Kyoung Hwan Koh

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.

Prospective Randomized Clinical Trial of Single- Versus Double-Row Suture Anchor Repair in 2- to 4-cm Rotator Cuff Tears: Clinical and Magnetic Resonance Imaging Results

PURPOSE The purpose of this study was to compare the clinical outcomes and the retear rates of arthroscopic single-row (SR) and double-row (DR) suture anchor repair in 2- to 4-cm rotator cuff tears. METHODS From 2005 to 2007, 71 patients with a 2- to 4-cm rotator cuff tear (proven by arthroscopy) were prospectively randomized to SR and DR repair groups. Of these patients, 62 (31 in each group) were available for evaluation at final follow-up. Demographic data, clinical scores, mean surgical times, and patient satisfaction were compared. Retear rates and clinical scores were also analyzed for 47 patients who underwent follow-up magnetic resonance imaging. RESULTS Comparisons of demographic data, tear size on preoperative magnetic resonance imaging, global fatty degeneration index, and concomitant procedures showed no differences between the SR and DR groups. Preoperative clinical scores were significantly improved postoperatively in both groups. No intergroup differences in pain visual analog scale, American Shoulder and Elbow Surgeons, Constant, or University of California, Los Angeles scores were found at final follow-up. Only mean surgical time was significantly different between the 2 groups. In the SR group, there were 4 full-thickness retears and 11 partial-thickness retears, whereas in the DR group, there were 6 full-thickness retears and 1 partial-thickness retear. However, despite numerical differences, these differences were not statistically different. Statistically, there were no significant differences both in full-thickness retear (P = .999) and retear including partial-thickness tear between the 2 groups (P = .124). CONCLUSIONS This study indicates that the clinical results and retear rates of DR repair with 1 additional medial suture anchor were not significantly different from those of SR repairs with 2 lateral suture anchors in patients with medium to large rotator cuff tear. LEVEL OF EVIDENCE Level I, randomized controlled trial.

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.

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.

Clinical and Second-Look Arthroscopic Evaluation of Repaired Medial Meniscus in Anterior Cruciate Ligament—Reconstructed Knees

Background Tears of the medial meniscus posterior horn (MMPH) are frequently found in knees with deficient anterior cruciate ligaments (ACLs). There are few studies that have evaluated healing of the menisci and the factors associated with healing. Hypothesis The repaired menisci would show good healing in the knees with reconstructed ACLs, and the healing capacity of the menisci would differ according to the size, type, and location of the tear as well as the age and gender. Study Design Case series; Level of evidence, 4. Methods From August 1997 to February 2007, 311 knees underwent MMPH repair using either a modified all-inside or inside-out technique with concomitant ACL reconstruction. Among these patients, a second-look arthroscopy was performed at a mean of 37.7 months postoperatively (range, 12-128 months) in 140 patients. Clinical parameters and outcomes were evaluated. The repaired menisci were divided into complete, incomplete, and failure-to-heal groups. The factors associated with meniscal healing were statistically assessed. Results Among 140 patients, 118 (84.3%) showed complete healing, 17 (12.1%) had incomplete healing, and 5 (3.6%) failed to heal. The clinical success rate was 96.4% (135/140) because patients in the incomplete group showed no clinical symptoms associated with meniscal tears. Healing was associated with the tear location (P < .001) and type of tear (P = .0237) on the univariate analysis and the location (P = .0401) only on the multivariate analysis. Conclusion Repaired MMPH tears in knees with reconstructed ACLs healed without complications and had satisfactory clinical results. The tear location and type were factors associated with healing on the univariate analysis and location only on the multivariate analysis.

The outcome of ultrasound-guided needle decompression and steroid injection in calcific tendinitis

HYPOTHESIS Needle lavage is frequently performed before consideration of surgical removal in shoulders with calcific tendinitis because this may avoid surgery. However, its role in nonoperative treatment has not been fully investigated in terms of clinical and radiographic response. We hypothesized that needle decompression and subacromial steroid injection would show good clinical results in chronic calcific tendinitis patients. MATERIALS AND METHODS Thirty-five shoulders in 30 consecutive patients with painful calcific tendinitis were treated by ultrasound-guided needle decompression and subacromial corticosteroid injection. Patients were prospectively evaluated using American Shoulder and Elbow Surgeons (ASES) and Constant scores at 1, 3, and 6 months after the intervention. Size and morphology of the calcific deposits were compared with those in baseline radiographs at each visit. RESULTS At 6 months after the index procedure, 25 shoulders (71.4%) showed ASES and Constant score improvements from 48.0 and 53.7 to 84.6 and 87.9, respectively (P < .01). Ten shoulders (28.6%) showed no symptom relief at the last follow-up. In shoulders with pain improvement, the mean size of calcific deposits reduced from 13.6 to 5.6 mm (P < .01), and in shoulders with no pain improvement or that underwent operation, mean size was 13.1 mm at initial visits and 12.7 mm at final visits (P = .75). DISCUSSION Shoulders showing little evidence of deposit size reduction at 6 months after needle decompression are less likely to achieve symptomatic improvement and may be considered as candidates for surgical removal. CONCLUSION Needle decompression with subacromial steroid injection is effective in 71.4% of calcific tendinitis within 6 months. The size of calcific deposits in patients that achieved symptom relief was reduced.

