Mark A. Slabaugh

Does the Literature Confirm Superior Clinical Results in Radiographically Healed Rotator Cuffs After Rotator Cuff Repair

PURPOSE Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. METHODS Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. RESULTS Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. CONCLUSIONS The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. LEVEL OF EVIDENCE Level IV, systematic review.

Recommendations and Treatment Outcomes for Patellofemoral Articular Cartilage Defects With Autologous Chondrocyte Implantation Prospective Evaluation at Average 4-Year Follow-up

Background Reported results of autologous chondrocyte implantation for chondral lesions in the patellofemoral joint have been encouraging when combined with realignment procedures. Purpose The objective of this study was to examine the clinical results of a patient cohort undergoing autologous chondrocyte implantation of the patellofemoral joint and elucidate characteristics associated with successful implantation. Study Design Case series; Level of evidence, 4. Methods The cohort included 62 patients who underwent autologous chondrocyte implantation of the PF joint. The mean defect size was 4.2 cm2 (61.6). The average age was 31.8 years (range, 15.8-49.4), and the average follow-up was 4 years (range, 2-7). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Scale (KOOS; includes the 5 categories of Pain, Symptoms, Activities of Daily Living, Sport, and Quality of Life), Tegner, Cincinnati, and Short Form-12. Results Mean improvement in the preoperative to postoperative scores was significant for the Lysholm (37-63, P<.001), International Knee Documentation Committee (31-57, P<.001), KOOS Pain (48-71, P<.001), KOOS Symptoms (51-70, P <.001), KOOS Activities of Daily Living (60-80, P <.001), KOOS Sport (25-42, P <.001), KOOS Quality of Life (24-49, P <.001), Short Form-12 Physical (38-41, P<.05), Cincinnati (43-63, P <.005), and Tegner (4-6, P <.05), but not for the Short Form-12 Mental. There was no statistical difference between outcomes in patients with a history of a previous failed cartilage procedure compared with those patients without a prior cartilage procedure (P > 05). Patients undergoing anteromedialization tended toward better outcomes than those without realignment. Forty-four percent of patients needed a subsequent procedure. There were 4 clinical failures (7.7%), which were defined as progression to arthroplasty or conversion to osteochondral allograft transplantation. Conclusion Autologous chondrocyte implantation is a viable treatment option for chondral defects of the patellofemoral joint. Combined autologous chondrocyte implantation with anteromedialization improves outcomes more than autologous chondrocyte implantation alone. Patients with failed prior cartilage procedures can also expect sustained and clinically meaningful improvement.

Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery

BACKGROUND Tenodesis of the long head of the biceps tendon is a common procedure used to alleviate pain caused by instability or inflammation of the tendon. The purpose of this study is to report on the incidence and types of complications following an open subpectoral biceps tenodesis (OBT) procedure. HYPOTHESIS Our hypothesis was that the rate of adverse events after OBT was low. METHODS From January 2005 to December 2007, all patients that underwent an OBT with bioabsorbable interference screw fixation performed by 1 of the 2 senior authors for biceps tendonitis were reviewed, excluding tenotomy, revision cases, or fixation methods other than interference screw fixation. RESULTS Over a 3-year period, 7 of 353 patients had complications with OBT with an incidence of 2.0%. The mean age of patients with complications was 44.67 years, with 57.1% males and 42.9% females. There were 2 patients (0.57%) with persistent bicipital pain. Two patients (0.57%) had failure of fixation resulting in a Popeye deformity. One patient (0.28%) presented with a deep postoperative wound infections that necessitated irrigation and debridement with intravenous antibiotics. Another patient (0.28%) developed a musculotaneous neuropathy. Another patient (0.28%) developed reflex sympathetic dystrophy necessitating pain management and stellate ganglion block. CONCLUSION The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2.0%.

Does the Literature Support Double-Row Suture Anchor Fixation for Arthroscopic Rotator Cuff Repair? A Systematic Review Comparing Double-Row and Single-Row Suture Anchor Configuration

PURPOSE The purpose of this study was to compare the clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair with a systematic review of the published literature. METHODS We searched all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials for the following key words: shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, arthroscopic-assisted, single row, double row, and transosseous equivalent. The inclusion criteria were cohort studies (Levels I to III) that compared SR and DR suture anchor configuration for the arthroscopic treatment of full-thickness rotator cuff tears. The exclusion criteria were studies that lacked a comparison group, and, therefore, case series were excluded from the analysis. RESULTS There were 5 studies that met the criteria and were included in the final analysis: 5 in the SR group and 5 in the DR group. Data were abstracted from the studies for patient demographics, rotator cuff tear characteristics, surgical procedure, rehabilitation, range of motion, clinical scoring systems, and imaging studies. CONCLUSIONS There are no clinical differences between the SR and DR suture anchor repair techniques for arthroscopic rotator cuff repairs. At present, the data in the published literature do not support the use of DR suture anchor fixation to improve clinical outcome, but there are some studies that report that DR suture anchor fixation may improve tendon healing. LEVEL OF EVIDENCE Level III, systematic review of Levels I to III studies.

