Lance E. LeClere

The Hill-Sachs lesion: diagnosis, classification, and management.

The Hill‐Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill‐Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill‐Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.

Posterior Instability of the Shoulder Diagnosis and Management

Recurrent posterior instability of the shoulder can be difficult to diagnose and technically challenging to treat. Although not as common as anterior instability, recurrent posterior shoulder instability is prevalent among certain demographic and sporting groups, and may be overlooked if one is not aware of the typical examination and radiographic findings. The diagnosis itself can be difficult as patients typically present with vague or confusing symptoms, and treatment has evolved from open to arthroscopic surgical techniques. This article is intended to review the anatomy and biomechanics associated with posterior shoulder instability, to discuss the pathogenesis and presentation of posterior instability, and to describe the variety of treatment options and clinical results.

Subpectoral biceps tenodesis.

The long head of the biceps brachii (LHB) tendon has long been recognized as a source of shoulder pain. Surgeons have debated the merits of tenotomy versus tenodesis, open versus arthroscopic approaches, and various fixation methods. This article reviews the clinical findings associated with LHB pathology, describes the operative technique of subpectoral biceps tenodesis, and reviews the current literature related to treatment of the symptomatic LHB tendon. The miniopen subpectoral approach is technically less demanding than purely arthroscopic techniques, and offers the potential for improved pain relief without cosmetic deformity by removing most of the LHB and its associated tenosynovium. As the literature on the topic continues to grow, subpectoral biceps tenodesis has emerged as an effective treatment for pathology of the LHB.

Postsurgical glenohumeral anchor arthropathy treated with a fresh distal tibia allograft to the glenoid and a fresh allograft to the humeral head

The treatment of extensive glenoid chondral defects in young, active patients remains a challenge. Chondrolysis and extensive chondral defects of the glenohumeral joint in young patients have been reported after shoulder surgery and have been associated with the use of thermal capsulorrhaphy, intra-articular pain pumps, and implanted fixation devices, such as suture anchors. Prominent glenohumeral anchors have been implicated in the early development of postoperative glenohumeral degenerative changes. A proud implant may cause local wear on the glenoid and the humerus, contributing to chondral loss, decreased range of motion, mechanical symptoms, and pain. Recently, a novel treatment of glenoid bone loss has been proposed that uses a distal tibia allograft. As our group described in a previous report, this technique was initially for the treatment of glenohumeral instability secondary to extensive glenoid bone loss. The lateral aspect of the distal tibia has excellent conformity to the radius of curvature of the humeral head and has been used as a fresh allograft for the treatment of glenoid bone loss. Given its successful early outcomes, this technique can potentially have broader applications in glenohumeral pathology. We present the case of a young, active patient with focal but extensive glenohumeral degenerative changes.

High-Tensile Strength Tape Versus High-Tensile Strength Suture: A Biomechanical Study

PURPOSE To determine which suture design, high-tensile strength tape or high-tensile strength suture, performed better at securing human tissue across 4 selected suture techniques commonly used in tendinous repair, by comparing the total load at failure measured during a fixed-rate longitudinal single load to failure using a biomechanical testing machine. METHODS Matched sets of tendon specimens with bony attachments were dissected from 15 human cadaveric lower extremities in a manner allowing for direct comparison testing. With the use of selected techniques (simple Mason-Allen in the patellar tendon specimens, whip stitch in the quadriceps tendon specimens, and Krackow stitch in the Achilles tendon specimens), 1 sample of each set was sutured with a 2-mm braided, nonabsorbable, high-tensile strength tape and the other with a No. 2 braided, nonabsorbable, high-tensile strength suture. A total of 120 specimens were tested. Each model was loaded to failure at a fixed longitudinal traction rate of 100 mm/min. The maximum load and failure method were recorded. RESULTS In the whip stitch and the Krackow-stitch models, the high-tensile strength tape had a significantly greater mean load at failure with a difference of 181 N (P = .001) and 94 N (P = .015) respectively. No significant difference was found in the Mason-Allen and simple stitch models. Pull-through remained the most common method of failure at an overall rate of 56.7% (suture = 55%; tape = 58.3%). CONCLUSIONS In biomechanical testing during a single load to failure, high-tensile strength tape performs more favorably than high-tensile strength suture, with a greater mean load to failure, in both the whip- and Krackow-stitch models. Although suture pull-through remains the most common method of failure, high-tensile strength tape requires a significantly greater load to pull-through in a whip-stitch and Krakow-stitch model. CLINICAL RELEVANCE The biomechanical data obtained in the current study indicates that high-tensile strength tape may provide better repair strength compared with high-tensile strength suture at time-zero simulated testing.

Plantar Flexion Influences Radiographic Measurements of the Ankle Mortise

BACKGROUND The treatment of ankle fractures often depends on the integrity of the deltoid ligament. Diagnosis of a deltoid ligament tear depends on the measurement of the medial clear space. We sought to evaluate the impact of ankle plantar flexion on the medial clear space. METHODS Mortise radiographs were made for twenty-five healthy volunteers, with the ankle in four positions of plantar flexion (0 degrees, 15 degrees, 30 degrees, and 45 degrees). Four observers measured the medial clear space and the superior clear space on each radiograph. The mean medial clear space at 0 degrees was defined as the control, and the deviation of the medial clear space from the control value was calculated at 15 degrees, 30 degrees, and 45 degrees of plantar flexion. The ratio of the medial clear space to the superior clear space was determined on all radiographs, and ratios that were false-positive for a deltoid ligament injury were identified. RESULTS Fourteen male and eleven female volunteers were evaluated. The average increase in the medial clear space when ankle plantar flexion was increased from 0 degrees to 45 degrees was 0.38 mm (95% confidence interval, 0.18 to 0.58 mm). This increase was significant (p = 0.005). The average increase in the medial clear space was 0.04 mm when ankle plantar flexion was increased from 0 degrees to 15 degrees and 0.22 mm when it was increased from 0 degrees to 30 degrees. Neither of these changes was significant (p = 0.99 and 0.20). The prevalence of false-positive findings of deltoid injury based on the ratio of the medial clear space to the superior clear space increased as ankle plantar flexion increased, but this increase did not reach significance in our study group (p = 0.18). CONCLUSIONS Plantar flexion of the ankle produces changes in radiographic measurements of the medial clear space. The potential for false-positive findings of deltoid disruption increases with increasing ankle plantar flexion.

