Novel all-arthroscopic biceps tenodesis technique incorporated into rotator cuff repair-two hundred cases with minimum 2-year follow-up

Background

Biceps tendon pathology is a common source of pain in the shoulder. It is frequently seen in conjunction with symptomatic rotator cuff tears. Biceps tendon management during arthroscopic rotator cuff repairs can be achieved via tenodesis with various techniques or tenotomy. Tenodesis of the biceps generally results in less deformity and reduced exertion-related cramping. However, most techniques require the addition of some type of hardware to provide fixation for the biceps tendon, which adds cost, time, and complexity. This study presents a technique for an all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair, requiring no additional hardware.

Methods

This study is a retrospective review of data that were prospectively collected for 200 consecutive patients for whom the procedure was performed. Patients were seen postoperatively at 2 weeks, 6 weeks, 4 months, and 6 months and in addition massive rotator cuff repairs were seen at 8 months. Additionally all patients were contacted at a minimum 2-year follow-up to access for the presence deformity, the American Shoulder and Elbow Surgeons (ASES) score, and SANE score. Descriptive statistics and comparisons to known minimal clinical important differences (MCIDs) for the patient recorded outcome measures were recorded.

Results

Two hundred patients were included in the study and 152 responded to the telephone interviews. The mean age of the patients at the time of surgery was 65.3 year old (standard deviation ± 9.1, range of 46-84), and the mean postoperative phone interview was 3.2 years postsurgery (standard deviation of ± 1.0, range of 2-5 years). The average ASES score improved from 52.6 to 94.6, which is 3 times greater than the minimal clinical important difference. The average postoperative SANE score was 94. Seven procedures out of the 200 were labeled as failures due to 1 patient's nonsatisfaction with the procedure and 3 for a Popeye deformity and 3 that had a revision RCR.

Discussion

The described method of an arthroscopic biceps tenodesis performed with a rotator cuff repair uses no extra hardware, requires minimal additional operative time, and is clinically effective. At a minimum 2-year follow-up, the all-arthroscopic biceps tenodesis in conjunction with a double-row rotator cuff repair resulted in a marked improvement in their ASES score with a 3.5% failure rate.

Conclusion

The all-arthroscopic bicep tenodesis performed in conjunction with a double-row rotator cuff repair demonstrated improved clinical outcome, without requiring any additional hardware to tenodese the biceps, at a minimum 2-year follow-up.

Obesity and sex influence fatty infiltration of the rotator cuff: the Rotator Cuff Outcomes Workgroup (ROW) and Multicenter Orthopaedic Outcomes Network (MOON) cohorts

BACKGROUND

Fatty infiltration (FI) is one of the most important prognostic factors for outcomes after rotator cuff surgery. Established risk factors include advancing age, larger tear size, and increased tear chronicity. A growing body of evidence suggests that sex and obesity are associated with FI; however, data are limited.

METHODS

We recruited 2 well-characterized multicenter cohorts of patients with rotator cuff tears (Multicenter Orthopaedic Outcomes Network [MOON] cohort [n = 80] and Rotator Cuff Outcomes Workgroup [ROW] cohort [n = 158]). We used multivariable logistic regression to evaluate the relationship between body mass index (BMI) and the presence of FI while adjusting for the participant's age at magnetic resonance imaging, sex, and duration of shoulder symptoms, as well as the cross-sectional area of the tear. We analyzed the 2 cohorts separately and performed a meta-analysis to combine estimates.

RESULTS

A total of 27 patients (33.8%) in the Multicenter Orthopaedic Outcomes Network (MOON) cohort and 57 patients (36.1%) in the Rotator Cuff Outcomes Workgroup (ROW) cohort had FI. When BMI < 25 kg/m2 was used as the reference category, being overweight was associated with a 2.37-fold (95% confidence interval [CI], 0.77-7.29) increased odds of FI and being obese was associated with a 3.28-fold (95% CI, 1.16-9.25) increased odds of FI. Women were 4.9 times (95% CI, 2.06-11.69) as likely to have FI as men.

CONCLUSIONS

Among patients with rotator cuff tears, obese patients had a substantially higher likelihood of FI. Further research is needed to assess whether modifying BMI can alter FI in patients with rotator cuff tears. This may have significant clinical implications for presurgical surgical management of rotator cuff tears. Sex was also significantly associated with FI, with women having higher odds of FI than men. Higher odds of FI in female patients may also explain previously reported early suboptimal outcomes of rotator cuff surgery and higher pain levels in female patients as compared with male patients.

Reliability of the modified Walch classification for advanced glenohumeral osteoarthritis using 3-dimensional computed tomography analysis: a study of the ASES B2 Glenoid Multicenter Research Group

BACKGROUND

Variations in glenoid morphology affect surgical treatment and outcome of advanced glenohumeral osteoarthritis (OA). The purpose of this study was to assess the inter- and intraobserver reliability of the modified Walch classification using 3-dimensional (3D) computed tomography (CT) imaging in a multicenter research group.

