Reuben Gobezie

The Outcome and Structural Integrity of Arthroscopic Rotator Cuff Repair with Use of the Double-Row Suture Anchor Technique

BACKGROUND The reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. The purpose of the present study was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs. METHODS A prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders). RESULTS There were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2+/-15.1 points (range, 8 to 83 points) preoperatively and 80.1+/-11.1 points (range, 46 to 100 points) postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion. CONCLUSIONS Arthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with a failed repair. After repair, large and massive rotator cuff tears result in more postoperative weakness than small tears do.

Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears.

BACKGROUND Isolated tears of the subscapularis occur less commonly than those involving the superior and posterior components of the rotator cuff. The purpose of the present study was to evaluate the structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. METHODS A prospective study of seventeen consecutive patients who were managed with an all-arthroscopic repair of the subscapularis tendon was performed. The study group included thirteen men and four women who had an average age of forty-seven years at the time of surgery. The average interval from the onset of symptoms to the time of surgery was twenty-four months. Thirteen tears were traumatic, and four were degenerative. Seven patients had a tear involving the superior third of the tendon, six had a tear involving the superior two-thirds of the tendon, and four had complete separation of the subscapularis from its insertion on the lesser tuberosity. Clinical findings were assessed for all patients preoperatively and postoperatively with use of the Constant and University of California at Los Angeles scoring systems, and all patients had postoperative computed tomographic arthrography studies to evaluate the structural integrity of the repair. RESULTS The average duration of follow-up was twenty-nine months. When the preoperative findings were compared with the most recent findings, the average relative Constant score had improved from 58% to 96% (p < 0.05), the average University of California at Los Angeles score had improved from 16 to 32 points (p < 0.05), the average pain score had improved from 5.9 to 13.5 points (p < 0.05), the average forward flexion had improved from 146 degrees to 175 degrees (p < 0.05), the average external rotation had improved from 50 degrees to 60.3 degrees (p < 0.05), the average internal rotation had improved from the level of the sacrum to L1-L2 (p < 0.05), and the average abduction strength had improved from 7.4 to 15.6 points (p < 0.05). The structural integrity of the repair was completely intact in fifteen patients and was partially reruptured in two patients on the basis of computed tomographic arthrography. Progression of fatty infiltration of the subscapularis was not observed in any patient. Subjectively, twelve patients were very satisfied with the result, four were satisfied, and one was not satisfied. CONCLUSIONS Arthroscopic repair of an isolated subscapularis tear can yield marked improvements in shoulder function, can significantly reduce pain, and can result in a durable structural repair. LEVEL OF EVIDENCE Therapeutic Level IV.

High abundance synovial fluid proteome: distinct profiles in health and osteoarthritis

The development of increasingly high-throughput and sensitive mass spectroscopy-based proteomic techniques provides new opportunities to examine the physiology and pathophysiology of many biologic fluids and tissues. The purpose of this study was to determine protein expression profiles of high-abundance synovial fluid (SF) proteins in health and in the prevalent joint disease osteoarthritis (OA). A cross-sectional study of 62 patients with early OA (n = 21), patients with late OA (n = 21), and control individuals (n = 20) was conducted. SF proteins were separated by using one-dimensional PAGE, and the in-gel digested proteins were analyzed by electrospray ionization tandem mass spectrometry. A total of 362 spots were examined and 135 high-abundance SF proteins were identified as being expressed across all three study cohorts. A total of 135 SF proteins were identified. Eighteen proteins were found to be significantly differentially expressed between control individuals and OA patients. Two subsets of OA that are not dependent on disease duration were identified using unsupervised analysis of the data. Several novel SF proteins were also identified. Our analyses demonstrate no disease duration-dependent differences in abundant protein composition of SF in OA, and we clearly identified two previously unappreciated yet distinct subsets of protein profiles in this disease cohort. Additionally, our findings reveal novel abundant protein species in healthy SF whose functional contribution to SF physiology was not previously recognized. Finally, our studies identify candidate biomarkers for OA with potential for use as highly sensitive and specific tests for diagnostic purposes or for evaluating therapeutic response.

