Jocelyn Wittstein

Isokinetic Strength, Endurance, and Subjective Outcomes After Biceps Tenotomy Versus Tenodesis A Postoperative Study

Background: Similar subjective outcomes have been reported for tenotomy or tenodesis of the long head of the biceps. Few studies have reported on postoperative strength and endurance. Hypothesis: Biceps tenodesis results in superior subjective outcomes, strength, and endurance compared with tenotomy. Study Design: Cohort study; Level of evidence, 3. Methods: Participants completed isokinetic strength and endurance testing for elbow flexion and supination on the operative and nonoperative sides a minimum of 2 years after biceps tenotomy or tenodesis. Modified American Shoulder and Elbow Surgeons (MASES) and Single Assessment Numeric Evaluation (SANE) scores were obtained. The operative/nonoperative strength and endurance scores were compared for the tenotomy and tenodesis groups, with the nonoperative shoulder serving as the control for each participant’s operative shoulder. Change scores for strength and endurance were reported as percentage increase or decrease as compared with the nonoperative side. Change scores and MASES and SANE scores were compared between the 2 groups. The presence of a “popeye” deformity or pain at the tenodesis site was noted. Results: Thirty-five patients (19 tenotomy, 16 tenodesis) were studied. No significant difference was noted in postoperative MASES and SANE scores. Operative-side peak supination torque was significantly decreased relative to the nonoperative side in the tenotomy group, which had a significantly larger decrease in supination peak torque than did the tenodesis group on comparison of change scores. No significant difference was noted for peak flexion torque or flexion/supination endurance between operative and nonoperative sides in either group or between change scores for peak flexion torque or flexion/supination endurance in the tenotomy and tenodesis groups. Four tenotomy patients had a popeye deformity, 2 of whom reported painful cramping. Two patients had pain at the tenodesis site. Conclusion: Subjective outcomes are similar for patients treated with tenotomy and tenodesis. Tenotomy decreases supination peak torque relative to the nonoperative side and tenodesis.

Endoscopic Compartment Release for Chronic Exertional Compartment Syndrome: Surgical Technique and Results

Background: Chronic exertional compartment syndrome is an entity that typically fails nonoperative management and requires operative treatment with fasciotomies for return to activity. Fasciotomies performed through single or multiple incisions may fail to totally release the fascia of the afflicted compartment(s) and may result in injury to neurovascular structures that cannot be visualized. Purpose: The authors report results of endoscopic compartment release with the assistance of a balloon dissector in the treatment of chronic exertional compartment syndrome. Study Design: Case series; Level of evidence, 4. Methods: The clinical outcomes of 14 cases of chronic exertional compartment syndrome in 9 patients treated with endoscopic release were assessed with a retrospective chart review and the results of mailed questionnaires. Results: Fourteen legs in 9 patients (4 male and 5 female; average age, 24 years) were treated with endoscopic compartment release for chronic exertional compartment syndrome. Eight of 9 patients were able to resume preoperative activities, including collegiate athletics in 5 cases and recreational sport in 3 cases. No neurovascular injuries occurred. Complications were isolated to postoperative hematomas that resolved in 2 patients. Seven patients completed questionnaires an average of 3.75 years after surgery. There were no recurrences of symptoms. Conclusion: Endoscopic compartment release is a cosmetic, safe, and effective means of treating chronic exertional compartment syndrome.

Evaluation of skill level between trainees and community orthopaedic surgeons using a virtual reality arthroscopic knee simulator.

