Sheila McRae

Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-thickness Rotator Cuff Tears: A Multicenter, Randomized Controlled Trial

BACKGROUND The primary objective of this prospective randomized controlled trial was to compare functional and quality-of-life indices and rates of revision surgery in arthroscopic rotator cuff repair with and without acromioplasty. METHODS Eighty-six patients consented and were randomly assigned intraoperatively to one of two study groups, and sixty-eight of them completed the study. The primary outcome was the Western Ontario Rotator Cuff (WORC) index. Secondary outcome measures included the American Shoulder and Elbow Surgeons (ASES) shoulder assessment form and a count of revisions required in each group. Outcome measures were completed preoperatively and at three, six, twelve, eighteen, and twenty-four months after surgery. RESULTS WORC and ASES scores improved significantly in each group over time (p < 0.001). There were no differences in WORC or ASES scores between the groups that had arthroscopic cuff repair with or without acromioplasty at any time point. There were no differences in scores on the basis of acromion type, nor were any interaction effects identified between group and acromion type. Four participants (9%) in the group that had arthroscopic cuff repair alone, one with a Type-2 and three with a Type-3 acromion, required additional surgery by the twenty-four-month time point. The number of patients who required additional surgery was greater (p = 0.05) in the group that had arthroscopic cuff repair alone than in the group that had arthroscopic cuff repair and acromioplasty. CONCLUSIONS Our findings are consistent with previous research reports in which there was no difference in functional and quality-of-life indices for patients who had rotator cuff repair with or without acromioplasty. The higher reoperation rate was found in the group without acromioplasty. Further study that includes follow-up imaging and patient-reported outcomes over a greater follow-up period is needed.

A Multicenter Randomized Controlled Trial Comparing Single-Row with Double-Row Fixation in Arthroscopic Rotator Cuff Repair

BACKGROUND Controversy exists regarding the optimal technique for arthroscopic rotator cuff repair. The purpose of this multicenter, randomized, double-blind controlled study was to compare the functional outcomes and healing rates after use of single-row and double-row suture techniques for repair of the rotator cuff. METHODS Ninety patients undergoing arthroscopic rotator cuff repair were randomized to receive either a single-row or a double-row repair. The primary objective was to compare the Western Ontario rotator cuff index (WORC) score at twenty-four months. Secondary objectives included comparison of the constant and american shoulder and elbow surgeons (ASES) scores and strength between groups. Anatomical outcomes were assessed with magnetic resonance imaging (MRI) or ultrasonography to determine the postoperative healing rates. RESULTS Baseline demographic data including age (p = 0.29), sex (p = 0.68), affected side (p = 0.39), and rotator cuff tear size (p = 0.28) did not differ between groups. The WORC score did not differ significantly between groups at any time point (p = 0.48 at baseline, p = 0.089 at three months, p = 0.52 at six months, p = 0.83 at twelve months, and p = 0.60 at twenty-four months). The WORC score at each postoperative time point was significantly better than the baseline value. The Constant score, ASES score, and strength did not differ significantly between groups at any time point. Logistic regression analysis demonstrated that a smaller initial tear size and double-row fixation were associated with higher healing rates. CONCLUSIONS No significant differences in functional or quality-of-life outcomes were identified between single-row and double-row fixation techniques. A smaller initial tear size and a double-row fixation technique were associated with higher healing rates as assessed with ultrasonography or MRI. LEVEL OF EVIDENCE Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Ipsilateral Versus Contralateral Hamstring Grafts in Anterior Cruciate Ligament Reconstruction A Prospective Randomized Trial

