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Paper 45: Ultrasound Guided Needling Combined with Extracorporal High Energy Shockwave Therapy for Treatment of Tendinosis Calcarea of the Shoulder: Improvement of an Established Treatment Technique
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ABSTRACTS
sional infusion of local anesthetics with or without interscalene brachial plexus block (ISB), and by continuous interscalene block (CISB) after arthroscopic shoulder surgery. We designed the prospective randomized case-controlled study, and 113 consecutive patients were allocated into five groups according to the method of postoperative analgesia; intravenous PCA (fentanyl 0.3-0.5(Mu)g/kg/ml, ketorolac 0.03 mg/kg/ml, and ondansetron 8mg/100ml with 1 mL/ hour), intravenous PCA with ISB (20ml of 0.25% ropivacaine), intra-articular or intra-subacromial continuous infusion of ropivacaine (10ml of 0.75% ropivacaine for initial bolus, 96ml of 0.5% ropivacaine infused at 2 ml/h), intralesional infusion with ISB, and continuous ISB (15ml of 0.2% ropivacaine for initial bolus, 192ml of 0.15% ropivacaine infused at 4 ml/h) after arthroscopic shoulder surgery. Postoperative pain was measured by visual analogue scale at 1 hour, and then at every 8 hour for 48 hours. Side effects and supplemental analgesics were recorded. Demographic and clinical characteristics of five groups were identical statistically. ISB and continuous ISB were effective to relieve pain and to reduce the amount of supplemental analgesics at 1, 8 hour postoperatively (p⬍0.05). Patients with intra-lesional infusion with ISB had less pain at 16, 48 hour postoperatively (p⬍0.05). Continuous intra-lesional infusion was superior to decrease analgesics-related side effects (p⬍0.05). There were much more complications or patients’ discomfort in CISB group including transient neurological deficit (21/25, 84%). All complications were disappeared after removal of catheter except two cases. There was no catheter-related infection in the intra-lesional infusion group. Our data suggests that a combination of interscalene brachial plexus block and continuous intra-lesional infusion of ropivacaine is effective and safe method of postoperative pain control in patients with arthroscopic shoulder surgery.
Paper 44: Long-Term Clinical and Anatomical Outcomes of Arthroscopic Repair of Small and Moderate-Sized Rotator Cuff Tears with Magnetic Resonance Arthrography Control MATTHIEU MEYER, MD, FRANCE, PRESENTING AUTHOR BLANDINE BORU, MD, FRANCE BENOI ROUSSELIN, FRANCE PHILIPPE P. HARDY, MD, FRANCE ABSTRACT Purpose: The goal of this continuous series was to evaluate the clinical and anatomical outcomes of ar-
throscopic rotator cuff repair at a minimal follow-up of two years. Materials and Methods: This study was retrospective concerning clinical and radiological preoperative data and prospective concerning data collected at last followup. Patients included had a small or moderate-sized supraspinatus tear with or without infraspinatus extension. The Constant score was used to evaluate the clinical preoperative status. All-arthroscopic fixation procedure was performed in all patients. The rotator cuff repair performed was a single-row fixation with simple stitches. The device used for bone fixation was the Arthrex Cork Screw. A long-head of biceps tenotomy and an acromioplasty were systematically performed during the surgical procedure. The clinical outcome at last follow-up was assessed using the Constant score. A rotator cuff Magnetic Resonance Arthrography (MRA) was performed to evaluate the anatomical outcome of the rotator cuff fixation at last follow-up. It was assessed independently by two radiologists who were blind with regard to the clinical outcome. The anatomical outcome was classified into four stages: Stage 1: Normal rotator cuff; Stage 2: intratendinous added image (partial thickness tear); Stage 3: small gadolinium leak (Full thickness tear); Stage 4: large gadolinium leak (Full thickness tear). Results: The mean follow-up of this study was 48 months [range: 24-88]. Twenty Nine patients (31 shoulders) had a clinical evaluation and 18 patients had a rotator cuff MRA. The clinical and radiological follow-up rates were 55% and 32 % respectively. The Constant mean score at last follow-up was 82.3 with a mean improvement of 24 %. 88 % of repairs showed a small (35%) or a large (53%) gadolinium leak on the MRA performed at last follow-up. There was no significant correlation between the clinical and anatomical outcomes. Conclusion: The interest of this small series is to show, at a long-term follow-up and using an invasive imaging technique, the high rate of rotator cuff iterative full thickness tears after an arthroscopic fixation procedure without having any influence on the clinical outcome. This rate might be explained by the extended follow-up at the time of the control MRA and by the high sensitivity of this imaging technique. Paper 45: Ultrasound Guided Needling Combined with Extracorporal High Energy Shockwave Therapy for Treatment of Tendinosis Calcarea of the Shoulder: Improvement of an Established Treatment Technique CHRISTIAN KRASNY, MD, AUSTRIA, PRESENTING AUTHOR MICHAEL ENENKEL, AUSTRIA NICOLAS AIGNER, MD, AUSTRIA FRANZ LANDSIEDL, MD, AUSTRIA
