Brian B. Gilmer

Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis.

PURPOSE The purpose of this study was to compare arthroscopic versus open examination of the proximal long head of the biceps tendon (LHB) in patients undergoing open, subpectoral tenodesis. METHODS Eighty consecutive patients were prospectively enrolled, of whom 62 were included in the study. During arthroscopy, the most distal extent of the LHB visualized was marked with a Bovie device. The tendon was pulled into the joint with an arthroscopic grasper, showing additional LHB and was again marked with the device. LHB fraying, flattening, redness, and degeneration were graded as absent, mild, moderate, or severe. During open subpectoral tenodesis, the grossly visualized LHB was graded in the same manner and the locations of both marks plus the total length of the LHB observed during open visualization were measured and recorded. After subpectoral tenodesis, the excised portion of the LHB was histologically graded as normal, fibrosis/tendinosis, or inflamed. RESULTS On average, during open tenodesis, 95 mm (range, 75 to 130 mm) of LHB was visualized. This was greater than the length visualized during diagnostic arthroscopy of 16 mm (range, 5 to 28 mm), or 17%, and the length visualized while pulling the tendon into the joint with an arthroscopic grasper of 30 mm (range, 15 to 45 mm), or 32%. The difference in LHB length observed during open versus arthroscopic examination with a grasper was statistically significant (P < .0001). In addition, when compared with LHB pathology observed in an open manner, arthroscopic visualization showed only 67% of pathology, underestimated noted pathology in 56% of patients, and overestimated noted pathology in 11% of patients. Histologic evaluation showed fibrosis/tendinosis in 100% of cases but inflammation in only 5%. CONCLUSIONS When compared with open inspection during subpectoral tenodesis, arthroscopic examination of the LHB visualizes only 32% of the tendon and may underestimate pathology. LEVEL OF EVIDENCE Level II, diagnostic study-development of diagnostic criteria based on consecutive patients with universally applied gold standard.

Knee Medial Collateral Ligament and Posteromedial Corner Anatomic Repair With Internal Bracing

An internal brace is a ligament repair bridging concept using braided ultrahigh-molecular-weight polyethylene/polyester suture tape and knotless bone anchors to reinforce ligament strength as a secondary stabilizer after repair and return to sports, which may help resist injury recurrence. An internal brace may provide augmentation during knee medial and posteromedial corner anatomic repair. In patients with combined, chronic, symptomatic anterior cruciate ligament (ACL)-posteromedial corner laxity, combined ACL reconstruction with posteromedial corner reconstruction is indicated. Our ACL technique was previously published with video illustration in Arthroscopy and Arthroscopy Techniques. The purpose of this article is to describe, with video illustration, knee posteromedial corner reconstruction using anatomic repair with internal brace augmentation.

A quantitative method for determining medial migration of the humeral head after shoulder arthroplasty: preliminary results in assessing glenoid wear at a minimum of two years after hemiarthroplasty with concentric glenoid reaming

HYPOTHESIS Glenoid erosion and medial migration of the humeral head prosthesis have been observed after most types of shoulder arthroplasty. A method of measuring the change in humeral head position with time after shoulder prosthetic arthroplasty was applied it to 14 shoulders that underwent humeral hemiarthroplasty with concentric glenoid reaming. We hypothesized that the measurement technique would be reproducible and that the rate of wear would be small in the series of shoulders studied. MATERIALS AND METHODS Standardized anteroposterior and axillary radiographs were obtained after surgery. Two examiners measured the position of the humeral head center in relation to scapular reference coordinates for the anteroposterior and axillary projections and plotted these values against time after surgery. The change in position was characterized as the slope of this plot. Shoulders were included if there were at least 3 sets of postoperative films, the last being at least 2 years after surgery. RESULTS The slopes measured by the 2 examiners agreed within 0.5 mm/y for the anteroposterior and the axillary projections. For the series of shoulder arthroplasties, the rate of movement of the head center toward the scapula was less than 0.4 mm/y for either examiner in either projection. DISCUSSION Medial migration is a concern after any type of shoulder arthroplasty, whether a hemiarthroplasty, a biological interpositional arthroplasty, or a total shoulder arthroplasty. Quantifying the rate of medial migration over time after shoulder arthroplasty is an important element of clinical follow-up. CONCLUSIONS This is an inexpensive, practical, and reproducible method that can be used to determine the rate of medial migration of the humeral head on plain radiographs after shoulder arthroplasty. The average rate of medial migration in the shoulders in this study was small.

