Ultrasound Guided Arthroscopic Removal of Calcific Tendonitis: A Minimum of 2-Year Followup.

Background: We have developed a novel technique for managing rotator cuff calcific tendonitis, involving arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance. While we have demonstrated encouraging results at six-month follow-up, the medium-term outcomes and the long-term outcomes of this technique at 2 years or beyond are unknown. The aim of this paper was to determine if this technique was successful in resolving symptoms after two years and beyond. Study Design: Retrospective Cohort Study. Methods: Patients who underwent arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance by a senior surgeon were evaluated using patient-rated pain scores and functional status with the use of the Likert scales and via examiner-rated shoulder range-of-motion and strength at the pre-operative visit, at 1, 6, 12, and 24 weeks post-operatively, and long-term at a mean of 249 weeks after surgery. Results: At a mean follow-up period of 4.8 years (range, 2-10 years), 31 patients (33 shoulders) experienced significant improvement in the severity of pain at rest, with overhead activities, and during sleep compared to their pre-operative presentation (p < 0.001). The patient experienced less frequent pain during activities and sleep, and a decreased frequency of extreme pain (p < 0.001). Passive range of abduction (p = 0.003), forward flexion (p < 0.001), and supraspinatus strength (p = 0.018) improved compared to the presurgical presentation. Out of 27 patients, 24 patients (89%) had complete resolution of calcific tendonitis, and 26 patients (96%) had an intact rotator cuff. Conclusion: Arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance was very effective. Patients had significant pain relief, improved range of motion, and a reduction in stiffness at a mean post-operative period of 4.8 years. Patients had a significant reduction in residual calcification, and rotator cuff integrity was largely preserved by long-term follow-up. What is known about this subject: Calcific tendonitis of the rotator cuff is one of the most painful and debilitating disorders of the shoulder. This condition is characterized by the deposition of calcium-phosphate crystals within the rotator cuff tendons. Arthroscopic debridement and excision of rotator cuff calcifications have proven to be efficacious treatments with regards to clinical and functional outcomes in the short and medium term. Identifying the calcific lesion intra-operatively, however, can prove to be challenging. Furthermore, inadequate excision of the calcific deposit has been shown to have poorer clinical outcomes. We designed a technique that utilizes the assistance of ultrasound to guide a localization-biopsy wire to the calcific lesion. This technique aids in precisely identifying the location of the lesion intra-operatively to optimize accuracy in removing the maximum amount of calcific deposit possible. A short-term follow-up study by us has demonstrated successful outcomes with regards to the return of function and relief of pain. However, there have been no studies evaluating the effectiveness of this particular technique beyond six months. What this study adds to current knowledge: At a mean of 4.8 years, arthroscopic debridement of calcific tendonitis, using our technique, was successful in relieving the severity and frequency of pain with overhead activities, pain at rest, and pain during sleep, as well as improving range of motion.

Can handheld dynamometry predict rotator cuff tear size? A study in 2100 consecutive patients.

BACKGROUND: This study aimed to determine whether handheld dynamometry measurements could predict rotator cuff tear size in patients who required surgical treatment of their shoulder pathology. METHODS: Handheld dynamometer readings were collected prior to surgery and analyzed retrospectively for 2100 consecutive patients. Post hoc, the cohort was divided into patients with rotator cuff tears (n = 1747) and those without rotator cuff tears (n = 353). The tear group was stratified into partial- vs. full-thickness tears and into 4 groups based on tear size area. RESULTS: Patients with partial-thickness tears had greater internal rotation (P = .03), external rotation (P < .001), and supraspinatus (P < .001) strength than patients with full-thickness tears. Patients with tears had lower supraspinatus strength than patients without tears (r = -0.82, P < .001). Patients with a larger tear size had lower values of external rotation (r = -1.46, P < .001) and supraspinatus (r = -1.18, P < .001) strength. A model involving internal rotation and supraspinatus strength could predict the presence of a tear with a sensitivity of 82% and specificity of 29%. The correct prediction rate was 73% overall (82% in tear group and 29% in no-tear group). The following formula was found to predict rotator cuff tear size, showing modest correlation with our raw data (r = 0.25, P < .001): Tear size = 482.8 + (3.9 × Internal rotation strength) + (1.6 × Adduction strength) - (7.2 × External rotation strength) - (2.0 × Supraspinatus strength). CONCLUSIONS: Handheld dynamometer readings could not reliably predict rotator cuff tear size, showing only modest correlation with our raw data. Handheld dynamometry readings could predict the presence of a tear, although tears in the intact cohort were overestimated (a specificity of 29% and negative predictive value of 25%).

