The modified Norwegian method of biceps tenodesis: how well does it work?

PURPOSE: The purpose of this study was to evaluate clinical outcomes and complications in a series of patients who underwent the modified Norwegian method (MNM) of biceps tenodesis by a single shoulder surgeon. METHODS: A retrospective review of charts from all patients who underwent the modified Norwegian method of biceps tenodesis by the senior author during a 5-year period between 2008 and 2013 was performed. After all patients were identified, informed consent was obtained and DASH and ASES surveys were administered. Inclusion criteria for the study were a minimum 2-year follow-up after MNM tenodesis and appropriate adherence to DASH and ASES survey protocol. Data obtained included: demographic data, time to follow-up, hand dominance, concomitant procedures, workman's compensation (WC) status, DASH and ASES surveys, and complications. A complication was defined as rupture of the tenodesis or post-operative infection. Residual shoulder pain was considered as treatment failure. The data were then analysed using statistical software. In this time period, 94 biceps tenodeses using the MNM technique were performed. Follow-up rate was 75/94 patients (80 %). Of 75 patients, 15 (20 %) had an isolated tenodesis performed. RESULTS: There was no statistically significant difference in DASH or ASES scores when comparing isolated tenodesis patients to those who had concomitant procedures. WC patients had worse DASH and ASES scores (p = 0.016; p = 0.002). The complication rate was 2/75 (3 %), which were both ruptured tenodeses. Of 75 patients, 3 (4 %) experienced treatment failure with residual anterior shoulder pain. CONCLUSIONS: There is debate in the literature regarding the optimal method of biceps tenodesis. This paper demonstrates that the MNM tenodesis appears to be a simple, efficient, and effective alternative to other methods of biceps tenodesis with subjective outcome scores and complication rates that parallel other methods previously described in the literature. LEVEL OF EVIDENCE: IV.

Case Report: Absence of the Long Head of the Biceps Brachii Tendon.

BACKGROUND: Absence of the long head of the biceps brachii (LHB) tendon is rare with an unknown incidence. It can occur bilaterally in patients with or without associated congenital anomalies. Diagnostic difficulty exists with both magnetic resonance imaging and physical examination. METHODS/RESULTS: We present the case of a 24-year-old female with a three year history of progressive right shoulder pain and instability with negative magnetic resonance arthrogram who was subsequently found to have absence of the LHB tendon. CONCLUSIONS: There may be a potential relationship between absence of the LHB tendon and an increased risk of acquired shoulder pain and instability. However, the relationship between the absence of the LHB and subsequent pain and function remains unclear. LEVEL OF EVIDENCE: Level IV.

Greater auricular nerve palsy after arthroscopic anterior-inferior and posterior-inferior labral tear repair using beach-chair positioning and a standard universal headrest.

Shoulder arthroscopy is a common treatment for numerous different pathologies. An iatrogenic nerve injury that occurs during shoulder arthroscopy is more common than previously recognized. However, though many nerve pathologies are increasingly being recognized, reported cases of greater auricular nerve injury are limited. For instance, a case of greater auricular nerve palsy was reported in only 2 series that used a horseshoe headrest. One set of authors discontinued and recommended against use of this headrest, and the other recommended a headrest redesign. Here we report on a case of greater auricular nerve palsy that occurred after the patient's anterior-inferior and posterior-inferior labral tear was arthroscopically repaired using beach-chair positioning and a standard universal headrest. The palsy resulted in numbness and dysesthesia, which lessened gradually over 3 months after surgery and was completely resolved by 6 months.

Biomechanical consequences of a nonanatomic posterior medial meniscal root repair.

BACKGROUND: Posterior medial meniscal root tears have been reported to extrude with the meniscus becoming adhered posteromedially along the posterior capsule. While anatomic repair has been reported to restore tibiofemoral contact mechanics, it is unknown whether nonanatomic positioning of a meniscal root repair to a posteromedial location would restore the loading profile of the knee joint. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the tibiofemoral contact mechanics of a nonanatomic posterior medial meniscal tear with that of the intact knee or anatomic repair. It was hypothesized that a nonanatomic root repair would not restore the tibiofemoral contact pressures and areas to that of the intact or anatomic repair state. STUDY DESIGN: Controlled laboratory study. METHODS: Tibiofemoral contact mechanics were recorded in 6 male human cadaveric knee specimens (average age, 45.8 years) using pressure sensors. Each knee underwent 5 testing conditions for the posterior medial meniscal root: (1) intact knee; (2) root tear; (3) anatomic transtibial pull-out repair; (4) nonanatomic transtibial pull-out repair, placed 5 mm posteromedially along the edge of the articular cartilage; and (5) root tear concomitant with an ACL tear. Knees were loaded with a 1000-N axial compressive force at 4 flexion angles (0°, 30°, 60°, 90°), and contact area, mean contact pressure, and peak contact pressure were calculated. RESULTS: Contact area was significantly lower after nonanatomic repair than for the intact knee at all flexion angles (mean = 44% reduction) and significantly higher for anatomic versus nonanatomic repair at all flexion angles (mean = 27% increase). At 0° and 90°, and when averaged across flexion angles, the nonanatomic repair significantly increased mean contact pressures in comparison to the intact knee or anatomic repair. When averaged across flexion angles, the peak contact pressures after nonanatomic repair were significantly higher than the intact knee but not the anatomic repair. In contrast, when averaged across all flexion angles, the anatomic repair resulted in a 17% reduction in contact area and corresponding increases in mean and peak contact pressures of 13% and 26%, respectively, compared with the intact knee. CONCLUSION: For most testing conditions, the nonanatomic repair did not restore the contact area or mean contact pressures to that of the intact knee or anatomic repair. However, the anatomic repair produced near-intact contact area and resulted in relatively minimal increases in mean and peak contact pressures compared with the intact knee. CLINICAL RELEVANCE: Results emphasize the importance of ensuring an anatomic posterior medial meniscal root repair by releasing the extruded menisci from adhesions and the posteromedial capsule. Similar caution toward preventing displacement of the meniscal root repair construct should be emphasized.

