Thomas R. Duquin

Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing? A Systematic Review

Background The purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery. Hypotheses We hypothesized that (1) the rotator cuff repair method will not affect retear rate, and (2) the surgical approach will not affect the retear rate for a given repair method. Study Design Systematic review of the literature. Methods The literature was systematically searched to find articles reporting imaging study assessment of structural healing rates after rotator cuff repair, with data stratified according to tear size. Retear rates were compared for transosseous (TO), single-row suture anchor (SA), double-row suture anchor (DA), and suture bridge (SB) repair methods, as well as for open (O), miniopen (MO), and arthroscopic (A) approaches. Results Retear rates were available for 1252 repairs collected from 23 studies. Retear rates were significantly lower for double-row repairs when compared with TO or SA for all tears greater than 1 cm and ranged from 7% for tears less than 1 cm to 41% for tears greater than 5 cm, in comparison with retear rates for single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than 5 cm, respectively. There was no significant difference in retear rates between TO and SA repair methods or between arthroscopic and nonarthroscopic approaches for any tear size. Conclusion Double-row repair methods lead to significantly lower retear rates when compared with single-row methods for tears greater than 1 cm. Surgical approach has no significant effect on retear rate.

Current trends in anterior cruciate ligament reconstruction.

In 2006, a survey regarding anterior cruciate ligament (ACL) reconstruction was mailed to physician members of the American Orthopaedic Society for Sports Medicine. A total of 993 responses were received from 1747 possible respondents (57%). The number of ACL reconstructions per year ranged from 1 to 275 (mean=55). The most important factors in the timing of surgery were knee range of motion and effusion. Bone-patellar tendon-bone (BPTB) autograft was most commonly preferred (46%), followed by hamstring tendon autograft (32%) and allografts (22%). Five years earlier, BPTB grafts were more frequent and hamstring tendon and allografts were less frequent (63%, 25%, and 12%, respectively). A single-incision arthroscopic technique was used by 90%. Most allowed return to full activity at 5 to 6 months, with a trend toward earlier return for BPTB grafts; quadriceps strength was an important factor in the decision. There was limited experience (4%) with double-bundle and computer-assisted ACL reconstruction. Arthroscopic-assisted, single-incision reconstruction using a BPTB autograft fixed with metal interference screws remains the most common technique used for primary ACL reconstruction. In the past 5 years, the use of alternative graft sources and methods of fixation has increased. Consensus regarding the best graft type, fixation method, and postoperative protocol is still lacking.

Repair of the Ruptured Distal Biceps Tendon A Systematic Review

Background Reinsertion of the acutely ruptured distal biceps is the preferred method of treatment for most patients and is designed to restore flexion and supination strength. It is not clear which, if any, method of fixation is superior or whether a 2-incision or single-incision approach is associated with fewer complications or better outcomes. Hypotheses (1) There is no difference in biomechanical performance between currently used fixation methods, (2) there is no difference in incidence of complications between the 2-incision and single-incision approach, and (3) there is no difference in clinical outcomes between the 2-incision and single-incision approach. Study Design Systematic review; Level of evidence, 4. Methods The authors performed a systematic review of the literature studying treatment of the ruptured distal biceps tendon to determine optimal fixation method as well as surgical approach with lowest incidence of complications and highest proportion of satisfactory results. Results The review identified 8 articles that had relevant biomechanical data, 23 with relevant complication data, and 19 with relevant clinical results data. EndoButton fixation performed best in comparative biomechanical studies. There was no difference in overall incidence of complications between 2-incision approaches (16%) and single-incision approaches (18%), but there were significantly more instances of significant loss of forearm rotation with the 2-incision approach. There were significantly more unsatisfactory clinical results in the 2-incision repair group (31 % vs 6%; odds ratio, 7.6; 95% confidence interval, 3.2-17.7), with the majority of unsatisfactory results in the 2-incision group due to loss of forearm rotation or rotational strength. Conclusion EndoButton fixation has the highest load and stiffness of currently available fixation methods. Two-incision repairs have a significantly greater proportion of unsatisfactory results than do single-incision repairs.

Antimicrobial Susceptibility of Propionibacterium acnes Isolates from Shoulder Surgery

ABSTRACT Orthopedic surgeons at our institution have noticed an increase in the number of infections due to Propionibacterium acnes, especially following operations on the shoulder. We collected P. acnes isolates from our hospital microbiology laboratory for 1 year and performed antimicrobial susceptibility testing on 28 strains from the shoulder. Antibiotics with the lowest MIC values against P. acnes (MIC50 and MIC90) included penicillin G (0.006, 0.125), cephalothin (0.047 and 0.094), and ceftriaxone (0.016, 0.045), while others also showed activity. Strains resistant to clindamycin were noted.

