Gregory J. Adamson

Ten-year assessment of primary rotator cuff repairs

A review of 30 patients who underwent a primary repair of their rotator cuff 10 years previously was performed. The average age of the patients at the time the operation was performed was 51 years (range 20 to 65 years). Twenty-seven men and three women were reviewed. An acromioplasty was performed in all patients. No patient had a distal clavicle excision. There were 12 small, 11 medium, five large, and two massive tears. A significant decrease in pain after surgery and a return to preinjury activities occurred in 82% of the patients. Subjective results were excellent or good in 70% of the patients. Good or excellent results were achieved in 80% of the 25 patients with objective data. In the overall results (subjective and objective), 64% of the patients had a good or excellent outcome. By Neers criteria, 72% satisfactory results were achieved. No significant prognostic indicators were identified in this study, although a trend toward better results occurred in patients less than 55 years old and in those patients with smallor medium-sized tears. The findings of this study confirm the view that the results of rotator cuff repairs do not deteriorate, with follow-up extending to 10 years.

Comparison of Preseason, Midseason, and Postseason Neurocognitive Scores in Uninjured Collegiate Football Players

Background College football players sustain an average of 3 subconcussive blows to the head per game. Concussions correlate with decreases in standardized neurocognitive test scores. It is not known whether repetitive, subconcussive microtrauma associated with participation in a full season of collision sport affects neurocognitive test scores. Hypothesis No difference exists between preseason, midseason, and postseason Standardized Assessment of Concussion (SAC) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores when collegiate football players sustain subconcussive microtrauma from forceful, repetitive contact activity. Study Design Case series; Level of evidence, 4. Methods Fifty-eight members of a Division III collegiate football team who had no known concussion during the season voluntarily completed the SAC and ImPACT instruments preseason, midseason, and postseason. A repeated measures analysis of variance was used to compare the scores at the 3 time intervals (P < .05). Results No statistically significant decreases were found in overall SAC or ImPACT scores or in any of the domains or composites of the tests (P < .05) when preseason, midseason, and postseason scores were evaluated. Conclusions ImPACT and SAC neurocognitive test scores are not significantly altered by a season of repetitive contact in collegiate football athletes who have not sustained a concussion. Clinical Relevance A diminution in SAC or ImPACT scores in concert with clinical symptoms and findings should be interpreted as evidence of a postconcussive event.

Relative contribution of acromioclavicular joint capsule and coracoclavicular ligaments to acromioclavicular stability

HYPOTHESIS We hypothesized that both the AC joint capsule and CC ligaments are biomechanically robust structures in the anterior-posterior (AP) and superior-inferior (SI) planes with low loads, and that these ligaments provide essential function in AC joint stability. MATERIALS AND METHODS Anterior-posterior (AP) and superior-inferior (SI) AC joint translations were quantified in 6 cadaver matched pairs with AC joint compressions of 10N, 20N and 30N, and with translational loads of 10N and 15N. Either the AC joint capsule or CC ligaments were transected, and measurements were then repeated. Biomechanical characteristics of the remaining AC joint capsule or CC ligaments were compared. RESULTS There were significant increases in AP translation with the cut AC joint capsule, and significant increases in SI translation with the cut CC ligaments (P < 0.0001). Compression significantly decreased translation (P < 0.0001). DISCUSSION Our study is supported by, and further develops, recent studies and anatomical knowledge. It offers two interpreted pieces of information for the sports medicine physician to consider for reconstruction of the AC joint. First, resection of the distal clavicle may have a detrimental effect. Second, repair of the AC joint capsule, in addition to the customarily repaired CC ligaments, appears to have a beneficial effect. CONCLUSION The AC joint capsule is a robust anatomical structure that contributes significantly to the AC joint stability, especially in the AP plane. Compression increases stability. LEVEL OF EVIDENCE Basic science study.

Biomechanical comparison of a modified Weaver-Dunn and a free-tissue graft reconstruction of the acromioclavicular joint complex.

