A modified Patte classification system for rotator cuff tendon retraction to predict reparability and tendon healing in arthroscopic rotator cuff repair.

PURPOSE: The purpose of this study was to propose a modified Patte classification system for tendon retraction, including the cut-off points for predicting reparability and rotator cuff healing after arthroscopic rotator cuff repair (ARCR) and assess its prediction accuracy and measurement reliability. METHODS: This retrospective study included 463 consecutive patients scheduled to undergo ARCR for full-thickness supraspinatus tears. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off points for predicting reparability and tendon healing. The modified Patte classification system, in which these cut-off points were combined with the original Patte classification, classified the tendon retraction as stages I-V. The prediction accuracy of reparability and tendon healing was assessed using the area under the curve (AUC). Measurement reliability was determined using Cohen's κ statistics. RESULTS: Of the 402 included patients, 32 rotator cuff tears were irreparable and 71 of the remaining 370 were diagnosed with healing failure. ROC analysis determined the cut-off point of reparability at the medial one-fifth and that of tendon healing at the medial one-third of the humeral head. The AUC of the modified Patte classification for predicting reparability and tendon healing was 0.897 (excellent) and 0.768 (acceptable), respectively. Intra-rater reliability was almost perfect (mean κ value: 0.875), and inter-rater reliability was substantial (0.797). CONCLUSION: Diagnostic performance of the modified Patte classification system was excellent for reparability and acceptable for rotator cuff healing, with high measurement reliability. The modified Patte classification system can be easily implemented in clinical practice for planning surgical procedures and counselling patients in the day-by-day clinical work. LEVEL OF EVIDENCE: Level III.

Repair Tension During Arthroscopic Rotator Cuff Repair is Correlated With Preoperative Tendon Retraction and Postoperative Rotator Cuff Integrity.

PURPOSE: This study aimed to examine the correlation of repair tension during arthroscopic rotator cuff repair (ARCR) with preoperative factors and to evaluate whether measuring tension during ARCR is effective for predicting rotator cuff integrity after ARCR. METHODS: Patients who underwent ARCR from May 2014 to June 2017 were enrolled in this study. Inclusion criteria were patients with medium or larger-sized tears and with a minimum of 6 months' follow-up. Patients with a partial repair were excluded. Intraoperative repair tension was measured according to Davidson's method. Correlation of repair tension with preoperative factors was evaluated with Pearson and Spearman correlation coefficient tests. Logistic regression analysis was performed on intraoperative factors, including repair tension, to identify independent predictors of retear after ARCR. Receiver operating characteristic (ROC) curve was used to determine the cutoff value of repair tension for retear. RESULTS: One-hundred twenty patients met the inclusion criteria. Mean repair tension was 26.6 ± 12.6 N, and retear was found in 29 shoulders (24.2%). Among the preoperative factors, tear size in the mediolateral (P < .001) and anteroposterior (P < .001) directions, DeOrio and Cofield's classification (P <0.001), geometric classification (P <.001), and fatty infiltration of supraspinatus (P = .006) and infraspinatus (P = .003) were significantly correlated with repair tension. However, multivariable logistic regression analysis identified only tear size in the mediolateral direction as an independent predictor of repair tension (P = .036). Logistic regression analysis showed that repair tension (P = .02) and geometric classification (P < .001) are significant factors affecting rotator cuff integrity after ARCR. ROC curve analysis showed the cutoff value of repair tension of large to massive tears for retear to be 35.6 N. CONCLUSION: This study demonstrated that intraoperative repair tension is strongly correlated with tear size in the mediolateral direction based on preoperative magnetic resonance imaging and that measuring tension during ARCR is effective for predicting rotator cuff integrity after ARCR. LEVEL OF EVIDENCE: Level IV, prognostic study.

Comparable clinical and structural outcomes after arthroscopic rotator cuff repair in diabetic and non-diabetic patients.