Onset of Frozen Shoulder Following Pneumococcal and Influenza Vaccinations.

OBJECTIVE: Adhesive capsulitis has been suggested as an adverse effect of vaccine administration into the shoulder area. The purpose of this case series is to report 3 cases of acute onset of adhesive capsulitis following pneumococcal and influenza vaccines. CLINICAL FEATURES: Patients reported painful shoulder and limited motion following routine vaccination. After clinical examination, a diagnosis of adhesive capsulitis was noted. INTERVENTION AND OUTCOME: All 3 patients were treated conservatively with physical therapy (active ranges of motion and active-assisted motion), nonsteroidal anti-inflammatory drugs, and activity modification with eventual resolution of symptoms. CONCLUSION: Reports implicating vaccination with adhesive capsulitis are rare. This case series raises the awareness of pneumococcal and influenza vaccinations as possible causes of adhesive capsulitis that appear to respond to standard treatment. Although vaccines are of tremendous importance in the prevention of serious illness, we emphasize the importance of administering them at the appropriate depth and location for each patient.

The modified norwegian method of biceps tenodesis.

This technical note describes a method of biceps tenodesis called the Modified Norwegian Method that is an all-arthroscopic, intra-articular, bony biceps tenodesis that uses a suture shuttle passer through an anterosuperolateral portal. It allows for easy passage of suture through the long head of the biceps tendon while one is viewing through the posterior portal. We believe this method to be a very reasonable and simple method of biceps tenodesis that has complication rates similar to those described for subpectoral and other methods of fixation.

Sensitivity of physical examination versus arthroscopy in diagnosing subscapularis tendon injury.

The purpose of this study was to examine the accuracy of physical examination in the detection of subscapularis tendon tears and compare it with the gold standard of arthroscopy to determine whether clinical examination can reliably predict the presence of subscapularis tendon tears. This was a retrospective analysis of 52 patients (52 shoulders) who underwent arthroscopic subscapularis tendon repairs between September 2008 and April 2012. Positive findings on any combination of the belly press, lift-off, and bear hug tests constituted a positive physical examination result. There was a positive finding on physical examination in 42 of 52 patients. The sensitivity of the physical examination as a whole was 81%. The literature has shown that the belly press, bear hug, and lift-off tests are specific to the subscapularis tendon. To the authors' knowledge, this is the first study to evaluate the sensitivity of these 3 separate clinical tests as a composite. Knowledge regarding the sensitivity of the subscapularis-specific physical examination as a composite can lead practitioners to implement all 3 components, even when 1 test has a negative finding, thus promoting a more thorough physical examination. Because unrepaired subscapularis tendon tears can result in poor outcomes in the repair of other rotator cuff tendons, a complete physical examination would be beneficial to patients with shoulder pathology. The authors conclude that physical examination, when performed consistently by an experienced practitioner, can reliably predict the presence of subscapularis tendon tears.

The accuracy of magnetic resonance imaging and magnetic resonance arthrogram versus arthroscopy in the diagnosis of subscapularis tendon injury.

PURPOSE: The main purpose of this study was to evaluate the accuracy of preoperative magnetic resonance imaging (MRI) in detecting subscapularis tears identified during the gold standard of arthroscopy and determine whether MRI can reliably predict which patients have subscapularis tears. A second purpose was to determine whether magnetic resonance (MR) arthrograms could better identify a subscapularis tear than conventional MRI. METHODS: This was a retrospective study evaluating 39 consecutive patients (40 shoulders) who had a preoperative 1.5-T MRI study and underwent an arthroscopic subscapularis tendon repair. All cases were performed between December 2007 and November 2010. RESULTS: Subscapularis tears were missed on preoperative MR scanning in 25 of 40 shoulders (62.5%). The sensitivity of noncontrast MRI was 40%, the sensitivity of MR arthrography was 36%, and the overall MR sensitivity was 37.5%. CONCLUSIONS: Preoperative 1.5-T MRI of the shoulder does not reliably predict subscapularis tendon tears, regardless of whether conventional MRI or MR arthrography is used. LEVEL OF EVIDENCE: Level II, development of diagnostic criteria on basis of consecutive patients with universally applied gold standard.

Self-limited healing of a radial tear of the lateral meniscus.

UNLABELLED: Radial tears of the meniscus have for decades been treated with partial meniscectomy. However, unstable radial tears usually involve the vascular zones where the circumferential collagen fibers are located. Therefore, in recent years, there has been a great strive to repair radial tears. To the author's knowledge, this is the first case report of a self-limited healing of a radial tear of the lateral meniscus. The patient had a prior injury where he sustained a radial tear to his lateral meniscus and underwent a limited partial meniscectomy. A second-look arthroscopy was performed only after a second injury to the same knee occurred several months later, and it revealed that the radial tear of the lateral meniscus had spontaneously healed. The patient recovered well and returned to full athletic activities. LEVEL OF EVIDENCE: Case-report, Level IV.