Stephen J. O’Brien

The Effect of the Shoe-Surface Interface in the Development of Anterior Cruciate Ligament Strain

The shoe-surface interface has been implicated as a possible risk factor for anterior cruciate ligament (ACL) injuries. The purpose of this study is to develop a biomechanical, cadaveric model to evaluate the effect of various shoe-surface interfaces on ACL strain. There will be a significant difference in ACL strain between different shoe-surface combinations when a standardized rotational moment (a simulated cutting movement) is applied to an axially loaded lower extremity. The study design was a controlled laboratory study. Eight fresh-frozen cadaveric lower extremities were thawed and the femurs were potted with the knee in 30 deg of flexion. Each specimen was placed in a custom-made testing apparatus, which allowed axial loading and tibial rotation but prevented femoral rotation. For each specimen, a 500 N axial load and a 1.5 Nm internal rotation moment were placed for four different shoe-surface combinations: group I (AstroTurf-turf shoes), group II (modern playing turf-turf shoes), group III (modern playing turf-cleats), and group IV (natural grass-cleats). Maximum strain, initial axial force and moment, and maximum axial force and moment were calculated by a strain gauge and a six component force plate. The preliminary trials confirmed a linear relationship between strain and both the moment and the axial force for our testing configuration. In the experimental trials, the average maximum strain was 3.90, 3.19, 3.14, and 2.16 for groups I-IV, respectively. Group IV had significantly less maximum strain (p<0.05) than each of the other groups. This model can reproducibly create a detectable strain in the anteromedial bundle of the ACL in response to a given axial load and internal rotation moment. Within the elastic range of the stress-strain curve, the natural grass and cleat combination produced less strain in the ACL than the other combinations. The favorable biomechanical properties of the cleat-grass interface may result in fewer noncontact ACL injuries.

Clinically Relevant Anatomy and Biomechanics of the Proximal Biceps

The biceps-labral complex represents the shared anatomic and clinical features of the biceps and labrum. It has 3 clinically relevant zones: inside, the superior labrum and the biceps anchor; junction, the intra-articular portion of the long head of the biceps tendon and its stabilizing pulley; and bicipital tunnel, the extra-articular long head of the biceps tendon from the articular margin through the subpectoral region and its fibro-osseous confinement. By embracing this more comprehensive understanding of the anatomy, pathoanatomy, and functional implications, clinicians can proceed with greater confidence and can more accurately select patient-specific surgical techniques.

Arthroscopic Subscapularis Bankart Technique as a Salvage Procedure for Failed Anterior Shoulder Stabilization

BackgroundShoulder instability is a relatively common problem. Even with contemporary surgical techniques, instability can recur following both open and arthroscopic fixation. Surgical management of capsular insufficiency in anterior shoulder stabilization represents a significant challenge, particularly in young, active patients. There are a limited number of surgical treatment options. The Laterjet technique can present with a number of intraoperative challenges and postoperative complication.Description of TechniqueWe report an arthroscopic subscapularis tenodesis technique as a salvage procedure for challenging glenohumeral instability cases. Sutures are passed through the subscapularis tendon and capsule before they are tied as one in the subdeltoid psace. The rotator interval is closed with superior and medial advancement of anterior and inferior tissue. This technical note carefully describes this procedure with useful technical tips, illustrations, and diagrams.Patients and MethodsTwo clinical cases are described involving patients with recurrent instability following failed surgery who were successfully managed with this procedure.ResultsBoth cases described resulted in improved shoulder stability, range of motion, and function following management with this surgical technique. This arthroscopic subscapularis tenodesis procedure is proposed as a useful alternative repair technique for cases of recurrent instability after failed surgery with isolated capsular insufficiency.ConclusionIt is believed that this arthroscopic subscapularis tenodesis technique can potentially provide similar outcomes to open bone block stabilization procedures, while reducing the risks associated with those procedures.