PURPOSE: To compare clinical outcome and rotator cuff integrity after arthroscopic rotator cuff repair (ARCR) in patients with and without diabetes mellitus. METHODS: This retrospective study involved 264 consecutive patients who underwent ARCR from 2012 to 2015. Inclusion criteria were a medium or large-sized tear and a minimum of 1-year follow-up. Clinical outcome measures included range of motion (ROM) and the Japanese Orthopaedic Association (JOA) and University of California, Los Angeles (UCLA) scores preoperatively and at final follow-up. Rotator cuff retear was evaluated with magnetic resonance imaging at 3 months post-surgery and final follow-up. Diabetic patients with poor control were pre-operatively hospitalized for intensive diabetic control. RESULTS: Our inclusion criteria were met by 30 diabetic patients and 126 non-diabetic patients. Demographic data were not significantly different between the groups, except body mass index (p = 0.021). Preoperative JOA and UCLA scores of the diabetic patients were significantly lower than those of the non-diabetic patients (p < 0.001, and p = 0.006, respectively); however, the scores at final follow-up were not different. ROM was significantly restricted in the diabetic patients before surgery (forward flexion, abduction, internal rotation: p < 0.001, external rotation: p = 0.035), but at the final follow-up, there was no significant difference except for internal rotation (p = 0.005). The retear rate in diabetic patients (23.3%) was not significantly different from that in non-diabetic patients (15.1%). CONCLUSIONS: Diabetic patients who had good perioperative glycemic control showed clinical and structural outcomes comparable to non-diabetic patients after ARCR. Intensive perioperative glycemic control and patient education are recommended for preoperative uncontrolled diabetic patients. LEVEL OF EVIDENCE: III.

Percutaneous drainage of psoas and iliopsoas muscle abscesses with a one-step technique under real-time computed tomography fluoroscopic guidance.

PURPOSE: To evaluate the utility and safety of drainage catheter installation for psoas/iliopsoas muscle abscesses using a one-step technique under the guidance of real-time computed tomography (CT) fluoroscopy. MATERIALS AND METHODS: Ten psoas or iliopsoas muscle abscesses in 7 patients that were treated with percutaneous drainage were included in this study. All drainage procedures were carried out using a one-step technique under real-time CT fluoroscopic guidance. RESULTS: The drainage catheter insertion was performed successfully with the one-step technique in all lesions. Improvements in the patients' symptoms and blood test results were seen after the drainage procedure in all cases. In addition, postoperative CT scans demonstrated that the abscesses had reduced in size or disappeared in all but one patient, who was transferred to another institution while the drainage catheter was still in place. No major complications were seen in any case. CONCLUSION: The one-step procedure is simple to perform. The percutaneous drainage of psoas or iliopsoas muscle abscesses with the one-step technique under real-time CT fluoroscopic guidance is accurate and safe. Moreover, compared with the two-step technique the one-step procedure results in a shorter drainage procedure and exposes the patient and operator to lower amounts of radiation. J. Med. Invest. 63: 323-327, August, 2016.

Diagnostic Value of the Supine Napoleon Test for Subscapularis Tendon Lesions.

PURPOSE: The purpose of this study was to compare the diagnostic value of the supine Napoleon test (a variation of the belly-press test that reduces compensatory motion) with other clinical tests for subscapularis tendon (SSC) tears. METHODS: One hundred thirty consecutive patients who were scheduled for arthroscopic rotator cuff repair were evaluated preoperatively with the lift-off test, Napoleon test, bear-hug test, and supine Napoleon test. The supine Napoleon test was performed by placing the patient's hand on their belly while they lay supine with an examiner holding their hand and shoulder to prevent compensatory motion. The patient was asked to move their elbow upward and the test was considered positive if they were unable to do so. During surgery, SSC lesions were classified with the Lafosse classification system. Sensitivity, specificity, accuracy, and positive and negative likelihood ratios (LR+, LR-) were calculated for each test. The ability to detect partial SSC tears was compared among the clinical tests. RESULTS: Fifty-two of 130 patients (40%) had SSC tears confirmed arthroscopically. For diagnosis of these tears, the supine Napoleon test was the most sensitive (84%), followed by the bear-hug test (74%), and the bear-hug test was the most specific (97%), followed by the supine Napoleon test (96%). The LR+ was greatest for the bear-hug test (28.4) and next greatest for the supine Napoleon test (21.9). The LR- was lowest for the supine Napoleon test (0.16) and the bear-hug test was second (0.27). The sensitivity of the supine Napoleon test (65%) was highest for detecting partial tears. CONCLUSIONS: In comparison with other clinical tests for SSC tears, the supine Napoleon test had the greatest diagnostic value for full-thickness SSC tears and was most able to detect partial tears. LEVEL OF EVIDENCE: Level III, diagnostic nonrandomized study.

