Tae Kang Lim

Prospective Randomized Clinical Trial of Single- Versus Double-Row Suture Anchor Repair in 2- to 4-cm Rotator Cuff Tears: Clinical and Magnetic Resonance Imaging Results

PURPOSE The purpose of this study was to compare the clinical outcomes and the retear rates of arthroscopic single-row (SR) and double-row (DR) suture anchor repair in 2- to 4-cm rotator cuff tears. METHODS From 2005 to 2007, 71 patients with a 2- to 4-cm rotator cuff tear (proven by arthroscopy) were prospectively randomized to SR and DR repair groups. Of these patients, 62 (31 in each group) were available for evaluation at final follow-up. Demographic data, clinical scores, mean surgical times, and patient satisfaction were compared. Retear rates and clinical scores were also analyzed for 47 patients who underwent follow-up magnetic resonance imaging. RESULTS Comparisons of demographic data, tear size on preoperative magnetic resonance imaging, global fatty degeneration index, and concomitant procedures showed no differences between the SR and DR groups. Preoperative clinical scores were significantly improved postoperatively in both groups. No intergroup differences in pain visual analog scale, American Shoulder and Elbow Surgeons, Constant, or University of California, Los Angeles scores were found at final follow-up. Only mean surgical time was significantly different between the 2 groups. In the SR group, there were 4 full-thickness retears and 11 partial-thickness retears, whereas in the DR group, there were 6 full-thickness retears and 1 partial-thickness retear. However, despite numerical differences, these differences were not statistically different. Statistically, there were no significant differences both in full-thickness retear (P = .999) and retear including partial-thickness tear between the 2 groups (P = .124). CONCLUSIONS This study indicates that the clinical results and retear rates of DR repair with 1 additional medial suture anchor were not significantly different from those of SR repairs with 2 lateral suture anchors in patients with medium to large rotator cuff tear. LEVEL OF EVIDENCE Level I, randomized controlled trial.

Magnetic Resonance Imaging Evaluation of Anterior Cruciate Ligament Reconstruction Using Quadrupled Hamstring Tendon Autografts Comparison of Remnant Bundle Preservation and Standard Technique

Background: Recently, variations of the remnant bundle preservation technique, including selective bundle reconstruction and preservation of the anterior cruciate ligament tibial remnant, have produced good outcomes. The authors chose to investigate whether remnant bundle preservation in anterior cruciate ligament reconstruction would affect the remodeling process without inducing complications. Hypothesis: An anterior cruciate ligament reconstruction graft can be augmented with a tensioned remnant of the native anterior cruciate ligament fibers without increasing the tendency of cyclops lesions. The magnetic resonance imaging signal intensity in an anterior cruciate ligament graft using the remnant bundle preservation technique would be lower than that using the standard technique. Study Design: Cohort study; Level of evidence, 3. Methods: Forty-one patients who underwent an anterior cruciate ligament reconstruction using the remnant bundle preservation technique with quadrupled hamstring tendon autograft were evaluated by magnetic resonance imaging at a mean of 6.3 ± 0.7 months after surgery. The control group included 41 consecutive patients who underwent a single-bundle anterior cruciate ligament reconstruction by the standard technique. The 2 groups did not differ significantly in gender, age distribution, mean time until postoperative magnetic resonance imaging, or other patient characteristics. The magnetic resonance imaging evaluation focused on 5 measurements as follows: (1) dimensions of the anterior cruciate ligament graft, (2) signal intensity of the anterior cruciate ligament graft using the signal/noise quotient (SNQ) from a region of interest analysis, (3) magnetic resonance imaging signal intensity and continuity of the preserved remnant bundle, (4) orientation of the anterior cruciate ligament, and (5) tibial tunnel placement. Results: The remnant bundle preservation group had a significantly larger mean anterior cruciate ligament graft (293.4 mm2) than did the standard group (219.6 mm2) (P < .0001). However, the SNQ values of the anterior cruciate ligament graft in the remnant bundle preservation group were not significantly lower than those in the standard group in any of the 3 zones. In the remnant bundle preservation group, magnetic resonance imaging signals obtained from preserved remnant bundles in 35 patients (85%) showed 14 knees with a grade I signal (homogeneous low intensity) and 21 knees with a grade II signal (a portion of the preserved bundle was edematous). The continuity of remnant bundles in 37 patients (90%) as determined by magnetic resonance imaging was partial in 20 patients and complete in 17. The 2 groups did not differ significantly in the number of cyclops lesions detected by postoperative magnetic resonance imaging. Conclusion: After anterior cruciate ligament reconstruction, magnetic resonance imaging showed significantly larger anterior cruciate ligament grafts in the remnant bundle preservation group than in the standard procedure group, and these preserved remnant bundles showed progressive remodeling in the anterior cruciate ligament graft with no increase in the incidence of cyclops lesions. To determine a clinical advantage for the remnant preservation technique, magnetic resonance imaging results such as these must be correlated with clinical findings.