Retrospective analysis of arthroscopic management of glenohumeral degenerative disease.

PURPOSE The purpose of this study was to examine the results of arthroscopic debridement for isolated degenerative joint disease of the shoulder. METHODS We retrospectively identified 81 patients who had arthroscopic debridement to treat glenohumeral arthritis. Of these patients, 71 (88%) were available for follow-up. The preoperative Simple Shoulder Test score, American Shoulder and Elbow Surgeons score, Short Form 12 score, visual analog scale score for pain, and range of motion were recorded. These were compared against postoperative scores by use of the statistical paired t test. In addition, patients completed postoperative University of California, Los Angeles; Constant; and Single Assessment Numeric Evaluation scores. Forty-six preoperative radiographs were blindly evaluated and classified. Finally, the need for subsequent shoulder arthroplasty was recorded. RESULTS The mean follow-up for the 55 patients who did not progress to arthroplasty was 27 months. The mean preoperative and postoperative American Shoulder and Elbow Surgeons, Simple Shoulder Test, and pain visual analog scale scores all significantly improved (P < .05). Furthermore, range of motion significantly improved (P < .05) in flexion, abduction, and external rotation. Additional postoperative scores were as follows: University of California, Los Angeles, 28.3; Single Assessment Numeric Evaluation, 71.1; Constant score for affected shoulder, 72.0; and Constant score for unaffected shoulder, 78.5. Of the patients, 16 (22%) underwent arthroplasty at a mean of 10.1 months after debridement. Radiographic review showed that 13 shoulders with a mean joint space of 1.5 mm and grade 2.4 arthrosis went on to have shoulder arthroplasty. In contrast, 33 shoulders with a mean joint space of 2.6 mm and grade 1.9 arthrosis did not go on to have shoulder arthroplasty. CONCLUSIONS Patients with residual joint space and an absence of large osteophytes can avoid arthroplasty and have increased function with decreased pain after arthroscopic debridement for degenerative joint disease. Significant risk factors for failure include the presence of grade 4 bipolar disease, joint space of less than 2 mm, and large osteophytes. LEVEL OF EVIDENCE Level IV, case series.

Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: Prospective evaluation at a minimum two-year follow-up

HYPOTHESIS Patients with type II superior labrum, anterior to posterior (SLAP) lesions will have improved function and decreased pain at a minimum of 2 years after arthroscopic SLAP repair using bioabsorbable suture anchor fixation. MATERIALS AND METHODS The study population consisted of 48 patients who underwent arthroscopic SLAP repair. Subjective shoulder scores, range of motion, and strength (postoperative only) were assessed preoperatively and at a minimum of 2 years postoperatively. RESULTS At an average of 3.4 years after surgery, statistically significant improvement was seen in American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Simple Shoulder Test scores, Constant activities of daily living, visual analog scale for pain, and Short Form-12 Health Survey physical outcome scores. Improvements were made in forward flexion, abduction, external rotation, and internal rotation. Subgroup analysis of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes showed preoperative to postoperative improvements in subjective outcomes scores. Overhead laborers and nonlaborers also showed preoperative to postoperative improvements in subjective shoulder scores. DISCUSSION No differences were seen between the outcomes of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes, suggesting that SLAP type II repair is successful independent of the patients vocation or sport. CONCLUSION These results show that arthroscopic SLAP repair of type II lesions with bioabsorbable suture anchors provides a significant improvement in functional capacity and pain relief.

Interobserver and Intraobserver Reliability of the Goutallier Classification Using Magnetic Resonance Imaging Proposal of a Simplified Classification System to Increase Reliability