Background: Benefits of graft harvest from the side contralateral to the anterior cruciate ligament (ACL)–deficient leg have been identified when using bone–patellar tendon–bone autografts in ACL reconstruction (ACLR). As hamstring tendon autografts are becoming more commonly used, a study examining the effect of contralateral graft harvest of semitendinosus gracilis (STG) tendons on patient quality of life was conducted. Purpose: To evaluate if ACLR using a hamstring tendon autograft results in better patient quality of life if the graft is harvested from the leg contralateral to the ACL rupture compared with the ipsilateral leg. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 100 participants between 16 and 50 years of age with a complete ACL tear were randomly assigned to undergo ACLR using either the ipsilateral or contralateral leg as the STG graft donor. Primary outcome measures were the ACL Quality of Life questionnaire (ACL-QOL), concentric knee flexion and extension strength at 60 and 240 deg/s, International Knee Documentation Committee (IKDC) knee assessment form, early postoperative pain and diary of analgesic use, and rate of reruptures. Outcome measures were evaluated before surgery and at 3, 6, 12, and 24 months after surgery. Results: The ACL-QOL score improved over time for both groups (P < .001), and there were no significant differences between groups at any time point (P = .528). Significant differences in knee flexion and extension strength were found at 3 months after surgery. There were no differences between groups in IKDC knee assessment scores or rerupture rates. Conclusion: There does not appear to be any measurable benefit or drawback in quality of life to the use of an STG graft from the unaffected limb. In light of this finding, further research to examine other possible effects on agility and balance as well as time and ability to return to sport should be conducted. Longer term follow-up beyond 2 years would allow for a more thorough evaluation of the risk of reruptures or contralateral reruptures using this novel approach.

Iliac crest allograft glenoid reconstruction for recurrent anterior shoulder instability in athletes: Surgical technique and results.

Performing a labral repair alone in patients with recurrent anterior instability and a large glenoid defect has led to poor outcomes. We present a technique involving the use of the iliac crest allograft inserted into the glenoid defect in athletes with recurrent anterior shoulder instability and large bony defects of the glenoid (>25% of glenoid diameter). All athletes with recurrent anterior shoulder instability and a large glenoid defect that underwent open anterior shoulder stabilization and glenoid reconstruction with the iliac crest allograft were followed over a 4-year period. Preoperatively, a detailed history and physical exam were obtained along with standard radiographs and magnetic resonance imaging of the affected shoulder. All patients also completed the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons (ASES) evaluation forms preoperatively. A computed tomography scan was obtained postoperatively to assess osseous union of the graft and the patient again went through a physical exam in addition to completing the SST, ASES, and Western Ontario Shoulder Instability Index (WOSI) forms. 10 patients (9 males, 1 female) were followed for an average of 16 months (4–36 months) and had a mean age of 24.4 years. All patients exhibited a negative apprehension/relocation test and full shoulder strength at final follow-up. Eight of 10 patients had achieved osseous union at 6 months (80.0%). ASES scores improved from 64.3 to 97.8, and SST scores improved from 66.7 to 100. Average postoperative WOSI scores were 93.8%. The use of the iliac crest allograft provides a safe and clinically useful alternative compared to previously described procedures for recurrent shoulder instability in the face of glenoid deficiency.

Achilles allograft stabilization of the shoulder in refractory multidirectional glenohumeral instability

ABSTRACT Treatment of multidirectional glenohumeral instability is a challenge for the orthopaedic surgeon and generally involves nonoperative therapy as the first line of treatment. In patients who fail conservative treatment, successful results can be achieved with open surgery. More recently, there has been increased interest in the use of arthroscopic techniques, including capsular plication, capsular shifting, and thermal modification with the use of laser or radiofrequency devices. Reports have indicated that these arthroscopic techniques can offer good short-term results. However, with longer-term outcome studies showing high long-term failure rates regardless of method, it is necessary to explore other procedural options of providing these patients with some form of relief. We present a salvage procedure involving Achilles tendon allograft reconstruction of the glenohumeral ligament complex in patients with severe multidirectional shoulder instability (most of whom also exhibited an underlying connective tissue disorder) who had previous failed attempts at stabilization using open soft tissue capsular shifting techniques. Although the long-term failure rate of our procedure was high, it did offer significant short-term relief and stability to most patients who stated that they would have the procedure again rather than undergo arthrodesis or replacement.