Unconstrained Shoulder Arthroplasty for Treatment of Proximal Humeral Nonunions

BACKGROUND Unconstrained shoulder arthroplasty is one of several methods for treatment of proximal humeral fracture nonunions. The goal of this study was to define the results and complications of this procedure. METHODS From 1976 to 2007, sixty-seven patients underwent unconstrained shoulder arthroplasty for proximal humeral nonunion and were followed for more than two years. There were forty-nine women and eighteen men with a mean age of sixty-four years and a mean duration of follow-up of nine years (range, two to thirty years). The fracture type according to the Neer classification was two-part in thirty-six patients, three-part in sixteen, and four-part in fifteen. Hemiarthroplasty was performed in fifty-four patients and total shoulder arthroplasty was done in the remaining thirteen. RESULTS There were thirty-three excellent or satisfactory results according to the modified Neer rating. Tuberosity healing about the prosthesis occurred in thirty-five shoulders. The mean pain score improved from 8.3 preoperatively to 4.1 at the time of follow-up (p < 0.001). The average active shoulder elevation and external rotation improved from 46° and 26° to 104° and 50° (p < 0.001). Shoulders with anatomic or nearly anatomic healing of the tuberosities had greater active elevation at the time of final follow-up (p = 0.02). There were fourteen complications in twelve patients, with twelve reoperations including five revisions. Kaplan-Meier survivorship with revision as the end point was 97% (95% confidence interval [CI]: 94.3, 100) at one year and 93% (95% CI: 88.0, 99.2) at five, ten, and twenty years. CONCLUSIONS Shoulder arthroplasty decreases pain and improves function in patients with a proximal humeral nonunion. However, the overall results are satisfactory in less than half of the patients. Tuberosity healing is inconsistent and influences the functional outcome.

Hemiarthroplasty of the distal humerus for acute and chronic complex intra-articular injuries

BACKGROUND Comminuted intra-articular distal humeral fractures represent a challenging upper extremity injury. This study reviews clinical and radiographic results in patients with distal humeral hemiarthroplasty (DHH). METHODS DHH with the Latitude prosthesis (Tornier, Saint-Ismier, France) was performed in 8 patients (mean age, 64 years; age range, 33-75 years) for unreconstructible fractures of the distal humerus or salvage of failed internal fixation. Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons elbow instrument; Mayo Elbow Performance Index; and Disabilities of the Arm, Shoulder and Hand questionnaire at a mean of 36 months. Radiologic assessment included radiographs and computed tomography to evaluate olecranon wear and densitometry (dual-energy x-ray absorptiometry). Range of motion, pain, and elbow satisfaction were recorded, and descriptive statistics were used for analysis. RESULTS Seven patients were available to participate in the follow-up examination. Acute cases (5 patients) scored better than salvage cases (2 patients) on the Mayo Elbow Performance Score (80 points [range, 67-95 points] and 65 points [range, 50-80 points], respectively) and Disabilities of the Arm, Shoulder and Hand score (31 points [range, 2.5-68 points] and 39 points [range, 17-62 points], respectively). The mean arc of elbow flexion and extension was 96° (range, 70°-130°), with mean flexion of 120° (range, 90°-135°) and a mean extension loss of 19° (range, 5°-30°). The mean arc of forearm rotation was 160° (range, 140°-180°). Reoperation was required in 4 patients because of painful retained hardware. Five patients reported pain with activities of daily living. CONCLUSION DHH should be used with caution until such time as longer-term outcome studies are able to show the efficacy of this procedure.

Effect of one- and two-pin reference anchoring systems on marker stability during total knee arthroplasty computer navigation

Objective: This study investigated different infrared marker reference base attachments in cadaveric bone and their effects on alignment outcome when different loads were applied. Material and Methods: Five cadaveric specimens were used to test four reference base attachments: a locking one-pin (4.0 mm and 5.0 mm pins) and a two-pin clamp (Hoffman fixator, 3.0 mm and 5.0 mm pins, Stryker Inc., NJ). Each was tested with metaphyseal and diaphyseal attachments. A navigation system (Stryker Navigation, MI) was used for testing with applied incremental loads and torques (65 N and 1.0 Nm) to the different reference base configurations. Results: With 65 N the maximum change in distance to a verification point was 4.3 + 1.6 mm with the 4.0 mm locking pin in metaphyseal bone. No difference in verification point distances was found with any two-pin configuration. Alignment changes greater than 4° resulted with the 65 N loads and a 4.0 mm pin. Conclusion: The results may prove beneficial in comparing the resulting error of different manufacturers and allow surgeons to realize the variability that may occur through incidental contact in the operating room.