BACKGROUND Several virtual reality simulators have been developed to assist orthopaedic surgeons in acquiring the skills necessary to perform arthroscopic surgery. The purpose of this study was to assess the construct validity of the ArthroSim virtual reality arthroscopy simulator by evaluating whether skills acquired through increased experience in the operating room lead to improved performance on the simulator. METHODS Using the simulator, six postgraduate year-1 orthopaedic residents were compared with six postgraduate year-5 residents and with six community-based orthopaedic surgeons when performing diagnostic arthroscopy. The time to perform the procedure was recorded. To ensure that subjects did not sacrifice the quality of the procedure to complete the task in a shorter time, the simulator was programmed to provide a completeness score that indicated whether the surgeon accurately performed all of the steps of diagnostic arthroscopy in the correct sequence. RESULTS The mean time to perform the procedure by each group was 610 seconds for community-based orthopaedic surgeons, 745 seconds for postgraduate year-5 residents, and 1028 seconds for postgraduate year-1 residents. Both the postgraduate year-5 residents and the community-based orthopaedic surgeons performed the procedure in significantly less time (p = 0.006) than the postgraduate year-1 residents. There was a trend toward significance (p = 0.055) in time to complete the procedure when the postgraduate year-5 residents were compared with the community-based orthopaedic surgeons. The mean level of completeness as assigned by the simulator for each group was 85% for the community-based orthopaedic surgeons, 79% for the postgraduate year-5 residents, and 71% for the postgraduate year-1 residents. As expected, these differences were not significant, indicating that the three groups had achieved an acceptable level of consistency in their performance of the procedure. CONCLUSIONS Higher levels of surgeon experience resulted in improved efficiency when performing diagnostic knee arthroscopy on the simulator. Further validation studies utilizing the simulator are currently under way and the additional simulated tasks of arthroscopic meniscectomy, meniscal repair, microfracture, and loose body removal are being developed.

Magnetic resonance imaging features of osteochondral lesions of the talus.

Background: Osteochondral lesions of the talus (OLT) traditionally have been thought to occur anterolaterally or posteromedially. Recent studies utilizing magnetic resonance imaging (MRI) have questioned this teaching. The purpose of this study was to use MRI to describe the location, frequency, and morphology of OLT and determine if any correlations exist between lesion location and other data points. Methods: The location, frequency, and size of OLT based on a nine-zone grid were recorded on 77 MRI examinations. Lateral ligaments were inspected for evidence of injury. Stability of the lesions was assessed based on four MRI criteria: presence or absence of cartilage defects, edema-like signal abnormality, T2 bright rim, and/or subchondral cysts. Demographic data including patient age, injury mechanism, and chronicity were recorded. An ANOVA model was used to determine if statistical differences existed between lesion size and location. Pearson correlation coefficients were used to examine any association between lesion location and demographic data. Results: Most of the lesions were located medially and centrally on the talar dome (54.5%), with the second highest frequency found laterally and centrally (31.2%). With the numbers available there was no statistical difference between the size of the lesions based on location. No strong correlations were found between lesion location and demographic data. Conclusion: This study refutes traditional teachings regarding the location of OLT and supports recent studies showing that most lesions are located medially and centrally on the talar dome. Level of Evidence: IV, Retrospective Case Series

Isokinetic testing of biceps strength and endurance in dominant versus nondominant upper extremities

BACKGROUND The strength and endurance of the contralateral biceps muscle can serve as a useful comparison for the operative limb following distal biceps repairs, mid-substance repairs, or tenotomy or tenodesis of the long head. There are limited data available on the effect of handedness on biceps strength and endurance. HYPOTHESIS The dominant upper extremity has greater elbow flexion and supination peak torque and endurance. MATERIALS AND METHODS Subjects with no history of prior upper extremity injury or limitations completed isokinetic testing of biceps flexion and supination peak torque and endurance on a Biodex machine. A paired student t test was used to compare peak torque and endurance for both supination and flexion for the dominant and nondominant upper extremities. The results were analyzed for the entire group, and for male and female subjects separately as well. RESULTS A power analysis revealed that 5 subjects were needed to achieve 80% power. Twenty subjects (10 male, 10 female) were tested. No significant difference was detected for peak torque or endurance for supination or flexion between the dominant and nondominant upper extremities. No difference was detected when the group was analyzed as a whole, nor when men and women were analyzed separately. CONCLUSIONS The dominant and nondominant upper extremities demonstrate similar peak torque and endurance for supination and flexion. The normal contralateral upper extremity can be used as a matched control in the evaluation of post operative biceps isokinetic strength and endurance without adjusting results for handedness.

Clinical and Radiographic Outcomes of the Simpliciti Canal-Sparing Shoulder Arthroplasty System: A Prospective Two-Year Multicenter Study.

