Michael Khazzam

Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis.

BACKGROUND The correlation between the structural integrity of rotator cuff repair and the clinical outcome for the patient remains controversial. The purpose of this study was to assess the relationship between patient function and structural integrity of the rotator cuff after repair. METHODS A systematic review and a meta-analysis were conducted for Level-I and Level-II studies showing outcome measures after rotator cuff repair and an imaging assessment of the structural integrity of the repair. Data extracted included patient demographics, tear size, repair type, clinical outcome measures, and repair integrity. Statistical analysis was performed to compare outcomes in patients on the basis of the structural integrity of repair at the time of the latest follow-up. RESULTS Fourteen studies met inclusion criteria and were included in the latest analysis. Of the 861 patients who underwent rotator cuff repair with a minimum of a one-year follow-up, 674 patients (78.3%) had intact repairs at the time of latest follow-up. There was no difference in tear size between patients with intact repairs and those with retears (p = 0.866). The University of California Los Angeles shoulder score, the Constant score, and the American Shoulder and Elbow Surgeons score increased and the visual analog scale score decreased in patients regardless of the structural integrity of the repair. Patients with intact repairs had higher Constant scores by 8.93 points (p < 0.0001) and higher University of California Los Angeles shoulder scores by 2.95 points (p = 0.0004). Postoperative American Shoulder and Elbow Surgeons scores were no different in patients with intact repairs or retears (p = 0.15). Postoperative visual analog scale scores were 0.93 points lower in patients with intact repairs (p = 0.01). Patients with intact repairs had increased strength in forward elevation by 2.40 kilograms (5.29 pounds) (p < 0.00001) and had a trend toward increased strength in shoulder external rotation (p = 0.06). Although these results are significant, the differences are not clinically important on the basis of the validation of these outcome measures. CONCLUSIONS The results of this study suggest that there is not a clinically important difference in validated functional outcome scores or pain for patients who have undergone rotator cuff repair regardless of the structural integrity of the repair. Patients with intact repairs do have significantly greater strength than those with retears.

Disorders of the long head of biceps tendon

Disorders of the long head of the biceps (LHB) tendon can exist in conjunction with several other shoulder pathologies. Currently, the function of the LHB tendon remains unresolved. It is clear, however, that this tendon can be a significant source of shoulder pain and dysfunction. We have reviewed the anatomy, pathophysiology, classification, diagnosis, and treatment of disorders involving the LHB tendon. We also have reviewed the literature to help make treatment decisions.

Magnetic Resonance Imaging Identification of Rotator Cuff Retears After Repair Interobserver and Intraobserver Agreement

Background: Magnetic resonance imaging (MRI) is the most commonly used imaging modality to assess the rotator cuff. Currently, there are a limited number of studies assessing the interobserver and intraobserver reliability of MRI after rotator cuff repair. Hypothesis: Fellowship-trained orthopaedic shoulder surgeons will have good inter- and intraobserver agreement with regard to features of the repaired rotator cuff (repair integrity, fat content, muscle volume, number of tendons involved, tear size, and retract) on MRI. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Seven fellowship-trained orthopaedic shoulder surgeons reviewed 31 MRI scans from 31 shoulders from patients who had previous rotator cuff repair. The scans were evaluated for the following characteristics: rotator cuff repair status (full-thickness retear vs intact repair), tear location, tendon thickness, fatty infiltration, atrophy, number of tendons involved in retear, tendon retraction, status of the long head of the biceps tendon, and bone marrow edema in the humeral head. Surgeons were asked to review images at 2 separate time points approximately 9 months apart and complete an evaluation form for each scan at each time point. Multirater kappa (κ) statistics were used to assess inter- and intraobserver reliability. Results: The interobserver agreement was highest (80%, κ = 0.60) for identifying full-thickness retears, tendon retear retraction (64%, κ = 0.45), and cysts in the greater tuberosity (72%, κ = 0.43). All other variables were found to have fair to poor agreement. The worst interobserver agreement was associated with identifying rotator cuff footprint coverage (47%, κ = −0.21) and tendon signal intensity (29%, κ = −0.01). The mean intraobserver reproducibility was also highest (77%-90%, κ = 0.71) for full-thickness retears, quality of the supraspinatus (47%-83%, κ = 0.52), tears of the long head of the biceps tendon (58%-94%, κ = 0.49), presence of bone marrow edema in the humeral head (63%-87%, κ = 0.48), cysts in the greater tuberosity (70%-83%, κ = 0.47), signal in the long head of the biceps tendon (60%-80%, κ = 0.43), and quality of the infraspinatus (37-90%, κ = 0.43). The worst intraobserver reproducibility was found in identification of the location of bone marrow edema (22%-83%, κ = −0.03). Conclusion: The results of this study indicate that there is substantial variability when evaluating MRI scans after rotator cuff repair. Intact rotator cuff repairs or full-thickness retears can be identified with moderate reliability. These findings indicate that additional imaging modalities may be needed for accurate assessment of the repaired rotator cuff.

Pilon fractures: advances in surgical management.

&NA; Pilon fractures are challenging to manage because of the complexity of the injury pattern and the risk of significant complications. Variables such as fracture pattern, soft‐tissue injury, and preexisting patient factors can lead to unpredictable outcomes. Avoiding complications associated with the soft‐tissue envelope is paramount to optimizing outcomes. In persons with soft‐tissue compromise, the use of temporary external fixation and staged management is helpful in reducing further injury and complications. Evidence in support of new surgical approaches and minimally invasive techniques is incomplete. Soft‐tissue management, such as negative‐pressure dressings, may be helpful in preventing complications.