Biomechanical Analysis of Internal Bracing for Treatment of Medial Knee Injuries

The internal brace technique uses a high-strength suture tie to augment injured tissues or a primary repair, allowing early rehabilitation. Anatomic repair with internal bracing is a novel and promising treatment for femoral-sided medial knee avulsion injuries of the medial collateral ligament and posterior oblique ligament. Unfortunately, biomechanical and clinical data are lacking. To evaluate this technique compared with other treatment options, 3 assays of 9 cadaveric matched pairs (54 knees) were tested to failure at 30° under valgus load in a biomechanical testing apparatus. The primary outcome measure was moment at failure (Nm), with secondary outcome measures of stiffness (Nm/°), valgus angulation at 10 Nm (°), and valgus angulation at failure (°). Repair with internal bracing was compared with the intact state, repair alone, and allograft reconstruction. The mean moment to failure (62.5±24.9 Nm) for internal bracing was significantly lower than that for intact specimens (107.2±39.7 Nm) (P=.009). Mean moment to failure and valgus angle at failure were significantly greater for internal bracing (95±31.9 Nm) than for repair (73.4±27.6 Nm) (P=.05). Internal bracing was similar to reconstruction for the primary outcome measure (53.5±26.3 Nm vs 66.9±28.8 Nm) (P=.227) and for all secondary outcome measures. These findings indicate that posteromedial knee repair with internal bracing for femoral-sided avulsions is superior to repair alone and is similar to allograft reconstruction for all parameters measured; however, this technique did not recreate biomechanical properties equivalent to the intact state. [Orthopedics. 2016; 39(3):e532-e537.].

Orthopaedic Residents Improve Confidence and Knot-Tying Speed With a Skills Course

PURPOSE To determine the effect of a knot-tying module, within an arthroscopic training course, on resident speed, resident confidence, and biomechanical quality of arthroscopically tied knots. METHODS Sixty-four participants (8 postgraduate year [PGY]-3 and 8 PGY-4 orthopaedic residents annually for 4 years) were enrolled in a 5-day training course, which included a daily knot-tying module. Self-assessed confidence was obtained by pre-course (day 1) and post-course (day 5) questionnaire. Each participant tied 5 sequential knots using an arthroscopic knot-tying station. Time per knot was recorded in seconds. Knots were later preloaded, cycled, and tested for peak load to failure and displacement change. Mean peak load to failure, displacement change, speed, and confidence were compared before and after training. RESULTS The mean time to complete 5 knots was significantly faster after training (12.8 minutes before the course [day 1] v 9.39 minutes after the course [day 5]) (P < .0001). Confidence improved from pre-course (mean, 3.3) to post-course (mean, 7.8) questionnaires (P < .0001). No statistically significant difference was found between peak force for pre-course (mean, 136 N) and post-course (mean, 138 N) knots (P = .076). No statistically significant difference was detected in mean displacement change (mean, 3.51 mm before the course v 3.57 mm after the course) (P = .61). Comparison of PGY-3 and PGY-4 residents was significant only for a higher pre-course confidence in PGY-4 residents (P = .02). CONCLUSIONS Participation in an arthroscopic knot-tying module improves resident speed and confidence in tying arthroscopic knots. Our data did not show a significant change in peak load to failure or loop security with training. These findings suggest that participation in a knot-tying module improves efficiency regarding arthroscopic knot tying by residents. CLINICAL RELEVANCE Residents who practice arthroscopic knot tying 5 days per year as part of an arthroscopic training course may be more efficient in the operating room.

Anatomic All-Inside Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autograft

All-inside anterior cruciate ligament reconstruction has recently gained popularity, in part because of its bone-sparing socket preparation and reported lower pain levels after surgery. However, because this technique uses suture loops and cortical suspension buttons for graft fixation, it has mostly been limited to looped graft constructs (e.g., hamstring autograft, peroneus longus allograft). Quadriceps tendon autograft offers several advantages in anterior cruciate ligament reconstruction but, until recently, has not been compatible with suture-loop and cortical suspensory fixation. We describe a technique that allows a relatively short (<75 mm) quadriceps tendon autograft (without bone block) to be used with established all-inside anatomic techniques.

