The effect of age on the outcomes of arthroscopic repair of type II superior labral anterior and posterior lesions.

BACKGROUND: The majority of clinical outcome studies of type II superior labral anterior and posterior (SLAP) repair assess patients younger than age 40. Biceps tenotomy or tenodesis is often recommended for patients older than age 40 with superior labrum-biceps complex injury. HYPOTHESIS: There is no difference in patient clinical outcomes comparing arthroscopic type II SLAP repair in patients younger or older than age 40. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Fifty-two patients stratified to groups younger than age 40 (21 patients; average age, 32.9 years) and older than age 40 (31 patients; average age, 55.1 years) were identified at a minimum 2-year follow-up (average, 28 months) after type II SLAP repair by a single surgeon using suture anchors. Outcome scores included American Shoulder and Elbow Society scores (ASES), Short Form-12 scores, Simple Shoulder Test scores, and visual analog pain scale. RESULTS: At follow-up, there was no statistical difference in visual analog pain scale (P = .16), ASES scores (P = .07), Simple Shoulder Test scores (P =.41), Short Form-12 testing, or range of motion testing. Patients older than age 40 noted their shoulder to be 87% of normal; 26 of 31 (84%) were satisfied to completely satisfied, and 28 of 31 (90%) would have the surgery again. Patients younger than 40 noted their shoulder to be approximately 89% of normal; 20 of 21 (95%) were satisfied to completely satisfied, and 18 of 21 (86%) would have the same procedure performed again. CONCLUSION: Our findings support that arthroscopic treatment of isolated type II SLAP repair using suture anchors can yield good to excellent results in patients older and younger than age 40. We found no statistically significant difference in patient outcome scores, satisfaction levels, or willingness to have the same procedure again when comparing arthroscopic SLAP repair in patients younger or older than age 40.

Cross-sectional analysis of the iliopsoas tendon and its relationship to the acetabular labrum: an anatomic study.

BACKGROUND: Hip pain in patients with normal bony anatomy and anterior labral injury may be related to compression of the iliopsoas tendon across the anterior capsulolabral complex. No attempts to characterize the 3-dimensional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum have been reported to date. HYPOTHESIS: The iliopsoas tendon directly overlies the capsulolabral complex. Contribution of the muscle belly and tendon to the overall circumference at the level of the labrum is approximately the same. STUDY DESIGN: Descriptive laboratory study. MATERIALS AND METHODS: Eight hip joints were dissected and cross-sectional measurements of the iliopsoas muscle-tendon complex were performed using digital calipers and image analysis software. RESULTS: The iliopsoas tendon in all specimens was located directly anterior to the anterosuperior capsulolabral complex at the 2 to 3 o'clock position. The overall length of the iliopsoas tendon from the lesser trochanter to the acetabular labrum was 75.4 +/- 0.9 mm. The circumference of the iliopsoas tendon at the lesser trochanter was 25.5 +/- 2.6 mm, the iliopsoas tendon at the level of the labrum was 28.4 +/- 2.8 mm, and the iliopsoas tendon-muscle belly complex at the level of the labrum was 63.8 +/- 7.4 mm. At the level of the labrum, the iliopsoas is composed of 44.5% tendon and 55.5% muscle belly. CONCLUSION: The close anatomic relationship of the iliopsoas tendon to the anterior capsulolabral complex suggests that iliopsoas pathologic changes at this level may lead to labral injury. Additionally, these data suggest that at the level of the labrum, 45% of the tendon-muscle belly complex should be released to release the entire tendinous portion. CLINICAL RELEVANCE: Knowledge of the cross-sectional anatomy of the iliopsoas tendon and its relationship to the acetabular labrum will better assist surgeons in treating lesions associated with iliopsoas injury.

Reconstruction of a chronic distal biceps tendon rupture 4 years after initial injury.

