Keun Jung Ryu

Clinical and Radiographic Outcomes After Arthroscopic Repair of Massive Rotator Cuff Tears Using a Suture Bridge Technique: Assessment of Repair Integrity on Magnetic Resonance Imaging

Background: High retear rates of arthroscopic massive rotator cuff repair have been reported with relatively satisfactory functional outcomes. Purpose: To assess the clinical and radiological outcomes of an arthroscopic repair of massive rotator cuff tears using a suture bridge technique. We also aimed to explore the various factors that may affect retears. Study Design: Case-control study; Level of evidence, 3. Methods: Sixty-six patients included in the study were divided into 2 groups according to the presence of retears on magnetic resonance imaging (MRI) evaluation at a minimum of 1 year after surgery. We evaluated the visual analog scale (VAS) for pain during motions, the University of California, Los Angeles (UCLA) score, and the absolute and relative Constant scores (mean follow-up, 25.4 months). Results: Twenty-eight of the 66 patients (42.4%) in this study had a retear. At the final follow-up visit, pain VAS, UCLA score, and absolute and relative Constant scores in the completely healed group were significantly superior to those in the retear group, with 2, 29.5, 76.0, and 95.2 points and 4, 26.0, 70.6, and 87.3 points, respectively (P < .05). From univariate analysis, the preoperative mean acromiohumeral distance, extent of retraction, and degree of fatty infiltration of the supraspinatus and infraspinatus were significantly different between the completely healed (7.83 mm, 2.97 cm, 1.74, and 0.71, respectively) and the retear group (6.36 mm, 3.97 cm, 2.54, and 2.07, respectively; P < .05). From multivariate logistic regression analysis, the preoperative degree of fatty infiltration of the infraspinatus and extent of retraction were the 2 most important factors associated with retears. Conclusion: Arthroscopic repair of massive rotator cuff tears using a suture bridge technique has a relatively high retear rate, and these structural failures appear to have a significant difference in clinical outcomes compared with the healed group. Degree of fatty infiltration of the infraspinatus and extent of retraction are the 2 most important factors associated with a retear. Orthopaedic surgeons should predict the possibility of retear before surgery and counsel patients about their expected functional results.

Retear Rate in the Late Postoperative Period After Arthroscopic Rotator Cuff Repair

Background: Few clinical studies have evaluated the integrity of repaired tendons and identified the timing of retears through the use of serial imaging. Hypothesis: Retears after arthroscopic rotator cuff repair are uncommon in the late postoperative period (after 3 months). Study Design: Case series; Level of evidence, 4. Methods: Among 221 arthroscopic rotator cuff repairs that were performed at a single hospital between May 2010 and February 2012, 61 were involved in this study. Rotator cuff tears consisted of 12 small, 31 medium, 8 large, and 6 massive rotator cuff tears. Additionally, 4 isolated subscapularis tears were included. For clinical evaluation, all patients were assessed both preoperatively and postoperatively by use of the University of California–Los Angeles Shoulder Rating Scale, absolute and relative Constant scores, and American Shoulder and Elbow Surgeons score; active range of motion was assessed as well. For radiological evaluation, all 61 patients had a magnetic resonance imaging (MRI) evaluation at 3 months postoperatively. Among them, 23 patients were evaluated for repaired tendon integrity on postoperative MRI at a minimum of 1 year after surgery (mean, 14.1 months; range, 12-19 months), and results were classified according to the Sugaya classification: type I, sufficient thickness with homogeneously low intensity on each image; type II, sufficient thickness, partial high-intensity area; type III, less than half the thickness without discontinuity; type IV, minor discontinuity; and type V, major discontinuity. The remaining 38 patients, who refused to undergo MRI again for financial reasons, were evaluated through ultrasound. Results: Statistically significant clinical improvements were observed after surgery. The MRI conducted at 3 months postoperatively identified 9 patients with Sugaya type I, 28 patients with type II, and 24 patients with type III repairs. No patients showed Sugaya type IV or V repairs at postoperative 3 months. Thirty-seven patients who had shown Sugaya type I or II repairs on 3-month postoperative MRI had no retear on imaging study at a minimum of 1 year. Of 24 patients who had shown type III repairs on 3-month postoperative MRI, 1 patient exhibited retear (Sugaya type IV) on 1-year postoperative MRI and 3 patients showed full-thickness retear on 1-year postoperative ultrasonography. All 4 of these patients had had large to massive tears preoperatively. Conclusion: Retears occurred infrequently in the late postoperative period (after 3 months) in well-healed tendons that had shown intact cuff repair integrity with sufficient mechanical and biological healing within the first 3 postoperative months.

