Dennis Liem

Magnetic resonance imaging of arthroscopic supraspinatus tendon repair.

BACKGROUND While a number of studies have documented the very good clinical results of arthroscopic rotator cuff repair, very few authors have specifically assessed cuff integrity, supraspinatus atrophy, and fatty infiltration and their influence on the clinical outcome. METHODS We evaluated fifty-three consecutive patients (average age, 60.9 years) who had undergone arthroscopic repair of an isolated supraspinatus tendon tear. After an average duration of follow-up of 26.4 months, all patients were evaluated clinically with use of the Constant score and underwent standardized magnetic resonance imaging at our institution. The preoperative and postoperative magnetic resonance images were evaluated by two independent observers who were blinded to the clinical outcome of the patient. Evaluation criteria were cuff integrity; atrophy of the supraspinatus; and fatty infiltration of the supraspinatus, infraspinatus, and subscapularis. These findings were correlated to the clinical outcome. RESULTS Regardless of the tendon integrity, every parameter of the Constant score was significantly improved after the repair. The overall average Constant score was improved from 53.5 to 83.4 points (p < 0.001). The retear rate in our series was 25% (thirteen of fifty-three). Patients who had a retear had significantly less abduction strength (p = 0.043) and a significantly lower total Constant score (p = 0.012) than those who had an intact repair. A higher degree of preoperative supraspinatus atrophy and Stage-2 fatty infiltration of the supraspinatus were positive predictors of a retear. Also, an older age was an important predictor of a retear (p = 0.011). Progression of structural changes in the rotator cuff was halted when the repair remained intact, but there was no significant reversal of fatty infiltration or muscle atrophy. When the repairs failed, there was significant progression of fatty infiltration and atrophy of the supraspinatus. CONCLUSIONS The clinical and structural results of arthroscopic repairs of isolated supraspinatus tears are equal to those reported following open repair. Fatty infiltration and muscle atrophy cannot be reversed by successful arthroscopic repair. Higher degrees of muscular atrophy and fatty infiltration preoperatively are associated with recurrence of the tear as well as progression of fatty infiltration and muscular atrophy and an inferior clinical result.

Injuries and Overuse Syndromes in Golf

Background Although golf is becoming more popular, there is a lack of reliable epidemiologic data on golf injuries and overuse syndromes, especially regarding their severity. Objective To perform an epidemiologic study of the variety of different musculoskeletal problems in professional and amateur golfers and to find associations of age, sex, physical stature (body mass index), warm-up routine, and playing level with the occurrence of reported injuries. Study Design Retrospective cohort study. Methods We analyzed the injury data from a total of 703 golfers who were randomly selected over two golfing seasons and interviewed with the use of a six-page questionnaire. Results Overall, 82.6% (N = 526) of reported injuries involved overuse and 17.4% (N = 111) were single trauma events. Professional golfers were injured more often, typically in the back, wrist, and shoulder. Amateurs reported many elbow, back, and shoulder injuries. Severity of reported injuries was minor in 51.5%, moderate in 26.8%, and major in 21.7% of cases. Carrying ones bag proved to be hazardous to the lower back, shoulder, and ankle. Warm-up routines were found to have a positive effect if they were at least 10 minutes long. Conclusions Overall, golf may be considered a rather benign activity, if overuse can be avoided. If not, golf can result in serious, chronic musculoskeletal problems.

Correlation of acromial morphology with impingement syndrome and rotator cuff tears

Background and purpose Indications for acromioplasty are based on clinical symptoms and are generally supported by typical changes in acromial morphology on standard radiographs. We evaluated 5 commonly used radiographic parameters of acromial morphology and assessed the association between different radiographic characteristics on the one hand and subacromial impingement or rotator cuff tears on the other. Patients and methods We measured acromial type (Bigliani), acromial slope (AS), acromial tilt (AT), lateral acromial angle (LAA), and acromion index (AI) on standard radiographs from 50 patients with full-thickness supraspinatus tendon tears, 50 patients with subacromial impingement, and 50 controls without subacromial pathology. Results The acromial type according to Bigliani was not associated with any particular cuff lesion. A statistically significant difference between controls and impingement patients was found for AS. AT of controls was significantly smaller than that of impingement patients and cuff-tear patients. LAA of cuff-tear patients differed significantly from that of controls and impingement patients, but LAA of controls was not significantly different from that of impingement patients. Differences between impingement patients and cuff-tear patients were also significant. AI of controls was significantly lower than of impingement patients and of cuff-tear patients. A good correlation was found between acromial type and AS. Interpretation A low lateral acromial angle and a large lateral extension of the acromion were associated with a higher prevalence of impingement and rotator cuff tears. An extremely hooked anterior acromion with a slope of more than 43° and an LAA of less than 70° only occurred in patients with rotator cuff tears.