METHODS

Deidentified preoperative CTs of patients with primary glenohumeral OA undergoing anatomic or reverse total shoulder arthroplasty (TSA) were reviewed with 3D imaging software by 23 experienced shoulder surgeons across 19 institutions. CTs were separated into 2 groups for review: group 1 (96 cases involving all modified Walch classification categories evaluated by 12 readers) and group 2 (98 cases involving posterior glenoid deformity categories [B2, B3, C1, C2] evaluated by 11 readers other than the first 12). Each case group was reviewed by the same set of readers 4 different times (with and without the glenoid vault model present), blindly and in random order. Inter- and intraobserver reliabilities were calculated to assess agreement (slight, fair, moderate, substantial, almost perfect) within groups and by modified Walch classification categories.

RESULTS

Interobserver reliability showed fair to moderate agreement for both groups. Group 1 had a kappa of 0.43 (95% confidence interval [CI]: 0.38, 0.48) with the glenoid vault model absent and 0.41 (95% CI: 0.37, 0.46) with it present. Group 2 had a kappa of 0.38 (95% CI: 0.33, 0.43) with the glenoid vault model absent and 0.37 (95% CI: 0.32, 0.43) with it present. Intraobserver reliability showed substantial agreement for group 1 with (0.63, range 0.47-0.71) and without (0.61, range 0.52-0.69) the glenoid vault model present. For group 2, intraobserver reliability showed moderate agreement with the glenoid vault model absent (0.51, range 0.30-0.72), which improved to substantial agreement with the glenoid vault model present (0.61, range 0.34-0.87).

DISCUSSION

Inter- and intraobserver reliability of the modified Walch classification were fair to moderate and moderate to substantial, respectively, using standardized 3D CT imaging analysis in a large multicenter study. The findings potentially suggest that cases with a spectrum of posterior glenoid bone loss and/or dysplasia can be harder to distinguish by modified Walch type because of a lack of defined thresholds, and the glenoid vault model may be beneficial in determining Walch type in certain scenarios. The ability to reproducibly separate patients into groups based on preoperative pathology, including Walch type, is important for future studies to accurately evaluate postoperative outcomes in TSA patient cohorts.

Surgeon Agreement on the Presence of Pathologic Anterior Instability on Shoulder Imaging Studies

Background

In the setting of anterior shoulder instability, it is important to assess the reliability of orthopaedic surgeons to diagnose pathologic characteristics on the 2 most common imaging modalities used in clinical practice: standard plain radiographs and magnetic resonance imaging (MRI).

Purpose

To assess the intra- and interrater reliability of diagnosing pathologic characteristics associated with anterior shoulder instability using standard plain radiographs and MRI.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Patient charts at a single academic institution were reviewed for anterior shoulder instability injuries. The study included 40 sets of images (20 radiograph sets, 20 MRI series). The images, along with standardized evaluation forms, were distributed to 22 shoulder/sports medicine fellowship-trained orthopaedic surgeons over 2 points in time. Kappa values for inter- and intrarater reliability were calculated.

Results

The overall response rate was 91%. For shoulder radiographs, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.49), estimate of glenoid lesion surface area (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.35), and estimate of Hill-Sachs surface area (κ = 0.50). Intrarater agreement was moderate for radiographs (κ = 0.48-0.57). For shoulder MRI, interrater agreement was fair to moderate for the presence of glenoid lesions (κ = 0.44), glenoid lesion surface area (κ = 0.35), Hill-Sachs lesion (κ = 0.33), Hill-Sachs surface area (κ = 0.28), humeral head edema (κ = 0.41), and presence of a capsulolabral injury (κ = 0.36). Fair agreement was found for specific type of capsulolabral injury (κ = 0.21). Intrarater agreement for shoulder MRI was moderate for the presence of glenoid lesion (κ = 0.59), presence of a Hill-Sachs lesion (κ = 0.52), estimate of Hill-Sachs surface area (κ = 0.50), humeral head edema (κ = 0.51), and presence of a capsulolabral injury (κ = 0.53), and agreement was substantial for glenoid lesion surface area (κ = 0.63). Intrarater agreement was fair for determining the specific type of capsulolabral injury (κ = 0.38).

Conclusion

Fair to moderate agreement by surgeons was found when evaluating imaging studies for anterior shoulder instability. Agreement was similar for identifying pathologic characteristics on radiographs and MRI. There was a trend toward better agreement for the presence of glenoid-sided injury. The lowest agreement was observed for specific capsulolabral injuries.

Shoulder Instability: Interobserver and Intraobserver Agreement in the Assessment of Labral Tears

Background:

The glenohumeral joint combines large range of motion and insufficient bony stabilization, making it susceptible to instability and dislocations. Arthroscopic surgery is routinely used as a diagnostic tool and has been considered the gold standard for the diagnosis of shoulder lesions. However, several studies have demonstrated variability in intraobserver and interobserver agreement.

