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Background: Rotator cuff tears are highly prevalent, and their association with critical shoulder angle (CSA) has been reported. There is controversy regarding whether the morphology of the acromion influences its incidence, as well as whether acromioplasty would impact the results of a rotator cuff repair. Lateral acromioplasty does not play a decompressive role; rather, it aims to correct the deltoid vector. According to some publications, this would achieve less loading on the repaired rotator cuff, a lower retear rate, and better function. CSA correction with lateral acromioplasty can be planned with radiography (2-dimensional [2D]), but its predictability has not been fully studied. The primary objective of this study is to evaluate the predictability of 2D planning with radiography in CSA correction in patients with rotator cuff repair. The secondary objective is to analyze the association between the correction of the CSA and the functional outcomes. Methods: This single-center, prospective, observational, analytical study included candidates for arthroscopic repair of a rotator cuff tear with a CSA > 35°. Lateral acromioplasty was performed as planned with preoperative radiography (2D) to achieve a CSA of 35°. The degrees to be corrected were calculated. CSA was recalculated with a postoperative radiography; and the error in the planned grades to be corrected was calculated. At the end of follow-up, Visual Analog Scale, Subjective Shoulder Value (SSV), and Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) scores were evaluated. Results: Forty one cases were included, 43.9% were men, and the mean age was 55.5 ± 8.6 years. The mean preoperative and postoperative CSA were 39.6° ± 1.9° and 35.7° ± 2.3°, respectively; 41.5% achieved a postoperative CSA ≤ 35°. The mean CSA planned correction error was 45.7 ± 28.8%. At the end of the follow-up, 33 (78.6%) had a functional evaluation, with an average follow-up of 41 ± 6.8 months. The mean Visual Analog Scale, Quick-DASH, and SSV were 0.9 ± 1.6, 5.3 ± 7.5, and 92.7 ± 10.6, respectively. There was a significant difference in Quick-DASH (P = .01) and SSV (P = .02) according to whether a postoperative CSA ≤ 35° was achieved. Conclusion: In lateral acromioplasty, planning of CSA correction with radiography (2D) is imprecise. Reaching a CSA ≤ 35° positively influences functional results.

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OBJECTIVES: Critical shoulder angle (CSA) and acromial index (AI) are two radiographic signs that can influence the risk of rotator cuff tears and the outcomes of repair. The purpose of this study was to determine the influence of CSA and AI on massive cuff tears and on the functional outcomes after repair. The hypothesis was that CSA and AI would be higher in posterosuperior compared to anterosuperior tears. METHODS: CSA and AI were retrospectively measured on radiographs of patients who underwent repair of two rotator cuff tendons. Functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score and Simple Shoulder Test (SST) at least six months postoperatively. Patients were divided according to the tendons repaired into anterosuperior group and posterosuperior group. Radiographic measurements and functional outcomes were compared. Patients in the posterosuperior group were subdivided into low or high CSA (cut-off value â€‹= â€‹39), and into low or high AI (cut-off value â€‹= â€‹0.75). All available preoperative magnetic resonance images were reviewed and graded according to Goutallier classification. Multivariate analysis was used to determine the influence of CSA, AI and Goutallier grade on functional outcomes. RESULTS: Eighty six patients were included. Both CSA and AI were statistically significantly higher in the posterosuperior group (p â€‹= â€‹0.0143 and 0.0052, respectively). After a mean follow-up of 33 months, ASES and SST were significantly better in patients with Goutallier grades 0-1 than grades>1 (multivariate p â€‹= â€‹0.03 and 0.009, respectively). No statistically significant differences were found between low and high CSA and AI groups in terms of functional outcomes of the posterosuperior group after repair (multivariate p â€‹= â€‹0.9). CONCLUSION: Higher CSA and AI seem to increase the risk of posterosuperior more than anterosuperior rotator cuff tears. Neither of these radiographic parameters influenced the functional outcomes of massive posterosuperior tears after repair. LEVEL OF EVIDENCE: Level III.

