Biceps Tenodesis as an Attractive Alternative to Superior Labral Anterior-Posterior (SLAP) Repair for Type II SLAP Lesions in Active-Duty Military Patients Younger Than 35 Years.

BACKGROUND: Biceps tenodesis has been suggested as a superior surgical technique compared with isolated labral repair for superior labral anterior-posterior (SLAP) tears in patients older than 35 years. The superiority of this procedure in younger patients, however, is yet to be determined. PURPOSE: To compare the outcomes of arthroscopic SLAP repair with those of arthroscopic-assisted subpectoral biceps tenodesis for type II SLAP tears in active-duty military patients younger than 35 years. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Preoperative and postoperative evaluations with a minimum 5-year follow-up including the visual analog scale (VAS), the Single Assessment Numeric Evaluation (SANE), and the American Shoulder and Elbow Surgeons (ASES) shoulder score were administered, and scores were compared between 2 groups of patients younger than 35 years. One group included 25 patients who underwent SLAP repair, and the second group included 23 patients who underwent arthroscopic-assisted subpectoral biceps tenodesis. RESULTS: The preoperative patient age (P = .3639), forward flexion (P = .8214), external rotation (P = .5134), VAS pain score (P = .4487), SANE score (P = .6614), and ASES score (P = .6519) did not vary significantly between the 2 study groups. Both groups demonstrated statistically significant increases in function as measured by the ASES and SANE and decreases in pain as measured by the VAS at a minimum of 5 years postoperatively. Also at a minimum of 5 years postoperatively, patients in the tenodesis group had lower pain (1.3 vs 2.6, respectively; P = .0358) and higher SANE (84.0 vs 63.3, respectively; P = .0001) and ASES (85.7 vs 75.4, respectively; P = .0342) scores compared with those in the repair group. Failure rate was 20.0% in the repair group versus 0.0% in the tenodesis group (P = .0234). CONCLUSION: Active-duty military patients younger than 35 years with type II SLAP tears had more predictable improvement in pain, better functional outcomes, and lower failure rates after biceps tenodesis compared with SLAP repair for type II SLAP tears. Overall, the results of this study indicate that arthroscopic- assisted subpectoral biceps tenodesis is superior to arthroscopic SLAP repair for the treatment of type II SLAP tears in military patients younger than 35 years.

Outcomes of Simultaneous Arthroscopic Rotator Cuff Repair and Inferior Labral Repair Among Active Patients Younger Than 40 Years.

Rotator cuff tears as a consequence of shoulder instability, which are uncommon among patients younger than 40 years, have been found to be more prevalent in active duty service members in this age group. As a result, this population provides a unique opportunity to study concurrent arthroscopic treatment of rotator cuff and inferior labrum tears in young, active patients, a topic that has not been studied extensively. The goal of this study was to report clinical outcomes of rotator cuff and inferior labral tears managed concurrently with all-arthroscopic repair for military patients younger than 40 years. Data were collected prospectively from 30 arthroscopic rotator cuff repair procedures with concurrent inferior labral repair performed on 29 individual military patients younger than 40 years (mean, 33.5 years; range, 21-39 years) and retrospectively analyzed. Preand postoperative evaluations conducted during a minimum 2-year follow-up period (mean, 35 months; range, 24-68 months) included visual analog scale (VAS) score, Subjective Shoulder Value (SSV), American Shoulder and Elbow Surgeons (ASES) shoulder score, and range of motion. Mean VAS score improved from 7.63±1.85 to 1.00±1.44 (P<.0001). Mean SSV improved from 54.83±17.10 to 90.83±9.75 (P<.0001). Mean ASES shoulder score improved from 45.37±12.99 to 90.43±10.67 (P<.0001). No significant improvement was found in range of motion; however, improved mean measurements were consistently noted in all directions. Complications (10%; 3 of 30) included 1 re-tear of the rotator cuff repair and 2 postoperative frozen shoulders. Arthroscopic repair of rotator cuff tears with concurrent repair of inferior labral tear in active patients younger than 40 years produced excellent patient outcomes, with high rates of return to preoperative level of recreational and military job activity and low risk of complications. [Orthopedics. 2021;44(3):e326-e330.].

