Mark Tauber

Rockwood type III acromioclavicular dislocation: Surgical versus conservative treatment

The best treatment for Rockwood type III injuries is still controversial. During a retrospective study, 24 patients who were treated surgically with a hook plate and 17 conservatively treated patients were examined with a mean follow-up of 34 months. The Oxford Shoulder Score, Simple Shoulder Test, and Constant score were assessed at the follow-up examination. Stress radiographs of both shoulders were taken, and the coracoclavicular distance, as well as the width of the acromioclavicular joint, was measured. The mean Constant score was 80.7 in the conservatively treated group and 90.4 in the group that underwent surgery. The mean coracoclavicular distance was 15.9 mm in the conservatively treated group and 12.1 mm in the surgically treated group. These differences were significant (P < .05, Mann-Whitney U test and Student t test). In this study, better results were achieved by surgical treatment with the hook plate than by conservative treatment.

Semitendinosus Tendon Graft Versus a Modified Weaver-Dunn Procedure for Acromioclavicular Joint Reconstruction in Chronic Cases A Prospective Comparative Study

Background Biomechanical studies comparing various surgical techniques for acromioclavicular joint reconstruction have reported that semitendinosus tendon graft for coracoclavicular ligament reconstruction provides a substantial improvement in initial stability and a load-to-failure equivalent to the intact coracoclavicular ligaments. Although it represents a biomechanical improvement compared with coracoacromial ligament transfer, there is still a lack of prospective comparative studies confirming the clinical relevance of these biomechanical findings. Hypothesis Semitendinosus tendon graft for coracoclavicular ligament reconstruction is associated with superior clinical results compared with a modified Weaver-Dunn procedure in chronic complete acromioclavicular joint dislocation. Study Design Cohort study; Level of evidence, 2. Methods Twenty-four patients (mean age, 42 years) with painful, chronic Rockwood type III through V acromioclavicular joint dislocations were subjected to surgical reconstruction. In 12 patients, a modified Weaver-Dunn procedure was performed; in the other 12 patients, autogenous semitendinosus tendon graft was used. Clinical evaluation was performed using the American Shoulder and Elbow Surgeons shoulder score and the Constant score after a mean follow-up time of 37 months. Preoperative and postoperative radiographs were compared. Results The mean American Shoulder and Elbow Surgeons shoulder score improved from 74 ± 7 points preoperatively to 86 ± 8 points postoperatively in the Weaver-Dunn group, and from 74 ± 4 points to 96 ± 5 points in the semitendinosus tendon group (P < .001 for both techniques). The mean Constant score improved from 70 ± 8 points to 81 ± 8 points in the Weaver-Dunn group, and from 71 ± 5 points to 93 ± 7 points in the semitendinosus tendon group (P < .001). The results in the semitendinosus tendon group were significantly better than in the Weaver-Dunn group (P < .001). The radiologic measurements showed a mean coracoclavicular distance of 12.3 ± 4 mm in the Weaver-Dunn group increasing to 14.9 ± 6 mm under stress loading, compared with 11.4 ± 3 mm increasing to 11.8 ± 3 mm under stress in the semitendinosus tendon group. The difference during stress loading was statistically significant (P = .027). In the semitendinosus tendon group, horizontal displacement of the lateral clavicle end could be reduced in all cases with type IV dislocation. Conclusion Semitendinosus tendon graft for coracoclavicular ligament reconstruction resulted in significantly superior clinical and radiologic outcomes compared to the modified Weaver-Dunn procedure.

Dynamic radiologic evaluation of horizontal instability in acute acromioclavicular joint dislocations.

