Neal S. ElAttrache

Biomechanical comparison of a single-row versus double-row suture anchor technique for rotator cuff repair

Background Reestablishment of the native footprint during rotator cuff repair has been suggested as an important criterion for optimizing healing potential and fixation strength. Hypothesis A double-row rotator cuff footprint repair will demonstrate superior biomechanical properties compared with a single-row repair. Study Design Controlled laboratory study. Methods In 9 matched pairs of fresh-frozen cadaveric shoulders, the supraspinatus tendon from 1 shoulder was repaired with a double-row suture anchor technique: 2 medial anchors with horizontal mattress sutures and 2 lateral anchors with simple sutures. The tendon from the contralateral shoulder was repaired using a single lateral row of 2 anchors with simple sutures. Each specimen underwent cyclic loading from 10 to 180 N for 200 cycles, followed by tensile testing to failure. Gap formation and strain over the footprint area were measured using a video digitizing system; stiffness and failure load were determined from testing machine data. Results Gap formation for the double-row repair was significantly smaller (P< .05) when compared with the single-row repair for the first cycle (1.67 ± 0.75 mm vs 3.10 ± 1.67 mm, respectively) and the last cycle (3.58 ± 2.59 mm vs 7.64 ± 3.74 mm, respectively). The initial strain over the footprint area for the double-row repair was nearly one third (P< .05) the strain of the single-row repair. Adding a medial row of anchors increased the stiffness of the repair by 46% and the ultimate failure load by 48% (P< .05). Conclusion Footprint reconstruction of the rotator cuff using a double-row repair improved initial strength and stiffness and decreased gap formation and strain over the footprint when compared with a single-row repair. Clinical Relevance To achieve maximal initial fixation strength and minimal gap formation for rotator cuff repair, reconstructing the footprint attachment with 2 rows of suture anchors should be considered.

Repair Site Integrity After Arthroscopic Transosseous-Equivalent Suture-Bridge Rotator Cuff Repair

Background Successful healing after arthroscopic rotator cuff repair remains a challenge. Earlier studies have shown a relatively high rate of failure. New surgical techniques may improve healing potential. The purpose of this study was to provide an objective evaluation of repair site integrity after arthroscopic transosseous-equivalent suture-bridge rotator cuff repair. Hypothesis Rotator cuff tears repaired using the transosseous-equivalent suture-bridge technique will show a higher intact rate on postoperative magnetic resonance imaging (MRI) evaluation. Study Design Case series; Level of evidence, 4. Methods The first 25 patients who underwent arthroscopic rotator cuff repair using the transosseous-equivalent suture-bridge technique underwent MRI evaluation of the postoperative shoulder. Minimum follow-up was 1 year. Demographic, clinical, and surgical factors, including tear size, were evaluated. Results Postoperative MRI demonstrated intact surgical repair sites in 22 of 25 patients (88%). Tears limited to the supraspinatus tendon were intact in 16 of 18 patients (89%). Tears of the supraspinatus involving part or all of the infraspinatus showed an 86% intact rate (6 of 7 patients). Of these tears, 3 were considered massive (complete 2-tendon or greater). These demonstrated an intact cuff on MRI. Conclusions The transosseous-equivalent suture-bridge technique demonstrates a high healing rate on imaging studies at 1 year. Of the first 25 patients repaired with the technique, 88% had an intact rotator cuff repair on MRI evaluation. This indicates excellent cuff healing, as judged by the intact repair sites, compared with most standard arthroscopic rotator cuff repair series. In this early report of the technique, a persistent tear could not be correlated with age or initial tear size; however, this may be due to the relatively small sample size.