Purpose:

To evaluate interobserver and intraobserver agreement in the assessment of intra-articular lesions associated with shoulder instability among fellowship-trained shoulder surgeons.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

A total of 24 arthroscopic videos from patients treated for recurrent shoulder instability were shown to a group of 10 fellowship-trained shoulder surgeons who are members of the Multicenter Orthopaedic Outcomes Network (MOON) Shoulder Group. They were presented to the surgeons on 2 different occasions at least 2 months apart. They were asked to classify labral tears by their position, type, extension, other intra-articular abnormality, and preferred treatment. No patient history or physical examination data were provided. The primary outcome was the median overall percentage of agreement for the surgeons performing a video review, measured for each variable evaluated. Intraclass correlation coefficients were used to evaluate continuous variables, and kappa values were used for categorical items.

Results:

Interobserver agreement was good for anterior labral lesions; good for Hill-Sachs lesions; and moderate for lesions of the superior labrum, posterior labrum, anterior sublabral foramen, and position and extension of the tear. Intraobserver agreement was either good or very good for all variables evaluated, except for being poor for inferior labral lesions and moderate for lesions of the meniscoid superior labrum.

Conclusion:

Interobserver and intraobserver reliability for the arthroscopic assessment of labral tears in patients with recurrent shoulder instability were good to moderate for the majority of anatomic structures assessed. There was relatively good agreement between shoulder instability surgeons on assessing and documenting shoulder instability–associated abnormalities. These findings are important when interpreting collaborative clinical cohort studies with numerous surgeons involved in the research.

Radiographic results of augmented all-polyethylene glenoids in the presence of posterior glenoid bone loss during total shoulder arthroplasty

BACKGROUND

Chronic osteoarthritis can result in glenohumeral subluxation and loss of posterior glenoid bone. This can alter normal glenohumeral biomechanics and affect the stress placed on the glenoid implant after total shoulder arthroplasty. This study evaluated the clinical and radiographic results of an augmented all-polyethylene glenoid for the treatment of glenoid osteoarthritis in the presence of posterior glenoid bone loss and determined whether any failures or complications occurred with short-term follow-up.

METHODS

During a 2-year period, 21 patients were treated with an augmented glenoid for an index diagnosis of osteoarthritis with a biconcave glenoid and average posterior glenoid bone loss of 4.7 mm. Clinical outcomes were recorded for the American Shoulder and Elbow Surgeons Shoulder Assessment, Simple Shoulder Test, and active motion. Radiographic analysis included glenoid version, humeral head subluxation, component seating, ingrowth, and loosening.

RESULTS

Significant improvements were demonstrated for American Shoulder and Elbow Surgeons Shoulder Assessment (52.3), Simple Shoulder Test (8.1), forward flexion (50°), external rotation (32°), and pain. Radiographic improvements were found for glenoid version (12°), humeral scapular alignment (23%), and humeral glenoid alignment (8%). Central peg ingrowth was demonstrated in all patients, and complete component seating was achieved in 19 patients. No complications were encountered, and no clinical or radiographic failures were identified.

CONCLUSION

Augmented polyethylene glenoid components demonstrated improved clinical outcome, without implant failure or complications, during short-term follow-up.

What factors are predictors of emotional health in patients with full-thickness rotator cuff tears?

BACKGROUND

The importance of emotional and psychological factors in treatment of patients with rotator cuff disease has been recently emphasized. Our goal was to establish factors most predictive of poor emotional health in patients with full-thickness rotator cuff tears (FTRCTs).

METHODS

In 2007, we began to prospectively collect data on patients with symptomatic, atraumatic FTRCTs. All patients completed a questionnaire collecting data on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcomes (12-Item Short Form Health Survey, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff Index [WORC], Single Assessment Numeric Evaluation score, Shoulder Activity Scale). Physicians recorded physical examination and imaging data. To evaluate the predictors of lower WORC emotion scores, a linear multiple regression model was fit.

RESULTS

Baseline data for 452 patients were used for analysis. In patients with symptomatic FTRCTs, the factors most predictive of worse WORC emotion scores were higher levels of pain (interquartile range odds ratio, -18.9; 95% confidence interval, -20.2 to -11.6; P < .0001) and lower Single Assessment Numeric Evaluation scores (rating of percentage normal that patients perceive their shoulder to be; interquartile range odds ratio, 6.2; 95% confidence interval, 2.5-9.95; P = .0012). Higher education (P = .006) and unemployment status (P = .0025) were associated with higher WORC emotion scores.

CONCLUSIONS

Education level, employment status, pain levels, and patient perception of percentage of shoulder normalcy were most predictive of emotional health in patients with FTRCTs. Structural data, such astendon tear size, were not. Those with poor emotional health may perceive their shoulder to be worse than others and experience more pain. This may allow us to better optimize patient outcomes with nonoperative and operative treatment of rotator cuff tears.