Background: Most surgical reconstructions of the separated acromioclavicular joint do not address the injured ligaments and capsule of the acromioclavicular joint. Purpose: This study was undertaken to compare the biomechanical characteristics of a modified Weaver-Dunn reconstruction and an intramedullary acromioclavicular joint reconstruction that uses a free-tissue graft for reconstruction of both the coracoclavicular and acromioclavicular ligaments. Study Design: Controlled laboratory study. Methods: Each pair of 6 matched pairs of cadaveric shoulders was randomly selected for a modified Weaver-Dunn reconstruction on 1 side and the contralateral side was used for free-tissue graft reconstruction of the coracoclavicular and acromioclavicular ligamentous complexes. Anterior-posterior and superior-inferior acromioclavicular joint translation (in millimeters) was measured with acromioclavicular joint compressions of 10, 20, and 30 N, and with translational loads of 10 and 15 N both before and after acromioclavicular joint reconstruction. Load-to-failure testing was then performed for each construct. Repeated-measures analysis of variance (translational testing) and Wilcoxon signed rank test (load-to-failure testing), both with P = .05, were used for statistical analysis. Results: Mean anterior-posterior and superior-inferior translation of the intramedullary acromioclavicular joint reconstruction was significantly less than that of the modified Weaver-Dunn under all loading conditions (P < .001 and P = .001, respectively), but was not significantly different from that of the intact state (P = .656 and P = .173, respectively). Although the mean ultimate and yield loads and linear stiffness for the intramedullary acromioclavicular reconstruction were greater than that of the modified Weaver-Dunn reconstruction, this did not reach statistical significance (P = .625, P = .625, and P = .625, respectively). Conclusion: Acromioclavicular joint reconstruction with free-tissue graft for both the coracoclavicular and acromioclavicular ligamentous complexes demonstrates initial stability significantly better than a modified Weaver-Dunn and similar to that of intact specimens. Clinical Relevance: This acromioclavicular joint reconstruction provides the surgeon with a relatively nondestructive option.

A prospective randomized study comparing a forearm strap brace versus a wrist splint for the treatment of lateral epicondylitis

BACKGROUND The outcome is unknown for 2 common bracing treatments utilized for patients with lateral epicondylitis. The purpose of this study was to compare the clinical outcomes of a wrist splint with that of a counterforce forearm strap for the management of acute lateral epicondylitis. MATERIALS AND METHODS Forty-two patients (44 elbows) received either a wrist extension splint (Group I-24 elbows) or a counterforce forearm strap (Group II-20 elbows). Measures on the Mayo Elbow Performance (MEP) and American Shoulder and Elbow Society (ASES) Elbow Assessment Form were collected prior to treatment and at 6 weeks. A total score was derived, utilizing the ASES Elbow Assessment, as was a score utilizing the standard scoring system for the MEP. RESULTS Group Is score derived from the ASES form improved 16 points and Group IIs score improved 13 points. Group Is score on the MEP improved 13 points and Group IIs score improved 12 points. There was no significant difference measured between the Groups with the ASES (P = .60) nor MEP (P = .63) scores. However, within the ASES derived score, pain relief was significantly better with the extension splint group (P = .027). No other variables were statistically significantly different. DISCUSSION Significant pain relief with the wrist extension splint may be due to improved immobilization of the wrist extensor muscles in a resting position. CONCLUSION The wrist extension splint allows a greater degree of pain relief than does the forearm strap brace for patients with lateral epicondylitis.

Biomechanical Comparison of Traditional and Locked Suture Configurations for Arthroscopic Repairs of the Rotator Cuff

Background The optimal suture configuration for arthroscopic rotator cuff repairs is controversial. “Locked” suture configurations, which use a combination of simple and transverse suture loops, have demonstrated better fixation strength than have traditional simple and horizontal mattress techniques. Purpose To compare traditional arthroscopic suture configurations to locked arthroscopic configurations in ability to resist gap formation under cyclic loading. Study Design Controlled laboratory study. Methods Crescent-shaped defects were created at the infraspinatus tendon insertion in 32 bovine shoulders. Four arthroscopic suture configurations were tested (8 specimens in each group): simple (group 1), horizontal mattress (group 2), locked mattress (group 3), and locked inverted mattress (group 4). A metal corkscrew suture anchor doubly loaded with No. 2 Fiberwire suture was used for the repairs. A cyclic loading protocol with application of forces from 10 to 180 N for a maximum of 2500 cycles was used. The number of cycles required to form gaps of 5 mm and 10 mm was recorded. Results The locked mattress configuration (group 3) outperformed all other groups in resisting 5-mm gap formation (P <. 0001), requiring a mean of 628 cycles in comparison to 65, 193, and 197 cycles for groups 1, 2, and 4, respectively. Both locked configurations (groups 3 and 4) were superior to traditional simple and horizontal mattress configurations in resisting 10-mm gap formation. Conclusion The locked mattress suturing technique (group 3) provided the most secure tendon fixation of all arthroscopic configurations tested. Clinical Relevance The use of locked suture configurations for arthroscopic rotator cuff repairs may enhance tendon fixation and limit gap formation in the early postoperative period.