Risk of Iatrogenic Axillary Nerve Injury During Acromioclavicular Joint Reconstruction.

Anatomical reconstruction of the coracoclavicular ligaments involves drilling the base of the coracoid or looping a graft around it, placing the axillary nerve at risk for injury. Rockwood type V acromioclavicular (AC) separation injuries involve disruption of the AC joint capsule and coracoclavicular ligaments, resulting in inferomedial displacement of the scapulohumeral complex and alteration of the normal anatomical relations of the shoulder girdle structures. This study evaluated the effect of Rockwood type V AC separation on the anatomical relation of the axillary nerve to the coracoid base. Ten shoulders of 6 adult human cadavers were dissected to determine the dimensions of the coracoid. A digital caliper was used to measure the coracoclavicular distance and the minimal distance between the coracoid base and the axillary nerve. A Rockwood type V AC separation was created by transecting the AC joint capsule and coracoclavicular ligaments, and applying 15 kg of longitudinal tension to the upper extremity. Changes in the distance between the coracoid base and the axillary nerve were measured. Mean width, length, and thickness of the coracoid was 15.05±0.93 mm, 23.1±1.75 mm, and 11.88±1.33 mm, respectively. Mean distance between the coracoid base and the axillary nerve was 26.0±3.9 mm. After simulated Rockwood type V AC separation, mean distance was 22.0±3.4 mm; this difference was statistically significant (P=.0263; 95% CI, 2.0-5.9 mm). The axillary nerve is closer to the coracoid base during simulated Rockwood type V AC separation than previously reported in the orthopedic literature. Anatomical reconstruction of the coracoclavicular ligaments for Rockwood type V AC separation presents a higher risk for axillary nerve iatrogenic injury than previously reported. [Orthopedics. 2021;44(1):e68-e72.].

Direct repair of chronic pectoralis major tears in active duty military patients.

OBJECTIVE: To express the significance and report the clinical outcomes of active duty military patients who underwent direct pectoralis major repairs in a chronic setting. METHODS: Retrospective review of data collected on 16 active duty military patients who underwent direct repair of a chronic pectoralis major tear. Pre-operative and post-operative evaluations (minimum 2 year follow up; mean, 53.46 months; range, 24-88 months) included range of motion, Bak classification, visual analog scale (VAS), Single Assessment Numerical Evaluation (SANE) Score, Quick Disabilities of the Arm, Shoulder and Hand (DASH) Score, and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. RESULTS: Using a Bak classification, 94% (15/16) of patients were reported with good or excellent results. Mean VAS score improved from 7.08 ± 1.66 to 0.54 ± 1.20 (p < 0.0001). Mean SANE score improved from 42.31 ± 19.96 to 94.62 ± 5.94 (p < 0.0001). The average Quick DASH score increased from 55.42 ± 15.34 to 7.30 ± 6.39 (p < 0.0001). The average ASES score increased from 48.71 ± 13.80 to 94.62 ± 7.63 (p < 0.0001). There was no loss of motion after surgery in forward flexion, external rotation or internal rotation. The average internal rotation muscle power increased from 4.15 ± 0.48 to 4.92 ± 0.28 (p < 0.0001). COMPLICATIONS: 6.25% (1/16) patients developed a keloid scar, tender to direct pressure post-operatively. 94% (15/16) of patients returned to their pre-operative level of recreational and military job activity. CONCLUSION: Military patients who underwent direct repair of a chronic pectoralis major tear had excellent clinical outcomes, low risk of complications, and a high return to pre-operative level of recreational and military job activity. LEVEL OF EVIDENCE: Case Series; IV.