Shoulder prosthetic arthroplasty options in 2014: what to do and when to do it

The number of shoulder arthroplasty procedures performed in the United States is steadily increasing as a result of an expansion in implant options, clinical indications, and surgical experience. Available options include stemmed implants, short-stemmed or stemless prostheses, fracture-specific designs, resurfacing implants, partial surface replacement, metal-backed or polyethylene glenoid components designed for cementation or bone ingrowth, and reverse total shoulder arthroplasty. Efforts to re-create anatomy, improve outcomes, and avoid complications have resulted in many changes in prosthesis design. Despite these changes, failures still occur, and revision surgery is sometimes necessary. A thorough knowledge of current arthroplasty options, indications, and the principles of implantation is necessary to optimize outcomes after shoulder arthroplasty.

The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears

HYPOTHESIS

The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength.

METHODS

We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms.

RESULTS

A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures.

CONCLUSIONS

There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease.

Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear

BACKGROUND

For many orthopaedic disorders, symptoms correlate with disease severity. The objective of this study was to determine if pain level is related to the severity of rotator cuff disorders.

METHODS

A cohort of 393 subjects with an atraumatic symptomatic full-thickness rotator-cuff tear treated with physical therapy was studied. Baseline pretreatment data were used to examine the relationship between the severity of rotator cuff disease and pain. Disease severity was determined by evaluating tear size, retraction, superior humeral head migration, and rotator cuff muscle atrophy. Pain was measured on the 10-point visual analog scale (VAS) in the patient-reported American Shoulder and Elbow Surgeons (ASES) score. A linear multiple regression model was constructed with use of the continuous VAS score as the dependent variable and measures of rotator cuff tear severity and other nonanatomic patient factors as the independent variables. Forty-eight percent of the patients were female, and the median age was sixty-one years. The dominant shoulder was involved in 69% of the patients. The duration of symptoms was less than one month for 8% of the patients, one to three months for 22%, four to six months for 20%, seven to twelve months for 15%, and more than a year for 36%. The tear involved only the supraspinatus in 72% of the patients; the supraspinatus and infraspinatus, with or without the teres minor, in 21%; and only the subscapularis in 7%. Humeral head migration was noted in 16%. Tendon retraction was minimal in 48%, midhumeral in 34%, glenohumeral in 13%, and to the glenoid in 5%. The median baseline VAS pain score was 4.4.

RESULTS

Multivariable modeling, controlling for other baseline factors, identified increased comorbidities (p = 0.002), lower education level (p = 0.004), and race (p = 0.041) as the only significant factors associated with pain on presentation. No measure of rotator cuff tear severity correlated with pain (p &gt; 0.25).

CONCLUSIONS

Anatomic features defining the severity of atraumatic rotator cuff tears are not associated with the pain level. Factors associated with pain are comorbidities, lower education level, and race.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

What went wrong and what was done about it: pitfalls in the treatment of common shoulder surgery

When performing revision shoulder surgery, it is important that the surgeon understands why the index procedure failed and has a clear plan to address problems in the revision procedure. The most common cause of failure after anterior instability shoulder surgery is a failure to treat the underlying glenoid bone loss. For most defects, a Latarjet transfer can effectively restore anterior glenoid bone stock and restore shoulder stability. Persistent anterior shoulder pain after rotator cuff surgery may be the result of missed biceps pathology. This can be effectively treated via a biceps tenodesis. The most difficult failures to treat after acromioclavicular joint reconstruction surgery are those involving fractures of either the coracoid or the clavicle. Clavicle hook plates can be used as supplemental fixation during the treatment of these fractures to help offload the fracture site and allow healing while restoring stability to the acromioclavicular articulation. A failed hemiarthroplasty for a proximal humeral fracture frequently results when the tuberosities fail to heal correctly. This complication can be avoided by paying close attention to the implant position and the tuberosity fixation. If hemiarthroplasty is unsuccessful, the patient is best treated with conversion to a reverse shoulder arthroplasty.

Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study

PURPOSE

To assess the effectiveness of a specific nonoperative physical therapy program in treating atraumatic full-thickness rotator cuff tears using a multicenter prospective cohort study design.

MATERIALS AND METHODS

Patients with atraumatic full-thickness rotator cuff tears who consented to enroll provided data via questionnaire on demographics, symptom characteristics, comorbidities, willingness to undergo surgery, and patient-related outcome assessments (Short Form 12 score, American Shoulder and Elbow Surgeons score, Western Ontario Rotator Cuff score, Single Assessment Numeric Evaluation score, and Shoulder Activity Scale). Physicians recorded physical examination and imaging data. Patients began a physical therapy program developed from a systematic review of the literature and returned for evaluation at 6 and 12 weeks. At those visits, patients could choose 1 of 3 courses: (1) cured (no formal follow-up scheduled), (2) improved (continue therapy with scheduled reassessment in 6 weeks), or (3) no better (surgery offered). Patients were contacted by telephone at 1 and 2 years to determine whether they had undergone surgery since their last visit. A Wilcoxon signed rank test with continuity correction was used to compare initial, 6-week, and 12-week outcome scores.

RESULTS

The cohort consists of 452 patients. Patient-reported outcomes improved significantly at 6 and 12 weeks. Patients elected to undergo surgery less than 25% of the time. Patients who decided to have surgery generally did so between 6 and 12 weeks, and few had surgery between 3 and 24 months.