Reamed Intramedullary Nailing has an Adverse Effect on Bone Regeneration During the Distraction Phase in Tibial Lengthening.

BackgroundThe lengthening over nail (LON) technique has gained popularity because it enables shorter periods of external fixation, prevents deformities during lengthening, and reduces the risk of refracture after removal of the frame compared with the classic Ilizarov method. However, it is not clear if the violation of endosteal blood supply by reamed intramedullary nailing in the LON technique has a negative effect on bone regeneration or a positive effect by compensatory enhancement of periosteal circulation.Questions/purposesThe purposes of this study were to (1) compare the amount of regenerate bone during the distraction phase between two tibial lengthening techniques, the LON technique and lengthening and then nail (LATN) technique; and (2) compare callus shape at the end of the distraction phase using the classification of Li et al.MethodsThis is a retrospective study comparing two treatment groups. Between September 2011 and June 2013, 120 patients underwent bilateral lower leg lengthening for familial short stature with either the LON or LATN technique, and were considered potentially eligible for inclusion in this retrospective, comparative study. During this same period, LON and LATN techniques were used in other patient populations, but all patients with familial short stature were considered for inclusion in the study. The specific contraindications for LON were diameter of the isthmus of the tibia narrower than 8 mm, length of the tibia shorter than 270 mm, and alignment of the lower extremity in valgus; in patients without these specific contraindications to LON, patients were offered either LATN or LON after counseling regarding the advantages and disadvantages of each procedure. The proposed advantages of LATN were shorter healing index and more stable internal fixation which might lead to earlier full weightbearing, whereas proposed disadvantages were a greater chance for deep infection, more deformity during lengthening, and subsequently longer external fixator period for correction. The groups were comparable in terms of age, sex distribution, smoking history, BMI, distraction rate, and final length gain. A longer period of external fixation was necessary in the LATN group, related to the relative stability of the segment without an intramedullary nail. Patients with tibial lengthening with the LON technique (31 patients, 62 tibiae) were compared with patients who had the LATN technique (89 patients, 178 tibiae) regarding the amount of bone regeneration at the anterior, posterior, medial, and lateral cortices of the lengthened area for each at 4, 8, and 12 weeks postoperatively using a pixel value ratio method. In addition, both groups were compared for callus shape and type at the end of the distraction phase (LON, 3.4 ± 0.06 months; LATN, 4.2 ± 0.05 months).ResultsThe pixel value ratios of the anterior, posterior, medial, and lateral cortices in the LON and LATN groups were 0.78 ± 0.06 and 0.74 ± 0.05; 0.82 ± 0.08 and 0.76 ± 0.05; 0.75 ± 0.06 and 0.72 ± 0.05; and 0.85 ± 0.06 and 0.82 ± 0.06, respectively at 4 weeks postoperatively(p value > 0.500 for all); 0.75 ± 0.05 and 0.77 ± 0.04; 0.78 ± 0.05 and 0.89 ± 0.04; 0.73 ± 0.05 and 0.82 ± 0.05; and 0.78 ± 0.06 and 0.88 ± 0.03, respectively at 8 weeks postoperatively (p value < 0.001 for the posterior, medial, and lateral cortices); 0.72 ± 0.05 and 0.76 ± 0.03; 0.75 ± 0.07 and 0.89 ± 0.03; 0.71 ± 0.05 and 0.82 ± 0.03; and 0.78 ± 0.06 and 0.91 ± 0.03, respectively at 12 weeks postoperatively (p value < 0.001 for the posterior, medial, and lateral cortices). A greater percentage of tibiae having the generally favored fusiform-shaped callus were seen with the LATN technique (61 of 178 segments) than with the LON technique (four of 62 segments; p < 0.001). There were no tibia showing the inferior concave, lateral, or central-shaped callus with the LATN technique, whereas eight tibiae (eight of 62 segments) showed concave-shaped callus with the LON technique (p < 0.001).ConclusionsThe potentially negative effect on callus regeneration from the concomitant use of reamed intramedullary nailing during the LON technique should not be overlooked. Based on our study, LATN may be a better choice for patients willing to accept the longer period of external fixation.Level of EvidenceLevel III, therapeutic study.

