Hongyun Li

Is the Extended Release of the Inferior Glenohumeral Ligament Necessary for Frozen Shoulder

PURPOSE The aims of our study were to assess effects of the extent of capsular release and to define the benefit of additional release of the inferior glenohumeral ligament (IGHL) from inferior to posterior in frozen shoulder. METHODS Seventy-four consecutive patients with refractory frozen shoulder underwent arthroscopic capsular release and were divided into 2 groups randomly. The release of anterior capsular structures, including the anterior band of the IGHL, was performed in group 1. In group 2 the release extended inferiorly and posteriorly. Constant functional scores were used to assess the outcome. The range of motion (ROM) in various directions was also recorded preoperatively and postoperatively. RESULTS Follow-up was obtained in 41 patients in group 1 and 29 patients in group 2, and it averaged 28 months. At the last follow-up, there was a significant improvement in Constant score (P < .01) postoperatively in all patients. There was a significant and rapid reduction in the visual analog scale score in both groups postoperatively. No statistical difference in the visual analog scale score was found between the 2 groups at the corresponding time points. Overall, patients had restored shoulder ROM at the last follow-up without difference between group 1 and group 2. Abduction, flexion, external rotation at 90 degrees of abduction, internal rotation at 0 degrees of abduction, and internal rotation at 90 degrees of abduction recovered more rapidly in group 2 within 3 months after surgery; however, there was no significant difference in ROM after 6 months. CONCLUSIONS In this broad group of patients with recalcitrant adhesive capsulitis, the addition of the posterior capsular release did not improve patient function or ROM over anterior capsular release alone at 6 months. The extended release of the inferior and posterior IGHL would improve ROM more rapidly within the first 3 months postoperatively. LEVEL OF EVIDENCE Level I, therapeutic randomized controlled trial.

Arthroscopic Repair of Lateral Ankle Ligament Complex by Suture Anchor

PURPOSE Arthroscopic repair of the lateral ligament complex with suture anchors is increasingly used to treat chronic ankle instability (CAI). Our aims are (1) to analyze and evaluate the literature on arthroscopic suture anchor repair of the anterior talofibular ligament and (2) to conduct a systematic review of the clinical evidence on the reported outcomes and complications of treating CAI with this technique. METHODS We performed a systematic review of the literature using PubMed, Ovid, Elsevier ScienceDirect, Web of Science-Conference Proceedings Citation Index, and the Cochrane Database of Systematic Reviews from 1987 to September 2013. Clinical studies using the arthroscopic suture anchor technique to treat CAI were included. Outcome measures consisted of clinical assessment of postoperative ligament stability and complications. In addition, the methodologic quality of the included studies was assessed by use of the modified Coleman Methodology Score. RESULTS After reviewing 371 studies, we identified 6 studies (5 retrospective case series and 1 prospective case series, all Level IV) that met the inclusion criteria, with a mean Coleman Methodology Score of 71.8 ± 7.52 (range, 63 to 82). In these studies 178 patients (179 ankles) underwent arthroscopic suture anchor repair of the anterior talofibular ligament with a mean follow-up period of 38.9 months (range, 6 to 117.6 months). All patients were reported to have subjective improvement of their ankle instability, with complications in 31 cases. CONCLUSIONS Studies of arthroscopic suture anchor technique to treat CAI are sparse, with moderate mean methodologic quality. The included studies suggest that the arthroscopic technique is a feasible procedure to restore ankle stability; however, on the basis of our review, this technique seems to be associated with a relatively high complication rate. Extensive cadaveric studies, clinical trials, and comparative studies comparing arthroscopic and open repair should be performed in the future. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.

Delayed Early Passive Motion Is Harmless to Shoulder Rotator Cuff Healing in a Rabbit Model

