Steven Klepps

Prospective Evaluation of the Effect of Rotator Cuff Integrity on the Outcome of Open Rotator Cuff Repairs

Background Open rotator cuff repairs have led to excellent clinical results; however, several studies have linked postoperative structural integrity to patient outcomes. The purpose of this study is to prospectively assess postoperative cuff integrity after open rotator cuff repair and assess its relationship to clinical outcome. Hypothesis Preoperative rotator cuff tear size and postoperative rotator cuff integrity are important factors in overall clinical outcomes. Study Design Prospective nonrandomized clinical outcomes study. Methods Forty-seven consecutive patients undergoing repair of full-thickness rotator cuff tears by a single surgeon were enrolled in this prospective study. A standardized evaluation was performed preoperatively and postoperatively at annual intervals. All patients underwent postoperative magnetic resonance imaging at least 1 year after surgery. Statistical evaluation was performed using paired and unpaired 2-tailed t tests for comparison. Results Thirty-two patients were available for evaluation. Overall, the patients experienced a significant (P < .05) improvement in their American Shoulder and Elbow Surgeons survey (40-85) and Constant (53-80) scores. The overall retear rate was 31%. Although patients with large tears preoperatively and retears postoperatively had lower overall outcomes scores, this was not significant. Conclusion These data support open rotator cuff repair as an effective technique that restores excellent shoulder function. The authors did not find postoperative cuff integrity to have a significant effect on outcomes when compared with those with an intact cuff. In fact, those with a retear still had a significant improvement in all clinical areas assessed, including strength.

Transitioning to arthroscopic rotator cuff repair: the pros and cons.

There has been much recent enthusiasm regarding complete arthroscopic rotator cuff repair, and it is becoming apparent that, for many, this newer technique may be a preferable alternative to the more traditional mini-open rotator cuff repair. Several short-term studies have demonstrated that complete arthroscopic repair has excellent results comparable with those of mini-open repair, which is also an excellent technique. The choice of which procedure may be better for an individual patient or surgeon can be based on a variety of considerations, including the patients expectations, the pathoanatomy of the cuff, and the surgical experience of the surgeon. The relative merits and disadvantages of arthroscopic rotator cuff repair are discussed on the basis of those considerations. When a surgeon is deciding which procedure to perform, it is important that the basic principles of rotator cuff repair not be compromised and that he or she perform the procedure that is most reproducible given his or her level of experience; however, for those who are now utilizing miniopen repair, arthroscopic repair may have important advantages and may be worth pursuing in the future. If a surgeon chooses to obtain the skills necessary to perform a complete arthroscopic repair, performance of the mini-open procedure offers an excellent opportunity to make an orderly transition.

Incidence of early radiolucent glenoid lines in patients having total shoulder replacements.

Glenoid loosening is the most common long-term complication occurring after total shoulder replacement. Imprecise cement technique and glenoid preparation may result in early radiolucent glenoid line formation. Early radiolucent lines may indicate inadequate initial fixation, which may contribute to early loosening. Improved cement techniques, refined instrumentation, and glenoid component design all may reduce early radiolucent lines. In our study, postoperative anteroposterior and axillary radiographs were obtained after 68 total shoulder replacements done by one surgeon using either an old free-hand, manual packing technique before November 1998 (n = 28) or a new instrument preparation and pressurization technique since November 1998 (n = 40). Three orthopaedic surgeons blindly reviewed the radiographs for the presence and thickness (mm) of radiolucent lines. The newer instrumented pressurization group had a lower incidence of radiolucent lines than the old manually packed group. In the new subgroup, pegged components had a lower incidence of radiolucent lines than keeled components. The incidence of radiolucent lines seems to be reduced using specially designed instruments, new glenoid designs, and modern cement techniques, which may lead to reduced long-term glenoid loosening. Level of Evidence: Therapeutic study, Level III-2 (retrospective cohort study). See the Guidelines for Authors for a complete description of levels of evidence.