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Purpose: To determine whether scapular morphology could predict isolated supraspinatus tendon tear propagation after exercise therapy. We hypothesised that a larger critical shoulder angle (CSA) and type III acromial morphology predict a positive change in tear size. Methods: Fifty-nine individuals aged 40-70 years with isolated symptomatic high-grade partial or full-thickness supraspinatus tendon tears were included. Individuals participated in a structured, individualised 12-week exercise therapy programme and underwent ultrasound to measure tear size at baseline and 12 months following therapy. Computed tomography images were segmented to create three-dimensional subject-specific bone models and reviewed by three trained clinicians to measure CSA and to determine acromion morphology based on the Bigliani classification. A binary logistic regression was performed to determine the predictive value of CSA and acromion morphology on tear propagation. Results: The CSA was 30.0 ± 5.4°. Thirty-one individuals (52.5%) had type II acromial morphology, followed by type III and type I morphologies (25.4% and 22.0%, respectively); 81.4% experienced no change in tear size, four (6.8%) individuals experienced tear propagation and seven (11.9%) individuals had a negative change in tear size. No significant difference in tear propagation rates based on CSA or acromion morphology (not significant [NS]) was observed. The model predicted tear size status in 81.4% of cases but only predicted tear propagation 8.3% of the time. Overall, CSA and acromion morphology only predicted 24.3% (R 2 = 0.243) of variance in tear propagation (NS). Conclusions: CSA and acromion morphology were NS predictors of tear propagation of the supraspinatus tendon 12 months following an individualised exercise therapy programme. Level of Evidence: II.

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BACKGROUND: This study aimed to compare the clinical effect of modified anterolateral and traditional acromioplasty in arthroscopic rotator cuff repair. METHODS: The clinical data of 92 patients with total rotator cuff tears admitted to the Department of Joint Surgery of Jinhua Central Hospital from January 2016 to December 2019 were retrospectively analyzed. Among them, 42 patients underwent traditional acromioplasty during arthroscopic rotator cuff repair, and 50 underwent modified anterolateral acromioplasty. Patients were evaluated for preoperative and postoperative shoulder function, pain and critical shoulder angle, and incidence of rotator cuff re-tear at 12 months postoperatively. RESULTS: The preoperative general data of patients in the classic and modified anterolateral acromioplasty groups did not differ significantly (P > 0.05) and were comparable. The UCLA, ASES, and Constant shoulder joint scores were significantly improved in both groups. The VAS score was significantly decreased at 12 months postoperative than preoperative, with a statistically significant difference (P ≤ 0.05). Shoulder function and pain scores did not differ significantly between the two groups at 12 months postoperatively (P > 0.05). The CSA did not differ significantly between preoperative and postoperative 12 months in the traditional acromioplasty group (P > 0.05). However, 12 months postoperative CSA in the modified anterolateral acromioplasty group was significantly smaller than the preoperative CSA, with a statistically significant difference (P ≤ 0.05). The rates of rotator cuff re-tears were 16.67% (7/42) and 4% (2/50) in the two groups at 12 months postoperatively, respectively, with statistically significant differences (P ≤ 0.05). CONCLUSIONS: Traditional and modified anterolateral acromioplasty while treating total rotator cuff tears using arthroscopic rotator cuff repair significantly improves shoulder joint function. However, modified anterolateral acromioplasty significantly reduced the CSA value and decreased the incidence of rotator cuff re-tears.

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Background: Shoulder pain is one of the most important musculoskeletal conditions affecting the upper extremities. Glenohumeral osteoarthritis (GHOA) and rotator cuff injuries (RCIs) are notable for their high prevalence. The critical shoulder angle (CSA) is a significant radiological measure for determining the diagnosis and progression of patients with these conditions. Although there are reports in the international literature about this measure, in our country, guideline values considering these two pathologies are unknown. Objective: Our objective was to assess patients diagnosed with GHOA and RCI using an AP X-ray view and the CSA. Methods: To conduct this, we identified differences between sexes and age categories. Fifty-nine adult patients with GHOA and RCI were included. CSA grades varied depending on the age category and type of injury evaluated. Results: Significant differences between the age ranges of 40 and 54 (p = 0.05), 55-69 (p = 0.001), and 70-84 (p = 0.017) were observed. Conclusions: Patients with RCI tended to be younger and have a higher CSA compared to those with GHOA. It is important to have more normative values and to continue monitoring the critical shoulder angle in these patients.

