Jin Hwan Ahn

Treatment of Biceps Tendon Lesions in the Setting of Rotator Cuff Tears Prospective Cohort Study of Tenotomy Versus Tenodesis

Background: During rotator cuff repair, biceps tendon lesions are frequently encountered. However, there is still controversy about optimal treatment for these lesions. Purpose: To compare the results of tenotomy and suture anchor tenodesis prospectively. Study Design: Cohort study; Level of evidence, 2. Methods: From January 2006 to June 2007, 90 patients (age, >55 years) with a rotator cuff tear and biceps tendon lesion (tear more than 30%, subluxation or dislocation, or degenerative superior labrum anterior to posterior lesion type II) were evaluated prospectively. The first 45 patients treated consecutively underwent biceps tenodesis, and the next 45 underwent biceps tenotomy. Postoperatively, patient evaluations were conducted with a focus on (1) “Popeye” deformity, (2) arm cramping pain, and (3) elbow flexion powers (measured with a hand dynamometer). Overall shoulder function was assessed with the American Shoulder and Elbow Surgeons (ASES) score and the Constant score. Results: At final follow-up, 43 in the tenodesis and 41 in the tenotomy groups were available for evaluation. There was no difference between groups in demographic data such as age, sex, dominant arm, and the time from symptom to surgery and in preoperative ASES score, Constant score, and rotator cuff tear size. A Popeye deformity occurred in 4 (9%) in the tenodesis group and in 11 (27%) in the tenotomy group (P = .0360). Mild cramping pain was observed in 2 in the tenodesis group and 4 in the tenotomy group (P = .4274). Mean elbow flexor power ratio (vs the contralateral side) showed no difference between the 2 groups, with mean values of 0.92 ± 0.15 (tenodesis) and 0.94 ± 0.19 (tenotomy) (P = .7475). The ASES and Constant scores were improved from 38.9 ± 14.2 and 52.1 ± 21.3 to 84.7 ± 13.6 and 82.9 ± 13.5 in the tenodesis group (P < .0001) and from 35.2 ± 10.5 and 48.1 ± 21.3 to 79.6 ± 15.8 and 78.3 ± 14.1 in the tenotomy group (P < .0001), respectively. Conclusion: Suture anchor tenodesis of the long head of the biceps tendon appears to lead to less Popeye deformity than tenotomy. No other clinical variables showed a difference between the 2 modalities.

A pull out suture for transection of the posterior horn of the medial meniscus: using a posterior trans-septal portal.

A transection (root tear or complete radial tear) injury of the medial meniscus posterior horn is not rare in the oriental area and needs to be repaired to restore the hoop tension and to reduce the extruded meniscus, which leads to osteoarthritis of the knee. In cases with transection of the medial meniscus posterior horn, the meniscus can be repaired by a pull out suture technique. However, it is difficult to manipulate a suture hook and drill a tibial tunnel in the narrow medial joint space using the traditional anterior arthroscopic technique. This article describes a new pull out suture technique for transection of the medial meniscus posterior horn using a posterior trans-septal portal that provides a safe and wide field of vision. The handling of the suture hook and a guide may reduce the possibility of a chondral or meniscal injury.

Diagnosis of Internal Derangement of the Knee at 3.0-T MR Imaging: 3D Isotropic Intermediate-weighted versus 2D Sequences

