hydrodensitometry and/or BodPod); muscle fibre cross-sec-tional area (CSA; measured in any fibre subtype (I, IIa, and/or IIx) obtained from either vastus lateralis ...
Vancomycin-Induced Nephrotoxicity February 2013 Volume 57 Number 2 aac.asm.org 735. TABLE 1 Details of studies examining vancomycin-associated nephrotoxicity a Study authors and type (reference) Study population Exclusions Deﬁnition of NT b (no., % o
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Arch Gen Psychiatry. Published online February 7, 2011. ... We describe a meta-analysis of studies reporting age at onset and substance use to …
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A Systematic Literature Review About Software Requirements Elicitation 299 Journal of Engineering Science and Technology February 2017, Vol. 12(2) Table 1. Selection and exclusion criteria.
J Shoulder Elbow Surg (2014) 23, 1913-1921
A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age Teun Teunis, MD, Bart Lubberts, BSc, Brian T. Reilly, BSc, David Ring, MD, PhD* Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA, USA Hypothesis and background: Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which the presence of an abnormality is associated with symptoms are topics of debate. Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year intervals. In addition, we assessed prevalence in 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation. Methods: We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, and included studies reporting rotator cuff abnormalities by age. Thirty studies including 6112 shoulders met our criteria. We pooled the individual patient data and calculated proportions of patients with and without abnormalities per decade (range, younger than 20 years to 80 years and older). Results: Overall prevalence of abnormalities increased with age, from 9.7% (29 of 299) in patients aged 20 years and younger to 62% (166 of 268) in patients aged 80 years and older (P < .001) (odds ratio, 15; 95% confidence interval, 9.6-24; P < .001). There was a similar increasing prevalence of abnormalities regardless of symptoms or shoulder dislocation. Discussion and conclusion: The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms. Level of evidence: Level III, Systematic Review. Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Rotator cuff; abnormalities; prevalence; age
The study was performed at the Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital–Harvard Medical School, Boston, MA, USA. Protocol registration: International Prospective Register of Systematic Reviews (PROSPERO) registration number CRD42014008670. *Reprint requests: David Ring, MD, PhD, Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital–Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA. E-mail address: [email protected] (D. Ring).
For many years, rotator cuff abnormalities were ascribed to subacromial abrasion/impingement caused by overhead activities.20,25 In 1995, Milgrom et al proposed natural aging as the primary reason for cuff changes, as most people participate in limited overhead activity.21 Additional studies have found rotator cuff abnormalities to be prevalent in both symptomatic and asymptomatic patients.49 In addition, bilateral cuff abnormalities are commonly found in patients
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.08.001
T. Teunis et al.
Flow chart of study selection.
with unilateral symptoms.48 Atraumatic rotator cuff defects are commonly referred to as tears, but if rotator cuff thinning is part of the normal aging process, the word teardwhich implies damage in need of repairdmay be inappropriate. Given that paindthe cognitive and emotional responses to nociceptiondmakes humans feel protective and prepare for the worst, accurate descriptions of the pathophysiologic processes that do not exacerbate maladaptive responses are important. We aimed to perform a systematic review to establish the prevalence of rotator cuff abnormalities and to determine if the prevalence of abnormalities increases with older age. In addition, we assessed prevalence in (1) asymptomatic patients, (2) the general population, (3) symptomatic patients, and (4) patients after a shoulder dislocation.
Materials and methods Selection criteria We performed a systematic review adhering to the published guidelines by the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.9,22 Our review is registered with PROSPERO,30 registration number CRD42014008670 (Appendix 1).40 We included studies that established rotator cuff abnormalities by the individual patient’s age or per decade in the English language. Case reports, meeting abstracts, reviews, and preclinical studies were excluded. We also omitted studies addressing rotator cuff tears with associated fractures, infections, neoplasms, or rheumatoid arthritis.
Search strategy We searched PubMed, EMBASE, and the Cochrane Library up to February 24, 2014, using the search string for title and abstract
(rotator cuff [mesh/emtree®ular]) AND (degeneration* OR tear* OR disruption* OR perforation* OR injury* OR ‘‘pathologic change*’’ OR ‘‘degenerative change*’’ OR defect* OR lesion* OR lesion* OR abnormality*) AND (age OR ages OR aged OR aging [mesh/emtree®ular]). See Appendix 2 for each specific search. This yielded 1222 results from PubMed, 1056 from EMBASE, and 43 from the Cochrane Library. Title and abstract for each result from the databases were independently examined by 2 reviewers (T.T. and B.L.), who subsequently screened the full texts of eligible articles. Both reviewers also scanned the reference lists for additional studies that met the inclusion criteria (Fig. 1). The final list of included studies was agreed to by consensus. We found 2 overlapping patient cohorts24,26,32,34 (same authors and patient population) and included only the largest and most detailed studies.24,26
Risk of bias assessment The relevant criteria from the Newcastle-Ottawa Scale for assessing quality of nonrandomized cohort studies were used to assess methodologic quality of the included studies.37 This scale provides a maximum of 3 stars for method of selection (1) and outcome assessment (2) (Appendix 3).