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OBJECTIVE: Although SLAP-5 lesions are associated with recurrent dislocations, their causes and pathomechanisms have not been fully elucidated. This study aimed to investigate the association between SLAP-5 lesions and scapular morphology in traumatic anterior shoulder instability (ASI). We hypothesized that there may be a relationship between SLAP-5 lesions and scapular morphology in traumatic ASI patients. MATERIALS AND METHODS: The study included 74 patients with isolated Bankart lesions and 69 with SLAP-5 lesions who underwent arthroscopic labral repair for ASI. Critical shoulder angle (CSA) was measured on the roentgenograms, while glenoid inclination (GI) and glenoid version (GV) were measured on magnetic resonance imaging (MRI) by two observers in two separate sessions blinded to each other. Both groups were compared in terms of CSA, GI, and GV. RESULTS: The mean ages of Bankart and SLAP-5 patients were 28.4±9.1 and 27.9±7.7 (P=0.89), respectively; their mean CSA values were 33.1°±2.6° and 28.2°±2.4°, respectively (P<0.001). The ROC analysis's cut-off value was 30.5°, with 75.0% sensitivity and 76.7% specificity (AUC = 0.830). SLAP-5 lesions were more common on the dominant side than isolated Bankart lesions (P=0.021), but no difference was found between the groups in terms of GI and GV (P=0.334, P=0.081, respectively). CONCLUSIONS: In ASI, low CSA values appeared to be related to SLAP-5 lesions, and the cut-off value of CSA for SLAP lesion formation was 30.5° with 75.0% sensitivity and 76.7% specificity. Scapula morphology may be related to the SLAP-5 lesions, and CSA can be used as an additional parameter in provocative diagnostic tests and medical imaging techniques for the detection of SLAP lesions accompanying Bankart lesions. LEVEL OF EVIDENCE: III retrospective case-control study.

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Background: This review aims to describe the origin and development of critical shoulder angle (CSA) and its correlation with different shoulder pathologies. Current literature is inconclusive in characterizing the role of CSA in predicting pathology and surgical outcomes. Methods: A literature search of both historical and more contemporary research articles on CSA was conducted to compare data points on the impact of CSA on shoulder pathology and postoperative clinical outcomes. This compilation of studies ranges from retrospective reviews to case series as well as cadaveric imaging studies. Results: The CSA is a reliable radiographic measure in predicting shoulder pathology in correctly oriented radiographs. Surgically modifying the CSA with arthroscopic lateral acromioplasty and results has largely shown improved recovery of strength postoperatively as with no increase in postsurgical complication rates. However, it remains unclear whether surgical alteration of CSA has a role in preventing clinical failure after arthroscopic procedures such as acromioplasty and rotator cuff repair as well as following shoulder arthroplasty. Discussion: Stronger conclusions regarding the prognostic utility of CSA are limited by the fact that most studies evaluating CSA are smaller retrospective cohorts. Moving forward, randomized controlled trials being conducted may offer greater insight as to how CSA can improve patient-reported outcomes postoperatively.

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BACKGROUND: An increased or decreased critical shoulder angle (CSA) is a known risk factor for osteoarthritis, lesions, and re-ruptures in the rotator cuff. A CSA greater than 35° correlates with degenerative rotator cuff tears, while a CSA of less than 30° correlates with osteoarthritis in the glenohumeral joint. The diagnostic gold standard for its determination is X-ray or MRI. OBJECTIVES: The primary objective of this research was to assess the viability of utilizing sonography imaging as a diagnostic tool to determine the modified critical shoulder angle (mCSA). This study aimed to investigate the feasibility and effectiveness of sonographic techniques in accurately diagnosing CSA compared to MRI. STUDY DESIGN AND METHODS: A cohort study was carried out (level of evidence 3). The CSA (MRI) and the mCSA (ultrasound) were assessed retrospectively by two independent board-certified investigators in 109 patients with shoulder pain by MRI and musculoskeletal sonography. The CSA in the MRI dataset was determined using routine protocols and then compared to the values assessed using the modified sonography-assisted method (mCSA). Both results were analyzed with linear regression to determine a possible correlation. All investigations were performed by a DEGUM (German Society for Medical Ultrasound)-certified specialist in musculoskeletal sonography. RESULTS: A total of 112 patients were included in this study, namely 40 female patients and 72 male patients with a mean age of 54.7 years at the time of the investigation. The mean CSA in MRI was 31.5° ± 3.899, and the mCSA in sonography was 30.1° ± 4.753. The inter- and intraobserver reliability for the CSA was factual with values of 0.993 and 0.967. The inter- and intraobserver reliability for mCSA was factual as well, with values of 0.989 and 0.948. The ANOVA analysis did not reveal a significant difference between the CSA and the mCSA values, and linear regression determined the R2 value to be 0.358 with p < 0.05. CONCLUSIONS: Diagnosing the mCSA using sonography is a safe and valid method. No statistically significant differences between the results in MRI and sonography could be seen. Although this is a retrospective, single-center study including only Caucasian mid-Europeans, and with the known limitations of ultrasound imaging, it nevertheless shows that sonography can be used as a simple, cheap, and fast technique to assess a modified CSA, which shows very good correlation with the standard CSA without losing the diagnostic quality.