Seven-Year Follow-up of Matrix-Induced Autologous Implantation in Talus Articular Defects.

BACKGROUND: Osteochondral lesions of the talus (OLT) are difficult to treat because of the poor intrinsic healing capability of articular cartilage. Matrix-induced autologous chondrocyte implantation (MACI) has been shown to be a reliable method for treating cartilage lesions that fail to respond to traditional microfracture and debridement. The purpose of this study was to assess 7-year clinical follow-up data of this technique and demonstrate midterm success of this implant. METHODS: A prospective investigation of MACI was performed on 10 patients with OLTs who had failed previous arthroscopic treatment. In all, 5 male and 5 female patients were included in the study. Of the 10 patients, 9 were available for 7-year follow-up. Functional and clinical evaluations were done at 7 years postoperatively using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot evaluation and the Short Form Health Survey (SF-36) and compared with preoperative values. RESULTS: SF-36 data at 7 years showed significant improvements in Physical Functioning (P < .01), Lack of Bodily Pain (P < .1), and Social Functioning (P < .001) compared with preoperative data. The mean AOFAS hindfoot scores of the 9 patients at 7 years was 78.3 ± 18.1 (P = .05) compared with their preoperative mean of 61.8 ± 14.3. CONCLUSIONS: MACI provides a stable midterm chondral replacement strategy for osteochondral lesions that fail initial microfracture. LEVELS OF EVIDENCE: Level IV: Prospective case series.

Computed tomography measurements of the lesser metatarsal heads: Anatomic considerations for surgeons performing distal metatarsal osteotomies.

BACKGROUND: The purpose of the current study was to provide a standardized, anatomical description of the lesser metatarsals to assist surgeons when planning distal metatarsal surgery and fixation. METHODS: Eighty CT scans were included for assessment, based on a priori power analysis. Patient age was a mean 52.7±16.6 years (24-83). Metatarsals two through five were assessed in all patients. Three independent observers completed measurements for all metatarsals. Three measurements were made on all metatarsals, including a vertical height and metatarsal head and neck measurements. Statistical analysis was performed (alpha value 0.05). Inter-observer reliability was assessed for all measurements and intra-class correlation (ICC) reported. RESULTS: A sequential decrease in metatarsal measurements was noted from the second to the fifth metatarsal. A mean vertical height measurement of 16.1±1.4mm (range, 13.4-19.4) was recorded for the second metatarsal, decreasing 13.0±1.1mm (range, 10.3-16.1) for fifth. There were no significant differences in metatarsal measurements based on gender in our study. Similar patient and metatarsal variability was seen head and neck measurements. Intraclass correlation coefficients (ICC) for metatarsal measurements were greater than 0.9 [95% CI; 0.936-0.991] correlation, denoting an 'excellent' interobserver reliability. CONCLUSION: This study provides a baseline anatomical description of the distal metatarsals. These findings, including the variation found between patients and between metatarsal two through five, are relevant to surgeons planning and performing distal metatarsal osteotomies.

Relationship Between Age and Rotator Cuff Retear: A Study of 1,600 Consecutive Rotator Cuff Repairs.