Biomechanical Evaluation of 2 Techniques for Ulnar Collateral Ligament Reconstruction of the Elbow

Background Elbow medial ulnar collateral ligament tears often result in pain and instability that may be career threatening in overhead-throwing athletes. Surgical reconstruction is frequently chosen to treat this injury. Ulnar collateral ligament reconstruction as described by Jobe is the most commonly used technique. Testing of this construct has not demonstrated that the biomechanical parameters of the native ligament are restored. A more recent construct, the docking technique, may more reliably reproduce these factors. Hypothesis Increasing the number of strands of palmaris longus tendon graft used in ulnar collateral ligament reconstruction and tensioning them using the docking technique result in a construct with improved biomechanical parameters as compared with the Jobe technique. Study Design Controlled laboratory study. Methods Thirty-three fresh-frozen human cadaveric elbows were randomized into 3 subgroups: Jobe (11), docking (12), and native (10). The Jobe and docking groups underwent reconstruction using their described palmaris tendon graft constructs. The ulnar collateral ligament was left intact in the native group. Elbows were potted and tested using a servohydraulic materials testing machine to apply a valgus moment at 30° of elbow flexion. Maximal moments to failure, stiffness, and strain at maximal moment and with a 3 N·m force applied were determined using a 2-camera motion analysis system to track reflective markers spanning the site. Results The docking (14.3 N·m) and native (18.8 N·m) subgroups resulted in higher maximal moment to failure than did the Jobe (8.9 N·m) subgroup (P <. 001). There was no significant difference between native and docking groups (P >. 05). Native ligaments were stiffer (301.4 N·m) than were Jobe (74.3 N·m) or docking (80.8 N·m; P <. 001). Native ligaments demonstrated lower strain at maximal force (0.087 mm/mm) and 3 N·m forces (0.030 mm/mm) than did the Jobe (0.198/0.057 mm/mm) or docking (0.287/0.042 mm/mm) subgroups. There was no difference in stiffness or strain between the Jobe and docking subgroups (P >. 05). Conclusion Neither technique reproduced the biomechanical profile of the native ulnar collateral ligament; the findings of this study suggest that the docking construct may offer initial biomechanical advantage over the Jobe construct.

Reliability and reproducibility of radiographs of greater tuberosity displacement. A cadaveric study.

BACKGROUND Classification of fractures of the greater tuberosity has shown poor reliability, in part as a result of an inability to assess fracture displacement accurately. We used fluoroscopic images of prepositioned osteotomized greater tuberosity fragments in cadavers to determine the accuracy of radiographic interpretation, the interobserver reliability, and the effect that radiographs might have on surgical decision-making. METHODS Twelve osteotomies of the greater tuberosity (three each with 2, 5, 10, and 15 mm of displacement) were created in whole-body cadavers. Six fluoroscopic images (anteroposterior views in external and internal rotation, anteroposterior views in neutral rotation with 15 degrees of cephalic and 15 degrees of caudal tilt, a lateral outlet view, and an axillary view) were made after each osteotomy. Four experienced orthopaedic surgeons measured displacement in millimeters on seventy-two randomized images. Four views in sequence (the anteroposterior view in internal rotation and the outlet view together, then the axillary view, and then the anteroposterior view in external rotation) of each osteotomy pattern were then viewed, and each surgeon was asked whether surgery would be indicated on the basis of each set of images. RESULTS No one fluoroscopic view was significantly more accurate than another. There was a trend toward increased accuracy of imaging of minimally displaced (</=5 mm) tuberosity fragments with the anteroposterior view in external rotation. When viewed sequentially, the anteroposterior view in external rotation, evaluated last, altered treatment in nine of forty-eight situations. There was substantial agreement (kappa = 0.71) among the surgeons with respect to their recommendations for treatment of the displaced greater tuberosities after they had inspected the four images. CONCLUSIONS AND CLINICAL RELEVANCE To our knowledge, we are the first to examine the accuracy and reliability of interpreting images of known displacements of the greater tuberosity. Multiple radiographic views are needed to evaluate displacement of the greater tuberosity appropriately. The anteroposterior view in external rotation can profile the greater tuberosity and help demonstrate small displacements. Treatment decisions should be consistent between surgeons when multiple views are used.

