Daniel J. Solomon

A Prospective Analysis of 179 Type 2 Superior Labrum Anterior and Posterior Repairs Outcomes and Factors Associated With Success and Failure

Background: There is a paucity of type 2 superior labrum anterior and posterior (SLAP) surgical outcomes with prospective data. Purpose: To prospectively analyze the clinical outcomes of the arthroscopic treatment of type 2 SLAP tears in a young, active patient population, and to determine factors associated with treatment success and failure. Study Design: Case-control study; Level of evidence, 3. Methods: Over a 4-year period, 225 patients with a type 2 SLAP tear were prospectively enrolled. Two sports/shoulder-fellowship-trained orthopaedic surgeons performed repairs with suture anchors and a vertical suture construct. Patients were excluded if they underwent any additional repairs, including rotator cuff repair, labrum repair outside of the SLAP region, biceps tenodesis or tenotomy, or distal clavicle excision. Dependent variables were preoperative and postoperative assessments with the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability (WOSI) scores and independent physical examinations. A failure analysis was conducted to determine factors associated with failure: age, mechanism of injury, preoperative outcome scores, and smoking. Failure was defined as revision surgery, mean ASES score below 70, or an inability to return to sports and work duties, which was assessed statistically with the Student t test and stepwise logarithmic regression. Results: There were 179 of 225 patients who completed the follow-up for the study (80%) at a mean of 40.4 months (range, 26-62 months). The mean preoperative scores (WOSI, 54%; SANE, 50%; ASES, 65) improved postoperatively (WOSI, 82%; SANE, 85%; ASES, 88) (P < .01). The mean postoperative range of motion was 159° of flexion, 151° of abduction, and 51° of external rotation at the side, which was less than the mean preoperative range of motion (164° of flexion, 166° of abduction, and 56° of external rotation at the side). Of the 179 patients, 66 patients (36.8%) met failure criteria. Fifty patients elected revision surgery. Advanced age within the cohort (>36 years) was the only factor associated with a statistically significant increase in the incidence of failure. Those who were deemed failed had a mean age of 39.2 years (range, 29-45 years) versus those who were deemed healed with a mean age of 29.7 years (range, 18-36 years) (P < .001). The relative risk for failure for patients older than 36 years was 3.45 (95% CI, 2.0-4.9). Conclusion: Arthroscopic SLAP repair provides a clinical and statistically significant improvement in shoulder outcomes. However, a reliable return to the previous activity level is limited; 37% of patients had failure, with a 28% revision rate. Age greater than 36 years was associated with a higher chance of failure. Additional work is necessary to determine the optimal diagnosis, indications, and surgical management for those with SLAP injuries.

Clinical Application of the "Glenoid Track" Concept for Defining Humeral Head Engagement in Anterior Shoulder Instability: A Preliminary Report.

Background: The optimal treatment of Hill-Sachs injuries is difficult to determine and is potentiated by the finding that a Hill-Sachs injury becomes more important in the setting of glenoid bone loss, making engagement of the humeral head on the glenoid inherently easier. The “glenoid track” concept was developed to biomechanically quantify the effects of a combined glenoid and humeral head bony defects on instability. Purpose: To clinically evaluate humeral head engagement on the glenoid by utilizing glenoid track measurements of both humeral head and glenoid bone loss. Study Design: Retrospective cohort. Methods: A total of 205 patients with recurrent anterior shoulder instability were evaluated, and of these, 140 patients (68%; 9 females [6%] and 131 males [94%]) with a Hill-Sachs lesion and a mean age of 27.6 years (range, 15-47 years; standard error of mean [SEM], 0.59) were included in the final magnetic resonance angiogram [MRA]) analysis. Bipolar bone loss measures of glenoid bone loss (sagittal oblique MRA) and multiple size measures of the Hill-Sachs injury (coronal, axial, and sagittal MRA) were recorded. Based on the extent of the bipolar lesion, patients were classified with glenoid track as either outside and engaging of the glenoid on the humeral head (OUT-E) or inside and nonengaging (IN-NE). The 2 groups were then compared with clinical evidence of engagement on examination under anesthesia (EUA) using video arthroscopy, number of dislocations, length of instability, and patient age. Results: The mean glenoid bone loss was 7.6% (range, 0%-29%; SEM, 1.20%), and 31 of 140 (22%) patients demonstrated clinical engagement on EUA. Radiographically, 19 (13.4%) patients were determined to be OUT-E, while 121 (86.6%) were IN-NE and not expected to engage. Of those 19 patients with suggested radiographic engagement (OUT-E), 16 (84.5%) had clinical evidence of engagement versus only 12.4% that clinically engaged (15/121) without radiographic evidence of engagement (IN-NE) (P < .001). Younger age and a greater number of recurrence events were jointly predictive of a patient being classified as OUT-E (11.8 vs 6.4 dislocations; P = .015). Conclusion: This study demonstrates that glenohumeral engagement was well predicted based on preoperative glenoid and humeral head bone loss measurements using the glenoid track method. In addition, younger age and a greater number of recurrences were predictive of engagement. The glenoid track concept may be important to fully assess the overall risk for engagement prior to surgery and may help guide surgical decision making such as bony augmentation procedures.