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PURPOSE OF THE STUDY: The critical shoulder angle (CSA) is formed by the combination of glenoid inclination and acromial index and has been shown related to rotator cuff tears and glenohumeral osteoarthritis. SLAP lesions today have an important place among bicipitolabral pathologies that cause intensive shoulder pain. We aimed to investigate the relationship between CSA and glenoid depth and SLAP lesions. MATERIAL AND METHODS: Between March 2017 and January 2022, 279 consecutive shoulder arthroscopy patients' MRI images were retrospectively examined. After the exclusion criteria, 191 patients were eligible. Patients with SLAP lesions (n=37) were assembled as the study group (Group 1), and patients with intact superior labrum (n=154) were named as the control group (Group 2). Critical shoulder angle (CSA) and glenoid depth measurements were performed using the preoperative MRI images. RESULTS: A total of 191 patients, of whom 84 were male (44%) were included. The mean age was 49.9±14.96 (range 18-79). There was a statistically signifi cant difference between the SLAP group (Group 1) and the control group (Group 2) in terms of CSA (p=0.032). The mean CSA was 31.66°±3.51° in Group 1 and 33.57° ±5.01° in Group 2. The cut-off value for CSA in patients with SLAP lesions was calculated as 32.85° and the area under the curve was 0.61, therefore a satisfactory association was observed between the groups. The mean glenoid depth was 4.32 ±1.25 mm in Group 1, and 4.39 ±0.32 mm in Group 2. There was no statistically signifi cant difference between the groups in terms of glenoid depth (p=0.136) and also no association between the glenoid depth and SLAP lesions was observed (cut-off=4.45 mm, AUC=0.32). CONCLUSIONS: Low CSA is associated with SLAP lesions, just as in glenohumeral osteoarthritis. Further prospective clinical studies are needed to enlighten the predisposing effect of CSA to SLAP lesions and the success of superior labral repairs. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

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BACKGROUND: The etiology of rotator cuff tears (RCTs) have been investigated for years and many underlying causes have been identified. Shoulder joint morphology is one of the extrinsic causes of RCTs. AIM: Morphometric measurements on MRI sections determined which parameters are an important indicator of RCT in patients with shoulder pain. The aim of this study was to determine the risk factors in the etiology of RCTs by evaluating the shoulder joint morphology with the help of previously defined radiological parameters. METHOD: Between January 2019-December 2020, 408 patients (40-70 years old) who underwent shoulder MRI and met the criteria were included in the study. There were 202 patients in the RCT group and 206 patients in the control group. Acromion type, acromial index (AI), critical shoulder angle (CSA), acromiohumeral distance (AHD), lateral acromial angle (LAA), acromial angulation (AA), acromion-greater tuberosity impingement index (ATI), and glenoid version angle (GVA) were measured from the MRI images of the patients. RESULTS: AI (0.64 vs. 0.60, p = 0.003) CSA (35.3° vs. 32.4°, p = 0.004), ATI (0.91 vs. 0.83, P < 0.001), and AA (13.6° vs. 11.9°, p = 0.011) values were higher in the RCT group than in the control group and the difference was significant. AHD (8.1 mm vs. 9.9 mm, P < 0.001), LAA (77.2° vs. 80.9°, p = 0.004) and GVA (-3.9° vs. -2.5°, P < 0.001) values were lower in the RCT group than in the control group, and again the difference was significant. According to the receiver operating characteristic curve analysis, the cutoff values were 0.623 for AI and 0.860 for ATI. CONCLUSION: Acromion type, AI, CSA, AHD, LAA, AA, ATI, and GVA are suitable radiological parameters to evaluate shoulder joint morphology. High AI, CSA, AA, ATI, GVA and low AHD and LAA are risk factors for RCT.

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BACKGROUND: The bone morphology of the greater tuberosity and lateral acromion plays a central role in subacromial impingement syndrome. The critical shoulder angle (CSA) and greater tuberosity angle (GTA) are two-dimensional measurement parameters that have been validated to evaluate it radiologically. These markers are, however, static and don't consider the dynamic effect of glenohumeral motion. OBJECTIVES: This study aimed to better understand the biomechanics in subacromial impingement with a dynamic simulation based on a validated 3D biomechanical model coupling joint kinematics and 3D reconstructed computed tomography. STUDY DESIGN & METHODS: Sixty-one patients were included in this study: a case group of 44 patients with degenerative rotator cuff tears involving only the supraspinatus, and a control group of 17 without a rotator cuff tear. Patients with previous surgeries, traumatic cuff tears, and cuff tear arthropathy were excluded. CSA, GTA, and impingement-free range of motion (IF-ROM) of the glenohumeral joint in scaption were calculated. Correlation tests were used to determine the relationship between ROM and CSA, GTA, and combined CSA and GTA values. RESULTS: CSA and GTA were significantly higher in the rotator cuff tear group (p = 0.001 and < 0.001), while IF-ROM was significantly higher in the control group (p = 0.001). There was no overall correlation between CSA and GTA (R = 0.02, p = 0.8). Individual correlation between both angles with IF-ROM was negatively weak for CSA (R = -0.4, p < 0.001) and negatively moderate for GTA and IF-ROM (R = -0.5, p < 0.001). However, combining both angles resulted in a negatively high correlation with IF-ROM (R = -0.7, p < 0.001). CONCLUSION: Subacromial space narrowing during scaption is highly correlated to the cumulative values of GTA and CSA. These findings suggest that the combined bony morphology of the lateral acromion and greater tuberosity plays an important role in subacromial impingement. LEVEL OF EVIDENCE: III.