Biomechanical Evaluation of a New Ulnar Collateral Ligament Reconstruction Technique with Interference Screw Fixation

Background Techniques for ulnar collateral ligament reconstruction have evolved. Hypothesis Ulnar collateral ligament reconstruction with interference screw fixation restores elbow kinematics and failure strength to that of the native ligament. Study Design Controlled laboratory study. Methods Of 10 matched pairs of cadaveric elbows, one underwent kinematic testing under conditions of an intact, released, and reconstructed ligament. Single 5-mm diameter bone tunnels were created at the isometric anatomic insertion sites on the medial epicondyle and sublime tubercle. Graft fixation was achieved with 5 × 15 mm soft tissue interference screws. The reconstructed and contralateral intact elbows were then tested to failure. Results Average stiffness for intact elbows (42.81 ± 11.6 N/mm) was significantly greater than for reconstructed elbows (20.28 ± 12.5 N/mm). Ultimate moment for intact elbows (34.0 ± 6.9 N·m) was not significantly different from reconstructed elbows (30.6 ± 19.2 N·m). Release of the ulnar collateral ligament caused a significant increase in valgus instability. Reconstruction restored valgus stability to near that of the intact elbow. Conclusions With this reconstruction method, failure strength was comparable with that of the native ligament and physiologic elbow kinematics were reliably restored. Clinical Relevance This technique returns elbow kinematics to near normal, with less soft tissue dissection and risk of ulnar nerve injury and ease of graft insertion, tensioning, and fixation.

The Effect of Pitching Biomechanics on the Upper Extremity in Youth and Adolescent Baseball Pitchers

Background Increased pitch counts have been linked to increased complaints of shoulder and elbow pain in youth baseball pitchers. Improper pitching mechanics have not been shown to adversely affect the upper extremity in youth pitchers. Hypothesis The correct performance of 5 biomechanical pitching parameters correlates with lower humeral internal rotation torque and elbow valgus load, as well as higher pitching efficiency, in youth and adolescent pitchers. Study Design Descriptive laboratory study. Methods In sum, 169 baseball pitchers (aged 9-18) were analyzed using a quantitative motion analysis system and a high-speed video while throwing fastballs. The correct performance of 5 common pitching parameters was compared with each pitchers age, humeral internal rotation torque, elbow valgus load, and calculated pitching efficiency. Results Motion analysis correlated with video analysis for all 5 parameters (P <. 05). Youth pitchers (aged 9-13) performing 3 or more parameters correctly showed lower humeral internal rotation torque, lower elbow valgus load, and higher pitching efficiency (P <. 05). Conclusions Youth pitchers with better pitching mechanics generate lower humeral internal rotation torque, lower elbow valgus load, and more efficiency than do those with improper mechanics. Proper pitching mechanics may help prevent shoulder and elbow injuries in youth pitchers. Clinical Relevance The parameters described in this study may be used to improve the pitching mechanics of youth pitchers and possibly reduce shoulder and elbow pain in youth baseball pitchers.

Reconstruction of the Lateral Collateral Ligament of the Knee With Patellar Tendon Allograft Report of a New Technique in Combined Ligament Injuries

This is a retrospective study of 10 patients with combined cruciate ligament and posterolateral instability who underwent surgical reconstruction between 1991 and 1994. All knees had at least 20° increased external rotation at 30° of knee flexion and from 1 to 3 varus instability. Five knees with posterior cruciate ligament ruptures had at least a 2 Lachman test result. (One knee had both anterior and posterior cruciate ligament injuries.) In all cases the lateral collateral ligament was reconstructed with a bone-patellar tendon-bone allograft secured with interference screws. Fixation tunnels were placed in the fibular head and at the isometric point on the femur. The cruciate ligaments were reconstructed with autograft or allograft material. The average follow-up was 28 months. Excessive external rotation at 30° of flexion was corrected in all but one knee. Six patients had no varus laxity, and four patients had 1 varus laxity at 30° of flexion. The posterior drawer test result decreased, on average, to 1 , and the Lachman test result decreased to between 0 and 1 . The average Tegner score was 4.6, with five patients returning to their preinjury level of activity and four returning to one level lower. These results indicate that this is a promising new procedure for patients with instability resulting from lateral ligament injuries of the knee.