A Radiographic Assessment of Failed Anterior Cruciate Ligament Reconstruction Can Magnetic Resonance Imaging Predict Graft Integrity

Background: Magnetic resonance imaging (MRI) showing an “intact” anterior cruciate ligament (ACL) graft may not correlate well with examination findings. Reasons for an ACL graft dysfunction may be from malpositioned tunnels, deficiency of secondary stabilizers, repeat injuries, or a combination of factors. Purpose: To evaluate the concordance/discordance of an ACL graft assessment between an arthroscopic evaluation, physical examination, and MRI and secondarily to evaluate the contributing variables to discordance. Study Design: Case series; Level of evidence, 4. Methods: A total of 50 ACL revisions in 48 patients were retrospectively reviewed. The ACL graft status was recorded separately based on Lachman and pivot-shift test data, arthroscopic findings from operative reports, and MRI evaluation and was categorized into 3 groups: intact, partial tear, or complete tear. Two independent evaluators reviewed all of the preoperative radiographs and MRI scans, and interrater and intrarater reliability were evaluated. Concordance and discordance between a physical examination, arthroscopic evaluation, and MRI evaluation of the ACL graft were calculated. Graft position and type, mechanical axis, collateral ligament injuries, chondral and meniscal injuries, and mechanism of injury were evaluated as possible contributing factors using univariate and multivariate analyses. Sensitivity and specificity of MRI to detect a torn ACL graft and meniscal and chondral injuries on arthroscopic evaluation were calculated. Results: The interobserver and intraobserver reliability for the MRI evaluation of the ACL graft were moderate, with combined κ values of .41 and .49, respectively. The femoral tunnel position was vertical in 88% and anterior in 46%. On MRI, the ACL graft was read as intact in 24%; however, no graft was intact on arthroscopic evaluation or physical examination. The greatest discordance was between the physical examination and MRI, with a rate of 52%. An insidious-onset mechanism of injury was significantly associated with discordance between MRI and arthroscopic evaluation of the ACL (P = .0003) and specifically with an intact ACL graft on MRI (P = .0014). The sensitivity and specificity of MRI to detect an ACL graft tear were 60% and 87%, respectively. Conclusion: Caution should be used when evaluating a failed ACL graft with MRI, especially in the absence of an acute mechanism of injury, as it may be unreliable and inconsistent.

A Prospective Outcome Evaluation of Humeral Avulsions of the Glenohumeral ligament (HAGL) Tears Repairs in an Active Population

Objectives: Humeral Avulsions of the Glenohumeral ligament (HAGL) are an infrequent and underappreciated cause of shoulder instability and dysfunction. The purposes of this study are to prospectively evaluate the presentation, clinical history and surgical outcomes of patients with HAGL tears. Methods: Over an eight-year period, patients with failed non-operative shoulder dysfunction with a confirmed HAGL tear on MR Arthrogram, who elected to undergo surgical treatment were prospectively investigated. Independent variables were patient demographics, clinical presentation, physical examination findings, and arthroscopic findings. The dependent variables assessed included return to work and activity rates, pre-operative and post-operative patient reported outcomes (ASES, SANE, WOSI scores) and independent physical examinations. Statistical analysis was via Student’s t-test and significance set at p <.05. Results: A total of 23 of 24 patients (96%) were evaluated at a mean of 32.1 months (Range 24-68 months). There were 11 females (48%) and 12 males (52%) at a mean age of 24.2 years (Range 18-33). Mechanism of injury was core training (cross-fit or equivalent) in 48%, pull-ups in 22%, and unknown in 30%. The primary complaint was pain in 82%; 20% of patients complained of instability symptoms. There were 12 patients with anterior HAGLs, 8 patients with reverse HAGLs and 3 with combined anterior and posterior lesions. 10 patients had both HAGL and labral tears, 13 with isolated HAGL. 9 patients underwent arthroscopic surgical repair and 14 underwent an open surgical repair. There was a clinically and statistically significant improvement in patient reported outcomes (WOSI=54%, SANE=50%) improved (WOSI=83%, SANE=87%, p<0.01). 21 of 23 (91%) patients returned demonstrated patient satisfaction and a return to full activity. Conclusion: This study demonstrates patients with symptomatic HAGL tears present with pain and shoulder dysfunction, that anterior and reverse HAGL tears are nearly distributed equally. After surgery, patients demonstrated statistically and clinically significant improved outcomes, a predictable return to activity and patient satisfaction. Additional work is necessary to determine optimal treatments, especially with combined HAGL and labral tears.