CONCLUSION

Nonoperative treatment using this physical therapy protocol is effective for treating atraumatic full-thickness rotator cuff tears in approximately 75% of patients followed up for 2 years.

Agreement in the classification and treatment of the superior labrum

BACKGROUND

The Snyder classification scheme is the most commonly used system for classifying superior labral injuries. Although this scheme is intended to be used for arthroscopic visual classification only, it is thought that other nonarthroscopic historical variables also influence the classification.

PURPOSE

This study was conducted to evaluate the intrasurgeon and intersurgeon agreement in classifying variable presentations of the superior labrum and to evaluate the influence of clinical variables on the classification and treatment choices of surgeons.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A group of arthroscopic shoulder surgeons were asked to rank in order of importance clinical variables considered in diagnosing and treating the superior labrum. The surgeons then watched 50 arthroscopic videos of the superior labrum, ranging from normal to pathologic, on 3 different occasions. The first and third viewings were accompanied by no clinical information. The second viewing was accompanied by a detailed clinical vignette for each video. The surgeons selected a classification and treatment for each video.

RESULTS

A patient's job/sport, age, and physical examination findings were considered the most important clinical variables surgeons consider during management of the superior labrum. Comparing the 2 viewings without clinical information, surgeons selected a different classification 28.5% of the time from the first to the second time. A different classification was chosen 71.5% of the time when the surgeon was supplied a clinical vignette at the subsequent viewing. Similarly, the treatment selected changed in 36% and 69.1% of cases when viewed again without vignettes and with vignettes, respectively. Intersurgeon agreement was moderate without clinical vignettes and fair with vignettes. Historical, physical examination, and surgical observations were found to influence the odds of change of classification.

CONCLUSION

There is significant intrasurgeon and intersurgeon variability in classification and treatment of the superior labrum. Clinical historical, examination, and surgical findings influence classification and treatment choices.

Reliability of determining and measuring acromial enthesophytes

BACKGROUND

Although the reliability of determining acromial morphology has been examined, to date, there has not been an analysis of interobserver and intraobserver reliability on determining the presence and measuring the size of an acromial enthesophyte.

QUESTIONS/PURPOSES

The hypothesis of this study was that there will be poor intraobserver and interobserver reliability in the (1) determination of the presence of an acromial enthesophyte, (2) determination of the size of an acromial enthesophyte, and (3) determination of acromial morphology.

PATIENTS AND METHODS

Fifteen fellowship-trained orthopedic shoulder surgeons reviewed the radiographs of 15 patients at two different intervals. Measurement of acromial enthesophytes was performed using two techniques: (1) enthesophyte length and (2) enthesophyte-humeral distance. Acromial morphology was also determined. Interobserver and intraobserver agreement was determined using intraclass correlation and kappa statistical methods.

RESULTS

The interobserver reliability was fair to moderate and the intraobserver reliability moderate for determining the presence of an acromial enthesophyte. The measurement of the enthesophyte length showed poor interobserver and intraobserver reliability. The measurement of the enthesophyte-humeral distance showed poor interobserver reliability and moderate intraobserver reliability. The interobserver and intraobserver reliability in determining acromial morphology was found to be moderate and good, respectively.

CONCLUSIONS

There is fair to moderate reliability among fellowship-trained shoulder surgeons in determining the presence of an acromial enthesophyte. However, there is poor reliability among observers in measuring the size of the enthesophyte. This study suggests that the enthesophyte-humeral distance may be more reliable than the enthesophyte length when measuring the size of the enthesophyte.

Partial-thickness articular surface rotator cuff tears: an all-inside repair technique

BACKGROUND

Treatment of partial-thickness articular surface rotator cuff tears varies from simple débridement with or without an acromioplasty to various repair techniques. These repair techniques have included in situ transtendinous methods, as well as completion of the tear and repairing the full-thickness defect. The transtendinous techniques can be associated with stiffness and completing the tear takes down normal intact tissue. Therefore, a technique was developed that repairs the articular-side partial- thickness rotator cuff tears with an all-inside approach that does not violate the intact bursal tissue and does not complete the tear.

QUESTIONS/PURPOSES

To compare the preoperative and postoperative Penn shoulder scores (PSS) associated with an in situ all-inside repair technique and the effects of such a repair on postoperative stiffness.

METHODS

Twenty patients with partial-thickness articular rotator cuff tears greater than 50% of the width of the tendon repaired with an all-inside repair technique were retrospectively reviewed. Two of the patients were high school athletes and the rest self-described as recreational athletes. The minimum followup was 16 months (average, 29 months; range, 16-41 months). A validated outcome measure (PSS) was used to assess clinical outcome, and postoperative ROM was measured.

RESULTS

The average PSS score improved from 74 (range, 56-84) to 92 (range, 86-99). All but one patient was able to return to the same level of play or higher.

CONCLUSIONS

In situ repairs of partial-thickness articular surface tears using an all-inside approach resulted in a substantial increase in PSS with no cases of major postoperative clinical stiffness.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is therapy necessary after distal biceps tendon repair?