BACKGROUND Stemmed humeral components have been used since the 1950s; canal-sparing (also known as stemless) humeral components became commercially available in Europe in 2004. The Simpliciti total shoulder system (Wright Medical, formerly Tornier) is a press-fit, porous-coated, canal-sparing humeral implant that relies on metaphyseal fixation only. This prospective, single-arm, multicenter study was performed to evaluate the two-year clinical and radiographic results of the Simpliciti prosthesis in the U.S. METHODS One hundred and fifty-seven patients with glenohumeral arthritis were enrolled at fourteen U.S. sites between July 2011 and November 2012 in a U.S. Food and Drug Administration (FDA) Investigational Device Exemption (IDE)-approved protocol. Their range of motion, strength, pain level, Constant score, Simple Shoulder Test (SST) score, and American Shoulder and Elbow Surgeons (ASES) score were compared between the preoperative and two-year postoperative evaluations. Statistical analyses were performed with the Student t test with 95% confidence intervals. Radiographic evaluation was performed at two weeks and one and two years postoperatively. RESULTS One hundred and forty-nine of the 157 patients were followed for a minimum of two years. The mean age and sex-adjusted Constant, SST, and ASES scores improved from 56% preoperatively to 104% at two years (p < 0.0001), from 4 points preoperatively to 11 points at two years (p < 0.0001), and from 38 points preoperatively to 92 points at two years (p < 0.0001), respectively. The mean forward elevation improved from 103° ± 27° to 147° ± 24° (p < 0.0001) and the mean external rotation, from 31° ± 20° to 56° ± 15° (p < 0.0001). The mean strength in elevation, as recorded with a dynamometer, improved from 12.5 to 15.7 lb (5.7 to 7.1 kg) (p < 0.0001), and the mean pain level, as measured with a visual analog scale, decreased from 5.9 to 0.5 (p < 0.0001). There were three postoperative complications that resulted in revision surgery: infection, glenoid component loosening, and failure of a subscapularis repair. There was no evidence of migration, subsidence, osteolysis, or loosening of the humeral components or surviving glenoid components. CONCLUSIONS The study demonstrated good results at a minimum of two years following use of the Simpliciti canal-sparing humeral component. Clinical results including the range of motion and the Constant, SST, and ASES scores improved significantly, and radiographic analysis showed no signs of loosening, osteolysis, or subsidence of the humeral components or surviving glenoid components. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Comparison Between Sexes of Bone Contusions and Meniscal Tear Patterns in Noncontact Anterior Cruciate Ligament Injuries

Background: Valgus load has been linked to female predominance and mechanism for noncontact anterior cruciate ligament (ACL) injuries. Magnetic resonance imaging (MRI) studies reporting frequent medial contusions in noncontact ACL injuries suggest anterior translation rather than a valgus mechanism. Hypothesis: Bone contusion and meniscal tear patterns differ between sexes. Study Design: Case series; Level of evidence, 4. Methods: This study included a review of clinic notes, operative reports, and MRI of patients younger than 20 years who underwent acute primary ACL reconstruction for a noncontact injury between January 1, 2005, and January 1, 2010. A blinded musculoskeletal MRI radiologist reported the incidence of medial and lateral femoral and tibial bone contusions on MRI, as well as the severity of medial versus lateral tibial contusions. The location of the bone contusions and meniscal tears and the maximal tibial contusion severity were compared through chi-square analysis (statistical significance, P < .05). Results: A total of 73 patients met inclusion criteria: 28 males, 45 females; mean age, 16.1 ± 1.7 years (males), 16.5 ± 1.7 years (females). No significant differences were noted between sexes for location of tibial contusions (P = .32), femoral contusions (P = .44), or meniscal tears (P = .715). The most common tibial contusion pattern was to have both medial and lateral tibial contusions, in both male (57%) and female (60%) patients. The most common femoral contusion pattern was lateral only in females (62%) and both medial and lateral in males (50%). The percentage of female (29%) and male (29%) patients with isolated medial meniscal tears was nearly identical. More males (29%) than females (18%) had isolated lateral meniscal tears (P = .72). No significant difference in the relative severity of the tibial contusions was noted (P = .246). The lateral tibial contusion was rated as being more severe than the medial in the majority of females (64%) and males (57%). Conclusion: No significant differences were detected between sexes with noncontact ACL injuries for location of tibial or femoral contusions or meniscal tears or for severity of medial versus lateral tibial contusions. The MRI data were not consistent with the valgus collapse mechanism of injury.