Modified Suture-Bridge Technique to Prevent a Marginal Dog-Ear Deformity Improves Structural Integrity After Rotator Cuff Repair

Background: The arthroscopic suture-bridge technique has proved to provide biomechanically firm fixation of the torn rotator cuff to the tuberosity by increasing the footprint contact area and pressure. However, a marginal dog-ear deformity is encountered not infrequently when this technique is used, impeding full restoration of the torn cuff. Purpose: To evaluate the structural and functional outcomes of the use of a modified suture-bridge technique to prevent a marginal dog-ear deformity compared with a conventional suture-bridge method in rotator cuff repair. Study Design: Cohort study; Level of evidence 2. Methods: A consecutive series of 71 patients aged 50 to 65 years who underwent arthroscopic rotator cuff repair for full-thickness medium-sized to massive tears was evaluated. Patients were divided into 2 groups according to repair technique: a conventional suture-bridge technique (34 patients; group A) versus a modified suture-bridge technique to prevent a marginal dog-ear deformity (37 patients; group B). Radiographic evaluations included postoperative cuff integrity using MRI. Functional evaluations included pre- and postoperative range of motion (ROM), pain visual analog scale (VAS), the University of California, Los Angeles (UCLA) shoulder rating scale, the Constant score, and the American Shoulder and Elbow Surgeons (ASES) score. All patients were followed up clinically at a minimum of 1 year. Result: When the 2 surgical techniques were compared, postoperative structural integrity by Sugaya classification showed the distribution of types I:II:III:IV:V to be 4:20:2:4:4 in group A and 20:12:4:0:1 in group B. More subjects in group B had a favorable Sugaya type compared with group A (P < .001). The postoperative healed:retear rate was 26:8 in group A and 36:1 in group B, with a significantly lower retear rate in group B (P = .011). However, there were no significant differences in ROM and all functional outcome scores between the 2 groups postoperatively. When surgical techniques were compared across healed (n = 62) and retear (n = 9) groups, significantly fewer modified suture-bridge technique repairs were found in the retear group (P = .03). There were significant differences between healed and retear groups in functional outcome scores, with worse results in the retear group. Conclusion: A modified suture-bridge technique to prevent a marginal dog-ear deformity provided better structural outcomes than a conventional suture-bridge technique for medium-sized to massive rotator cuff tears. This technique may ultimately provide better functional outcomes by decreasing the retear rate.

Case of genochondromatosis type I in an 8-year-old boy

Case of Genochondromatosis Type I in an 8-Year-Old Boy Yoon Seok Lee, Jinmyoung Dan,* Keun Jung Ryu, Byung Kook Kim, Soo-Hong Han, and Hyeong Jong Kim Department of Orthopaedic Surgery, CHA Gumi Medical Center, School of Medicine, CHA University, Gumi-si, Kyungsangbuk-do, Republic of Korea Department of Orthopaedic Surgery, CHA Bundang Medical Center, School of Medicine, CHA University, Seongnam-si, Gyeonggi-do, Republic of Korea

Low Serum Vitamin D Is Not Correlated With the Severity of a Rotator Cuff Tear or Retear After Arthroscopic Repair