Patient-Related Factors and Complications After Arthroscopic Tenotomy of the Long Head of the Biceps Tendon

Background: Tenotomy of the long head of the biceps tendon (LHBT) has been reported to provide reliable pain relief and require little postoperative rehabilitation. Complications such as cosmetic deformity, decrease in elbow flexion strength, decrease in supination strength, and fatigue discomfort have been reported after tenotomy of the LHBT. Purpose: To evaluate the complications of arthroscopic tenotomy of the LHBT in the shoulder–specifically, cosmetic deformity, decreased elbow flexion strength, and a cramplike arm pain–and to identify the patient-related factors that affect the rate of complications after tenotomy, such as, age, sex, involvement of the dominant arm, and body mass index (BMI). Study Design: Case series; Level of evidence, 4. Methods: In sum, 132 patients were evaluated. They had a mean age of 63 years (range, 26 to 82 years) at the time of surgery and a mean follow-up of 21 months (range, 12 to 53 months). The presence of so-called Popeye deformity, a cramplike arm pain at resisted elbow flexion, and strength of elbow flexion were evaluated. The development of each complication was compared by age, sex, involvement of the dominant arm, and BMI. Results: Of the 132 patients, 60 (45%) had Popeye deformity, and it was significantly more frequent in men (76%) than women (31%) (P < .001). However, statistical analysis showed no difference in Popeye deformity frequency by age, arm dominance, or BMI. Male sex was found to be the only risk factor associated with the development of Popeye deformity, with an odds ratio of 10.21 versus women (95% confidence interval, 3.97 to 26.27; P < .001). Ten patients (8%) complained of a cramplike arm pain. Elbow flexion strength decreased in 60 patients (45%), although no intergroup differences were found for elbow flexion strength. Conclusion: The current study showed a 45% prevalence of Popeye deformity and 8% cramplike arm pain on exertion after tenotomy of the LHBT. Among patient factors such as sex, age, dominant arm relation, and body mass index, the male sex was the only factor correlated with occurrence of a Popeye deformity. Other factors did not show any correlation with deformity, elbow flexion strength, and cramplike arm pain.

Clinical and Magnetic Resonance Imaging Results of Arthroscopic Full-Layer Repair of Bursal-Side Partial-Thickness Rotator Cuff Tears

