James N. Gladstone

Fatty Infiltration and Atrophy of the Rotator Cuff Do Not Improve After Rotator Cuff Repair and Correlate With Poor Functional Outcome

Background The role of degenerative changes in rotator cuff musculature with respect to the functional outcomes of rotator cuff repair have only recently been recognized and are still not well understood. In addition, the reversibility of these changes with repair of the tendons is questionable. Hypothesis Poorer preoperative muscle quality negatively affects outcome, and a successful outcome (in terms of a healed repair) might demonstrate improvements in fatty infiltration and muscle atrophy. Study Design Cohort study; Level of evidence, 2. Methods Thirty-eight patients (mean age, 62 years) were prospectively evaluated with preoperative and 1-year postoperative clinical examination and appropriate magnetic resonance image sequencing to determine grades of muscle atrophy and fatty infiltration of the supraspinatus and infraspinatus muscles. American Shoulder and Elbow Society (ASES), Constant, and pain scores were determined as well as strength measurements. The retear rate and progression of muscle degeneration were also evaluated. Independent predictors of outcome measurements and cuff integrity were determined. Results The overall clinical outcome, including ASES, Constant, and pain scores, improved significantly (P < .0001). Strength in forward elevation improved significantly (P < .006), while external rotation strength did not. There was a strongly negative correlation between muscle quality and outcome results in most cases. When the results were adjusted for multivariate effect, muscle atrophy and fatty infiltration of the infraspinatus muscle were the only independent predictors of ASES and Constant scores (P < .03). Tear size and rotator cuff healing did not play an independent role. Tear size, however, was the only independent predictor of ultimate cuff integrity (P = .002). Both atrophy and fatty infiltration progressed significantly over the course of the study. In cases in which the tendon had re-torn, the progression was found to be more significant than when the repair proved successful (P < .003). Conclusion Muscle atrophy and fatty infiltration of the rotator cuff muscles, particularly of the infraspinatus, play a significant role in determining functional outcome after cuff repair. Tear size appears to have the most influential effect on repair integrity. A successful repair did not lead to improvement or reversal of muscle degeneration and a failed repair resulted in significantly more progression. In general, healed repairs demonstrated minimal progression. These findings suggest that repairs should be performed, if possible, before more significant deterioration in the cuff musculature in order to optimize outcomes, and that understanding the degree of muscle atrophy and fatty infiltration before surgery can help guide patient expectations.

Interscalene regional anesthesia for shoulder surgery

BACKGROUND Despite a trend toward the use of regional anesthesia for orthopaedic procedures, there has been resistance to the use of interscalene regional block for shoulder surgery because of concerns about failed blocks and potential complications. METHODS We retrospectively reviewed the cases of 568 consecutive patients who had shoulder surgery under interscalene regional block in a tertiary-care, university-based practice with an anesthesiology residency program. The blocks were performed by a group of anesthesiologists who were dedicated to the concept of regional anesthesia in their practice. Complete anesthetic and orthopaedic records were available for 547 patients. The surgical procedure, planned type of anesthesia, occurrence of block failure, and the presence of complications were noted. RESULTS Of the 547 patients, 295 underwent an arthroscopic procedure and 252 (including eighty who had an arthroplasty) underwent an open procedure. General anesthesia was the initial planned choice for sixty-nine patients because of the complexity or duration of the procedure, the anatomic location, or patient insistence. Thirty-four of the sixty-nine patients also received an interscalene regional block. Interscalene regional block alone was planned for 478 patients. A total of 462 patients (97%) had a successful block whereas sixteen required general anesthesia because the block was inadequate. The success of the block was independent of the type or length of the surgery. No patient had a seizure, pneumothorax, cardiac event, or other major complication. Twelve (2.3%) of the 512 patients who had a block had minor complications, which included sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. CONCLUSIONS Interscalene regional block provides effective anesthesia for most types of shoulder surgery, including arthroplasty and fracture fixation. When administered by an anesthesiologist committed to and skilled in the technique, the block has an excellent rate of success and is associated with a relatively low complication rate.

Graft selection in anterior cruciate ligament reconstruction

Selecting the appropriate graft for ACL reconstruction depends on numerous factors including surgeon philosophy and experience, tissue availability (affected by anatomical anomalies or prior injury or surgery), and patient activity level and desires. Although the patella tendon autograft has the widest experience in the literature, and is probably the most commonly used graft source, this must be tempered with the higher reported incidences of potential morbidity and pitfalls associated with its use. The hamstring tendons are gaining increasing popularity, mostly due to reduced harvest morbidity and improved soft tissue fixation techniques, and many recent studies in the literature report equal results to BTB ACL reconstruction with respect to functional outcome and patient satisfaction. On the other hand, many of these studies report higher degrees of instrument (KT-100) tested laxity for hamstring reconstruction, and some have reported lower returns to preinjury levels of activity. One question that remains to be addressed is how closely objectively measured laxity tests correlate with subjectively assessed outcomes and ability to return to high levels of competitive sports. Allograft use, which decreased in popularity during the 1990s, appears to be undergoing a resurgence, with better sterilization processes and new graft sources (tibialis tendons), leading to increased availability and improved fixation techniques. The benefits of decreased surgical morbidity and easier rehabilitation must be weighed against the potential for greater failure of biologic incorporation, infection, and possibly slower return to activities. In our practice, for high-demand individuals (those playing cutting, pivoting, or jumping sports and skiing) BTB tends to be the graft of choice. For lower demand or older individuals, hamstring reconstructions will be performed. Allograft tissue will be used in older individuals (generally over 45 years old), those with signs of arthritis (and compelling evidence of instability), or those individuals who understand the pros and cons of allograft use fully and do not want their own tissue used.