Outpatient Orthopedic Rehabilitation in New York State During the COVID-19 Pandemic: Therapist Perspectives.

The COVID-19 pandemic has had a strong impact on the care of orthopedic patients. This impact has been particularly difficult in New York State, which experienced the largest number of COVID-19 cases and led to a state- mandated pause on all elective surgeries. As a result, physical and occupational therapists became the principal providers of care and had to adjust their workflow to ensure quality care. Understanding the perspectives and needs of therapists relative to the circumstances created by COVID-19 is critical to safe and effective care. The goal of this study was to define the perspectives of therapists in New York State regarding the impact of COVID-19 on their work. An email-based 20-question survey was distributed to 250 therapists from all 10 regions of New York State who treated outpatient orthopedic patients during the peak of the pandemic in early April 2020. The survey collected demographic and practice information as well as responses regarding several clinical practice issues. The results provide insight into the concerns of therapists regarding the delivery of care, and responses clarify indications for therapy and for the use of telemedicine to achieve goals during the pandemic. The COVID-19 pandemic is profoundly impacting the work of therapists worldwide. Therapists responded to this survey expressing concerns about the safe delivery of care, access to personal protective equipment, use of telemedicine, and their role within health care during the pandemic. The results of this study can be used to establish guidelines for safe, effective, and efficient therapy during the pandemic. [Orthopedics. 2020;43(5):292-294.].

Arthroscopic Repair of Full-Thickness Rotator Cuff Tears in Active Patients Younger Than 40 Years: 2- to 5-Year Clinical Outcomes.

This study characterized injury patterns and reported clinical outcomes of all-arthroscopic management of full-thickness rotator cuff tears among military patients younger than 40 years. A retrospective review was performed of prospective data for 42 patients younger than 40 years who underwent arthroscopic rotator cuff repair and, in some cases, concomitant labral repair. Preoperative and postoperative evaluations (minimum follow-up, 2 years; mean, 41 months; range, 24-66 months) included range of motion, visual analog scale (VAS) score, Subjective Shoulder Value (SSV), and American Shoulder and Elbow Surgeons (ASES) Shoulder Score. Of the patients, 97.6% (41 of 42) had improved VAS, SST, and ASES scores. Mean VAS score improved from 8.09±1.51 to 1.19±1.85 (P<.01). Mean SSV improved from 47.88±19.56 to 89.45±14.04 (P<.01). Mean ASES score improved from 38.97±12.70 to 89.88±14.26 (P<.01). No difference for VAS, SSV, and ASES scores was noted between (1) all 42 patients, (2) the 26 patients who had rotator cuff repair but not labral repair, and (3) the 16 patients who had both rotator cuff repair and labral repair. Complications (7.1%; 3 of 42) included 2 postoperatively frozen shoulders and 1 retear of the rotator cuff. Of the patients, 95.2% (40 of 42) returned to their preoperative level of recreational and military job activity. Military patients younger than 40 years who have a full-thickness rotator cuff tear have a high prevalence of concomitant shoulder injury, especially labral tear. For patients younger than 40 years, arthroscopic rotator cuff repair, with or without labral repair, resulted in excellent clinical outcomes, a low risk of complications, and a high rate of return to the preoperative level of recreational and military job activity. [Orthopedics. 2018; 41(1):e52-e57.].

Elastic Intramedullary Nailing of a Medial Clavicle Fracture in a Pediatric Patient.

INTRODUCTION: Injuries to the medial clavicle in pediatric patients typically involve the physis and/or sternoclavicular joint. Clavicle fractures are one of the most common injuries in children, but ones at its medial end are rare. Most medial clavicle fractures are treated nonoperatively, but surgery is indicated in some cases. This original case report is unique in describing the use of an elastic intramedullary nail for fixation of a completely displaced medial clavicle fracture in a pediatric patient. CASE PRESENTATION: A pediatric patient sustained a completely displaced fracture of the medial clavicle. The fracture was lateral to the medial physis of the clavicle and did not involve the sternoclavicular joint. Internal fixation was achieved in an anatomic position with an elastic intramedullary nail. The postoperative course was unremarkable and resulted in complete healing of the fracture in an anatomic position. The patient returned to full activities without any pain or dysfunction. CONCLUSION: The use of elastic intramedullary nails is a viable option for internal fixation of displaced medial clavicle fractures. Knowledge of the surgical anatomy, potential implant complications, and rehabilitation principles is essential to a successful outcome.