BACKGROUND: The prevalence of rotator cuff tears increases with age, and many patients undergo surgical repair. Retears are not uncommon, with rates ranging between 9% and 36% in recent studies, and are a major concern. The aim of this study was to investigate the relationship between patient age and the chance of healing following rotator cuff repair. METHODS: This was a retrospective cohort study of patients who had undergone arthroscopic rotator cuff repair performed by a single surgeon. All patients had an ultrasound performed by a musculoskeletal sonographer 6 months after rotator cuff repair to assess the repair integrity. RESULTS: The cohort of 1,600 patients was normally distributed in terms of age, with a mean age (and standard error of the mean) of 59 ± 0.3 years and a range of 15 to 91 years. The 212 patients (13%) who had a retear at 6 months were also normally distributed in terms of age, with a mean age of 65 ± 0.8 years and a range of 15 to 88 years. The retear rate in patients <50 years old was 5%. This increased to 10% in patients aged 50 to 59 years, 15% in those aged 60 to 69 years, 25% in those aged 70 to 79 years, and 34% in those aged ≥80 years. Multiple logistic regression analysis showed that patient age was an independent factor strongly associated with retears. CONCLUSIONS: The rate of rotator cuff retears is low in patients <50 years of age. The relationship between age and rotator cuff retears is linear in patients 50 to 69 years of age, with an increase of 5% between decades, and increases substantially in patients ≥70 years old. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand.

BACKGROUND: Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. OBJECTIVE: We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. METHODS: Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. RESULTS: Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. CONCLUSION: In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB.

The Relationship Between Intraoperative Tear Dimensions and Postoperative Pain in 1624 Consecutive Arthroscopic Rotator Cuff Repairs.

BACKGROUND: Rotator cuff repair often results in significant pain postoperatively, the cause of which is undetermined. Purpose/Hypothesis: The aim of this study was to evaluate the relationship between rotator cuff tear area and postoperative pain in patients who had undergone arthroscopic rotator cuff repair. We hypothesized that larger tears would be more painful because of elevated repair tension at 1 week postoperatively but that smaller tears would be more painful because of a greater healing response, especially from 6 weeks postoperatively. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1624 patients who underwent arthroscopic rotator cuff repair were included in this study. Exclusion criteria were moderate to severe osteoarthritis, isolated subscapularis repair, calcific tendinitis, synthetic patch repair, revision surgery, and retears on ultrasound at 6 months after surgery. Rotator cuff tears were subdivided into groups based on the tear size and retear rate found for each group. A modified L'Insalata questionnaire was given before surgery and at 1 week, 6 weeks, 3 months, and 6 months after surgery. Pearson and Spearman correlation coefficient tests were performed between rotator cuff tear areas and pain scores. RESULTS: Intraoperative rotator cuff tear areas did not correlate with pain scores preoperatively or at 1 week after surgery. A smaller tear area was associated with more frequent and severe pain with overhead activities, at rest, and during sleep as well as a poorer perceived overall shoulder condition at 6 weeks, 3 months, and 6 months after repair ( r = 0.11-0.23, P < .0001). Patients who were younger, had partial-thickness tears, and had occupational injuries experienced more pain postoperatively ( r = 0.10-0.28, P < .0001). Larger tears did not have more pain at 1 week after surgery. The retear rate was 7% in tears <2 cm2 but reached 44% in tears >8 cm2. CONCLUSION: There were fewer retears with smaller tears, but they were more painful than large tears postoperatively from 6 weeks to 6 months after surgery. Smaller tears may heal more vigorously, causing more pain. Patients with smaller tears experienced more pain after rotator cuff repair compared with patients with larger tears. These findings are contrary to previous ideas about tear size and postoperative pain. Healing is likely a determinant of postoperative pain.

The effect of rotator cuff repair on early overhead shoulder function: a study in 1600 consecutive rotator cuff repairs.

