Yong-Min Chun

Arthroscopic Partial Repair of Irreparable Large to Massive Rotator Cuff Tears

PURPOSEnThe aim of this study was to evaluate the outcome of arthroscopic partial repair and margin convergence of irreparable large to massive rotator cuff tears.nnnMETHODSnBetween January 2003 and July 2008, 27 patients who met the inclusion criteria underwent arthroscopic partial repair and margin convergence of irreparable large to massive rotator cuff tears. An irreparable tear was defined as a tear with a minimum anterior-to-posterior width of 3 cm or larger, where it was not feasible to completely cover the humeral head with the cuff at the time of surgery.nnnRESULTSnThe mean preoperative tear size was 42.1 ± 6.2 mm. The mean size of the postoperative residual defect in the repaired tendon along the medial margin of the greater tuberosity was 12.0 ± 5.5 mm. All shoulder scores showed improvement. The Simple Shoulder Test improved from 5.1 ± 1.2 to 8.8 ± 2.1 (P < .001), the Constant score from 43.6 ± 7.9 to 74.1 ± 10.6 (P < .001), and the University of California, Los Angeles score from 10.5 ± 3.0 to 25.9 ± 5.0 (P < .001). Both Constant and University of California, Los Angeles shoulder scores also showed an inverse correlation with defect size. We compared muscle strength between the affected and contralateral sides and found that the strength of the affected side was not restored to the same level as the contralateral side (P < .001).nnnCONCLUSIONSnArthroscopic partial repair and margin convergence showed satisfactory short-term outcomes in irreparable large to massive rotator cuff tears. Thus it is suggested that, even in a large to massive tear that appears irreparable, attempting to repair it as much as possible to possibly convert it into a functional rotator cuff tear by re-creating a balanced forced couple can be helpful in reducing pain, as well as improving functional outcomes.nnnLEVEL OF EVIDENCEnLevel IV, therapeutic case series.

Arthroscopic repair of massive contracted rotator cuff tears: aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity.

BACKGROUNDnFew studies of large-to-massive contracted rotator cuff tears have examined the arthroscopic complete repair obtained by a posterior interval slide and whether the clinical outcomes or structural integrity achieved are better than those after partial repair without the posterior interval slide.nnnMETHODnThe study included forty-one patients with large-to-massive contracted rotator cuff tears, not amenable to complete repair with margin convergence alone. The patients underwent either arthroscopic complete repair with a posterior interval slide and side-to-side repair of the interval slide edge (twenty-two patients; Group P) or partial repair with margin convergence (nineteen patients; Group M). The patient assignment was not randomized. The Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and range of motion were used to compare the functional outcomes. Preoperative and six-month postoperative magnetic resonance arthrography (MRA) images were compared within or between groups.nnnRESULTSnAt the two-year follow-up evaluation, the SST, ASES score, UCLA score, and range of motion had significantly improved (p < 0.001 for all) in both groups. However, no significant differences were detected between groups. Even though the difference in preoperative tear size on MRA images was not significant, follow-up MRA images identified a retear in twenty patients (91%) in Group P and a significant difference in tear size between groups (p = 0.007).nnnCONCLUSIONSnThe complete repair group with an aggressive release had no better clinical or structural outcomes compared with the partial repair group with margin convergence alone for large-to-massive contracted rotator cuff tears. In addition, the complete repair group had a 91% retear rate and a greater defect on follow-up MRA images. Even though this study had a relatively short-term follow-up, a complete repair of large-to-massive contracted rotator cuff tears, with an aggressive release such as posterior interval slide, may not have an increased benefit compared with partial repair without posterior interval slide.

Medial opening wedge high-tibial osteotomy using a kinematic navigation system versus a conventional method: a 1-year retrospective, comparative study

High tibial osteotomy is a realignment procedure to transfer weight-bearing load to the intact compartment of the knee to alleviate symptoms, slow disease progression, and defer subsequent total knee arthroplasty. To prevent overcorrection or undercorrection, it is not only important to have an exact preoperative calculation of the desired correction angle, but it is also critical to have an accurate intraoperative technique. 85 consecutive patients (90 knees) were enrolled, who were available at 1-year follow-up after a medial opening wedge high tibial osteotomy using a kinematic navigation system or a conventional method, for medial unicompartmental osteoarthritis. On radiographic assessment, the navigation group showed better results than the conventional group in both the mechanical axis and the coordinate of the weight-bearing line on a full-length standing anteroposterior radiograph (3.9°xa0±xa01.0° vs. 2.7°xa0±xa02.2° of valgus, Pxa0<xa00.01), (62.3xa0±xa02.9% vs. 58.7xa0±xa06.6% coordinate at the tibial plateau, Pxa0<xa00.01). There was no significant difference in the alteration of tibial slope between the two groups. On clinical assessment, the navigation group showed better results in both the mean Hospital for Special Surgery knee score (84xa0±xa08 vs. 79xa0±xa07, Pxa0<xa00.01) and the mean Lysholm knee score (85xa0±xa06 vs. 83xa0±xa05, Pxa0<xa00.05). There was no significant difference in operation times between the two groups. Kinematic navigation-guided high tibial osteotomy is a reproducible and reliable procedure compared to conventional high tibial osteotomy.

