Kyung-Soo Oh

Clinical and Radiological Outcomes of Type 2 Superior Labral Anterior Posterior Repairs in Elite Overhead Athletes

Background: Although there are multiple reports on surgical outcomes of type 2 superior labral anterior posterior (SLAP) repairs, a literature review noted a paucity of data on clinical and radiological outcomes in elite overhead athletes. Purpose: To determine midterm clinical outcomes of type 2 SLAP repairs in elite overhead athletes and whether labral integrity provides consistent return to play. Study Design: Case series; Level of evidence, 4. Methods: Medical records were retrospectively reviewed of 24 elite overhead athletes who underwent arthroscopic type 2 SLAP repairs. There were 18 men and 6 women, and their mean age was 22.7 years (range, 19-30 years); the majority of them (16/24) were baseball players. Four outcome measures were used: visual analog scale (VAS) for pain and satisfaction, American Shoulder and Elbow Surgeons (ASES) score, subjective feeling of recovery, and return to play. Multidetector computed tomographic arthrography was performed to evaluate labral integrity after surgery. Results: At a mean follow-up of 45.8 months (range, 24-68 months), overall pain and function improved significantly. The VAS for pain was 5.7 preoperatively and 2.0 postoperatively (P < .01), and VAS for satisfaction was 8.6. The ASES score was 55.8 preoperatively and 87.1 postoperatively (P < .01). The overall mean value of subjective feeling of recovery was approximately 76%. Twelve of 24 athletes (50%) returned to play after the operation. Although there was a trend toward higher return rate in the other overhead athletes (75%) compared with the baseball players (38%), this trend did not reach statistical significance (P = .097). Labral retear with clinical significance was noted in 2 athletes who failed to return to play. Osteolysis was observed in 2 athletes, 1 of whom had a retear. A statistical relation between the integrity of the repair and return to play was not found (P > .05). Conclusion: Arthroscopic SLAP repairs show favorable clinical and radiological outcomes; however, the study findings raise a concern that return to play may still be problematic in elite baseball players. This study also indicates that labral healing does not ensure consistent return to play in elite overhead athletes.

The effect of physical characteristics and field position on the shoulder and elbow injuries of 490 baseball players: confirmation of diagnosis by magnetic resonance imaging.

Objective:To evaluate the distribution of shoulder and elbow injuries confirmed by magnetic resonance imaging in throwing athletes. Study Design:Descriptive epidemiological study. Setting:Tertiary institution. Participants:Five hundred fifty-four baseball players referred to our institute for shoulder and elbow rehabilitation. Interventions:All injured players except those with fractures underwent magnetic resonance imagings, which were read by a radiologist, and players were diagnosed by orthopedic surgeons based on the clinical and imaging findings. Main Outcome Measures:Analysis of baseball-related injuries was performed according to the physical characteristics of each athlete and his positions on the team. Results:Junior high school players sustained a higher proportion of osteochondritis dissecans compared with high school and collegiate players. High school and collegiate players were more likely to have ulnar collateral ligament (UCL) injuries or superior labrum anterior-posterior (SLAP) lesions than junior high school players. Pitchers and outfielders were more likely to have UCL injuries than the infielders. In the junior high school group, the players with UCL injuries were taller and heavier than the players in the control group. In the high school group with UCL injuries or SLAP lesions, the players were both taller and heavier than the players in the control group. Conclusions:These data support the conclusion that there is a significant difference in the distribution of injuries according to the players age and position. For the age-matched comparison, taller and heavier players are more likely to be affected by UCL injury or SLAP lesion.

Modification of serine 392 is a critical event in the regulation of p53 nuclear export and stability

Although it has been shown that phosphorylations of p53 serine its residues are critical events for the regulation of their function, the specific biological effects of each of these phosphorylations, especially at serine 392, remain to be elucidated. Serine 392 has been proposed to play a role in the tetramerization of p53 and in the enhancement of its DNA‐binding affinity. However, this is not consistent with other reports showing that substitution of serine 392 does not disrupt p53 function. These discrepancies suggest that modification of serine 392 may contribute to p53 activity through other transactivating pathways. In this study, we demonstrate that this C‐terminal serine residue (p53‐392S) in fact plays a critical role in the regulation of p53 stability such that substitution with alanine (p53‐392A) strongly enhances p53 stability without disrupting mouse double minute 2 binding. Additionally, the p53‐392A mutant is localized mainly in the nucleus, whereas both wild‐type p53 and a glutamic acid mutant, p53‐392E, are evenly distributed throughout the cytoplasm and nucleus. However, each of these p53 species had similar effects on both cell cycle inhibition and apoptosis, in response to either UV or adriamycin treatment. Moreover, p53‐392A protein was resistant to E6‐mediated degradation. Our results suggest that although serine 392 is not essential for the transactivation and nuclear import of p53, it exerts important effects upon p53 stability via the inhibition of its nuclear export mechanism.