Background: Biplane radiologic evaluation is indispensable for the correct diagnosis of acute acromioclavicular (AC) joint injuries. Thus far, no functional radiographic techniques have been quantified to evaluate horizontal instability in acute AC joint dislocations. Hypothesis: Supine dynamic axillary lateral shoulder views detect horizontal instability of the distal clavicle in patients with acute AC joint dislocations. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Twenty-five consecutive patients with a mean age of 39 ± 14 years with acute AC joint injury underwent biplane radiologic evaluation, including a conventional Zanca view and an axillary lateral view in a sitting position. In addition, supine axillary lateral views with the arm in 90° of abduction and 60° of flexion and extension were taken to evaluate the horizontal dynamics of the distal clavicle. The gleno-acromio-clavicular angle (GACA) was introduced and used to quantify the horizontal clavicular dynamics in terms of angle differences. The unaffected shoulders served as the control group. Results: Superior dislocation of the lateral clavicle in the Zanca view was classified as Rockwood type II in 7 patients, type III in 15, and type V in 3. The axillary lateral view in a sitting position showed posterior dislocation of the distal clavicle in 8 patients (Rockwood type IV injury). Dynamic radiologic evaluation revealed an average GACA difference between the neutral and anterior position of the arm of 7.1° ± 5.5° for the unaffected shoulder. In the injured AC joints, 11 patients showed no radiologic evidence of horizontal instability (group A) with a GACA difference of 7.1° ± 4.8°. Increased anteroposterior translation was evident in 14 patients (group B) with a GACA difference of 30.3° ± 14.3° (P < .001). Conclusion: Functional axillary radiologic evaluation seems to represent a simple imaging tool to reveal dynamic horizontal instability. Clinical Relevance: Horizontal instability of the distal clavicle in acute AC joint injuries represents an indication for surgical treatment. Dynamic axillary radiologic evaluation may detect previously missed unstable injuries. This evaluation might be relevant when deciding on surgical AC joint stabilization.

Latissimus Dorsi Tendon Transfer for Irreparable Rotator Cuff Tears: A Modified Technique to Improve Tendon Transfer Integrity

BACKGROUND Latissimus dorsi tendon transfer is a well-established method for the treatment of massive irreparable posterosuperior defects of the rotator cuff. Subsequent rupture of the transferred tendon may contribute to the rate of failure of the index procedure. We hypothesized that modification of our technique of tendon harvesting would lead to greater fixation stability and a reduced failure rate. METHODS Forty-two patients (mean age, fifty-eight years) with a massive irreparable posterosuperior tear of the rotator cuff were managed with a latissimus dorsi tendon transfer. Sharp separation of the latissimus tendon from the humerus was performed in twenty-two patients (Group A), whereas the tendon harvest was carried out with a modified technique that involved removal of some bone along with the tendon at the humeral insertion in a subsequent group of twenty patients (Group B). The mean duration of follow-up was forty-seven months. Outcome measures included the Constant and American Shoulder and Elbow Surgeons (ASES) scores and a patient subjective satisfaction scale. Standard radiographs were made to determine the stage of osteoarthritis and proximal migration of the humeral head, and magnetic resonance imaging was performed to assess the integrity of the transferred muscle. RESULTS In Group A, the mean Constant score improved from 43.4 preoperatively to 64.8 points at the time of follow-up and the mean ASES score improved from 49.3 to 69.6 points (p < 0.05). In Group B, the mean Constant score increased from 40.2 to 74.2 points and the mean ASES score, from 47.2 to 77.1 points (p < 0.05). The Constant pain score improved from 5.6 to 11.9 points in Group A and from 5.2 to 13.8 points in Group B. The results in Group B were significantly superior to those in Group A (p < 0.05). Magnetic resonance imaging revealed complete rupture at the tendon insertion with tendon retraction in four patients in Group A and none in Group B. The final outcome was rated as poor in 27% of the patients in Group A and in 10% in Group B. CONCLUSIONS Latissimus dorsi tendon transfer achieves satisfactory clinical results in most patients who have a massive irreparable posterosuperior tear of the rotator cuff. Harvesting the tendon along with a small piece of bone enables direct bone-to-bone transosseous fixation, resulting in better tendon integrity and clinical results.

