Literature Review of Subscapularis Tear, Associated injuries, and the Available Treatment Options.

The population of Hawai'i is uniquely connected to the Ocean and to open water sports. Shoulder injuries, particularly those to the rotator cuff, are among the most common injuries sustained to athletes participating in ocean sports such as surfing, paddling, and swimming. In addition, rotator cuff injuries increase in prevalence with advanced age. As a consequence, the number of patients in Hawai'i who present with an injury to the subscapularis tendon will continue to rise. However, limited research has been done to delineate the involvement of subscapularis injuries in this population. This article covers the anatomy and function of the subscapularis, the epidemiology and classification of tears in this tendon, and the management of tears. The anatomy section will cover innervation, vascular supply and insertional anatomy of the subscapularis tendon. The function of the subscapularis in regards to both stability and motion of the glenohumeral joint will be examined. The focus of the article will then shift to the tears of the subscapularis, starting with an in depth look at the epidemiology and classification of these tears. The article will then cover the different imaging modalities and their utility in regards to subscapularis tears. Finally, the operative and non-operative management and indications for each modality will be discussed in detail.

The Learning Curve for Hip Arthroscopic Surgery: A Prospective Evaluation With 2-Year Outcomes in Patients With Femoroacetabular Impingement.

BACKGROUND: The use of hip arthroscopic surgery in the treatment of femoroacetabular impingement (FAI) is increasing, but it is universally known as a technically demanding procedure with a "steep" learning curve. There are limited data investigating the correlation between surgeon experience and patient-reported outcomes (PROs) as well as procedure and traction times. PURPOSE: To prospectively evaluate the relationship between surgeon experience and PROs after hip arthroscopic surgery for the treatment of FAI. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 190 patients undergoing primary hip arthroscopic surgery for FAI were prospectively enrolled during a sports medicine fellowship-trained surgeon's first 36 months of practice. A radiographic evaluation as well as PRO surveys including the 12-Item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS) were administered preoperatively and at 2 years postoperatively. Logistic regression as well as analysis of variance was performed to evaluate for correlations between surgical experience and PROs, procedure time, and traction time. RESULTS: Of the 190 patients, 168 (88%; mean age, 35.3 ± 9.6 years; mean body mass index, 25.07 ± 3.98) completed a 2-year follow-up and were included for analysis. The mean procedure time was 91.5 ± 23.9 minutes, and the mean traction time was 54.0 ± 17.7 minutes. Patients demonstrated significant improvements at 2 years after surgery for all PRO scores (mHHS, HOOS, and SF-12 physical component summary; P < .001), except the SF-12 mental component summary, which had no change (P = .43). The procedure time significantly decreased after 70 cases, while the traction time continued to decrease until 110 cases (R 2 = 0.99; P < .0001). There was no correlation between increasing case volume and 2-year PRO scores (P > .2 for mHHS, HOOS, and SF-12). There was also no difference with increasing case volume and amount of improvement from preoperative to 2-year postoperative PRO scores for the SF-12 and HOOS. Case volume did not affect the complication rate, as this cohort experienced 4 minor cases of neurapraxia. CONCLUSION: Surgical efficiency in hip arthroscopic surgery for the treatment of FAI was maximized after 110 cases in this cohort. However, significant PRO improvements can be achieved early in a surgeon's practice prior to maximizing surgical efficiency.

Patellar tendon reconstruction with hamstring autograft for the treatment of chronic irreparable patellar tendon injuries.