Prospective Evaluation of the Effectiveness of a Home-Based Program of Isometric Strengthening Exercises: 12-Month Follow-up

Background The aim of this prospective randomized clinical trial was to investigate the efficacy of a home-based program of isometric strengthening exercises for the treatment of the lateral epicondylitis (LE) of the distal humerus. We hypothesized that 1) use of isometric strengthening exercises would result in clinical benefits similar to those provided by medication and pain relief and 2) functional improvements after exercise would be time-dependent. Methods Patients were assigned to one of two groups: 1) an immediate physical therapy group (group I), or 2) a delayed physical therapy group (group D). Group I patients (n = 16) were instructed how to do the exercises at their first clinic visit and immediately carried out the exercise program. Group D patients (n = 15) learned and did the exercises after being on medications for 4 weeks. Results Outcomes at the 1-month clinic visit indicated that pain (measured using a visual analogue scale [VAS]) had been significantly reduced in group I compared to group D (p < 0.01). However, significant differences between groups were not found at 3-, 6-, and 12-month follow-up for either VAS scores or Mayo elbow performance scores. For modified Nirschl/Pettrone scores, a significant difference between groups was found only at the 1-month follow-up visit. By then, the number of participants who returned to all activities with no pain or occasional mild pain was six (37%) in Group I and two (13%) in Group D (p = 0.031). At the final follow-up visit, 88% of all participants performed physical activities without pain. Conclusions Isometric strengthening exercises done early in the course of LE (within 4 weeks) provides a clinically significant improvement.

Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial

BACKGROUND The aim of this prospective randomized study was to compare the efficacy of 3 injection methods, intra-articular injection, subacromial injection, and hydrodilatation (HD), in the treatment of primary frozen shoulder. METHODS Patients with primary frozen shoulder were randomized to undergo intra-articular injection (n = 29), subacromial injection (n = 29), or HD (n = 28). Evaluations using a visual analog scale for pain, Simple Shoulder Test, Constant score, and passive range of shoulder motion were completed before treatment and 1 month, 3 months, and 6 months after treatment. RESULTS Among the 3 injection methods for primary frozen shoulder, HD resulted in a greater range of motion in forward flexion and external rotation, a lower visual analog scale score for pain after 1 month, and better outcomes for all functional scores after 1 month and 3 months of follow-up. However, there were no significant differences in any clinical outcomes among the 3 groups in the final follow-up at 6 months. CONCLUSIONS Although HD yielded more rapid improvement, the 3 injection methods for primary frozen shoulder resulted in similar clinical improvement in the final follow-up at 6 months.

Is Arthroscopic Coracoplasty Necessary in Subcoracoid Impingement Syndrome

PURPOSE The purpose of this study was to analyze the outcomes of arthroscopic coracoplasty in the treatment of subcoracoid impingement syndrome. METHODS We compared 23 shoulders that underwent arthroscopic coracoplasty for the treatment of subcoracoid impingement syndrome with 28 shoulders that did not undergo arthroscopic coracoplasty for the treatment of subcoracoid impingement syndrome, which comprised the control group. All the shoulders had subcoracoid and subacromial impingement syndrome with or without rotator cuff tear. Subcoracoid impingement was defined as a coracohumeral distance of less than 6 mm on the preoperative magnetic resonance image with anterior shoulder pain or tenderness. The 2 groups were further divided into several subgroups according to the size of concomitant rotator cuff tear, and a comparative analysis of functional outcomes after surgery among the subgroups was performed. RESULTS In the 2 groups, the overall functional outcomes improved after surgery. The study group showed a significant increase in internal rotation compared with that in the control group (P = .001) at the last follow-up. The large to massive rotator cuff tear subgroup of the study group showed a significant increase in internal rotation (P = .017). On the other hand, no significant difference was seen in the subgroups with small to medium rotator cuff tears including isolated subscapularis tears. The no rotator cuff tear subgroup of the study group showed a significant increase in internal rotation (P = .046). CONCLUSIONS Arthroscopic coracoplasty for subcoracoid impingement syndrome can provide a satisfactory outcome. In particular, a significant increase in internal rotation of the treated group was achieved after surgery in comparison with the untreated group, especially in the large to massive rotator cuff tear subgroup and in the no rotator cuff tear subgroup. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Arthroscopic repair of large U-shaped rotator cuff tears without margin convergence versus repair of crescent- or L-shaped tears.