Anatomic shoulder arthroplasty for treatment of proximal humerus malunions

BACKGROUND Malunion of proximal humeral fractures complicated by damage to the glenohumeral cartilage and injury to the joint capsule and rotator cuff can include treatment requiring anatomic shoulder arthroplasty. This study defines results and complications of this procedure and identifies factors associated with success or failure. METHODS From 1976 to 2007, 109 patients underwent shoulder arthroplasty for proximal humerus malunions. Ninety-five met the criteria for analysis with a mean follow-up period of 9.2 years. Fracture types according to the Neer classification were two part in 20, three part in 37, four part in 31, and head splitting in 2, with 16 fracture-dislocations. Hemiarthroplasty was performed in 45 patients, with 50 undergoing total arthroplasty. RESULTS Pain scores improved from 7.8 to 3.1 (P < .001). The mean active elevation and external rotation improved from 69° to 109° and from 8° and 39°, respectively (P = .001). Of 31 patients with available radiographs, 20 had healed tuberosity osteotomies. Sixteen complications required 10 reoperations, including 6 of 9 patients with severe postoperative instability. There were 57 excellent or satisfactory results by use of the Neer rating. No patient, injury pattern, previous treatment, surgical, or radiologic variation was significantly associated with an increased risk of an unsatisfactory result, except for severe postoperative instability. Kaplan-Meier survivorship for reoperation, in 109 shoulders, was 94.8% (95% confidence interval, 90.5%-99.4%) at 5 years and 90.1% (95% confidence interval, 83.6%-97.1%) at 10 and 15 years. CONCLUSION Anatomic shoulder arthroplasty improves pain and motion. Surgery is complex. Tuberosity osteotomies often heal. Postoperative instability is the most common complication leading to reoperation and is usually associated with rotator cuff and shoulder capsule injury.

Arthroscopic Visualization of the Popliteus Tendon

PURPOSE This study was conducted to define what portion of the normal popliteus musculotendinous unit can be visualized during standard diagnostic arthroscopy. METHODS Knee arthroscopy was performed on 5 fresh-frozen cadaveric human knees by use of standard anterolateral and anteromedial portals. The most proximal and distal portions of the popliteus that could be visualized were tagged with arthroscopic sutures. The knees were subsequently dissected, and 4 measurements were made per specimen: the total length of the popliteus tendon; the length of the popliteus tendon that was able to be visualized; the extrasynovial segment at the femoral attachment, which was unable to be visualized; and the distance from the distal-most visible point of the tendon to the musculotendinous junction of the popliteus. RESULTS The mean total length of the popliteus tendon was 42.0 mm. The arthroscopically tagged portion of the popliteus tendon that was able to be visualized averaged 18.2 mm, or 43.8% of the tendon length. The mean distance from the musculotendinous junction to the visualized portion was 15.1 mm, or 35.8% of the total tendon length. The mean distance from the most proximal visualized portion of the tendon to the femoral attachment was 8.7 mm, or 20.4% of the total tendon length. The musculotendinous junction was not arthroscopically visible in any specimen. CONCLUSIONS On standard knee arthroscopy, less than half of the normal popliteus tendon is visible, and the femoral insertion and musculotendinous junction are not visualized. Because most reported popliteus injuries have occurred here, reliance on arthroscopic visualization alone is inadequate. CLINICAL RELEVANCE The limitations of arthroscopic visualization of the normal popliteus tendon have implications for the diagnosis and treatment of posterolateral corner injuries.

Innervation of the supinator muscle and its relationship to two-incision distal biceps tendon repair: an anatomic study.

Reinsertion of the ruptured distal biceps tendon has been performed using either a single‐anterior incision or a two‐incision approach. A systematic review of these two repair methods has identified a higher incidence of supination weakness following the two‐incision approach. The objective of this study was to describe the innervation of the supinator muscle and its implications regarding a two‐incision distal biceps repair. Twelve fresh upper extremity specimens from 12 males were dissected with the forearm in full pronation. The number of branches of the posterior interosseous nerve (PIN) to the supinator, their site of exit from the PIN trunk, and their distance from a variety of known anatomic landmarks were recorded. Specimens were characterized as high (<5 mm), moderate (6–10 mm), or low (>10 mm) risk of nerve branch injury depending on the proximity of nerve branches to the bicipital tuberosity. In general, we found the innervation of the supinator to be highly variable. There were from two to nine branches of the PIN which supplied the supinator, with 0–3 arising from the ulnar side of the nerve. Four specimens were at low, five at moderate, and three at high risk of nerve branch injury during dorsal exposure of the bicipital tuberosity. We conclude that there is a substantial amount of variability in the innervation of the supinator, with certain patterns being at higher risk of nerve branch injury if dissection of the supinator is carried out over the bicipital tuberosity. Clin. Anat. 23:413–419, 2010.