Does Additional Biceps Augmentation Improve Rotator Cuff Healing and Clinical Outcomes in Anterior L-Shaped Rotator Cuff Tears? Clinical Comparisons With Arthroscopic Partial Repair.

BACKGROUND: The repair of anterior L-shaped tears is usually difficult because of the lack of anterior rotator cuff tendon to cover the footprint. The biceps tendon is usually exposed from the retracted anterolateral corner of the torn tendon and can be easily used to augment rotator cuff repair. Hypothesis/Purpose: This study compared the clinical outcomes of the biceps augmentation technique with those of partial tendon repair for the arthroscopic treatment of large anterior L-shaped rotator cuff tears to evaluate the role of additional biceps augmentation in tendon healing. We hypothesized that the biceps augmentation technique would lead to a lower rotator cuff tendon retear rate and provide satisfactory functional outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This study included 64 patients with anterior L-shaped rotator cuff tears who underwent arthroscopic repair. Patients were divided into 2 groups: group A (31 patients) underwent repair of an anterior L-shaped tear combined with biceps augmentation, and group B (33 patients) had a partially repaired tendon whose footprint was exposed after repair without undue tension on the retracted tendon. Clinical evaluations were performed using the American Shoulder and Elbow Surgeons (ASES) score, Constant score, muscle strength, visual analog scale for pain, and patient satisfaction. Magnetic resonance imaging (MRI) was performed for tendon integrity at 6 months postoperatively. RESULTS: The mean period of follow-up was 29.1 ± 3.5 months (range, 24-40 months). The mean ASES and Constant scores significantly improved from 52.8 ± 10.6 and 43.2 ± 9.9 preoperatively to 88.2 ± 6.9 and 86.8 ± 6.2 at final follow-up in group A ( P < .001) and from 53.0 ± 11.8 and 44.3 ± 11.3 preoperatively to 87.4 ± 7.2 and 87.9 ± 7.3 at final follow-up in group B ( P < .001). Overall muscle strength (given as % of the other side's strength) significantly increased from preoperatively to final follow-up in group A (forward flexion [FF]: 62.0 ± 8.2 to 89.0 ± 8.6; external rotation [ER]: 57.5 ± 9.9 to 86.8 ± 9.3; internal rotation [IR]: 68.1 ± 10.8 to 88.1 ± 8.4; P < .001) and group B (FF: 59.9 ± 9.6 to 87.7 ± 9.0; ER: 58.6 ± 9.3 to 86.2 ± 7.5; IR: 70.0 ± 9.3 to 87.0 ± 8.4; P < .001). Twenty-one patients (67.7%) in group A and 20 patients (60.6%) in group B showed a healed rotator cuff tendon on postoperative MRI. The retear rate between the 2 groups showed no significant difference ( P = .552). Regarding clinical outcomes, both groups had no significant difference in the ASES score ( P = .901), Constant score ( P = .742), and muscle strength. CONCLUSION: There was no significant difference in the clinical outcomes and retear rate of anterior L-shaped tears between biceps augmentation and partial tendon repair. Additional biceps augmentation proved to have no enhancement in tendon healing. A precise method such as only partial tendon repair for reducing the footprint exposure without undue tension may be considered as one of the treatment options for large anterior L-shaped rotator cuff tears.

Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography.

PURPOSE: In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45 years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography. METHODS: Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS). RESULTS: Pain had significantly improved from 5.2 ± 2.2 to 1.0 ± 1.1 (p < 0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4 months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85 %) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p < 0.001). CONCLUSIONS: Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment. CLINICAL RELEVANCE: Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports. LEVEL OF EVIDENCE: IV.

Comparison of Intra-articular Findings and Clinical Features Between Patients With Symptomatic Anterior Instability After Recurrent Shoulder Subluxation and Dislocation.

PURPOSE: The purpose of this study was to compare the prevalence of concomitant intra-articular pathologies and clinical manifestations after arthroscopic stabilization between patients with symptomatic anterior instabilities following recurrent shoulder subluxations and dislocations. METHODS: Among patients who underwent arthroscopic stabilization, 28 patients who experienced shoulder subluxations (subluxation group, 26.7 ± 1.8 years) and 84 who had shoulder dislocations (dislocation group, 25.9 ± 2.2 years) were included. Recurrent shoulder subluxation was defined as instability caused by repeated injuries without a history of frank dislocation or manual reduction maneuver. Common inclusion criteria were positive clinical test of anterior instability and Bankart lesion with less than 25% of glenoid bone loss. The pathoanatomies in radiologic and arthroscopic examinations and postoperative clinical outcomes were compared. RESULTS: The number of instability events was significantly fewer in the subluxation group (5.0 ± 1.3) than in the dislocation group (12.1 ± 2.0; P = .01). The pathologic findings in preoperative radiology demonstrated no intergroup differences, except for the prevalence of Hill-Sachs lesions. In the subluxation group, the Hill-Sachs lesions were significantly less commonly detected with computed tomography and magnetic resonance arthrography (28.6%) than in the dislocation group (63.1%, 60.7%; P = .001, P = .003, respectively). There were no significant differences in arthroscopic findings in both groups including superior labral anterior to posterior lesion (subluxation group, 39.3%; dislocation group, 45.2%), anterior labral periosteal sleeve avulsion lesion (21.4%, 29.8%), and bony Bankart lesion (21.4%, 28.6%). Preoperative and postoperative functional outcomes also did not differ between the groups. There was no statistical difference in terms of the rate of revision or postoperative subjective instability. CONCLUSIONS: Patients who had anterior instability after recurrent shoulder subluxation demonstrated a similar rate of concomitant intra-articular pathologies requiring the same level of management as recurrent shoulder dislocation. Recurrent shoulder subluxation also displayed similar functional outcomes and failure rate after arthroscopic stabilization procedures as recurrent dislocation. Thus, the clinical importance of symptomatic recurrent subluxation should be considered comparable with that of recurrent dislocation. LEVEL OF EVIDENCE: Level IV, case control study.