PURPOSE To compare three-dimensional (3D) isotropic fast spin-echo (SE) intermediate-weighted magnetic resonance (MR) imaging with two-dimensional (2D) fast SE MR imaging-both performed at 3.0 T-for performance in the diagnosis of internal derangements of the knee. MATERIALS AND METHODS The institutional review board approved this HIPAA-compliant study, and the requirement for informed consent was waived. The authors retrospectively reviewed 87 knee MR images obtained in 85 patients who had undergone both 3D isotropic and 2D MR examinations of the knee at 3.0 T and subsequent arthroscopic surgery. The 2D MR images included intermediate-weighted coronal and sagittal images, intermediate-weighted axial images with fat saturation, and T2-weighted sagittal images. The 3D isotropic MR images were obtained with multiplanar reformation (MPR), a fast SE intermediate-weighted sequence, and a reconstruction voxel size of 0.5 x 0.5 x 0.5 mm. Two radiologists retrospectively and independently evaluated the 2D and 3D data sets, at different sessions, for the presence of medial meniscus (MM), lateral meniscus (LM), anterior cruciate ligament (ACL), and posterior cruciate ligament (PCL) tears. These interpretations were compared with the arthroscopic surgery findings. The statistical differences between the sensitivities, specificities, and accuracies of the two methods were determined at McNemar testing, with surgical findings serving as the reference standard. Interobserver agreement was calculated by using kappa coefficients. RESULTS For both reviewers, the sensitivity, specificity, and accuracy of both MR techniques were higher than 95% for the diagnosis of ACL and PCL tears, higher than 85% for the diagnosis of MM tears, and higher than 80% for the diagnosis of LM tears. There were no significant differences in sensitivity, specificity, or accuracy between the two methods. Interobserver agreement for evaluation of all lesions was excellent and ranged from 0.81 (LM tears evaluated with 3D and 2D sequences) to 0.93 (ACL tears evaluated with 3D and 2D sequences, PCL tears evaluated with 2D sequence, and MM tears evaluated with 3D sequence). CONCLUSION The performance of 3D isotropic fast SE intermediate-weighted MR imaging with MPR was not significantly different from that of 2D MR imaging in the diagnosis of cruciate ligament and meniscal tears of the knee.

Longitudinal Tear of the Medial Meniscus Posterior Horn in the Anterior Cruciate Ligament–Deficient Knee Significantly Influences Anterior Stability

Background: Longitudinal tears of the medial meniscus posterior horn (MMPH) are commonly associated with a chronic anterior cruciate ligament (ACL) deficiency. Many studies have demonstrated the importance of the medial meniscus in terms of limiting the amount of anterior-posterior tibial translation in response to anterior tibial loads in ACL-deficient knees. Hypothesis: An MMPH tear in an ACL-deficient knee increases the anterior-posterior tibial translation and rotatory instability. In addition, MMPH repair will restore the tibial translation to the level before the tear. Study Design: Controlled laboratory study. Methods: Ten human cadaveric knees were tested sequentially using a custom testing system under 5 conditions: intact, ACL deficient, ACL deficient with an MMPH peripheral longitudinal tear, ACL deficient with an MMPH repair, and ACL deficient with a total medial meniscectomy. The knee kinematics were measured at 0°, 15°, 30°, 60°, and 90° of flexion in response to a 134-N anterior and 200-N axial compressive tibial load. The rotatory kinematics were also measured at 15° and 30° of flexion in a combined rotatory load of 5 N·m of internal tibial torque and 10 N·m of valgus torque. Results: Medial meniscus posterior horn longitudinal tears in ACL-deficient knees resulted in a significant increase in anterior-posterior tibial translation at all flexion angles except 90° (P < .05). An MMPH repair in an ACL-deficient knee showed a significant decrease in anterior-posterior tibial translation at all flexion angles except 60° compared with the ACL-deficient/MMPH tear state (P < .05). The total anterior-posterior translation of the ACL-deficient/MMPH repaired knee was not significantly increased compared with the ACL (only)–deficient knee but was increased compared with the ACL–intact knee (P > .05). A total medial meniscectomy in an ACL-deficient knee did not increase the anterior-posterior tibial translation significantly compared with MMPH tears in ACL-deficient knees at all flexion angles (P > .05). In a combined rotatory load, tibial rotation after MMPH tears or a total medial meniscectomy in an ACL-deficient knee were not affected significantly at all flexion angles. Conclusion: This study shows that an MMPH longitudinal tear in an ACL-deficient knee alters the knee kinematics, particularly the anterior-posterior tibial translation. MMPH repair significantly improved anterior-posterior tibial translation in ACL-deficient knees. Clinical Relevance: These findings may help improve the treatment of patients with ACL and MMPH longitudinal tear by suggesting that the medial meniscal repairs should be performed for greater longevity when combined with an ACL reconstruction.