Data extraction Two reviewers (T.T. and B.T.R.) independently extracted study data using standardized sheets. Discordance was resolved by both reviewers rechecking their extracted data until data sheets corresponded. For each study, we extracted author, year, institute, retrospective/prospective design, specimen type, rotator cuff visualization, definition of abnormality, number of patients and shoulders, rotator cuff abnormality, and individual age or per decade. We included only tears of the supraspinatus tendon as this was most consistently reported throughout the included studies. We contacted 70 corresponding authors of studies published after 2006 that did not report individual age but described eligible
Study baseline characteristics
Definition of abnormality
Jerosch et al14 Hijioka et al10
Toolanen et al42
Milgrom et al21 Needell et al24
Panni et al26 Taylor and Arciero38 Pevny et al29 Berbig et al3 Tempelhof et al39
Thinning, fraying, or fibrous degradation and fullthickness ruptures McLaughlin criteria20 (1) Loss of bursa cuff; (2) tendon surface degeneration; (3) cuff ulcer formation; (4) fullthickness cuff tear Partial: tendon thinning or irregularity; full: tendon identification impossible and humeral head close to deltoid Partial-thickness tears >4 mm High-intensity signal on T2-weighted images with discontinuity in the normal signal void not evident on the proton density–weighted scans NR NR Patient self-reported rotator cuff tear Partial: <1 cm; full: >1 cm Partial: not included; full: loss of tendon convexity in a longitudinal and transverse plane NR (1) Tendon identification impossible and humeral head close to deltoid; (2) hypoechoic defect bursal to articular tendon surface; (3) cuff sandglass-like diameter shift, focal thinning, hypoechogenic discontinuity, or nonvisualization Partial: hypoechoic area at tendon’s fullthickness side; full: hypoechoic defect passing from the articular to the tendon’s bursal side Partial: not included; full: intra-articular gadolinium extending from the glenohumeral joint through the disrupted tendon into the subacromial/subdeltoid bursa Snyder classification35 Partial: focal flattening or loss of convexity at cuff’s bursal side or hypoechoic (or mixed) in longitudinal and transverse plane; full: cuff not visualized or focal defect when retracting torn tendon ends
20 63 52 167 411
40 63 52 167 411
14 0 18 53 96
35% 0% 35% 32% 23%
(continued on next page)
Aging of the rotator cuff
Definition of abnormality
Moosmayer et al),23
Vlychou et al),44
Wissman et al),46
Yamamoto et al49
Zaiton et al),50 van der Veen et al),43 Iagnocco et al11 Abate et al),1
Asymptomatic athletes Dislocation (acute and chronic) Dislocation (chronic) Symptomatic
Partial: not included; full: cuff absence, hypoechoic or anechoic discontinuity and contour concavity at tendon’s superior border in two planes Partial: focal hypoechoic or anechoic defect in the tendon, involving either the bursal or the articular surface and manifested in two planes; full: NR Partial: intermediate or fluid signal on fatsuppressed fast spin-echo T2-weighted image on any imaging plane; full: fluid-filled gap through tendon’s entire thickness on fatsuppressed fast spin-echo T2-weighted images on any imaging plane Partial: regarded as nontears; full: discontinuity and thinning of the rotator NR NR NR Partial not included; full: tendon defects from the bursal margin to the articular margin NR NR
Clavert et al),6
NR Discrete measurable fluid or contrast signal defect on T1- or T2-weighted fat-suppressed sequences within the rotator cuff on at least 2 planes Cuff retraction to zone 2 at most and fatty infiltration 2
Des, design; P, prospective; R, retrospective; NOS, Newcastle-Ottowa scale; NA, not applicable; Pat, patients; Shoul, shoulders; Prop, proportion; NR, not reported; US, ultrasound; MRI, magnetic resonance imaging. ) Full data set by correspondence with authors.
T. Teunis et al.
We pooled the results of individual patients from each study. Subsequently, we calculated the prevalence of tears of the supraspinatus (odds ratios and 95% confidence intervals [CI]) per decade, ranging from younger than 20 years to older than 80 years of age. We included both partial and complete tears if both were reported. In addition, we assessed prevalence in (1) asymptomatic patients, (2) patients with abnormalities when symptoms were unknown (ie, the general population, including cadavers), (3) symptomatic patients, and (4) patients with previous shoulder dislocations. We assessed differences by Pearson c2 test and regarded a P value < .05 as significant. The specific cohorts in our study are drafted from different populations. Asymptomatic patients and patients with abnormalities when symptoms are unknown come from the general population; symptomatic patients and patients with shoulder dislocation come from mainly surgically treated cohorts. This difference in cohort selection introduces too much selection bias to appropriately compare subgroups directly.
