Kawan Rakhra

A Multicenter Randomized Controlled Trial Comparing Single-Row with Double-Row Fixation in Arthroscopic Rotator Cuff Repair

BACKGROUND Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicenter, randomized, double-blind controlled study was to compare the functional outcomes and healing rates after use of single-row and double-row suture techniques for repair of the rotator cuff. METHODS Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either a single-row or a double-row repair. The primary objective was to compare the Western Ontario rotator cuff index (WORC) score at twenty-four months. Secondary objectives included comparison of the constant and american shoulder and elbow surgeons (ASES) scores and strength between groups. Anatomical outcomes were assessed with magnetic resonance imaging (MRI) or ultrasonography to determine the postoperative healing rates. RESULTS Baseline demographic data including age (p = 0.29), sex (p = 0.68), affected side (p = 0.39), and rotator cuff tear size (p = 0.28) did not differ between groups. The WORC score did not differ significantly between groups at any time point (p = 0.48 at baseline, p = 0.089 at three months, p = 0.52 at six months, p = 0.83 at twelve months, and p = 0.60 at twenty-four months). The WORC score at each postoperative time point was significantly better than the baseline value. The Constant score, ASES score, and strength did not differ significantly between groups at any time point. Logistic regression analysis demonstrated that a smaller initial tear size and double-row fixation were associated with higher healing rates. CONCLUSIONS No significant differences in functional or quality-of-life outcomes were identified between single-row and double-row fixation techniques. A smaller initial tear size and a double-row fixation technique were associated with higher healing rates as assessed with ultrasonography or MRI. LEVEL OF EVIDENCE Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Can T1-rho MRI detect acetabular cartilage degeneration in femoroacetabular impingement?: a pilot study.

Advanced MRI cartilage imaging such as T(1)-rho (T1ρ) for the diagnosis of early cartilage degradation prior to morpholgic radiological changes may provide prognostic information in the management of joint disease. This study aimed first to determine the normal T1ρ profile of cartilage within the hip, and secondly to identify any differences in T1ρ profile between the normal and symptomatic femoroacetabular impingement (FAI) hip. Ten patients with cam-type FAI (seven male and three female, mean age 35.9 years (28 to 48)) and ten control patients (four male and six female, mean age 30.6 years (22 to 35)) underwent 1.5T T1ρ MRI of a single hip. Mean T1ρ relaxation times for full thickness and each of the three equal cartilage thickness layers were calculated and compared between the groups. The mean T1ρ relaxation times for full cartilage thickness of control and FAI hips were similar (37.17 ms (SD 9.95) and 36.71 ms (SD 6.72), respectively). The control group demonstrated a T1ρ value trend, increasing from deep to superficial cartilage layers, with the middle third having significantly greater T1ρ relaxation values than the deepest third (p = 0.008). The FAI group demonstrated loss of this trend. The deepest third in the FAI group demonstrated greater T1ρ relaxation values than controls (p = 0.028). These results suggest that 1.5T T1ρ MRI can detect acetabular hyaline cartilage changes in patients with FAI.

Diagnostic imaging of femoroacetabular impingement.

&NA; Imaging studies play a key role in establishing the diagnosis of femoroacetabular impingement (FAI). When clinical examination is suggestive of FAI, radiographic evidence should confirm the diagnosis. Imaging findings must be evaluated in the context of the patients clinical presentation and recreational activities. Plain radiographic evaluation remains the initial diagnostic modality. Three‐dimensional imaging such as MRI and CT often is obtained for the evaluation of labral and cartilage pathology, definition of bony anatomy, and surgical planning.

Magnetic Resonance Imaging of Acetabular Labral Tears

The acetabular labrum plays an important role in hip biomechanical function and stability. Labral tears can result in appreciable clinical symptoms and joint dysfunction and may predispose the hip to chondral damage and osteoarthritis. Magnetic resonance imaging is an effective tool for detecting and characterizing labral tears. Direct magnetic resonance arthrography is the most commonly used and validated technique for evaluating the labrum. However, indirect magnetic resonance arthrography and non-arthrographic magnetic resonance imaging are two less invasive and less resource-intensive techniques that should also be considered. Orthopaedic surgeons and radiologists should strive to develop and implement minimally and noninvasive diagnostic magnetic resonance imaging protocols for the investigation of labral pathology.