Complete Fatty Infiltration of Intact Rotator Cuffs Caused by Suprascapular Neuropathy

Suprascapular neuropathy is generally considered to be a diagnosis of exclusion, although it has been described in association with several activities and conditions. To our knowledge, this is the first description of suprascapular neuropathy with complete neurogenic fatty replacement in patients with intact rotator cuff tendons in the absence of traction or compression mechanisms. We present 4 cases of patients who presented with complete fatty infiltration of the supraspinatus (1 patient), infraspinatus (2 patients), and both (1 patient) resulting from suprascapular neuropathy. Each of these patients underwent arthroscopic suprascapular nerve decompression and subsequently had immediate improvement in pain and subjective shoulder value.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

Background: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. Purpose: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. Study Design: Case series; Level of evidence, 4. Methods: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. Results: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively (P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. Conclusion: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

A Prospective Outcome Evaluation of Humeral Avulsions of the Glenohumeral ligament (HAGL) Tears Repairs in an Active Population

Objectives: Humeral Avulsions of the Glenohumeral ligament (HAGL) are an infrequent and underappreciated cause of shoulder instability and dysfunction. The purposes of this study are to prospectively evaluate the presentation, clinical history and surgical outcomes of patients with HAGL tears. Methods: Over an eight-year period, patients with failed non-operative shoulder dysfunction with a confirmed HAGL tear on MR Arthrogram, who elected to undergo surgical treatment were prospectively investigated. Independent variables were patient demographics, clinical presentation, physical examination findings, and arthroscopic findings. The dependent variables assessed included return to work and activity rates, pre-operative and post-operative patient reported outcomes (ASES, SANE, WOSI scores) and independent physical examinations. Statistical analysis was via Student’s t-test and significance set at p <.05. Results: A total of 23 of 24 patients (96%) were evaluated at a mean of 32.1 months (Range 24-68 months). There were 11 females (48%) and 12 males (52%) at a mean age of 24.2 years (Range 18-33). Mechanism of injury was core training (cross-fit or equivalent) in 48%, pull-ups in 22%, and unknown in 30%. The primary complaint was pain in 82%; 20% of patients complained of instability symptoms. There were 12 patients with anterior HAGLs, 8 patients with reverse HAGLs and 3 with combined anterior and posterior lesions. 10 patients had both HAGL and labral tears, 13 with isolated HAGL. 9 patients underwent arthroscopic surgical repair and 14 underwent an open surgical repair. There was a clinically and statistically significant improvement in patient reported outcomes (WOSI=54%, SANE=50%) improved (WOSI=83%, SANE=87%, p<0.01). 21 of 23 (91%) patients returned demonstrated patient satisfaction and a return to full activity. Conclusion: This study demonstrates patients with symptomatic HAGL tears present with pain and shoulder dysfunction, that anterior and reverse HAGL tears are nearly distributed equally. After surgery, patients demonstrated statistically and clinically significant improved outcomes, a predictable return to activity and patient satisfaction. Additional work is necessary to determine optimal treatments, especially with combined HAGL and labral tears.

Validation of varus stress radiographs for anterior cruciate ligament and posterolateral corner knee injuries: A biomechanical study.

PURPOSE The purpose of this study was to determine the effect of isolated anterior cruciate ligament (ACL) insufficiency on the radiographic varus stress test, and to provide reference data for the increase in lateral compartment opening under varus stress for a combined ACL and PLC injury. METHODS Ten cadaveric lower extremities were fixed to a jig in 20° of knee flexion. Twelve Newton-meter (Nm) and clinician-applied varus loads were tested, first with intact knee ligaments, followed by sequential sectioning of the ACL, fibular collateral ligament (FCL), popliteus tendon and the popliteofibular ligament (PFL). Lateral compartment opening was measured after each sequential sectioning. RESULTS Maximum increase in lateral compartment opening for an isolated ACL deficient knee was 1.06mm with mean increase of 0.52mm (p=0.021) for the clinician-applied load. Mean increase in lateral compartment opening in an ACL and FCL deficient knee compared to the intact knee was 1.48mm (p<0.005) and 1.99mm (p<0.005) for the 12-Nm and clinician-applied loads, respectively, increasing to 1.94mm (p<0.005) and 2.68mm (p<0.005) with sectioning of the ACL and all PLC structures. CONCLUSIONS Anterior cruciate ligament deficiency contributes to lateral compartment opening on varus stress radiographs though not sufficiently to confound previously established standards for lateral ligament knee injuries. We did not demonstrate the same magnitude of lateral compartment opening with sectioning of the PLC structures as previously reported, questioning the reproducibility of varus stress radiographic testing among institutions. Clinicians are cautioned against making surgical decisions based solely on current standards for radiographic stress examinations.