ABSTRACTS ABSTRACT Purpose: This prospective randomized controlled two trailed study was performed to assess the clinical and radiographic results after needling combined with high energetic shock wave therapy for calcifying tendonitis. Methods: 80 patients at a mean age of 48,4 years (range 32,5 - 67,3 y) with painful calcifying tendonitis were selected to one of two study groups. The treatment of the 40 patients in group I consisted of ultrasonic guided needling followed by high energetic shock wave therapy. The 40 patients of group II received high energy shock wave therapy only. In both groups one treatment session with 2500 impulses of shock waves with an energy flux density of 0,36 mJ/mm2 was applied. Clinical and radiological outcome was assessed with the 100 point Constant shoulder score system and standardized radiographs. The mean follow up period was 4,1 months and no patient was lost to follow up. Results: Both groups improved significantly in the Constant shoulder score (Group I: from 47,1 points before treatment to 76,8 points after treatment and Group II: from 44,2 points to 67,3 points). Radiographs showed in 60,0% of the shoulders of group I disappearance of the calcified deposit and in 32,5% of the shoulders of group II (p ⬍ 0,05). Significant better clinical and radiological results were obtained in group I compared to group II. In 32 patients (80,0%) of group I and in 22 patients (55,0%) of group II arthroscopic removal of the calcium deposit could be avoided (p ⬍ 0,05). No severe side effects were recorded. Conclusion: Ultrasound guided needling in combination with high energy shock wave therapy improves the effectiveness of the shock wave treatment. This new treatment method leads to significantly higher elimination rates of the calcium deposits, better clinical results and reduces the frequency of surgery significantly. Paper 46: Inman Was Right: Verification of Glenohumeral Motion In Vivo PAULA M. LUDEWIG, USA, PRESENTING AUTHOR JONATHAN PATRICK BRAMAN, MD, USA VANDANA PHADKE, USA DANIEL R. HASSETT, USA FRED A. WENTORF, MS, USA ROBERT F. LAPRADE, MD, PHD, USA ABSTRACT Introduction: Since the ground-breaking work of Inman in 1944, most subsequent investigations which have evaluated three-dimensional glenohumeral motion in vivo have used non-invasive techniques. This limits direct evaluation of the humeral and scapular motion. The
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technique of this study allows exact real-time determination of position of these bones. Methods: Nine patients with no history of shoulder problems and a normal shoulder clinical screening exam were consented for this IRB approved study. Using fluoroscopy, 2.5 mm stainless steel pins were inserted into the clavicle, the scapular spine, and the humerus. These were connected to three-dimensional motion sensors and patients moved actively through a range of motion. A thoracic marker was placed on the skin over the sternum for reference. Humeral motion was described relative to the thorax and glenohumeral motion described for the humerus relative to the scapula. The contribution of glenohumeral elevation was then identified as a percentage of total motion (humerus relative to the thorax). Results: All values are in average⫹/⫺standard deviation. Average age was 30.3 (⫹/⫺ 7.4 ) years. Seven tested shoulders were non-dominant and two were dominant. Active frontal plane abduction averaged a maximum of 138.9 degrees (⫹/⫺ 14.8). This was composed of a glenohumeral contribution of 68% (⫹/⫺ 2) and a scapulothoracic portion of 32% (⫹/⫺ 2). Active forward flexion averaged a maximum of 132.6 degrees (⫹/⫺ 15.7). This was composed of a glenohumeral contribution of 71% (⫹/⫺ 4) and a scapulothoracic portion of 29% (⫹/⫺ 4). Discussion: Since the work of Inman et al., clinicians have accepted the idea that 2/3 or 66.6% of shoulder motion was glenohumeral while 1/3 (33.3%) of it was scapulothoracic. While our analysis did not yield 180 degrees of elevation as theirs did, very similar ratios were reproduced in our data. This important verification of the accepted standard has ramifications for non-operative rehabilitation programs, implant design, as well as prognosis after traumatic injuries to the shoulder girdle. Further analysis of the motion data will enable investigation of the relationships of the osteology during different portions of the motion cycle. Paper 47: Arthroscopic Versus Mini-Open Rotator Cuff Repair With Suture Anchor CHIH-HWA CHEN, MD, TAIWAN, PRESENTING AUTHOR TAI-YUAN CHUANG, MD, TAIWAN KUO-YAO HSU, TAIWAN KUN-CHUENG WANG, TAIWAN WEN-JER CHEN, TAIWAN CHUN-HSIUNG SHIH, TAIWAN ABSTRACT Purpose: The goal of the study was to compare the results of all-arthroscopic rotator cuff repair with miniopen rotator cuff repair using suture anchor.