Perivascular cells of the supraspinatus tendon express both tendon- and stem cell-related markers

Tendons and ligaments are often affected by mechanical injuries or chronic impairment but other than muscle or bone they possess a low healing capacity. So far, little is known about regeneration of tendons and the role of tendon precursor cells in that process. We hypothesize that perivascular cells of tendon capillaries are progenitors for functional tendon cells and are characterized by expression of marker genes and proteins typical for mesenchymal stem cells and functional tendon cells. Immunohistochemical characterization of biopsies derived from intact human supraspinatus tendons was performed. From these biopsies perivascular cells were isolated, cultured, and characterized using RT-PCR and Western blotting. We have shown for the first time that perivascular cells within tendon tissue express both tendon- and stem/precursor cell-like characteristics. These findings were confirmed by results from in vitro studies focusing on cultured perivascular cells isolated from human supraspinatus tendon biopsies. The results suggest that the perivascular niche may be considered a source for tendon precursor cells. This study provides further information about the molecular nature and localization of tendon precursor cells, which is the basis for developing novel strategies towards tendon healing and facilitated regeneration.

Effects of crystalline glucocorticoid triamcinolone acetonide on cultered human supraspinatus tendon cells.

Background Rotator cuff tears are a common cause of shoulder pain and impairment. Subacromial glucocorticoid injections are widely used for treatment of epiphenomenons of chronic impingement syndrome with the possible side effects of tendon rupture and impaired tendon healing. Methods Using qRT-PCR, western blot, immunoflourescence, and measurement of 3H-thymidine uptake we investigated the effects of the crystalline glucocorticoid triamcinolone acetonide (TAA) when added to the culture medium of isolated human rotator cuff tendon cells. Results After 2 weeks of incubation, the cells had lost their fibroblastic appearance and parallel orientation, which is characteristic of cellular degeneration in vivo. Moreover, expression and secretion of collagen I was strongly reduced, and there was a decrease in proliferation rate. Cell migration was blocked and the rate of expression of the matrix metalloproteinases MMP2, MMP8, MMP9, and MMP13 was reduced, but expression of TIMP1 (a tissue inhibitor of MMPs) was upregulated, indicating a reduction in the cellular capacity for tendon repair. In addition, changes in cellular differentiation were observed: the number of adipocytes increased and levels of the protein Sox9—a marker of differentiating and mature chondrocytes—were elevated in triamcinolone acetonide treated cells. Interpretation These results may indicate that the use of TAA is one reason for weaker mechanical tendon properties and for the high rate of re-rupture after supraspinatus tendon repair.

Secondary Intracranial Hemorrhage After Mild Head Injury in Patients With Low-dose Acetylsalicylate Acid Prophylaxis

BACKGROUND Low-dose acetylsalicylate acid (LDA) therapy is accepted as a major risk factor for intracranial hemorrhages (ICH) in head injuries. Coincidentally, patient admissions that might be indicated for in hospital observation of neurologic function causes increased health care costs. In the literature, there is no evidence concerning the incidence of secondary intracranial hemorrhagic events (SIHE) in patients with LDA prophylaxis that had negative primary computed tomography (CT)-scan of the head. METHODS In this prospective study, we enrolled 100 consecutive trauma patients older than 65 years presenting in a Level I urban trauma center after a mild head injury (Glasgow Coma Scale score of 15) who had LDA prophylaxis. Patients included had a negative primary head CT-scan concerning ICH. For analysis of the incidence of SIHEs patients had routine repeat head CT (RRHCT) after 12 hours to 24 hours. RESULTS Sixty-one patients were women and 39 men. Mean age was 81 years +/- 10 years. Injury mechanism was a level fall in 84 cases and others in 16. In four patients (4%) an SIHE was detected in the RRHCT (p < 0.00001). In two patients (2%) major secondary ICH had occurred without neurologic deterioration at the time of RRHCT with fatal outcome in one patient and neurosurgical intervention in another. The remaining two patients (2%) had minor SIHE with an uneventful clinical course. CONCLUSION The incidence of SIHE has been neglected until now. The current study revealed that patients with LDA prophylaxis after mild head injury with negative primary head CT should be subjected to RRHCT within 12 hours to 24 hours to accurately identify SIHE. Alternatively to RRHCT, patients should be subjected to a prolonged in-hospital observation for at least 48 hours.