Arthroscopic Transtibial Posterior Cruciate Ligament Reconstruction With Preservation of Posterior Cruciate Ligament Fibers Clinical Results of Minimum 2-Year Follow-up

Background The transtibial technique for posterior cruciate ligament reconstructions can potentially lead to poor clinical outcomes due to the “killer turn” effect. Hypothesis Preserving the original posterior cruciate ligament fibers in the reconstruction will contribute significantly to the posterior stability of the knee joint, healing of the graft, and prevention of graft failure. Study Design Case series; Level of evidence, 4. Methods Sixty-one patients (45 men and 16 women; mean age, 30.4 years) underwent transtibial posterior cruciate ligament reconstruction with preservation of the cruciate ligament fibers; they were reviewed at a mean period of 40.8 months. All patients were assessed with the Lysholm knee score, International Knee Documentation Committee subjective and objective evaluations, and KT-2000 arthrometry. Follow-up magnetic resonance imaging was performed in 40 patients; images were assessed for graft continuity, thickness, and signal intensity. Second-look arthroscopy was performed in 42 patients. Results The mean Lysholm score improved from 65.8 to 92.9. The final International Knee Documentation Committee subjective evaluation rated all patients as normal or nearly normal, and the objective evaluation showed normal or nearly normal in 59 patients (97%) and abnormal in 2 patients (3%). The mean side-to-side difference on the KT-2000 arthrometer was 2.79 mm. All patients showed well-preserved graft continuity on magnetic resonance images. Mean graft thickness was 9.9 mm in the sagittal plane and 12.3 mm in the coronal oblique plane. Images for all patients revealed homogeneously low signal intensity in the distal portion of the graft, with complete healing of the graft and original posterior cruciate ligament fibers as one ligament. Graft loosening or graft tear by the killer turn effect was not detected in any patients. Second-look arthroscopy revealed complete healing and graft integration, with the original posterior cruciate ligament fibers in all patients. Conclusion In transtibial posterior cruciate ligament reconstructions, poor outcomes from the killer turn effect may be reduced by preserving the original posterior cruciate ligament fibers.

Rotator Cuff Integrity After Arthroscopic Repair for Large Tears With Less-Than-Optimal Footprint Coverage

PURPOSE The purpose of this study was to evaluate the clinical results and healing status of rotator cuff repairs with less than 50% footprint coverage. METHODS During the 18-month period from October 2005 to March 2007, 89 large to massive rotator cuff tears were arthroscopically repaired. Among them, 23 consecutive large to massive rotator cuff tears were repaired completely but with less than 50% of the original footprint. All tears were arthroscopically repaired with suture anchors. Preoperative and postoperative clinical assessments were performed with the Constant score, American Shoulder and Elbow Surgeons score, and pain visual analog scale. The healing status of repaired tendon was evaluated by postoperative magnetic resonance imaging with a focus on tendon integrity, muscle fatty degeneration, and muscle atrophy. RESULTS The mean follow-up period was 30.2 months (range, 24 to 41 months). At final follow-up visits, American Shoulder and Elbow Surgeons score, Constant score, and score on pain visual analog scale were found to have improved significantly from 40.1, 35.9, and 57.7 to 82.4, 86.6, and 12.3, respectively (P < .01). The overall retear rate was 45.5% (10 cases). However, clinical results showed no difference between the retear group and no retear group. Furthermore, rerupture size was smaller than original tear size in all 10 patients, and no significant progression of fatty degeneration or muscle atrophy of rotator cuff muscles was observed. CONCLUSIONS Less-than-optimal coverage of the original greater tuberosity footprint during arthroscopic repair of large to massive rotator cuff tears was found to be associated with a relatively high retear rate (45.5%). However, clinical results improved significantly, and no significant difference was observed in the clinical results between the retear and no retear groups. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Anterior Cruciate Ligament Reconstruction Using Remnant Preservation and a Femoral Tensioning Technique: Clinical and Magnetic Resonance Imaging Results