Effects of Beach-Chair Position and Induced Hypotension on Cerebral Oxygen Saturation in Patients Undergoing Arthroscopic Shoulder Surgery

PURPOSEnWe investigated the effects of the beach-chair position and induced hypotension on regional cerebral oxygen saturation (rSO(2)) in patients undergoing arthroscopic shoulder surgery by using near-infrared spectroscopy.nnnMETHODSnTwenty-eight patients scheduled for arthroscopic shoulder surgery were enrolled prospectively. After induction of anesthesia, mechanical ventilation was controlled to maintain Paco(2) at 35 to 40 mm Hg. Anesthesia was maintained with sevoflurane and remifentanil. After radial artery cannulation, mean arterial pressure (MAP) was measured at the external auditory meatus level and maintained between 60 and 65 mm Hg. The rSO(2) was measured by use of near-infrared spectroscopy. MAP and rSO(2) were recorded at the following times: before induction (T(0)), immediately after induction (T(1) [baseline]), after beach-chair position (T(2)), immediately after induced hypotension (T(3)), 1 hour after induced hypotension (T(4)), and after supine position at the end of surgery (T(5)). Cerebral desaturation was defined as a reduction in rSO(2) to less than 80% of baseline value for 15 seconds or greater.nnnRESULTSnA total of 27 patients were evaluated until the end of this study. The MAP at T(2) was significantly lower than that at T(1). The MAP values at T(3) and T(4) were significantly lower than those at T(1) and T(2). The rSO(2) at T(2) was significantly lower than that at T(1). Unlike the pattern of change in the MAP, there was no additional decrease in rSO(2) at T(3) and T(4). There were 2 patients who had an episode of cerebral desaturation.nnnCONCLUSIONSnThe beach-chair position combined with induced hypotension significantly decreases rSO(2) in patients undergoing shoulder arthroscopic surgery under general anesthesia.nnnLEVEL OF EVIDENCEnLevel IV, study of nonconsecutive patients without consistently applied reference gold standard.

Anterolateral Transtibial Posterior Cruciate Ligament Reconstruction Combined With Anatomical Reconstruction of Posterolateral Corner Insufficiency Comparison of Single-Bundle Versus Double-Bundle Posterior Cruciate Ligament Reconstruction Over a 2- to 6-Year Follow-Up

Background: There is a paucity of clinical studies comparing single- and double-bundle posterior cruciate ligament (PCL) reconstruction combined with a posterolateral corner reconstruction. Purpose: To compare the clinical outcomes of single- and double-bundle transtibial PCL reconstruction combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. Study Design: Cohort study; Level of evidence 3. Methods: The study population consisted of 42 patients for whom a minimum of 2 years of follow-up data were available. The authors compared the clinical outcomes of 2 surgical techniques: a single-bundle technique (23 patients) and a double-bundle technique (19 patients), each combined with reconstruction of the lateral collateral ligament and popliteus tendon for posterolateral corner insufficiency. Results: There was no significant difference between the single- and double-bundle groups in mean side-to-side difference of posterior translation as measured with Telos stress radiography (4.2 ± 1.7 vs 3.9 ± 1.6 mm; P = .628). Rates of residual increased laxity greater than 5 mm were 22% in the single-bundle group and 21% in the double-bundle group. Regarding posterolateral rotatory instability, there were no differences between the 2 groups in mean side-to-side difference in the dial test (5.3° ± 2.7° vs 5.1° ± 2.4° at 30° of flexion [P = .800]; 6.7° ± 2.7° vs 6.7° ± 2.4° at 90° of flexion [P = .917]) or in varus stress radiography (1.2 ± 1.2 vs 1.3 ± 1.4 mm; P = .722). The Lysholm knee scores were 85.7 ± 7.6 in the single-bundle group and 87.7 ± 7.3 in the double-bundle group, and there was no significant difference between them (P = .392). There was also no difference between the groups in International Knee Documentation Committee knee score (P = .969); from this, the rates of abnormal and severely abnormal were 30% in the single-bundle group and 26% in the double-bundle group. Conclusion: In this series, double-bundle PCL reconstruction combined with posterolateral corner reconstruction did not appear to have advantages over single-bundle PCL reconstruction combined with posterolateral corner reconstruction with respect to the clinical outcomes or posterior knee stability.

