Seong Cheol Moon

Analysis of “Hidden Lesions” of the Extra-articular Biceps After Subpectoral Biceps Tenodesis The Subpectoral Portion as the Optimal Tenodesis Site

Background: In biceps tenodesis for intra-articular tears, determining the distal extension of the lesions through the biceps groove is important in choosing the optimal tenodesis site. Purpose: To determine the optimal tenodesis site by analyzing the extension and delamination of an extra-articular lesion, or a “hidden lesion,” in the retrieved biceps after subpectoral biceps tenodesis. Study Design: Case series; Level of evidence, 4. Methods: A total of 36 subpectoral tenodeses were performed, and the retrieved biceps were analyzed. The biceps lesions were divided into zones according to their location as follows: the proximal intra-articular (zone A), middle intragroove (zone B), and distal extra-articular portions (zone C); the lesions in zones B and C were called “hidden lesions.” The length and delamination depth of the biceps tears were examined, and the severity of the accompanying tenosynovitis and degeneration was assessed. Results: Tears invaded zone B in all the cases and extended to zone C in 28 cases (77.8%). Tenosynovitis was observed along the tear in 28 cases (77.8%) and extended to zone C in 26 cases (72.2%). The mean tear length in the hidden lesions, including the tear and tenosynovitis, was 34.2 mm. Degenerative changes in the proximal intra-articular and middle intragroove portions were observed in all the cases and up to the distal extra-articular portion in 29 cases (80.6%). Conclusion: In approximately 80% of the intra-articular biceps tears evaluated in this study, a “hidden lesion” was observed going beyond the bicipital groove and extending to the distal extra-articular portion. Therefore, the subpectoral portion may be considered the optimal tenodesis site for the complete removal of all hidden biceps lesions.

The Influence of Diabetes Mellitus on Clinical and Structural Outcomes After Arthroscopic Rotator Cuff Repair

Background: The clinical effect of sustained hyperglycemia on tendon-to-bone healing after rotator cuff repair has not been well characterized. Purpose: To compare the clinical and structural outcomes between diabetic and nondiabetic patients after arthroscopic rotator cuff repair and to determine the effect of a diabetic phenotype on tendon-to-bone healing. Study Design: Cohort study; Level of evidence, 3. Methods: This study retrospectively evaluated a total of 335 shoulders that were available for magnetic resonance imaging (MRI) evaluation at least 6 months after arthroscopic rotator cuff repair using the suture-bridge technique with a minimum follow-up of 1 year. Only patients who had medium- to large-sized tears with supraspinatus of fatty infiltration <2 and no or mild atrophy were enrolled in this study. There were 271 nondiabetic patients (group A) and 64 diabetic patients (group B). The mean age at the time of operation for groups A and B was 57.7 and 58.2 years, respectively, and the mean duration of follow-up after surgery was 27.8 and 24.8 months, respectively. Results: At the last follow-up, there were no statistically significant differences between the 2 groups with regard to pain at rest and during motion (P = .212 and .336, respectively). Both groups reported statistically significant improvement in Constant and Shoulder Rating Scale of the University of California at Los Angeles scores (P = .323 and .241, respectively), but there was no statistically significant difference between the 2 groups. In assessing the repair integrity with postoperative MRI scans, 39 of 271 cases in group A (14.4%) and 23 of 64 cases in group B (35.9%) had retears, and the difference between the 2 groups was statistically significant (P < .001). In analyzing the retear rates according to the severity of sustained hyperglycemia in group B, retear was found in 16 of 37 (43.2%) uncontrolled diabetic patients with poor glycemic control (≥7.0% of preoperative serum glycosylated hemoglobin [HbA1c] levels) and in 7 of 27 (25.9%) controlled diabetic patients (<7.0%) (P < .001). Conclusion: Pain, range of motion, and function all significantly improved after arthroscopic rotator cuff repair using the suture-bridge technique, regardless of the presence of diabetes. However, sustained hyperglycemia increased the possibility of anatomic failure at the repaired cuff. In diabetic patients, an effective glycemic control was associated with better rate of healing after rotator cuff repair.