PURPOSE The purpose of this study was to investigate the clinical and magnetic resonance imaging (MRI) results of anterior cruciate ligament (ACL) reconstruction with autogenous hamstring tendon by use of remnant preservation and a femoral tensioning technique. METHODS A total of 53 patients who had ACL reconstruction by use of remnant ACL stump preservation and a femoral tensioning technique were evaluated. Clinical evaluation at a minimum of 2 years after surgery included range of motion, Lachman test, pivot-shift test, KT-2000 arthrometer testing (MEDmetric, San Diego, CA), and clinical scores. Plain radiographs were evaluated for tunnel enlargement. MRI was obtained for evaluation of graft continuity, cyclops-like mass lesion, and positioning of the tibial tunnel. Second-look arthroscopy was performed in 33 patients. RESULTS The clinical scores improved postoperatively. There were statistically significant differences between preoperative and postoperative Lachman tests, pivot-shift tests, and KT-2000 arthrometer measurements. Postoperative MRI was available in 48 patients, and it showed intact graft in 45 patients, 2 partial tears, and 1 complete loss of graft. There were cyclops-like mass lesions in 12 patients, but none showed an extension limitation or pain at extension. The position of the tibial tunnel on the sagittal and coronal view was similar to the position of the normal ACL tibial insertion. The measured tibial tunnel widening on the radiographs at final follow-up was 2.2 ± 1.5 mm. CONCLUSIONS Reconstruction of the ACL by use of preservation and femoral tensioning of the remnant tissue showed good clinical results without increased concerns regarding incorrect tunnel formation. Postoperative MRI showed an increased incidence of cyclops-like mass lesions, but no clinical significance was observed. LEVEL OF EVIDENCE Level IV, case series.

Magnetic Resonance Imaging Evaluation of Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Tendon Autografts Comparison of Remnant Bundle Preservation and Standard Technique

Background: Recently, variations of the remnant bundle preservation technique, including selective bundle reconstruction and preservation of the anterior cruciate ligament tibial remnant, have produced good outcomes. The authors chose to investigate whether remnant bundle preservation in anterior cruciate ligament reconstruction would affect the remodeling process without inducing complications. Hypothesis: An anterior cruciate ligament reconstruction graft can be augmented with a tensioned remnant of the native anterior cruciate ligament fibers without increasing the tendency of cyclops lesions. The magnetic resonance imaging signal intensity in an anterior cruciate ligament graft using the remnant bundle preservation technique would be lower than that using the standard technique. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-one patients who underwent an anterior cruciate ligament reconstruction using the remnant bundle preservation technique with quadrupled hamstring tendon autograft were evaluated by magnetic resonance imaging at a mean of 6.3 ± 0.7 months after surgery. The control group included 41 consecutive patients who underwent a single-bundle anterior cruciate ligament reconstruction by the standard technique. The 2 groups did not differ significantly in gender, age distribution, mean time until postoperative magnetic resonance imaging, or other patient characteristics. The magnetic resonance imaging evaluation focused on 5 measurements as follows: (1) dimensions of the anterior cruciate ligament graft, (2) signal intensity of the anterior cruciate ligament graft using the signal/noise quotient (SNQ) from a region of interest analysis, (3) magnetic resonance imaging signal intensity and continuity of the preserved remnant bundle, (4) orientation of the anterior cruciate ligament, and (5) tibial tunnel placement. Results: The remnant bundle preservation group had a significantly larger mean anterior cruciate ligament graft (293.4 mm2) than did the standard group (219.6 mm2) (P < .0001). However, the SNQ values of the anterior cruciate ligament graft in the remnant bundle preservation group were not significantly lower than those in the standard group in any of the 3 zones. In the remnant bundle preservation group, magnetic resonance imaging signals obtained from preserved remnant bundles in 35 patients (85%) showed 14 knees with a grade I signal (homogeneous low intensity) and 21 knees with a grade II signal (a portion of the preserved bundle was edematous). The continuity of remnant bundles in 37 patients (90%) as determined by magnetic resonance imaging was partial in 20 patients and complete in 17. The 2 groups did not differ significantly in the number of cyclops lesions detected by postoperative magnetic resonance imaging. Conclusion: After anterior cruciate ligament reconstruction, magnetic resonance imaging showed significantly larger anterior cruciate ligament grafts in the remnant bundle preservation group than in the standard procedure group, and these preserved remnant bundles showed progressive remodeling in the anterior cruciate ligament graft with no increase in the incidence of cyclops lesions. To determine a clinical advantage for the remnant preservation technique, magnetic resonance imaging results such as these must be correlated with clinical findings.