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BACKGROUND: The 2D:4D ratio (an indicator of prenatal testosterone-estrogen balance) is the ratio of the second finger length to the fourth finger length. We hypothesized that low 2D:4D values indicating high prenatal testosterone exposure may be associated with increased critical shoulder angle (CSA). AIMS: The aim of this study was to evaluate the relationship between CSA and 2D:4D ratio. METHODS: Meeting the study criteria, 252 patients were included in the study. We measured CSA on true anterior-posterior radiographs, glenoid version(GV) and glenoid inclination(GI) on MRI images and the lengths of the second and fourth fingers on both hands of the patients. Additionally, we compared 2D:4D ratios and CSA, GV, GI measurements. RESULTS: We found a significant negative correlation between CSA and the 2D:4D ratio in both hands (p < 0.001). Patients with CSA > 35° had a significantly lower 2D:4D ratio than patients with CSA < 35° (p < 0.001). When the patients were grouped according to CSA35°, the cut-off value for the left-hand 2D:4D ratio was 0.96, which showed 84.8 % sensitivity and 83.3 % specificity(AUC:0.911). Patients were compared in terms of CSA by categorizing as 2D:4D > 1 and 2D:4D < 1. Accordingly, the CSA value was significantly lower in patients with 2D:4D > 1. In the classification made according to this length classification of the left hand, the cut-off value was 30.25°. This value showed 92.2 % sensitivity and 85 % specificity(AUC:0.956). CONCLUSION: The 2D:4D ratio is related to CSA. A low 2D:4D ratio(<0.96), indicating high intrauterine testosterone exposure, is associated with CSA > 35°, while a high 2D:4D ratio (>1), indicating low intrauterine testosterone exposure, is associated with a low CSA(<30.25°).

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Background: The purpose of this study was to determine if scapular anatomy differs between younger and older patients with atraumatic full-thickness supraspinatus tears. Methods: The critical shoulder angle, acromial index and lateral acromial angle were measured on standardized radiographs of two groups of patients who underwent arthroscopic repair of full-thickness degenerative supraspinatus tears. Group 1 included 61 patients under the age of 50 years while Group 2 included 45 patients over the age of 70 years. The mean critical shoulder angle, acromial index, and lateral acromial angle were then compared. Results: There was no significant difference between groups for the critical shoulder angle (p = .433), acromial index (p = .881) or lateral acromial angle (p = .263). Interobserver reliability for critical shoulder angle, acromial index, and lateral acromial angle was nearly perfect (interclass correlation coefficient 0.996, 0.996, 0.998, respectively). No significant correlation existed between age and critical shoulder angle (p = .309), acromial index (p = .484) or lateral acromial angle (p = .685). Discussion: While the critical shoulder angle and acromial index were found to be high and in the typical range for patients with rotator cuff tears in both groups, there were no significant differences in acromial morphology between Groups 1 and 2.

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Background: Various radiological parameters have been measured in the Reverse Shoulder Arthroplasty (RSA) and correlated to patient outcomes, to determine best baseplate position. Results remain unclear with respect to certain parameters such as inferior baseplate tilt. We have investigated our series of patients to clarify the relationship between radiological parameters and patient outcomes. Methods: We conducted a UK based bi-centre retrospective review of 156 prostheses. Critical shoulder angle (CSA), RSA angle (RSAA), Overhang and Deltoid Lever Arm (DLA) were measured on preoperative and postoperative radiographs. Range of motion and Oxford Shoulder Score (OSS) (range 1-8 years) were obtained. We assessed for scapular notching at minimum 1 year follow up (n = 138). Results: Decreased postoperative CSA and increased DLA were associated with higher OSSs (P = 0.001 and 0.019). Increased overhang and DLA were associated with increased flexion (P = 0.033 and 0.024 respectively). Multivariate analysis showed that CSA and DLA affected notching rate (P = 0.002 and 0.007). Conclusions: Baseplate tilt in relation to the acromion (CSA) and DLA are the most predictive parameters for notching and OSS. We recommend considering a maximum CSA of 26 degrees to decrease notching rate and improve OSS. We recommend considering an Overhang of at least 6 mm to improve FF.