ABSTRACTS
sional infusion of local anesthetics with or without interscalene brachial plexus block (ISB), and by continuous interscalene block (CISB) after arthroscopic shoulder surgery. We designed the prospective randomized case-controlled study, and 113 consecutive patients were allocated into five groups according to the method of postoperative analgesia; intravenous PCA (fentanyl 0.3-0.5(Mu)g/kg/ml, ketorolac 0.03 mg/kg/ml, and ondansetron 8mg/100ml with 1 mL/ hour), intravenous PCA with ISB (20ml of 0.25% ropivacaine), intra-articular or intra-subacromial continuous infusion of ropivacaine (10ml of 0.75% ropivacaine for initial bolus, 96ml of 0.5% ropivacaine infused at 2 ml/h), intralesional infusion with ISB, and continuous ISB (15ml of 0.2% ropivacaine for initial bolus, 192ml of 0.15% ropivacaine infused at 4 ml/h) after arthroscopic shoulder surgery. Postoperative pain was measured by visual analogue scale at 1 hour, and then at every 8 hour for 48 hours. Side effects and supplemental analgesics were recorded. Demographic and clinical characteristics of five groups were identical statistically. ISB and continuous ISB were effective to relieve pain and to reduce the amount of supplemental analgesics at 1, 8 hour postoperatively (p⬍0.05). Patients with intra-lesional infusion with ISB had less pain at 16, 48 hour postoperatively (p⬍0.05). Continuous intra-lesional infusion was superior to decrease analgesics-related side effects (p⬍0.05). There were much more complications or patients’ discomfort in CISB group including transient neurological deficit (21/25, 84%). All complications were disappeared after removal of catheter except two cases. There was no catheter-related infection in the intra-lesional infusion group. Our data suggests that a combination of interscalene brachial plexus block and continuous intra-lesional infusion of ropivacaine is effective and safe method of postoperative pain control in patients with arthroscopic shoulder surgery.
Paper 44: Long-Term Clinical and Anatomical Outcomes of Arthroscopic Repair of Small and Moderate-Sized Rotator Cuff Tears with Magnetic Resonance Arthrography Control MATTHIEU MEYER, MD, FRANCE, PRESENTING AUTHOR BLANDINE BORU, MD, FRANCE BENOI ROUSSELIN, FRANCE PHILIPPE P. HARDY, MD, FRANCE ABSTRACT Purpose: The goal of this continuous series was to evaluate the clinical and anatomical outcomes of ar-
throscopic rotator cuff repair at a minimal follow-up of two years. Materials and Methods: This study was retrospective concerning clinical and radiological preoperative data and prospective concerning data collected at last followup. Patients included had a small or moderate-sized supraspinatus tear with or without infraspinatus extension. The Constant score was used to evaluate the clinical preoperative status. All-arthroscopic fixation procedure was performed in all patients. The rotator cuff repair performed was a single-row fixation with simple stitches. The device used for bone fixation was the Arthrex Cork Screw. A long-head of biceps tenotomy and an acromioplasty were systematically performed during the surgical procedure. The clinical outcome at last follow-up was assessed using the Constant score. A rotator cuff Magnetic Resonance Arthrography (MRA) was performed to evaluate the anatomical outcome of the rotator cuff fixation at last follow-up. It was assessed independently by two radiologists who were blind with regard to the clinical outcome. The anatomical outcome was classified into four stages: Stage 1: Normal rotator cuff; Stage 2: intratendinous added image (partial thickness tear); Stage 3: small gadolinium leak (Full thickness tear); Stage 4: large gadolinium leak (Full thickness tear). Results: The mean follow-up of this study was 48 months [range: 24-88]. Twenty Nine patients (31 shoulders) had a clinical evaluation and 18 patients had a rotator cuff MRA. The clinical and radiological follow-up rates were 55% and 32 % respectively. The Constant mean score at last follow-up was 82.3 with a mean improvement of 24 %. 88 % of repairs showed a small (35%) or a large (53%) gadolinium leak on the MRA performed at last follow-up. There was no significant correlation between the clinical and anatomical outcomes. Conclusion: The interest of this small series is to show, at a long-term follow-up and using an invasive imaging technique, the high rate of rotator cuff iterative full thickness tears after an arthroscopic fixation procedure without having any influence on the clinical outcome. This rate might be explained by the extended follow-up at the time of the control MRA and by the high sensitivity of this imaging technique. Paper 45: Ultrasound Guided Needling Combined with Extracorporal High Energy Shockwave Therapy for Treatment of Tendinosis Calcarea of the Shoulder: Improvement of an Established Treatment Technique CHRISTIAN KRASNY, MD, AUSTRIA, PRESENTING AUTHOR MICHAEL ENENKEL, AUSTRIA NICOLAS AIGNER, MD, AUSTRIA FRANZ LANDSIEDL, MD, AUSTRIA