Study characteristics Thirty full-text articles met our inclusion criteria and were included in this review. Sixteen studies (53%) were conducted prospectively; one study did not mention time of enrollment. Ten studies reported abnormalities in asymptomatic volunteers1,11,16,18,21,23,24,33,39,47; 5 studies (4 of which were cadaver studies) reported prevalence in the general population10,14,26,28,49; 8 included symptomatic patients6,7,31,36,44,46,50,51; and 7 described patients with acute or chronic shoulder dislocations.3,27,29,38,42,43,52 The majority of the studies used ultrasound to image the rotator cuff (43%; 13 of 30). Twelve studies did not define rotator cuff abnormality; the remaining studies used various definitions (Table I). Median quality score was 2 stars, ranging from 0 to 3 (Table I). We could not grade anatomic studies as no good grading tools exist.
Study population We included 6112 shoulders in 4331 patients with 1452 cuff abnormalities. A total of 2444 shoulders were asymptomatic; 1881, of which 473 were cadaveric, were sampled from the general population; 1193 were symptomatic; and 594 had experienced a dislocated shoulder.
Results Overall prevalence of abnormalities ranged from 9.7% (29 of 299) in patients aged 20 years and younger and increased to 62% (166 of 268) in patients of 80 years and older (P < .001; Fig. 2); odds ratio, 15; 95% CI, 9.6-24; P < .001 (Table II).
Abnormalities Overall (proportion) .2 .4
patient cohorts. Seven e-mail addresses were no longer working; 27 were unresponsive, and efforts were abandoned after 3 attempts; 24 replied but were unable to cooperate because of Institutional Review Board restrictions or because data were no longer available; and 12 authors provided us with their data set.
Aging of the rotator cuff
Figure 2 Histogram of rotator cuff abnormalities by age group across all studies.
Increasing prevalence persisted, regardless of symptoms, in the general population and in patients with a dislocated shoulder. Abnormalities ranged from 6.7% (5 of 75) in asymptomatic patients older than 20 years to 56% (33 of 59) in patients 80 years and older (P < .001) (odds ratio, 18; 95% CI, 6.3-50; P < .001); from 0% to 65% (106 of 164) in the general population (P < .001) (odds ratio, 62; 95% CI, 22-177; P < .001); from 9.9% (26 of 264) to 50% (4 of 8) symptomatic patients (P < .001) (odds ratio, 9.2; 95% CI; 2.2-39; P ¼ .003); and from 9% (3 of 33) to 62% (23 of 37) in patients with shoulder dislocation (P < .001) (odds ratio, 16; 95% CI, 4.2-64; P < .001). Because one study49 made up 22% of our cohort, we conducted a sensitivity analysis by excluding this study from analysis. Increased prevalence over time remained significant at P < .001, both overall and in the general population (Appendix 4).
Discussion Abnormalities of the rotator cuff are more common with age, but the exact prevalence of abnormalities and the extent to which abnormalities cause symptoms are topics of debate. Our aim was to perform a systematic review to determine the general prevalence of rotator cuff abnormalities and to determine the prevalence according to symptoms and after dislocation. We identified a high rate of rotator cuff abnormalities in both symptomatic and asymptomatic patients, in the general population, and after shoulder dislocations, increasing with ageda prevalence high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging. Whereas many surgeons favor a ‘‘wear and tear’’ theory, it is also possible, and in our opinion more likely, that the rotator cuff is subject to an inherent degenerative process similar to thinning and graying of the hair. Our study has several limitations. First, abnormalities are established by various methods, of which direct
Overall prevalence of rotator cuff abnormalities and in asymptomatic patients, in the general population, in symptomatic patients, and after shoulder dislocation Decades
Overall Number of shoulders Prevalence cuff abnormality (n) P value Odds ratio (95% CI) P value Asymptomatic Number of shoulders Prevalence cuff abnormality (n) P value Odds ratio (95% CI) P value General population Number of shoulders Prevalence cuff abnormality (n) P value Odds ratio (95% CI) P value Symptomatic Number of shoulders Prevalence cuff abnormality (n) P value Odds ratio (95% CI) P value Dislocations Number of shoulders Prevalence cuff abnormality (n) P value Odds ratio (95% CI) P value
CI, confidence interval; n, number; overall sums asymptomatic, general population, symptomatic, and dislocations; general population includes cadavers. Italic text indicates statistically significant difference.
