Mutsumi Ohue

Functional and Structural Outcomes of Single-Row Versus Double-Row Versus Combined Double-Row and Suture-Bridge Repair for Rotator Cuff Tears

Background: Although previous biomechanical research has demonstrated the superiority of the suture-bridge rotator cuff repair over double-row repair from a mechanical point of view, no articles have described the structural and functional outcomes of this type of procedure. Hypothesis: The structural and functional outcomes after arthroscopic rotator cuff repair may be different between the single-row, double-row, and combined double-row and suture-bridge (compression double-row) techniques. Study Design: Cohort study; Level of evidence, 3. Methods: There were 206 shoulders in 201 patients with full-thickness rotator cuff tears that underwent arthroscopic rotator cuff repair. Eleven patients were lost to follow-up. Sixty-five shoulders were repaired using the single-row, 23 shoulders using the double-row, and 107 shoulders using the compression double-row techniques. Clinical outcomes were evaluated at an average of 38.5 months (range, 24-74 months) after rotator cuff repair. Postoperative cuff integrity was determined using Sugaya’s classification of magnetic resonance imaging (MRI). Results: The retear rates after arthroscopic rotator cuff repair were 10.8%, 26.1%, and 4.7%, respectively, for the single-row, double-row, and compression double-row techniques. In the subcategory of large and massive rotator cuff tears, the retear rate in the compression double-row group (3 of 40 shoulders, 7.5%) was significantly less than those in the single-row group (5 of 8 shoulders, 62.5%, P < .001) and the double-row group (5 of 12 shoulders, 41.7%, P < .01). Postoperative clinical outcomes in patients with a retear were significantly lower than those in patients without a retear for all 3 techniques. Conclusion: The additional suture bridges decreased the retear rate for large and massive tears. The combination of the double-row and suture-bridge techniques, which had the lowest rate of postoperative retear, is an effective option for arthroscopic repair of the rotator cuff tendons because the postoperative functional outcome in patients with a retear is inferior to that without retear.

Effect of Anterior Capsular Laxity on Horizontal Abduction and Forceful Internal Impingement in a Cadaveric Model of the Throwing Shoulder

Background: Excessive anterior capsular laxity (elongation of the anterior capsular ligaments) causes shoulder subluxation during acceleration of the throwing motion, leading to a disabled throwing shoulder. Few biomechanical studies have investigated the relationship between anterior capsular laxity and internal impingement, another cause of the disabled throwing shoulder. Purpose/Hypothesis: The purpose of this study was to assess the effect of anterior capsular laxity on forceful internal impingement during the late cocking phase. The hypothesis was that excessive anterior shoulder laxity caused by elongation of the anterior capsular ligaments will increase the horizontal abduction angle to increase glenohumeral contact pressure. Study Design: Controlled laboratory study. Methods: Eight fresh-frozen cadaveric shoulders were tested with the shoulder abducted to 90° and at maximal external rotation to simulate the late cocking phase of the throwing motion. The angle of external rotation, anterior translation, angle of horizontal abduction, locations of the articular insertion of the rotator cuff tendons (supraspinatus and infraspinatus) on the greater tuberosity relative to the glenoid, and the glenohumeral contact pressure and area during internal impingement were measured. All data were compared between intact and elongated anterior capsule, which was created by repeatedly applying external rotational stretching. Results: Elongation of the anterior capsular ligaments was confirmed by the increase in glenohumeral external rotation and anterior translation after our stretching technique. Location data showed that the posterior half of supraspinatus tendon, the entire infraspinatus tendon, and the posterosuperior labrum were impinged between the greater tuberosity and glenoid. Maximal glenohumeral horizontal abduction (2.2% increase; P = .003) and glenohumeral contact pressure (27.3% increase; P = .04) were significantly increased in the shoulder joint with increased anterior capsular laxity as compared with the intact condition. Conclusion: Increased anterior capsular laxity created by applying repetitive excessive external rotational torque significantly increased horizontal abduction and contact pressure in the glenohumeral joint. Concurrently, the supraspinatus and infraspinatus tendons and posterosuperior labrum were impinged between the greater tuberosity and glenoid. Clinical Relevance: Increased anterior capsular laxity may exacerbate forceful internal impingement during the late cocking phase of the throwing motion.