Mast cells contribute to autoimmune inflammatory arthritis via their tryptase/heparin complexes.

Although mast cells (MCs) often are abundant in the synovial tissues of patients with rheumatoid arthritis, the contribution of MCs to joint inflammation and cartilage loss remains poorly understood. MC-restricted tryptase/heparin complexes have proinflammatory activity, and significant amounts of human tryptase β (hTryptase-β) are present in rheumatoid arthritis synovial fluid. Mouse MC protease-6 (mMCP-6) is the ortholog of hTryptase-β, and this serine protease is abundant in the synovium of arthritic mice. We now report that C57BL/6 (B6) mice lacking their tryptase/heparin complexes have attenuated arthritic responses, with mMCP-6 as the dominant tryptase responsible for augmenting neutrophil infiltration in the K/BxN mouse serum-transfer arthritis model. While inflammation in this experimental arthritis model was not dependent on protease-activated receptor-2, it was dependent on the chemokine receptor CXCR2. In support of the latter data, exposure of synovial fibroblasts to hTryptase-β/heparin or mMCP-6/heparin complexes resulted in expression of the neutrophil chemotactic factors CXCL1/KC, CXCL5/LIX, and CXCL8/IL-8. Our proteomics, histochemistry, and immunohistochemistry data also revealed substantial loss of cartilage-derived aggrecan proteoglycans in the arthritic joints of wild-type B6 mice but not mMCP-6-null B6 mice. These observations demonstrate the functional contribution of MC-restricted tryptase/heparin complexes in the K/BxN mouse arthritis model and connect our mouse findings with rheumatoid arthritis pathophysiology.

The exposure of autoantigens by microparticles underlies the formation of potent inflammatory components: the microparticle‐associated immune complexes

Immunoglobulins, antigens and complement can assemble to form immune complexes (IC). ICs can be detrimental as they propagate inflammation in autoimmune diseases. Like ICs, submicron extracellular vesicles termed microparticles (MP) are present in the synovial fluid from patients affected with autoimmune arthritis. We examined MPs in rheumatoid arthritis (RA) using high sensitivity flow cytometry and electron microscopy. We find that the MPs in RA synovial fluid are highly heterogeneous in size. The observed larger MPs were in fact MP‐containing ICs (mpICs) and account for the majority of the detectable ICs. These mpICs frequently express the integrin CD41, consistent with platelet origin. Despite expression of the Fc receptor FcγRIIa by platelet‐derived MPs, we find that the mpICs form independently of this receptor. Rather, mpICs display autoantigens vimentin and fibrinogen, and recognition of these targets by anti‐citrullinated peptide antibodies contributes to the production of mpICs. Functionally, platelet mpICs are highly pro‐inflammatory, eliciting leukotriene production by neutrophils. Taken together, our data suggest a unique role for platelet MPs as autoantigen‐expressing elements capable of perpetuating formation of inflammatory ICs.

Interference Screw vs. Suture Anchor Fixation for Open Subpectoral Biceps Tenodesis: Does it Matter?

BackgroundBioabsorbable interference screw fixation has superior biomechanical properties compared to suture anchor fixation for biceps tenodesis. However, it is unknown whether fixation technique influences clinical results.HypothesisWe hypothesize that subpectoral interference screw fixation offers relevant clinical advantages over suture anchor fixation for biceps tenodesis.Study DesignCase Series.MethodsWe performed a retrospective review of a consecutive series of 88 patients receiving open subpectoral biceps tenodesis with either interference screw fixation (34 patients) or suture anchor fixation (54 patients). Average follow up was 13 months. Outcomes included Visual Analogue Pain Scale (0–10), ASES score, modified Constant score, pain at the tenodesis site, failure of fixation, cosmesis, deformity (popeye) and complications.ResultsThere were no failures of fixation in this study. All patients showed significant improvement between their preoperative and postoperative status with regard to pain, ASES score, and abbreviated modified Constant scores. When comparing IF screw versus anchor outcomes, there was no statistical significance difference for VAS (p = 0.4), ASES score (p = 0.2), and modified Constant score (P = 0.09). One patient (3%) treated with IF screw complained of persistent bicipital groove tenderness, versus four patients (7%) in the SA group (nonsignificant).ConclusionSubpectoral biceps tenodesis reliably relieves pain and improves function. There was no statistically significant difference in the outcomes studied between the two fixation techniques. Residual pain at the site of tenodesis may be an issue when suture anchors are used in the subpectoral location.