Arthroscopic all inside repair of the lateral meniscus root tear.

It has been reported that lateral meniscus tears, including posterior horn tears, stable radial flap tears, or peripheral or posterior third tears that are combined with an Anterior Cruciate Ligament (ACL) injury can be treated with being left in situ. However, our experience has shown that the tear patterns are not so simple. They can show complex configurations and the inner side can be lost in chronic cases. Regarding the repair technique, there has been some controversy concerning the follow up results with repair devices and reduction is difficult using these devices if the inner side is non-viable or lost. If the tear involves whole width of bony insertion, it is believed that the meniscal function would be lost, particularly because the anatomic configuration is different in this area. In cases of chronic inner loss types, the meniscus was repaired using a side to side repair or pull out repair technique. Complete healing was achieved using this technique in some patients. Conclusively, Posterior Lateral Meniscus Root Tear (PLMRT) must be managed with different method with tears of other areas because the tear configuration is complex than simple looking.

Correlation of Arthroscopic Repairability of Large to Massive Rotator Cuff Tears With Preoperative Magnetic Resonance Imaging Scans

PURPOSE The purpose of this study was to determine whether there are preoperative magnetic resonance imaging (MRI) variables that could predict the repairability of large to massive rotator cuff tears (RCTs), especially in terms of distinguishing between complete repair and incomplete repair. METHODS Fifty-one consecutive patients who had large to massive RCTs were treated by arthroscopic repair with suture anchors. The primary repair was subclassified into 4 types. Types I and II were complete repairs with coverage of the lateral end of the greater tuberosity footprint (type I) or to the medial one half or less of the footprint (type II). Types III and IV were incomplete repairs with either small exposure of the humeral head (<10 mm) (type III) or moderate exposure of the head with repair of the force couple of the rotator cuff (type IV). Six preoperative MRI measurements (fatty degeneration index [FDI] in all planes, occupational grade, tangent sign, coronal oblique tear distance [COTD], sagittal oblique tear distance [SOTD], and coronal oblique thickness) that were reported in the previous literature were examined. These measurements were correlated with our classification of repair. RESULTS There were 28 large and 23 massive tears. Interobserver reproducibility was good to excellent. When we compared the completely and incompletely repaired groups, the FDI values for sagittal oblique sections of the supraspinatus and the infraspinatus and the FDI values for COTD and SOTD showed statistically significant differences. The cutoff values for SOTD and COTD were 32 mm and 31 mm, respectively. Regarding FDI, values greater than 3 on sagittal oblique sections of the supraspinatus and greater than 2 on sagittal oblique sections of the infraspinatus can be discouraging findings for complete repair. CONCLUSIONS On preoperative MRI of RCTs, FDI values of greater than 3 on sagittal oblique sections of the supraspinatus and greater than 2 on sagittal oblique sections of the infraspinatus with greater than 31 mm in COTD and 32 mm in SOTD can imply incomplete arthroscopic repair of the torn tendon or type III/IV repair. LEVEL OF EVIDENCE Level II, development of diagnostic criteria based on consecutive patients with universally applied gold standard.