Continuous passive motion after arthroscopically assisted anterior cruciate ligament reconstruction: comparison of short-versus long-term use

The use of continuous passive motion (CPM) following anterior cruciate ligament (ACL) reconstruction has become common. The duration of use of CPM for maximal therapeutic benefit is not known. This study compared 4-day CPM use with 14-day CPM use following arthroscopic ACL reconstruction using a bone-patellar tendon-bone autograft prospectively in 20 patients. The patients were randomly allocated to the CPM 4-day group [6 h daily CPM for 4 days in hospital followed by intermittent passive motion (IPM) at home] or to the CPM 14-day group (6 h daily CPM for 14 days). The objective parameters measured were girth measurements at four lower limb locations for joint swelling and muscle atrophy; range of motion of the knee, measured goniometrically; and KT-1000 arthrometry measurements for joint laxity. The measurements were made prior to surgery, and on days 2, 7, 14, and 42, postoperatively. There were no statistically significant differences (p greater than 0.05) at 42 days postoperatively between groups in all parameters measured with the exception of KT-1000 laxity at 42 days.

Nonoperative treatment ofacromioclavicular joint injuries

Abstract Nonoperative treatment is generally the choice for Type I and II acromioclavicular (AC) joint injuries. The situation issomewhat more controversial when Type III AC dislocations are considered, particularly with respect to athletes and heavy laborers. A number of recent studies have supported conservative treatment in these groups. There is general consensus as to the need for surgical intervention for Type IV, V, and VI AC injuries. Integral to any form of management, nonoperative or operative, is a rehabilitation program that addresses range of motion, strength, and neuromuscular control. We describe our program, which is divided into four phases: (1) Pain control and immediate protected range of motion and isometric exercises; (2) strengthening exercises using isotonic contractions and proprioceptive neuromuscular facilitation (PNF) exercises; (3) Unrestricted functional participation with the goal of increasing strength, power, endurance, and neuromuscular control; and (4) return to activity with sport specific functional drills. An athlete is ready to return to competitive sports once the following criteria are met: full range of motion (ROM), no pain or tenderness, satisfactory clinical exam, and demonstration of adequate strength on isokinetic testing. The unique considerations in a throwing athlete with an AC injury are also addressed. The primary goal of the nonoperative treatment protocol is to return the athlete to full activities as quickly and as safely as possible.

Anatomy of the posterior rotator interval: implications for cuff mobilization.

Release of the posterior rotator interval between the supraspinatus and infraspinatus tendons may be necessary to obtain appropriate mobilization for an anatomic rotator cuff repair. Ten cadaver shoulders were dissected to expose the region between the infraspinatus and supraspinatus from the spinoglenoid notch to the greater tuberosity. Measurements were made from the spinoglenoid notch to the glenoid rim, the glenoid rim to the confluence of the supraspinatus and infraspinatus musculotendinous junction, and from the confluence of the tendons to the insertion on the humerus. The histologic features of the posterior rotator interval were examined. The posterior rotator interval is a clear structure, consisting of the glenohumeral capsule medially, which fuses with the supraspinatus and infraspinatus tendons laterally. The average length of the posterior rotator interval was 77.8 mm which includes the distance from the spinoglenoid notch to the glenoid rim (25 mm; standard deviation, 2.89 mm; range, 21–28 mm), from the glenoid to the tendon confluence (25 mm; standard deviation, 1.95 mm; range, 21–28 mm), and from the tendon confluence to insertion (28 mm; standard deviation, 2.36 mm; range, 24–31 mm). Release of the posterior rotator interval can be important to realign the supraspinatus tendon if it is retracted and scarred at its posterior edge.

Determination of radiographic guidelines for percutaneous fixation of proximal humerus fractures using a cadaveric model.

