Junji Ide

Arthroscopic Transtendon Repair of Partial-Thickness Articular-Side Tears of the Rotator Cuff Anatomical and Clinical Study

Background The precise results of arthroscopic transtendon repair of partial-thickness articular-side tears of the rotator cuff remain to be reported. Hypothesis Arthroscopic transtendon repair is useful in patients with Ellman grade 3 (>6 mm) partial-thickness articular-side tears of the supraspinatus tendon. Study Design Descriptive laboratory study and case series; Level of evidence, 4. Methods In 43 cadaveric shoulders (mean age, 80 years; range, 50-97 years), the authors measured the width of the supraspinatus insertion (medial-to-lateral direction) and the distance between the articular cartilage edge and the tendon insertion at a site 10 mm lateral to the anterior margin of the greater tuberosity. A clinical study group of 17 patients (mean age, 42 years; range, 17-51 years) was observed for a mean follow-up of 39 months (range, 25-57 months). University of California at Los Angeles and Japanese Orthopaedic Association shoulder scores and postoperative overhead athletic activities were evaluated. Results The mean width of the supraspinatus insertion was 9.6 mm (SD, 1.6 mm; range, 7-13 mm; 95% confidence interval, 9.1-10.1 mm; 95% prediction interval, 6.4-12.8 mm). The mean distance between the articular cartilage edge and the tendon insertion was 0.3 mm (range, 0-2 mm). After the procedure, the mean University of California at Los Angeles and Japanese Orthopaedic Association scores significantly improved from 17.3 and 68.4 points to 32.9 and 94.8 points, respectively (P <. 01). Rated on the Japanese Orthopaedic Association scale, results were excellent in 14, good in 2, and fair in 1 patient; there were no poor results. Of 6 overhead-throwing athletes, 2 returned to their previous sports at the same level, 3 returned at a lower level, and 1 was unable to return. Conclusion Arthroscopic transtendon repair is a safe, reliable procedure in patients with grade 3 partial-thickness articular-side tears. In the majority of patients, partial tears of more than 6 mm of the supraspinatus tendon thickness involved more than 50% of the entire tendon thickness.

Arthroscopic Bankart Repair Using Suture Anchors in Athletes Patient Selection and Postoperative Sports Activity

Purpose The purpose of this study was to evaluate the results in selected high-risk patients who underwent arthroscopic stabilization of shoulders with recurrent anterior instability. Hypothesis Arthroscopic stabilization using suture anchors is useful for athletes younger than 25 years or for contact athletes without a large bone loss of glenohumeral articulation. Study Design Prospective cohort study. Methods The study group comprised 55 patients, with a mean follow-up of 42 months (range, 25-72 months). Thirty-two patients had recurrent dislocations, 14 had recurrent subluxations, and 9 had recurrent subluxations after a single dislocation. Rowe score, range of motion, recurrence, and sports activities were evaluated. Results Mean Rowe score improved from 30.1 to 92.3 points; 45 scores (82%) were excellent, 5 (9%) good, 1 fair (2%), and 4 (7%) poor. Patients had lost a mean of 4° of external rotation in adduction. Four (7%) had recurrence. The recurrence rate in contact athletes (9.5%, 2 of 21) was not statistically different from that in noncontact athletes (6%, 2 of 34). Forty-four (80%) returned at the same levels. The complete return rate in overhead-throwing athletes (68%, 17 of 25) was lower than that in nonoverhead athletes (90%, 27 of 30) (P = .0423). Five patients had unsatisfactory results. Conclusion Arthroscopic stabilization is a reliable procedure in selected high-risk patients.

Arthroscopic repair of traumatic combined rotator cuff tears involving the subscapularis tendon.

BACKGROUND Although the use of arthroscopic repair to treat rotator cuff tears involving the subscapularis has increased, there are few studies on treatment outcomes and repair integrity. We hypothesized that arthroscopic repair of combined rotator cuff tears that include the subscapularis yields successful functional and structural outcomes. METHODS Our study population consisted of seventeen men and three women (twenty shoulders) whose mean age was 61.7 years. The mean duration of follow-up was 36.1 months, and all patients were followed for at least two years. All had traumatic full-thickness tears of the subscapularis and supraspinatus, and seven had a concomitant infraspinatus tear. The mean time from the injury to the surgery was 2.7 months. An arthroscopic suture-anchor technique was used for the repair. The shoulders were evaluated before and after the procedure with use of the University of California at Los Angeles (UCLA) score, the Japanese Orthopaedic Association (JOA) score, plain radiographs, and magnetic resonance imaging scans. RESULTS After arthroscopic repair, the mean UCLA and JOA scores significantly improved from 14.9 and 55.7 points to 31.1 and 91.0 points, respectively (p < 0.0001). According to the JOA rating scale, the outcome was excellent for thirteen patients (65%), good for five (25%), fair for one (5%), and poor for one (5%). Of the twenty patients, seven (35%) had recurrent tears after the surgery; four of them had originally had a three-tendon tear and the other three had had a two-tendon tear. Of these seven patients, one had an excellent outcome; five, a good outcome; and one, a fair outcome. The postoperative mean JOA score was significantly lower for the patients with a failed repair than it was for those with an intact repair (p = 0.0034). The patients with a failed repair also had a significantly higher mean age (68.4 years compared with 58.1 years for those with an intact repair; p = 0.014), and the prevalence of recurrent tears was significantly higher in the patients with severe tendon retraction compared with those with minimal or moderate tendon retraction (p = 0.0191). CONCLUSIONS Arthroscopic repair with use of the suture anchor technique is a safe and effective procedure for the treatment of combined rotator cuff tears involving the subscapularis tendon; it can alleviate shoulder pain and improve function and the range of motion. The postoperative integrity of the repair correlates with the clinical results. Patient age and the degree of tendon retraction can affect the integrity of the repair.