Arthroscopic debridement of massive irreparable rotator cuff tears.

PURPOSE The purpose of this study was to evaluate clinical and radiologic results of arthroscopic debridement of massive irreparable rotator cuff tears. METHODS Thirty-one patients (mean age, 70.6 years) were retrospectively reviewed for a mean of 47 months (range, 24 to 69 months) after arthroscopic debridement of an irreparable rotator cuff tear. Operative treatment included biceps tenotomy in 24 cases (77.4%). No acromioplasty was performed to maintain the coracoacromial arch. Clinical outcome was assessed by use of the American Shoulder and Elbow Surgeons (ASES) and Constant scores, as well as measurement of abduction strength and elbow flexion strength compared with the contralateral side at final follow-up. Preoperative and follow-up radiographs were evaluated for acromiohumeral distance and grade of osteoarthritis according to the Samilson-Prieto classification. RESULTS The mean ASES score was significantly improved from 24.0 to 69.8 points at follow-up. Scores for pain were reduced from 7.8 to 2.9 points on a visual analog scale ranging from 0 to 10 points. The age- and gender-adjusted Constant score was 72.2%. Radiologic analysis showed progression of osteoarthritis in 10 cases (32.3%); this had no influence on the ASES score. Acromiohumeral distance decreased from 8.3 to 7.0 mm. Biceps strength was 6.1 kg on the operated side and 6.3 kg on the contralateral side. Abduction strength was significantly lower on the operated side at 2.6 kg versus 3.7 kg on the contralateral side. No complication related to the procedure was reported. CONCLUSIONS For elderly patients with low functional demands, arthroscopic debridement in combination with biceps tenotomy is a safe procedure and leads to significant functional improvement without loss of biceps strength. Progression of osteoarthritic changes cannot be prevented, but no influence on the clinical result could be shown. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Calcifying Tendinitis of the Shoulder: Midterm Results After Arthroscopic Treatment

Background: Calcifying tendinitis is a common and painful disorder of the shoulder characterized by the presence of calcific deposits in the tendons of the rotator cuff. When nonoperative treatment over a prolonged period of time fails, surgical treatment should be considered. Midterm success rates are inconsistent, and the role of subacromial decompression is still unclear. Hypothesis: Our hypotheses were that the rate of supraspinatus tears after arthroscopic treatment of calcifying tendinitis is comparable with that in the contralateral uninvolved shoulder and that subacromial decompression does not have beneficial effects compared with calcium removal alone. Study Design: Case series; Level of evidence, 4. Methods: In 70 shoulders of 62 patients with a mean age of 54 years, arthroscopic removal of calcium deposits of the supraspinatus tendon was performed. In 44 shoulders, additional subacromial decompression was performed. After a mean follow-up of 6 years (range, 2-13 years), patients were clinically investigated, and function was statistically evaluated using Constant and American Shoulder and Elbow Surgeons (ASES) scores. Affected and contralateral shoulders were examined by ultrasound in 48 shoulders, and rotator cuff tears were documented. Results: The mean Constant scores of the operated shoulders were significantly lower than those of the healthy shoulders (P < .001). The ASES scores significantly (P < .001) increased after surgery but were still lower than the ASES scores of the healthy shoulders (P < .001). Concerning the additional subacromial decompression, there were no significant differences in the overall ASES and Constant scores; the subitem “pain” was significantly better in the subacromial decompression group (P = .048). Ultrasound examination at last follow-up (48 shoulders) showed a partial supraspinatus tendon tear in 11 operated and 3 contralateral shoulders. Conclusion: Although the good clinical results after arthroscopic treatment of calcifying tendinitis of the shoulder persist midterm, the affected shoulders present significantly lower clinical scores than healthy shoulders. The rate of partial supraspinatus tendon tears seems to be higher after calcium removal. Additional subacromial decompression seems to reduce postoperative pain.