The EndoButton technique of distal biceps tendon repair provides strong biomechanical fixation. This strength of fixation may allow earlier postoperative range of motion (ROM). A retrospective review of 15 male patients undergoing single incision EndoButton repairs was used. Six subjects participated in conventional supervised postoperative rehabilitation while nine subjects were allowed unrestricted ROM after 2 weeks. Final ROM, time to full ROM, and Disabilities of Arm Shoulder and Hand (DASH) scores were compared. There was a significant difference for time to full ROM (p < 0.05). The mean time to full ROM was 8.67 weeks for the supervised therapy group and 4.38 weeks for the unrestricted group. There were no reruptures in either group. There were no significant differences in final ROM or DASH scores. These data suggest that unrestricted ROM results in a quicker return to full ROM without an increased risk of rerupture.

Interobserver agreement in the classification of rotator cuff tears using magnetic resonance imaging

BACKGROUND

Although magnetic resonance imaging (MRI) is a standard method of assessing the extent and features of rotator cuff disease, the authors are not aware of any studies that have assessed the interobserver agreement among orthopaedic surgeons reviewing MRI scans for rotator cuff disease.

HYPOTHESIS

Fellowship-trained orthopaedic shoulder surgeons will have good interobserver agreement in predicting the more salient features of rotator cuff disease such as tear type (full thickness versus partial thickness), tear size, and number of tendons involved but only fair agreement with more complex features such as muscle volume, fat content, and the grade of partial-thickness cuff tears.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Ten fellowship-trained orthopaedic surgery shoulder specialists reviewed 27 MRI scans of 27 shoulders from patients with surgically confirmed rotator cuff disease. The ability to interpret full-thickness versus partial-thickness tears, acromion type, acromioclavicular joint spurs or signal changes, biceps lesions, size and grade of partial-thickness tears, acromiohumeral distance, number of tendons involved and amount of retraction for full-thickness tears, size of full-thickness tears, and individual muscle fatty infiltration and atrophy were assessed. Surgeons completed a standard evaluation form for each MRI scan. Interobserver agreement was determined and a kappa level was derived.

RESULTS

Interobserver agreement was highest (>80%) for predicting full- versus partial-thickness tears of the rotator cuff, and for quantity of the teres minor tendon. Agreement was slightly less (>70%) for detecting signal in the acromioclavicular joint, the side of the partial-thickness tear, the number of tendons involved in a full-thickness tear, and the quantity of the subscapularis and infraspinatus muscle bellies. Agreement was less yet (60%) for detecting the presence of spurs at the acromioclavicular joint, a tear of the long head of the biceps tendon, amount of retraction of a full-thickness tear, and the quantity of the supraspinatus. The best kappa statistics were found for detecting the difference between a full- and partial-thickness rotator cuff tear (0.77), and for the number of tendons involved for full-thickness tears (0.55). Kappa for predicting the involved side of a partial-thickness tear was 0.44; for predicting the grade of a partial-thickness tear, it was -0.11.

CONCLUSIONS

Fellowship-trained, experienced orthopaedic surgeons had good agreement for predicting full-thickness rotator cuff tears and the number of tendons involved and moderate agreement in predicting the involved side of a partial-thickness rotator cuff tear, but poor agreement in predicting the grade of a partial-thickness tear.

Flexor tendon sheath ganglions: results of surgical excision

The purpose of our study was to review the clinical features and determine the results following surgical excision of a flexor tendon sheath ganglion. A retrospective analysis of 24 consecutive patients (25 ganglions) who underwent excision of a painful flexor tendon sheath ganglion by the same surgeon was performed. The patient's medical and operative records were reviewed. Each patient was invited to return for an evaluation, which consisted of a clinical interview, completion of a questionnaire, and physical examination. Those patients that were unable to return underwent a detailed telephone interview. Sixteen patients returned for a clinical evaluation, while eight patients underwent a telephone interview. There were 15 women and nine men, with an average age of 43 years (range, 21-68 years). The dominant hand was involved in 15 patients. The long finger was most commonly involved (11 cases). The ganglion arose from the A1 pulley in 13 cases, between the A1 and A2 pulleys in three cases, and from the A2 pulley in nine cases. At an average follow-up of 18.5 months (range, 5-38 months), all of the patients were satisfied with their final result. No patient developed a recurrence and all returned to their previous functional level. There were two minor complications that resolved uneventfully; one patient experienced mild incisional tenderness, while an additional patient experienced transient digital nerve paresthesias. We conclude that surgical excision is a simple, safe, and effective method for treating a painful ganglion of the digital flexor tendon sheath.

Interobserver agreement in the classification of rotator cuff tears

BACKGROUND

Six classification systems have been proposed for describing rotator cuff tears designed to help understand their natural history and make treatment decisions.

