Mustafa Özer

Grade of coracoacromial ligament degeneration as a predictive factor for impingement syndrome and type of partial rotator cuff tear

BACKGROUND The purpose of this study was to investigate the role of coracoacromial ligament degeneration and specific anatomic parameters in the etiology of partial-thickness rotator cuff tears. MATERIALS AND METHODS This study retrospectively assessed 96 patients (mean age, 50.1 years [17-76]; 34 men, 62 women) diagnosed with bursal-side and articular-side rotator cuff tears with a history of failed conservative treatment and persistent shoulder pain who underwent arthroscopic surgery. Video records of the surgery were used to evaluate the type of cuff tear, grade of coracoacromial ligament degeneration, and associated pathologic changes; preoperative magnetic resonance images were used to measure acromioglenoid angle, supraspinatus glenoid angle, and subacromial distance. RESULTS Most of the patients with articular-side tears demonstrated grade 0 and grade 1 coracoacromial ligament degeneration, whereas patients with bursal-side tears had grade 1 and grade 2. There was a significant positive correlation between the grade of coracoacromial ligament degeneration and bursal-side partial rotator cuff tears, whereas no correlation was observed with articular-side tears. There was no significant difference between bursal-side and articular-side partial cuff tears regarding acromioglenoid angle, supraspinatus glenoid angle, and subacromial distance. CONCLUSIONS Grade 1 and grade 2 coracoacromial ligament degeneration is a strong predictive factor for impingement syndrome in the etiology of bursal-side partial cuff tears and can guide the surgeon to consider ligament release and débridement or acromioplasty in these patients.

Arthroscopic treatment of intra-artricularly localised pigmented villonodular synovitis of the ankle: 4 cases with long-term follow-up

BACKGROUND CONTEXT Pigmented villonodular synovitis (PVNS) is a rare, locally aggressive benign proliferative pathology of synovial tissue. Lesions are classified regarding location as diffuse or localised which are same as histologically. Intra-articularly localised type is relatively rare, especially in the ankle joint. Because of the high recurrence rate and aggressive nature, localised lesions should be excised totally. PURPOSE We performed a retrospective study of 4 patients with intra-articularly localised PVNS in the ankle joint who were treated by total arthroscopic excision and evaluated for functional results and recurrence rate. STUDY DESIGN Case series. PATIENT SAMPLE The mean age of the patients was 27 (17-46) years at the time of arthroscopic surgery. The mean follow-up time was 33 (24-48) months. METHODS Functional evaluation according to the Musculoskeletal Tumour Society Score was performed, and patients were evaluated for recurrence by MR imaging. RESULTS In all patients, functional results were excellent and there was no recurrence. CONCLUSIONS This study demonstrates that the intra-articularly localised PVNS can be successfully treated with arthroscopic procedures without recurrence.

Kyphoplasty for Intractable Pain Due to Glucocorticosteroid-induced Osteoporotic Vertebra Fracture of a 9-Year-Old Patient With Systemic Lupus Erythematosus: 8-Year Follow-up.

Background Context: The incidence of glucocorticoid-induced osteoporosis is approximately 50% in patients treated for >6 months, and in the long-term usage fracture risk is approximately 34%. The awareness of pediatric vertebral fractures due to glucocorticoid-induced osteoporosis is increasing. Although most of these fractures are asymptomatic, a small number of children may have severe pain. Purpose: In this case report we are presenting long-term result of a 9-year-old patient with intractable pain due to glucocorticoid-induced osteoporotic vertebral fracture managed by kyphoplasty. Study Design: Case report. Patient Sample: Case report of a 9-year-old girl who had L3 vertebral fracture due to glucocorticoid-induced osteoporosis treated by kyphoplasty. Methods: The patient was a 9-year-old girl with severe back pain, and lupus nephritis. Glucocorticoid-induced L3 vertebral fracture was detected and the case was resistant to conservative treatment. Seeing this, we have performed balloon kyphoplasty procedure to L3 vertebrae. Results: No complication and pain was observed after the operation although L3 vertebral height could not restored. On the 8-year control, L3 vertebral height was almost totally restored with a compression index of 10% without any clinical problem. Conclusions: To the best of the authors’ knowledge, the patient sample of this case report is the first and the youngest patient who was treated with kyphoplasty for vertebral compression fracture intractable pain due to glucocorticoid-induced osteoporosis, mentioned in literature. During the 8-year follow-up, no adverse effect was reported that was related to kyphoplasty procedure. This case report indicates that kyphoplasty can be an alternative method for selective pediatric intractable painful vertebral glucocorticoid-induced osteoporotic fractures, but it should be performed after careful consideration in pediatric group. We do not advise routine usage of kyphoplasty for pediatric vertebral fractures.

