Dan Guttmann

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.

Management of Disorders of the Rotator Cuff: Proceedings of the ISAKOS Upper Extremity Committee Consensus Meeting

The goal of this article is to consolidate the International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine (ISAKOS) Upper Extremity Committees (UECs) current knowledge on rotator cuff disease and management, as well as highlight key unresolved issues. The rotator cuff is an anatomically complex structure important for providing glenohumeral function and stability as part of a closed chain system. Current consensus suggests rotator cuff injuries are most accurately diagnosed, at levels similar to diagnosis by magnetic resonance imaging, with a combination of cuff- and impingement-specific clinical tests. Updates in the understanding of acromion morphology, the insertional anatomy of the rotator cuff, and the role of suprascapular nerve release may require changes to current classification systems and surgical strategies. Although initial management focuses on nonoperative protocols, discussion continues on whether surgery for isolated impingement is clinically more beneficial than rehabilitation. However, clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other. Biceps tenodesis, however, in non-isolated cuff tears has proven more successful in addressing the etiology of shoulder pain and yields improved outcomes over tenotomy. Data reviewing the benefits of tendon transfers, shoulder prostheses, and mechanical scaffolds, as well as new research on the potential benefit of platelet-rich plasma, pluripotential stem cells, and gene therapies, will also be presented.

Complications in the treatment of medial and lateral sided injuries of the knee joint.

Complications may result from nonoperative and surgical management of medial or lateral sided knee injuries. Because these injuries are often associated with injury to the medial or lateral meniscus and the anterior or posterior cruciate ligaments (ACL and PCL, respectively), injury to these structures will also be considered. We group these complications in 3 categories: (1) complications associated with either operative or nonoperative management, (2) intraoperative complications, and (3) postoperative complications. Greater understanding of complications of medial and lateral knee ligament injuries may result in improved clinical outcomes.

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.

Editorial Commentary: You May Not Have Seen It, but It Has Seen You: Diagnosis of Long Head Biceps Tendon and Subscapularis Pathology in Association With Shoulder Rotator Cuff Pathology Can Be Challenging

The shoulder can humble you. It is often challenging in determining the extent of pathology even when there is an adequate magnetic resonance imaging performed preoperatively and even during the so-called diagnostic portion of the arthroscopy. Abnormalities of the long head of the biceps tendon and the rotator cuff especially the subscapularis can be difficult to diagnose definitively. Experience can be very helpful in predicting pathology based on patterns seen before and knowing certain pearls that can make diagnosis and ultimately treatment more accurate.

Rotator Cuff Pathology: A Comparison of Magnetic Resonance Imaging and Arthroscopic Findings

Appropriate imaging and interpretation of magnetic resonance imaging (MRI) is critical for successful preoperative planning of arthroscopic rotator cuff repairs. Osseous features may be significant in the pathogenesis and pathoanatomy of rotator cuff tears as in the case of subacromial and subcoracoid impingement. Soft tissue features may determine the repairability of tears, impact repair technique, and determine the prognosis for healing.

Arthroscopy and Repair

The current literature regarding classification appears to be underpowered for valid conclusions. The comprehensive ISAKOS Rotator Cuff Disease Classification System previously presented at this book will be helpful for research and daily practice guidelines.

AANA traveling shoulder fellowship : An experience of a lifetime

Our Arthroscopy Association of North America houlder Traveling Fellowship began April 24, 2006, n Chicago. The Fellows included Dan Guttmann Taos, NM), Ilya Voloshin (Rochester, NY), Derek chiai (Arlington, VA), and our “godfather” Howard weeney, Professor Emeritus at Northwestern Uniersity. Our educational journey began at Rush University. e were hosted by Drs. Brian Cole, Tony Romeo, ernard Bach, Charles Bush-Joseph, and Greg Niholson. There we observed Dr. Brian Cole performng patellar autologous cartilage implantation with nteromedialization of the patella, pectoralis major ransfers for winging scapula, and rotator cuff repairs. r. Bernard Bach demonstrated an anterior cruciate igament reconstruction, as well as a posterolateral orner reconstruction. We also observed Dr. Greg icholson performing total shoulder replacements as ell as reverse shoulder replacements. We picked up ome good tips on facilitating total shoulder arthrolasty, including cutting an arm board in half so that he shoulder can be supported without having a full rm board blocking the surgeon. Dr. Cole introduced s to his style of multitasking, juggling his e-mail, cell hone, and concurrent conversations with aplomb. ne of us (D.G.) had a chance to spend some time