BACKGROUND: Rotator cuff tears are often surgically repaired, generally with good results. However, repairs not infrequently retear, and how important repair integrity is with respect to early functional outcomes after rotator cuff repair is unclear. Thus, the purpose of this study was to determine the effect of a retear on overhead activities in a large cohort of patients after rotator cuff repair. METHODS: This was a retrospective cohort study of prospectively collected data from 1600 consecutive rotator cuff repairs. Outcomes were based on patient responses to the L'Insalata Shoulder Questionnaire and findings on examination preoperatively and at 6 months of follow-up. Repair integrity was determined by ultrasound imaging at the 6-month follow-up visit. RESULTS: The 1600 patients (885 men, 715 women) were a mean age of 58 years. Postoperative ultrasound imaging found 13% (211 of 1600) of repairs had retorn. Significant improvements were seen irrespective of rotator cuff integrity in pain levels with overhead activity (P < .0001) and range of motion in forward flexion (P < .001) and abduction (P < .01). Patients with intact repairs had 9.5 N greater supraspinatus strength (P < .0001) and 6.9 N greater external rotation strength (P < .01) than those with a retear. CONCLUSION: To our knowledge, this is the largest study to evaluate the effect of rotator cuff repair integrity on shoulder function. Patients who had an arthroscopic rotator cuff repair reported significant improvements in overhead pain levels irrespective of the repair integrity at 6 months. Repair integrity influenced supraspinatus and external rotation power, where patients with intact repairs were stronger than those with a retear.

Ultrasound determination of rotator cuff tear repairability.

BACKGROUND: Rotator cuff repair aims to reattach the torn tendon to the greater tuberosity footprint with suture anchors. The present study aimed to assess the diagnostic accuracy of ultrasound in predicting rotator cuff tear repairability and to assess which sonographic and pre-operative features are strongest in predicting repairability. METHODS: The study was a retrospective analysis of measurements made prospectively in a cohort of 373 patients who had ultrasounds of their shoulder and underwent rotator cuff repair. Measurements of rotator cuff tear size and muscle atrophy were made pre-operatively by ultrasound to enable prediction of rotator cuff repairability. Tears were classified following ultrasound as repairable or irreparable, and were correlated with intra-operative repairability. RESULTS: Ultrasound assessment of rotator cuff tear repairability has a sensitivity of 86% (p < 0.0001) and a specificity of 67% (p < 0.0001). The strongest predictors of rotator cuff repairability were tear size (p < 0.001) and age (p = 0.004). Sonographic assessments of tear size ≥4 cm(2) or anteroposterior tear length ≥25 mm indicated an irreparable rotator cuff tear. CONCLUSIONS: Ultrasound assessment is accurate in predicting rotator cuff tear repairability. Tear size or anteroposterior tear length and age were the best predictors of repairability.

Advanced glycation end products in idiopathic frozen shoulders.

BACKGROUND: The pathophysiologic mechanisms behind proliferation of fibroblasts and deposition of dense collagen matrix in idiopathic frozen shoulder remain unclear. Accumulation of advanced glycation end products (AGEs) with cross-linking and stabilization of collagen has been hypothesized to contribute to this pathophysiologic process. This study investigated whether the immunoreactivity of AGEs is higher in patients with idiopathic frozen shoulder than in the control groups. METHODS: Shoulder capsule samples were collected from 8 patients with idiopathic frozen shoulder, 6 with unstable shoulders (control 1), and 8 with rotator cuff tears (control 2). The samples were hematoxylin and eosin stained and analyzed by immunohistochemistry using antibodies against AGEs. Immunoreactivities were rated in a blinded fashion from none (0) to strong (3). Immunohistochemical distribution within the capsule was noted. RESULTS: Frozen shoulder patients had greater frequency and severity of self-reported pain (P = .02) than rotator cuff tear patients and more restricted range of motion in all planes (P < .05) than patients of the instability and rotator cuff tear groups. Hematoxylin and eosin-stained capsular tissue from frozen shoulder showed fibroblastic proliferation, increased numbers of adipocytes, and increased subsynovial vascularity. Immunoreactivity of AGEs was stronger in frozen shoulder capsules (2.8) than in instability (0.3; P = .0001) and rotator cuff tear (1.1; P = .016) capsules. CONCLUSION: This study highlights a potential role for AGEs in the pathogenesis of frozen shoulder. The overexpression of AGEs may explain the fibroblastic proliferation and deposition of collagen matrix in idiopathic frozen shoulder. LEVEL OF EVIDENCE: Basic Science Study; Histology.

