized center of rotation had a greater improvement in external rotation. This may portend a benefit of lateralization in the setting of an intact posterior rotator cuff.
Rotator Cuff Tear Natural History
A Level-I prospective cohort study of patients with asymptomatic rotator cuff tears evaluated patterns of tear progression over time.2 Of specific interest was whether the integrity of the anterior supraspinatus cable influenced tear size and/or risk for tear enlargement. Cable-disrupted tears were 9 mm larger at baseline, but cable integrity did not influence risk for tear enlargement or time to enlargement. This understanding may help inform patient discussions about the risks of nonoperative management of rotator cuff tears.
Rotator Cuff Repair
Do patients with symptomatic degenerative rotator cuff tears fare better with surgery or nonoperative management? Only three prospective randomized trials have been published comparing outcomes after randomizing patients to nonoperative management or surgical repair. This Level-I trial randomized patients (mean age of 61) with degenerative full thickness cuff tears to either a course of non-operative management (corticosteroid injection, physical therapy, and oral analgesics) or surgical rotator cuff repair. 3 Patients who underwent surgery experienced a greater reduction in VAS pain and VAS disability scores compared with the nonoperative cohort at 1 year of follow-up.
In another prospective randomized study, authors randomized patients who were ≥55 years of age with painful degenerative supraspinatus tears into one of three treatments: 1) physical therapy alone, 2) acromioplasty and physical therapy, and 3) rotator cuff repair, acromioplasty, and physical therapy. Patients in this study were older than those in the study mentioned above, with a mean age of 65 (range 55 to 81). At the 2-year follow-up, no significant differences among the three interventions were seen in the Constant score, VAS pain score, or patient satisfaction. This data supports initial conservative treatment in older patients with degenerative atraumatic cuff tears. However, the importance of tear progression over time and the age threshold that separates “older” patients from “younger” patients remain to be determined.
Biological Supplementation
Can we improve the biologic healing environment for rotator cuff repair healing? A Level-I prospective randomized controlled study evaluated leukocyte and platelet-rich fibrin in rotator cuff repairs.4 Patients underwent arthroscopic rotator cuff repair with and without leukocyte and platelet-rich fibrin applied to the repair site. No beneficial effect of leukocyte and platelet-rich fibrin was found in overall clinical outcome, healing rate, postoperative defect size, and tendon quality at the 1-year follow-up. A reliable biological augmentation solution for rotator cuff healing remains elusive.
References
1 Greiner S, Schmidt C, Herrmann S, Pauly S, Perka C. Clinical performance of lateralized versus non-lateralized reverse shoulder arthroplasty: a prospective randomized study. J. Shoulder Elbow Surg. [Internet]. 2015;24(9):1397–404. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002864doi:10.1016/j.jse.2015.05.041
2 Keener JD, Hsu JE, Steger-May K, Teefey SA, Chamberlain AM, Yamaguchi K. Patterns of tear progression for asymptomatic degenerative rotator cuff tears. J. Shoulder Elbow Surg. [Internet]. 2015 Dec 1;24(12):1845–1851. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615004759
3 Lambers Heerspink FO, van Raay JJAM, Koorevaar RCT, van Eerden PJM, Westerbeek RE, van ’t Riet E, et al. Comparing surgical repair with conservative treatment for degenerative rotator cuff tears: a randomized controlled trial. J. Shoulder Elbow Surg. [Internet]. 2015;24(8):1274–81. Available from: http://www.sciencedirect.com/science/article/pii/S1058274615002852doi:10.1016/j.jse.2015.05.040
4 Zumstein MA, Rumian A, Thélu CÉ, Lesbats V, O’Shea K, Schaer M, et al. SECEC Research Grant 2008 II: Use of platelet- and leucocyte-rich fibrin (L-PRF) does not affect late rotator cuff tendon healing: a prospective randomized controlled study. J. Shoulder Elbow Surg. [Internet]. 2016 Jan 1;25(1):2–11. Available from: http://linkinghub.elsevier.com/retrieve/pii/S1058274615005388
What’s New in Shoulder and Elbow Surgery: Level I and II Studies
Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the October 21, 2015 Specialty Update on shoulder and elbow surgery:
Shoulder
–A prospective evaluation of 224 subjects with asymptomatic rotator cuff tears followed annually for an average of five years found that the risk of tear enlargement and muscle degeneration was greater in full-thickness tears, and that pain and supraspinatus muscle degeneration were associated with tear enlargement.