Biomechanical Evaluation of the Acromioclavicular Capsular Ligaments and Reconstruction With an Intramedullary Free Tissue Graft

Background Multiple techniques have been reported to treat chronic acromioclavicular joint injuries. However, many have failed to restore native stability, and few have addressed reconstructing the acromioclavicular ligaments. Hypothesis An intramedullary free semitendinosus graft reconstruction of the acromioclavicular ligaments will demonstrate joint stability comparable with that of the intact acromioclavicular joint. Study Design Controlled laboratory study. Methods Six matched pairs of cadaveric specimens with only the acromioclavicular capsule/ligament intact were tested at 10 N and 15 N in the anteroposterior and superoinferior directions under acromioclavicular joint compression loads of 10 N, 20 N, and 30 N. One of each pair randomly underwent reconstruction of the acromioclavicular ligaments with an intramedullary free semitendinosus graft, and the translational testing was repeated. Both the intact and reconstructed specimens then underwent load-to-failure testing via superior clavicle distraction at a rate of 50 mm/min. Results The reconstructed specimens reproduced the stability of the intact specimens during all translational and joint compression load trials. Progressively decreased translation was observed for the reconstructed specimens that reached statistical significance (P < .05) in the anteroposterior direction at 10 N of joint compression under 10-N and 15-N translation loads and in the superoinferior direction at 10 N of joint compression and 10-N translational load. With regard to load-to-failure testing, the reconstructed specimens demonstrated significantly lower (P < .05) values for linear stiffness, yield load, ultimate load, and energy absorbed, ranging from 40% to 48% of the values for the intact specimens. Conclusion Intramedullary free semitendinosus graft reconstruction of the acromioclavicular ligaments reproduced anteroposterior and superoinferior translational stability and partially reproduced load-to-failure characteristics. Clinical Relevance When surgical intervention after higher grade acromioclavicular joint injuries is required, reconstruction of the acromioclavicular ligaments with an intramedullary free semitendinosus graft, in addition to reconstructing the coracoclavicular ligaments, may result in improved stability of the joint complex, improved maintenance of joint reduction, and increased patient satisfaction.

Arthroscopically Assisted Medial Reefing Without Routine Lateral Release for Patellar Instability

Background Patellofemoral instability in patients with normal alignment has been effectively treated with medial reefing procedures and a lateral release. Recent research suggests that a lateral release may not be necessary in patients without excessive patellar tilt. Hypothesis Arthroscopically assisted medial reefing without lateral release is as effective as techniques with a lateral release reported in the literature. Study Design Case series; Level of evidence, 4. Methods Twenty-four patients (25 knees) were observed for an average of 60 months. Preoperatively, patients underwent a history, physical examination, and radiographic evaluation. At follow-up, a physical examination and radiographic evaluation were repeated. Preoperative and postoperative Lysholm and Tegner scores were calculated. A subjective questionnaire was also completed. Comparative statistics were used for the preoperative and postoperative scores (P < .05). Results Ninety-six percent (24/25) were satisfied with their results, and all patients would have the same procedure performed again. Subjective symptom scores improved significantly. Lysholm knee scores improved from an average of 54 to 91 (P < .001). Tegner activity level improved from an average of 3.3 to 6.2 (P < .001). Significant improvement was seen in patellar mobility, apprehension, and patellofemoral tenderness with compression. Range of motion, muscle atrophy, and tilt did not change significantly. Congruence angles improved from 4.4° to —2.5° (P = .009), lateral patellofemoral angles improved from 5.5° to 8.7° (P = .011), and lateral patellar displacement improved from 2.0 to 0.2 mm (P < .044). There were no recurrent dislocations or subluxations. Conclusion Arthroscopically assisted medial reefing, without lateral release, is an effective treatment for patients with recurrent patellofemoral instability and normal alignment.