No Increased Occurrence of Osteoarthritis After Anterior Cruciate Ligament Reconstruction After Isolated Anterior Cruciate Ligament Injury in Athletes

PURPOSE To evaluate the long-term radiographic and clinical results of anterior cruciate ligament (ACL) reconstruction by comparing the injured knee with the contralateral knee in athletes with isolated ACL tear returning to preinjury sports. METHODS Twenty-eight patients with isolated ACL tears without concomitant injuries at baseline returning to previous sports were selected. ACL reconstruction was performed with patella or hamstring tendon graft. Conventional radiographs and a 3-T magnetic resonance imaging study of both knees were obtained at a mean follow-up of 10 years after ACL reconstruction and were compared with each other. The International Knee Documentation Committee score and Tegner activity index were used for clinical evaluation and the Knee Injury and Osteoarthritis Outcome Score for evaluating self-reported knee function. RESULTS The 3-T magnetic resonance imaging study showed positive signs of osteoarthritis in 33% of operated knees and 39% of nonoperated knees (P = .64). Conventional radiographs showed ongoing signs of radiographic osteoarthritis in 14% of uninjured knees according to Kellgren and Lawrence, in comparison with 21% of injured knees (P = .73). The functional outcomes between the injured knee and uninjured knee did not show any statistical differences. The mean postoperative International Knee Documentation Committee score was 89.2 ± 9.3 points, and the total Knee Injury and Osteoarthritis Outcome Score was 92.7 ± 7.8. The median preinjury Tegner score was 8 ± 2, corresponding to 7 ± 2 at follow-up. In 68% of patients, the Tegner score was unchanged from preinjury to follow-up. CONCLUSIONS Athletes with an isolated ACL rupture showed no increased risk of the development of post-traumatic osteoarthritis in the long-term after ACL replacement when compared with the uninjured contralateral knee. Our findings support the evidence to perform ACL replacement in athletes. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Effects of rotator cuff ruptures on the cellular and intracellular composition of the human supraspinatus muscle

Ruptures of the rotator cuff tendons of the human shoulder are a common incidence and lead to functional impairment of the four muscles connected to the cuff, entailing profound changes of their cellular tissue composition. Most importantly, such tendon tears lead to atrophy, fatty degeneration and fibrosis of the corresponding muscles. The muscle most commonly affected with such changes is the M. supraspinatus. The present study uses biopsy samples from the supraspinatus muscle of 12 elderly patients and 6 controls to examine the rupture-induced muscle change at both the cellular and the intracellular (ultrastructural) levels. Amounts of fatty tissue, connective tissue and muscle were assessed by light microscopy-based morphometry and stereology. Stereology of electron micrographs was employed to determine volume densities of muscle fibre mitochondria, myofibrils and intracellular lipid. Results demonstrate that the supraspinatus muscles of patients with a massive rupture contain significantly higher amounts not only of fatty tissue but also of intracellular lipid than those of control subjects. These patients further exhibit a major decrease in relative amounts of myofibrils, thus confirming that change of intracellular composition is a major component of the observed muscle degeneration. The results contribute to establish the true spectrum of supraspinatus muscle damage in humans induced by tendon rupture.

Transosseous arthroscopic repair of partial articular-surface supraspinatus tendon tears

Partial articular-surface tendon avulsion (PASTA) lesions of the supraspinatus muscle represent a common cause for shoulder impairment and a preceding pathology for full-thickness tendon tears. Arthroscopic tendon repair is a possible surgical method of treatment. The purposes of cuff repair are anatomical tendon healing, prevention of tear size progression to completion and reduction of shoulder pain. In this report, we describe a transtendon arthroscopic technique of transosseous refixation of articular-side partial tears leaving the bursal layer of the supraspinatus tendon intact. A curved hollow needle is used to perform an all arthroscopic transosseous mattress suture. Thus, anatomical tendon-to-bone contact of the rotator cuff to the footprint is restored. Preliminary clinical results of 16 patients are convincing with significant pain relief and functional improvement.