–The authors of a randomized trial comparing physical therapy and primary surgical repair for initial management of degenerative rotator cuff tears concluded that the effects of surgery were not profound enough to justify surgical management for patients who present initially with painful degenerative cuff tears.
–A randomized trial comparing clinical outcomes in 58 patients with a rotator cuff tear and symptomatic acromioclavicular joint arthritis found no differences in function or pain scores between those who underwent cuff repair + distal clavicle resection and those who underwent cuff repair alone.1
–After two years of follow-up, no differences in functional outcomes or rate or quality of postoperative tendon healing were found in a randomized trial comparing patients who received platelet-rich plasma following surgical cuff repair and those who did not.2
–In a three-way randomized trial comparing physical therapy, acromioplasty + physical therapy, and cuff repair + acromioplasty + physical therapy for treating symptomatic, nontraumatic supraspinatus tendon tears in patients older than 55, there were no between-group differences in the mean Constant score one year after treatment.3
–A randomized trial comparing treatments for calcific tendinitis found that ultrasound-guided needling plus a subacromial corticosteroid injection resulted in better functional scores and larger decreases in calcium-deposit size than extracorporeal shock wave therapy.4
–A randomized trial of 196 patients with recurrent traumatic anterior shoulder instability found no significant differences in WOSI and ASES scores or range of motion between groups that underwent open or arthroscopic stabilization procedures.
–A randomized study comparing the effectiveness of immobilization in abduction (15°) and external rotation (10°) versus adduction and internal rotation after primary anterior shoulder dislocation found that after two years, only 3.9% of patients in the abduction/external-rotation group had repeat instability, compared to 33.3% in the adduction/internal-rotation group.5 A separate randomized trial found no significant difference in instability recurrence after one year between a group immobilized in internal rotation (sling) and a group immobilized in adduction and external rotation (brace).6
–A randomized trial of 250 patients (mean age of 65 years) with displaced surgical neck fractures of the proximal humerus compared surgical treatment (internal fixation or hemiarthroplasty) with conservative treatment. Finding no statistically or clinically significant difference in outcomes, the authors concluded that these results do not support the recent trend toward surgical management for proximal humeral fractures.7
–A randomized trial comparing reverse shoulder arthroplasty with hemiarthroplasty for acute proximal humeral fractures found that after two years of follow-up, reverse arthroplasty yielded better functional scores, better active elevation, and fewer complications than hemiarthroplasty.8
–A randomized trial comparing the use of concentric and eccentric glenospheres in reverse shoulder arthroplasty revealed no differences in scapular notching rates or clinical outcomes at a minimum follow-up of two years.
–A systematic review comparing radiographic and clinical survivorship of all-polyethylene versus metal-backed glenoid components used in total shoulder arthroplasty found that all-poly glenoids had a higher rate of radiolucencies and radiographic loosening but a much lower rate of revision after a mean follow-up of 5.8 years.
–A retrospective review found that arthroscopic biopsy was much more accurate than fluoroscopically guided fluid aspiration in diagnosing periprosthetic shoulder infections caused by Propionibacterium acnes.
–In a randomized trial of 76 workers’-comp patients with a displaced midshaft clavicular fracture, those receiving surgical management had faster time to union and return to work and better Constant scores than those managed conservatively.9
–Two studies compared plate fixation with intramedullary fixation for stabilizing clavicular fractures. One that randomized 59 patients found no differences in functional outcomes or time to healing. The other, which randomized 120 patients, found no between-group differences in DASH or Constant-Murley scores, but shoulder function improved more quickly in the plate-fixation group.