Clinical Outcomes of the DANE TJ Technique to Treat Ulnar Collateral Ligament Insufficiency of the Elbow

Background Many improvements in ulnar collateral ligament reconstruction have been made since Jobe et al first described the procedure. A novel elbow ulnar collateral ligament reconstruction technique that combines interference screw fixation on the ulna with docking of the graft on the humeral side (DANE TJ) has been reported. Hypothesis Outcomes of ulnar collateral ligament reconstructions performed with the DANE TJ technique are as good as other recently published results of ulnar collateral ligament reconstruction, particularly in cases of insufficient bone stock on the sublime tubercle and revision reconstructions. Study Design Case series; Level of evidence, 4. Methods During a 3-year period, 22 athletes were treated with surgical reconstruction of the ulnar collateral ligament using proximal docking and distal interference screw fixation of the ligament (DANE TJ technique). All patients had a history, physical examination findings, and magnetic resonance imaging results consistent with ulnar collateral ligament injury. Patients were evaluated at a mean of 36 months postoperatively. Outcomes were classified using a modified Conway Scale. Results At the most recent follow-up, 19 of 22 patients had excellent results. There were 2 fair results and 1 poor result. The poor result was in a revision case. The 2 other revision ulnar collateral ligament reconstructions had excellent outcomes. When used in 2 cases of sublime tubercle avulsions, the results were excellent. Postoperative complications occurred in 4 patients: 2 developed ulnar neuritis, and 2 required second surgeries for lysis of adhesions. Three of these 4 patients went on to have excellent outcomes. Conclusion Clinically, the initial results compare favorably with other published techniques of elbow ulnar collateral ligament reconstruction. These early data support the use of the DANE TJ technique for revision cases and cases of sublime tubercle insufficiency.

Outcome of Type II Superior Labral Anterior Posterior Repairs in Elite Overhead Athletes Effect of Concomitant Partial-Thickness Rotator Cuff Tears

Background: There are conflicting reports in the literature regarding the outcome of superior labral anterior posterior (SLAP) repairs in overhead athletes and a paucity of data demonstrating ability to return to prior level of competition. Hypothesis: Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score provides more accurate assessment of shoulder function and ability to return to previous level of athletic competition after SLAP lesion repair than does the conventional American Shoulder and Elbow Surgeons scoring system. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-three elite (collegiate or professional) overhead athletes who were more than 1-year status postarthroscopic repair of type II SLAP lesions were evaluated using both the Kerlan-Jobe Orthopaedic Clinic shoulder and elbow score and American Shoulder and Elbow Surgeons score. P values were computed using the analysis of variance model. Postoperative American Shoulder and Elbow Surgeons and Kerlan-Jobe Orthopaedic Clinic scores from subjects were compared with control values obtained from a healthy athletic cohort; the relationship between the scores was investigated using the linear regression model and assessed using Pearson correlations. Results: At a mean 38-month follow-up, 13 athletes were playing pain free at the time of the questionnaire administration, 6 were playing with pain, and 4 were not playing because of pain. Regarding American Shoulder and Elbow Surgeons scores, 22 athletes (96%) had good-excellent scores, whereas 1 (4%) had a fair score. The Kerlan-Jobe Orthopaedic Clinic scores revealed 9 excellent (39%), 3 good (13%), 4 fair (17%), and 7 poor (30%) results for the same study group. Of the 23 patients, 13 (57%) had returned to their pain-free preinjury levels of competition at final follow-up. The inability to return to this level of competition correlated with the presence of a partial-thickness rotator cuff tear (P = .0059). The Kerlan-Jobe Orthopaedic Clinic demonstrated better overall accuracy (85%) than did the American Shoulder and Elbow Surgeons (70%) in evaluating return to pain-free preinjury levels. Conclusion: Return to preinjury level of competition for elite overhead athletes after type II SLAP lesion repairs was 57%, despite high American Shoulder and Elbow Surgeons scores. Return to play status correlated with the presence of a partial-thickness rotator cuff tear. The Kerlan-Jobe Orthopaedic Clinic score, designed specifically for the evaluation of the overhead athlete, was a more accurate assessment tool than was the American Shoulder and Elbow Surgeons in this population of elite overhead athletes with SLAP tears.

Understanding shoulder and elbow injuries in baseball.