Return to Sports and Physical Work After Arthroscopic Superior Capsule Reconstruction Among Patients With Irreparable Rotator Cuff Tears

Background: Although sports participation and heavy physical work can contribute to rotator cuff tears, many patients expect to return to these activities after surgery; however, irreparable rotator cuff tears can preclude this outcome. A new surgical treatment—arthroscopic superior capsule reconstruction (SCR)—restores shoulder stability and muscle balance in patients with irreparable rotator cuff tears; consequently, it improves shoulder function and relieves pain. Purpose: To evaluate the rates of return to sports and physical work among patients treated with arthroscopic SCR. Study Design: Cohort study; Level of evidence, 3. Methods: From 2007 to 2014, we performed arthroscopic SCR in 105 patients with irreparable rotator cuff tears, 5 of whom were lost to follow-up. Consequently, 100 patients (mean age, 66.9 years; range, 43-82 years) were enrolled in the study. Before surgery, 26 patients had participated in sports (2 competitive, 24 recreational), and 34 patients had physical work. Rates of return to sports and physical work, the American Shoulder and Elbow Surgeons (ASES) score, active shoulder range of motion, and rate of graft tear were evaluated. The mean time to final follow-up was 48 months (range, 24-88 months). Results: All 26 patients who played sports before their injuries returned fully to them. In addition, 32 patients returned fully to their previous physical work, whereas the 2 remaining patients returned with reduced hours and workloads. As compared with the nonsports group, the sports group had significantly higher postoperative active elevation (160° ± 32° vs 146° ± 39°; P = .04) and higher postoperative ASES scores (97 ± 7 vs 91 ± 12; P = .02). The shoulder range of motion and ASES scores before and after surgery did not differ significantly between the physical and nonphysical work groups (P = .11-.99). The rate of graft tear did not differ between the sports group (4%) and nonsports group (5%) (P = .75) and between the physical work group (6%) and nonphysical work group (5%) (P = .77). Conclusion: Arthroscopic SCR restored shoulder function and resulted in high rates of return to recreational sports and physical work.

Relationship Between Humeral Retroversion and Career of Pitcher in Elementary and Junior High Schools

Objectives: Repetitive throwing motion generates tremendous stress on the dominant shoulder in baseball players, resulting in osseous change in the shoulder joint, especially increased humeral retroversion. Here we hypothesized that the career of a pitcher in elementary and junior-high schools might increase humeral torsion on the dominant shoulder. The objective of this study was to assess the effect of baseball position in youth and adolescent athletes on humeral torsion. Methods: We studied 153 high school baseball players who began to play baseball in elementary school at the age of 8.1±1.6 years old. All subjects completed questionnaires about their baseball experience, throwing activity, and past injuries; they then were physically examined. We divided them into four groups according to their baseball positions in elementary and junior-high schools: 35 players were pitchers in both elementary and junior-high school (group 1), 32 players were pitchers in elementary school but fielders in junior-high school (group 2), 17 players were fielders in elementary school but pitchers in junior-high school (group 3), and 69 players were fielders in both elementary and junior-high school (group 4). Humeral torsion was assessed bilaterally by using ultrasound. Humeral torsion was defined as the angle between the long axis of the forearm and a line parallel to the trunk, when the line tangential to the bicipital groove was parallel to the horizontal baseline in supine position with the shoulder at 90º abduction, the elbow at 90º flexion, and the forearm in the neutral position. Results: Beginning age of baseball did not differ significantly among four groups. Among the 153 high school baseball players, 113 players (73.9%) had history of shoulder or elbow injuries. Humeral torsion was significantly greater (p<0.01) on the dominant shoulder than on the non-dominant shoulder in all groups. Humeral torsion on the dominant shoulder was significantly greater (p=0.03) in group 1 than in group 4 (mean difference, 7.1º). A logistic regression analysis showed that humeral torsion on the dominant shoulder was not a predictive factor for shoulder and elbow injuries (odds ratio, 0.99; 95% confidence interval, 0.96 - 1.02; p value, 0.70). Conclusion: In high school baseball players, humeral torsion was greater on the dominant shoulder than on the non-dominant shoulder. Players who played baseball as pitchers during both elementary and junior-high school had greater humeral torsion on the dominant side than did players who were fielders during both periods. Given that pitchers throws more frequently than do fielders, this study suggests that increased time pitching in youth and adolescent athletes increases the humeral torsion on the dominant shoulder. Increased humeral torsion on the dominant shoulder was not the predictive factor for shoulder and elbow injuries.