Background: Despite the essential role of vitamin D in muscle function, the prevalence of vitamin D deficiency has been reported to be very high. Recently, low vitamin D level was found to correlate with fatty degeneration of the rotator cuff tendon in humans and to negatively affect early healing at the rotator cuff repair site in an animal study. However, the effects of vitamin D level on severity of rotator cuff tear and healing after surgical repair have not been documented. Purpose: To evaluate (1) the prevalence of vitamin D deficiency among patients who underwent arthroscopic repair for a full-thickness rotator cuff tear, (2) the relationship of vitamin D level with severity of the rotator cuff tear, and (3) surgical outcomes after repair. Study Design: Cohort study; Level of evidence, 2. Methods: A consecutive series of 91 patients (age, 50-65 years) who underwent arthroscopic rotator cuff repair for full-thickness, small-sized to massive tears were evaluated. Preoperative serum vitamin D levels (25-hydroxyvitamin) were analyzed to detect correlations with the features of a preoperative rotator cuff tear as well as postoperative structural and functional outcomes. All patients were followed clinically for a minimum of 1 year. Results: Preoperative vitamin D levels were deficient (<20 ng/mL) in 80 subjects (88%), insufficient (20-30 ng/mL) in 8 subjects (9%), and normal (>30 ng/mL) in 3 subjects (3%). No correlation was found between preoperative tear size (P = .23), extent of retraction (P = .60), degree of fatty infiltration of each cuff muscle (P > .50 each), or the global fatty infiltration index (P = .32). Similarly, no correlations were detected between vitamin D level and postoperative Sugaya type (P = .66) or any of the functional outcome scores (P > .50 each). Conclusion: Low serum vitamin D level was not related to tear size, extent of retraction, or the degree of fatty infiltration in cuff muscles. It also had no significant relationships with postoperative structural integrity and functional outcomes after arthroscopic repair. The results suggest that low serum vitamin D level is not a significant risk factor for the severity of rotator cuff tear or poor healing after repair.

CORR Insights®: Does Tourniquet Use in TKA Affect Recovery of Lower Extremity Strength and Function? A Randomized Trial

T ourniquet use during TKA [1] offers better visibility, decreases intraoperative bleeding, and helps in cement-bone interdigitation during surgery [4, 10]. Despite these benefits, the development of thromboembolic events like deep venous thrombosis [2, 13], pulmonary embolism [5], or multiple cerebral and cardiac microemboli [8, 9] all remain a concern when considering tourniquet use. Other complications include increased leg swelling and pain after release [11, 12], tourniquet-induced wound problems [7], peripheral nerve injury [6], or decreased knee ROM [3]. Although there are ongoing debates regarding the pros and cons of tourniquet use, no sufficient investigations have beenmade on its possible negative effect on the recovery of lower extremity strength and function, which are vital to postsurgical recovery. The current study by Dennis and colleagues adds to our understanding by finding greater postoperative quadriceps strength and lesser pain for patients in the nontourniquet cohort. In contrast, researchers found no differences in hamstring strength, quadriceps voluntary activation, or unilateral balance ability in patients who underwent bilateral simultaneous TKA. Additionally, the study results found more intraoperative blood loss in the nontourniquet group, but no differences in total blood loss or operative time when compared to the group undergoing same-day bilateral TKA.

Is there an Increase in Valgus Deviation in Tibial Distraction Using the Lengthening Over Nail Technique