Comparative study of tibial posterior slope angle following cruciate-retaining total knee arthroplasty using one of three implants

PurposePre- and postoperative tibial posterior slope angles (PSAs) were assessed in patients who underwent cruciate-retaining total knee arthroplasty (TKA).Material and methodsA total of 386 cruciate retaining TKA were performed in 308 patients and retrospectively reviewed. Based on the prostheses, 202 cases using NexGen® were classified as group I, 120 cases using PFC sigma® as group II, and 64 cases using Vanguard® as group III. Postoperative PSA of groups I, II, and III were compared.ResultsIn groups I, II, and III, postoperative PSA was 6.0˚, 6.0˚, and 4.5˚, respectively (p < 0.001). Between preoperative measurement and final follow-up examination, mean knee score (59.7 to 97.3), function score (54.2 to 90.5), and range of motion (ROM; 126.7° to 132.2°) improved. These three values did not differ significantly among groups.ConclusionsThe 3° slope of the Vanguard® polyethylene insert caused the difference in PSAs. This design characteristic should be considered when using this implant in TKA.

“Hidden Lesions” of the Extra-articular Biceps After Subpectoral Biceps Tenodesis: Response

Dear Editor: While we commend Moon and colleagues for drawing attention to the extra-articular portion of the long head of the biceps tendon (LHBT), they inadequately define the term ‘‘hidden lesion,’’ offer a limited assessment of lesion distribution, and improperly conclude that open subpectoral biceps tenodesis is a panacea. To accurately define hidden lesions of the LHBT, one must first understand the limits of diagnostic glenohumeral arthroscopy and the anatomy and histology of what we have termed the ‘‘bicipital tunnel,’’ which confines the extra-articular segment of the LHBT. Cadaveric experiments by our group demonstrated that the fibroosseous bicipital tunnel is a closed space from the articular margin through the proximal 3 cm of the subpectoral region in all specimens. We divided the bicipital tunnel into 3 zones. Zone 1 represents the traditional bicipital groove, extending from the articular margin to the inferior margin of the subscapularis tendon. While some lesions affecting the LHBT in this zone remain hidden, it should be noted that 78% of the tendon here is actually visualized during diagnostic arthroscopy. Others have reported similar limits of diagnostic arthroscopy. Zone 2 represents a ‘‘no-man’s-land’’ between the inferior margin of the subscapularis and the proximal margin of the pectorals major tendon. This biologically active zone is particularly relevant because of its invisibility to glenohumeral arthroscopy above and to open subpectoral exposure below. Zone 3 of the bicipital tunnel represents the subpectoral region. Cross-sectional analysis of the bicipital tunnel revealed similarities between zones 1 and 2, including, most important, a dense connective tissue roof and the presence of synovial tissue. Quantitative analysis further demonstrated that zones 1 and 2 had similarly limited percentage empty tunnel, suggesting a vulnerability to a range of space-occupying lesions, such as scar, osteophytes, and loose bodies, as well as hypertrophic tenosynovium. Hidden lesions, in fact, encompass a wide array of objective findings—including loose bodies, osteophytes, cysts, osseous stenosis, soft tissue stenosis, inflamed vinculae, hypertrophic scar, and extra-articular LHBT instability—in addition to the partial tears and tenosynovitis reported by Moon et al. Acknowledgment of these lesions’ existence is critical to our comprehensive understanding of the pathogenesis and diagnosis of biceps tendinitis. In fact, we first reported the diverse nature of these lesions at the March 2013 AAOS annual meeting in a large cohort study of chronically symptomatic patients; the study was later recognized with the J. Whit Ewing Award at the AANA and was published in the journal Arthroscopy. The offending lesions of 277 patients with chronic bicepslabral complex symptoms were categorized as ‘‘inside,’’ ‘‘junctional,’’ or ‘‘bicipital tunnel’’ based strictly on direct intraoperative visualization. Inside lesions were those of the labrum and biceps anchor. Junctional lesions were those of the LHBT that could be visualized by pull test during diagnostic glenohumeral arthroscopy. We defined hidden bicipital tunnel lesions as only those visualized directly from with the subdeltoid space after complete release of the fibrous sheath in zones 1 and 2 of the bicipital tunnel. We determined that 47% of patients had true ‘‘hidden lesions’’ and that hypertrophic scar, extra-articular instability, and stenosis were actually more common than the extension of proximal partial tears reported by Moon et al. Furthermore, nearly half of patients with a normal-appearing LHBT on glenohumeral arthroscopy had 1 of the aforementioned hidden lesions, and 18% of this large clinical cohort had their essential lesion occurring within the bicipital tunnel. There are several merits to the open subpectoral biceps tenodesis technique. We would argue that the most important is its effective decompression of the bicipital tunnel, as the authors pointed out, but one should use caution in concluding that this makes it the optimal technique for all patients. A recent paper by Werner et al, for example, demonstrated equivalence of clinical outcomes for suprapectoral and subpectoral biceps tenodesis techniques. Many patients fare well with tenotomy and proximal tenodesis techniques that do not decompress the bicipital tunnel. They may be quicker, require less hardware, and reduce morbidity. Must we subject the patient with isolated proximal pathology to the infection risk associated with an axillary incision, to the risk of neurovascular injury, or to the risk of fracture? The real question is, how can we determine the location of offending lesions and use that information to select the most appropriate tenodesis technique for a particular patient? For example, age may be a risk factor for bicipital tunnel pathology. We found that patients with tunnel lesions were statistically 6 years older than those without (P = .003). Furthermore, in a large prospective study investigating the comprehensive physical examination of the biceps-labral complex, we showed that tenderness to palpation of the bicipital tunnel and the active compression test (O’Brien sign) had negative predictive values of 96% and 93%, respectively, for the aforementioned hidden lesions. The Speed test and Yergason test were quite specific for presence of these lesions, at 87% and 98%, respectively. Biceps surgery is not a one-size-fits-all strategy; rather, it is our charge as clinicians to select the optimal treatment strategy for an individual patient. In summary, it is imperative that health care providers understand the existence of the bicipital tunnel and full array of ‘‘hidden lesions’’ that are present in chronically symptomatic patients. We must not limit our The American Journal of Sports Medicine, Vol. 43, No. 3 2015 The Author(s)