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.

The teres minor muscle in rotator cuff tendon tears.

OBJECTIVES: Although the teres minor has received little attention in the literature compared to the other musculotendinous units of the rotator cuff, it is an important component of shoulder function. Our purpose was to study the appearance of the teres minor muscle on CT and MRI images in various patterns of rotator cuff tears. MATERIALS AND METHODS: We analyzed the appearance of the teres minor according to the Walch classification (normal, hypertrophic, atrophic, or absent) in 1,332 CT and in 240 MRI images of rotator cuff tears and we correlated it with the type of rotator cuff tears, time period between initial onset of symptoms and diagnostic imaging, age of the patient at the time of imaging, and degree of fatty infiltration of other rotator cuff muscles. RESULTS: The teres minor was classified as normal in 90.8% of cases, hypertrophic in 5.8%, atrophic in 3.2%, and absent in 0.2%. Significant variability existed in the appearance of the teres minor muscle among different patterns of rotator cuff tears in the CT (P < 0.0001) and MRI groups (P < 0.0001). The teres minor appeared most frequently hypertrophic in anterior tears and atrophic in posterior-superior tears. CONCLUSIONS: The teres minor was normal in most rotator cuff tears. A morphologic classification system allowed the appearance of the teres minor to be defined in isolated and multiple rotator cuff tears in CT and MRI images.

Subscapularis management in open shoulder surgery.

Management of the subscapularis in open shoulder surgery is a controversial topic. Subscapularis tenotomy has been the traditional approach, but other techniques have recently been developed to preserve the integrity of the subscapularis tendon. These include subscapularis peel, subscapularis split, and lesser tuberosity osteotomy. The biologic healing and biomechanical properties associated with each surgical approach must be evaluated to determine the best option for each patient. A strong, anatomic repair is required to achieve optimal clinical outcomes.

Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears.

BACKGROUND: In some patients nonoperative treatment of a rotator cuff tear is sufficient, while in others it is only the first stage of treatment prior to surgery. Fatty infiltration progresses throughout the nonoperative treatment although it is not known at what point fatty infiltration contributes to poor functional outcomes, absence of healing, or increased rerupture rates. QUESTIONS/PURPOSES: We therefore identified factors related to the appearance of supraspinatus muscle fatty infiltration, determined the speed of appearance and progression of this phenomenon, and correlated fatty infiltration with muscular atrophy. METHODS: We retrospectively reviewed 1688 patients with rotator cuff tears and recorded the following: number of tendons torn, etiology of the tear, time between onset of shoulder symptoms and diagnosis of rotator cuff tear. Fatty infiltration of the supraspinatus was graded using either CT or MRI classification. Muscular atrophy was measured indirectly using the tangent sign. RESULTS: Moderate supraspinatus fatty infiltration appeared an average of 3 years after onset of symptoms and severe fatty infiltration at an average of 5 years after the onset of symptoms. A positive tangent sign appeared at an average of 4.5 years after the onset of symptoms. CONCLUSIONS: Our results suggest that rotator cuff repair should be performed before the appearance of fatty infiltration (Stage 2) and atrophy (positive tangent sign)-especially when the tear involves multiple tendons. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Current perspectives on rotator cuff anatomy.

Understanding the anatomy of the rotator cuff and the surrounding structures that influence its function is essential to treating rotator cuff disease. During the past decade, advances in basic science and surgical technology have improved our knowledge of this anatomy. This review article presents the current concepts on rotator cuff anatomy and how they should be used in the surgical management of rotator cuff tears.