Arthroscopic Rotator Cuff Repair in Overhead-throwing Athletes

Background When overhead-throwing athletes suffer from a rotator cuff tear, their ability to perform sporting activities is significantly impaired. Hypothesis Arthroscopic rotator cuff repair allows amateur overhead-throwing athletes to return to their preoperative level of overhead-throwing sports. Study Design Cohort study; Level of evidence, 3. Methods Twenty-one overhead-throwing athletes (14 male and 7 female; average age, 58.9 years, range, 46-69 years) were reviewed for clinical outcome with the Constant Score and structural integrity of the repair on magnetic resonance imaging. The average follow-up was 25.7 months (24-29 months). Athletes were asked to retrospectively assess their sporting activity for pain, strength, endurance, and range of motion before onset of symptoms, preoperatively and at follow-up. They also were asked to evaluate their overall performance as a percentage of their original performance (0% to 100%). Retear rates and Constant Scores were compared with those of 32 patients who were not overhead-throwing athletes and who were operated on during the same time span. Results Patients significantly improved their Constant Score from 54.9 to 84.2 (P < .001). Sporting activity was not significantly influenced by repair integrity; the retear rate was 23.8% (5/21). There was no significant difference for retear rate (25%; 8/32) or clinical outcome (Constant Score 84.5, P = .993) compared with patients who were not involved in overhead-throwing sports or any sports. All patients returned to their overhead-throwing sport an average of 6.3 months (3-12 months) after the surgery. Participation (2.1 per week) and duration (2.3 hours) of overhead-throwing activity postoperatively were not significantly lower than before the Patient was injured (2.2 per week, P = .290; and 2.4 hours, P = .285). Patients estimated their overall activity level to be 91.9% of their original, noninjured condition, which was significantly improved from the preoperative condition of 34.8% (P < .001). Conclusion Arthroscopic rotator cuff repair led to good clinical results in this group of overhead-throwing athletes. Patients were able to return to overhead-throwing sports, most of them at the same preoperative level.

Long–term Results of Arthroscopic Bankart Repair with a Bioabsorbable Tack:

Background Short-term to midterm data are available on arthroscopic shoulder stabilization using bioabsorbable tacks or suture anchors. It remains unknown whether these techniques can equal the success of open Bankart repair in the long term. Purpose To assess the long-term outcome of arthroscopic Bankart repair using bioabsorbable tacks in patients with traumatic anterior shoulder instability with a minimum follow-up of 7 years. Study Design Case series; Level of evidence, 4. Methods Treatment outcomes were determined prospectively according to the Rowe score and retrospectively according to the Constant and American Shoulder and Elbow Surgeons scores. Included in this study were 18 consecutive patients with a mean age of 26.8 years (range, 16-62 years) who underwent arthroscopic Bankart repair using bioabsorbable tacks for traumatic anterior shoulder instability. The study group consisted of 14 male and 4 female patients. The mean follow-up was 8.7 years (range, 7.0-9.8 years). Results One patient had recurrent dislocations requiring further surgery, for an overall failure rate of 5.6%. An additional patient had 1 traumatic subluxation episode within the first postoperative year that did not recur. According to the Rowe score, which increased to 90.3 (17.8) from 32.8 (8.3) points preoperatively, 15 patients (83.3%) achieved a good or excellent result. The mean Constant score was 91.3 (SD, 6.9) points, and the mean American Shoulder and Elbow Surgeons score was 92.1 (SD, 6.9) points postoperatively. A return to the preinjury level of sports competition was reported by 64% of patients. No signs of synovitis occurred in any patient postoperatively. Conclusion Arthroscopic Bankart repair for the treatment of recurrent traumatic anterior shoulder instability repair using bioabsorbable tacks offers reliable results with respect to failure rate, range of motion, and shoulder function during a minimum follow- up of 7.0 years. In contrast to previous reports on arthroscopic Bankart repair, results did not deteriorate during follow-up.