Arthroscopic Superior Capsule Reconstruction for Irreparable Rotator Cuff Tears A Prospective Clinical Study in 100 Consecutive Patients with 1 to 8 Years of Follow-up

Objectives: An arthroscopic superior capsule reconstruction, in which the fascia lata autograft attached medially to the superior glenoid and laterally to the greater tuberosity, restores shoulder stability and muscle balance in patients with irreparable rotator cuff tears; consequently, it improves shoulder function specifically deltoid muscle function and relieves pain. We assessed the clinical outcome of arthroscopic superior capsule reconstruction (Figure 1) in 100 consecutive patients with irreparable rotator cuff tears. Specifically, we focused on the rates of return to sport and work. Methods: From 2007 to 2014, we performed arthroscopic superior capsule reconstruction on 107 consecutive patients (mean 66.7 years; range, 43 to 82) with irreparable rotator cuff tears that had failed conservative treatment. Seven patients were lost to follow-up because of other medical problems or reasons. In the remaining 100 patients there were 56 supraspinatus and infraspinatus tears; 39 supraspinatus, infraspinatus, and subscapularis tears; 3 supraspinatus, infraspinatus, teres minor, and subscapularis tears; and 2 supraspinatus, infraspinatus, and teres minor tears. Physical examination, radiography, and MRI were performed before surgery; at 3, 6, and 12 months after surgery; and yearly thereafter. Rates of return to sport and work were also investigated in those patients who had been employed (34 patients: 21 manual workers, 10 farmers, 1 butcher, 1 cook, and 1 athletic trainer) or played sport (26 patients: 6 golf, 4 table tennis, 4 swimming, 3 martial arts, 2 baseball, 2 yoga, 1 tennis, 1 badminton, 1 skiing, 1 mountain-climbing, and 1 ground golf) before injury. Results: The average preoperative American Shoulder and Elbow Surgeons (ASES) score was 31.6 points (range, 3.3 to 63.3 points) and the average Japanese Orthopaedic Association (JOA) score was 51.6 points (26.5 to 68.5 points). Average postoperative clinical outcome scores all improved significantly at final follow-up (mean, 36.6 months after surgery; range, 12 to 96 months; ASES, 93.3 points; JOA, 92.2 points) (P < .00001). Ninety-two patients (92%) had neither graft tear nor re-tear of the repaired rotator cuff tendon during the follow-up period (5 to 8 years of follow-up, 17 patients; 3 to 4 years of follow-up, 19 patients; 1 to 2 years of follow-up, 56 patients). Postoperative clinical outcome scores and active elevation at final follow-up were significantly better in healed patients (ASES, 95.5 points; JOA, 93.7 points, 154.8° ± 24.2°) than in unhealed patients suffering from graft tear or re-tear of the repaired rotator cuff tendon (ASES, 76.3 points, P < 0.0001; JOA, 79.5, P < 0.001; 115.0° ± 41.8°, P < 0.001). Thirty-two patients returned fully to their previous jobs, whereas two patients returned with reduced hours and workloads. All 26 patients who had played sport before their injuries returned fully to their previous sports, although most of the patients had been playing at recreational level before their injuries. Conclusion: Arthroscopic superior capsule reconstruction restored shoulder function and resulted in high rates of return to recreational sport and work. Graft tear or re-tear of the repaired rotator cuff tendon exacerbated the clinical outcome after superior capsule reconstruction. These results suggest that arthroscopic superior capsule reconstruction is a viable surgical option for irreparable rotator cuff tears, especially in patients who work and enjoy sport.

Paraarticular osteochondroma of a lumbar facet joint presenting with radiculopathy.

Conventional osteochondroma is a common benign osteocartilaginous tumor that typically originates near the end of a long bone with an osseous stalk and cartilaginous cap. This type of tumor grows away from the joint and is treated via marginal resection [1,2]. In contrast, “paraarticular osteochondroma” is a rare osteocartilaginous tumor that arises in the soft tissue that is adjacent to a joint, which does not exhibit bone continuity [1,3]. It is reported as a pathological entity which is distinguished from conventional osteochondroma. Several reports describe “paraarticular osteochondroma” existing adjacent to the joints of the extremities, particularly the knee joints [1,3]. However, spinal involvement of this tumor is very rare. To the best of our knowledge, Okamoto et al. have reported the only case of “paraarticular osteochondroma” that existed in the cervical spinal canal, which was adjacent to the facet joint and caused spinal cord compression [4]. In the present report, we describe a case of “paraarticular osteochondroma” in the lumbar spinal canal, which exhibited characteristics that were quite similar to those that were reported by Okamoto et al. The patients were informed