Aging of the rotator cuff visualization by arthroscopy or arthrotomy is considered the reference standard. This might lead to both underreporting and overreporting when other modalities are used. Second, there was wide variety of definitions and criteria for diagnosis of cuff abnormalities. Recording of abnormalities may have varied by study, which could hinder determination of a definitive rate. Also, the large variation in the definition of an abnormalitydalong with the differences in mean age between studiesdmight explain the variation in the proportion of cuff abnormalities between individual studies. A common interpretation would benefit future studies and clinical practice. Third, after contacting the corresponding author, we were able to include previously unreported individual patient data from 12 studies. These data were not verified by peer review. Fourth, cadaver studies could not be assessed for methodologic quality. Finally, there was no accounting for the severity of the abnormality, so we do not know if symptomatic or postdislocation abnormalities were larger defects on average. When a pathophysiologic process such as rotator cuff tendinopathy is common in patients with and without symptoms, it becomes more difficult to confidently associate symptoms with pathophysiologic changes and more difficult to prove that interventions that address this pathophysiologic process are better than the natural history of the untreated condition. Rotator cuff defects can lead to weak external rotation16 and rotator cuff arthropathy because of a lack of centralization in the glenoid during activity.13 Given this, it could be argued that even asymptomatic defects merit treatment; but that remains to be proved because it is not clear that surgery can prolong the durability and function of the rotator cuff17 or avoid rotator cuff arthropathy.13 In fact, relief of subjective symptoms (which are subject to regression to the mean,2,4,5 the self-limiting course of symptoms,17 and the placebo effect45) is more predictable than integrity of the cuff12,19; although there is a high rate of recurrent defects, people feel better after surgery.15,41 Without well-designed placebo-controlled surgical trials, we cannot be certain about the effectiveness of surgery on subjective outcomes such as pain. A recent systematic review of sham surgery– controlled trials emphasizes the strong placebo effect associated with surgery; in half of the included studies, placebo performed as well as the investigated procedure.45 It is important to be sure that operative interventions for the rotator cuff are a wise investment of hope, an effective use of resources, and worth the small but real risk of iatrogenic harm, the risk of medicalizing common symptoms, and the risk of interfering with the development of effective coping strategies. Interestingly, our study suggests that abnormalities found after shoulder dislocations increase with age, similar to other groups in our study, complicating accurate distinction of acute tears from more typical defects on imaging tests. A high prevalence of asymptomatic abnormalities makes interpretation of diagnostic test
1919 results more difficult and the likelihood that a given abnormality is new or even the direct cause of symptoms much lower. More work is needed on techniques for distinguishing acute tears from attritional defects and for determining whether a radiologic finding is the cause of the symptoms. One approach might be to perform bilateral imaging with ultrasound; if an abnormality is present in the contralateral shoulder with no history of trauma, it might be reasonable to conclude that the abnormality present in the traumatic shoulder is unlikely to be truly new. Other methods, such as ratings of fatty infiltration and atrophy of the associated muscles, might also be important. Those approaches merit additional research.8 For future prospective studies to determine the positive and negative predictive value of various diagnostic tests, we need consensus on the reference standard for a symptomatic abnormality. To gain confidence in the diagnosis and treatment of rotator cuff disease, several lines of investigation are necessary. First, we must establish the prevalence of normal variations and age-related changes and quantify the chance that a given abnormality causes symptoms. Second, we must reliably and accurately identify tears that progress to rotator cuff arthropathy. Third, we must prove that our interventions are better than placebo interventions or better than the natural history of the disease. This systematic review begins to address the first of these aims by reviewing all the studies of age-related prevalence of rotator cuff abnormalities. Our study confirms that abnormalities are more common with age (1) in asymptomatic patients, (2) in the general population, (3) in symptomatic patients, and (4) after shoulder dislocation. Abnormalities can therefore be difficult to isolate as the primary symptom generator. Surgeons and patients should be aware of the current limitations in the management of shoulder pain that may or may not be attributed to a rotator cuff abnormality.
Conclusions Our aim was to review the published literature to establish the prevalence of abnormalities of the rotator cuff and to determine if the prevalence of abnormalities increases with older age in 10-year age intervals. In addition, we assessed 4 separate groups: (1) asymptomatic patients, (2) general population, (3) symptomatic patients, and (4) patients after shoulder dislocation. The prevalence of rotator cuff abnormalities in asymptomatic people is high enough for degeneration of the rotator cuff to be considered a common aspect of normal human aging and to make it difficult to determine when an abnormality is new (e.g., after a dislocation) or is the cause of symptoms. In addition, we need evidence that treatment of these abnormalities improves symptoms better than placebo does.
Acknowledgment We would like to thank Carol Mita from the Harvard Countway Library of Medicine for her assistance in drafting the search strategy. She has given explicit permission to be named here and agrees with the content of this work.
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Supplementary data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.jse.2014.08.001.
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