What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?

BackgroundIsolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear.Questions/purposesThe objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms.MethodsBetween June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images.ResultsPatients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2–46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8–333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2–168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%).ConclusionsIsolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field.Level of evidenceLevel III, prognostic study.

Comparison of Clinical and Radiological Results in the Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without the Anterior Attachment of the Rotator Cable:

Background: The anterior rotator cable is critical in force transmission of the rotator cuff. However, few clinical studies have examined the correlation between the integrity of the anterior supraspinatus tendon and surgical outcomes in patients with rotator cuff tears. Purpose: To compare the clinical and structural outcomes of the arthroscopic repair of full-thickness rotator cuff tears with and without anterior disruption of the supraspinatus tendon. Study Design: Cohort study; Level of evidence, 3. Methods: One hundred eighty-one shoulders available for magnetic resonance imaging (MRI) at least 6 months after arthroscopic rotator cuff repair, with a minimum 1-year follow-up, were enrolled. The anterior attachment of the rotator cable was disrupted in 113 shoulders (group A) and intact in 68 shoulders (group B). The mean age at the time of surgery in groups A and B was 59.6 and 59.2 years, respectively, and the mean follow-up period was 24.2 and 25.1 months, respectively. Results: There were statistically significant differences in the preoperative tear size and pattern and muscle fatty degeneration between the 2 groups (P = .004, P = .008, and P < .001, respectively). At final follow-up, the mean visual analog scale (VAS) for pain score during motion was 1.31 ± 0.98 and 1.24 ± 0.90 in groups A and B, respectively (P = .587). The mean Constant score was 77.5 ± 11.2 and 78.0 ± 11.9 points in groups A and B, respectively (P = .875). The mean University of California, Los Angeles score was 30.5 ± 4.1 and 31.0 ± 3.0 points in groups A and B, respectively (P = .652). In assessing the repair integrity on postoperative MRI, the retear rate was 23.9% and 14.7% in groups A and B, respectively (P = .029). Conclusion: Irrespective of involvement in the anterior attachment of the rotator cable, the mean 24-month follow-up demonstrated excellent pain relief and improvement in the ability to perform activities of daily living after arthroscopic rotator cuff repair. However, tears with anterior disruption of the rotator cable showed a significantly larger and more complex tear pattern and more advanced fatty degeneration. Additionally, the retear rate was significantly higher in patients with a tear involving the anterior attachment of the rotator cable.