Isolated Iliotibial Band Rupture After Corticosteroid Injection as a Cause of Subjective Instability and Knee Pain in a Military Special Warfare Trainee

Iliotibial band friction syndrome (ITBFS) of the knee is a common overuse injury in athletes, especially in runners. The syndrome occurs when the ITB, a lateral thickening of the fascia lata of the thigh moves repetitively over the lateral femoral condyle. A variety of nonoperative measures are used for ITBFS treatment, including stretching, core strengthening, and therapeutic injection. Isolated distal ITB rupture is a rare entity and has never yet to be reported in the orthopedic literature. We present a case of isolated ITB rupture as a cause of varus instability and knee pain in a Naval Special Warfare candidate diagnosed with ITBFS and previously treated with several local corticosteroid injections before ITB rupture. Because of continued knee pain and a sense of instability, along with an inability to return to his military special warfare duties, the ITB was surgically repaired. This case highlights the presentation and management of isolated distal ITB rupture and discusses some of the potential risk factors for rupture, including prior local corticosteroid injection.

Medical Care for Swimmers.

Swimming is one of the most popular sports worldwide. Competitive swimming is one of the most watched sports during the Olympic Games. Swimming has unique medical challenges as a result of a variety of environmental and chemical exposures. Musculoskeletal overuse injuries, overtraining, respiratory problems, and dermatologic conditions are among the most common problems swimmers encounter. Although not unique to swimming, overtraining is a serious condition which can have significant negative impact on swimmers’ health and performance. This review article is an attempt to discuss various issues that a medical team should consider when caring for swimmers.

Outcomes of Primary Biceps Sub-pectoral Tenodesis in an Active Population: A prospective Evaluation of 101 Patients

Objectives: SLAP tears and tendonitis disorders of the long head of the biceps tendon (LHBT) remain a challenge to treat in an active population. The purpose of this study is to prospectively compare the surgical outcomes of a primary biceps tenodesis for SLAP tears and biceps tenosynovitis in a young active population. Methods: Over a 6-year period, 125 patients with mean age of 42.6 (range, 26.3 to 56.5) with a diagnosis of LHBT were prospectively evaluated. Inclusion criteria included patients with a clinical diagnosis of a type II SLAP or anterior shoulder pain who failed conservative management and underwent a diagnostic shoulder arthroscopy. Patients were excluded for full-thickness rotator cuff tears, AC joint pathology, and labral pathology outside of the SLAP lesion. Patients with an arthroscopically confirmed labral tear or biceps tendonopathy underwent a mini-open subpectoral tenodesis with interference screw and were independently evaluated with patient reported outcome measurements (SANE, WORC), and a biceps position examination. Statistical analysis was via Student’s t-test and significance set at p <.05. Results: 101 of 125 patients (81%) completed the study requirements at a mean of 2.75 years (range 1.5 to 5.7 years). 50 Patients were diagnosed with SLAP II tears (40%) and 75 patients with biceps tendonitis (60%), 28 (22%) underwent a rotator cuff debridement for a concomitant low-grade partial rotator cuff tear and LHBT instability. There was a clinically and statistical improvement in patient outcomes scores: (WORC=54%, SANE=58) improved to (WORC=89%, SANE=89.5, p<0.01). 82% of patients returned to work and full activity at a mean of 4.1 months. The biceps muscle measured relative to the antecubital fossa of operative (mean 3.20 cm) versus non-operative (3.11 cm) was not clinically different (p=0.57), except in the 3 that failed tenodesis fixation. There was an 8% complication rate: 3 patients sustained failure of the LHBT tenodesis requiring revision; 2 superficial infections treated with antibiotics; and 3 transient musculoskeletal neruopraxias. Conclusion: A primary biceps tenodesis for pathology of the LHBT provides a clinical and statistically significant improvement in shoulder outcomes with a reliable and efficient return to previous activity level and low risk for surgical complications. However, additional work is necessary to define optimal primary treatment of LHB disorders.

Use of Intra-Articular and Intrabursal Pulsed Radiofrequency for the Treatment of Persistent Arthrogenic Shoulder Pain

Dear Editor: Shoulder pain is one of the most common types of joint pain, with an estimated lifetime prevalence of 67% among adults ⇓. Despite readily available treatments, chronic shoulder pain often results in substantial disability. Although the utility of pulsed radiofrequency (PRF) for relieving diarthrodial joint pain has been reported ⇓, no long-term follow-up has been documented, and only a single-needle technique has been used either intra-articularly or in subscapular areas of the shoulder. This article describes three cases with persistent arthrogenic shoulder pain for whom long-term pain relief was achieved with intrabursal PRF treatment delivered by a 20-gauge, 15-cm insulated needle with a 10-mm active tip at 42°C. Current delivery was at 500 KHz applied at 2 bursts/second, with each burst lasting 20 milliseconds for a total of 360 seconds. Case 1 was a 36-year-old Caucasian woman injured in a motor vehicle accident who complained of persistent severe burning and stabbing pain in the right shoulder that was exacerbated with any movement. Nonsteroidal anti-inflammatory drugs (NSAIDs) and oral narcotics temporarily relieved night pain. Additional treatment included 1 year of physical therapy and two intra-articular corticosteroid injections. One year following her injury, the patient reported a pain score of 8/10 on the visual analog scale (VAS) ⇓ at rest. After being diagnosed with rotator cuff tendinitis with partial thickness tearing and degenerative arthritis with acromioclavicular (AC) joint pain, the patient underwent right shoulder arthroscopy with subacromial decompression and open distal clavicle excision. Pain …