Postoperative Management and Rehabilitation

Protocols for postoperative management of frozen shoulder after arthroscopic capsular release vary widely. Data for the effectiveness of any particular protocol are lacking. Some options to aid in the management have included hospital admission, continuous passive motion (CPM), brief immobilization, various pain management modalities, and outpatient physical therapy. Outpatient physical therapy is a mainstay of nonoperative and postoperative treatments. While treatment should always be modified according to each individual patient’s needs, this chapter details a protocol consisting of four basic phases of rehabilitation: early range of motion, active range of motion, strengthening, and advanced strengthening. It is important to note that these phases likely will overlap to varying degrees.

A reproducible and practical method for documenting the position of the humeral head center relative to the scapula on standardized plain radiographs

BACKGROUND Recent articles in this journal showed the clinical importance of the position of the humeral head center in relation to the glenoid. However, the precision, reproducibility, and sensitivity of this and other methods of documenting the head center position have not been evaluated in detail. MATERIALS AND METHODS We used templates to fit a coordinate system to the scapular anatomy visible on standardized radiographs. Two observers then used these templates to measure the position of the head center relative to this coordinate system on 25 normal shoulder radiographs and on 25 radiographs of shoulders with cuff tear arthropathy (CTA). RESULTS Head center measurements had excellent precision. Normal shoulder radiographs showed a consistent head center position (0.7 ± 1.7 mm medial and 0.6 ± 1.3 mm inferior to the coordinate origin on the anteroposterior view and 0.1 ± 1.3 mm medial and 0.0 ± 1.3 mm anterior to the coordinate origin on the axillary view). The head center of CTA shoulder radiographs was 10.18 ± 5.16 mm above the coordinate origin on the anteroposterior view, significantly different from that for the normal shoulder radiographs (P < .001). DISCUSSION The relative position of the humeral head center to the scapula determines the resting length and the moment arms of the scapulohumeral muscles. Correlation of shoulder function with the head center position may provide insights into both shoulder pathomechanics and the optimization of shoulder arthroplasty. CONCLUSION This practical technique showed a high degree of precision and reproducibility for normal and CTA shoulder radiographs as well as a high level of discrimination between these two groups.

Editorial Commentary: Goldilocks and the Three Grafts: Managing Tendon Harvest and Graft Length Problems in Autograft Anterior Cruciate Ligament Reconstruction

Autograft hamstring tendon harvest in anterior cruciate ligament (ACL) reconstruction can occasionally result in a graft length that is inadequate for creation of a robust ACL graft. Patients at risk for an abnormally short hamstring may also be high risk for ACL reinjury. Graft augmentation with allograft may be a suboptimal solution to this problem. Therefore, a reliable means for preoperative estimation of hamstring tendon length by magnetic resonance imaging measurement could avoid this pitfall. However, even with a reliable correlation between magnetic resonance imaging measurement and actual harvested tendon length, establishing a simple, clinically relevant threshold below which hamstring grafts should be avoided remains elusive. By contrast, all-soft-tissue quadriceps autograft avoids the potential length problems inherent to both bone tendon bone (graft-tunnel mismatch) and hamstring tendon grafts, but intermediate- and long-term outcome studies are still needed to validate all-soft-tissue quadriceps autograft in ACL reconstruction.

Diagnosis of long head of the biceps tendon pathology: current concepts

The history, physical examination and diagnosis of long head biceps tendon (LHBT) lesions is challenging. The LHBT has both intra-articular and extra-articular components, often engages only in specific arm positions and activities, takes a long oblique course across the shoulder joint and is adjacent to and associated with other critical structures around the glenohumeral joint. Previous reviews have described the limitations of examination and diagnosis of the LHBT through various modalities. The purpose of this review is to summarise the current tools available for LHBT diagnosis, assess their effectiveness and discuss emerging techniques to improve diagnostic accuracy. Directions for future study are described to improve preoperative planning and intraoperative detection of LHBT pathology.