ABSTRACTS ABSTRACT Purpose: This prospective randomized controlled two trailed study was performed to assess the clinical and radiographic results after needling combined with high energetic shock wave therapy for calcifying tendonitis. Methods: 80 patients at a mean age of 48,4 years (range 32,5 - 67,3 y) with painful calcifying tendonitis were selected to one of two study groups. The treatment of the 40 patients in group I consisted of ultrasonic guided needling followed by high energetic shock wave therapy. The 40 patients of group II received high energy shock wave therapy only. In both groups one treatment session with 2500 impulses of shock waves with an energy flux density of 0,36 mJ/mm2 was applied. Clinical and radiological outcome was assessed with the 100 point Constant shoulder score system and standardized radiographs. The mean follow up period was 4,1 months and no patient was lost to follow up. Results: Both groups improved significantly in the Constant shoulder score (Group I: from 47,1 points before treatment to 76,8 points after treatment and Group II: from 44,2 points to 67,3 points). Radiographs showed in 60,0% of the shoulders of group I disappearance of the calcified deposit and in 32,5% of the shoulders of group II (p ⬍ 0,05). Significant better clinical and radiological results were obtained in group I compared to group II. In 32 patients (80,0%) of group I and in 22 patients (55,0%) of group II arthroscopic removal of the calcium deposit could be avoided (p ⬍ 0,05). No severe side effects were recorded. Conclusion: Ultrasound guided needling in combination with high energy shock wave therapy improves the effectiveness of the shock wave treatment. This new treatment method leads to significantly higher elimination rates of the calcium deposits, better clinical results and reduces the frequency of surgery significantly. Paper 46: Inman Was Right: Verification of Glenohumeral Motion In Vivo PAULA M. LUDEWIG, USA, PRESENTING AUTHOR JONATHAN PATRICK BRAMAN, MD, USA VANDANA PHADKE, USA DANIEL R. HASSETT, USA FRED A. WENTORF, MS, USA ROBERT F. LAPRADE, MD, PHD, USA ABSTRACT Introduction: Since the ground-breaking work of Inman in 1944, most subsequent investigations which have evaluated three-dimensional glenohumeral motion in vivo have used non-invasive techniques. This limits direct evaluation of the humeral and scapular motion. The
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technique of this study allows exact real-time determination of position of these bones. Methods: Nine patients with no history of shoulder problems and a normal shoulder clinical screening exam were consented for this IRB approved study. Using fluoroscopy, 2.5 mm stainless steel pins were inserted into the clavicle, the scapular spine, and the humerus. These were connected to three-dimensional motion sensors and patients moved actively through a range of motion. A thoracic marker was placed on the skin over the sternum for reference. Humeral motion was described relative to the thorax and glenohumeral motion described for the humerus relative to the scapula. The contribution of glenohumeral elevation was then identified as a percentage of total motion (humerus relative to the thorax). Results: All values are in average⫹/⫺standard deviation. Average age was 30.3 (⫹/⫺ 7.4 ) years. Seven tested shoulders were non-dominant and two were dominant. Active frontal plane abduction averaged a maximum of 138.9 degrees (⫹/⫺ 14.8). This was composed of a glenohumeral contribution of 68% (⫹/⫺ 2) and a scapulothoracic portion of 32% (⫹/⫺ 2). Active forward flexion averaged a maximum of 132.6 degrees (⫹/⫺ 15.7). This was composed of a glenohumeral contribution of 71% (⫹/⫺ 4) and a scapulothoracic portion of 29% (⫹/⫺ 4). Discussion: Since the work of Inman et al., clinicians have accepted the idea that 2/3 or 66.6% of shoulder motion was glenohumeral while 1/3 (33.3%) of it was scapulothoracic. While our analysis did not yield 180 degrees of elevation as theirs did, very similar ratios were reproduced in our data. This important verification of the accepted standard has ramifications for non-operative rehabilitation programs, implant design, as well as prognosis after traumatic injuries to the shoulder girdle. Further analysis of the motion data will enable investigation of the relationships of the osteology during different portions of the motion cycle. Paper 47: Arthroscopic Versus Mini-Open Rotator Cuff Repair With Suture Anchor CHIH-HWA CHEN, MD, TAIWAN, PRESENTING AUTHOR TAI-YUAN CHUANG, MD, TAIWAN KUO-YAO HSU, TAIWAN KUN-CHUENG WANG, TAIWAN WEN-JER CHEN, TAIWAN CHUN-HSIUNG SHIH, TAIWAN ABSTRACT Purpose: The goal of the study was to compare the results of all-arthroscopic rotator cuff repair with miniopen rotator cuff repair using suture anchor.