Dana P. Piasecki

Glenoid Bone Deficiency in Recurrent Anterior Shoulder Instability: Diagnosis and Management

&NA; Recurrent anterior shoulder instability may result from a spectrum of overlapping, often coexistent factors, one of which is glenoid bone loss. Untreated, glenoid bone loss may lead to recurrent instability and poor patient satisfaction. Recent studies suggest that the glenoid rim is altered in up to 90% of shoulders with recurrent instability, thus underscoring the need for careful diagnosis, quantification, and preoperative evaluation. Biomechanical and clinical studies offer criteria that may be used in both primary and revision settings to judge whether shoulder stability is compromised by a bony defect. Along with patient activity level, these criteria can help guide the surgeon in selecting treatment options, which range from nonsurgical care to isolated soft‐tissue repair as well as various means of bony reconstitution.

Anterior Cruciate Ligament Reconstruction: Can Anatomic Femoral Placement Be Achieved With a Transtibial Technique?

Background: Recent reports have suggested that a traditional transtibial technique cannot practically accomplish an anatomic anterior cruciate ligament (ACL) reconstruction. Hypothesis: The degree to which a transtibial technique can anatomically position both tibial and femoral tunnels is highly dependent on tibial tunnel starting position. Study Design: Descriptive laboratory study. Methods: Eight fresh-frozen adult knee specimens were fixed at 90° of flexion and then dissected to expose the femoral and tibial ACL footprints. After the central third patellar tendon length was measured for each specimen, computer-assisted navigation was used to identify 2 idealized tibial tunnel starting points, optimizing alignment with the native ligament in the coronal plane but distal enough on the tibia to provide manageable bone-tendon-bone autograft–tibial tunnel mismatch (point A = 10-mm mismatch; point B = 0-mm mismatch). Tibial tunnels were then reamed to the center of the tibial insertion using point A in half of the knees and point B in the other half. Guide pin positioning on the femoral side was then assessed before and after tibial tunnel reaming, after beveling the posterolateral tibial tunnel rim, and after performing a standard notchplasty. After the femoral tunnel was reamed, the digitized contours of the native insertions were compared with those of both tibial and femoral tunnels to calculate percentage overlap. Results: Starting points A and B occurred 15.9 ± 4.5 mm and 33.0 ± 3.3 mm distal to the joint line, respectively, and 9.8 ± 2.4 mm and 8.3 ± 4.0 mm from the medial edge of the tibial tubercle, respectively. The anterior and posterior aspects of both tibial tunnels’ intra-articular exits were within a few millimeters of the native insertion’s respective boundaries. After the tibial tunnel was reamed from the more proximal point A, a transtibial guide pin was positioned within 2.1 ± 1.6 mm of the femoral insertion’s center (vs 9.3 ± 1.9 mm for point B; P = .02). After beveling a mean 2.6 mm from the back of the point A tibial tunnels, positioning improved to within 0.3 ± 0.7 mm from the center of the femoral insertion (vs 4.2 ± 1.1 mm for the point B tibial tunnels; P = .008). Compared with the more distal starting point, use of point A provided significantly greater insertional overlap (tibial: 97.9% ± 1.4% vs 71.1% ± 15.1%, P = .03; femoral: 87.9% ± 9.2% overlap vs 59.6% ± 8.5%, P = .008). No significant posterior femoral or tibial plateau breakthrough occurred in any specimen. Conclusion: Tibial and femoral tunnels can be positioned in a highly anatomic manner using a transtibial technique but require careful choice of a proximal tibial starting position and a resulting tibial tunnel that is at the limits of practical. Traditional tibial tunnel starting points will likely result in less anatomic femoral tunnels. Clinical Relevance: A transtibial single-bundle technique can accomplish a highly anatomic reconstruction but does require meticulous positioning of the tibial tunnel with little margin for error and some degree of graft-tunnel mismatch.

Biomechanical similarities among subscapularis repairs after shoulder arthroplasty