–A study that compared standard arthroscopic capsular release with capsular release extending to the posterior capsule for treating frozen shoulder found no difference in postoperative clinical or range-of-motion outcomes between the two groups.10
Elbow
–A randomized trial comparing regional analgesia to local anesthetic injections in patients undergoing elbow arthroscopy found no differences in pain, oral analgesic use, or patient satisfaction within 48 hours after surgery.11
–A randomized trial comparing eccentric and concentric resistance exercises for the treatment of chronic lateral epicondylitis found that the eccentric-exercise group had faster pain regression, lower pain scores at 12 months, and greater strength increases.12
References
- Park YB, Koh KH, Shon MS, Park YE, Yoo JC. Arthroscopic distal clavicle resection in symptomatic acromioclavicular joint arthritis combined with rotator cuff tear: a prospective randomized trial. Am J Sports Med. 2015 Apr;43(4):985-90.Epub 2015 Jan 12.
- Malavolta EA, Gracitelli ME, Ferreira Neto AA, Assunção JH, Bordalo-RodriguesM, de Camargo OP. Platelet-rich plasma in rotator cuff repair: a prospective randomized study. Am J Sports Med. 2014 Oct;42(10):2446-54. Epub 2014 Aug 1.
- Kukkonen J, Joukainen A, Lehtinen J, Mattila KT, Tuominen EK, Kauko T, Aärimaa V.Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014 Jan;96-B(1):75-81.
- Kim YS, Lee HJ, Kim YV, Kong CG. Which method is more effective in treatment of calcific tendinitis in the shoulder? Prospective randomized comparison between ultrasound-guided needling and extracorporeal shock wave therapy. J Shoulder Elbow Surg. 2014 Nov;23(11):1640-6. Epub 2014 Sep 12.
- Heidari K, Asadollahi S, Vafaee R, Barfehei A, Kamalifar H, Chaboksavar ZA,Sabbaghi M. Immobilization in external rotation combined with abduction reduces the risk of recurrence after primary anterior shoulder dislocation. J Shoulder Elbow Surg. 2014 Jun;23(6):759-66. Epub 2014 Apr 13.
- Whelan DB, Litchfield R, Wambolt E, Dainty KN; Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS).External rotation immobilization for primary shoulder dislocation: a randomized controlled trial. Clin Orthop Relat Res. 2014 Aug;472(8):2380-6.
- Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L,Chuang LH, Hewitt C, Torgerson D; PROFHER Trial Collaborators. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47.
- Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014Oct;23(10):1419-26. Epub 2014 Jul 30
- Melean PA, Zuniga A, Marsalli M, Fritis NA, Cook ER, Zilleruelo M, Alvarez C.Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg.2015 Apr;24(4):587-92. Epub 2015 Jan 22.
- Kim YS, Lee HJ, Park IJ. Clinical outcomes do not support arthroscopic posterior capsular release in addition to anterior release for shoulder stiffness: a randomized controlled study. Am J Sports Med. 2014 May;42(5):1143-9. Epub 2014 Feb 28.
- Wada T, Yamauchi M, Oki G, Sonoda T, Yamakage M, Yamashita T. Efficacy of axillary nerve block in elbow arthroscopic surgery: a randomized trial. J Shoulder Elbow Surg. 2014 Mar;23(3):291-6. Epub 2014 Jan 15.
- Peterson M, Butler S, Eriksson M, Svärdsudd K.A randomized controlled trial of eccentric vs. concentric graded exercise in chronic tennis elbow (lateral elbow tendinopathy). Clin Rehabil. 2014 Sep;28(9):862-72. Epub 2014 Mar 14.
JBJS Editor’s Choice: Age Is Only One Factor in Rotator Cuff Decision Making
In the November 4, 2015 Level I JBJS study by Kukkonen et al., patients over the age of 55 were randomized to one of three treatment arms for management of a rotator cuff tear—physical therapy alone and acromioplasty with and without rotator cuff repair. We learn that over a two-year follow up, treatment with physiotherapy produced results as clinically favorable as surgery in this “older” age group, although tear size was significantly smaller in the repair group than in the other two.