Postoperative deep shoulder infections following rotator cuff repair

Rotator cuff repair (RCR) is one of the most commonly performed surgical procedures in orthopaedic surgery. The reported incidence of deep soft-tissue infections after RCR ranges between 0.3% and 1.9%. Deep shoulder infection after RCR appears uncommon, but the actual incidence may be higher as many cases may go unreported. Clinical presentation may include increasing shoulder pain and stiffness, high temperature, local erythema, swelling, warmth, and fibrinous exudate. Generalized fatigue and signs of sepsis may be present in severe cases. Varying clinical presentation coupled with a low index of suspicion may result in delayed diagnosis. Laboratory findings include high erythrocyte sedimentation rate and C-reactive protein level, and, rarely, abnormal peripheral blood leucocyte count. Aspiration of glenohumeral joint synovial fluid with analysis of cell count, gram staining and culture should be performed in all patients suspected with deep shoulder infection after RCR. The most commonly isolated pathogens are Propionibacterium acnes, Staphylococcus epidermidis, and Staphylococcus aureus. Management of a deep soft-tissue infection of the shoulder after RCR involves surgical debridement with lavage and long-term intravenous antibiotic treatment based on the pathogen identified. Although deep shoulder infection after RCR is usually successfully treated, complications of this condition can be devastating. Prolonged course of intravenous antibiotic treatment, extensive soft-tissue destruction and adhesions may result in substantially diminished functional outcomes.

Radiostereometric analysis of keeled versus pegged glenoid components in total shoulder arthroplasty: a randomized feasibility study

Background This study aimed to assess differences in the fixation and functional outcomes between pegged and keeled all-polyethylene glenoid components for standard total shoulder arthroplasty. Methods Patients were randomized to receive a keeled or pegged all-polyethylene glenoid component. We used model-based radiostereometric analysis (RSA) to assess glenoid fixation and subjective outcome measures to assess patient function. Follow-up examinations were completed at 6 weeks and 6, 12 and 24 months after surgery. Modifications to the RSA surgical, imaging and analytical techniques were required throughout the study to improve the viability of the data. Results Stymied enrolment resulted in only 16 patients being included in our analyses. The RSA data indicated statistically greater coronal plane migration in the keeled glenoid group than in the pegged group at 12 and 24 months. Functional outcome scores did not differ significantly between the groups at any follow-up. One patient with a keeled glenoid showed high component migration after 24 months and subsequently required revision surgery 7 years postoperatively. Conclusion Despite a small sample size, we found significant differences in migration between glenoid device designs. Although clinically these findings are not robust, we have shown the feasibility of RSA in total shoulder arthroplasty as well as the value of a high-precision metric to achieve objective results in a small group of patients.

Open Versus Arthroscopic Tennis Elbow Release: Randomized Controlled Trial

Objectives: The primary objective of this study was to determine if quality of life and function are different following arthroscopic versus open tennis elbow release surgery. Based on retrospective studies, both approaches have been found to be beneficial, but no prospective randomized comparison has been conducted to date. Methods: Following a minimum six-months of conservative treatment, seventy-one patients (>16 yrs old) were randomized intraoperatively to undergo either arthroscopic or open lateral release. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), a 5-question VAS Pain Scale, and grip strength. Study assessments took place pre-, and 6-week, 3-, 6-, and 12-months post-surgery. Comparisons between groups and within groups over time were conducted using repeated measures ANOVA. A minimal clinically significant difference for the DASH had been previously identified as 15 points, and was used to compare groups as well at 12-months post-operative (Beaton et al. 2001). Results: Fifteen women and 19 men underwent the open procedure with a mean age of 47.1 years (6.7) and 13 women and 21 men were in the arthroscopic group with a mean age of 45.0 (6.9). No pre-surgery differences were found between groups based on age, sex, DASH or VAS scores. Both groups demonstrated a significant improvement in subjective measures and grip strength by 12-months post-surgery, and no significant differences were found between groups at any time point. The DASH, our primary outcome, decreased from a mean (SD) of 47.5 (14.5) pre-surgery to 21.9 (21.8) at 12-months post-surgery in the Open group and from 52.7 (16.0) to 22.6 (21.1) in the Arthroscopic group. VAS-pain scores (%) decreased in the Open group from 62.5 (17.2) pre-operatively to 30.0 (26.5) at 12-months. In the arthroscopic group, scores decreased from 63.7 (15.9) to 26.2 (24.6). Grip strength (kg) increased on the affected side from 23.6 (14.9) to 29.3 (16.3) and 21.4 (15.4) to 29.8 (15.4) for Open and Arthroscopic groups, respectively. The number of participants to reach the minimum clinically significant change did not differ between groups, 17 in the open group and 19 in the arthroscopic group. Ten in each group did not reach this threshold. Based on post hoc regression analysis, no factors (age, gender, WCB status, or smoking status) were found to be significant predictors of DASH or VAS outcome at 12-months post-surgery. However, this study was not adequately powered to draw any specific conclusions in this regard. The only significant difference between study groups was that the arthroscopic technique resulted in longer surgery time, 34.0 versus 22.5 minutes (p=0.005). Conclusion: Based on this study, there is no difference between arthroscopic and open tennis elbow release surgery in subjective outcome, specifically DASH and VAS pain scale, or in function, specifically, grip strength, at 12-months post-operative. Therefore, there may not be any benefit to the increased experience and operating room time required to perform a lateral release arthroscopically versus an open approach.