Effects of arthroscopic meniscectomy on the long-term prognosis for the discoid lateral meniscus

This study compared the long-term clinical and radiological outcomes, according to the extent of arthroscopic meniscectomy, of complete and incomplete types of the discoid lateral meniscus. A total of 125 discoid menisci (74 complete and 51 incomplete types) without significant cartilage erosion at the time of surgery were included. The extent of meniscectomy was decided along with tear patterns and the stability of the discoid meniscus. Both clinical and radiological results were evaluated after total or partial meniscectomy. In the complete type of discoid meniscus with less than 5xa0years of follow-up, the total meniscectomy group showed better clinical results than the partial meniscectomy group. However, with over 5xa0years of follow-up, there were no differences between the two groups. In the radiological results, there was no significant difference between the two groups during the first 5xa0years after operation. However, with more than 5xa0years of follow-up, the partial meniscectomy group showed better results than the total meniscectomy group. In the incomplete-type discoid meniscus, clinical results were better in the partial meniscectomy group regardless of the follow-up periods. In the radiological results, the partial meniscectomy group showed better results for only more than 5xa0years of follow-up. The long-term prognosis after arthroscopic meniscectomy for the torn discoid lateral meniscus was related to the volume of the meniscus removed.

Does Severity or Specific Joint Laxity Influence Clinical Outcomes of Anterior Cruciate Ligament Reconstruction

It generally is believed generalized joint laxity is one of the risk factors for failure of anterior cruciate ligament (ACL) reconstruction. However, no consensus exists regarding whether adverse effects on ACL reconstruction are attributable to joint-specific laxity or are related to the severity of generalized joint laxity. We therefore asked whether knee stability and functional outcomes would be related to joint-specific laxity and would differ according to the severity of generalized joint laxity. The Beighton and Horan criteria were used to assess joint laxity in 272 subjects. All elements are added to give an overall joint laxity score ranging from 0 to 5. Knee translation did not increase in proportion to the severity of the generalized joint laxity. Patients with scores less than 4 showed similar knee stability. When all variables, including the severity of generalized joint laxity, were considered, only hyperextension of the knee independently predicted knee stability and function. In patients with knee hyperextension, a bone-patellar tendon-bone autograft provided superior stability and function compared with a hamstring tendon autograft. Our data suggest knee hyperextension predicts postoperative stability and function regardless whether patients have severe generalized joint laxity.Level of Evidence: Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic Repair of Concomitant Type II SLAP Lesions in Large to Massive Rotator Cuff Tears Comparison With Biceps Tenotomy

Background: There are no studies examining superior labrum anterior and posterior (SLAP) repair combined with repair of large to massive rotator cuff tears, and it is unclear whether a combined SLAP repair would lead to better outcomes than biceps tenotomy. Hypothesis: Tenotomy and rotator cuff repair would lead to better outcomes compared with those of combined SLAP and rotator cuff repair. Study Design: Cohort study; Level of evidence, 2. Methods: Our study population consisted of 36 patients who had undergone either combined SLAP and rotator cuff repair (when the biceps was too healthy to cut; group R = 16 patients) or tenotomy and rotator cuff repair (when any fraying or partial tear existed in the biceps tendon; group T = 20 patients) for concomitant type II SLAP lesions and large to massive rotator cuff tears. The cuff repair was performed in a single row for both groups. Outcomes were assessed by comparing range of motion as well as Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores between the 2 groups. Results: At the 2-year follow-up, both groups demonstrated significant improvements in functional shoulder scores and range of motion. However, group T had better SST scores (group T, 9.3 ± 1.6; group R, 7.8 ± 1.9; P = .012), ASES scores (group T, 88.6 ± 8.9; group R, 80.4 ±8.9; P = .009), UCLA scores (group T, 29.6 ± 3.0; group R, 26.0 ± 4.2; P = .007), and forward flexion (group T, 145.9° ± 13.0°; group R, 132.5° ± 15.3°; P = .008). The mean tear size and the degree of preoperative muscle atrophy and fatty infiltration on magnetic resonance imaging were similar between the groups. Conclusion: For patients with concomitant type II SLAP lesions and large to massive rotator cuff tears, the outcomes of simultaneous arthroscopic SLAP and rotator cuff repair were inferior to those of arthroscopic biceps tenotomy and cuff repair in terms of functional shoulder scores and range of motion. Biceps tenotomy and rotator cuff repair may be a more reliable method to address concomitant type II SLAP lesions and large to massive rotator cuff tears in patients, although a randomized controlled trial is needed to confirm the results.

