Jeffrey E. Budoff

Current Concepts Review - Débridement of Partial-Thickness Tears of the Rotator Cuff without Acromioplasty. Long-Term Follow-up and Review of the Literature*

The rotator cuff, a musculotendinous unit that acts in combination with the deltoid to allow elevation of the shoulder, is a frequent source of pain and disability. In addition, the rotator cuff maintains the humeral head centered on the glenoid and opposes the superior translatory and shearing force of the deltoid by compressing the humeral head in the glenoid concavity as well as by imparting an inferiorly directed force vector to the proximal aspect of the humerus.nnThe term impingement syndrome has been used to describe symptoms related to the rotator cuff in the absence of a full-thickness tear of the cuff. The abnormality of the rotator cuff may range in severity from an acute strain or tendinitis to frank tearing. In all but the most acute situations, the lesion is one of chronic tendinopathy or angiofibroblastic hyperplasia rather than tendinitis. We recommend the use of the term tendinosis in lieu of the histologically inaccurate term tendinitis, since histopathological studies as well as analyses of cadaveric specimens have repeatedly shown that inflammatory cells are not part of the abnormality. Disorders of the rotator cuff may be due to an intrinsic factor, such as intrasubstance degenerative tearing or tendinosis caused by avascularity, aging, or overuse. Alternatively, they may be due to an extrinsic factor, such as outlet stenosis or glenohumeral instability19.nnThe most commonly performed procedure to treat symptoms of impingement in the absence of a full-thickness tear of the rotator cuff is acromioplasty. This treatment is based on the theory that primary abnormal acromial morphology (an extrinsic cause), popularized by Neer36 in 1972, is the initiating factor leading to dysfunction of the rotator cuff and eventual tearing. Therefore, subacromial decompression, which is now often performed arthroscopically, is done in an attempt to alter presumed aberrant acromial morphology, …

Internal impingement in the etiology of rotator cuff tendinosis revisited

PURPOSEnThe theory of internal impingement holds that, in overhead athletes, repeated contact between the undersurface of the rotator cuff and the posterosuperior glenoid rim leads to articular-sided partial-thickness rotator cuff tears and superior labral lesions. However, we have noted this same constellation of lesions in our general patient population. These recreational athletic patients do not routinely assume the position of extreme abduction and external rotation, and thus are unlikely to experience significant internal impingement forces. The goal of this study was to document the prevalence of superior labral lesions in patients being treated for partial-thickness undersurface rotator cuff tears.nnnTYPE OF STUDYnRetrospective case series.nnnMETHODSnWe retrospectively reviewed the records of 75 shoulders arthroscopically treated for partial-thickness articular-sided rotator cuff tears. With the exception of one professional tennis player, no patients were playing sports at a professional or major college level. No professional or collegiate throwing athletes were included. The prevalence of these lesions and their association with recreational athletics was noted.nnnRESULTSnWe found that 55 of 75 (73.3%) shoulders with articular-sided partial-thickness rotator cuff tears also had superior labral lesions. A statistically significant increased prevalence of superior labral lesions in the dominant shoulder was seen (P =.03). In addition, our patients who engaged in overhand throwing had significantly fewer superior labral lesions in the dominant shoulders than did nonthrowers (P =.017).nnnCONCLUSIONSnThe kissing lesions of undersurface rotator cuff tears and posterosuperior labral damage may be explained by mechanisms other than internal impingement.

The Origins of the Thenar and Hypothenar Muscles

This paper presents an anatomical study of the origins of the thenar and hypothenar muscles and postulates the causes of weakness and pillar pain following carpal tunnel release.

MRI study of the capitate, lunate, and lunate fossa with relevance to proximal row carpectomy.

PURPOSEnTo study the articular morphology (radius of curvature), (diameter, depth, circularity, and percent of circle) of the capitate, proximal lunate, and the lunate fossa of the distal radius using both magnetic resonance imaging (MRI) scans and plain radiographs. The correlation between plain radiographs and MRI scans for these measurements will also be assessed.nnnMETHODSnTwenty MRI scans and 17 sets of radiographs of asymptomatic volunteers were evaluated. Standardized surface landmarks were digitized and measured in both the sagittal and coronal planes. The parameters of interest were calculated from the digitized data using specialized software.nnnRESULTSnUsing MRI data, we determined the radius of curvature of the capitate to be only 37% +/- 10 of the lunate fossa of the distal radius on the coronal (anteroposterior) view and to be 57% +/- 10 on the sagittal (lateral) view. In both planes, the proximal lunate had a significantly larger diameter and radius of curvature than did the capitate. The ratio of the radius of curvature of the proximal capitate to the proximal lunate on the coronal projection ranged from .366 to .811, and on the sagittal projection the values ranged from .46 to .71. Plain radiographs were not sufficiently accurate to determine the radius of curvature ratio of the capitate to the lunate or to the lunate fossa of the distal radius on the coronal view based on a comparison with MRI data. Plain radiography did not correlate with MRI for most clinically relevant parameters.nnnCONCLUSIONSnThe articular morphology of the capitate does not closely correspond with that of the lunate fossa when compared with the proximal lunate articular surface. Based on observed variations in capitate morphology and the potential for associated alterations in joint contact forces after proximal row carpectomy, preoperative MRI may facilitate the selection of patients with more favorable capitate morphology.

Biomechanical Analysis of Medial Collateral Ligament Reconstruction Grafts of the Elbow

Background There are no biomechanical studies evaluating different tendon grafts for elbow medial collateral ligament reconstruction. Hypothesis Using a larger tendon for the graft will yield greater resistance to valgus load for medial collateral ligament docking technique reconstructions. The type of graft used for a medial collateral ligament docking technique reconstruction will have a significant effect on the resistance to valgus loads. Study Design Controlled laboratory study. Methods Cadaveric elbows from male donors were cyclically loaded to 3 and 5 mm elongation, both intact and after a docking technique medial collateral ligament reconstruction using palmaris longus, gracilis, semitendinosus, and patellar tendon grafts. Results There was no significant difference in load to 3 or 5 mm elongation, number of cycles to failure, or stiffness between any tendon graft studied. Every tendon graft reconstruction tested was significantly weaker and less stiff than was the native medial collateral ligament. Conclusion There appears to be no biomechanical advantage to be gained by using a larger tendon graft instead of a palmaris longus graft. Clinical Relevance The most readily available graft source with the lowest morbidity (often the palmaris longus tendon) should be used for medial collateral ligament reconstruction.

The reliability of the "Scratch test".

The “Scratch Test” uses a sharp scalpel to scrape areas of suspected tendinosis in the management of lateral and medial epicondylitis. As claimed in the literature, this tissue is friable and peels off, whereas normal tendon does not. The purpose of this study was to determine whether, or not, the “Scratch Test” is able to differentiate between tendinosis and more normal adjacent tendon. Nineteen specimens from patients treated for tendinosis about the elbow were examined histologically. Three groups of specimens were compared: (1) grossly abnormal tendon, (2) tendon that was scraped out using the “Scratch Test” and (3) tendon that remained behind following the “Scratch Test”. There was no significant histological difference between visibly degenerated tendon (group 1) and that which was scraped out using the “Scratch Test” (group 2). There was, however, a significant histological difference between both these groups and the more normal tendon tissue that the “Scratch Test” left behind (group 3).