Analysis of Interobserver and Intraobserver Variability in the Diagnosis and Treatment of SLAP Tears Using the Snyder Classification

Background Superior labral anterior posterior lesions are a relatively rare entity, and classification as a basis for selection of treatment has remained a point of controversy. Hypothesis There will be substantial interobserver and intraobserver variability in the diagnosis and treatment of superior labral anterior posterior tears by experienced arthroscopic specialists. Study Design Cohort study (diagnosis), Level of evidence, 2. Methods Compact discs containing 22 video vignettes of approximately 15 seconds duration were sent to the membership of the Arthroscopy Association of North America, American Shoulder and Elbow Society, and AOSSM. Each surgeon was asked to review the vignettes, classify the superior labral anterior posterior lesion type, and provide a treatment recommendation for each vignette. Seventy-three expert surgeons responded to the solicitation with a completed analysis. The same CD-ROM was re-sent to each of these 73 surgeons at a minimum of 12 months after the first viewing to obtain data on intraobserver reliability. Seventeen of the 73 surgeons returned this second CD-ROM with a complete analysis. Demographic data were also obtained from each surgeon. Multivariable logistic regression analysis was used to analyze the data, and 95% confidence intervals were established for each superior labral anterior posterior type (I-IV) with regard to diagnosis and treatment decision. Results The 22 vignettes analyzed by 73 surgeons resulted in 1606 responses. Several significant trends were noticed with regard to diagnosis and treatment from the responses: (1) surgeons had difficulty distinguishing type III lesions from type IV lesions, (2) the treatment of type III lesions is much more variable than that of any other subtype, and (3) surgeons had difficulty distinguishing normal shoulders from type II superior labral anterior posterior tears. No relationship was identified between correct treatment decisions based on diagnosis and any of the demographic factors analyzed. Our analysis of intraobserver variability showed only moderate agreement. The analysis of interobserver variability improved significantly when the diagnoses were analyzed based on treatment decision. Conclusions There is substantial interobserver and intraobserver variability among experienced shoulder arthroscopic specialists with regard to diagnosis and treatment of superior labral anterior posterior tears. Intraobserver agreement using the Snyder classification indicated only moderate agreement. Analysis of interobserver agreement based on treatment decisions results in superior concordance among experienced surgeons for the diagnosis of superior labral anterior posterior lesions.

Early Structural and Functional Outcomes for Arthroscopic Double-Row Transosseous-Equivalent Rotator Cuff Repair