Extra- and Intramuscular Fat Accumulation Early after Rabbit Supraspinatus Tendon Division: Depiction with CT

PURPOSE To quantify the accumulation, progression, and distribution of fat separately in and around the supraspinatus muscle from the onset of tendon detachment and to validate computed tomography (CT) for quantification of fat content by using volumetry and histomorphometry as reference standards. MATERIALS AND METHODS Institutional animal care committee approval was obtained. The supraspinatus tendon of 30 adult female rabbits (3.0 kg) was detached. Rabbits were sacrificed in groups of 10 after 4, 8, and 12 weeks. Fifteen rabbits that did not undergo surgery served as control subjects. Fat accumulations in and around the proximal, middle, and distal supraspinatus muscle were quantified, volumetrically and histologically, and were compared with extramuscular presence and intramuscular attenuation at CT. Weight, volume, histologic findings, and CT determinations of fat were compared by using one-way analysis of variance. The Pearson test was used to correlate intramuscular fat accumulation with CT observations. RESULTS Four weeks after tendon detachment significant extra- and intramuscular fat had accumulated (both P < .05) and progressed during 12 weeks, with accumulation of extramuscular fat being three times greater than that of intramuscular fat (both P < .05). An increasing proximal-to-distal gradient existed for both extra- and intramuscular accumulation (both P < .05). CT depicted the onset, progression, and gradient of extra- and intramuscular fat accumulation (all P < .05). CT attenuation correlated strongly with histologic findings (P < .05). CONCLUSION Fat accumulated early, along an increasing proximal-to-distal gradient, and progressed with time after supraspinatus tendon detachment. CT proved to be a valid tool for monitoring the onset, progression, and gradient separately for extra- and intramuscular fat accumulation.

Supraspinatus tendon repair into a bony trough in the rabbit: mechanical restoration and correlative imaging.

Recurrence of tears is a common complication after rotator cuff surgery. Retearing seems to occur early after surgery and may be attributed to too early or too vigorous exercises. We found no experimental data correlating the strength of the rotator cuff early after surgery and imaging. Our objectives were to measure the peak load to failure of rabbit supraspinatus tendon–bone constructs at early times postoperatively, to determine their mode of failure, and to determine whether computed tomography (CT) can predict their strength. We divided one supraspinatus tendon of 40 adult female white New Zealand rabbits and, after resection of the enthesis, sutured the tendon into a bony trough. Ten rabbits were killed immediately and 10 each at 1, 2, and 6 weeks postoperatively. The explanted tendons of both shoulders were imaged on CT and tested to failure. Compared to normal tendons (mean 210 ± 42 N), the mean strength was very low at 0 weeks (57 ± 21 N) and 1 week (86 ± 33 N) (both p < 0.05); it had recovered by 6 weeks (324 ± 66 N). Early on, suture pullout was the most common mode of failure, whereas at 6 weeks, mid‐substance tears predominated (p < 0.05). Hypoattenuation on CT was associated with increased strength of the tendon–bone construct (p < 0.05). The strength of the surgical construct is very low in the early postoperative period. Therefore, the shoulder should be submitted only to loads not interfering with healing.

Acetabular labral limbus as a cause of hip pain: a report of five cases.

The treatment of hip disease in the young adult is a rapidly evolving and growing area of orthopaedic surgery1, driven by improved imaging techniques2,3, safe and reproducible open hip surgery4, and less invasive techniques such as hip arthroscopy5. Currently, the most common indication for hip arthroscopy is the treatment of labral abnormalities6, usually from one of four causes7: trauma, a degenerative condition, dysplasia, and impingement. Labral abnormalities are often associated with acetabular chondral damage8,9, varying in severity from a softening and/or fibrillation to complete cartilage detachment from its osseous bed. Because the treatment of the labral abnormality varies, depending on the underlying etiology and associated pathological condition, it is critical that variant anatomy of the labrum and the labral chondral junction be recognized and treated accordingly7,10. Descriptions of variations of the labral anatomy have focused mainly on the manner in which arthroscopic findings correlate with magnetic resonance imaging (MRI) findings. The primary variation has been termed sublabral sulcus, defined as a cleft between the labrum and adjacent articular cartilage. The reported location of this sublabral sulcus is variable, as is the prevalence, although it is most commonly noted anteriorly. Byrd was the first, as far as we know, to describe as “normal anomalous variations” these partial separations of the labrum from the lateral aspect of the osseous rim of the acetabulum11. However, previous studies have some limitations since the magnetic resonance arthrography (MRA) was reviewed retrospectively to determine the prevalence and location of these sulci, making the exact location difficult to interpret. We report on a clinical series of five female patients seen with mechanical hip pain secondary to an acetabular labral limbus. The clinical presentation, …

LIMS2 mutations are associated with a novel muscular dystrophy, severe cardiomyopathy and triangular tongues

Limb girdle muscular dystrophy (LGMD) is a heterogeneous group of genetic disorders leading to progressive muscle degeneration and often associated with cardiac complications. We present two adult siblings with childhood‐onset of weakness progressing to a severe quadriparesis with the additional features of triangular tongues and biventricular cardiac dysfunction. Whole exome sequencing identified compound heterozygous missense mutations that are predicted to be pathogenic in LIMS2. Biopsy of skeletal muscle demonstrated disrupted immunostaining of LIMS2. This is the first report of mutations in LIMS2 and resulting disruption of the integrin linked kinase (ILK)–LIMS–parvin complex associated with LGMD.