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BACKGROUND: The Critical Shoulder Angle Related Acromion Morphological Parameter (CSA- RAMP) is a valuable tool in the analyzing the etiology of the rotator cuff tears (RCTs). However, its clinical application has been limited by the time-consuming and prone to inter- and intra-user variability of the measurement process. OBJECTIVES: To develop and validate a deep learning algorithm for fully automated assessment of shoulder anteroposterior radiographs associated with RCTs and calculation of CSA-RAMP. METHODS: Retrospective analysis was conducted on radiographs obtained from computed tomography (CT) scans and X-rays performed between 2018 and 2020 at our institution. The development of the system involved the utilization of digitally reconstructed radiographs (DRRs) generated from each CT scan. The system's performance was evaluated by comparing it with manual and semiautomated measurements on two separate test datasets: dataset I (DRRs) and dataset II (X-rays). Standard metrics, including mean average precision (AP), were utilized to assess the segmentation performance. Additionally, the consistency among fully automated, semiautomated, and manual measurements was comprehensively evaluated using the Pearson correlation coefficient and Bland-Altman analysis. RESULTS: A total of 1080 DRRs generated from 120 consecutive CT scans and 159 X-ray films were included in the study. The algorithm demonstrated excellent segmentation performance, with a mean AP of 57.67 and an AP50 of 94.31. Strong inter-group correlations were observed for all CSA-RAMP measurements in both test datasets I (automated versus manual, automated versus semiautomated, and semiautomated versus manual; r = [0.990---0.997], P < 0.001) and dataset II (r = [0.984---0.995], P < 0.001). Bland-Altman analysis revealed low bias for all CSA-RAMP measurements in both test datasets I and II, except for CD (with a maximum bias of 2.49%). CONCLUSIONS: We have successfully developed a fully automated algorithm capable of rapidly and accurately measuring CSA-RAMP on shoulder anteroposterior radiographs. A consistent automated CSA- RAMP measurement system may accelerate powerful and precise studies of disease biology in future large cohorts of RCTs patients.

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Resumen: Introducción: es bien conocida la conexión existente entre un ángulo crítico del hombro (ACH) mayor a 35o y las lesiones del manguito rotador (LMR). Sin embargo, se desconoce si existe una asociación entre los valores más elevados de ACH y la presencia de LMR de mayor severidad. Material y métodos: estudio de corte transversal, descriptivo, observacional, prospectivo y analítico, en el que a los pacientes con LMR se les evaluó por imagen el ACH y mediante artroscopía el grado de lesión. Se formaron cuatro grupos (sin lesión; lesión parcial; lesión completa; lesión masiva) y se compararon mediante la estadística paramétrica ANOVA. Se estudió la asociación entre LMR y ACH por medio del coeficiente rho de Spearman. Resultados: se estudiaron 71 pacientes, 15 sin LMR (ACH de 34.13 ± 0.98), 17 con lesión parcial (ACH de 36.00 ± 1.15), 22 con lesión completa (ACH de 40.77 ± 0.69) y 17 con lesión masiva (ACH de 41.53 ± 0.68). No se encontró diferencia significativa entre el ACH de los grupos sin lesión y lesión parcial (p = 0.486; 35o), pero sí existió diferencia entre los grupos de lesión completa y lesión masiva (p = 0.000 y p = 0.001; 35o). Se encontró una asociación positiva significativa entre ACH y LMR (rho = 0.605, p = 0.000). Conclusiones: un ACH por arriba de 35o se asocia con LMR de tipo completas y masivas y funciona como factor predictivo de severidad para estas lesiones.

