The Law of Use and Disuse: Critical Shoulder Angle and Rotator Cuff Tears—Association Does Not Imply Causation

Lädermann, Alexandre

doi:10.1016/j.arthro.2020.04.030

Cited by 14 publications

(11 citation statements)

References 13 publications

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“…However, the role of acromioplasty in 2021 is still not clearly defined. [8][9][10] Some have argued that gliding of the rotator cuff under the acromiohumeral arch is probably part of human evolution, since we stand erect to compensate the deficiency of the superior rotator cuff. 11,12 Similarly to Ulysses, 150 years after the initial description of Duplay and a tumultuous journey, subacromial impingement has in some respects returned to its starting position (Fig 1).…”

Section: Proper Indications For Shoulder Subacromial Decompression Results In Excellent Outcomesmentioning

confidence: 99%

Proper Indications for Shoulder Subacromial Decompression Result in Excellent Outcomes

Lädermann

Denard

2021

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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Section: Proper Indications For Shoulder Subacromial Decompression Results In Excellent Outcomesmentioning

confidence: 99%

Proper Indications for Shoulder Subacromial Decompression Result in Excellent Outcomes

Lädermann

Denard

2021

Arthroscopy: The Journal of Arthroscopic & Related Surgery

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“…In addition, higher CSAs increase the rate of retears following RCR 33–38 . However, other studies have questioned the diagnostic value and reliability of the CSA 39–42 . One important reason fueling the debate was the inherent measurement error of the CSA reported in previous studies.…”

Section: Discussionmentioning

confidence: 99%

The Critical Shoulder Angle Can be Accurately and Reliably Determined from Three‐Dimensional Computed Tomography Images

Long

Zhou

et al. 2023

Orthopaedic Surgery

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ObjectiveAnteroposterior (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).MethodsIn 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.ResultsWe 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.ConclusionCSA 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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“…In the study by Chalmers et al [ 6 ], using the same criteria, 21% of their images could be used to measure CSA and both these studies confirm that regular shoulder AP views most often do not qualify for CSA measuring. Previous studies, investigating associations between scapular anatomy and development of RCT and GH OA, have most often used radiographs taken without considering scapula positioning and the interpretation of these studies could, therefore, be questioned [ 2 , 7 , 8 , 13 , 17 , 18 , 20 ]. In the present study, the CSA and AI followed the same trends, between individuals and over time.…”

Section: Discussionmentioning

confidence: 99%

“…True anteroposterior (AP) radiographs are needed for the calculation of CSA and AI as described by Nyffeler et al [ 21 ] and Moor et al [ 19 ]. Interobserver reliability for CSA and AI has been reported to be excellent, but a small deviation from a true AP view affects the CSA since the accuracy of CSA depends on the spatial relationship between the scapula and the radiograph beam, which varies with patient position and posture [ 11 , 12 , 16 , 17 , 26 ]. To prevent inaccurate CSA, Suter and Henninger (SH) presented a classification of valid AP radiographic views, based on 3-dimensional computed tomography reconstructions of the scapula [ 26 ].…”

Section: Introductionmentioning

confidence: 99%

Neither critical shoulder angle nor acromion index were related with specific pathology 20 years later!

Hallgren

Adolfsson

2021

Knee Surg Sports Traumatol Arthrosc

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Purpose The critical shoulder angle (CSA) and the acromion index (AI) are measurements of acromial shape reported as predictors of degenerative rotator cuff tears (RCT) and glenohumeral osteoarthritis (GH OA). Whether they are the cause or effect of shoulder pathologies is uncertain since pre-morbid radiographs most often are lacking. The main aim of this study was to investigate if CSA or AI were related to the development of RCT or GH OA after 20 years. A secondary aim was to investigate if the CSA and AI had changed over time. Methods In the hospital archive, 273 preoperative plain shoulder radiographs were found of patients scheduled for elective surgery other than cuff repair and arthroplasty. Forty-five images fulfilled the strict criteria published by Suter and Henninger (2015) and were used to measure CSA and AI with two independent assessors. No patient had any sign of OA in the index radiographs or any information in the medical records indicating RCT. After a median of 20 (16–22) years, 30 of these patients were radiologically re-examined with bilateral true frontal views and ultrasound of the rotator cuff. There were 19 men (20 study shoulders) and 11 females (12 study shoulders). Results Mean age at follow-up was 56 (32–78) years. There was no correlation between CSA (r = 0.02) (n.s) or AI (r = − 0.13) (n.s) in the primary radiographs and OA at follow-up. Nor was any correlation found between index CSA (r = 0.12) (n.s) or AI (r = − 0.13) (n.s) and RCT at follow-up. Mean difference in CSA was − 1.7 (− 10–3) degrees and mean AI difference was − 0.04 (− 0.13–0.09) between the first and the second radiographs, 20 years later. Bilaterally, mean CSA was 32 and AI 0.61 at follow-up. Conclusion In this study, no correlation between the CSA, AI and development of OA or RCT could be found. The mean CSA and AI decreased over a 20-year period but the difference was very small. No difference was found between the study shoulders and the contralaterals. These findings question previously reported etiological associations between scapular anatomy and the development of OA or RCT and thereby the use of these calculations as the basis of treatment. Level of evidence III.

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The Law of Use and Disuse: Critical Shoulder Angle and Rotator Cuff Tears—Association Does Not Imply Causation

Cited by 14 publications

References 13 publications

Proper Indications for Shoulder Subacromial Decompression Result in Excellent Outcomes

Proper Indications for Shoulder Subacromial Decompression Result in Excellent Outcomes

The Critical Shoulder Angle Can be Accurately and Reliably Determined from Three‐Dimensional Computed Tomography Images

Neither critical shoulder angle nor acromion index were related with specific pathology 20 years later!

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