Background: For large-sized tears of the rotator cuff, data according to the tear shape have not yet been reported for repair methodology, configuration, and subsequent integrity. Hypothesis: The retear rate after the repair of large mobile tears, such as crescent- or L-shaped tears, is believed to be lower compared with retear rates after the repair of large U-shaped tears that are accompanied by anterior or posterior leaves of the rotator cuff. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected and analyzed from 95 consecutive patients with a large-sized rotator cuff tear who underwent arthroscopic suture-bridge repair. Patients were divided into 2 groups: those having crescent- or L-shaped tears (mobile tear group, 53 patients) and those having U-shaped tears (U-shaped tear group, 42 patients). The integrity of the repaired constructs was determined by ultrasonography at 4.5, 12, and 24 months. Moreover, clinical evaluations were performed by using the Constant score, the American Shoulder and Elbow Surgeons (ASES) score, and muscle strength at intervals of 3, 6, 12, and 24 months postoperatively. Results: On ultrasonography at 4.5, 12, and 24 months, a retear was detected in 6, 2, and 1 patients in the mobile tear group and in 5, 2, and 1 patients in the U-shaped tear group, respectively. Significant differences in retear rates were not detected between the groups overall or at each time point. Moreover, clinical scores were similar between groups, except for the presence of a temporarily higher Constant score at 12 months in the mobile tear group. With regard to shoulder strength, between-group comparisons indicated no statistically significant difference, either in abduction or external rotation, except for the presence of temporarily higher external rotation strength at 3 months in the mobile tear group. Conclusion: Arthroscopic repair of large-sized rotator cuff tears yielded substantial improvements in shoulder function, regardless of tear retraction, during midterm follow-up. Moreover, the findings did not indicate significant differences in retear rates between the repair of crescent- or L-shaped tears and that of U-shaped tears either overall or at a particular time point.

Combined Subscapularis Tears in Massive Posterosuperior Rotator Cuff Tears: Do They Affect Postoperative Shoulder Function and Rotator Cuff Integrity?

Background: Previous studies on massive rotator cuff tears have not addressed the outcomes of tears extending to the subscapularis tendon. Hypothesis: The retear rate in patients with a massive posterosuperior rotator cuff tear combined with a subscapularis tear is higher than that in patients with a massive posterosuperior rotator cuff tear with an intact subscapularis tendon. Study Design: Cohort study; Level of evidence, 3. Methods: Data were collected and analyzed from 92 consecutive patients who underwent arthroscopic repair of a massive posterosuperior rotator cuff tear. Patients were divided into 3 groups according to the status of the subscapularis tendon: intact subscapularis tendon (I-massive tear; n = 42), tear involving half or less than half of the subscapularis tendon (S-massive tear; n = 22), and tear involving more than half of the subscapularis tendon (L-massive tear; n = 28). The integrity of the rotator cuff was determined by ultrasonography at 4.5 and 12 months or later after surgery. Clinical evaluations were performed using the visual analog scale (VAS) pain score, the American Shoulder and Elbow Surgeons (ASES) score, the Constant score, and active shoulder range of motion. Data were collected on the day before surgery and at final follow-up (at least 24 months postoperatively). Results: A total of 25 retears (27%) were identified based on an ultrasonographic evaluation. Although statistical significance was not found, there was a trend toward a higher retear rate in patients with an L-massive tear (43%) compared with those with an S-massive tear (18%; P = .050) or I-massive tear (21%; P = .059) at final follow-up. The subclassification of retears according to the involved tendons revealed that subsequent retears of the subscapularis tendon were noted only in patients with an L-massive tear. In patients with an L-massive tear, postoperative data comparison between patients with intact subscapularis tendons and those with failed subscapularis tendons revealed that a significant difference was noted in the VAS (1.1 vs 3.8, respectively) and ASES (90.6 vs 58.5, respectively) scores. The improvement in clinical scores after repair was statistically significant in all groups but not different between the groups. Conclusion: The arthroscopic repair of massive tears results in substantial improvements in shoulder function, regardless of the presence of combined subscapularis tears. However, this study showed a trend toward a high failure rate for the repair of massive posterosuperior rotator cuff tears extending over half of the subscapularis tendon. Therefore, other treatment options should also be considered for this type of rotator cuff tear.