Abstract: Introduction: the connection between a critical shoulder angle (CSA) greater than 35o and the presence rotator cuff tears (RCT) is well known. However, it remains unidentified if there is an association between a higher CSA value and the presence of more severity RCT. Material and methods: cross-sectional, descriptive, observational, prospective and analytical study in which patients with RCT had their CSA evaluated by imaging and the degree of the RCT by arthroscopy. Four groups were formed (without lesion; partial lesion; complete lesion; massive lesion) and were compared using ANOVA parametric statistics. The association between RCT and CSA was studied by rho Spearman coefficient. Results: 71 patients were studied, 15 without RCT (CSA of 34.13 ± 0.98), 17 with partial lesion (CSA of 36.00 ± 1.15), 22 with complete lesion (CSA of 40.77 ± 0.69) and 17 with massive lesion (CSA of 41.53 ± 0.68). No significant statistical difference was found between the CSA of the groups without lesion and partial lesion (p = 0.486; 35o) but there was a difference between the groups with complete and massive lesion (p = 0.000 and p = 0.001; 35o). A significant positive association was found between CSA and RCT (rho = 0.605, p = 0.000). Conclusions: an CSA above 35o is associated to complete and massive RCT and it works as a predictor of severity for these lesions.

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Objective: To investigate the synergistic interaction between the deltoid muscle and the rotator cuff muscle group in patients with rotator cuff tears (RCT), as well as the impact of the critical shoulder angle (CSA) on deltoid muscle strength. Methods: A retrospective analysis was conducted on clinical data from 42 RCT patients who met the selection criteria and were treated between March 2022 and March 2023. There were 13 males and 29 females, with an age range of 42-77 years (mean, 60.5 years). Preoperative visual analogue scale (VAS) score was 6.0±1.6. CSA measurements were obtained from standard anteroposterior X-ray films before operation, and patients were divided into two groups based on CSA measurements: CSA>35° group (group A) and CSA≤35° group (group B). Handheld dynamometry was used to measure the muscle strength of various muscle group in the shoulder (including the supraspinatus, infraspinatus, subscapularis, and anterior, middle, and posterior bundles of the deltoid). The muscle strength of the unaffected side was compared to the affected side, and muscle imbalance indices were calculated. Muscle imbalance indices between male and female patients, dominant and non-dominant sides, and groups A and B were compared. Pearson correlation analysis was used to examine the relationship between muscle imbalance indices and CSA as well as VAS scores. Results: Muscle strength in all muscle groups on the affected side was significantly lower than on the unaffected side ( P<0.05). The muscle imbalance indices for the supraspinatus, subscapularis, infraspinatus, and anterior, middle, and posterior bundles of the deltoid were 14.8%±24.4%, 5.9%±9.7%, 7.2% (0, 9.1%), 17.2% (5.9%, 26.9%), 8.3%±21.3%, and 10.2% (2.8%, 15.4%), respectively. The muscle imbalance indices of the anterior bundle of the deltoid, supraspinatus, and infraspinatus were significantly lower in male patients compared to female patients ( P<0.05); however, there was no significant difference in muscle imbalance indices among other muscle groups between male and female patients or between the dominant and non-dominant sides ( P>0.05). There was a positive correlation between the muscle imbalance indices of infraspinatus and VAS score ( P<0.05), and a positive correlation between CSA and the muscle imbalance indices of middle bundle of deltoid ( P<0.05). There was no correlation between the muscle imbalance indices of other muscle groups and VAS score or CSA ( P>0.05). Preoperative CSA ranged from 17.6° to 39.4°, with a mean of 31.1°. There were 9 cases in group A and 33 cases in group B. The muscle imbalance indices of the anterior bundle of the deltoid was significantly lower in group A compared to group B ( P<0.05), while there was no significant difference in muscle imbalance indices among other muscle groups between group A and group B ( P>0.05). Conclusion: Patients with RCT have a phenomenon of deltoid muscle strength reduction, which is more pronounced in the population with a larger CSA.

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INTRODUCTiON: It is estimated that 5-30% of traumatic anterior shoulder dislocations are accompanied by greater tuberosity fracture (GTF), and the pathomechanism of these fractures is not yet clear. Our hypothesis is to examine the relationship between the scapula morphology and anterior shoulder dislocation (ASD) accompanying GTF. MATERiALS AND METHODS: The patients were divided into two groups according to the accompanying GTF. 40 patients with isolated traumatic ASD and 31 patients with accompanying GTF were included in the study. Critical shoulder angle (CSA), glenoid inclination (GI), acromial index (AI) and greater tuberosity angle (GTA) values were measured in two sessions by two independent observers in the standard antero-posterior radiographs of the patients in both groups. RESULTS: The mean CSA was 40.82°±3.19° and 35.49°±2.19° in accompanying GTF group and the isolated ASD group, respectively. The mean CSA was significantly higher in accompanying GTF group than isolated ASD group(P<0.001). The GI was significantly higher in the isolated ASD than in accompanying GTF group (P = 0.001). The mean GI was 18.7°±6.85° and 10.45°±4.87° in accompanying GTF group and the isolated ASD, respectively. Cut-off value of CSA and GI was 38° (88.2% sensitivity,88.9% specificity) and 14.5° (70.6% sensitivity and 72.2% specificity), respectively. There was no significant difference regarding the mean GTA and AI values between GTF group and the isolated ASD group (P = 0.98, P = 0.63). CONCLUSiONS: Increased CSA and GI values are associated with traumatic anterior shoulder dislocation accompanied by greater tuberosity fracture.