Background Partial rotator cuff tears are being diagnosed more often because of high-resolution magnetic resonance imaging (MRI). Articular-side partial tears are much more common than bursal-side tears, and all-inside or PASTA repairs that preserve the bursal tissue have gained popularity. In contrast, there have been few reports about preserving the articular tissue during bursal tear repair. Purpose To report clinical and radiological results of bursal-side partial-thickness rotator cuff tear (PTRCT) repair with preservation of as much of the intact articular-side tendon as possible. Study Design Case series; Level of evidence, 4. Methods From May 2006 to March 2008, 109 patients with PTRCT underwent arthroscopic repair. Among them, 38 consecutive patients who received a full-layer repair on the bursal side for greater than 50% thickness PTRCT were retrospectively evaluated. All repairs were performed with a technique that preserved intact articular fibers. To assess the outcome, pain visual analog scale (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score were evaluated at final follow-up. Postoperative MRI at least 6 months after surgery was evaluated for repair integrity. Results All 38 patients (21 men and 17 women) were available for final follow-up. The mean age at surgery was 50.8 years (range, 30-58 years), and the mean follow-up time was 26.9 months (range, 24-41 months). There were 21 right shoulders and 17 left shoulders, for which the mean time from the onset of symptoms to surgery was 47.0 months (±83.3 months). The PVAS improved from 5.2 (±2.5) to 1.6 (±1.5), and mean ASES and Constant scores improved from 53.1 (±20.4) and 59.9 (±15.3) to 87.2 (±9.4) and 83.2 (±12.0), respectively. Postoperative MRI was available in 33 patients at a mean 8.2 months after surgery. Twenty-nine shoulders (87.9%) had an intact repaired tendon, while 3 patients had shown partial-thickness delaminated retears, and 1 patient demonstrated a full-thickness retear on postoperative MRI. Conclusion For bursal-side PTRCT, clinical outcomes and tendon healing showed good results at a minimum 2 years after surgery, with minimal damage to intact articular tendon fibers on postoperative MRIs.

Treatment of Avascular Proximal Pole Scaphoid Nonunions With Vascularized Distal Radius Bone Grafting

PURPOSE To investigate the outcomes of vascularized distal radius pedicled bone grafting secured with K-wires for scaphoid nonunions with small avascular proximal fragments. METHODS We included patients with scaphoid nonunions and small, avascular proximal fragments that were too small for screw fixation. The mean size of the proximal pole fragments was 21% (range, 9% to 28%) of the entire scaphoid, based on quantitative radiographic measurement. All patients had distal radius bone grafting based on the 1,2-intercompartmental supraretinacular artery pedicle and fixation with K-wires. There were 21 wrists in 18 men and 2 women with the mean age of 34 years (range, 22 to 57 y). The mean duration of postoperative follow-up was 40 months (range, 12 to 103 mo). Radiographic union and clinical outcomes, including the ranges of wrist motion, grip strength, and the modified Mayo wrist score, were evaluated. RESULTS Union was achieved in 18 of 21 wrists (86%) at a mean time of 14 weeks after surgery (range, 8 to 28 wk). Nonunions with proximal fragments less than 20% of the total scaphoid healed in 6 of 8 wrists. In a subset of these 8 wrists in which the proximal fragment was less than 15%, healing occurred in 2 of 4. The modified Mayo wrist score significantly improved from 46 to 78 points, and final wrist functions were rated as excellent in 5, good in 5, fair in 10, and poor in 1. Ranges of motion and grip strengths did not show significant changes after surgery. CONCLUSIONS Vascularized distal radius bone grafting and K-wire fixation can heal scaphoid nonunions with small avascular proximal fragments, although motion and grip strength remain unchanged. Healing may be related to the size of the proximal pole fragment.

Preoperative Factors Affecting Footprint Coverage in Rotator Cuff Repair

Background: One of the goals of rotator cuff repair is to restore the torn tendon to its original insertion anatomically. However, it is sometimes difficult to restore the entire footprint. Purpose: This study was undertaken to evaluate the variables affecting this repair coverage and to discern the differences in retear rate and clinical results between complete and incomplete footprint coverage in rotator cuff surgery. Study Design: Case series; Level of evidence, 4. Methods: From 2007 to 2009, a total of 85 consecutive repairs for medium-to-large rotator cuff tears were identified as having complete or incomplete coverage of their original footprints. We defined the complete footprint coverage (CC) group as patients who had >50% of their footprint covered during repair and the incomplete (IC) group as <50% of their footprint. Factors affecting the amount of footprint coverage were evaluated, and multivariable analysis was conducted to identify independent factors. To assess the final outcome according to the amount of footprint coverage, retear and clinical outcomes were compared between the CC and IC groups. Results: Fifty-seven repairs were defined in the CC group and 28 repairs in the IC group. Preoperatively, age, tear size in coronal oblique and sagittal oblique planes, Goutallier fatty infiltration, and atrophy of the supraspinatus affected the amount of footprint coverage in univariate analysis. In multivariable analysis, however, tear size in the coronal plane was the only independent factor affecting footprint coverage in rotator cuff repair. On postoperative MRI, 45.6% of the CC group had an intact tendon, 45.6% had a delaminated partial retear, and 8.8% had a full-thickness retear; in the IC group, 17.9% had an intact tendon, 60.7% had a delaminated partial retear, and 21.4% had a full-thickness retear. There was a statistically significant difference in the proportion of tendon integrity between groups (P = .028). Clinical scores and range of motion at final follow-up showed no difference between the 2 groups. Conclusion: Tear size in the coronal plane was the only independent factor affecting the amount of footprint coverage. Repair quality based on retear classification was different between the 2 groups. However, both complete and incomplete footprint coverage in rotator cuff repair showed no differences in clinical scores and range of motion at short-term follow-up.