Current concepts review: revision rotator cuff repair

Failed rotator cuff repair may be caused by surgical complications, diagnostic errors, technical errors, failure to heal, and traumatic failure. Revision rotator cuff repair is made technically more difficult by poor tissue quality, tissue adhesions, and retained suture and suture anchor material. Historically, open revision rotator cuff repair yields inferior results compared with primary rotator cuff repair; however, more recent studies show 52% to 69% satisfactory results in small-sized or medium-sized tears. Arthroscopic revision rotator cuff repair yields greater than 60% good or excellent results. Poor tissue quality, detachment of the deltoid origin, and multiple previous surgeries are risk factors for poor results in revision rotator cuff repair.

Humeral avulsion of glenohumeral ligaments

Abstract Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra‐articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini‐open techniques involve limited incision in the lower one half of the subscapularis.

Quantitative motion analysis in patients with hallux rigidus before and after cheilectomy.

The purpose of this study was to quantify changes in temporal‐spatial parameters and multisegmental foot/ankle kinematics in a group of patients with hallux rigidus following cheilectomy. Three‐dimensional motion analysis was conducted using a 15‐camera Vicon Motion Analysis System on a population of 19 patients who underwent cheilectomy for hallux rigidus. Data were analyzed using the four‐segment Milwaukee Foot Model. Preoperative and postoperative tests were compared using paired parametric methods. Results showed significant improvements in walking speed, cadence, stride length, and stance/swing ratio from preoperative to postoperative state. Altered hallux and forefoot positions preoperatively showed shifts towards normal after cheilectomy. Although clinical improvements in pain and passive range of motion were statistically significant, similar improvements in range of motion were not demonstrated during ambulatory testing. The results of this study provide insight into ambulatory improvements following cheilectomy, and suggest further study of the rehabilitation process to improve the recovery of functional range of motion.

Surgical reconstruction of posterior tibial tendon dysfunction: prospective comparison of flexor digitorum longus substitution combined with lateral column lengthening or medial displacement calcaneal osteotomy.

Posterior tibial tendon dysfunction (PTTD) may require surgical intervention when nonoperative measures fail. Different methods of bony reconstruction may supplement tendon substitution. This study compares two types of bony procedures used to reinforce reconstruction of the posterior tibial tendon-the lateral column lengthening (LCL), and the medial displacement calcaneal osteotomy (MDCO). Twenty patients with PTTD were evaluated before and after scheduled reconstruction comprised of either flexor digitorum longus (FDL) substitution combined with MDCO (MDCO group, 14 patients) or FDL substitution with LCL fusion or osteotomy (LCL group, 6 patients). Foot/ankle kinematics and temporal-spatial parameters were analyzed using the Milwaukee Foot Model, and results were compared to a previously evaluated normal population of 25 patients. Post-operatively, both patient groups demonstrated significantly improved stride length, cadence and walking speed, as well as improved hindfoot and forefoot position in the sagittal plane. The LCL group also demonstrated greater heel inversion. All post-operative subjects revealed significant improvement in the talo-MT1 angle in the A/P and lateral planes, calcaneal pitch and medial cuneiform-MT5 height. Surgical reconstruction of PTTD with either the LCL or MDCO shows comparable improvements in gait parameters, with better heel inversion seen with the LCL, but improved 1st ray plantarflexion and varus with the MDCO. Both procedures demonstrated comparable improvements in radiographic measurements.

Comparison of Neurotization Versus Nerve Repair in an Animal Model of Chronically Denervated Muscle

Purpose Reinnervation of chronically denervated muscle is clinically unpredictable and poorly understood. Current operative strategies include either direct nerve repair, nerve grafting, nerve transfer, or neurotization. The goal of this study is to compare muscle recovery using microneural repair versus neurotization in a rat model of chronic denervation. Methods Fifty-eight Sprague-Dawley rats had surgical denervation of the tibialis anterior muscle by transecting the common peroneal nerve. After 0, 8, 12, or 22 weeks of denervation, animals were assigned to either a direct repair or a neurotization cohort. An additional 7 animals were used for a sham cohort, and 7 of the 58 were used as controls. After a 12-week recovery period, animals had contractile strength and EMG testing of the tibialis anterior muscle. Peak force and characteristics were compared to the unoperated, contralateral limb. Tibialis anterior muscles were then harvested for mass and histologic evaluation. Results Sixty-two animals completed testing. Denervated controls demonstrated a significant decrease in muscle mass, contractile strength, and peak motor nerve conduction amplitude compared to sham animals. In all groups, chronicity of denervation adversely affected functional recovery. On average, repair animals performed better than neurotization animals with respect to muscle mass, contractile strength, and peak motor amplitude. Differences in contractile force, however, were significant only at the 0 week denervation group (94% ± 30 vs 50% ± 20, repair vs neurotization). Neurotized muscles processed for histologic analysis demonstrated acetylcholinesterase activity at the nerve-muscle interface, confirming the formation of motor end plates de novo. Conclusions We demonstrated that neurotization is capable of reinnervating de novo end plates in chronically denervated muscle. Our data do not support the hypothesis that direct muscle neurotization is superior to nerve repair for functional restoration of chronically denervated muscle. However, as the duration of denervation increases, the difference between outcomes of the neurotization and repair group narrows, suggesting that neurotization may offer a viable surgical alternative in the setting of prolonged denervation.

Extensor Tendon Triggering by Impingement on the Extensor Retinaculum: A Report of 5 Cases

We describe 4 patients who were treated for symptomatic triggering of the index and small fingers with pain on the dorsum of the hand and were found to have impingement of an extensor tendon on the extensor retinaculum at the wrist. All cases were treated by release of the extensor retinaculum and excision of pathologic structures.