Rupture of the distal biceps insertion can produce, on average, a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow. In acute biceps tendon ruptures in which a patient will not tolerate resulting functional deficits, anatomical reinsertion of the biceps tendon into the radial tuberosity is usually recommended. The various surgical techniques that have been described for anatomical repair of distal biceps rupture include passage of the tendon stump through a transosseous tunnel and use of suture anchors, interference screws, and EndoButtons (Smith & Nephew, Andover, Mass). Reported results for these techniques have mostly been excellent with respect to restoration of functionality. Chronic cases, however, may involve retraction of the native tendon and extensive scar formation, which preclude anatomical repair. In these situations, one of several described reconstructive techniques, including use of semitendinosus autograft and Achilles tendon allograft, may be needed to reestablish acceptable function. Delayed (< or = 18 months) reconstruction of chronic ruptures, using allograft soft-tissue constructs, has been described in the literature. We present the case of a chronic distal biceps rupture reconstructed 4 years after initial injury using a single-incision technique with free semitendinosus autograft and EndoButton fixation.

Arthroscopic treatment of multidirectional shoulder instability with minimum 270 degrees labral repair: minimum 2-year follow-up.

PURPOSE: The purpose of this study was to analyze results of arthroscopic stabilization with labral repair in a subset of patients with multidirectional shoulder instability and frank labral tear. METHODS: A review of 13 patients (10 male and 3 female; mean age, 27.2 years) with multidirectional instability involving a labral tear of 270 degrees or greater requiring arthroscopic labral repair was performed at a mean follow-up of 56 months (range, 29 to 72 months). All patients were evaluated by use of the Short Form 12, Western Ontario Shoulder Instability Index, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and visual analog pain scale. Physical examination included range of motion, strength testing, and stability testing. RESULTS: Of the 13 patients, 2 (15%) had recurrent instability after repair (subluxation or dislocation). Of the patients, 9 (69%) were completely satisfied, 2 (15%) were mostly satisfied, and 2 (15%) were completely unsatisfied. At final follow-up, the median scores were as follows: Western Ontario Shoulder Instability Index, 471; American Shoulder and Elbow Surgeons score, 96.7; Simple Shoulder Test score, 12; visual analog pain scale, 0; and Short Form 12 mental component/physical component, 57/44. There were no differences in range of motion compared with the opposite extremity. Cybex strength testing (Lumex, Ronkonkoma, NY) did show a statistically different difference in forward elevation (P < .005). There were no complications, and no patient has undergone reoperation. CONCLUSIONS: Arthroscopic stabilization with labral repair in patients with multidirectional instability and a minimum 270 degrees labral pathology provided good results (85%) in terms of pain relief and clinical stability at a minimum 2-year follow-up.

The direct posterior approach to the knee: surgical and anatomic approach.

The direct posterior surgical approach to the knee provides broad exposure of posterior neurovascular structures, the posterior aspect of the femoral condyles and tibial plateau, the posterior joint capsule, and a variety of additional soft-tissue structures including the popliteus, hamstring insertions, and origins of the gastrocnemius. Reported indications for this approach include tumor resection, posterior synovectomy, open reduction and internal fixation of posterior tibial plateau shear fractures, fixation of bone avulsions associated with a posterior cruciate ligament (PCL) injury, repair of posterior vascular injuries, and more recently, posterior inlay PCL reconstructions. However, use of this approach is uncommon and as a result, orthopedic residents and practicing orthopedic surgeons may not be familiar with the appropriate surgical anatomy. This report demonstrates in stepwise fashion the surgical approach and relevant anatomy through a detailed series of fresh cadaveric dissections.

The posterolateral corner of the knee: anatomic dissection and surgical approach.

The surgical anatomy and biomechanical role of the posterolateral corner of the knee has received significant attention in recent years. Nevertheless, because of the relative infrequency with which injuries to this area are treated operatively, the surgical approach to this area of the knee may be unfamiliar to many residents and practicing orthopedic surgeons. Accurate knowledge of the appropriate anatomy, planes of dissection, and surgical approach is vital to the safe access of these structures for purposes of repair or reconstruction. This article describes the step-by-step anatomic approach to the posterolateral corner of the knee using paired cadaveric images, with emphasis on the relevant surgical anatomy.