Revisit to scapular dyskinesis: three-dimensional wing computed tomography in prone position

BACKGROUND Three-dimensional (3D) wing computed tomography (CT) showed a high inter-rater reliability in assessing scapular dyskinesis. METHODS The 330 scapular movements of 165 patients were classified into 4 types by 7 blinded observers. Then, 3D wing CT was performed with patients prone, and 4 blinded observers measured 5 angles, consisting of upward rotation (UR) superior translation (ST), anterior tilting (AT), protraction (PRO), and internal rotation (IR). The inter-rater reliability (IRR) of 2 methods was calculated, and cutoff values were determined for the 5 angles on the 3D wing CT images. RESULTS The IRR was 0.783 for the observational method of scapular dyskinesis and 0.981 for 3D wing CT in the prone position. UR and ST angles were significantly larger in type 3 more than in the other types (P < .001, P < .001), and the AT angle showed a similar pattern in type 1 (P < .001). The PRO angle was significantly larger in types 1, 2, and 3 more than in type 4 (P < .001, P < .001, P = .013), and the IR angle was significantly larger in type 2 more than in the other types (P < .001). The cutoff values of the 5 angles were UR, 117°; ST, 90°; AT, 8°; PRO, 99°; and IR, 51°. The UR angle showed a significant correlation with glenohumeral internal rotation deficit (odds ratio, 0.436; P = .029) and the IR angle with MDI (odds ratio, 8.947; P = .048). CONCLUSION The patients with a high UR angle showed a low rate of glenohumeral internal rotation deficit and those with a high IR angle had a high rate of the MDI in affected shoulder by the determinant of the cutoff value of the 5 angles. LEVEL OF EVIDENCE Level III, development of diagnostic criteria with nonconsecutive patients, diagnostic study.

Effect of Capsular Release in the Treatment of Shoulder Stiffness Concomitant With Rotator Cuff Repair Diabetes as a Predisposing Factor Associated With Treatment Outcome

Background: In spite of the high prevalence of shoulder stiffness during rotator cuff repair, optimal management remains unclear. Purpose: To identify the effect of capsular release during rotator cuff repair on the outcomes of patients with both shoulder stiffness and a rotator cuff tear, based on subgroup analyses. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-nine consecutive patients (mean age, 61.5 ± 8.3 years) were enrolled who underwent arthroscopic repair of a small- to large-sized full-thickness rotator cuff tear and manipulation for concomitant shoulder stiffness (passive forward flexion ≤120°, external rotation at the side ≤45°). The first 21 consecutive patients underwent manipulation alone to treat stiffness; the second 28 consecutive patients underwent capsular release with manipulation. Among the 49 patients, 25 showed severe stiffness (forward flexion ≤100°, external rotation at the side ≤30°; 11 in the first series and 14 in the second series), and 15 had diabetes mellitus (30.6%; 6 in the first series and 9 in the second series). Shoulder range of motion was measured 6 weeks, 3 months, 6 months, and 1 year postoperatively and at final follow-up visit. Simultaneously, functional outcome was evaluated by visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and muscle strength ratio (involved/uninvolved), and cuff integrity was assessed ultrasonographically at least 1 year postoperatively. Results: All range of motion measurements, functional scores, and muscle strength ratios significantly improved postoperatively regardless of the treatment method of stiffness. No outcome measure differed significantly between patients who did and did not undergo capsular release, regardless of the severity of stiffness, except for a temporary improvement in external rotation at side 3 months postoperatively in favor of those who underwent capsular release in cases with severe stiffness. Among patients with diabetes mellitus however, those who underwent capsular release showed greater improvement in forward flexion after 3 months and 1 year and in external rotation at the side for all time points (all P < .05), except for 6 weeks postoperatively; these patients also had a significantly higher final American Shoulder and Elbow Surgeons score (P = .03). Of 21 patients who underwent manipulation alone and of 28 who underwent capsular release and manipulation, 2 and 1 developed retears, respectively. Conclusion: Both manipulation and capsular release with manipulation significantly improved range of motion and produced satisfactory functional outcomes. The outcomes did not differ between treatment methods for stiffness regardless of the severity of stiffness. In patients with diabetes mellitus however, capsular release at the time of rotator cuff repair seems to be beneficial, especially for external rotation and final postoperative function.