Risk Factors for Revision Surgery After Superior Labral Anterior-Posterior Repair: A National Perspective

Background: Data regarding risk factors for revision surgery after superior labral anterior-posterior (SLAP) repair are limited to institutional series. Purpose: To define risk factors for revision surgery after SLAP repair among patients in a large national database. Study Design: Case-control study; Level of evidence, 3. Methods: A national insurance database was queried for patients undergoing arthroscopic SLAP repair (Current Procedural Terminology [CPT] code 29807) for the diagnosis of a SLAP tear. Patients without a CPT modifier for laterality were excluded. Revision surgery was defined as (1) subsequent ipsilateral SLAP repair (CPT 29807), (2) ipsilateral arthroscopic debridement for the diagnosis of a SLAP tear (CPT 29822 or 29823, with diagnosis code 840.7), (3) subsequent ipsilateral arthroscopic biceps tenodesis (CPT 29828), (4) subsequent ipsilateral open biceps tenodesis (CPT 23430), and (5) subsequent biceps tenotomy (CPT 23405). Multivariable binomial logistic regression analysis was performed to identify risk factors for revision surgery after SLAP repair, including patient demographics/comorbidities, concomitant diagnoses, and concomitant procedures performed. Odds ratios (ORs), 95% CIs, and P values were calculated. The estimated financial impact of revision surgery was also calculated. Results: There were 4751 patients who met inclusion and exclusion criteria. Overall, 121 patients (2.5%) required revision surgery after SLAP repair. Regression analysis identified numerous risk factors for revision surgery, including age >40 years (OR, 1.5; 95% CI, 1.2-1.8; P = .045), female sex (OR, 1.5; 95% CI, 1.3-1.8; P = .010), obesity (OR, 1.8; 95% CI, 1.5-2.2; P = .001), smoking (OR, 2.0; 95% CI, 1.6-2.4; P < .0001), and diagnosis of biceps tendinitis (OR, 3.5; 95% CI, 3.0-4.2; P < .0001) or long head of the biceps tearing (OR, 5.1; 95% CI, 4.1-6.3; P < .0001) at or before the time of surgery. Concomitant rotator cuff repair and distal clavicle excision were not significant risk factors for revision surgery. The cost of revision surgery averaged almost

The Quality of Open-Access Video-Based Orthopaedic Instructional Content for the Shoulder Physical Exam is Inconsistent

9000. Conclusion: Risk factors for revision surgery after SLAP repair include age >40 years, female sex, obesity, smoking, and diagnosis of biceps tendinitis or long head of the biceps tearing. The diagnosis of biceps tendinitis (OR, 3.5) or long head of the biceps tearing (OR, 5.1) at or before the time of surgery was an especially significant risk factor for revision surgery. The high cost of revision surgery highlights the importance of appropriate indications to avoid the need for subsequent procedures.

“Hidden Lesions” of the Extra-articular Biceps After Subpectoral Biceps Tenodesis: Letter to the Editor

BackgroundThe internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open-access video content designed for provider use.Questions/PurposesThe primary goal of the study was to determine the accuracy of internet-based instructional videos featuring the shoulder physical examination.MethodsAn assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a surrogate for the “best-case scenario” due to its widely accepted components that are stable over time. Three search terms (“shoulder,” “examination,” and “shoulder exam”) were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopaedic surgeons. Quality and accuracy were assessed in accordance with previously published standards.ResultsOf the 39 video tutorials reviewed, 61% were rated as fair or poor. Specific maneuvers such as the Hawkins test, O’Brien sign, and Neer impingement test were accurately demonstrated in 50, 36, and 27% of videos, respectively. Inter-rater reliability was excellent (mean kappa 0.80, range 0.79–0.81).ConclusionOur results suggest that information presented in open-access video tutorials featuring the physical examination of the shoulder is inconsistent. Trainee exposure to such potentially inaccurate information may have a significant impact on trainee education.

Superior Labrum Anterior-Posterior Lesion: Arthroscopic Reconstruction of the Superior Labrum and Biceps Anchor

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)

Open-Access Video-Based Orthopaedic Instructional Content is Inaccurate

This chapter outlines arthroscopic reconstruction of the superior labrum and biceps anchor indicated for patients with refractory symptoms attributed to a superior labral lesion who have failed conservative treatment. Evaluation includes a thorough shoulder examination with consideration of the biceps-labral complex. MRI may also be useful in evaluating the soft tissue structures surrounding the glenohumeral joint. This chapter defines the three sections of the biceps-labral complex and differentiates normal and pathological anatomy. Surgical procedure is carefully outlined including portal placement for proper visualization, identification of lesions, and appropriate arthroscopic reconstructive techniques. Postoperative course should include a gradual return to activity guided by the severity of arthroscopic findings and postoperative clinical examination.