Retrospective evidence on outcomes and experiences of pregnancy and childbirth in epidermolysis bullosa in Australia and New Zealand.

BACKGROUND: Pregnancy in epidermolysis bullosa (EB) has not been comprehensively studied. OBJECTIVE: We aimed to develop a foundational database, which could provide peri-obstetric advice in EB. METHODS: Survey questionnaires were sent to obstetricians, unaffected mothers of EB babies, and mothers with EB. Results were analyzed using chi-square, Fisher exact, and t-tests. RESULTS: Out of 1346 obstetricians surveyed, 195 responded, and only 14 had encountered EB. All recommended normal vaginal delivery (NVD), except for one elective Caesarean section (CS). We received responses from 75 unaffected mothers who had delivered EB babies. They had significantly more complications in their EB pregnancies compared to their non-EB pregnancies. A further 44 women with various types of EB who had given birth responded. Most delivered via NVD and had no significant increase in complications in both their EB and non-EB pregnancies. In both groups, there were no significant differences in blistering at birth in babies delivered via NVD and CS. CONCLUSION: In conclusion, most patients with EB who are capable of giving birth do not have an increased risk for pregnancy-related complications and NVD appears to be safe. Awareness of this data amongst obstetricians and dermatologists should lead to improved quality of care for mothers and babies affected with EB.

Surgical repair of the gluteal tendons: a report of 72 cases.

Lateral hip pain is a common problem in middle-aged women. This pain is usually attributed to trochanteric bursitis and treated as such. This study reports the results of investigation, the findings at surgery, the operative technique, the histopathologic findings, and the results of gluteal tendon repair in 72 patients with long-standing trochanteric pain and reports a classification of the operative findings. Six patients (7%) in the original study cohort of 89 patients were lost to follow-up, but of the remaining patients, 65 of 72, or 90%, were pain-free or had minimal pain (P < .00001). Surgical reconstruction of detached gluteal tendons causing chronic lateral hip pain addresses the problem directly and reliably relieves the symptoms of so-called "trochanteric bursitis."

Matrix-induced autologous chondrocyte implantation of talus articular defects.

BACKGROUND: Osteochondral injury of the talus can be challenging to treat because the damaged articular cartilage has a poor intrinsic reparative capability. Autologous Chondrocyte Implantation has become an effective means for treating persistent cartilage lesions that fail to respond to routine ankle arthroscopy. The purpose of this study was to assess the results of Matrix-induced autologous chondrocyte implantation (MACI) for the treatment of osteochondral defects of the talar dome using a technique which does not require an osteotomy of the tibia or fibula. MATERIALS AND METHODS: A prospective investigation of MACI was performed on ten patients with full-thickness lesions of the talus. The patients had a documented talus lesion on MRI, failure of conservative treatment and arthroscopic debridement/curettage, persistent ankle pain and swelling, the absence of tibiotalar arthritis and a stable ankle. Five males and five females, with an average of 1.7 previous procedures prior to Matrix-induced autologous implantation, were included in this study. All patients were available for followup at 1 and 2 years. Lesions were graded during the harvesting procedure using the Cheng-Ferkel grading system, the Outerbridge classification, and the International Cartilage Repair Society system. Clinical and functional evaluation was done preoperatively, and at 1 and 2 years postoperatively using the AOFAS hindfoot evaluation and the SF-36 Health Survey. RESULTS: Preoperative AOFAS hindfoot scores were 61.2 (range, 42 to 76) which improved 1 year postoperatively to 74.7 (range, 46 to 87) (p < 0.05) and 2 years postoperatively to 73.3 (range, 42 to 90) (p = 0.151). At both 1 and 2 years postoperatively, the results of the SF36 evaluation demonstrated a significant improvement in the Physical Functioning (p = 0.002) and Bodily Pain (p < 0.001) components. Subjectively, all ten patients believed this procedure helped them. CONCLUSION: The results of this study suggest that MACI may be an effective way to treat full-thickness lesions of the talus using harvested chondrocytes from the talus without malleolar osteotomy. We recommend it for patients who do not respond to initial curettage and microfracture.