The Prevalence of Rotator Cuff Tears Is the Contralateral Shoulder at Risk

Background: Rotator cuff tears are a common cause of pain and disability of the shoulder. Information on the prevalence and identification of potential risk factors could help in early detection of rotator cuff tears and improve treatment outcome. Hypothesis: Patients treated for a symptomatic rotator cuff tear on one side have a higher prevalence of rotator cuff tears and decreased shoulder function on the contralateral side compared with an age- and sex-matched group of healthy individuals. Study Design: Case control study; Level of evidence, 3. Methods: One group consisted of 55 patients who had been arthroscopically treated on one shoulder for rotator cuff tear (tear group). In this group, the nonoperated contralateral shoulder was examined. For comparison, the matching shoulder in a control group consisting of 55 subjectively healthy individuals matched by age (±1 year) and sex to the tear group was included. Diagnosis of a rotator cuff tear was made by ultrasound. Outcomes were measured using the Constant score. Results: The prevalence of supraspinatus tears was significantly higher (P < .0001) in the tear group (67.3%) compared with the control group (11.0%). The Constant score for the activities of daily living subscale, however, was significantly lower (18.4) in the tear group compared with the control group (19.9; P = .012). No other subcategory score nor the overall score showed a significant difference. There was a significantly higher tear prevalence in the tear group of patients aged between 50 and 59 years (P < .001) and 60 and 69 years (P = .004). No tear was diagnosed in the control group in individuals younger than 60 years. Conclusion: Patients treated for partial and full-thickness rotator cuff tears have a significantly higher risk of having a tear on the contralateral side and have noticeable deficits in their shoulder function regarding activities of daily living even if the tear is otherwise asymptomatic.

Defect Characteristics of Reverse Hill-Sachs Lesions

Background: Little scientific evidence regarding reverse Hill-Sachs lesions (RHSLs) in posterior shoulder instability exists. Recently, standardized measurement methods of the size and localization were introduced, and the biomechanical effect of the extent and position of the defects on the risk of re-engagement was determined. Purpose: To analyze the characteristics and patterns of RHSLs in a large case series using standardized measurements and to interpret the results based on the newly available biomechanical findings. Study Design: Case series; Level of evidence, 4. Methods: In this multicenter study, 102 cases of RHSLs in 99 patients were collected from 7 different shoulder centers between 2004 and 2013. Patient- as well as injury-specific information was gathered, and defect characteristics in terms of the size, localization, and depth index were determined on computed tomography or magnetic resonance imaging scans by means of standardized measurements. Additionally, the position (gamma angle) of the posterior defect margin as a predictor of re-engagement was analyzed. Results: Three types of an RHSL were distinguished based on the pathogenesis and chronicity of the lesion: dislocation (D), locked dislocation (LD), and chronic locked dislocation (CLD). While the localization of the defects did not vary significantly between the subgroups (P = .072), their mean size differed signficantly (D: 32.6° ± 11.7°, LD: 49.4° ± 17.2°, CLD: 64.1° ± 20.7°; P < .001). The mean gamma angle as a predictor of re-engagement was similarly significantly different between groups (D: 83.8° ± 14.5°, LD: 96.5° ± 17.9°, CLD: 108.7° ± 18.4°; P < .001). The orientation of the posterior defect margin was consistently quite parallel to the humeral shaft axis, with a mean difference of 0.3° ± 8.1°. Conclusion: The distinction between the 3 different RHSL types based on the pathogenesis and chronicity of the defect helps identify defects prone to re-engagement. The gamma angle as a measurement of the position of the posterior defect margin and therefore a predictor of re-engagement varies significantly between the defect types.

The Influence of Arthroscopic Subscapularis Tendon and Capsule Release on Internal Rotation Strength in Treatment of Frozen Shoulder

Background Arthroscopic release of the capsule is a popular treatment option for chronic refractory frozen shoulder. Additional release of the intra-articular part of the subscapularis is controversial regarding possible impairment of subscapularis function. Hypothesis Arthroscopic release of the intra-articular part of the subscapularis produces good clinical results and does not lead to reduced internal rotation strength. Study Design Case series; Level of evidence, 4. Methods Twenty-two patients were retrospectively evaluated 53 months (range, 12–106) after undergoing arthroscopic anterior capsular release, including release of the intra-articular portion of the subscapularis. Clinical outcome was evaluated using the American Shoulder and Elbow Surgeons score and the Constant score. Isometric and isokinetic strength for internal and external rotation were determined at the time of follow-up in both shoulders using a Cybex dynamometer. Results The Constant score was improved significantly from 17.7 points to 82.8 points (P < .0001) and the American Shoulder and Elbow Surgeons score increased significantly from 23.5 points to 76.8 points (P < .0001). The mean range of motion was significantly improved for external rotation from 16° to 58°, from 66° to 142° for abduction, and from 76° to 155° for forward flexion. Isometric and isokinetic strength in the standard abduction position of the Cybex dynamometer showed no significant side-to-side difference. Conclusion Arthroscopic capsular release combined with a release of the intra-articular portion of the subscapularis tendon revealed good clinical results in the arthroscopic treatment of adhesive capsulitis without significant loss of internal rotation strength.