As Dr. Ken Yamaguchi points out in his commentary on the study, the average patient age for surgical repair of a rotator cuff tear is currently the mid-50s, and we know that the likelihood of repair failure with lack of healing increases in patients beyond their mid-60s. In fact, historic post-mortem studies have identified rotator cuff tears in 70% to 80% of all subjects, making this is a common wear-and-tear phenomenon among humans, akin to degenerative disc disease and declining hearing and vision.
So is the take-home message from Kukkonen et al. that any patient over the age of 55 should be treated with physiotherapy, with no discussion of surgical repair? I think not. The message is that we should be more supportive of a decision to start down the physiotherapy path with patients in their mid-50s than ones in their mid-40s. Although this study emphasizes the age factor, we should also remember that age is only one data point in a shared decision making discussion. An athletic, fit woman in her mid-50s who participates in yoga and zumba four days a week in addition to resistance training is a very different patient than the sedentary, deconditioned woman of the same age.
In the discussion of what is best for each patient, we need to leverage our knowledge regarding the musculoskeletal problem coupled with the wisdom to consider each patient’s functional demands and goals for activity return. As our population ages and the level of older-patient fitness hopefully increases, these discussions will take more time, but will result in higher-quality decisions for the individual patient.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
JBJS Classics: Anterior Acromioplasty for Chronic Shoulder Impingement
Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
For a good long while, the 1972 JBJS article titled “Anterior Acromioplasty for the Chronic Impingement Syndrome in the Shoulder” by Charles S. Neer II completely changed the treatment approach for patients with shoulder disability. Impingement of the rotator cuff beneath the coracoacromial arch was recognized at that time as the cause of chronic shoulder disability, and complete acromionectomy and lateral acromionectomy at various levels had been advocated for the condition. However, disappointment with the results, such as postoperative deltoid weakness, stimulated Neer to publish this study, based on his experiences with patients from 1965 to1970. The paper describes relevant anatomical findings and then discusses the indications, technique, and preliminary results of anterior acromioplasty.
Neer first dissected 100 cadaveric scapulae from donors who had been in their sixth decade or older at the time of death, and he noted spurs and excrescences on the undersurface along the anterior-inferior rim of the acromion in many shoulders that also had rotator cuff derangement. Without exception, the anterior lip and undersurface of the anterior third of the acromion were involved. He concluded that this part of the acromion rubbed against the supraspinatus when the arm was abducted and caused the rotator cuff to tear over time.
Neer later resected this part of the acromion in fifty shoulders in forty-six patients. When he reexamined twenty-nine of the shoulders between nine months and five years after surgery, he found symptomatic relief in a large percentage of patients. A recent PubMed search identified 471 publications about acromioplasty, the majority of which reference this paper and 50 of which specifically mention Neer by name. Neer’s basic surgical principles are still followed, although this surgery today is performed arthroscopically.
Neer reserved this surgical procedure for patients with long-term disability from chronic bursitis and partial tears of the supraspinatus tendon, or those with complete tears of the supraspinatus associated with tears of varying degree of the adjacent rotator cuff. He emphasized that patients with incomplete tears should not have surgery until the stiffness of the shoulder resolved, and the disability had to persist for at least nine months before surgery was performed. Many patients not included in his series were suspected of having impingement but responded well to conservative treatment.
Neer’s anatomical approach to the challenge of chronic shoulder pain provides readers with photographs of cadaveric shoulders combined with drawings illustrating the pathogenesis and the surgical procedure. Neer described the results well and in a subsequent discussion concluded that “it is a rare cuff tear that cannot be repaired through this simple approach.” The paper lacked a control group and a detailed description of the rehabilitation protocol, but these shortcomings have been remedied by more recent published research.
Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.
Lars Engebretsen, MD, PhD
JBJS Deputy Editor
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