PURPOSE

To assess the interobserver variation for these classification systems and identify the method with the best interobserver agreement.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Six rotator cuff tear classification systems were identified in a literature search. The components of these systems included partial-thickness rotator cuff tears and classification by size, shape, configuration, number of tendons involved, and by extent, topography, and nature of the biceps. Twelve fellowship-trained orthopaedic surgeons who each perform at least 30 rotator cuff repairs per year reviewed arthroscopy videos from 30 patients with a random assortment of rotator cuff tears and classified them by the 6 classification systems. Interobserver variation was determined by a kappa analysis.

RESULTS

Interobserver agreement was high when distinguishing between full-thickness and partial-thickness tears (0.95, kappa = 0.85). The investigators agreed on the side (articular vs bursal) of involvement for partial-thickness tears (observed agreement 0.92, kappa = 0.85) but could not agree when classifying the depth of the partial-thickness tear (observed agreement 0.49, kappa = 0.19). The best agreement for full-thickness tears was seen when the tear was classified by topography (degree of retraction) in the frontal plane (observed agreement 0.70, kappa = 0.54).

CONCLUSION

With the exception of distinguishing partial-thickness from full-thickness rotator cuff tears and identifying the side (articular vs bursal) of involvement with partial-thickness tears, currently described rotator cuff classification systems have little interobserver agreement among experienced shoulder surgeons. Researchers should consider describing full-thickness rotator cuff tears by topography (degree of retraction) in the frontal plane.

Treatment of grade III acromioclavicular joint injuries: a systematic review

Although nonoperative treatment is considered the standard of care for the treatment of Grade I and II acromioclavicular (AC) joint injuries, the treatment of Grade III injuries is controversial. There are as many methods of nonoperative treatment as there are for operative stabilization. Most of the literature represents Level IV evidence with very few Level II and III studies upon which to base decisions. A systematic review of the English-language literature was performed to determine if Grade III AC joint separations are best treated operatively or nonoperatively. Based on limited low-evidence, nonoperative treatment was deemed more appropriate than traditional nonoperative treatments because the results of the latter were not clearly better and were associated with higher complication rates, longer convalescence, and longer time away from work and sport.

The effect of humeral component anteversion on shoulder stability with glenoid component retroversion

BACKGROUND

Posterior glenoid bone loss is often seen in association with glenohumeral osteoarthritis. This posterior asymmetric wear can lead to retroversion of the glenoid component and posterior instability after total shoulder arthroplasty. Options for the treatment of this asymmetric wear include eccentric reaming of the so-called high side, bone-grafting, and/or anteverting the humeral component. Although anteverting the humeral component has been advocated by many, it has not been substantiated on the basis of biomechanical data. The purpose of the present study was to determine whether anteverting the humeral component increases the stability of a total shoulder replacement with a retroverted glenoid component.

METHODS

A total shoulder arthroplasty was performed in eight human cadaveric shoulders. The glenoid component was placed in 15 degrees of retroversion. Two humeral versions were tested for each specimen: anatomic version and 15 degrees of anteversion relative to anatomic version. The specimens were mounted supine in a custom fixture on a servohydraulic testing system. The humerus was translated posteriorly by one-half of the width of the glenoid. Three positions of humeral rotation were tested for each position of humeral version. Both the energy and the peak load were analyzed as measures of joint stability.

RESULTS

There was no significant difference in either energy or peak load between the tests performed with the humeral component in 15 degrees of anteversion and those performed with the component in anatomic version in any of the three rotational positions (p > 0.05).

CONCLUSIONS

Although anteverting the humeral component during total shoulder arthroplasty to compensate for glenoid retroversion has been advocated, these data suggest that compensatory anteversion of the humeral component does not increase the stability of a shoulder replacement with a retroverted glenoid component.

Prosthetic positioning in total shoulder arthroplasty

Accurate positioning of the prosthetic humeral head is necessary to reproduce normal glenohumeral kinematics and to avoid damage to the rotator cuff and impingement on the glenoid component or coracoacromial arch. Proper positioning of the head requires accurate placement of the stem and prosthetic designs that allow the head position to adapt to the variations in both normal and pathologic humeral anatomy. Glenoid malpositioning can lead to both humeral instability and increased stress of the glenoid component that may lead to premature glenoid loosening. This review summarizes the cadaveric and finite-element model that defines the abnormalities associated with humeral and glenoid component malpositioning.

Biomechanical analysis of reconstructions for sternoclavicular joint instability

BACKGROUND

A variety of reconstructive methods have been described for the treatment of sternoclavicular joint instability, yet none have been analyzed in the laboratory, to our knowledge. The purpose of the present study was to evaluate three different reconstruction techniques with use of a cadaveric model: (1) intramedullary ligament reconstruction, (2) subclavius tendon reconstruction, and (3) reconstruction with use of a semitendinosus graft placed in a figure-of-eight fashion through drill-holes in the clavicle and manubrium.

METHODS

Thirty-six fresh cadaveric specimens were mounted supine on a materials testing machine in a custom testing fixture and were subjected to anterior and posterior subfailure translation to determine stiffness in the intact state after preloading. One of the three reconstruction methods was performed, and the specimens were subjected to anterior or posterior translation to failure. Changes in stiffness compared with the intact state were analyzed statistically.