Development of secondary ossification centres of the acromion in Japanese youth: a computed tomographic study.

PURPOSE: To determine the age range when the secondary ossification centres of the acromion appear and fuse in Japanese youth using computed tomography (CT). METHODS: CT scans of 85 shoulders in 35 male and 14 female consecutive patients aged 6 to 20 (mean, 16) years were reviewed. No patient had pain or tenderness at the acromion. Appearance and fusion of the secondary ossification centres of the acromion were determined twice by an orthopaedist. A secondary ossification centre was considered to have appeared when a low-density line was noted at the juxta-epiphyseal area and to have fused when the line had disappeared. Intra-observer reliability was determined. RESULTS: The intra-observer reliability was 0.93. The secondary ossification centres of the acromion had appeared at around 10 years of age and had fused at around 15 years of age, with one exception. CONCLUSION: In these Japanese subjects, the secondary ossification centres of the acromion had appeared at around 10 years of age and had fused at 15 to 16 years.

Arthroscopic Removal of a Wire Fragment from the Posterior Septum of the Knee following Tension Band Wiring of a Patellar Fracture.

Tension band wiring with cerclage wiring is most widely used for treating displaced patellar fractures. Although wire breakage is not uncommon, migration of a fragment of the broken wire is rare, especially migration into the knee joint. We describe here a rare case of migration of a wire fragment into the posterior septum of the knee joint after fixation of a displaced patellar fracture with tension band wiring and cerclage wiring. Although it was difficult to determine whether the wire fragment was located within or outside the knee joint from the preoperative plain radiographs or three-dimensional computed tomography (3D CT), we found it arthroscopically through the posterior transseptal portal with assistance of intraoperative fluoroscopy. Surgeons who treat such cases should bear in mind the possibility that wire could be embedded in the posterior septum of the knee joint.

Plantar fascia rupture in a professional soccer player.

We report the case of a 29-year-old male professional soccer player who presented with symptoms of plantar fasciitis. His symptoms occurred with no remarkable triggers and gradually worsened despite conservative treatments including taping, use of insoles, and physical therapy. Local corticosteroid injection was given twice as a further intervention, but his plantar fascia partially ruptured 49 days after the second injection. He was treated conservatively with platelet-rich plasma, and magnetic resonance imaging showed regenerative change of the ruptured fascia. Five months after the rupture, he returned to his original level of training. If professional athletes find it difficult to refrain from athletic activity, as in the present case, the risk of rupture due to corticosteroid injection should not be overlooked.

Perineural but not systemic low-dose dexamethasone prolongs the duration of interscalene block with ropivacaine: a prospective randomized trial.

PURPOSE: To determine the effects of intravenous and perineural dexamethasone on the duration of interscalene brachial plexus block (ISB) with ropivacaine in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: In this prospective, randomized, placebo-controlled trial, patients presenting for arthroscopic shoulder surgery with an ISB were randomized to receive ropivacaine 0.75% (group C), ropivacaine 0.75% plus perineural dexamethasone 4 mg (group Dperi), or ropivacaine 0.75% plus intravenous dexamethasone 4 mg (group Div). The primary outcome was the duration of analgesia, defined as the time between performance of the block and the first request for analgesic. RESULTS: Thirty-nine patients were randomized. The median times of sensory block in groups C, Dperi, and Div were 11.2 hours (interquartile range [IQR] 8.0-15.0 hours), 18.0 hours (IQR 14.5-19.0 hours), and 14.0 hours (IQR 12.7-15.1 hours), respectively. Significant differences were observed between groups Dperi and C (P=0.001). Kaplan-Meier analysis for the first analgesic request showed significant differences between groups Dperi and C (P=0.005) and between groups Dperi and Div (P=0.008), but not between groups C and Div. CONCLUSION: Perineural but not intravenous administration of 4 mg of dexamethasone significantly prolongs the duration of effective postoperative analgesia resulting from a single-shot ISB with ropivacaine 0.75%.

