Michael K. Shindle

Endoscopic Repair of Gluteus Medius Tendon Tears of the Hip

Background Tears of the gluteus medius tendon at the greater trochanter have been termed “rotator cuff tears of the hip.” Previous reports have described the open repair of these lesions. Hypothesis Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term. Study Design Case series; Level of evidence, 4. Methods Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys. Results At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal. Conclusion With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

Magnetic resonance imaging of the shoulder. Current techniques and spectrum of disease.

Magnetic resonance imaging is an excellent modality for imaging pathological processes of the shoulder joint. It allows high-resolution imaging of all anatomic structures, including the glenoid, the humeral head, the articular cartilage, the acromion, the muscles and tendons of the rotator cuff, the labrum, the biceps tendon, and the glenohumeral ligaments, in multiple orthogonal planes. Numerous technical options and several pulse sequences can be utilized for the performance of magnetic resonance imaging of the shoulder. The aim of this review is to update orthopaedic surgeons on the technical aspects of performing magnetic resonance imaging of the shoulder. In addition, this report will define the normal anatomy of the shoulder as demonstrated by magnetic resonance imaging and review the spectrum of disease detectable with this technique. After reviewing this article, the reader should (1) have a basic understanding of the physics, pulse sequences, and terminology of magnetic resonance imaging; (2) be able to systematically evaluate the findings of a complete magnetic resonance imaging examination of the shoulder and know the features of normal shoulder anatomy; (3) be able to identify various tissue types on T1-weighted, fat-suppressed T2-weighted, and proton-density images; and (4) be able to diagnose certain pathological processes of the shoulder on the basis of magnetic resonance imaging findings. ### Process of Image Production First, the subject is positioned in the scanner. For magnetic resonance imaging of the shoulder, the patient is supine and the arm is held at the side, as opposed to across the chest, in order to minimize transmission of respiratory motion to the shoulder. The arm is placed in slight external rotation to optimally orient the supraspinatus tendon in order to prevent confusing overlap with the infraspinatus tendon on coronal oblique images1. The external rotation also allows maximum visualization of the supraspinatus insertion2. The magnetic field of …

Rotator Cuff Degeneration: Etiology and Pathogenesis

By virtue of its anatomy and function, the rotator cuff is vulnerable to considerable morbidity, often necessitating surgical intervention. How we intervene is governed by our understanding of the pathological mechanisms in cuff disease. These factors can be divided into those extrinsic to the rotator cuff (impingement, demographic factors) and those intrinsic to the cuff (age-related degeneration, hypovascularity, inflammation, and oxidative stress, among others). In an era where biologic interventions are increasingly being investigated, our understanding of these mechanisms is likely to become more important in designing effective new interventions. Here we present a literature review summarizing our current understanding of the pathophysiological mechanisms underlying rotator cuff degeneration.

Arthroscopic Management of Labral Tears in the Hip

Over the last decade, the diagnosis and arthroscopic management of labral tears of the hip in the young athletic population has evolved substantially due to improvements in clinical examination, diagnostic tools, surgical techniques, and flexible instrumentation in hip arthroscopy. Arthroscopic management of labral injuries in the hip has become an accepted therapeutic modality in appropriately selected patients. The treatment of labral tears and their associated disorders is crucial for hip preservation in young and active patients because several studies have demonstrated an association between labral tears and the early onset of osteoarthritis1-3. This paper will review the main causes of labral tears in the hip, including labral tears secondary to trauma, femoroacetabular impingement, instability, psoas impingement, dysplasia, and degenerative arthritis. We will discuss relevant anatomy and history, typical findings on physical examination, types of imaging studies performed, and treatment options, with a focus on the arthroscopic management of labral injuries, including labral repair. The outcomes associated with open surgical dislocation as compared with arthroscopic treatment of femoroacetabular impingement will also be reviewed. The acetabular labrum is a fibrocartilaginous structure that is located circumferentially around the acetabular perimeter and becomes attached to the transverse acetabular ligament posteriorly and anteriorly. Neuroreceptors have been identified within the labrum, and these structures may provide proprioception to the hip joint4. The articular surface of the labrum has decreased vascularity and a limited synovial covering in comparison with the portion of the labrum at the peripheral capsulolabral junction5 (Figs. 1-A and 1-B). Thus, similar to the healing potential of the menisci in the knee, which is greatest at the periphery, the healing potential of the labrum is greatest at the peripheral capsulolabral junction5-8. The labrum has an important sealing function in the hip. It plays …

Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair.