The effect of a local application of fibroblast growth factor-2 on tendon-to-bone remodeling in rats with acute injury and repair of the supraspinatus tendon

METHODS We investigated the effect of application of fibroblast growth factor (FGF)-2 on the tendon-to-bone remodeling of repaired supraspinatus tendon in rats subjected to bilateral detachment. FGF-2 (100 mg/kg) in a fibrin sealant or sealant alone was applied on the right and left shoulders, respectively. Twelve animals each at 2, 4, and 6 weeks after surgery were sacrificed for histological analysis (n = 5) and biomechanical Q1 testing (n = 7). RESULTS Histologically, at 2 weeks, FGF-treated specimens had significantly higher tendon-to-bone insertion maturing scores then untreated specimens (P < .002). At 4 and 6 weeks, the scores of FGF-treated and untreated specimens were similar (P > .05). Biomechanically, FGF-treated specimens were stronger at 2 weeks (P = .001); at 4 and 6 weeks, both specimens exhibited similar strength (P > .05). CONCLUSIONS The initial tendon-to-bone remodeling was accelerated by a local application of FGF-2. This may represent a clinically important improvement in rotator cuff repair.

The Effects of Fibroblast Growth Factor-2 on Rotator Cuff Reconstruction With Acellular Dermal Matrix Grafts

PURPOSE Our purpose was to determine whether the local application of fibroblast growth factor (FGF) 2 accelerates regeneration and remodeling of rotator cuff tendon defects reconstructed with acellular dermal matrix (ADM) grafts in rats. METHODS Thirty adult male Sprague-Dawley rats were divided into equal groups undergoing FGF-treated and FGF-untreated repairs. All rats underwent placement of an ADM graft for the supraspinatus defect (3 x 5 mm). FGF-2 (100 microg/kg) in a fibrin sealant was applied to both shoulders in the FGF-treated group, whereas only fibrin sealant was applied in untreated group. At 2, 6, and 12 weeks after surgery, 5 rats (10 shoulders) in each group were sacrificed for histologic analysis (3 shoulders) and biomechanical testing (7 shoulders). The controls were 5 unoperated rats (3 histologic and 7 biomechanical control specimens). RESULTS Unoperated control tendons inserted into the bone by direct insertion; there was a zone of fibrocartilage between the tendon and bone. At 2 weeks, the FGF-treated group had tendon maturing scores similar to those in the untreated group (P > .05). At 6 and 12 weeks, the FGF-treated group had significantly higher scores (P < .05). At 2 weeks, specimens in both the treated and untreated groups exhibited similar strength; the ultimate tensile failure load was 6.0 +/- 4.0 N and 5.8 +/- 2.0 N, respectively (P > .05). At 6 weeks, the FGF-treated specimens were stronger, with an ultimate tensile failure load of 10.2 +/- 3.1 N compared with 7.2 +/- 2.2 N in the untreated group (P = .02). At 12 weeks, the FGF-treated specimens were stronger, with an ultimate tensile failure load of 15.9 +/- 1.6 N compared with 13.2 +/- 2.0 N in the untreated group (P = .0072), and there were no significant differences in strength compared with the controls (17.8 +/- 2.6 N) (P > .05). CONCLUSIONS The remodeling of ADM grafts placed in rat rotator cuff tendon defects was accelerated by the local administration of FGF-2. CLINICAL RELEVANCE The application of FGF-2 may result in improved histologic characteristics and biomechanical strength in ADM graft constructs in humans.

Symptoms and signs of irritation of the brachial plexus in whiplash injuries

We investigated the incidence of evidence of irritation of the brachial plexus in 119 patients with whiplash injuries sustained in road-traffic accidents. We compared the symptoms, physical signs, autonomic status, psychological status and findings from radiographs of the cervical spine using examination charts and a modified Cornell Medical Index Health questionnaire, in patients in two distinct groups: those with irritation of the brachial plexus and those without. There were 45 patients (37.8%) in the first group. The ratio of women to men was significantly higher in patients with irritation of the plexus as was the incidence of symptoms other than neck pain. There was no significant difference between the two groups with regard to psychological status or findings in radiographs of the cervical spine. Symptoms and signs attributable to stretching of the brachial plexus do occur in a significant proportion of patients after a whiplash injury. Their presence and persistence are associated with a poor outcome.

Shoulder-strengthening exercise with an orthosis for multidirectional shoulder instability: quantitative evaluation of rotational shoulder strength before and after the exercise program.