Background: Postoperative passive motion is the most widely accepted rehabilitation protocol after rotator cuff repair; however, a rotator cuff retear remains a frequent surgical complication. Clinical outcomes indicate that early passive motion is harmless to rotator cuff healing, but no laboratory evidence supports this proposition. Hypotheses: (1) Immediate postoperative immobilization improves rotator cuff healing in rabbits. (2) Early passive motion after short-term immobilization does not harm rotator cuff healing in rabbits. Study Design: Controlled laboratory study. Methods: An injury to the supraspinatus tendon was created and repaired in 90 New Zealand White rabbits, after which they were randomly separated into 3 groups: (1) nonimmobilization (NI; n = 30), (2) continuous immobilization (IM; n = 30), and (3) immobilization with early passive motion (IP; n = 30). At 3, 6, and 12 weeks postoperatively, 5 rabbits from each group were sacrificed for histological evaluation, biomechanical testing, and magnetic resonance imaging. Results: The histological study demonstrated better postoperative healing in the IM and IP groups, with clusters of chondrocytes accumulated at the tendon-bone junction. Magnetic resonance imaging illustrated that the tendon-bone junction was intact in the IM and IP groups. The magnetic resonance quantification analysis showed that the signal-to-noise quotient (SNQ) of the NI group was not significantly higher than that of the immobilization groups at 3 weeks (P = .232) or 6 weeks (P = .117), but it was significantly different at 12 weeks (NI vs IM, P = .006; NI vs IP, P = .009). At 12 weeks, the failure load was significantly higher in the IM and IP groups than in the NI group (NI vs IM, P = .002; NI vs IP, P = .002), but no difference was found between the IM and IP groups (P = .599). Conclusion: Immediate postoperative immobilization led to better tendon-bone healing than immediate postoperative mobilization, and under immobilization, early passive motion was harmless to tendon-bone healing in this study. Clinical Relevance: The results have an implication in supporting the rehabilitation protocol of early passive motion after rotator cuff repair.

Difference in Postural Control Between Patients With Functional and Mechanical Ankle Instability

Background: Lateral ankle sprain is one of the most common injuries. Since the structural and pathological differences in mechanical ankle instability (MAI) and functional ankle instability (FAI) may not be the same, it may be better to treat these as separate groups. The purpose of this study was to compare the difference in postural sway between MAI and FAI in patients with chronic ankle instability (CAI). Methods: Twenty-six patients with CAI and 14 healthy control participants were included in the study. The CAI patients were subdivided into MAI (15 patients) and FAI (11 patients) groups. Patients who were diagnosed with lateral ankle ligaments rupture by magnetic resonance imaging and ultrasonography were assigned to the MAI group. All participants performed single-limb postural sway tests 3 times on each leg with eyes closed and open. The average distances from the mean center of pressure position in the mediolateral and anteroposterior directions were recorded and compared among the 3 groups. Results: The unstable ankles in the MAI group showed significantly greater postural sway in the anterior, posterior, and medial directions compared with those in the control group with eyes closed. With eyes open, significantly greater postural sway was found in the anterior direction. In the FAI group, no difference was found in postural sway compared with those in the control group. The MAI group showed significantly greater postural sway in the anterior direction compared with the FAI group with eyes closed and open. No significant difference in postural sway was found between the unstable and stable ankles in the MAI or FAI groups, with or without vision. Conclusions: Patients with MAI have deficits in postural control, especially in anterior-posterior directions. However, no difference was found in postural sway in patients with FAI compared with healthy people. Clinical Relevance: As MAI patients suffer from deficits in postural control, balance training should be applied in those patients. In addition, special training should also include the contralateral side after a unilateral ankle ligament injured.

Activity Level and Function 2 Years After Anterior Talofibular Ligament Repair: A Comparison Between Arthroscopic Repair and Open Repair Procedures:

Background: The open modified Broström anatomic repair technique is widely accepted as the reference standard for lateral ankle stabilization. Despite recent increases in publications regarding arthroscopic repair of the anterior talofibular ligament (ATFL) for treatment of chronic ankle instability, research is lacking that compares the functional outcomes between arthroscopic repair and open repair procedures for chronic ankle instability. Purpose: To compare function and activity level after arthroscopic repair versus open repair of the ATFL in patients with lateral ankle instability. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent arthroscopic or open surgical Broström repair of the ATFL between January 2012 and August 2014 were invited to participate in this study. All of the patients had consented for arthroscopic repair if feasible. In cases in which arthroscopic repair was impossible, the open modified Broström procedure was performed after arthroscopy. Patients accepted a systematic rehabilitation program postoperatively. American Orthopaedic Foot and Ankle Society (AOFAS) score, Karlsson Ankle Functional Score (KAFS), and Tegner activity score were used to evaluate ankle function preoperatively and at a minimum follow-up of 2 years. Magnetic resonance imaging (MRI) was performed to evaluate the signal to noise ratio (SNR) of the repaired ATFL. Results: A total of 60 patients were included in this study. They were assigned to 1 of 2 groups according to their surgical procedure: 23 patients underwent arthroscopic repair (arthroscopic group) and 37 patients underwent open repair (open group). No patient in either group had ankle instability at follow-up postoperatively. After surgery, the AOFAS score (P < .001), KAFS (P < .001), and Tegner activity score (P < .001) increased significantly in both groups. However, no significant difference was found in AOFAS score (93.3 ± 8.9 vs 92.4 ± 8.6; P = .7), KAFS (90.3 ± 12.5 vs 89.4 ± 10.6; P = .75), and Tegner score (5 ± 2 vs 5 ± 2; P = .61) between the arthroscopic group and the open group, respectively. As well, no significant difference was found in the mean SNR value of ATFL between the arthroscopic group and the open group (9.1 ± 2.7 vs 8.8 ± 2.3; P = .39, respectively). Conclusion: When compared with open lateral ankle repair, arthroscopic repair of lateral ankle ligament when feasible produced similarly favorable outcomes. Arthroscopic ATFL repair, as a minimally invasive technique, provided favorable outcomes.