Repetitive overhead throwing exerts significant mechanical stress on the shoulder and elbow joint; this stress can lead to developmental anatomic changes in the young thrower. Asymptomatic pathology in the shoulder and elbow joint is prevalent and, with overuse, can progress to disabling injury. Joint injury occurs as a result of the bodys inability to properly coordinate motion segments during the pitching delivery, leading to further structural damage. Identifying and preventing overuse is the key to avoiding injury, particularly in the young pitcher. Injury prevention and rehabilitation should center on optimizing pitching mechanics, core strength, scapular control, and joint range of motion.

The Development and Validation of a Functional Assessment Tool for the Upper Extremity in the Overhead Athlete

Background There are no validated upper extremity instruments designed specifically to evaluate the performance and function of overhead athletes. Current shoulder and elbow scoring systems may not be sensitive to subtle changes in performance in this high-demand population. Hypothesis The scoring system developed in this study will be valid, reliable, and responsive in the evaluation of overhead athletes. Study Design Cross-sectional study; Level of evidence, 3. Methods Based on the results of a pilot questionnaire administered to 21 overhead athletes, a final 10-item questionnaire was developed. Two hundred eighty-two healthy, competitive overhead athletes completed the new questionnaire, as well as 2 established upper extremity questionnaires, and were self-assigned into injury categories: (1) playing without pain, (2) playing with pain, and (3) not playing due to pain. Correlations between the scores and differences between injury categories were measured. Responsiveness testing was performed in an additional group of 55 injured athletes, comparing their scores before and after an intervention. Results The new score showed high correlation with the Disabilities of the Arm, Shoulder and Hand (DASH) score and the DASH sports/performing arts module. The new score correctly stratified overhead athletes by injury category (P < .0001). The new score also demonstrated excellent responsiveness, varying appropriately with improvements in injury category after treatment of injuries (P < .05). Conclusion The new patient-reported instrument is valid and responsive in the evaluation of overhead athletes. Reliability was also demonstrated for the 13-item pilot questionnaire. The results support its use for the functional assessment of overhead athletes in future studies.

The Effect of Dynamic External Rotation Comparing 2 Footprint-Restoring Rotator Cuff Repair Techniques

Background Allowing for humeral external rotation while loading rotator cuff repairs has been shown to affect tendon biomechanics when compared with testing with the humerus fixed. Adding dynamic external rotation to a tendon-loading model using footprint-restoring repairs may improve our understanding of rotator cuff repair response to a common postoperative motion. Hypothesis A tendon suture-bridging repair will demonstrate better load sharing compared to a double-row repair, and there will be a differential gap formation between the anterior and posterior tendon regions. Study Design Controlled laboratory study. Methods In 6 fresh-frozen human cadaveric shoulders, a tendon suture-bridging rotator cuff repair was performed; a suture limb from each of 2 medial anchors was bridged over the tendon and fixed laterally with an interference screw. In 6 contralateral match-paired specimens, a double-row repair was performed. For all specimens, a custom jig was employed that allowed dynamic external rotation (0° to 30°) with loading. A materials testing machine was used to cyclically load each repair from 0 N to 90 N for 30 cycles; each repair was then loaded to failure. A deformation rate of 1 mm/s was employed for all tests. Gap formation between tendon edge and insertion was measured using video digitizing software. Results The yield load for the suture-bridging technique (161.88 ± 35.09 N) was significantly larger than the double-row technique (135.17 ± 24.03 N) (P = .026). The yield gap between tendon and lateral footprint was significantly greater anteriorly than posteriorly (1.62 ± 0.82 mm and 0.68 ± 0.47 mm, respectively) for the suture-bridging technique (P = .024) but not for the double-row technique (1.35 ± 0.52 mm and 1.05 ± 0.50 mm, respectively) (P = .34). There were no differences for gap formation, stiffness, ultimate load to failure, and energy absorbed to failure between the 2 repairs (P > .05). The anterior regions of the repair were the first to fail in all constructs. The suture-bridging repair remained interconnected for 5 of 6 repairs. Conclusions The tendon suture-bridging rotator cuff repair has a yield load that is higher than the double-row repair when allowing for external rotation during load testing. External rotation can accentuate gap formation anteriorly at a repaired rotator cuff footprint. Clinical Relevance Based on the tension of repair, there may be a role for reinforcing the repair anteriorly and limiting external rotation postoperatively.