Shoulder pain in elite swimmers: primarily due to swim-volume-induced supraspinatus tendinopathy.

BACKGROUND/HYPOTHESIS: Shoulder pain in elite swimmers is common, and its pathogenesis is uncertain. HYPOTHESIS/STUDY DESIGN: The authors used a cross-sectional study design to test Jobe's hypothesis that repetitive forceful swimming leads to shoulder laxity, which in turn leads to impingement pain. METHODS: Eighty young elite swimmers (13-25 years of age) completed questionnaires on their swimming training, pain and shoulder function. They were given a standardised clinical shoulder examination, and tested for glenohumeral joint laxity using a non-invasive electronic laxometer. 52/80 swimmers also attended for shoulder MRI. RESULTS: 73/80 (91%) swimmers reported shoulder pain. Most (84%) had a positive impingement sign, and 69% of those examined with MRI had supraspinatus tendinopathy. The impingement sign and MRI-determined supraspinatus tendinopathy correlated strongly (r(s)=0.49, p<0.00001). Increased tendon thickness correlated with supraspinatus tendinopathy (r(s)=0.37, p<0.01). Laxity correlated weakly with impingement pain (r(s)=0.23, p<0.05) and was not associated with supraspinatus tendinopathy (r(s)=0.14, p=0.32). The number of hours swum/week (r(s)=0.39, p<0.005) and weekly mileage (r(s)=0.34, p=0.01) both correlated significantly with supraspinatus tendinopathy. Swimming stroke preference did not. CONCLUSIONS: These data indicate: (1) supraspinatus tendinopathy is the major cause of shoulder pain in elite swimmers; (2) this tendinopathy is induced by large amounts of swimming training; and (3) shoulder laxity per se has only a minimal association with shoulder impingement in elite swimmers. These findings are consistent with animal and tissue culture findings which support an alternate hypothesis: the intensity and duration of load to tendon fibres and cells cause tendinopathy, impingement and shoulder pain.

Restore orthobiologic implant: not recommended for augmentation of rotator cuff repairs.

BACKGROUND: Following repairs of large-to-massive tears of the rotator cuff, the rates of tendon retears are high and often involve tissue deficiency. Animal studies of the Restore Orthobiologic Implant, a collagen-based material derived from the small intestine mucosa of pigs, have indicated that it might be used to help overcome such problems. We carried out a study to determine whether patients who received this xenograft to augment a rotator cuff repair exhibited greater shoulder strength, shoulder function, and/or resistance to retearing. METHODS: We compared data from a group of patients who had undergone conventional rotator cuff repair with xenograft augmentation (the xenograft group) with data from a group in whom a repair had been done by the same surgeon without augmentation (the controls). The groups were matched for gender, mean age, and mean size of the rotator cuff tear. All subjects completed a pain and function questionnaire and were given a systematic clinical shoulder examination preoperatively and at three, six, and twenty-four months postoperatively. The twenty-four-month visit included magnetic resonance imaging to determine whether a retear had occurred. RESULTS: Four patients who had received a xenograft had a severe postoperative reaction requiring surgical treatment. At two years after the surgery, six of the ten tendons repaired with a xenograft and seven of the twelve control tendons had retorn, as documented by magnetic resonance imaging. The patients with a xenograft had significantly less lift-off strength, as measured with a dynamometer, and significantly less strength in internal rotation and adduction than the controls at two years after the surgery (all p < 0.05). Also, the xenograft group had significantly more impingement in external rotation, a slower rate of resolution of pain during activities, more difficulty with hand-behind-the-back activities, and less sports participation (all p < 0.05). CONCLUSIONS: Two years after surgical repair of a large rotator cuff defect supplemented with a xenograft, patients had several persisting deficits and no recognizable benefit as compared with the results in a control group. In view of these findings, together with the unsatisfactorily high proportion of patients with a severe inflammatory reaction to the xenograft, we do not recommend use of the Restore Orthobiologic Implant in its present form. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Reliability of MRI assessment of supraspinatus tendinopathy.