Background: The arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair is growing in popularity. The current body of literature supports this technique; however, the number of patients in these studies is relatively small. The authors conducted this study to learn more about the natural history of this construct in a large sample of patients. Hypothesis: The double-row TOE rotator cuff repair will have an acceptable structural failure rate with improved clinical outcomes at 1-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Between June 2006 and October 2007, 225 patients underwent an all-arthroscopic rotator cuff repair at 2 surgical centers. A total of 155 TOE primary rotator cuff repairs were performed, and 154 of these patients met the inclusion criteria. Assessment of structural integrity was based on evaluation of postoperative magnetic resonance imaging or computed tomography arthrogram at a minimum of 12 months after surgery. The Constant scores, visual analog pain scale, range of motion, strength, and complications were the clinical outcomes analyzed for the study. Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. Results: The 154 patients were clinically and radiologically evaluated at a mean of 15 months postoperatively (range, 12-26.1 months). The study included 47 small (30.5%), 89 large (57.1%), and 19 massive (12.3%) rotator cuff tears. Analysis of postoperative imaging demonstrated that 92%, 83%, and 84% of the small, large, and massive rotator cuff tears, respectively, were intact. The mean Constant score improved from 44.42 points preoperatively to 80.47 points postoperatively (P < .001). The mean preoperative pain score improved from 3.83 to 12.77 (P < .001) postoperatively. The mean forward flexion improved from 123.06° preoperatively to 162.39° postoperatively (P < .001). Seventeen patients (of 154) had postoperative shoulder stiffness at follow-up. Conclusion: The short-term results of this study indicate that the clinical outcomes and structural integrity of TOE double-row rotator cuff repair (the suture-bridge technique) have results that compare favorably with those reported for other double-row suture anchor techniques employed in rotator cuff repairs. Long-term follow-up will be necessary to determine if the durability of these repairs and the structural integrity of these constructs maintain their performance over time.

A novel anti-inflammatory role for secretory phospholipase A2 in immune complex-mediated arthritis

Phospholipase A2 (PLA2) catalyses the release of arachidonic acid for generation of lipid mediators of inflammation and is crucial in diverse inflammatory processes. The functions of the secretory PLA2 enzymes (sPLA2), numbering nine members in humans, are poorly understood, though they have been shown to participate in lipid mediator generation and the associated inflammation. To further understand the roles of sPLA2 in disease, we quantified the expression of these enzymes in the synovial fluid in rheumatoid arthritis and used gene‐deleted mice to examine their contribution in a mouse model of autoimmune erosive inflammatory arthritis. Contrary to expectation, we find that the group V sPLA2 isoform plays a novel anti‐inflammatory role that opposes the pro‐inflammatory activity of group IIA sPLA2. Mechanistically, group V sPLA2 counter‐regulation includes promotion of immune complex clearance by regulating cysteinyl leukotriene synthesis. These observations identify a novel anti‐inflammatory function for a PLA2 and identify group V sPLA2 as a potential biotherapeutic for treatment of immune‐complex‐mediated inflammation.

Biomechanical and Clinical Evaluation of a Novel Lesser Tuberosity Repair Technique in Total Shoulder Arthroplasty

A s with arthroplasty of other large joints, shoulder replacement reliably improves a patients quality of life1-8. However, although shoulder replacement is frequently successful, complications do occur9-15. Injury to the subscapularis can lead to weakness, decreased motion and stability, and diminished satisfaction following shoulder arthroplasty. Compromise or dysfunction of the subscapularis resulting from routine division and repair during the arthroplasty is a complication that is being recognized more frequently16,17. Subscapularis dysfunction may lead to a loss of active terminal internal rotation with an abnormal belly-press or lift-off test or the inability to perform a shirt-tuck test18. In a recent study, >65% of patients had subscapularis dysfunction following shoulder arthroplasty with a soft-tissue subscapularis repair17. While dysfunction is sometimes subtle, resulting in minor functional disabilities, rupture of the subscapularis is a devastating problem that can lead to gross anterior instability. Anterior instability following arthroplasty is typically secondary to rupture of the repaired subscapularis13,19. Reported rates of subscapularis rupture following primary arthroplasty have ranged from 3% to 11%19-22. Instability is the most frequent complication following shoulder arthroplasty and is the most common indication for revision surgery9,11,19,23-25. While the etiology of instability is often multifactorial, the greatest cause is soft-tissue imbalance13,19,24,26,27. In order to strengthen our subscapularis repairs and to prevent rupture, we have been performing a lesser tuberosity osteotomy to reflect the subscapularis and expose the joint in shoulder arthroplasties. The lesser tuberosity osteotomy does not violate the subscapularis tendon, and its repair provides a strong, secure closure that allows bone-healing. The strength of the repair is due …