HYPOTHESIS Many authors suggest that subscapularis deficiency after shoulder arthroplasty has a negative effect on long-term outcomes. Thus, increasing emphasis has been placed on the technique for repair of the tendon. This study evaluated the biomechanical strength of 3 different repairs: osteotomy, tendon to bone, and a combined method. MATERIALS AND METHODS Twenty-four paired shoulders from deceased donors were prepared for shoulder arthroplasty. The subscapularis tendon was removed/repaired with the lesser tuberosity in the osteotomy group, was removed periosteally in the bone-to-tendon group, and was tenotomized in the combined group. The tendon-to-bone repair used bone tunnels, and the combined construct added tendon-to-tendon fixation. A materials testing system machine was used for cycling. A digital motion analysis system with spatial markers was used for analysis. RESULTS There were no significant differences (P > .05) in age, bone mineral density, or construct thickness. No statistically significant differences (P > .05) in elongation amplitude (P = .67) or cyclic elongation (P = .58) were detected within the constructs or between repair techniques. Failure testing revealed no differences in maximum load, stiffness, or mode of failure. DISCUSSION There remains no consensus about the optimal method of repairing the subscapularis tendon during shoulder arthroplasty. Furthermore, the results of the current study do not support one technique over another with regard to initial fixation properties. All constructs investigated exhibited comparably robust biomechanical performance. Durability may, therefore, be more a result of healing potential than the specific construct chosen.

Outcomes After Arthroscopic Revision Rotator Cuff Repair

Background Although a number of reports have documented outcomes after open revision rotator cuff repair, there are few studies reporting results after arthroscopic revision. Hypothesis Arthroscopic repair of failed rotator cuff results in significant improvement in shoulder functional outcome and pain relief. Study Design Case series; Level of evidence, 4. Methods Multiple variables including demographic data, the number of prior ipsilateral shoulder surgeries, and tear size were recorded from chart review. An independent examiner then measured shoulder strength, range of motion, and shoulder functional outcome scores including American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Paired t tests were performed to compare preoperative and postoperative measures. Additionally, contingency table analysis was performed to identify prognostic factors for failure of repair requiring further surgery and American Shoulder and Elbow Surgeons score less than 50. Results Fifty-four patients (88.5%) were available for follow-up evaluation with a mean age of 54.9 ± 10.1 years (range, 22.7-82.5 years) and a mean follow-up of 31.1 ± 11.9 months. American Shoulder and Elbow Surgeons scores improved from 43.8 ± 5.7 (mean ± 95% confidence interval) before revision to 68.1 ± 7.2 at final follow-up (P = .0039). The Simple Shoulder Test improved significantly from 3.56 ± 0.8 before surgery to 7.5 ± 1.1 at most recent follow-up (P < .0001). Visual analog pain scale scores improved from 5.17 ± 0.8 to 2.75 ± 0.8 (P = .03), and forward elevation increased from 121.0° ± 12.3° to 136° ± 11.8° postoperatively (P = .025). Greater than 1 prior shoulder surgery was associated with cases that required additional surgery (P = .031). Female gender (P = .007) and preoperative abduction less than 90° (P = .009) were associated with American Shoulder and Elbow Surgeons scores less than 50. Conclusion Arthroscopic revision rotator cuff repair may be a reasonable treatment option even after prior open repairs and provides both improved pain relief and shoulder function. Nonetheless, results are not completely optimal. Female patients and those who have undergone more than 1 ipsilateral shoulder surgery are at increased risk for poorer results.

Arthroscopic decompression of the suprascapular nerve at the spinoglenoid notch and suprascapular notch through the subacromial space.

Suprascapular nerve entrapment can cause disabling shoulder pain. Suprascapular nerve release is often performed for compression neuropathy and to release pressure on the nerve associated with arthroscopic labral repair. This report describes a novel all-arthroscopic technique for decompression of the suprascapular nerve at the suprascapular notch or spinoglenoid notch through a subacromial approach. Through the subacromial space, spinoglenoid notch cysts can be visualized between the supraspinatus and infraspinatus at the base of the scapular spine. While viewing the subacromial space through the lateral portal, the surgeon can use a shaver through the posterior portal to decompress a spinoglenoid notch cyst at the base of the scapular spine. To decompress the suprascapular nerve at the suprascapular notch, a shaver through the posterior portal removes the soft tissue on the acromion and distal clavicle to expose the coracoclavicular ligaments. The medial border of the conoid ligament is identified and followed to its coracoid attachment. The supraspinatus muscle is retracted with a blunt trocar placed through an accessory Neviaser portal. The transverse scapular ligament, which courses inferior to the suprascapular artery, is sectioned with arthroscopic scissors, and the suprascapular nerve is decompressed.

Tears of the Subscapularis Tendon in Athletes-Diagnosis and Repair Techniques

Isolated injury to the subscapularis tendon is an uncommon - but potentially debilitating - injury among athletes. The most frequent injury pattern seen in younger athletes is an acute, traumatic tendon avulsion. In the older athletic population, chronic degenerative tearing of the tendon may precede sports-related rupture, particularly following shoulder dislocation. This article reviews how to diagnose this injury in athletes, and describes both conservative and operative treatment options and their outcomes.