BackgroundDuring tibial lengthening, the soft tissues of the posterolateral compartment produce distraction-resisting forces causing valgus angulation. Although this occurs with the classic Ilizarov method, whether a valgus deformity develops with the lengthening over nail (LON) technique is questioned, because the intramedullary nail is thought to resist deforming forces and adequately maintain alignment of the distracted bone.Questions/purposesThe purposes of this study were to (1) determine the amount of valgus deviation during tibial lengthening with the LON technique; and (2) analyze the factors that may be associated with valgus deviation with the LON technique.MethodsBetween June 2009 and September 2013, we performed 346 tibial lengthenings using the LON technique, lengthening and then nail technique, or lengthening with an intramedullary lengthening device. Sixty patients (120 tibias) who underwent bilateral lower leg lengthening with the LON technique were enrolled in this retrospective study. To limit the number of variables, we analyzed only the right tibia in all patients (60 tibias). The mean followup was 42 months (range, 26–71 months). The mean age of the patients was 25 years (range, 18–40 years). There were 36 male and 24 female patients. The mean final length gain was 67 ± 9 mm. The mean time for distraction was 100 ± 25 days. The overall valgus deviation was assessed by measuring the change in the medial proximal tibial angle and mechanical femorotibial angle on radiographs obtained before and after surgery and after completion of lengthening. Several demographic, surgical, and distraction-related variables were considered possible factors to prevent valgus deviation: proximal fixation method; presence of a blocking screw; diameter and length of the intramedullary nail; degree of nail insertion; length of the nail in the distal segment after completion of distraction; final length gain; and patient’s BMI. During the period studied, the blocking screw was to maintain the mechanical axis in patients who had neutral or valgus alignment preoperatively, or to prevent more valgus change in patients who underwent acute correction of varus deformity intraoperatively. Uni- and multivariate analyses were conducted.ResultsValgus deviation occurred during the tibial LON. The medial proximal tibial angle increased from 86° (95% CI, 85°–86°) to 90° (95% CI, 89°–91°) (p < 0.001). The mechanical femorotibial angle changed from 2.2° varus (95% CI, 3°–1.4° varus) to 2.6° valgus (95% CI, 1.8°–3.4° valgus) (p < 0.001). Valgus deviation was evident in proximal and distal segments. In the multivariate regression model, use of a blocking screw was the only factor that was associated with decreased valgus deviation, and its effect size, although detectable, was small (−2.62; 95% CI, −4.65 to −0.59; p = 0.013).ConclusionsWe found that valgus deviation does occur during tibial lengthening using the LON technique, but that blocking screw placement may help to minimize the likelihood that severe valgus deviation will occur. Future prospective studies should be conducted to confirm this preliminary finding.Level of EvidenceLevel III, therapeutic study.

Fixator-assisted Technique Enables Less Invasive Plate Osteosynthesis in Medial Opening-wedge High Tibial Osteotomy: A Novel Technique

Background Opening-wedge high tibial osteotomy is a well-established procedure in the management of medial osteoarthritis of the knee and correction of proximal tibia vara. Recently, surgical approaches using less invasive plate osteosynthesis have been used with the goal of minimizing complications from more extensive soft tissue exposures. However, to our knowledge, less invasive fixator-assisted plate osteosynthesis has not been tested in the setting of opening-wedge high tibial osteotomy.

CORR Insights®: Cardiovascular and Cerebrovascular Events Are Associated With Nontraumatic Osteonecrosis of the Femoral Head

Nontraumatic osteonecrosis of the femoral head (ONFH) is a clinically important pathologic process that leads to pain and disability and often results in hip replacement. It is known to be associated with long-term use of corticosteroids, alcohol abuse, and coagulopathies [4, 7, 10]. However, its pathogenesis remains poorly understood, and several biological mechanisms have been suggested, including interruption of extraosseous blood supply to the femoral head by multiple nontraumatic stresses, intraosseous hypertension by altered lipid metabolism and its accumulation to the femoral head, and intravascular coagulopathies with various causes [3, 8, 9]. Endothelial (progenitor) cell dysfunction and inadequate nitric oxide production, which is known to be associated with atherosclerosis and the development of major adverse cardiovascular and cerebrovascular events (MACCE), may also be associated with ONFH [1, 5, 11]. The current study by Sung and colleagues [12] helps us better understand the relationship between MACCE and ONFH, and in it, the authors suggest that a mechanism could be a shared pathophysiology between MACCE and ONFH, such as endothelial (progenitor) cell dysfunction, although in an observational study of this sort, there is no way to prove this contention. Where Do We Need to Go?