Validity of arthroscopic measurement of glenoid bone loss using the bare spot.

PURPOSE: Our aim was to test the validity of using the bare spot method to quantify glenoid bone loss arthroscopically in patients with shoulder instability. METHODS: Twenty-seven patients with no evidence of instability (18 males, nine females; mean age 59.1 years) were evaluated arthroscopically to assess whether the bare spot is consistently located at the center of the inferior glenoid. Another 40 patients with glenohumeral anterior instability who underwent shoulder arthroscopy (30 males, ten females; mean age 25.9 years) were evaluated for glenoid bone loss with preoperative three-dimensional computed tomography (3D-CT) and arthroscopic examination. In patients without instability, the distances from the bare spot of the inferior glenoid to the anterior (Da) and posterior (Dp) glenoid rim were measured arthroscopically. In patients with instability, we compared the percentage glenoid bone loss calculated using CT versus arthroscopic measurements. RESULTS: Among patients without instability, the bare spot could not be identified in three of 27 patients. Da (9.5±1.2 mm) was smaller than Dp (10.1±1.5 mm), but it was not significantly different. However, only 55% of glenoids showed less than 1 mm of difference between Da and Dp, and 18% showed more than 2 mm difference in length. The bare spot could not be identified in five of 40 patients with instability. Pearson's correlation coefficient showed significant (P<0.001) and strong (R (2)=0.63) correlation in percentage glenoid bone loss between the 3D-CT and arthroscopy method measurements. However, in ten shoulders (29%), the difference in percentage glenoid bone loss between 3D-CT and arthroscopic measurements was greater than 5%. CONCLUSION: The bare spot was not consistently located at the center of the inferior glenoid, and the arthroscopic measurement of glenoid bone loss using the bare spot as a landmark was inaccurate in some patients with anterior glenohumeral instability. LEVEL OF EVIDENCE: Level II, prospective comparative study.

Safety screw fixation technique in a case of coracoid base fracture with acromioclavicular dislocation and coracoid base cross-sectional size data from a computed axial tomography study.

Coracoid base fracture accompanied by acromioclavicular joint dislocation with intact coracoclavicular ligaments is a rare injury. Generally, an open reduction with screw fixation is the first treatment choice, as it protects the important structures around the coracoid process. This report presents a new technique of screw fixation for coracoid base fracture and provides anatomic information on cross-sectional size of the coracoid base obtained by computed tomography (CT). An axial image of the coracoid base was visualized over the neck of the scapula, and a guidewire was inserted into this circle under fluoroscopic guidance. The wire was inserted easily into the neck of scapula across the coracoid base fracture with imaging in only 1 plane. In addition, 25 measurements of the coracoid base were made in 25 subjects on axial CT images. Average length of the long and short axes at the thinnest part of the coracoid base was 13.9 ± 2.0 mm (range 10.6-17.0) and 10.5 ± 2.2 mm (6.6-15.1), respectively. This new screw fixation technique and measurement data on the coracoid base may be beneficial for safety screw fixation of coracoid base fracture.

Comparison of tunnel orientation between transtibial and anteromedial portal techniques for anatomic double-bundle anterior cruciate ligament reconstruction using 3-dimensional computed tomography.