RESULTS

In the anterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than that of the intramedullary ligament reconstruction but was not significantly different from that of the subclavius tendon reconstruction. The peak load to failure (as defined by translation equal to the anteroposterior diameter of the medial head of the clavicle) was 230.3 +/- 146.1 N for the semitendinosus figure-of-eight reconstruction, 84.6 +/- 45.7 N for the intramedullary ligament reconstruction, and 75.6 +/- 19.0 N for the subclavius tendon reconstruction. In the posterior direction, the stiffness of the semitendinosus figure-of-eight reconstruction was significantly greater than those of both of the other reconstructions. The peak load to failure was 241.4 +/- 49.7 N for the semitendinosus figure-of-eight reconstruction, 85.0 +/- 22.8 N for the intramedullary ligament reconstruction, and 51.5 +/- 28.9 N for the subclavius tendon reconstruction.

CONCLUSIONS

The figure-of-eight semitendinosus reconstruction for sternoclavicular joint instability has initial biomechanical properties that are superior to those of the intramedullary ligament reconstruction and subclavius tendon reconstruction techniques.

CLINICAL RELEVANCE

While it is difficult to extrapolate in vitro data to the clinical situation, the figure-of-eight semitendinosus technique has superior initial biomechanical properties and may produce improved clinical outcomes in the surgical treatment of sternoclavicular joint instability.

The role of arthroscopic synovectomy in the management of hemarthrosis in hemophilia patients: financial perspectives

PURPOSE

The purpose of this study was to determine the financial efficacy of arthroscopic synovectomy in hemophilia patients with recurrent hemarthroses.

TYPE OF STUDY

Cost-benefit analysis.

METHODS

A retrospective chart review from 1993 through 1999 yielded 11 cases of arthroscopic synovectomies performed for recurrent hemarthroses at the University of Michigan. There were 7 ankle arthroscopies, 3 elbow arthroscopies, and 1 knee arthroscopy. The average age of the patients was 8 years (range, 4-13 years). All had the severe form of hemophilia A. The average follow-up was 41 months (range, 9-75 months). The preoperative costs were determined by multiplying the number of preoperative bleeds by the dollar amount of the replacement therapy used to treat the hemarthroses. The surgical costs included the surgery itself as well as the hospital stay and the dollar amount of the replacement therapy used in the perioperative period. The total postoperative costs included the surgical costs and the dollar amount of any replacement therapy used to treat any postoperative hemarthroses.

RESULTS

The financial benefit of arthroscopic synovectomy was found to be statistically significant when average preoperative cost per month ($7,500) was compared with the average postoperative cost per month ($900), P =.028. Arthroscopic synovectomy was again found to be financially beneficial when the average total preoperative cost ($88,000) was compared with the average total postoperative cost ($24,000), P =.028. The average number of hemarthroses preoperatively was 71 and the average postoperatively was 7, which was statistically significant (P =.028).

CONCLUSIONS

In this small series of patients with intermediate follow-up, arthroscopic synovectomy was found to be cost effective in the treatment of patients with recurrent hemarthroses.

Ligamentous restraints to anterior and posterior translation of the sternoclavicular joint

This experiment was conducted to determine the primary ligamentous restraints to anterior and posterior translation of the sternoclavicular joint. Twenty-four unpaired cadaver specimens were mounted in a custom fixture. Anterior and posterior translations were measured under a sub-failure load in the intact specimen and again after transecting one randomly chosen ligament (anterior capsule, posterior capsule, interclavicular ligament, and costoclavicular ligament; n = 6 for each group). Cutting the posterior capsule resulted in significant increases in anterior translation and posterior translation. Cutting the anterior capsule produced significant increases in anterior translation. Cutting the costoclavicular and interclavicular ligaments had little effect on sternoclavicular joint translation. The posterior capsule is the most important restraint for anterior and posterior translation of the sternoclavicular joint. The anterior capsule is another important restraint for anterior translation. The costoclavicular and interclavicular ligaments have little effect on anterior or posterior translation of the sternoclavicular joint.

Behavior of sutures used in anterior cruciate ligament reconstructive surgery

This study was performed to determine the material properties of sutures commonly used in orthopedic surgery in order to allow selection of the most appropriate one for securing a hamstring or quadriceps tendon graft in anterior cruciate ligament (ACL) reconstruction. Three suture materials (number 5 Ticron, number 5 Ethibond, and 5 mm Mersilene tape) were tested. The ultimate tensile load (UTL) with and without a knot, modulus of elasticity, effect of conditioning on the behavior of the suture, and plastic deformation were determined for each suture. Prior conditioning significantly improved the plastic deformation characteristics of all three sutures. Mersilene possessed the highest UTL both with and without knots, and its plastic deformation was significantly lower than that of Ticron or Ethibond. We feel that these characteristics make it the best suture for use in securing hamstring or tendon grafts in ACL surgery. Because of the high UTL achieved by Mersilene tape in the knotted surgical loop construct (nearly 500 N), it may be possible to achieve fixation integrity approaching that of interference fixation with bone blocks.