MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum.

BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Is there a correlation between outcomes after hip arthroscopy for femoroacetabular impingement syndrome and patient cortical bone thickness?

In order to determine the associations between age, sex, cortical bone thickness (CBT), and outcomes following hip arthroscopy for FAIS, a retrospective study of patients undergoing hip arthroscopy for FAIS from a single institution from 2012 to 2014 was performed. Based on preoperative radiographs, femoral cortical index (FCI) and femoral canal-to-calcar ratio (FCC) were used as measures of CBT and used to classify patients using the Dorr classification. Linear and logistic regression was used to determine whether CBT was predictive of 2-year patient reported outoutcomes. Patients were stratified by sex and age (<45 or =45 years old) to determine whether variables were potential effect modifiers on the association between outcomes and CBT. A total of 108 patients were included in the study, with 27 patients in each of the following groups: females <45, females =45, males <45, and males =45 years. The results showed that at 2-year follow-up, all groups demonstrated significant improvements in reported outcomes (HOS-ADL, HOS-SS, and mHHS) (p<0.001). Females =45 scored significantly worse than other groups on all scores (p<0.05 for all). Chi-square test for trend showed a linear by linear association between Dorr classification type and gender/age group (p=0.018). Analysis of the whole study population showed a linear association between FCC and HOS-ADL and mHHS scores. However, CBT measures were not predictive of achieving MCID. In conclusion, patients undergoing hip arthroscopy for FAIS, older female patients had the worst patient-reported outcomes and lowest CBT measures. Furthermore, FCC is independently associated with the HOS-ADL and mHHS. LEVEL OF EVIDENCE: Retrospective comparative study, Level III. WHAT IS KNOWN ABOUT THE SUBJECT: Among patients undergoing hip arthroscopy for FAIS, female patients over the age of 45 have been reported to be at risk for inferior post-operative outcomes. Meanwhile, this patient population is also the most at risk for deteriorating CBT. WHAT THIS STUDY ADDS TO EXISTING KNOWLEDGE: This study demonstrates that female patients with FAIS over the age of 45 have inferior CBT indices than their male and younger-aged counterparts. Furthermore, this study presents an association between the FCC and 2-year patient-reported outcome measures, suggesting that CBT characterization may withhold prognostic value.

Preoperative Symptom Duration Is Associated With Outcomes After Hip Arthroscopy.

BACKGROUND: Prolonged disease chronicity has been implicated as a cause of suboptimal clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), possibly due to disease progression, deconditioning, and the development of compensatory pathomechanics. PURPOSE: To evaluate the effect of increasing duration of preoperative symptoms on patient-reported outcomes, reoperation, and clinical failure of hip arthroscopy for FAIS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective cohort study was performed to identify all patients undergoing primary hip arthroscopy between January 1, 2012, and July 30, 2014, by a single surgeon, with minimum follow-up of 2 years. Patient demographics, comorbid medical conditions, and preoperative outcome scores were compared between patients with preoperative symptoms lasting less than 2 years and those with symptoms lasting 2 years or longer. Multivariate regressions were used to compare Hip Outcome Score Activities of Daily Living (HOS-ADL), Hip Outcome Score Sport-Specific (HOS-SS), and modified Harris Hip Score (mHHS) between the 2 cohorts at 2 years of follow-up. RESULTS: A total of 624 patients were included, with an average age of 34.0 ± 13.5 years; 235 (37.7%) patients had experienced preoperative symptoms 2 years or longer. Patients with symptoms lasting less than 2 years had statistically significant higher outcome scores than those with symptoms lasting 2 or more years for the HOS-ADL (86.3 ± 16.4 vs 80.3 ± 19.9, respectively), HOS-SS (75.0 ± 25.3 vs 65.1 ± 29.0), and mHHS (79.1 ± 16.6 vs 74.0 ± 18.8), as well as higher satisfaction (82.1 ± 30.7 vs 71.1 ± 31.6) and lower pain scores (2.6 ± 2.3 vs 3.5 ± 2.6). On multivariate analysis, patients with symptoms 2 years or longer had significantly higher visual analog scale-Pain score (ß = 0.6, P = .039) and lower HOS-ADL (ß = -3.4, P = .033), HOS-SS (ß = -6.3, P = .012), and satisfaction (ß = -6.7, P = .028) at 2-year follow-up. Patients with longer duration of symptoms also demonstrated less improvement in HOS-SS (ß = -10.3, P = .001) at 2 years after surgery. Patients with symptoms for 2 years or longer were significantly less likely to achieve a patient acceptable symptomatic state for HOS-ADL (relative risk [RR] = 0.8, P = .024) and HOS-SS (RR = 0.8, P = .032) at 2 years of follow-up. Patients with symptoms 2 years or longer also demonstrated significantly higher rates of revision arthroscopy (RR = 10.1, P = .046). CONCLUSION: Patients with untreated, FAIS-related symptoms lasting 2 years or longer before arthroscopic management had significantly worse patient-reported outcomes and higher rates of reoperation at 2 years after surgery when compared with those patients with a shorter duration of preoperative symptoms.