Posterior shoulder dislocation with lesser tuberosity and scapular spine fractures

G lenohumeral fracture-dislocations are well described in the literature.7 Anterior dislocations are considerably more common than posterior dislocations and can be associated with displaced greater tuberosity fractures,2,6 which may reduce after the shoulder joint is reduced. If this occurs, the injury may be treated without surgery. We report a posterior dislocation with a concomitant displaced lesser tuberosity fracture and acromial spine fracture. The lesser tuberosity fracture reduced after closed reduction of the posterior glenohumeral dislocation.

Determination of radiographic guidelines for percutaneous fixation of proximal humerus fractures using a cadaveric model.

The humeral heads of whole body cadaveric shoulders underwent fluoroscopic evaluation with the head divided into three zones on both anteroposterior (AP) and axillary views creating nine zones. Five AP and three axillary fluoroscopic images in different rotational positions were assessed for pin penetration. All images were evaluated for pin penetration and the AP view was evaluated for lesser tuberosity location. Pins placed appropriately below the subchondral bone did not appear to penetrate the joint on any fluoroscopic image. Pins placed 2 mm beyond the articular surface were appropriately viewed exiting the head on most views (64%) but falsely appeared within the head on several others (36%). Pins perforating the posterior head were problematic for accurate detection on AP views (missed in 87%), but this was avoided by externally rotating the humerus to 60 degrees. Articular penetration cannot always be appreciated radiographically and special efforts are necessary to avoid this problem including the use of various rotational views as well as the use of appropriate landmarks for orientation such as the lesser tuberosity position.

A retrospective radiographic review of hemophilic shoulder arthropathy.

Bleeding into large joints is the most common orthopaedic manifestation of hemophilia. Involvement of the shoulder rarely is reported, lending to its relative neglect in the orthopaedic literature. Through retrospective chart and radiographic reviews, the incidence and progression of radiographic and clinical changes that occur in the shoulder of patients with hemophilia is described. We retrospectively reviewed 822 patient charts and found 93 patients with symptomatic shoulders. Seventy-nine of these 93 patients were rated according to Pettersson’s scoring method. The clinical charts were reviewed for the presence of shoulder symptoms and dysfunction. A spectrum of radiographic changes was seen beginning with mild subchondral irregularity and greater tuberosity cyst formation progressing to joint space narrowing, osteophyte formation, marginal erosion, and deformity. Of the 54 patients for whom an adequate shoulder history was available, the severity of symptoms correlated with the Pettersson score. The current study is the largest to date examining the type and progression of radiographic changes caused by hemophilic shoulder arthropathy. We observed a consistent pattern of radiographic changes, the severity of which correlated directly with shoulder symptoms.

Management of Glenoid Bone Deficiency During Shoulder Replacement

Recent studies have shown that resurfacing the glenoid during shoulder replacement provides predictable pain relief and functional improvement for patients with degenerative arthritis. Therefore, the current trend is to replace the glenoid whenever the patient has adequate soft tissue support and glenoid bone stock. For patients who are believed to have a deficient glenoid, various approaches have been developed, and, in fact, the approach chosen depends largely on surgeon preference and experience. This article will review glenoid replacement and the surgical indications and different techniques that have developed for dealing with glenoid deficiency.

Osteoarticular Allograft and Endoprosthesis-Allograft Reconstruction for Tumors of the Proximal Humerus

The proximal humerus is a common location for malignant lesions of the bone. With the advent of limb-sparing approaches, several reconstructive options have been developed. Although allograft reconstructions are technically difficult and fraught with potential complications, they may provide a better functional outcome. One major drawback to using allografts is the articular degeneration that almost universally occurs. One recently developed method for avoiding this problem is the use of endoprosthesis-allograft composites. This article will relate the specific indications and the appropriate preoperative assessment for performing allograft or endoprosthesis-allograft reconstructions for malignant lesions of the proximal humerus. The focus will be on the specifics of the operative technique and the critically important postoperative rehabilitation. Finally, the limited results that have been reported on this topic to date will be discussed.