PURPOSE: The aim of this study was to compare femoral and tibial tunnel placement, angle, and length between transtibial and anteromedial portal techniques for anatomic double-bundle anterior cruciate ligament (ACL) reconstruction. METHODS: Fifty patients were randomized to the 2 groups, and a femoral tunnel was created through the tibial tunnel (transtibial) and the far anteromedial portal (AMP) in 25 patients each. Both groups underwent anatomic double-bundle ACL reconstruction with hamstring tendons. Volume-rendering computed tomography (CT) was used to evaluate femoral and tibial tunnel placement, and transparent 3-dimensional CT image reconstruction, to evaluate tunnel angles, on the seventh postoperative day. Femoral tunnel length was measured intraoperatively. RESULTS: Anteromedial bundle (AMB) and posterolateral bundle (PLB) femoral tunnels were placed significantly lower and deeper with the AMP technique (shallow/deep direction: 21% and 30%, high/low direction: 18% and 48%) than with the transtibial technique (25% and 34%, 12% and 43%). Except for the tibial tunnel angle in the axial plane, AMB and PLB femoral and tibial tunnel angles differed significantly in 3 dimensions. AMB and PLB femoral tunnel lengths were significantly shorter with the AMP technique (AMB: 33 mm, PLB: 32 mm) than with the transtibial technique (AMB: 49 mm, PLB: 37 mm) (P < .001 and P = .001). Both femoral tunnel lengths in the AMP group correlated significantly with the tunnel angle in the sagittal (AMB: r = 0.69, PLB: r = 0.51) and axial (AMB: r = 0.58, PLB: r = 0.75) planes. CONCLUSIONS: AMB and PLB femoral tunnels were placed significantly deeper, lower, and closer to the femoral footprint reported in previous cadaveric studies in the anteromedial portal technique than in the transtibial technique. Femoral tunnel length was significantly shorter in the anteromedial portal group than in the transtibial group. LEVEL OF EVIDENCE: Level II, prospective comparative study.

In vivo magnetic resonance imaging measurement of tibiofemoral relation with different knee flexion angles after single- and double-bundle anterior cruciate ligament reconstructions.

PURPOSE: Double-bundle anterior cruciate ligament (ACL) reconstruction has been shown to restore better kinematics in vitro, but it is uncertain whether this technique can achieve this in vivo. We investigated whether anatomic double-bundle ACL reconstruction can restore a better tibiofemoral relation in the sagittal plane under static unloading conditions. METHODS: The tibiofemoral relation was assessed with an open magnetic resonance imaging scanner (0.5 T) in 15 patients with anatomic double-bundle reconstruction (double-bundle group) and 14 patients with single-bundle reconstruction (single-bundle group) by use of hamstring tendons. T1-weighted magnetic resonance imaging for both knees was obtained at 0 degrees, 45 degrees, 90 degrees, and 120 degrees of flexion without external force and muscle contraction 6 months after surgery. The position of the posterior femoral condyles relative to the tibia was measured in the midmedial and midlateral sagittal sections of the knee. Clinical evaluation (range of motion, KT-2000 measurement [MEDmetric, San Diego, CA], and pivot-shift test) was performed at the same time. RESULTS: KT-2000 testing showed that the mean side-to-side difference in the double-bundle group (0.7 mm) was significantly smaller than that in the single-bundle group (1.7 mm). In the double-bundle group, the tibiofemoral relation in operated knees was not significantly different from that in the contralateral knees at 0 degrees, 45 degrees, 90 degrees, and 120 degrees of flexion, although at 0 degrees of flexion, the femoral condyles were positioned anteriorly relative to the tibia compared with that in the contralateral knees. Similar results were obtained in the single-bundle group. The difference in the tibiofemoral relation between reconstructed and contralateral knees was not significantly different between the 2 groups. CONCLUSIONS: According to KT-2000 measurement, this study found that anteroposterior stability was better with anatomic double-bundle ACL reconstruction than with single-bundle ACL reconstruction. However, under static conditions without an anterior drawer force, anatomic double-bundle ACL reconstruction did not show superiority in terms of restoring a better tibiofemoral relation compared with single-bundle ACL reconstruction. LEVEL OF EVIDENCE: Level III, comparative study.

Conservative treatment for osteochondrosis of the humeral capitellum.