SRS-22r Scores in Nonoperated Adolescent Idiopathic Scoliosis Patients With Curves Greater Than Forty Degrees.

STUDY DESIGN: Case control comparative series. OBJECTIVE: Describe surgical range adolescent idiopathic scoliosis (AIS) patients electing to forgo surgery and compare health-related quality-of-life outcomes to a similar cohort of operated AIS patients by the same single surgeon. SUMMARY OF BACKGROUND DATA: No data have been published either documenting SRS-22r scores of nonoperated patients with curves ≥40° or comparing these scores to a demographically similar operated cohort. METHODS: Individuals with curves ≥40°, age ≥18 years, and electing to forgo surgery were identified. All patients completed an SRS-22r questionnaire. This nonoperated cohort's SRS-22r scores were compared to those of a large demographically similar cohort operated by the same surgeon. Group differences between the SRS-22r scores were evaluated by comparing these to published Minimal Clinically Important Differences (MCID) for the SRS-22r. RESULTS: One hundred ninety subjects with nonoperated curves were compared to 166 individuals who underwent surgery. The nonoperated cohort averaged 23.5 years of age, averaged 7.7 years since curve reached 40°, and had an average 50° Cobb angle at last follow-up. No statistical significant differences were found between the groups on the Pain, Function, or Mental Health domains of the SRS-22r. Statistically significant differences in favor of the operative cohort were found for self-image, satisfaction, and total score. The observed group differences did not meet the established thresholds for minimal clinically important differences in any of the domain scores, the average total score, or raw scores. CONCLUSION: There are no meaningful clinically significant differences in SRS-22r scores at average 8-year follow-up between AIS patients with curves ≥40° treated with or without surgery. These data in conjunction with an absence of long-term evidence of serious medical consequences with nonsurgical management of curves ≥40° should encourage surgeons to reevaluate the benefits of routine surgical care. LEVEL OF EVIDENCE: 3.

Macroscopic anatomical, histological and magnetic resonance imaging correlation of the lateral capsule of the knee.

PURPOSE: The objective of the present study was to correlate macroscopic and microscopic anatomy of the lateral capsule of the knee joint with high-quality magnetic resonance imaging (MRI), with a hypothesis that a distinct lateral capsular ligament would be inconsistently observed via surgical dissection and that high-quality MRI imaging would correlate to findings from dissection. METHODS: Ten fresh-frozen human cadaveric knee specimens were utilized for this study. MRI of each knee was obtained pre- and post-dissection. The lateral knee was dissected and analysed for the presence or absence of a discrete capsular thickening or an independent ligamentous structure. A musculoskeletal radiologist analysed the pre- and post-dissection MRI. Subsequently, two specimens with positive lateral capsular thickening were prepared for histology. RESULTS: On macroscopic dissection, none of the ten specimens were found to have a discrete lateral capsular ligament. A palpable macroscopic thickening of the lateral capsule was identified in 4/10 specimens. MRI analysis revealed a 2-4 mm thickening of the central third of the lateral capsule in 3/10 specimens. On histological analysis, the lateral capsular thickening demonstrated properties similar to both capsule and ligament. CONCLUSIONS: In fresh-frozen cadaveric specimens, macroscopic and MRI evaluation of the lateral capsule of the knee revealed variations in morphology without consistent capsuloligamentous anatomy and specifically no discrete lateral capsular ligament. Further investigation in the form of clinical and mechanical relevance of the lateral capsular structures is of paramount importance before limited anatomical data can be utilized to drive clinical decision-making and patient care.