OBJECTIVE: To determine the interobserver and intraobserver reliability of the interpretation of MRIs for supraspinatus tendinosis. METHODS: In the interobserver trial, the MRIs of 52 athletes' shoulders were observed by 3 observers on one occasion within a 2-month period. All 52 images were read by the most experienced musculoskeletal radiologist on 3 different occasions on separate days without access to the previous readings for the intraobserver trial. Supraspinatus tendinosis was graded using a modified 4-point scale from grades 0 to grade 3. RESULTS: The grading of MRI-determined supraspinatus tendinosis was reliable, having an intraclass correlation (ICC) of 0.85 when assessed by the single well-trained observer. Interobserver reliability was only fair to good (ICC = 0.55). CONCLUSIONS: Supraspinatus tendinosis can be accurately identified on MRI with little variation by a single well-trained observer. Interobserver reliability was only fair to good. Our data indicated that the reliability of the assessment was much greater in more experienced radiologists than in those with less experience.

A comparative study between transmission electron microscopy and immunofluorescence mapping in the diagnosis of epidermolysis bullosa.

The classification of epidermolysis bullosa (EB) into 3 main subtypes has been based on transmission electron microscopy (TEM) that is able to directly visualize and quantify specific ultrastructural features. Immunofluorescence antigenic mapping (IFM) is a technique that determines the precise level of skin cleavage by determining binding sites for a series of antibodies. To date, no study has compared the accuracy of these two techniques in diagnosing the major types of EB. A prospective cohort of 33 patients thought to have EB on clinical grounds had TEM, IFM, and genetic testing performed. The sensitivities and specificities of TEM and IFM were calculated compared with the genetic results. Of 33 cases, 30 had a positive EB diagnosis. TEM subclassified EB into its three major forms in 24/30 cases (80%) and IFM in 29/30 cases (97%). Overall, TEM sensitivities and specificities when compared with genetic results were 71% and 81%, respectively. IFM sensitivities and specificities when compared with genetic results were 97% and 100%, respectively. If a patient tested positive for EB by IFM, the likelihood ratio of having a particular type of EB was consistently greater than 20 against the reference standard (compared with a likelihood ratio less than 10 for TEM). Our results indicate that the diagnosis of EB is improved (sometimes substantially) by the use of IFM compared with TEM.

Arthroscopic stabilization of superior labral (SLAP) tears with biodegradable tack: outcomes to 2 years.

PURPOSE: This prospective study aimed to document the pain and functional outcomes, over time, of patients whose SLAP lesions had been repaired with biodegradable tacks. METHODS: Superior labral tears were identified in 24 patients from a cohort of 500 patients who had shoulder problems sufficiently disabling to warrant arthroscopic evaluation and management. These labral tears were arthroscopically repaired with 1 to 3 biodegradable tacks (mean, 1.6). Before surgery, all patients completed a questionnaire regarding their shoulder pain and function and were given a systematic clinical examination. To observe their postoperative outcomes over time, the same assessments were made at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery. RESULTS: After labral reattachment, decreases were noted in the patients' mean shoulder pain scores at rest (64% at 3 months), at night (76% at 3 months), and with activity (73% at 6 months). The most significant reductions in mean scores occurred between 6 and 12 weeks (P < .001). Patient-perceived weakness, instability, and stiffness scores also improved from week 6. The ranking of the patients' "overall problem" reduced from an average ranking of "severe" to "mild" by the third preoperative month (P < .001) and was still at this level by the time of their 2-year follow-up appointment. Activity levels for 22 of 24 patients returned to their preinjury levels by 6 months after surgery. CONCLUSIONS: Arthroscopically delivered biodegradable tacks effectively managed superior labral tears and, on average, resulted in a near-complete improvement of pain and recovery of function by 3 months. These good outcomes did not improve further or deteriorate at the 2-year follow-up appointment. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Assessing leg length discrepancy after femoral fracture: clinical examination or computed tomography?