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Background: Although arthroscopic subacromial decompression (ASD) is a commonly used procedure during arthroscopic rotator cuff repair (ARCR), the effect of ASD on the clinical outcomes for ARCR is controversial. The purpose of this study was to compare the clinical outcomes of ARCR with or without ASD. Methods: Patients (n = 315 with 320 shoulders) who underwent ARCR for small to medium-sized rotator cuff tears were followed for at least 24 months. ARCR was performed with ASD (180 shoulders, group A) or without ASD (140 shoulders, group N). There were no significant differences in patient demographics, including mean age and mean follow-up time. Rotator cuff repair was performed using the suture-bridge technique in all shoulders, and all patients were treated using the same rehabilitation protocol after surgery. University of California at Los Angeles score, Constant score, re-tear rates, revision surgery rates, and operating time were compared between groups. Re-tear was defined as Sugaya classification Types 4 and 5 using postoperative magnetic resonance imaging at more than 12 months. Results: There was no statistically significant difference in clinical outcomes before and after ARCR between groups. However, the University of California at Los Angeles scores and Constant scores significantly improved in both groups after surgery (P < .001). Furthermore, there was no major difference in the re-tear rates between groups A (7/180 shoulders, 3.9%) and N (11/140 shoulders, 7.9%) (P = .146). Revision surgeries were performed on 3/180 shoulders (1.7%) in group A (due to postoperative deep infection in one shoulder and revision ARCR for re-tear in two shoulders). No revisions surgeries were needed in group N patients (P = .259). The mean surgical time for group A was 62.0 ± 27.0 minutes (29-138 min.) and 52.4 ± 26.1 minutes (17-124 min.) for group N (P = .007). Conclusion: These results suggest that ASD has a limited effect on clinical outcomes of ARCR for small to medium-sized rotator cuff tears.

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OBJECTIVE: Anteroposterior (AP) radiographs do not necessarily offer the optimal approach to measuring the critical shoulder angle (CSA) due to the malposition of the scapula. Three-dimensional computed tomography (3D-CT) may offer some advantages, including the ability to rotate the scapula for position alignment and pre-operative planning for reducing CSA. This study aimed to investigate the accuracy and reliability of CSA measurement in 3D-CT and to determine whether there is an association between CSA and rotator cuff tears (RCTs). METHODS: In this retrospective study we identified 200 patients who received shoulder arthroscopy from 2019 to 2021, including 142 patients (81 females, 61 males) with RCTs and 58 patients (14 females, 44 males) with non-RCTs. For each participant, CSA was measured from standard shoulder AP radiographs and anterior views of 3D-CT of the scapula by two independent assessors. Inter- and intra-observer agreements were assessed by the intraclass correlation coefficient (ICC). The relationship between the two measurement methodologies was determined by Spearman's correlation coefficient and Bland-Altman plots. Discriminative capacity was calculated by using receiver operating curve (ROC) analyses in the whole cohort and age sub-groups above and below 45 years. RESULTS: We found perfect inter-observer (ICC >0.96) and intra-observer (ICC >0.97) reliabilities for CSA measurements obtained from the standard AP radiographs and the 3D-CT. There was a strong correlation between the two methods (r = 0.960, P < 0.001). The mean CSA was 31.7° ± 4.2° in the standard AP radiographs and 31.8° ± 4.4° in the 3D-CT (mean difference 0.02°, P = 0.940; bias 0.02°, limits of agreement -2.29° to +2.33°). ROC analysis of the whole cohort showed that the CSA measured in the standard AP radiographs (area under the ROC curve [AUC] = 0.812, P < 0.001) and the 3D-CT (AUC = 0.815, P < 0.001) predicted RCT with high confidence. ROC analysis of patients aged ≥45 years showed that the CSA measured from the standard AP radiographs (AUC = 0.869, P < 0.001) and the 3D-CT (AUC = 0.870, P < 0.001) were very good at predicting RCTs. CONCLUSION: CSA measured from standard AP radiographs and 3D-CT showed high consistency, and the CSA could be accurately and reliably measured using 3D-CT. CSAs measured from standard AP radiographs and 3D-CT could predict RCTs, especially in patients aged ≥45 years.

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