Relationship Between Functional Knee Joint Position Sense and Functional Performance Scores Following Anterior Cruciate Ligament Reconstruction (Pilot Study)

Objectives: The aim of this study was to assess the relationship between functional knee joint position sense (JPS) and functional performance following ACL reconstruction Methods: Seven male patients (mean age=32,66 ±6,47) who had undergone ACL reconstruction and 10 male healthy control subjects participated in the study. Knee joint position sense was evaluated by reproduction of 20° knee flexion angle in weight-bearing position with single and bilateral limb movement into flexion and extension. The deviations in the angle were recorded and compared to both noninjured side and healthy controls’. Functional performance was evaluated with Single Leg Hop Test in both injured and non-injured sides. The scores were also compared with healthy controls and non-injured sides. Relationship between measured values was tested with Spearman Correlation Analysis. Results: There was no significant difference in knee joint position sense in functional position between the operated and uninjured knees of patients or between patients and healthy controls (p>0,05). However, there is significant difference in Single Leg Hop test scores between operated and non-operated or between patients and healthy controls (p=0,037; p<0,05). There was no significant correlation between Single Leg Hop test scores and knee joint position sense (p>0,05). Conclusion: There was no evidence of impaired joint position sense in weight-bearing positions in subjects with ACL reconstruction but there was a decrease in functional performance. This decrease in functional performance may depend on the other parameters except proprioceptive deficits.

The evaluation of two different surgical approaches in total hip arthroplasty according to the patient satisfaction, plantar pressure distribution and trendelenburg sign

The aim of this prospective study was to analyze the results of two different surgical aproaches for total hip arthroplasty as Trendelenburg sign, plantar pressure distribution with the help of dynamic pedobarography and clinical results by Harris Hip Score. A total of 28 patients who underwent unilateral total hip arthroplasty using two different types of lateral approach as conventional lateral Hardinge approach and intermuscular Hardinge approach described by Pai were included in this study. Plantar pressures have maesured by EMED-SF pedobarography device and analysed by the help of a commercial software; that seperates the foot to the four different parts which are called masks. TrendelenburgÂ’s sign has been estimated as grade 1 and grade 2 by the method which was described by Hardcastle and Nade. Clinical outcome was measured by comparing Harris Hip Scores pre-operatively and postoperatively at last clinic visit. In both groups after the two years from the surgery; total contact time has increased at the operation side when the results were compared before the surgery at the same side and at the other side after the surgery. Also when we looked at the first and second masks which show the significant part of the stance phase; contact areas have similarly increased and the changes at the peak pressures were similar as contact areas. In both groups Harris Hip score was increased significantly after the operation. This is the first study to compare two different lateral approaches by pedobarographic analysis, clinical evaluation and functional scoring. The fuctional and clinical early results are similar in both lateral hip approaches for total hip arthroplasty when superior gluteal nerve protection, conjuant tendon repair and postoperative rehabilitation have done well.