Surgical Correction of Cam Deformity in Association with Femoroacetabular Impingement and Its Impact on the Degenerative Process within the Hip Joint

Background: Cam morphology in association with femoroacetabular impingement (FAI) is a recognized cause of hip pain and cartilage damage and proposed as a leading cause of arthritis. The purpose of this study was to analyze the functional and biomechanical effects of the surgical correction of the cam deformity on the degenerative process associated with FAI. Methods: Ten male patients with a mean age of 34.3 years (range, 23.1 to 46.5 years) and a mean body mass index (and standard deviation) of 26.66 ± 4.79 kg/m2 underwent corrective surgery for cam deformity in association with FAI. Each patient underwent a computed tomography (CT) scan to assess acetabular bone mineral density (BMD), high-resolution T1&rgr; magnetic resonance imaging (MRI) of the hips to assess proteoglycan content, and squatting motion analysis as well as completed self-administered functional questionnaires (Hip disability and Osteoarthritis Outcome Score [HOOS]) both preoperatively and 2 years postoperatively. Results: At a mean follow-up of 24.5 months, improvements in functional scores and squat performance were seen. Regarding the zone of impingement in the anterosuperior quadrant of the acetabular rim, the mean change in BMD at the time of follow-up was −31.8 mg/cc (95% confidence interval [CI], −11 to −53 mg/cc) (p = 0.008), representing a 5% decrease in BMD. The anterosuperior quadrant also demonstrated a significant decrease in T1&rgr; values, reflecting a stabilization of the cartilage degeneration. Significant correlations were noted between changes in clinical functional scores and changes in T1&rgr; values (r = −0.86; p = 0.003) as well as between the BMD and maximum vertical force (r = 0.878; p = 0.021). Conclusions: Surgical correction of a cam deformity in patients with symptomatic FAI not only improved clinical function but was also associated with decreases in T1&rgr; values and BMD. These findings are the first, to our knowledge, to show that alteration of the hip biomechanics through surgical intervention improves the overall health of the hip joint. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Acetabular and spino-pelvic morphologies are different in subjects with symptomatic cam femoro-acetabular impingement: ACETABULAR AND SPINOPELVIC MORPHOLOGY IN FAI

Acetabular and spino‐pelvic (SP) morphological parameters are important determinants of hip joint dynamics. This prospective study aimed to determine whether acetabular and SP morphological differences exist between hips with and without cam morphology and between symptomatic and asymptomatic hips with cam morphology. A cohort of 67 patients/hips was studied. Hips were either asymptomatic with no cam (Controls, n = 18), symptomatic with cam (n = 26) or asymptomatic with cam (n = 23). CT‐based quantitative assessments of femoral, acetabular, pelvic, and spino‐pelvic parameters were performed. Measurements were compared between controls and those with a cam deformity, as well as between the three groups. Morphological parameters that were independent predictors of a symptomatic cam were determined using a regression analysis. Hips with cam deformity had slightly smaller subtended angles superior‐anteriorly (87° vs. 84°, p = 0.04) and greater pelvic incidence (53° vs. 48°, p = 0.003) compared to controls. Symptomatic cams had greater acetabular version (p < 0.01), greater subtended angles superiorly and superior‐posteriorly (p = 0.01), higher pelvic incidence (p = 0.02), greater alpha angles and lower femoral neck‐shaft angles compared to asymptomatic cams (p < 0.01) and controls (p < 0.01). The four predictors of symptomatic cam included antero‐superior alpha angle, femoral neck‐shaft angle, acetabular depth, and pelvic incidence. In conclusion, this study illustrates that symptomatic hips had a greater amount of supero‐posterior coverage; which would be the contact area between a radial cam and the acetabulum, when the hip is flexed to 90°. Furthermore, individuals with symptomatic cam morphology had greater PI. Acetabular‐ and SP parameters should be part of the radiological assessment of femoro‐acetabular impingement.