Effect of highly purified capsaicin on articular cartilage and rotator cuff tendon healing: An in vivo rabbit study.

Highly purified capsaicin has emerged as a promising injectable compound capable of providing sustained pain relief following a single localized treatment during orthopedic surgical procedures. To further assess its reliability for clinical use, the potential effect of highly purified capsaicin on articular cartilage metabolism as well as tendon structure and function warrants clarification. In the current study, rabbits received unilateral supraspinatus transection and repair with a single 1 ml injection of capsaicin (R+C), PEG-only placebo (R+P), or saline (R+S) into the glenohumeral joint (GHJ). An additional group received 1 ml capsaicin onto an intact rotator cuff (I+C). At 18 weeks post-op, cartilage proteoglycan (PG) synthesis and content as well as cell viability were similar (p>0.05) across treatment groups. Biomechanical testing revealed no differences (p>0.05) among tendon repair treatment groups. Similarly, histologic features of both cartilage and repaired tendons showed minimal differences across groups. Hence, in this rabbit model, a single injection of highly purified capsaicin into the GHJ does not induce a deleterious response with regard to cartilage matrix metabolism and cell viability, or rotator cuff healing. These data provide further evidence supporting the use of injectable, highly purified capsaicin as a safe alternative for management of postoperative pain following GHJ surgery.

Hematoma block versus sedation for the reduction of distal radius fractures in children.

PURPOSE: To determine which mode of anesthesia, hematoma block (HB) or procedural sedation (PS), was preferable for distal radius fracture (DRF) reduction in children. METHODS: Fifty-two children (mean age, 12 y; range, 5-16 y) presenting with DRFs requiring reduction were prospectively enrolled and offered either PS or HB for anesthesia. Following reduction, families completed a satisfaction survey regarding mode of anesthesia and overall care (rated 0-10, with 10 being the best score) and an assessment of discomfort (rated 0-10, with 0 being no pain). Length of stay in the emergency department (ED) and complications related to procedure and method of anesthesia were recorded. Radiographic alignment was evaluated before and after reduction. RESULTS: Twenty-six patients underwent reduction with either PS or HB. Midazolam was used in addition to HB in 8 patients. One patient was converted from HB to PS due to inadequate block. There was no significant difference in prereduction and postreduction angulation between the groups, and reductions maintained satisfactory alignment. Overall satisfaction and satisfaction with anesthesia were excellent for both groups, with respective means of 9.5 and 9.5 for PS and 9.3 and 9.6 for HB. Patient discomfort was minimal in both groups, with a mean of 1.6 for PS and 2.2 for HB. Length of stay was significantly shorter for HB patients, with patients spending a mean of 2.2 hours less in the ED. Three patients required further intervention following initial reduction. One patient in each group required revision reduction, and 1 PS patient underwent closed reduction and pinning. CONCLUSIONS: Use of HB for the reduction of pediatric DRFs provided radiographic alignment, patient satisfaction, and pain control comparable with that of PS, while significantly decreasing ED time and resources.

Clinical outcome of revision meniscal allograft transplantation: minimum 2-year follow-up.

PURPOSE: The purpose of this study was to assess the clinical and radiographic outcomes after revision meniscal allograft transplantation (RMAT). METHODS: Eleven patients underwent RMAT performed by the senior author (B.J.C.). These patients were studied prospectively and completed standardized outcome surveys (including International Knee Documentation Committee [IKDC], Cincinnati Knee-Rating System, Tegner score, Lysholm score, Short Form-12, Knee Injury and Osteoarthritis Outcome Score [KOOS], and overall satisfaction) preoperatively and annually thereafter for a minimum of 2 years. Radiographic analysis before surgery and at the most recent follow-up included anteroposterior, Rosenberg, lateral, and sunrise views graded by the Kellgren and Lawrence (K & L) scale. The status of the articular cartilage was graded intraoperatively using the Outerbridge classification. Two patients were lost to follow-up and one declined further participation. RESULTS: The average time to RMAT from the index procedure was 3.45 ± 2.52 years, with a mean follow-up after RMAT of 3.83 ± 1.3 years. One patient progressed to arthroplasty during follow-up and was not included in subjective outcome score follow-up. Clinical outcome scores that demonstrated significant improvements included IKDC (43 ± 12 to 61 ± 16; P = .03) and KOOS pain score (66 ± 12 to 79 ± 11; P = .047). Along with this, the subjective symptom rate significantly improved from 5.0 ± 0.9 preoperatively to 6.7 ± 1.8 postoperatively (P = .011). Radiographic (P = .7) and Outerbridge (P = .809) grading did not show progression. Seven of 8 patients would have surgery again, and satisfaction at final follow-up was 7.6 ± 2.6. CONCLUSIONS: In this small series with short-term follow-up, RMAT resulted in high patient satisfaction and significant symptom reduction on validated outcome scores (IKDC and KOOS pain score), proving the original hypothesis that outcomes after RMAT would be improved compared with preoperative conditions. Identifiable causes of MAT failure may help predict response to RMAT. Because arthroplasty is still not favored in young active patients, a thorough discussion with the patient is necessary to best align their goals with those of the surgery when considering revision meniscus transplantation. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Persistence, localization, and external control of transgene expression after single injection of adeno-associated virus into injured joints.