Do subscapularis tears really result in superior humeral migration

Objectives The aim of this study was to analyse the effect of subscapularis tear on superior humeral excursion (SHE) and acromiohumeral distance (AHD). The hypothesis was that subscapularis tears do not result in superior humeral excursion. Methods Patients who underwent shoulder arthroscopy between August of 2011 and 2015 were reevaluated. Those with isolated Bankart lesion were used as control group and included in the Group 1, isolated full-thickness supraspinatus tear in the Group 2, isolated subscapularis tear in the Group 3, and combined subscapularis and supraspinatus tear in the Group 4. The mean SHE and AHD measurements on magnetic resonance imaging of these groups were compared to reveal any difference in superior humeral migration (SHM). Results There were 30 patients in each group. The mean age of Group 1 (26.44 ± 8.34) was younger than the other 3 groups. The mean AHD and SHE were higher in Group 1 and 3 (Mean AHD: 12.89 ± 2.24 and 12.28 ± 1.9, respectively. Mean SHE: −3.2 ± 0.99 and −2.78 ± 0.64, respectively) than Group 2 and 4 (Mean AHD: 6.2 ± 1.78 and 6.16 ± 1.52, respectively. Mean SHE: 0.72 ± 0.65 and 1.24 ± 0.63, respectively). The AHD and SHE were strongly correlated with each other (Pearson correlation coefficient = 0.184). The inter-observer and intra-observer correlation of the measurements of SHE on MRI were excellent with intraclass correlation coefficient of 0.95 and 0.94, respectively. Conclusion Subscapularis tears do not lead to SHM and subacromial impingement. However, superior rotator cuff tears can still lead to SHM and subacromial impingement even when subscapularis tendon is intact. Level of evidence Level III, diagnostic study.

Incidence of accompanying intraarticular lesions in patients treated with arthtroscopic surgery for acromioclavicular degeneration

Purpose: Acromioclavicular joint degeneration is a common disease that causes antero-superior shoulder pain. İn physical examination regional pain at acromioclavicular joint can occur with cross-body adduction or internal rotation. Surgery should be planned if the patient has not relieved with minimum 6 months of nonoperative treatment, and has no infection or instability. In this study, we aimed the incidence of accompanying intraarticular conditions in patients applied arthroscopic distal clavicula resection. Method: Documents and intraoperative videos of 128 patients undergone artroscopic distal clavicula resection between 2005-2014 has been analyzed restospectively. The incidence of other intraarticular conditions accompanying acromioclavicular arthritis. Results: The average of the age of the 128 patients was 56,9(18-70). 43 of them were male (%33,6) and 85 were female (66,4). 3 (%2,3) patients had anterior instability and treated with Bankart repairment. 50 patients had Superior Labrum Anterior Posterior (SLAP) lesion (39,1) (SLAP1:12, SLAP2:36, SLAP4:1, SLAP5:2). 37 of the were treated with SLAP repairment. Bufford complex had been spotted in one patient. 19 (%14,8) patients had accompanying biceps lesions. 2 patients had biceps brachii long head rupture. 10 patients had been treated with biceps tenotomy, 3 atients had been treated with biceps tenodesis. 7 (%5,5) patients had accompanying subscapularis lesion and treated with repairment. 58(%45,3) patients had accompanying rotator cuff tears (12 partial, 45 total, 1 massive) and48 treated with repairment. In conclusion; 100 (%78,1) 128 patients had accompanying intraarticular lesions needed surgical intervention Outcomes: The most common complication of distal clavicle resection is pain as a result of insufficient resection and instability due to aggressive resection. İndications sould be chosen carefully to avoid complications and for patient satisfaction. After evaluation of the accompanying lesions that require operative treatment, acromioclavicular lesion should be evaluated again. In our study accompanying lesions can be unnoticed using open surgery, as a consequence incomplete treatment and low patien satisfaction. In radographic imaging, if acromioclavicular arthritis is not compatible with clinical symptoms it is essential to evaluate accompanying lesions, on the other hand it should not be forgotten that acromioclavicular arthritis can imitate other lesions