The humeral heads of whole body cadaveric shoulders underwent fluoroscopic evaluation with the head divided into three zones on both anteroposterior (AP) and axillary views creating nine zones. Five AP and three axillary fluoroscopic images in different rotational positions were assessed for pin penetration. All images were evaluated for pin penetration and the AP view was evaluated for lesser tuberosity location. Pins placed appropriately below the subchondral bone did not appear to penetrate the joint on any fluoroscopic image. Pins placed 2 mm beyond the articular surface were appropriately viewed exiting the head on most views (64%) but falsely appeared within the head on several others (36%). Pins perforating the posterior head were problematic for accurate detection on AP views (missed in 87%), but this was avoided by externally rotating the humerus to 60 degrees. Articular penetration cannot always be appreciated radiographically and special efforts are necessary to avoid this problem including the use of various rotational views as well as the use of appropriate landmarks for orientation such as the lesser tuberosity position.

Endoscopic anterior cruciate ligament reconstruction with patella tendon autograft.

The patella tendon is the most commonly used graft source for ACL reconstruction because of its biomechanical strength and stiffness, the availability of bone-to-bone healing on either end, and the ability to firmly secure the graft within the tunnels. Consistently good results have been reported in the literature, with expectations to return to all activities at pre-injury levels of performance. We outline our technique for endoscopic ACL reconstruction using a patella tendon autograft. The technique is divided into the critical stages of pre-operative assessment, graft harvest, notch preparation, tunnel placement, graft passage, graft fixation, and rehabilitation. Methods for avoiding pitfalls and overcoming mishaps are described.

Anterior cruciate ligament reconstruction

Over the past 20 years, the anterior cruciate ligament (ACL) has been studied as much as any orthopedic structure. A literature search through PubMed reveals almost 5000 articles published over the past two decades. Research in anatomy, biomechanics, epidemiology, graft sources, fixation methods, and clinical outcomes of the ACL and its reconstruction has led to an explosive understanding of this ligament, as well as the ability to consistently and predictably reconstruct it. ACL injuries were once considered to be careerending. These days, they are often a mere blip in an athlete’s career path, and surgical reconstruction commonly allows a return to preinjury levels of performance. Moreover, clearer understandings are evolving regarding how ACL injuries occur in noncontact situations and why women are significantly more predisposed to ACL ruptures; from this, techniques are being developed to precondition the knee to decrease the rate of injury. As with many orthopedic procedures, there is more than one way ‘‘to skin a cat’’ when it comes to ACL reconstruction. An understanding of the anatomy, adherence to sound biomechanical principles, and appropriate rehabilitation programs ensure good results—more so than the choice of a particular graft or fixation method. Also important is the increasing knowledge of the biomechanics of the ACL-deficient knee and the potential for long-term damage, or lack thereof, depending on activity level. This knowledge has helped the orthopedist and patient make better decisions regarding the ultimate need for ACL reconstruction. As surgical techniques (arthroscopic, in particular) improve, the ability to tackle increasingly complex problems evolves. Complex decisions regarding meniscal repair and transplantation and cartilage repair and regeneration are now commonplace, as are decisions regarding the need for osteotomies in arthritically unstable knees. Our mission in developing this two-part series on ACL reconstruction for the Orthopedic Clinics of North America was to compile all of this information into a definitive, up-to-date reference. Having reviewed all of the articles, we were most impressed with the depth and clarity the authors brought to their work. We are extremely grateful to our contributors, many of whom are groundbreakers in the science of ACL reconstruction, for their commitment of time and effort time taken away from their practices and families. In the procedure-related articles, we asked that the authors describe their surgical procedures in a way such that the reader would be able to reproduce the technique, complete with tips on avoiding pitfalls and pearls obtained through years of experience. In each case this request was followed to a fault. We are also indebted to Deb Dellapena of W.B. Saunders for her support, expertise, and gentle per-

The Influence of Incision Type on Patient Satisfaction After Plate Fixation of Clavicle Fractures

Background: Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons. Purpose: To compare patient satisfaction and subjective outcomes between patients with a longitudinal incision versus those with a necklace incision for the treatment of diaphyseal clavicle fractures. Study Design: Cohort study; Level of evidence, 3. Methods: Thirty-six patients with a diaphyseal clavicle fracture (Orthopaedic Trauma Association type 15-B) were treated by 1 of 7 orthopaedic surgeons. The intervention was ORIF with anatomic contoured plates. Patients were divided into a necklace incision group and a longitudinal incision group depending on the surgical approach used. Medical records were reviewed, and participants completed an online survey with questions related to pain, numbness, scar appearance, and satisfaction. Function was assessed using the American Shoulder and Elbow Surgeons score. Statistical significance was determined with P < .05. Results: There were 16 patients in the necklace incision group and 20 in the longitudinal incision group. Patients in the necklace incision group were significantly more satisfied with the appearance of their scars (P = .01), which correlated with overall satisfaction (P = .05). There were no differences in overall satisfaction, pain, numbness, or reoperation rates for hardware removal between the necklace (6%) and longitudinal groups (15%). Conclusion: Patients undergoing clavicle ORIF with a necklace incision are more satisfied with their scar appearance than those with a longitudinal incision. The overall satisfaction, rate of numbness, and plate removal were similar in both groups.