Arthroscopic repair of anterosuperior rotator cuff tears: in-continuity technique vs. disruption of subscapularis-supraspinatus tear margin: comparison of clinical outcomes and structural integrity between the two techniques.

Fig. E-1B Fig. E-1A The thickened medial sling of the biceps (T) on the superolateral corner of the subscapularis (S) in the right shoulder, viewed from the posterior portal (intra-articular approach). B = medially subluxated biceps tendon. Fig. E-1B Schematic drawing of related structures. S = subscapularis, T = thickened medial sling of the biceps, B = medially subluxated biceps tendon, G = glenoid, and H = humeral head.BACKGROUNDnThe purpose of this study was to compare the clinical outcomes and structural integrity after two techniques of arthroscopic anterosuperior rotator cuff repair: in continuity and disruption of the tear margin.nnnMETHODSnThis study included fifty-nine patients who underwent arthroscopic repair of an anterosuperior rotator cuff tear that was done either by disrupting the margin between the subscapularis and supraspinatus tears (Group A) or by performing the repair in continuity without disrupting the margin (Group B). Clinical outcomes were assessed on the basis of a visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California at Los Angeles (UCLA) shoulder score, and active range of motion of the shoulder. Subscapularis strength was assessed with use of the modified belly-press test. Magnetic resonance arthrography (MRA) or computed tomographic arthrography (CTA) was performed at six months after surgery to assess the structural integrity of the repair.nnnRESULTSnAt the two-year follow-up evaluation, VAS pain scores, SSVs, ASES scores, UCLA shoulder scores, subscapularis strength, and active range of motion improved significantly in both groups compared with preoperatively (p < 0.001). There were no significant differences between groups for any of these follow-up measurements. On follow-up MRA or CTA, the overall retear rate did not differ significantly different between Group A (22%; five of twenty-three) and Group B (19%; six of thirty-two).nnnCONCLUSIONSnIn conclusion, in patients treated with arthroscopic repair of anterosuperior full-thickness subscapularis and supraspinatus tears of the rotator cuff, the technique of in-continuity repair did not produce better clinical outcomes or structural integrity than the technique involving disruption of the tear margin. If the muscle in an anterosuperior rotator cuff tear is of good quality, it does not appear to matter whether the tear margin between the subscapularis and supraspinatus is preserved or disrupted.

Clinical Comparison of Conventional and Remnant-Preserving Transtibial Single-Bundle Posterior Cruciate Ligament Reconstruction Combined With Posterolateral Corner Reconstruction

Background: Despite persistent continuity of the attenuated posterior cruciate ligament (PCL) in most PCL insufficient knees, few reconstruction techniques that preserve the PCL remnant have been presented. Furthermore, data regarding the clinical outcomes of these approaches are even more limited, and the clinical validity of remnant preservation has not yet been established. Purpose: To compare the clinical outcomes of transtibial PCL reconstructions that incorporate remnant preservation with conventional techniques (in which remnant preservation is not performed). Study Design: Cohort study; Level of evidence 3. Methods: The authors retrospectively evaluated 53 cases of PCL reconstruction with simultaneous posterolateral corner reconstruction. Of these, 23 were performed with a conventional approach without remnant preservation (group C), and 30 incorporated a remnant-preserving technique (group R). In all cases, the minimum follow-up period was 24 months. Each patient was evaluated using the following variables: Lysholm knee score, Tegner activity scale, return to activity, International Knee Documentation Committee (IKDC) knee score and grade, and degree of posterior laxity on stress radiograph. Results: The mean side-to-side differences in posterior tibial translation, Lysholm knee score, return to activity, and objective IKDC grade were similar between group C (4.4 ± 3.0 mm; 82.6 ± 11.0; 21.7%; A and B: 73.9%) and group R (4.1 ± 3.4 mm; 84.1 ± 10.7; 26.7%; A and B: 83.3%; P = .761, .611, .679, .755). However, the final Tegner activity scale, near–return to activity, and subjective IKDC score differed significantly between group C (3.5 ± 0.8; 43.5%; 64.5 ± 8.8) and group R (4.3 ± 1.1; 73.3%; 70.6 ± 7.9; P = .007, .028, .012). Conclusion: Techniques combining remnant-preserving transtibial single-bundle PCL reconstruction with posterolateral corner reconstruction resulted in somewhat better activity-related outcomes compared with those of approaches without remnant preservation. However, incorporation of remnant preservation does not appear to provide increased posterior stability or result in clinically superior outcomes versus those of techniques without remnant preservation.