A single intra-articular injection of adeno-associated virus (AAV) results in stable and controllable transgene expression in normal rat knees. Because undamaged joints are unlikely to require treatment, the study of AAV delivery in joint injury models is crucial to potential therapeutic applications. This study tests the hypotheses that persistent and controllable AAV-transgene expression are (1) highly localized to the cartilage when AAV is injected postinjury and (2) localized to the intra-articular soft tissues when AAV is injected preinjury. Two AAV injection time points, postinjury and preinjury, were investigated in osteochondral defect and anterior cruciate ligament transection models of joint injury. Rats injected with AAV tetracycline response element (TRE)-luciferase received oral doxycycline for 7 days. Luciferase expression was evaluated longitudinally for 6 months. Transgene expression was persistent and controllable with oral doxycycline for 6 months in all groups. However, the location of transgene expression was different: postinjury AAV-injected knees had luciferase expression highly localized to the cartilage, while preinjury AAV-injected knees had more widespread signal from intra-articular soft tissues. The differential transgene localization between preinjury and postinjury injection can be used to optimize treatment strategies. Highly localized postinjury injection appears advantageous for treatments targeting repair cells. The more generalized and controllable reservoir of transgene expression following AAV injection before anterior cruciate ligament transection (ACLT) suggests an intriguing concept for prophylactic delivery of joint protective factors to individuals at high risk for early osteoarthritis (OA). Successful external control of intra-articular transgene expression provides an added margin of safety for these potential clinical applications.

Rotator cuff healing after continuous subacromial bupivacaine infusion: an in vivo rabbit study.

BACKGROUND: The objective of this study was to evaluate the effects of continuous subacromial bupivacaine infusion on supraspinatus muscle and rotator cuff tendon healing using gross, biomechanical, and histologic analyses. MATERIALS AND METHODS: Thirty-three New Zealand White rabbits underwent unilateral supraspinatus transection and rotator cuff repair (RCR). Rabbits were assigned to 1 of 3 groups: (1) RCR only, (2) RCR with continuous saline infusion for 48 hours, or (3) RCR with continuous 0.25% bupivacaine with epinephrine (1:200,000) infusion for 48 hours. Rabbits were euthanized postoperatively at 2 weeks (for histologic assessment) or 8 weeks (for biomechanical and histologic assessment). RESULTS: Tensile testing showed a significantly higher load to failure in intact tendons compared with repaired tendons (P < .01); however, no statistical differences were detected among RCR only, RCR saline, and RCR bupivacaine groups. Histologically, the enthesis of repaired tendons showed increased cellularity and disorganized collagen fibers compared with intact tendons, with no differences between treatment groups. Muscle histology demonstrated scattered degenerative muscle fibers at 2 weeks in RCR saline and RCR bupivacaine groups, but no degeneration was noted at 8 weeks. CONCLUSIONS: The healing supraspinatus tendons exposed to bupivacaine infusion showed similar histologic and biomechanical characteristics compared with untreated and saline-infused RCR groups. Muscle histology showed fiber damage at 2 weeks for the saline and bupivacaine-treated groups, with no apparent disruption at 8 weeks, suggesting a recovery process. Therefore, subacromial bupivacaine infusion in this rabbit rotator cuff model does not appear to impair muscle or tendon after acute injury and repair.

Effects of doxycycline on mesenchymal stem cell chondrogenesis and cartilage repair.