BACKGROUND: Patellar tendon injuries not amenable to primary repair present a challenging problem for surgeons and patients alike. No standard surgical technique exists for these injuries and few studies report outcomes after surgical treatment. METHODS: A retrospective analysis was conducted for patients undergoing surgical treatment for irreparable patellar tendon tears. Patients were treated with an indirect tendon reconstruction technique using high-strength suture to set initial patellar height and hamstring autograft for biologic augmentation. Patients who underwent this procedure between 2012 and 2018 and met minimum two-year follow-up with completion of all outcome measurements including KOOS, PROMIS, VAS pain and satisfaction scores were included. RESULTS: Eleven patients met inclusion criteria. Ten of eleven patients (91%) had intact repairs and final patient outcomes were collected at a mean of 54.9 ± 23.1 months after surgery. Only one patient experienced extensor lag at final follow-up (p < 0.001). The preoperative Caton-Dechamps ratio was 1.77 ± 0.58, which decreased to 0.98 ± 0.25 after surgery (p < 0.001). The mean postoperative KOOS ADL score was 61.5. The mean postoperative PROMIS Global Mental and Physical Health scores were 46.9 ± 8.7 and 42.0 ± 9.8. Post-operative mean VAS satisfaction score was 5.6 ± 3.4. CONCLUSIONS: Patellar tendon reconstruction with autologous hamstring tendon graft and suture augmentation allows for acceptable outcomes in the setting of patellar tendon disruption with segmental defects when direct repair is not possible.

Arthroscopic Single-Portal Subscapularis Tendon Repair.

Tears of the subscapularis tendon can be challenging to diagnose and treat. Because the subscapularis plays an important role in shoulder function, careful arthroscopic evaluation and treatment are necessary to restore function. Previous surgical techniques have ranged from full open repairs to complex arthroscopic procedures needing suture passer and/or retriever devices. We describe an arthroscopic surgical technique of subscapularis repair through a single anterior portal using only penetrating graspers. This approach can be used for partial upper-border subscapularis tears, as well as complete and retracted subscapularis tendon tears.

Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones.

BACKGROUND: Tibial osseous defects can present a serious challenge in primary total knee arthroplasty. We describe a technique of using porous tantalum cones along with primary arthroplasty implants to address large tibial osseous defects in primary total knee arthroplasty and present the short-term results. METHODS: We present 17 cases (15 patients) in which primary total knee implants and porous tantalum cones were used to address large tibial bony defects. Clinical results were evaluated using Knee Society Scores, pre- and postoperative knee range of motion, and serial radiographs. RESULTS: At an average of 3.5 years of follow-up, all 17 knees had functioning implants with stable metaphyseal cones demonstrating radiographic evidence of osteointegration. At a minimum follow-up of two years, no patient had signs of osteolysis, instability, infection, or systemic complications. All 15 patients had excellent results with an average post-operative Knee Society Score of 94.6. Knee flexion improved by an average of 12.0° and knee extension improved to neutral in all patients. CONCLUSION: Primary total knee arthroplasty with porous tantalum cone augmentation produced excellent short-term results and should be considered an effective method for addressing large tibial osseous defects in primary total knee arthroplasty.

Treatment of median arcuate ligament syndrome via traditional and robotic techniques.

Median arcuate ligament syndrome (MALS) is a rare entity characterized by extrinsic compression of the celiac artery and symptoms of postprandial epigastric pain, nausea, vomiting, and weight loss mimicking mesenteric ischemia. We present two patients diagnosed with MALS, the first treated with an open laparotomy by a vascular surgeon and the second using a robot assisted laparoscopic approach by a general surgeon with a vascular surgeon on standby. This is the second ever report of this approach. Both patients recovered without complications and experienced resolution of their symptoms. A discussion of the pathophysiology, literature review, and multispecialty treatment approach are presented.

Subcutaneous emphysema, pneumopericardium, pneumomediastinum and pneumoretroperitoneum secondary to sigmoid perforation: a case report.

A 50-year-old woman presented with chronic epigastric abdominal pain and constipation. She underwent diagnostic upper and lower endoscopy for further evaluation. Several hours following the procedure, she developed chest and subcutaneous emphysema of her upper chest, neck, and face. A chest X-ray demonstrated marked subcutaneous emphysema, pneumopericardium, and pneumomediastinum. A CT scan revealed a small leak at the rectosigmoid junction. Because the patient did not have peritoneal signs, she was treated conservatively and discharged on hospital day seven. The complications of both esohagogastroduodenoscoy, and colonoscopy are discussed, with an emphasis on perforations.