Rotator cuff repair is one of the most common surgical procedures performed in the shoulder, and the benefit of repair is well known1-5. Over the past decade, the treatment of rotator cuff tears has evolved from an open procedure to an arthroscopic-assisted (mini-open) technique to an all-arthroscopic technique. Traditional open rotator cuff repairs produce satisfactory results when used for the treatment of nonmassive tears (<5 cm). However, this procedure has been associated with morbidity such as severe early postoperative pain, deltoid detachment and/or weakness, and arthrofibrosis6-8. Mini-open repairs were developed because they had the potential advantage of less deltoid morbidity, and they have demonstrated results that have been similar to those of open repairs (Figs. 1-A through 1-D)9-14. With recent advances in arthroscopic techniques, many surgeons are now performing complete arthroscopic repairs. The potential advantages of this procedure include less pain, more rapid rehabilitation, the ability to treat intra-articular lesions, smaller skin incisions, less soft-tissue dissection, and an extremely low risk of deltoid detachment (Figs. 2-A through 2-E). In the short and long term, the arthroscopic approach has shown promising results3,7,15-27. Despite these advantages, the use of the complete arthroscopic repair is technically demanding and requires a large-volume practice in order for a surgeon to obtain proficiency in this procedure28. Because of the technical demands of this procedure, many orthopaedic surgeons still consider the mini-open repair to be the gold standard for rotator cuff repair29. We hypothesized that arthroscopic rotator cuff repair produces clinical results comparable with those of mini-open rotator cuff repair, with fewer complications. In order to compare the mini-open and all-arthroscopic techniques, we performed a qualitative systematic review with use of a …

Complications of circular plate fixation for four-corner arthrodesis

Four corner arthrodesis is an accepted salvage operation for scapholunate advanced collapse and scaphoid non-union advanced collapse. Circular plates were introduced in 1999 and promoted as a rapid and more stable method for this procedure. A retrospective chart review was performed on all patients who were treated with the Spider Limited Wrist Fusion Plate (Kinetikos Medical Inc., San Diego, CA). Sixteen patients were identified and followed clinically and with X-rays for an average of 16 (range 5–38) months. Nine out of the 16 patients (56%) had complications, including non-union (25%), delayed union (6%), dorsal impingement (25%), radial styloid impingement (6%) and broken screws (13%). The purpose of this study was to compare our complication rate using circular plates with published outcomes using traditional methods of fixation: this study identified a significantly higher complication rate and lower union rate using circular plate fixation for four-corner arthrodesis compared with previously published techniques.

Magnetic Resonance Imaging and Clinical Evaluation of Patellar Resurfacing With Press-Fit Osteochondral Autograft Plugs

BACKGROUND Autologous osteochondral transplantation (AOT) has been successfully used in the femoral condyle and trochlea and is an attractive treatment option for full-thickness patellar cartilage lesions. HYPOTHESIS Patients treated with AOT for the repair of symptomatic, isolated patellar cartilage lesions will demonstrate improvement in functional outcomes and postoperative magnetic resonance imaging appearance. STUDY DESIGN Case series; Level of evidence, 4. METHODS Between 2002 and 2006, patients with focal patellar cartilage lesions treated with AOT were prospectively followed. The mean age at the time of surgery was 30 years. Clinical assessment was performed with the International Knee Documentation Committee (IKDC), activities of daily living of the Knee Outcome Survey (ADL), and Short Form-36 (SF-36) at baseline and most recent follow-up. Magnetic resonance imaging was used to evaluate the cartilage repair morphologic characteristics in 14 cases. RESULTS Twenty-two patients met the study criteria with a mean follow-up of 28.7 months (range, 17.7-57.8 months). The mean patellar lesion size was 165.6 +/- 127.8 mm(2), and the mean size of the donor plug was 9.7 +/- 1.1 mm in diameter with 1.8 +/- 1.4 plugs/defect. The mean preoperative IKDC score was 47.2 +/- 14.0 and improved to 74.4 +/- 12.3 (P = .028). The mean preoperative ADL score was 60.1 +/- 16.9 and increased to 84.7 +/- 8.3 (P = .022). The mean SF-36 also demonstrated an improvement, from 64.0 +/- 14.8 at baseline to 79.4 +/- 15.4 (P = .059). Nine patients underwent concomitant distal realignment and demonstrated improvement between preoperative and postoperative outcomes scores, but these differences were not statistically significant. Magnetic resonance imaging appearance demonstrated that all plugs demonstrated good (67%-100%) cartilage fill, 64% with fissures < 2 mm at the articular cartilage interface, 71% with complete trabecular incorporation, and 71% with flush plug appearance. CONCLUSION Patellar AOT is an effective treatment for focal patellar chondral lesions, with significant improvement in clinical follow-up. This study suggests that patients with patellar malalignment may represent a subset of patients who have a poor prognostic outlook compared with patients with normal alignment.