OBJECTIVE: Strategies to improve cartilage repair tissue quality after bone marrow cell-based procedures may reduce later development of osteoarthritis. Doxycycline is inexpensive, well-tolerated, and has been shown to reduce matrix-metalloproteinases (MMPs) and osteoarthritis progression. This study tests the hypotheses that doxycycline reduces MMP, enhances chondrogenesis of human bone marrow-derived mesenchymal stem cells (hMSC), and improves in vivo cartilage repair. DESIGN: Ninety hMSC pellets were cultured in chondrogenic media with either 0-, 1- or 2-µg/mL doxycycline. Pellets were evaluated with stereomicroscopy, proteoglycan assay, qRT-PCR, and histology. Osteochondral defects (OCDs) were created in the trochlear grooves of 24-Sprague-Dawley rats treated with/without oral doxycycline. Rats were sacrificed at 12-weeks and repair tissues were examined grossly and histologically. RESULTS: hMSC pellets with 1-µg/mL (P = 0.014) and 2-µg/mL (P = 0.002) doxycycline had larger areas than pellets without doxycycline. hMSC pellets with 2-µg/mL doxycycline showed reduced mmp-13 mRNA (P = 0.010) and protein at 21-days. Proteoglycan, DNA contents, and mRNA expressions of chondrogenic genes were similar (P > 0.05). For the in vivo study, while the histological scores were similar between the two groups (P = 0.116), the gross scores of the OCD repair tissues in doxycycline-treated rats were higher at 12-weeks (P = 0.017), reflective of improved repair quality. The doxycycline-treated repairs also showed lower MMP-13 protein (P = 0.029). CONCLUSIONS: This study shows that doxycycline improves hMSC chondrogenesis and decreases MMP-13 in pellet cultures and within rat OCDs. Doxycycline exerted no negative effect on multiple measures of chondrogenesis and cartilage repair. These data support potential use of doxycycline to improve cartilage repair to delay the onset of osteoarthritis.

The role of ACL injury in the development of posttraumatic knee osteoarthritis.

Acute anterior cruciate ligament (ACL) tears are most frequently sustained by young, physically active individuals. ACL injuries are seen at high incidence in adolescents and young adults performing sports and occupational activities that involve pivoting. Young women participating in pivoting sports have a 3 to 5 times higher risk of ACL injury than men. Studies show that ACL injury increases osteoarthritis (OA) risk with symptomatic OA appearing in roughly half of individuals 10-15 years later. Because the majority of patients sustaining acute ACL tears are younger than 30, this leads to early onset OA with associated pain and disability during premium work and life growth years between ages 30 and 50. Effective strategies to prevent ACL injury and to reduce subsequent OA risk in those sustaining acute ACL tears are needed.

Interobserver and intraobserver reliability of the Goutallier classification using magnetic resonance imaging: proposal of a simplified classification system to increase reliability.

BACKGROUND: The Goutallier classification of fatty infiltration of the rotator cuff was developed for use in axial computed tomography arthrography. Now the Goutallier classification is being used with magnetic resonance imaging (MRI). Not only is there debate on the validity of the use of this system in MRI, but current literature is unclear as to the clinical use of the Goutallier classification. HYPOTHESIS: There will be significant inter- and intraobserver variability of the Goutallier classification grading system for patients with chronic rotator cuff tears. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: An online database consisting of 35 single MRI images from 35 patients with chronic rotator cuff tears was designed and sent to members of the American Shoulder and Elbow Society. Surgeons were asked to identify the stage of rotator cuff fatty infiltration using the Goutallier classification system. Thirty surgeons responded and completed the survey in its entirety. At a minimum of 2 months later, 28 of the 30 initial respondents completed evaluations of the same online database. The responding surgeons were divided dichotomously according to their demographics and the interobserver reliability of the groups compared. A kappa analysis was performed to determine inter- and intraobserver reliability using 95% confidence intervals (95% CIs). A simplified 3-tiered classification was proposed combining Goutallier grades 0 and 1 as well as grades 2 and 3. RESULTS: Statistical analysis of all respondent data demonstrated moderate intraobserver variability with a κ value of 0.56 (95% CI, 0.53-0.60). In addition, moderate interobserver variability was shown with a κ value of 0.43 (range, 0.16-0.74). With the simplified classification, intraobserver reliability was 0.70 (95% CI, 0.66-0.74) and interobserver reliability was 0.61 (range, 0.21-0.87). Correlation analysis showed no correlation with the presence or absence of fellowship training or board certification with either the Goutallier classification or the proposed modification (P > .05). Sports versus shoulder/elbow fellows had statistically better intraobserver variability (κ = 0.63 vs 0.50) with the Goutallier classification. Years in practice was negatively correlated with the level of agreement for both classifications (-r value, P < .05). The number of rotator cuff repairs performed per year negatively correlated with the level of agreement in the proposed modification only (r = -0.44, P = .022). Percent of practice dedicated to the shoulder did not correlate significantly with either classification (P > .05). CONCLUSION: There is significant inter- and intraobserver variability observed among experienced shoulder surgeons using the Goutallier classification for assessing fatty infiltration of the rotator cuff muscles after chronic rotator cuff tears. Respondents were more likely to agree with themselves than with other respondents. A simplification of the MRI classification system is proposed that takes into consideration the variability determined by this study.