Background: The Goutallier classification of fatty infiltration of the rotator cuff was developed for use in axial computed tomography arthrography. Now the Goutallier classification is being used with magnetic resonance imaging (MRI). Not only is there debate on the validity of the use of this system in MRI, but current literature is unclear as to the clinical use of the Goutallier classification. Hypothesis: There will be significant inter- and intraobserver variability of the Goutallier classification grading system for patients with chronic rotator cuff tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: An online database consisting of 35 single MRI images from 35 patients with chronic rotator cuff tears was designed and sent to members of the American Shoulder and Elbow Society. Surgeons were asked to identify the stage of rotator cuff fatty infiltration using the Goutallier classification system. Thirty surgeons responded and completed the survey in its entirety. At a minimum of 2 months later, 28 of the 30 initial respondents completed evaluations of the same online database. The responding surgeons were divided dichotomously according to their demographics and the interobserver reliability of the groups compared. A kappa analysis was performed to determine inter- and intraobserver reliability using 95% confidence intervals (95% CIs). A simplified 3-tiered classification was proposed combining Goutallier grades 0 and 1 as well as grades 2 and 3. Results: Statistical analysis of all respondent data demonstrated moderate intraobserver variability with a κ value of 0.56 (95% CI, 0.53-0.60). In addition, moderate interobserver variability was shown with a κ value of 0.43 (range, 0.16-0.74). With the simplified classification, intraobserver reliability was 0.70 (95% CI, 0.66-0.74) and interobserver reliability was 0.61 (range, 0.21-0.87). Correlation analysis showed no correlation with the presence or absence of fellowship training or board certification with either the Goutallier classification or the proposed modification (P > .05). Sports versus shoulder/elbow fellows had statistically better intraobserver variability (κ = 0.63 vs 0.50) with the Goutallier classification. Years in practice was negatively correlated with the level of agreement for both classifications (–r value, P < .05). The number of rotator cuff repairs performed per year negatively correlated with the level of agreement in the proposed modification only (r = −0.44, P = .022). Percent of practice dedicated to the shoulder did not correlate significantly with either classification (P > .05). Conclusion: There is significant inter- and intraobserver variability observed among experienced shoulder surgeons using the Goutallier classification for assessing fatty infiltration of the rotator cuff muscles after chronic rotator cuff tears. Respondents were more likely to agree with themselves than with other respondents. A simplification of the MRI classification system is proposed that takes into consideration the variability determined by this study.

Clinical Outcomes After Microfracture of the Glenohumeral Joint

Background Microfracture is an effective surgical treatment for isolated, full-thickness cartilage defects with current data focused on applications in the knee. No studies describing clinical outcomes of patients who have undergone microfracture in the shoulder joint have been reported. Hypothesis Treatment of glenohumeral joint articular defects using microfracture would demonstrate similar short-term clinical outcomes when compared with other joints. Study Design Case series; Level of evidence, 4. Methods From March 2001 to August 2007, 16 patients (17 shoulders) who underwent arthroscopic microfracture of the humeral head and/or glenoid surface were retrospectively reviewed. All patients were examined by an independent, blinded examiner and completed surveys containing the Simple Shoulder Test (SST), American Shoulder and Elbow Score (ASES), and visual analog scale (VAS). Results Two patients were lost to follow-up, for a follow-up rate of 88%. Three patients went on to subsequent shoulder surgery and were considered to have failed results. The mean age was 37.0 years (range, 18-55 years) with an average follow-up of 27.8 months (range, 12.1-89.2 months). The average size of humeral and glenoid defects was 5.07 cm2 (range, 1.0-7.84 cm2) and 1.66 cm2 (range, 0.4-3.75 cm2), respectively. There was a statistically significant decrease from 5.6 ± 1.7 to 1.9 ± 1.4 (P < .01) in VAS after surgery as well as statistically significant improvements (P < .01) in SST (5.7 ± 2.1 to 10.3 ± 1.3) and ASES (44.3 ± 15.3 to 86.3 ± 10.5). Twelve (92.3%) patients claimed they would have the procedure again. Conclusion Microfracture of the glenohumeral joint provides a significant improvement in pain relief and shoulder function in patients with isolated, full-thickness chondral injuries. Longer term studies are required to determine if similar results are maintained over time.

Lateral hip pain in an athletic population: differential diagnosis and treatment options.

Context: Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population. Evidence Acquisition: Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010. Results: Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases. Conclusions: Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Rapid Chondrolysis of the Knee After Anterior Cruciate Ligament Reconstruction: A Case Report

Chondrolysis is a devastating complication of surgery on any joint, resulting in the rapid and extensive destruction of the articular cartilage. Associated with this destruction is an equally large inflammatory response that causes adhesions in the lining of the involved joint. The inflammatory response manifests as arthrofibrosis and is typically seen within six months after the operation. Management of this unique complication is difficult because most patients are very young and have active lifestyles. Chondrolysis causes more immediate symptoms of pain and limited range of motion than does osteoarthritis, which often takes years to become symptomatic. The exact cause of postoperative chondrolysis is unknown; however, several hypotheses have been entertained, such as the use of thermal treatment1, occult infection with Propionibacterium acnes 2,3, idiopathic or iatrogenic osteochondral injury, high temperature of fluid during arthroscopic irrigation4, improperly placed implants, and the use of nonsteroidal anti-inflammatory medications. Recently, the use of intra-articular pain pumps for the administration of local anesthetics has come under scrutiny because of a possible association with early chondrolysis in the glenohumeral joint5-10. We are unaware, however, of any previously reported cases of chondrolysis in the knee associated with the use of an intra-articular pain pump. Here we report the case of a patient with chondrolysis of the knee; this case of our patient was clinically similar to several cases of patients with chondrolysis of the shoulder who had been referred for treatment at our institution. The patient and her parents were informed that data concerning the case would be submitted for publication, and they consented. A seventeen-year-old girl sustained anterior cruciate ligament and lateral meniscal tears during a tackling injury in a soccer game (Fig. 1). She underwent a routine anterior cruciate ligament reconstruction with use of …