We evaluated the results of shoulder-strengthening exercises with our novel shoulder orthosis to stabilize the scapula in 46 patients with multidirectional shoulder instability. We quantified the changes in muscle strength produced by our rehabilitation program. Our study included 34 female patients and 12 male patients (mean age, 20 years) with 73 affected shoulders. All patients performed the prescribed exercise program for 8 weeks. Their mean total scores on the modified Rowe grading system significantly increased from 51.9 to 74.9 points (P <.001). The mean peak torque of internal and external rotation, measured with an isokinetic dynamometer, significantly increased (P <.05); the mean external/internal peak torque ratios significantly decreased (P <.05) and were normalized upon completion of the rehabilitation program. Because of failure of conservative treatment, 3 patients underwent surgery at a mean follow-up duration of 7 years. We conclude that the prescribed shoulder-strengthening exercise represents a useful treatment option for patients with multidirectional shoulder instability.

Reconstruction of large rotator-cuff tears with acellular dermal matrix grafts in rats

HYPOTHESIS With the acellular dermal matrix (ADM), it may be possible to bridge large rotator cuff tears and induce tendon regeneration. MATERIALS AND METHODS A 3 x 5 mm defect of the rotator cuff was created on both shoulders of adult male Sprague-Dawley rats. The graft group (n = 15) underwent reconstruction of the rotator cuff defect with an ADM patch graft; in the defect group (n = 15) no repair was performed. We sacrificed 5 rats from each group at 2, 6, and 12 weeks after surgery and harvested both shoulders; 3 specimens were subjected to histological analysis and the other 7 specimens were used for biomechanical testing. The controls were 5 unoperated rats; they were sacrificed to obtain 3 histologic and 7 biomechanical control shoulder specimens. RESULTS At each time points, the graft group had significantly higher modified tendon maturing scores than the defect group (p < 0.002); specimens from the graft group demonstrated a greater mean ultimate force to failure than those from the defect group (p < 0.05). Within 12 weeks, the ADM graft was histologically incorporated into a structure resembling control specimen; the mean ultimate force to failure in control was significantly greater than in specimens from both groups (p < 0.01). DISCUSSION Although the defect was restored in the defect group, histologically and biomechanically specimens from the defect group were inferior to the graft group. CONCLUSION ADM grafts were useful as a scaffold in the reconstruction of large rotator cuff defects in rats. LEVEL OF EVIDENCE Basic science study.

An Anatomic Study of the Subscapularis Insertion to the Humerus: The Subscapularis Footprint

PURPOSE The purpose of this study was to elucidate the morphology of the subscapularis insertion into the humerus. METHODS Using 40 cadaveric shoulders from 12 men and 8 women (mean age, 91 years), we measured the maximum longitudinal (superior-to-inferior direction) and transverse (medial-to-lateral direction) length of the subscapularis insertion. The size of the bare area between the articular cartilage edge and the most medial tendon insertion at the proximal end, at the maximum transverse distance, and at the distal end was also measured. RESULTS In all cadavers the subscapularis insertion consisted of a proximal tendinous part and a distal muscular part. The mean longitudinal and transverse length of the insertion was 39.5 mm (SD, 6.7 mm) and 16.0 mm (SD, 2.2 mm), respectively. The mean longitudinal length of the tendon part was 26.3 mm (SD, 2.3 mm). The mean size of the bare area at the proximal end, at the maximum transverse distance, and at the distal end was 3.2 mm (SD, 1.7 mm), 6.5 mm (SD, 1.8 mm), and 16.8 mm (SD, 7.1 mm), respectively. The longitudinal and transverse length of the insertion and the size of the bare area at the maximum transverse distance and the distal end position were significantly greater in male specimens than in female specimens (P < .05). None of the measurements differed significantly on different sides. CONCLUSIONS The subscapularis footprint was broad proximally and tapered distally, exhibiting a comma shape. It consisted of a proximal tendinous part and a distal muscular part. With the exception of the bare area at the proximal end, the measured values were significantly larger in male specimens than in female specimens. CLINICAL RELEVANCE The precise anatomic measurements presented here are useful for the evaluation and repair of tears of the subscapularis.

Acute stretching of peripheral nerves inhibits retrograde axonal transport

The conjugation of horseradish peroxidase with wheat germ agglutinin was used to identify the effect on retrograde axonal transport of stretching the rat sciatic nerve indirectly by 10% and 20% femoral lengthening with a unilateral external fixator. To investigate the relationship between retrograde axonal transport and blood flow in the stretched nerve, nerve blood flow in the sciatic nerve was measured by a hydrogen washout technique. At 11% strain (20% femoral lengthening), the numbers of horseradish peroxidase-labelled motor neuron cells and nerve blood flow had decreased by 43% and 50%, respectively. Histological examination demonstrated ischaemic changes, but not mechanical damage. However, at 6% strain (10% femoral lengthening) there were no significant abnormalities. These findings suggest that the inhibition of retrograde axonal transport can be induced by acute stretching of the peripheral nerve and that circulatory disturbance is the main cause of the inhibition of retrograde axonal transport at the low strain.