Rotator cuff repair augmentation using a novel polycarbonate polyurethane patch: preliminary results at 12 months' follow-up.

BACKGROUND: Preventing anatomic failure after rotator cuff repair (RCR) remains a challenge. Augmentation with a surgical mesh may permanently reinforce the repair and decrease failure rates. The purpose of this study is to assess the postoperative outcomes of open RCR augmented with a novel reticulated polycarbonate polyurethane patch. MATERIALS AND METHODS: Ten patients with supraspinatus tendon tears underwent open RCR augmented with a polycarbonate polyurethane patch secured in a 6-point fixation construct placed over the repaired tendon. Patients were evaluated with preoperative and postoperative outcome measures, including the Simple Shoulder Test, visual analog pain scale, American Shoulder and Elbow Surgeons shoulder score, Cumulative Activities of Daily Living score, and University of California, Los Angeles shoulder scale, as well as range of motion. Postoperative magnetic resonance imaging was used to evaluate repair status. RESULTS: Patients showed significant improvements in visual analog pain scale, Simple Shoulder Test, and American Shoulder and Elbow Surgeons shoulder scores at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). The University of California, Los Angeles postoperative score was good to excellent in 7 patients at 6 months and in 8 patients at 12 months. Range of motion in forward flexion, abduction, internal rotation, and external rotation was significantly improved at both 6 and 12 months postoperatively (P < .05 and P < .01, respectively). Magnetic resonance imaging at 12 months showed healing in 90%; one patient had a definitive persistent tear. We found no adverse events associated with the patch, including the absence of fibrosis, mechanical symptoms, or visible subacromial adhesions. DISCUSSION: The polycarbonate polyurethane patch was designed to support tissue in growth and enhance healing as shown by preclinical animal studies. Clinically, the patch is well tolerated and shows promising efficacy, with a 10% retear rate at the 12-month time point.

Medial versus lateral supraspinatus tendon properties: implications for double-row rotator cuff repair.

BACKGROUND: Rotator cuff repair retear rates range from 25% to 90%, necessitating methods to improve repair strength. Although numerous laboratory studies have compared single-row with double-row fixation properties, little is known regarding regional (ie, medial vs lateral) suture retention properties in intact and torn tendons. HYPOTHESIS: A torn supraspinatus tendon will have reduced suture retention properties on the lateral aspect of the tendon compared with the more medial musculotendinous junction. STUDY DESIGN: Controlled laboratory study. METHODS: Human supraspinatus tendons (torn and intact) were randomly assigned for suture retention mechanical testing, ultrastructural collagen fibril analysis, or histologic testing after suture pullout testing. For biomechanical evaluation, sutures were placed either at the musculotendinous junction (medial) or 10 mm from the free margin (lateral), and tendons were elongated to failure. Collagen fibril assessments were performed using transmission electron microscopy. RESULTS: Intact tendons showed no regional differences with respect to suture retention properties. In contrast, among torn tendons, the medial region exhibited significantly higher stiffness and work values relative to the lateral region. For the lateral region, work to 10-mm displacement (1592 ± 261 N-mm) and maximum load (265 ± 44 N) for intact tendons were significantly higher (P < .05) than that of torn tendons (1086 ± 388 N-mm and 177 ± 71 N, respectively). For medial suture placement, maximum load, stiffness, and work of intact and torn tendons were similar (P > .05). Regression analyses for the intact and torn groups revealed generally low correlations between donor age and the 3 biomechanical indices. For both intact and torn tendons, the mean fibril diameter and area density were greater in the medial region relative to the lateral (P ≤ .05). In the lateral tendon, but not the medial region, torn specimens showed a significantly lower fibril area fraction (48.3% ± 3.8%) than intact specimens (56.7% ± 3.6%, P < .05). CONCLUSION: Superior pullout resistance of medially placed sutures may provide a strain shielding effect for the lateral row after double-row repair. Larger diameter collagen fibrils as well as greater fibril area fraction in the medial supraspinatus tendon may provide greater resistance to suture migration. CLINICAL RELEVANCE: While clinical factors such as musculotendinous integrity warrant strong consideration for surgical decision making, the present ultrastructural and biomechanical results appear to provide a scientific rationale for double-row rotator cuff repair where sutures are placed more medially at the muscle-tendon junction.

