The effect of dynamic external rotation comparing 2 footprint-restoring rotator cuff repair techniques.

BACKGROUND: Allowing for humeral external rotation while loading rotator cuff repairs has been shown to affect tendon biomechanics when compared with testing with the humerus fixed. Adding dynamic external rotation to a tendon-loading model using footprint-restoring repairs may improve our understanding of rotator cuff repair response to a common postoperative motion. HYPOTHESIS: A tendon suture-bridging repair will demonstrate better load sharing compared to a double-row repair, and there will be a differential gap formation between the anterior and posterior tendon regions. STUDY DESIGN: Controlled laboratory study. METHODS: In 6 fresh-frozen human cadaveric shoulders, a tendon suture-bridging rotator cuff repair was performed; a suture limb from each of 2 medial anchors was bridged over the tendon and fixed laterally with an interference screw. In 6 contralateral match-paired specimens, a double-row repair was performed. For all specimens, a custom jig was employed that allowed dynamic external rotation (0 degrees to 30 degrees ) with loading. A materials testing machine was used to cyclically load each repair from 0 N to 90 N for 30 cycles; each repair was then loaded to failure. A deformation rate of 1 mm/s was employed for all tests. Gap formation between tendon edge and insertion was measured using video digitizing software. RESULTS: The yield load for the suture-bridging technique (161.88 +/- 35.09 N) was significantly larger than the double-row technique (135.17 +/- 24.03 N) (P = .026). The yield gap between tendon and lateral footprint was significantly greater anteriorly than posteriorly (1.62 +/- 0.82 mm and 0.68 +/- 0.47 mm, respectively) for the suture-bridging technique (P = .024) but not for the double-row technique (1.35 +/- 0.52 mm and 1.05 +/- 0.50 mm, respectively) (P = .34). There were no differences for gap formation, stiffness, ultimate load to failure, and energy absorbed to failure between the 2 repairs (P > .05). The anterior regions of the repair were the first to fail in all constructs. The suture-bridging repair remained interconnected for 5 of 6 repairs. CONCLUSIONS: The tendon suture-bridging rotator cuff repair has a yield load that is higher than the double-row repair when allowing for external rotation during load testing. External rotation can accentuate gap formation anteriorly at a repaired rotator cuff footprint. CLINICAL RELEVANCE: Based on the tension of repair, there may be a role for reinforcing the repair anteriorly and limiting external rotation postoperatively.

Dual direct lateral portals for treatment of osteochondritis dissecans of the capitellum: an anatomic study.

PURPOSE: The purpose of this study was to quantify the distance of dual direct lateral (posterolateral radiocapitellar) arthroscopic portals to the lateral ligamentous structures and to report the percentage of capitellum accessible through these portals. METHODS: Arthroscopy was performed on 10 fresh-frozen cadaveric elbows via a standard 6-portal approach. The portals included dual direct lateral portals created in the posterolateral soft spot. The arthroscope was placed through one direct lateral portal; an arthroscopic electrocautery device was placed through the other direct lateral portal and was used to mark all accessible areas of the capitellum. Open dissection allowed measurement of the distances of the portals from the lateral ligamentous structures, as well as determination of the percentage of capitellum accessible through these portals. RESULTS: The more ulnar of the dual lateral portals averaged 9.1 mm from the lateral ulnar collateral ligament, 11.5 mm from the annular ligament, and 13.1 mm from the radial collateral ligament. The more radial of the dual lateral portals averaged 1.5 mm, 9.7 mm, and 7.0 mm from these ligaments, respectively. Seventy-eight percent of the capitellum was accessible for instrumentation with these portals. CONCLUSIONS: Correct placement of dual direct lateral portals does not disrupt the lateral ligamentous complex and allows access to a large portion of the capitellum. CLINICAL RELEVANCE: Use of dual direct lateral portals is safe and practical for arthroscopic treatment of capitellar osteochondritis dissecans.

Hip fracture outcomes in patients with Parkinson's disease.

In a prospective, consecutive study conducted at a university teaching hospital, we evaluated the effects of Parkinson's disease (PD) on hip fracture outcomes. We followed 920 community-dwelling patients, aged 65 or older, who sustained a hip fracture that was operatively treated between July 1, 1987, and June 30, 1998. Presence or absence of PD had no bearing on type of surgery performed. Examined outcomes were postoperative complication rates; in-hospital mortality; length of hospital stay; discharge status (to home or to a skilled nursing facility); and mortality rate, place of residence, recovery of prefracture ambulatory ability, and return to prefracture activities of daily living (ADLs) 1 year after surgery Thirty-one patients (3.4%) had a history of PD before hip fracture. Patients with PD were more likely to be male, to live with another person, to have less ambulatory ability, and to be dependent in ADLs before hip fracture. Compared with patients without PD, they were hospitalized significantly longer and were more likely to be discharged to a skilled nursing facility. In addition, they declined more in level of independence in basic ADLs but not as much in instrumental ADLs at 1-year follow-up. Rates of postoperative complications, recovery of ambulatory ability within 1 year, and mortality within 1 year did not differ. These findings may guide orthopedic surgeons in counseling patients with PD and a hip fracture.

Symptomatic snapping hip: targeted treatment for maximum pain relief.

A painful condition known as snapping hip may prevent athletes from attaining peak performance, and it presents diagnostic and treatment challenges to the sports medicine physician as well. Three types of snapping hip (external, internal, and intra-articular) are known, and each has a distinct pathomechanic cause, specific symptoms, and classic clinical presentation. History and physical exam are coupled with a variety of imaging modalities to help distinguish the three types. Nonoperative approaches are the mainstay of treatment, but, if unsuccessful, operative treatments also achieve good results. Patients may resume their activities when pain subsides.

The impact of medicare reimbursement policies on simultaneous bilateral total hip and knee arthroplasty.

In October of 1992, Medicare reimbursement decreased by 50% for a second total hip or knee arthroplasty performed as part of a simultaneous bilateral procedure. The Medicare records of 67726 patients who underwent total hip and knee arthroplasty were reviewed using data from the New York State Department of Health in the period from October 1, 1989, to September 30, 1996. Simultaneous bilateral total hip arthroplasties represented 1.8% of the total number of total hip replacements performed in fiscal year 1991 (60 of 3418) compared with 1.7% (77 of 4547) performed in fiscal year 1994 (P=.902). Similarly, the number of simultaneous bilateral total knee arthroplasties did not change significantly, with simultaneous bilateral procedures representing 5.9% of the total number of total knee replacements performed in fiscal year 1991 (214 of 3620) compared with 6.2% (369 of 5,931) performed in fiscal year 1994 (P=.568).