Patient-Related Factors and Complications After Arthroscopic Tenotomy of the Long Head of the Biceps Tendon

Background: Tenotomy of the long head of the biceps tendon (LHBT) has been reported to provide reliable pain relief and require little postoperative rehabilitation. Complications such as cosmetic deformity, decrease in elbow flexion strength, decrease in supination strength, and fatigue discomfort have been reported after tenotomy of the LHBT. Purpose: To evaluate the complications of arthroscopic tenotomy of the LHBT in the shoulder–specifically, cosmetic deformity, decreased elbow flexion strength, and a cramplike arm pain–and to identify the patient-related factors that affect the rate of complications after tenotomy, such as, age, sex, involvement of the dominant arm, and body mass index (BMI). Study Design: Case series; Level of evidence, 4. Methods: In sum, 132 patients were evaluated. They had a mean age of 63 years (range, 26 to 82 years) at the time of surgery and a mean follow-up of 21 months (range, 12 to 53 months). The presence of so-called Popeye deformity, a cramplike arm pain at resisted elbow flexion, and strength of elbow flexion were evaluated. The development of each complication was compared by age, sex, involvement of the dominant arm, and BMI. Results: Of the 132 patients, 60 (45%) had Popeye deformity, and it was significantly more frequent in men (76%) than women (31%) (P < .001). However, statistical analysis showed no difference in Popeye deformity frequency by age, arm dominance, or BMI. Male sex was found to be the only risk factor associated with the development of Popeye deformity, with an odds ratio of 10.21 versus women (95% confidence interval, 3.97 to 26.27; P < .001). Ten patients (8%) complained of a cramplike arm pain. Elbow flexion strength decreased in 60 patients (45%), although no intergroup differences were found for elbow flexion strength. Conclusion: The current study showed a 45% prevalence of Popeye deformity and 8% cramplike arm pain on exertion after tenotomy of the LHBT. Among patient factors such as sex, age, dominant arm relation, and body mass index, the male sex was the only factor correlated with occurrence of a Popeye deformity. Other factors did not show any correlation with deformity, elbow flexion strength, and cramplike arm pain.

Effect of Immobilization without Passive Exercise After Rotator Cuff Repair Randomized Clinical Trial Comparing Four and Eight Weeks of Immobilization

BACKGROUND While animal studies have shown better healing with a longer duration of protection without motion exercise after rotator cuff repair, supporting clinical studies are rare. The purpose of this study was to assess the effect of immobilization following rotator cuff repair and to determine whether there was any difference in clinical outcome related to the duration of immobilization. METHODS One hundred patients who underwent arthroscopic single-row repair of a posterosuperior rotator cuff tear (mean, 2.3 cm in the coronal-oblique plane and 2.0 cm in the sagittal-oblique plane) were prospectively randomized to be treated with immobilization for four or eight weeks. During the immobilization period, no passive or active range-of-motion exercise, including pendulum exercise, was allowed. According to the intention-to-treat protocol and full analysis set, eighty-eight patients were evaluated clinically and with magnetic resonance imaging postoperatively, after exclusion of twelve patients without postoperative clinical evaluation. Ranges of motion, clinical scores, and retear rates were compared between the four and eight-week groups. Ninety-eight patients were contacted by telephone at a mean of thirty-five months to investigate the clinical outcomes. RESULTS The mean duration of immobilization was 4.1 weeks in the four-week group and 7.3 weeks in the eight-week group. There were nine full-thickness retears (10%), and 89% of the patients rated their result as excellent or good. There were five full-thickness retears in the four-week group and four in the eight-week group (p = 0.726). At the time of final follow-up, the two groups showed no differences in range of motion or clinical scores. However, the proportion showing stiffness was higher in the eight-week group (38% compared with 18%, p = 0.038). CONCLUSIONS Eight weeks of immobilization did not yield a higher rate of healing of medium-sized rotator cuff tears compared with four weeks of immobilization.

Serial structural and functional assessments of rotator cuff repairs: do they differ at 6 and 19 months postoperatively?

BACKGROUND Some studies have shown that rotator cuff tendon (RCT) retears occur early after surgery and ultimate failure strength is reached at between 3 and 6 months. However, few clinical studies have been reported to support their theory. The purpose of this study was to determine whether the RCT integrity after repair showed any difference at 6 months and at 19 months postoperatively. METHODS Thirty-one patients who underwent complete repair for full-thickness RCT tears that were medium-sized tears or larger and had 2 postoperative follow-up magnetic resonance imaging (MRI) scans were included in this study. Retear, fatty degeneration, and muscle atrophy were evaluated during the first and second MRI sessions. Clinical assessment was performed by use of the American Shoulder and Elbow Surgeons score, Constant score, and pain visual analog scale preoperatively and at the time of the first and second MRI scans. RESULTS The mean time for the two consecutive MRI scans was 5.9 months (range, 3.1-8.3 months) and 19.7 months (range, 10.1-24.3 months). On the first MRI scans, 24 patients had no retear, 5 had partial retears, and 2 had full-thickness retears. In terms of rotator cuff retears, the 2 sets of MRI scans showed exactly the same statuses. The only statistically significant improvement was a reduction in tendinosis on the second MRI scans. In addition, significant improvements in clinical status were observed between the 2 periods. CONCLUSION Our study shows that the structural status of RCTs after arthroscopic repair can be assessed at 6 months after surgery. Furthermore, although functional status improved with time after 6 months, the structural status of repaired cuffs remained unchanged.