Intra-articular lesions and their relation to arthroscopic stabilization failure in young patients with first-time and recurrent shoulder dislocations.

BACKGROUND: This study aimed to compare the frequency of intra-articular lesions between young patients with first-time shoulder dislocations and those with recurrent shoulder dislocations and to assess the correlation between intra-articular lesions and failure of arthroscopic stabilization. METHODS: The study enrolled 33 patients who underwent arthroscopic Bankart repair after first-time shoulder dislocation before the age of 30 years. There were 89 age-matched patients who were treated arthroscopically for recurrent dislocation included as a control group. RESULTS: Among intra-articular pathologic findings, anterior glenoid erosion (P = .043) and anterior labral periosteal sleeve avulsion lesions (P = .048) were found more frequently in the recurrent dislocation group. There was no statistically significant difference between the 2 groups in American Shoulder and Elbow Surgeons (P = .675) and Rowe (P = .132) scores at the last follow-up. However, there was a significant difference in the failure rate after operation between the 2 groups (P = .039). In the first-time dislocation group, 1 patient had redislocation and none showed positive apprehension. In the recurrent dislocation group, 6 patients had redislocation and 10 patients had positive apprehension. Eight of 10 patients who showed positive apprehension had either anterior labral periosteal sleeve avulsion lesions or anterior glenoid erosion. The patients' satisfaction with daily activities was significantly better in the first-time dislocation group (93.0 ± 5.2) than in the recurrent dislocation group (82.7 ± 7.2; P < .001). CONCLUSIONS: Primary surgical treatment for first-time traumatic anterior shoulder dislocation provided satisfactory functional outcomes and improved quality of life. Primary arthroscopic stabilization can be considered one of the treatment options in patients younger than 30 years with first-time shoulder dislocation to prevent further intra-articular injuries that may contribute to recurrence.

Efficacy of a Subacromial Corticosteroid Injection for Persistent Pain After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase. PURPOSE: To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively. RESULTS: In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04). CONCLUSION: A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.

Recovery of Muscle Strength After Intact Arthroscopic Rotator Cuff Repair According to Preoperative Rotator Cuff Tear Size.

BACKGROUND: The recovery of muscle strength after arthroscopic rotator cuff repair based on the preoperative tear size has not yet been well described. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the recovery period of muscle strength by a serial assessment of isometric strength after arthroscopic rotator cuff repair based on the preoperative tear size. The hypothesis was that muscle strength in patients with small and medium tears would recover faster than that in those with large-to-massive tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 164 patients who underwent arthroscopic rotator cuff repair were included. Isometric strength in forward flexion (FF), internal rotation (IR), and external rotation (ER) was evaluated preoperatively and at 6, 12, 18, and 24 months after surgery. Preoperative magnetic resonance imaging scans were assessed to evaluate the quality of the rotator cuff muscle, including fatty infiltration, occupation ratio, and tangent sign. Patient satisfaction as well as visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES), and Constant scores were assessed at every follow-up. RESULTS: Muscle strength demonstrated the slowest recovery in pain relief and the restoration of shoulder function. To reach the strength of the uninjured contralateral shoulder in all 3 planes of motion, recovery took 6 months in patients with small tears and 18 months in patients with medium tears. Patients with large-to-massive tears showed continuous improvement in strength up to 18 months; however, they did not reach the strength of the contralateral shoulder at final follow-up. At final follow-up, mean strength in FF, IR, and ER was 113.0%, 118.0%, and 112.6% of the contralateral shoulder in patients with small tears, respectively; 105.0%, 112.1%, and 102.6% in patients with medium tears, respectively; and 87.6%, 89.5%, and 85.2% in patients with large-to-massive tears, respectively. Muscle strength in any direction did not significantly correlate with postoperative patient satisfaction (P = .374, .515, and .692 for FF, IR, and ER, respectively), whereas it highly correlated with preoperative quality of the muscle. CONCLUSION: The recovery of muscle strength after arthroscopic repair was poorly correlated with patient satisfaction. This study recommends that regardless of pain relief and improved shoulder function, patients with larger than medium tears should be encouraged to continue with rehabilitation for the maximal restoration of muscle strength beyond 1 year postoperatively.

The effect of defect orientation and size on glenohumeral instability: a biomechanical analysis.

