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The Relationship Between the Critical Shoulder Angle and the Incidence of Chronic, Full-Thickness Rotator Cuff Tears and Outcomes After Rotator Cuff Repair: A Systematic Review

      Purpose

      To summarize the available evidence and examine the relationship between the critical shoulder angle (CSA) and (1) the incidence of chronic full-thickness rotator cuff tears (RCTs) and (2) outcomes after rotator cuff repair (RCR).

      Methods

      A comprehensive search of MEDLINE, Embase, and CINAHL was completed. Comparative studies were included and the influence of the CSA on either the incidence of chronic, full-thickness RCTs, or outcomes following RCR was evaluated. Demographic variables and outcomes were collected.

      Results

      Seven comparative studies analyzed the influence of the CSA on the incidence of chronic, full-thickness RCTs (the control group constituted patients with a normal rotator cuff). High heterogeneity limited pooling of studies, but the majority concluded that a greater CSA significantly increased the likelihood of a chronic, full-thickness RCT. Conversely, 5 comparative studies analyzed the influence of CSA on outcomes following RCR, and although a greater CSA was associated with a greater re-tear rate, the majority reported that CSA did not significantly influence postoperative functional outcomes, including patient-reported outcome measures (PROMs), range of motion (ROM), and strength.

      Conclusions

      Based on the available evidence, there appears to be a relationship between a greater CSA and the presence of a chronic, full-thickness RCT. Furthermore, a greater CSA may be associated with a greater re-tear rate following RCR; however, CSA does not appear to influence functional outcomes following RCR. Despite these observations, the available evidence is of poor quality, and the clinical utility and role of the CSA in the diagnosis and surgical management of a chronic, full-thickness RCT remains in question.

      Level of Evidence

      Level IV: Systematic review of Level II-IV studies.
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      References

