Robert A. Gallo

Cuff tear arthropathy: current trends in diagnosis and surgical management.

SUMMARY Massive tears of the rotator cuff resulting in arthritis of the glenohumeral joint remain a difficult challenge. Although cuff tear arthropathy (CTA) has been recognized for more than 150 years, a treatment strategy with uniformly satisfactory outcomes remains elusive, partly due to the difficulty in defining CTA in the literature. Most studies combine true CTA, rheumatoid arthritis, and massive rotator cuff tears under the CTA diagnosis. Determining outcomes from these studies is difficult. Hemiarthroplasty and total shoulder arthroplasty have led to pain relief, but the high rate of glenoid component loosening after total shoulder arthroplasty is a concern, and active range of motion remains limited after hemiarthroplasty. There is increasing interest in the use of a constrained or reverese total shoulder arthroplasty to treat this complex process, with promising early results. This review article studies current trends in the diagnosis and management of arthritis due to massive cuff tears and CTA.

Defining the relationship between rotator cuff injury and proximal humerus fractures.

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Management of Osteoarthritis of the Knee in the Active Patient

Abstract Total knee arthroplasty has been extremely successful in elderly patients with osteoarthritis. However, there is considerable controversy regarding how best to treat the younger, athletic patient with advanced arthritis. Treatment options range from nonsurgical management with exercise and nonsteroidal anti‐inflammatory drugs, to joint arthroplasty with activity modification. When properly indicated, arthroscopic débridement, high tibial osteotomy, unicondylar knee arthroplasty, and total knee arthroplasty allow younger patients with arthritis to maintain an active, healthy lifestyle.

The Barefoot Debate: Can Minimalist Shoes Reduce Running-Related Injuries?

Abstract Running has evolved throughout history from a necessary form of locomotion to an athletic and recreational pursuit. During this transition, our barefoot ancestors developed footwear. By the late 1970s, running popularity surged, and footwear manufacturers developed the running shoe. Despite new shoe technology and expert advice, runners still face high injury rates, which have yet to decline. Recently, “minimalist” running, marked by a soft forefoot strike and shorter, quicker strides, has become increasingly popular within the running community. Biomechanical studies have suggested that these features of barefoot-style running may lead to a reduction in injury rates. After conducting more outcomes-based research, minimalist footwear and gait retraining may serve as new methods to reduce injuries within the running population.

Vascularity of the supraspinatus tendon three months after repair: characterization using contrast-enhanced ultrasound.

BACKGROUND There has been limited in-vivo assessment of rotator cuff vascularity following repair. This study aims to characterize the vascularity of the shoulder 3 months following supraspinatus tendon repair. METHODS Twenty-nine patients (average age, 61.4 years) underwent Perflutren lipid microsphere contrast-enhanced shoulder ultrasound examinations 3 months after arthroscopic rotator cuff repair. Each shoulder was scanned at rest and following exercise using linear phased array 9-MHz transducer optimized to detect the contrast agent. Blood flow was quantified off-line using ultrasound imaging quantification and analysis software (QLAB, Philips, Andover, MA). Peak enhancement (vascular volume) and rate of rise (perfusion) were determined for 3 regions of interest: peribursal area, supraspinatus tendon, and anchor site. RESULTS Peak enhancement and rate of rise were greatest in the peribursal soft tissue and anchor site. Resting peak enhancement and rate of rise were significantly lower within the tendon compared to the other 2 regions (P < .001). Exercise resulted in increased enhancement and rate-of-rise to all 3 regions, but had a significant predilection towards increasing vascular volume within the peri-bursal region (P = .026). CONCLUSION At 3 months following repair, the majority of blood flow to the repair is derived from the peribursal soft tissues and the anchor site. The tendon, particularly those with a defect at 3 months, is relatively avascular. Though limited by inclusion of only a single time point, this study introduces a new technique to quantify vascularity following supraspinatus repairs and suggests that the surrounding vascular milieu may play a role in tendon healing. LEVEL OF EVIDENCE Basic Science.

Two-incision technique for treatment of complex proximal humerus fractures.

The treatment of complex proximal humerus fractures that involve displacement of the greater tuberosity remains challenging. Good functional outcomes and decreased pain are possible with open reduction and internal fixation. Keys to a successful outcome include preservation of blood supply through decreased soft-tissue stripping, restoration of normal anatomic relationships (particularly the greater tuberosity), and stable internal fixation that allows early range of motion. To attain these goals, we advocate fixation with a fixed-angle locking proximal humerus plate using a 2-incision approach. A deltopectoral incision is used to expose the humeral shaft and head while the greater tuberosity is visualized by using a lateral incision. The fracture fragments are reduced and the plate is secured by working through these 2 incisions.

Contrast-enhanced ultrasound characterization of the vascularity of the repaired rotator cuff tendon: short-term and intermediate-term follow-up

BACKGROUND The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up. MATERIALS AND METHODS Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest--supraspinatus tendon, peribursal tissue, and bone anchor site--were evaluated before and after rotator cuff-specific exercises. RESULTS The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair. CONCLUSION Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff.

Common Leg Injuries of Long-Distance Runners: Anatomical and Biomechanical Approach

Context Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed. Evidence Acquisition Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012. Results Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction. Conclusion Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions.

Patients' attitudes and factors in their selection of grafts for anterior cruciate ligament reconstruction

Surgeon recommendation is the primary influence for patients choosing a graft for their ACL reconstruction. However, it is unknown if demographic factors also play a role. We hypothesize that education, age, and living in an urban setting may influence a patients graft choice. Patients who had an ACL reconstruction from 2005 to 2009 were identified retrospectively, and received a written survey on their demographics and the factors affecting graft choice. They also rated their perception of those factors based on a Likert scale. Out of 471 surveys distributed, 151 responses were received. The mean follow-up time was 19 months (range, 1 to 63 months). Autograft was used in 57%. Surgeon recommendation was the primary factor in graft choice (63%). 87.4% of patients felt they made the right choice; only 4.6% would have picked a different graft if they could choose over again. More than half (51.7%) of patients did significant personal research, and used mostly medical websites (41.1%). 67.6% of patients were not adverse to allograft. The primary factor for patients in graft choice was surgeon recommendation. Still, the use of medical websites was widespread, and patients in an urban environment were less likely to rely solely on their surgeons recommendation. Older patients were more concerned with autograft donor site morbidity, and patients with a higher level of education were less averse to allograft.

The Evaluation and Treatment of Rotator Cuff Pathology

Rotator cuff pathology accounts for most presentations of shoulder pain to primary care clinics. History and physical examination are important for excluding other causes of shoulder pain, while imaging assists in confirming the diagnosis and defining the severity of the abnormality. Treatment options include nonsteroidal anti-inflammatory agents, subacromial corticosteroid injections, and exercise therapy. Surgical intervention is generally reserved for those failing nonoperative measures and/or healthy, young, and middle-aged adults with full-thickness rotator cuff tears. No surgical technique has proved to be superior. Despite surgery, about 20% of patients experience retears, more likely occurring in those with larger tears.