Correlation Analysis of Potential Factors Influencing Graft Maturity After Anterior Cruciate Ligament Reconstruction

Background: Postoperatively, signal changes of the reconstructed anterior cruciate ligament (ACL) graft on magnetic resonance imaging (MRI) images commonly occurs, which may be a cause for concern. The signal intensity changes are usually expressed by signal/noise quotient (SNQ) value, representing graft maturity. To date, little is known about the factors influencing the SNQ value of the reconstructed ACL graft. Purpose: To evaluate ACL graft SNQ value and associated factors after ACL reconstruction. Study Design: Case series; Level of evidence, 4. Methods: Male patients who underwent ACL reconstruction using autograft or allograft tendon from September 2004 to September 2011 were randomly invited to take part in this investigation, including functional scores, physical examination, and MRI scan. The femoral side graft was fixed with Endobutton CL or Rigidfix pins, and the tibial side graft was fixed with a bio-intrafix. SNQ values of each graft were measured on MRI to represent graft maturity. Sagittal ACL angle, ACL–Blumensaat line angle, and medial and lateral posterior tibial slope (PTS) were measured using MRI 3-dimensional dual-echo steady-state images. Potential risk factors, including age, body mass index, postoperative time, Tegner activity scale (TAS), sagittal ACL angle, ACL–Blumensaat line angle, medial PTS, lateral PTS, and primary graft diameter, were tested for their association with the graft SNQ value by multivariate stepwise regression analysis. Results: A total of 104 male subjects (mean follow-up, 30.7 months) were examined, including 62 allograft and 42 autograft reconstructions. There was a significant association between graft SNQ and postoperative time (r = −0.431, P < .001), TAS (r = 0.295, P = .002), and ACL–Blumensaat line angle (r = −0.304, P = .002). Univariate regression analysis showed that TAS (β = 6.15, P < .001) positively correlated, postoperative time (β = −0.26, P < .001) negatively correlated, and ACL–Blumensaat line angle (β = −0.40, P = .038) negatively correlated with graft SNQ. Multivariate stepwise regression analysis showed that TAS, postoperative time, ACL–Blumensaat line angle, and age were significant independent factors associated with graft SNQ. Conclusion: The graft SNQ value had a significant positive correlation with physical activity level and a significant negative correlation with postoperative time in this study. Males with a shorter postoperative time and a higher physical activity level had higher graft signal intensity postoperatively.

MRI Identification of the Fibular and Talus Position in Patients with Mechanical Ankle Instability

Specific anatomic variations of the ankle mortise may be found in people with ankle instability. The purpose was to evaluate the fibular and talus position in subjects with mechanical ankle instability (MAI). In this study, MR images of 54 patients with MAI and 51 patients from the authors institution for reasons unrelated to ankle instability were reviewed. The position of the fibular in relation to the talus (axial malleolar index, AMI) and medial malleolus (intermalleolar index, IMI) were evaluated at the axial plane. Meanwhile, the rotation of the talus was measured and calculated using a new index, the Malleolar Talus Index (MTI), which is measured in relation to the medial malleolar. The results showed that the AMI in the MAI patients increased significantly when compared to that in the control group. However, there was no statistically significant difference in the IMI between instability and control groups. The MTI increased significantly in the MAI patients when compared to that in the control group. The conclusion was that the patients with MAI have more of an internally rotated talus than a variation of fibular position.