        • Banas M.P.
        • Miller R.J.
        • Totterman S.
        Relationship between the lateral acromion angle and rotator cuff disease.
        J Shoulder Elbow Surg. 1995; 4: 454-461
        • Balke M.
        • Schmidt C.
        • Dedy N.
        • Banerjee M.
        • Bouillon B.
        • Liem D.
        Correlation of acromial morphology with impingement syndrome and rotator cuff tears.
        Acta Orthop. 2013; 84: 178-183
        • Pandey V.
        • Vijayan D.
        • Tapashetti S.
        • et al.
        Does scapular morphology affect the integrity of the rotator cuff?.
        J Shoulder Elbow Surg. 2016; 25: 413-421
        • Neer C.S.
        Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report.
        J Bone Joint Surg Am. 1972; 54: 41-50
        • Neer C.S.
        Impingement lesions.
        Clin Orthop Relat Res. 1983; : 70-77
        • Aoki M.
        • Ishii S.
        • Usui M.
        The slope of the acromion and rotator cuff impingement.
        Orthop Trans. 1986; : 228
        • Moor B.K.
        • Wieser K.
        • Slankamenac K.
        • Gerber C.
        • Bouaicha S.
        Relationship of individual scapular anatomy and degenerative rotator cuff tears.
        J Shoulder Elbow Surg. 2014; 23: 536-541
        • Moor B.K.
        • Bouaicha S.
        • Rothenfluh D.A.
        • Sukthankar A.
        • Gerber C.
        Is there an association between the individual anatomy of the scapula and the development of rotator cuff tears or osteoarthritis of the glenohumeral joint? A radiological study of the critical shoulder angle.
        Bone Joint J. 2013; 95-B: 935-941
        • Bishop J.L.
        • Kline S.K.
        • Aalderink K.J.
        • Zauel R.
        • Bey M.J.
        Glenoid inclination: In vivo measures in rotator cuff tear patients and associations with superior glenohumeral joint translation.
        J Shoulder Elbow Surg. 2009; 18: 231-236
        • Hughes R.E.
        • Bryant C.R.
        • Hall J.M.
        • et al.
        Glenoid inclination is associated with full-thickness rotator cuff tears.
        Clin Orthop Relat Res. 2003; : 86-91
        • Karns M.R.
        • Jacxsens M.
        • Uffmann W.J.
        • Todd D.C.
        • Henninger H.B.
        • Burks R.T.
        The critical acromial point: The anatomic location of the lateral acromion in the critical shoulder angle.
        J Shoulder Elbow Surg. 2018; 27: 151-159
        • Nyffeler R.W.
        • Werner C.M.L.
        • Sukthankar A.
        • Schmid M.R.
        • Gerber C.
        Association of a large lateral extension of the acromion with rotator cuff tears.
        J Bone Joint Surg Am. 2006; 88: 800-805
        • Gomide L.C.
        • Carmo T.C.D.
        • Bergo G.H.M.
        • Oliveira G.A.
        • Macedo I.S.
        Relationship between the critical shoulder angle and the development of rotator cuff lesions: A retrospective epidemiological study.
        Rev Bras Ortop. 2017; 52: 423-427
        • Li X.
        • Olszewski N.
        • Abdul-Rassoul H.
        • Curry E.J.
        • Galvin J.W.
        • Eichinger J.K.
        Relationship between the critical shoulder angle and shoulder disease.
        JBJS Rev. 2018; 6: e1
        • Blonna D.
        • Giani A.
        • Bellato E.
        • et al.
        Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder.
        J Shoulder Elbow Surg. 2016; 25: 1328-1336
        • Cherchi L.
        • Ciornohac J.F.
        • Godet J.
        • Clavert P.
        • Kempf J.-F.
        Critical shoulder angle: Measurement reproducibility and correlation with rotator cuff tendon tears.
        Orthop Traumatol Surg Res. 2016; 102: 559-562
        • Heuberer P.R.
        • Plachel F.
        • Willinger L.
        • et al.
        Critical shoulder angle combined with age predict five shoulder pathologies: A retrospective analysis of 1000 cases.
        BMC Musculoskelet Disord. 2017; 18
        • Miswan M.F.
        • Saman M.S.
        • Hui T.S.
        • Al-Fayyadh M.Z.
        • Ali M.R.
        • Min N.W.
        Correlation between anatomy of the scapula and the incidence of rotator cuff tear and glenohumeral osteoarthritis via radiological study.
        J Orthop Surg (Hong Kong). 2017; 25 (230949901769031)
        • Moor B.K.
        • Röthlisberger M.
        • Müller D.A.
        • et al.
        Age, trauma and the critical shoulder angle accurately predict supraspinatus tendon tears.
        Orthop Traumatol Surg Res. 2014; 100: 489-494
        • Peltz C.D.
        • Divine G.
        • Drake A.
        • et al.
        Associations between in-vivo glenohumeral joint motion and morphology.
        J Biomech. 2015; 48: 3252-3257
        • Shinagawa K.
        • Hatta T.
        • Yamamoto N.
        • et al.
        Critical shoulder angle in an East Asian population: Correlation to the incidence of rotator cuff tear and glenohumeral osteoarthritis.
        J Shoulder Elbow Surg. 2018; 27: 1602-1606
        • Spiegl U.J.
        • Horan M.P.
        • Smith S.W.
        • Ho C.P.
        • Millett P.J.
        The critical shoulder angle is associated with rotator cuff tears and shoulder osteoarthritis and is better assessed with radiographs over MRI.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 2244-2251
        • Watanabe A.
        • Ono Q.
        • Nishigami T.
        • Hirooka T.
        • Machida H.
        Differences in risk factors for rotator cuff tears between elderly patients and young patients.
        Acta Med Okayama. 2018; 72: 67-72
        • Bjarnison A.O.
        • Sørensen T.J.
        • Kallemose T.
        • Barfod K.W.
        The critical shoulder angle is associated with osteoarthritis in the shoulder but not rotator cuff tears: A retrospective case-control study.
        J Shoulder Elbow Surg. 2017; 26: 2097-2102
        • Chalmers P.N.
        • Salazar D.
        • Steger-May K.
        • Chamberlain A.M.
        • Yamaguchi K.
        • Keener J.D.