The Role of MRI in Diagnosing Biceps Chondromalacia

Objectives: The internet has an increasing role in both patient and physician education. While several recent studies critically appraised the quality and accuracy of web-based written information available to patients, no studies have evaluated such parameters for open access video content designed for provider use. The present study sought to determine utilization of video resources by orthopaedic residents and assess the quality and accuracy of their content Methods: Surveys were distributed to orthopaedic surgery residents to to determine their use of open access instructional video content. An assessment of quality and accuracy of said video content was performed using the basic shoulder examination as a suragate for the “best-case scenario” due to its widely accepted components that are stable over time. Three search terms (“shoulder”, “examination” and “shoulder exam”) were entered into the four online video resources most commonly accessed by orthopaedic surgery residents (VuMedi, G9MD, Orthobullets, and YouTube). Videos were captured and independently reviewed by three orthopedic surgeons. Quality and accuracy were assessed in accordance with previously published standards. Results: Of the 72 orthopaedic residents surveyed, 70% use open-access videos as a resource monthly and 25% weekly. Over 70% or respondents perceived the video content to be accurate and informative. We reviewed 39 unique video tutorials on physical examination. Of the 39 videos, 61% rated poor (<25% accurate) or fair (<50% accurate). Specific shoulder tests such as Hawkins, O’Brien Sign, and Neer Impingement were accurately demonstrated in only 50%, 36%, and 27% of videos respectively. Inter-rater reliability was excellent (mean Kappa 0.80, range 0.79-0.81). Conclusion: We demonstrated that orthopaedic surgery residents often turn to open-access video tutorials as a supplemental education tool. While the majority residents believed the content is accurate, our results suggest an alarming inaccuracy of these video tutorials. Trainee exposure to inaccurate information has far reaching implications on the education process. As such, training programs should help guide their residents to pre-screened or peer-reviewed video resources.

Proximal biceps tendon pain: current trends and philosophy

Objectives: Sisterman described the “Biceps Footprint”, Castagna et al reported on “Chondral Imprints,” and Kuhn et al identified “Humeral Head Abrasions.”[1],[2],[3] These can be considered types of biceps chondromalacia (BCM), as we define it, which is an attritional lesion on the humeral head, caused by abrasion of the LHBT over time. BCM occurs in two distinct types: “Junctional” or “Medial”. Junctional BCM (Figure 1) is found along the articular margin of the humeral head where the biceps tendon exits the joint. Medial BCM (Figure 2) is found on the anteromedial portion of the articular surface and may result from chronic “incarceration” of the LHBT between the humeral head and glenoid, a dynamic lesion elicited by the arthroscopic active compression test.[4] The pre-operative assessment of BCM has never been addressed. The purpose of the study was to evaluate the ability of pre-operative MRI to diagnose BCM. Methods: A retrospective review was conducted looking at preoperative MRI and intra-operative digital photos comparing three groups: 1) patients operated on for painful BLC lesions with demonstrable BCM seen at surgery (n=34); 2) patients operated on for painful BLC lesions without demonstrable BCM seen at surgery (n=21); and 3) patients without clinical BLC pain operated on for shoulder instability (n=29), who were used as a control group against the BLC pain groups. Groups one and two were age matched, both with a mean age of 42 years, while the average age of patients in group 3 was 29. The MRIs were scored once by an orthopedic surgeon, who graded based on presence or absence of a visible lesion, and again by an experienced radiologist, who blindly and independently scored the MRIs based on chondral loss, bone marrow edema, subchondral signal change, and tendinosis or fraying of the biceps tendon. Results: In group 1, 85% of patients had cartilage loss, 64% had subchondral signal changes, and 85% had a pathological signal in the proximal biceps. In group 2, 86% of patients had cartilage loss, 52% had subchondral signal changes, and 81% had a pathological signal in the proximal biceps, even though no BCM was grossly identified at surgery. In group 3, however, only 51% of patients had cartilage loss, 34% subchondral signal change, and 44% pathological signal in the proximal biceps tendon. Groups 1 and 2 were statistically similar to each other, but varied significantly when compared to group 3. This was particularly true with regard to cartilage loss (p=0.004), signal in proximal biceps (p=0.001), and subchondral signal change (p=0.041). Conclusion: MRI is a valuable pre-operative assessment tool that can alert the surgeon to the presence of BCM even if such a lesion has not yet become grossly apparent at arthroscopy. BCM characteristics on MRI include abnormal signal in the proximal biceps, subchondral bone, and cartilage loss. MRI findings consistent with BCM should prompt the physician to consider the biceps as the source of the patients pain. This is especially relevant when differentiating between a labral tear and the LHBT as inciting pathology. It should be noted, for example, that Provencher et al reported 28% of patients with type II SLAP tears, ultimately underwent a biceps surgery for persistent symptoms. [1] This study adds to our collective diagnostic acumen related to the biceps labral complex and highlights the utility of preoperative MRI.