Superior labrum almost always tears following subscapularis injuries

Purpose and Hypothesis: The subscapularis tendon is the major medial support of the long head of biceps tendon (LHBT). Thus, tears of subscapularis may cause biceps tendon subluxation or dislocation. A subluxated biceps tendon may cause a superior labrum injury because of the changed direction of the biceps tendon pulling vector. The purpose of this study is to express the frequency of superior labrum anterior posterior (SLAP) lesions accompanying subscapularis tears. Methods: The digital files of 2010 patients who underwent shoulder arthroscopy were reviewed retrospectively. 141 videos of 141 patients with subscapularis tear were examined in terms of superior labrum and biceps tendon injuries by one of the authors in this study. The results were compared with those of all the 2010 patients who underwent shoulder arthroscopy for any reason. The statistical analysis was made with a statistics programme by the Independent Samples T-Test. Results: There were 113 videos on which the superior labrum and LHBT could be examined precisely. Mean age was 57.8 and 66% of the patients were female. 96.4% of the 113 patients were having a SLAP lesion. 10.6% of those were SLAP I and 89.4% were SLAP II lesion. Out of 2010 patients, the SLAP lesion ratio was 32.2% of which 4.9% were SLAP I. That difference between the patients with and without subscapularis tear was statistically significant. Conclusions: Following the loss of medial support, the LHBT and its pulling vector subluxate anteriorly resulting in a tear of the superior labrum from anterior to posterior. In this study, SLAP lesions were strongly correlated with subscapularis tears as well. Furthermore, the synovial hypertrophy initiated after a superior labrum pathology at superior aspect of the glenoid spreads over the LHBT. An inflamed LHBT firstly degenerates, and then ruptures. According to this study, tears of subscapularis should be repaired when encountered in order to prevent the upcoming secondary intra-articular disorders. Figure 1 Figure shows the concurrent subscapularis tear and SLAP lesion in a patient who underwent shoulder arthroscopy.

Risk factors of recurrence after an arthroscopic stabilisation procedure performed for traumatic anterior shoulder instability in pediatric population

Arthroscopic stabilisation of traumatic anterior shoulder instability is being performed also in pediatric age group, and reports associated with risks of recurrent instability have been presented. The aim of the current study was determining the risk factors of recurrence after the arthroscopic anatomic repair preformed in pediatric age group. 46 patients who underwent arthroscopic Bankart repair for traumatic anterior shoulder instability with the mean age of 17 ±0.8 (15-18) were included in this study. After an average follow-up time of 40.4± 22.7(24-155) months age, gender, dominant side, number of dislocations before surgery, participation in contact sports, Rowe and Oxford shoulder scores, labral lesion type, number of anchor used, and capsular laxity were assessed, and their correlation with recurrence were investigated. Recurrence was encountered in 9 (19,5%) patients, on average, 16.1 ±13.43 months after surgery. The only risk factor of recurrence was found to be the history of five or more times of dislocation before surgery (p=0,006). Although statistically insignificant, when evaluated separately, it was found that patients with contact sports history had double times of recurrence rate if they had ALPSA or SLAP lesion and triple times of recurrence rate if they had capsular laxity. The recurrence rate was found to be 38,4% when accompained by capsular laxity, 50% when accompained by both capsular laxity and ALPSA lesion, and 100% when accompanied by all capsular laxity, ALPSA lesion and contact sports history. Arthroscopic stabilisation of traumatic anterior shoulder instability in pediatric population is an appropriate technique, especially in those with less than five times of dislocation because of the low recurrence rate (3.4%). Surgical procedures that are non-anotomic, such as coracoid transfer or anterior glenoid bone block, should be considered in patients with high risk of recurrence rate after an arthroscopic anatomic repair because of the risk factors like history of five or more times of dislocation, being accompanied by an ALPSA, SLAP lesion, or a capsular laxity and participation in contact sports.

Surgical Management of Stiff Shoulder

Stiffness problem in the shoulder, is a symptom that can be caused by many pathologies. It can be seen in different clinical presentations like primary or secondary simple stiffness, adhesive capsulitis, frozen shoulder or algodystrophy. The etiology is intricate and multifactorial, so that treatment of stiff shoulder is often empirical and confederated [1].