INTRODUCTION: Femoral shaft fractures treated with intramedullary nailing often heal with a leg length discrepancy (LLD). LLD is commonly evaluated by clinical examination and computed tomography (CT) scanogram. We assessed the correlation between these two techniques of calculating LLD. METHODS: We reviewed 35 skeletally mature patients who sustained a femoral shaft fracture between January 1997 and December 1999. Leg length was measured clinically with direct measurement and a block test. Each patient was asked whether they felt they walked with a limp and whether they felt they had a leg length discrepancy. Each patient underwent a CT scanogram to measure femoral and total leg length. The correlation between clinical examination and scanogram was analysed using the Pearson Product Moment Correlation. RESULTS: Of the 35 patients, 15 patients (43%) had a measurable LLD. There was a positive correlation between direct leg length measurement and the block test (P = 0.003), and between the block test and patient perception of limp and LLD. CT scanogram was performed on 29/35 patients. There was no correlation between CT scanogram and clinical measurement of leg length or between CT scanogram and patient perception of LLD or limp. DISCUSSION: Leg length discrepancy commonly occurs following treatment of femoral shaft fractures. We found that there was a strong correlation between direct leg length measurement and the block test, and between both methods of clinical leg length measurement and patient perception of a limp or LLD. Our study found no correlation between CT scanogram and clinical leg length measurement or patient perception of limp or LLD. CONCLUSION: Our study shows that physical examination (direct measurement and the block test) is more reliable and clinically relevant than CT scanogram measurement in the assessment of LLD after femoral fracture.

The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability.

BACKGROUND: The effectiveness of arthroscopic thermal capsulorrhaphy in the prevention of recurrent instability in primary anterior stabilization is undetermined. PURPOSE: To determine if patients with recurrent anterior shoulder instability who have labral repair plus arthroscopic thermal capsulorrhaphy have better outcomes than those with labral repair alone. STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: There were 72 patients who underwent arthroscopic anterior shoulder stabilization with Suretac II tacks (n = 32) during 1996 to 1999 or with Suretac II tacks plus arthroscopic radiofrequency capsular shrinkage (n = 40) from 1999 to 2002. Standardized patient-determined and examiner-determined outcome measures were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Statistical analyses included a Kaplan-Meier analysis of time to recurrent instability. RESULTS: Of the 72 patients, 66 had complete follow-up, including 28 patients treated with the Suretac stabilization and 38 patients with the Suretac plus radiofrequency shrinkage, for a mean follow-up of 58 and 30 months, respectively. All patients had a Bankart lesion. Both groups had similar results with respect to patient-determined and examiner-determined outcome measures. The only adverse outcome was postoperative recurrent instability in 6 of 28 cases in the Suretac group alone and 8 of 38 cases in the Suretac-plus -shrinkage group. Most recurrent instability occurred between 6 and 24 months. Kaplan-Meier analysis for time to recurrent instability showed no differences in the rate of instability recurrence between the 2 groups. CONCLUSION: Arthroscopic thermal capsulorrhaphy neither enhanced nor impaired the outcomes of arthroscopic labral repair with biodegradable tacks in patients with primary recurrent anterior shoulder instability.