Aberrant origin of the long head of the biceps: a case series.

BACKGROUND Variants of the origin of the long head of the biceps have been described intraoperatively. It is unclear whether these variants contribute to shoulder pathology. Our purpose was to describe an anatomic variation of the origin of the long head of the biceps and associated clinical presentations of 2 subjects and to review existing reports of other variants. METHODS We present the history and physical examination, imaging, and arthroscopic findings of 2 cases of an abnormal variant of the origin of the long head of the biceps. RESULTS In 2 subjects, the long head of the biceps was noted to have a Y-shaped origin with 1 limb coming from the rotator cable and the other limb taking origin medial to the superior glenoid tubercle. A 42-year-old male weightlifter presented with distal clavicle osteolysis confirmed by diagnostic injection and had resolution of symptoms after a distal clavicle excision. A 38-year-old female retired military officer presented with subcoracoid impingement confirmed by magnetic resonance imaging findings and a diagnostic injection and did well after subcoracoid decompression. In neither case did the biceps tendon appear diseased or related to shoulder pathology. CONCLUSIONS In rare cases, the long head of the biceps takes origin from the rotator cable and has a second origin medial to the supraglenoid tubercle. This variant does not appear to contribute to shoulder pathology because standard treatment of concomitant diagnoses resulted in resolution of symptoms.

Chronic Tears of the Reflected Head of the Rectus Femoris: Results of Operative Treatment

Background: While the majority of quadriceps muscle strains can be managed nonoperatively, rare cases remain symptomatic despite nonoperative treatment. Purpose: The purpose of this study is to report on results of surgical treatment of a limited number of cases of persistently symptomatic tears of the reflected head of the rectus femoris. Study Design: Case series; Level of evidence, 4. Methods: The records of 5 patients with chronic tears of the rectus femoris treated with excision of the reflected head were reviewed. A telephone interview regarding return to sport and current limitations was completed if patients were available for further follow-up. Results: A review of 5 cases of surgical treatment of chronic tears of the reflected head of the rectus was completed. Patients included 1 woman and 4 men with an average age of 21 years (range, 18-24 years). Three patients played football (2 kickers) and 2 played soccer at a collegiate level. All 5 reported a significant decrease in pain during sport and activities of daily living and were able to return to collegiate athletics. Two patients had a late recurrence of pain with kicking that resolved with nonoperative treatment, 1 had residual thigh pain with intense play, 1 had no pain but noted decreased kicking accuracy, and 1 patient returned to play without symptoms. Conclusion: Strain injuries to the reflected head of the rectus femoris can benefit from delayed excision in rare cases that fail nonoperative management. High-level kicking athletes are likely to experience significant reduction in pain, but may have some residual or recurrent symptoms that limit competitive level of play postoperatively.

MRI of Selected Abnormalities at the Anterior Superior Aspect of the Shoulder: Potential Pitfalls and Subtle Diagnoses

OBJECTIVE MRI has proven to be a helpful tool in the detection and description of pathologic changes of the rotator cuff, biceps tendon, and glenoid labrum and has thus become a mainstay in the evaluation of patients with shoulder pain. This review seeks to illustrate some of the more subtle abnormalities that can be detected on shoulder MRI and to highlight some normal anatomic variants that may mimic pathologic processes, concentrating on structures at the anterior superior aspect of the shoulder. CONCLUSION Shoulder MRI can provide a very accurate evaluation of shoulder pathologic processes and can assist in elucidating abnormalities that can be difficult to diagnose clinically. Awareness of the known anatomic variants and the sometimes subtle potential pain generators at the anterior superior aspect of the shoulder will allow a more accurate interpretation and can therefore increase the diagnostic yield of shoulder MRI.