Exertional Compartment Syndrome of the Forearm in an Elite Flatwater Sprint Kayaker

Chronic exertional compartment syndrome (CECS) is a potentially debilitating entity among athletes across a variety of sports. Defined as an intermittent and reversible pathologic elevation of compartment pressures following exertion, it has been best recognized in the lower extremities. Only rarely has CECS been reported in the upper limbs, with just 25 reported cases of exertional compartment syndrome in the forearm. Where noted, the majority of these reported cases involve activities that place substantial demands on the forearm musculature, including manual labor, motorcycle racing, tennis, rock climbing, and weight lifting. We report a novel case of CECS in an elite flatwater kayaker, discuss this patient’s management, and present a review of the literature.

Environmental issues for team physicians.

As outdoor sports continue to gain popularity, understanding the environmental factors that may influence athletes is becoming a more important aspect of medical care for team physicians. Temperature, ultraviolet light, lightning, and altitude are some of the most common elements that cause illness. Understanding how to prevent, diagnose, and promptly treat conditions caused by environmental factors is essential to optimizing athletic performance in outdoor sports and avoiding morbidity.

Cortical Button Fixation

Background: Patellar tendon ruptures require surgical repair to optimize outcomes, but no consensus exists regarding the ideal repair technique. Cortical button fixation is a secure method for tendon repair that has not been studied in patellar tendons. Hypothesis: Cortical button repair is biomechanically superior to the standard transpatellar repair and biomechanically equivalent to suture anchor repair. Study Design: Controlled laboratory study. Methods: Twenty-three fresh-frozen cadaveric knees were used to compare 3 techniques of patellar tendon repair after a simulated rupture at the inferior pole of the patella. Repairs were performed at 45° of flexion using a standard transpatellar suture repair (n = 7), polyetheretherketone (PEEK) suture anchor repair (n = 8), or cortical button repair (n = 8). All specimens were tested on a custom apparatus to simulate cyclic open kinetic chain quadriceps contraction from extension to 90o of flexion. Outcomes of gap formation up to 250 cycles, maximum load to failure, and mode of failure were evaluated. Results: Cortical button repair had significantly less gap formation than anchor repair after 1 cycle (P < .001) and 20 cycles (P < .01) and significantly less gap formation than suture repair from 1 to 250 cycles (P < .05). Cortical button repair sustained significantly higher loads to failure than anchor repair and suture repair (P < .001). All suture repairs failed through the suture. Anchor repairs failed at the suture-anchor eyelet interface (n = 4) or by anchor pullout (n = 3). Cortical button repairs either failed through the suture (n = 5), secondary failure of the patellar tendon (n = 2), or subsidence of the button through the anterior cortex of the patella (n = 1). Conclusion: Patellar tendon repair using cortical button fixation demonstrated mechanical advantages over suture repair and anchor repair in cadaveric specimens. Cortical button fixation showed less cyclic gap formation and withstood at least twice the load to failure of the construct. Clinical Relevance: The biomechanical superiority of cortical button fixation may impart clinical advantages in accelerating postoperative rehabilitation.

Biceps Tenodesis: Biomechanical Assessment of 3 Arthroscopic Suprapectoral Techniques.

Biceps tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps with an associated predictable clinical outcome compared with tenotomy. Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach. This study biomechanically compared 3 arthroscopic suprapectoral biceps tenodesis techniques performed with a suture anchor with lasso loop technique, an interference screw, and a compressive rivet. For a total of 15 randomized paired tests, 15 pairs of human cadaveric shoulders were used to test 1 technique vs another 5 times with 3 customized setups. Biomechanical testing was performed with an electromechanical testing system. The tendon was preloaded with 10 N and cyclically loaded at 0 to 40 N for 50 cycles. Load to failure testing was performed at 1 mm/s until failure occurred. The compressive rivet, interference screw, and suture anchor with lasso loop had mean load to failure of 97.1 N, 146.4 N, and 157.6 N, respectively. The difference in ultimate strength between the suture anchor with lasso loop and the compressive rivet was statistically significant (P=.04). No significant differences were found between the suture anchor with lasso loop and the interference screw (P=.93) or between the interference screw and the rivet (P=.10). When adjusted for sex, the load to failure overall among the 3 constructs was not significantly different. All 3 techniques had a different predominant mechanism of failure. The suture anchor with lasso loop showed superior load to failure compared with the compressive rivet. The minimum load to failure required to achieve clinically reliable biceps tenodesis is unknown. [Orthopedics. 2017; 40(6):e1009-e1016.].