Subscapularis Tendon Repair Using Suture Bridge Technique

The subscapularis tendon plays an essential role in shoulder function. Although subscapularis tendon tears are less common than other rotator cuff tears, tears of the subscapularis tendon have increasingly been recognized with the advent of magnetic resonance imaging and arthroscopy. A suture bridge technique for the treatment of posterosuperior rotator cuff tears has provided the opportunity to improve the pressurized contact area and mean footprint pressure. However, suture bridge fixation of subscapularis tendon tears appears to be technically challenging. We describe an arthroscopic surgical technique for suture bridge repair of subscapularis tendon tears that obtains ideal cuff integrity and footprint restoration. Surgery using such a suture bridge technique is indicated for large tears, such as tears involving the entire first facet or more, tears with a disrupted lateral sling, and combined medium to large supraspinatus/infraspinatus tears.

Total Volar Extrusion of the Lunate and Scaphoid Proximal Pole With Concurrent Scapholunate Dissociation

This article describes a case of a 24-year-old man with a total volar extrusion of the lunate and scaphoid proximal pole with concurrent scapholunate dissociation. The viability of the lunate and the proximal pole of the scaphoid are at high risk in this type of injury. Scaphoid nonunion, avascular necrosis of the lunate and proximal pole of the scaphoid, and carpal instability are inevitable unless the blood supply is restored. Thus, proximal row carpectomy at injury may be an acceptable option to avoid these complications and late sequelae, including chronic wrist pain and dysfunction. However, the authors attempted accurate reduction of the extruded bones and internal fixation.Final radiographs and magnetic resonance imaging 12 years postoperatively showed healing without avascular necrosis. Carpal indices involving the scapholunate angle, radiolunate angle, and carpal height ratio were similar in both wrists without evidence of carpal instability or collapse. Range of motion and grip power were 75% and 76%, respectively, compared with those of the uninjured wrist. Clinical scores showed good results, and the patient reported no pain during activities of daily living and was satisfied with his surgical results. Open reduction and internal fixation can be a viable option in this rare pattern of injury.

Is a short arm cast appropriate for stable distal radius fractures in patients older than 55 years? A randomized prospective multicentre study:

We conducted a prospective randomized, multicentre study to compare short arm and long arm plaster casts for the treatment of stable distal radius fracture in patients older than 55 years. We randomly assigned patients over the age of 55 years who had stable distal radius fracture to either a short arm or long arm plaster cast at the first review 1 week after their injury. Radiographic and clinical follow-up was conducted at 1, 3, 5, 12 and 24 weeks following their injury. Also, degree of disability caused by each cast immobilization was evaluated at the patient’s visit to remove the cast. There were no significant differences in radiological parameters between the groups except for volar tilt. Despite these differences in volar tilt, neither functional status as measured by the Disabilities of the Arm, Shoulder and Hand, nor visual analogue scale was significantly different between the groups. However, the mean score of disability caused by plaster cast immobilization and the incidence rate of shoulder pain were significantly higher in patients who had a long plaster cast. Our findings suggest that a short arm cast is as effective as a long arm cast for stable distal radius fractures in the elderly. Furthermore, it is more comfortable and introduces less restriction on daily activities. Level of evidence: II