A comprehensive review of partial anterior cruciate ligament tears.

A partial tear of the anterior cruciate ligament is characterized by an asymmetric Lachman-test result, a negative pivot-shift test, a low-grade KT-1000 arthrometer measurement (< or =3 mm), and arthroscopic evidence of anterior cruciate ligament injury. The pivot shift test is the most important test in determining anterior cruciate ligament insufficiency. A positive test, independent of the grade, is indicative of a functionally deficient anterior cruciate ligament. Nonoperative management results in an acceptable clinical outcome in the majority of cases. Progression to knee instability (anterior translation and rotation) depends on the extent of the anterior cruciate ligament injury and the activity level of the patient. Thermal treatment is not recommended for partial tears of the anterior cruciate ligament. Symptomatic instability is treated reliably with anterior cruciate ligament reconstruction.

Environmental issues for team physicians.

As outdoor sports continue to gain popularity, understanding the environmental factors that may influence athletes is becoming a more important aspect of medical care for team physicians. Temperature, ultraviolet light, lightning, and altitude are some of the most common elements that cause illness. Understanding how to prevent, diagnose, and promptly treat conditions caused by environmental factors is essential to optimizing athletic performance in outdoor sports and avoiding morbidity.

Functional outcome of arthroscopic rotator cuff repairs: a correlation of anatomic and clinical results.

Even though several studies have revealed excellent clinical results with arthroscopic repair of rotator cuff tendons, poor healing of the repair and retearing of the tendon occur in many cases. Patterns of outcome correlating functional capacity and anatomic integrity of the repaired rotator cuff are not well defined. The goal of this prospective study was to determine the pattern of anatomic and functional outcomes among patients undergoing single-row arthroscopic rotator cuff repair. This study confirmed that single-row arthroscopic repair of small- and medium-sized supraspinatus tendon tears significantly improves rotator cuff integrity and functional outcomes. A completely healed tendon was observed in 60% of the cases. Age is a predictor of cuff integrity after the operation. Functional improvement was greater and significant in patients with complete healing at follow-up; however, a recurrent tear did not preclude positive functional results.

The floating shoulder.

The floating shoulder is an uncommon but important injury pattern. Although it is frequently defined as an ipsilateral fracture of the clavicle and scapular neck, recent studies suggest that ligament disruption associated with a scapular neck fracture contributes to the functional equivalent of this injury pattern, with or without an associated clavicle fracture. Determining the specific injury patterns indicates the potential for significant instability, and correlating these patterns with clinical outcome is a challenge. Because the degree of ligament disruption is difficult to assess on radiographs, indications for nonsurgical and surgical management are not well defined. Minimally displaced fractures typically do well with nonsurgical care. However, the degree of fracture displacement and ligament disruption that results in less predictable outcomes after nonsurgical treatment is uncertain, and the indications for surgery can be controversial. Internal fixation of a displaced clavicle fracture restores the contour of the shoulder, regulates soft-tissue tension, and often indirectly reduces the scapular neck fracture. Fixation of both fractures is recommended in certain fracture patterns. Because these controversies cannot be resolved by current evidence, surgeons must choose an individualized approach based on an understanding of the pathoanatomy and personal experience.

Radial nerve injuries associated with humeral fractures.

A radial nerve injury associated with a humeral shaft fracture is an important injury pattern among trauma patients. It is the most common peripheral nerve injury associated with this fracture. Although treatment for this injury pattern is a controversial subject among upper-extremity surgeons, certain principles of management need to be applied in all cases. As our understanding of the pathoanatomy of the humerus and surrounding neurovascular structures has evolved, surgeons have adapted their strategies to improve outcome and avoid long-term morbidity. The principles of management and the clinical outcomes of various treatment strategies, defined in the literature, are reviewed in this article.