PURPOSE: The purpose of this study was to determine the relationship between bony stability and percentage of anterior glenoid bone loss and the effect of bone loss orientation. METHODS: Twelve cadaveric shoulders were studied. Glenoid bone defects were simulated in two different osteotomy angles: 0° and 45° to the superoinferior (SI) axis of the glenoid. The force and displacement required for dislocation were measured under two compressive forces of 40 and 60N. Testing was performed for the intact glenoid and glenoid defects of 2, 4, 6, 8, and 10 mm from the anterior margin. RESULTS: The maximum force for dislocation with the 2-mm glenoid defect was significantly decreased compared with intact glenoid (p = 0.01), and this force also significantly decreased with each increase in defect size (p < 0.05). The dislocation force for 45° osteotomy was significantly higher than that for 0° osteotomy for all defect widths up to 8 mm with 40N compression and 6 mm with 60N compression (p < 0.001). The displacement at dislocation did not significantly decrease until the 8-mm defect with the 45° osteotomy but significantly decreased with the 4-mm defect with the 0° osteotomy. The required force for dislocation with 60N compression was significantly higher than that with 40N compression for all osteotomy sizes and orientations. CONCLUSIONS: The decrease in stability even with glenoid bone loss as small as 2 mm or 7.5 % of the glenoid width suggests that bony restoration is recommended whenever any bone loss exists. Bone defects parallel to SI axis may be more susceptible to recurrent instability, and shoulder muscle strengthening exercises may increase glenohumeral compressive force and thus improve glenohumeral stability. Bony restoration is recommended whenever bone loss exists even with small bone fragments particularly those in line with the superior-inferior axis of the glenoid.

Use of plate fixation without coracoclavicular ligament augmentation for unstable distal clavicle fractures.

BACKGROUND: The purpose of this study was to evaluate the clinical and radiologic outcomes of unstable distal clavicle fractures treated with anatomic plate fixation without coracoclavicular ligament augmentation and to compare the outcome of Neer type IIA with that of type IIB. METHODS: Twenty-five patients with unstable distal clavicle fractures who underwent anatomic plate fixation without coracoclavicular ligament augmentation were enrolled prospectively, including 9 patients of Neer type IIA and 16 patients of Neer type IIB. Clinical outcomes were evaluated using Constant and University of California-Los Angeles (UCLA) scores. Coracoclavicular distance was measured on plain radiographs. RESULTS: Bone union was achieved in all patients. Satisfactory clinical and radiologic outcomes were obtained regardless of fracture type. After operation, the mean coracoclavicular distance on the injured side was increased by 10% compared with the uninjured side. However, between the patients who showed an increased coracoclavicular distance >10% (Constant score, 89.4 ± 3.7; UCLA score, 32.6 ± 3) and the patients with increased coracoclavicular distance <10% of the uninjured side (Constant score, 88.7 ± 3.6; UCLA score, 31.9 ± 3), there was no statistically significant difference in clinical outcomes of Constant score (P = .934) and UCLA score (P = .598). CONCLUSION: In unstable distal clavicle fractures, precontoured anatomic plate fixation without coracoclavicular ligament augmentation showed satisfactory clinical outcomes and high union rates even with a small lateral fragment. Patients who had increased coracoclavicular distance also demonstrated satisfactory shoulder functional outcomes regardless of the fracture type. Therefore, anatomic plate fixation without additional coracoclavicular ligament augmentation can be considered one of the treatment options for unstable distal clavicle fracture. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

The Correlation of Tunnel Position, Orientation and Tunnel Enlargement in Outside-in Single-Bundle Anterior Cruciate Ligament Reconstruction.

PURPOSE: Tunnel widening after anterior cruciate ligament (ACL) reconstruction is a frequently described phenomenon. The possible etiology is multi-factorial with some mechanical and biological factors. Among those, we intended to determine the relation between the location and orientation of the femoral tunnel and the femoral tunnel enlargement after outside-in single-bundle ACL reconstruction. MATERIALS AND METHODS: A retrospective study including 42 patients who received single-bundle ACL reconstruction with the outside-in technique was conducted. Femoral and tibial tunnel locations were evaluated with the quadrant method and bird's-eye view using volume-rendering computed tomography. The angle and diameter of bone tunnel and the degree of tunnel enlargement were evaluated using standard radiographs. RESULTS: The degree of femoral tunnel enlargements were 42% and 36% on the anteroposterior (AP) and lateral radiographs, respectively, and the degree of tibial tunnel enlargements were 22% and 23%, respectively. Shallower location of the femoral tunnel was significantly correlated with greater femoral tunnel enlargement on the AP radiograph (r=0.998, p=0.004) and the lateral radiograph (r=0.72, p=0.005) as was the higher location of the femoral tunnel on the AP radiograph (r=-0.47, p=0.01) and the lateral radiograph (r=-0.36, p=0.009) at 12 months after surgery. CONCLUSIONS: This study revealed that more anterior and higher location and more horizontal orientation of the femoral tunnel in coronal plane could result in widening of the femoral tunnel in outside-in single-bundle ACL reconstruction.