Outcomes of type II superior labrum, anterior to posterior (SLAP) repair: prospective evaluation at a minimum two-year follow-up.

HYPOTHESIS: Patients with type II superior labrum, anterior to posterior (SLAP) lesions will have improved function and decreased pain at a minimum of 2 years after arthroscopic SLAP repair using bioabsorbable suture anchor fixation. MATERIALS AND METHODS: The study population consisted of 48 patients who underwent arthroscopic SLAP repair. Subjective shoulder scores, range of motion, and strength (postoperative only) were assessed preoperatively and at a minimum of 2 years postoperatively. RESULTS: At an average of 3.4 years after surgery, statistically significant improvement was seen in American Shoulder and Elbow Surgeons score, University of California, Los Angeles score, Simple Shoulder Test scores, Constant activities of daily living, visual analog scale for pain, and Short Form-12 Health Survey physical outcome scores. Improvements were made in forward flexion, abduction, external rotation, and internal rotation. Subgroup analysis of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes showed preoperative to postoperative improvements in subjective outcomes scores. Overhead laborers and nonlaborers also showed preoperative to postoperative improvements in subjective shoulder scores. DISCUSSION: No differences were seen between the outcomes of nonathletes, nonoverhead athletes, recreational overhead athletes, and collegiate overhead athletes, suggesting that SLAP type II repair is successful independent of the patient's vocation or sport. CONCLUSION: These results show that arthroscopic SLAP repair of type II lesions with bioabsorbable suture anchors provides a significant improvement in functional capacity and pain relief.

Restoring the labral height for treatment of Bankart lesions: a comparison of suture anchor constructs.

PURPOSE: The purpose of this study was to evaluate glenoid labral heights before injury and after repair with 2 suture anchors: (1) traditional suture anchor secured with knots and (2) knotless suture anchor. METHODS: Ten matched pairs of human cadaveric glenoids were examined. In each specimen the labrum was detached from the 3-o'clock position to the 6:30 clock position on the anteroinferior glenoid, and labral repair was performed with either (1) traditional Bio-SutureTak suture anchors (n = 10) (Arthrex, Naples, FL) or (2) knotless PushLock suture anchors (n = 10, contralateral side) (Arthrex). By use of a 3-dimensional digitizer, the labral height, measured from the deepest point of the glenoid articular surface to the highest tip of the labrum, was measured in all specimens before injury and after repair at the 3:30, 4:30, and 5:30 clock positions. The degree of labral height increase was computed as a percent increase in labral height from before injury to after repair. RESULTS: Labral height increased significantly for all specimens from before injury (5.35 mm) to after repair (8.05 mm) (159.1% +/- 13.7%, P < .0001). Increases in labral height from before injury to after repair were similar (P > .05) for Bio-SutureTak suture anchors (164.6% +/- 18.7%, P < .0001) and PushLock suture anchors (153.6% +/- 5.8%, P < .0001). The amount of labral height increase did not vary by anatomic location (157.0% +/- 50.2%, 168.9% +/- 51.0%, and 150.4% +/- 35.2% at 3:30, 4:30, and 5:30, respectively; P = .46). CONCLUSIONS: An increase in labral height can be achieved to create a significant height increase from before injury to after labral repair. The difference in labral height afforded by a traditional suture anchor and a knotless anchor is not statistically significant. CLINICAL RELEVANCE: Both traditional and knotless suture anchor constructs provide a reliable restoration of labral height in an acute Bankart model.