        Does the critical shoulder angle correlate with rotator cuff tear progression?.
        Clin Orthop Relat Res. 2017; 475: 1608-1617
        • Mantell M.T.
        • Nelson R.
        • Lowe J.T.
        • Endrizzi D.P.
        • Jawa A.
        Critical shoulder angle is associated with full-thickness rotator cuff tears in patients with glenohumeral osteoarthritis.
        J Shoulder Elbow Surg. 2017; 26: e376-e381
        • Garcia G.H.
        • Liu J.N.
        • Degen R.M.
        • et al.
        Higher critical shoulder angle increases the risk of retear after rotator cuff repair.
        J Shoulder Elbow Surg. 2017; 26: 241-245
        • Kirsch J.M.
        • Nathani A.
        • Robbins C.B.
        • Gagnier J.J.
        • Bedi A.
        • Miller B.S.
        Is there an association between the “critical shoulder angle” and clinical outcome after rotator cuff repair?.
        Orthop J Sports Med. 2017; 5 (232596711770212)
        • Lee M.
        • Chen J.Y.
        • Liow M.H.L.
        • Chong H.C.
        • Chang P.
        • Lie D.
        Critical shoulder angle and acromial index do not influence 24-month functional outcome after arthroscopic rotator cuff repair.
        Am J Sports Med. 2017; 45: 2989-2994
        • Li H.
        • Chen Y.
        • Chen J.
        • Hua Y.
        • Chen S.
        Large critical shoulder angle has higher risk of tendon retear after arthroscopic rotator cuff repair.
        Am J Sports Med. 2018; 46: 1892-1900
        • Higgins J.P.T.
        • Green S.
        Cochrane Handbook for Systematic Reviews of Interventions, Version 5.1.0.
        www.handbook.cochrane.org
        Date: 2011
        Date accessed: October 30, 2018
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • The PRISMA Group
        Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA statement.
        PLoS Med. 2009; 6: e1000097
        • Slim K.
        • Nini E.
        • Forestier D.
        • Kwiatkowski F.
        • Panis Y.
        • Chipponi J.
        Methodological index for non-randomized studies (minors): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Ekhtiari S.
        • Horner N.S.
        • Bedi A.
        • Ayeni O.R.
        • Khan M.
        The learning curve for the Latarjet procedure: A systematic review.
        Orthop J Sports Med. 2018; 6 (232596711878693)
        • McGinn T.
        Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic).
        Can Med Assoc J. 2004; 171: 1369-1373
        • Scheiderer B.
        • Imhoff F.B.
        • Johnson J.D.
        • et al.
        Higher critical shoulder angle and acromion index are associated with increased retear risk after isolated supraspinatus tendon repair at short-term follow up.
        Arthroscopy. 2018; 34: 2748-2754
        • Moosikasuwan J.B.
        • Miller T.T.
        • Burke B.J.
        Rotator cuff tears: Clinical, radiographic, and US findings.
        Radiographics. 2005; 25: 1591-1607
        • Sambandam S.N.
        Rotator cuff tears: An evidence based approach.
        World J Orthop. 2015; 6: 902
        • Murrell G.A.
        • Walton J.R.
        Diagnosis of rotator cuff tears.
        Lancet. 2001; 357: 769-770
        • Song J.G.
        • Yun S.J.
        • Song Y.W.
        • Lee S.H.
        High performance of critical shoulder angle for diagnosing rotator cuff tears on radiographs.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 289-298
        • Jain N.B.
        • Fan R.
        • Higgins L.D.
        • Kuhn J.E.
        • Ayers G.D.
        Does my patient with shoulder pain have a rotator cuff tear? A predictive model from the ROW cohort.
        Orthop J Sports Med. 2018; 6 (232596711878489)
        • Gerber C.
        • Catanzaro S.
        • Betz M.
        • Ernstbrunner L.
        Arthroscopic correction of the critical shoulder angle through lateral acromioplasty: A safe adjunct to rotator cuff repair.
        Arthroscopy. 2018; 34: 771-780
        • Katthagen J.C.
        • Millett P.J.
        Editorial commentary: Lateral acromioplasty is clinically safe and has the potential to reduce the risk for rotator cuff re-tears.
        Arthroscopy. 2018; 34: 781-783
        • Katthagen J.C.
        • Marchetti D.C.
        • Tahal D.S.
        • Turnbull T.L.
        • Millett P.J.
        The effects of arthroscopic lateral acromioplasty on the critical shoulder angle and the anterolateral deltoid origin: An anatomic cadaveric study.
        Arthroscopy. 2016; 32: 569-575
        • Abechain J.J.K.
        • Godinho G.G.
        • Matsunaga F.T.
        • Netto N.A.
        • Daou J.P.
        • Tamaoki M.J.S.
        Functional outcomes of traumatic and non-traumatic rotator cuff tears after arthroscopic repair.
        World J Orthop. 2017; 8: 631
        • Verma N.N.
        • Bhatia S.
        • Baker C.L.
        • et al.
        Outcomes of arthroscopic rotator cuff repair in patients aged 70 years or older.
        Arthroscopy. 2010; 26: 1273-1280
        • Donigan J.A.
        • Wolf B.R.
        Arthroscopic subacromial decompression: acromioplasty versus bursectomy alone—does it really matter? A systematic review.
        Iowa Orthop J. 2011; 31: 121-126
        • Familiari F.
        • Gonzalez-Zapata A.
        • Iannò B.
        • Galasso O.
        • Gasparini G.
        • McFarland E.G.
        Is acromioplasty necessary in the setting of full-thickness rotator cuff tears? A systematic review.
        J Orthop Traumatol. 2015; 16: 167-174
        • Faber J.
        • Fonseca L.M.
        How sample size influences research outcomes.
        Dental Press J Orthod. 2014; 19: 27-29
        • Suter T.
        • Gerber Popp A.
        • Zhang Y.
        • Zhang C.
        • Tashjian R.Z.
        • Henninger H.B.
        The influence of radiographic viewing perspective and demographics on the critical shoulder angle.
        J Shoulder Elbow Surg. 2015; 24: e149-e158

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