BACKGROUND: Conservative treatment is recommended for the early stage of osteochondrosis of the humeral capitellum. However, the outcome of conservative treatment has not been well documented. HYPOTHESIS: Osteochondrosis of the humeral capitellum detected at an early stage responds well to conservative treatment. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively reviewed 176 patients with osteochondrosis of the humeral capitellum. There were 134 lesions that were stage I (radiolucent area) in patients with a mean age of 11.5 years and 42 lesions that were stage II (nondisplaced fragments) in patients with a mean age of 13.9 years based on anteroposterior radiographs of the elbow in 45 degrees of flexion. Conservative treatment was performed on 101 patients. The remaining 75 patients did not follow the authors' advice. Conservative treatment consisted of discontinuation of heavy use of the elbow for at least 6 months. Follow-up radiographs were taken at 1-month intervals. At a mean follow-up of 24 months, all patients were evaluated clinically and radiographically. RESULTS: Conservative management produced healing in 90.5% of stage I lesions and 52.9% of stage II lesions. The mean period required for healing was 14.9 months in stage I and 12.3 months in stage II. Sixty-six of 84 (78.6%) stage I patients and 9 of 17 (52.9%) stage II patients returned to competitive-level baseball. Of the 75 patients who did not follow our advice, healing was observed in 17 (22.7%). The healing rate was higher for the 101 patients who followed our advice as opposed to the 75 patients who did not. CONCLUSION: Osteochondrosis of the humeral capitellum can be successfully treated conservatively if treatment is begun in an early stage of the disease.

Hamstring muscle function after tendon harvest for anterior cruciate ligament reconstruction: evaluation with T2 relaxation time of magnetic resonance imaging.

BACKGROUND: Regeneration of the semitendinosus and gracilis tendons after harvesting for anterior cruciate ligament reconstruction has been reported; however, muscle belly function after tendon regeneration has not been well documented. HYPOTHESIS: The semitendinosus and gracilis muscles are highly activated during knee flexion if their tendons are well regenerated after anterior cruciate ligament reconstruction. STUDY DESIGN: Descriptive laboratory study. METHODS: Hamstring muscle activation in 11 patients who had undergone anterior cruciate ligament reconstruction with semitendinosus and gracilis tendons was evaluated by measuring the increase of T2 relaxation time measured via magnetic resonance imaging after knee flexion exercise. Tendon regeneration was evaluated via magnetic resonance imaging. RESULTS: Both muscles increased T2 relaxation time after knee flexion exercise in the operated legs, and there was no significant difference in those values between the operated and nonoperated legs. All the semitendinosus tendons were regenerated at or below the joint line, but no gracilis tendons were observed beyond the joint line. The results indicated that both muscles were highly recruited during knee flexion, regardless of the degree of their tendon regeneration. CONCLUSION: The semitendinosus and gracilis muscles are able to restore or maintain their contractile capability after harvest of their tendons for anterior cruciate ligament reconstruction, regardless of the degree of regeneration.

The most effective exercise for strengthening the supraspinatus muscle: evaluation by magnetic resonance imaging.

BACKGROUND: Electromyography has been used to determine the best exercise for strengthening the supraspinatus muscle, but conflicting results have been reported. Magnetic resonance imaging T2 relaxation time appears to be more accurate in determining muscle activation. PURPOSE: To determine the best exercises for strengthening the supraspinatus muscle. STUDY DESIGN: Criterion standard. METHODS: Six male volunteers performed three exercises: the empty can, the full can, and horizontal abduction. Immediately before and after each exercise, magnetic resonance imaging examinations were performed and changes in relaxation time for the subscapularis, supraspinatus, infraspinatus, teres minor, and deltoid muscles were recorded. RESULTS: The supraspinatus muscle had the greatest change among the studied muscles in relaxation time for the empty can (10.5 ms) and full can (10.5 ms) exercises. After the horizontal abduction exercise the change in relaxation time for the supraspinatus muscle (3.6 ms) was significantly smaller than that for the posterior deltoid muscle (11.5 ms) and not significantly different from that of the other muscles studied. CONCLUSION: The empty can and full can exercises were most effective in activating the supraspinatus muscle.