Intramedullary Acromioclavicular Ligament Reconstruction Strengthens Isolated Coracoclavicular Ligament Reconstruction in Acromioclavicular Dislocations

Background Techniques for reconstruction of the dislocated acromioclavicular (AC) joint abound. Most, however, do not address the injured AC ligaments and capsule. Evidence exists supporting the horizontal stabilizing effect of these ligaments on the AC joint. A novel AC and coracoclavicular (CC) reconstruction technique with an intramedullary free-tissue graft secured by suture buttons is low-profile, technically straightforward, and reproducible. Hypothesis A novel intramedullary AC reconstruction will strengthen an isolated free-tissue reconstruction of the CC ligaments. Study Design Controlled laboratory study. Methods Six cadaveric matched pair shoulders were tested with a custom testing system. Anterior-posterior and superior-inferior AC joint displacements (mm) were measured with AC joint compressions of 10 N, 20 N, and 30 N, and with translational loads of 10 N and 15 N. The same measurements were made after performing either a free-tissue tendon allograft CC reconstruction, or a free-tissue graft reconstruction of the CC and AC ligamentous complexes in the corresponding contralateral matched shoulder. The AC ligamentous complex was reconstructed with an intramedullary free-tissue graft secured by suture buttons. Load-to-failure testing was then performed on each construct. A paired t test was used for statistical analysis (P < .05). Results Mean anterior-posterior translation of the reconstruction of the CC and AC ligamentous complexes was 50% or less than that of the CC reconstruction in all loading conditions (P < .05). Mean superior-inferior translation did not differ among the groups. Overall load-to-failure testing did not differ between groups. Conclusion Intramedullary AC complex reconstruction utilizing free-tissue graft for reconstruction of both the CC and AC ligaments demonstrates significantly greater initial horizontal stability than a free tissue isolated CC reconstruction and is similar to intact specimens. Clinical Relevance This novel intramedullary AC ligament reconstruction may be considered when seeking to improve horizontal stability in an anatomical CC ligament reconstruction.

Ulnar Collateral Ligament Reconstruction Using Bisuspensory Fixation A Biomechanical Comparison With the Docking Technique

Background: Many ulnar collateral ligament (UCL) reconstruction techniques have been created and biomechanically tested. Single-bundle reconstructions aim to re-create the important anterior bundle of the UCL. To date, no technique has utilized suspensory fixation on the ulnar and humeral sides to create a single-bundle reconstruction. Hypothesis: The bisuspensory technique will restore valgus laxity to its native state, with comparable load-to-failure characteristics to the docking technique. Study Design: Controlled laboratory study. Methods: Six matched pairs of fresh-frozen cadaveric elbows were randomized to undergo UCL reconstruction using either the docking technique or a novel single-bundle bisuspensory technique. Valgus laxity and rotation measurements were quantified using a MicroScribe 3DLX digitizer at various flexion angles for the native ligament, transected ligament, and 1 of the 2 tested reconstructed ligaments. Laxity testing was performed from maximum extension to 120° of flexion. Each reconstruction was then tested to failure, and the method of failure was recorded. Results: Valgus laxity was restored to the intact state at all degrees of elbow flexion for both the docking and bisuspensory techniques. In load-to-failure testing, there was no significant difference with regard to stiffness, ultimate torque, ultimate torque angle, energy absorbed, and applied moment to reach 10° of valgus. Yield torques for the bisuspensory and docking reconstructions were 18.7 ± 7.8 N·m and 18.6 ± 4.4 N·m, respectively (P = .95). The ultimate torque for the bisuspensory technique measured 26.5 ± 9.2 N·m and for the docking technique measured 25.1 ± 7.1 N·m (P = .78). Conclusion: The bisuspensory fixation technique, a reproducible single-bundle reconstruction, was able to restore valgus laxity to the native state, with similar load-to-failure characteristics as the docking technique. Clinical Relevance: This reconstruction technique could be considered in a clinical setting as a primary method of UCL reconstruction or as a backup fixation method should intraoperative complications occur.