Vertebral height restoration in osteoporotic compression fractures: kyphoplasty balloon tamp is superior to postural correction alone

IntroductionKyphoplasty has been shown to restore vertebral height and sagittal alignment. Proponents of vertebroplasty have recently demonstrated that many vertebral compression fractures (VCFs) are mobile and positional correction can lead to clinically significant height restoration. The current investigation tested the hypothesis that positional maneuvers do not achieve the same degree of vertebral height correction as kyphoplasty balloon tamps for the reduction of low-energy VCFs.MethodsTwenty-five consecutive patients with a total of 43 osteoporotic VCFs were entered into a prospective analysis. Each patient was sequentially evaluated for postural and balloon vertebral fracture reduction. Preoperative standing and lateral radiographs of the fractured vertebrae were compared with prone cross-table lateral radiographs with the patient in a hyper-extension position and on pelvic and sternal rolls. Following positional manipulation, patients underwent a unilateral balloon kyphoplasty. Postoperative standing radiographs were evaluated for the percentage of height restoration related to positioning and balloon kyphoplasty.ResultsIn the middle portion of the vertebrae, the percentage available for restoration restored with extension positioning was 10.4% (median 11.1%) and after balloon kyphoplasty was 57.0% (median 62.2%). This difference was statistically significant (p<0.001). Thus, kyphoplasty provided an additional 46.6% of the height available for restoration from the positioning alone. With operative positioning, 51.2% of VCFs had >10% restoration of the central portion of the vertebral body, whereas 90.7% of fractures improved at least 10% following balloon kyphoplasty (p<0.002).ConclusionAlthough this study supports the concept that many VCFs can be moved with positioning, balloon kyphoplasty enhanced the height reduction >4.5-fold over the positioning maneuver alone and accounted for over 80% of the ultimate reduction. If height restoration is the goal, kyphoplasty is clearly superior in most cases to the positioning maneuver alone.

Prospective analysis of arthroscopic rotator cuff repair: Subgroup analysis

BACKGROUND The rotator cuff registry was established to evaluate prospectively the effectiveness of arthroscopic rotator cuff repair. The purpose of the present study is to report the preliminary data at the 1- and 2-year time point and perform subgroup analysis to identify factors that may affect outcome. METHODS A total of 193 patients underwent all-arthroscopic repair of a rotator cuff tear and met the inclusion criteria and 127 (65.8%) completed 2-year follow-up. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. RESULTS The pre-operative ASES score was 52.37 +/- 24.09 and improved to 83.88 +/- 19.28 at 1 year (P < .0001) and 92.65 +/- 11.36 at 2 years (P < 0.0001). The percent healing for all patients was 64.10% at 3 months and 64.34% at 1 year (P = .4080). At 2 years, there was a significant increase in the percentage of healed tendon at 75.42% compared to the 3-month (P (1/4) .0001) and 1-year (P = 0.0332) time points. Patients with intact tendons had an ASES score of 93.9 +/- 10.2 compared to tendon defects with a score of 88.0 +/- 15.6 (P = .0623). Gender, tear size, and acromioclavicular joint involvement have a significant effect on ASES score. Rotator cuff characteristics such as tear size, biceps pathology, acromioclavicular joint pathology, and tissue quality have a significant effect on postoperative tendon integrity. CONCLUSION Arthroscopic rotator cuff repair demonstrates significant improvement in clinical outcomes and good rate of healing by postoperative ultrasound. Longer-term studies are necessary to determine the efficacy over time.

Stress fractures about the tibia, foot, and ankle.

&NA; In competitive athletes, stress fractures of the tibia, foot, and ankle are common and lead to considerable delay in return to play. Factors such as bone vascularity, training regimen, and equipment can increase the risk of stress fracture. Management is based on the fracture site. In some athletes, metabolic workup and medication are warranted. High‐risk fractures, including those of the anterior tibial diaphysis, navicular, proximal fifth metatarsal, and medial malleolus, present management challenges and may require surgery, especially in high‐level athletes who need to return to play quickly. Noninvasive treatment modalities such as pulsed ultrasound and extracorporeal shock wave therapy may have some benefit but require additional research.