Surgical reconstruction of chronic latissimus dorsi tear using Achilles tendon allograft

The function of the latissimus dorsi muscle (LD) includes extension, adduction, and internal rotation (IR) of shoulder. The medial attachments of the LD are the spinous processes of the inferior 6 thoracic vertebrae, thoracolumbar fascia, iliac crest, and inferior 4 ribs, and the lateral attachment is the floor of the intertubercular sulcus on the anterior side of the humerus. Rupture of the LD is extremely rare, with a limited number of cases reported in the literature. Reported mechanisms of injury include forceful resisted extension and/or adduction. Both conservative and surgical treatments have been outlined as management approaches. Only 1 chronic case of LD rupture has been reported that was managed surgically with a primary repair. We report a case of chronic rupture of the LD that was managed surgically by using non-irradiated Achilles tendon to reconstruct the symptomatic and irreparably ruptured LD. To our knowledge, no similar case has been previously reported in the literature.

Prospective Randomized Trial of Ipsilateral Versus Contralateral Hamstring Graft in ACL Reconstruction (SS-59)

Introduction The purpose of this randomized controlled trial was to compare the quality of life and strength in patients undergoing ACL reconstruction when contralateral versus ipsilateral semitendinosus/gracilis (STG) autograft is used. Methods One hundred participants were randomly assigned intraoperatively to either the ipsilateral (IPSI) or contralateral (CONTRA) autograft group. The primary outcome was ACL Quality of Life (ACL-QOL) and secondary outcomes were concentric isovelocity knee flexion/extension strength measured on a dynamometer at five speeds (60, 90, 150, 210, 240°s-1). Data was gathered pre-surgery, and at 3, 6, 12, and 24 months post-surgery. Repeated measures ANOVAs were performed for within group comparisons and t-tests were performed to compare between groups with a significance level of p Results ACL-QOL scores improved significantly from baseline to post-surgery in both groups and no differences between groups were identified across time. Comparing between groups, knee flexion strength of the reconstructed limb was significantly greater in the CONTRA group than the IPSI group at 12 months at 150, 210, 240°s-1. In the non-reconstructed knee, flexion was greater in the IPSI group compared to the CONTRA group at 3 months post-surgery only. Post-hoc comparisons revealed hamstring/quadriceps (H/Q) ratios were higher in the reconstructed limb of the CONTRA group than the non-reconstructed limb and also greater than either limb of the IPSI group. Conclusion Our hypothesis that the use of contralateral hamstring autograft in ACL reconstruction leads to greater quality of life than ipsilateral autograft was not supported. However, there may be some advantages to contralateral autograft with respect to strength at higher velocities. This study also reveals that contralateral graft harvest may normalize the H/Q ratio in the reconstructed limb. This may have some bearing on function and re-injury risk that should be further investigated.