The effect of biceps tenotomy on humeral migration and clinical outcomes in arthroscopic rotator cuff repair.

PURPOSE: To evaluate the effect of biceps tenotomy on humeral migration and clinical outcomes in patients who underwent arthroscopic rotator cuff (RC) repair. METHODS: This is a retrospective study of 60 patients who underwent arthroscopic RC repair. Patients were divided into two groups, whether they underwent concomitant biceps tenotomy or not. The group underwent concomitant biceps tenotomy, tenotomy ( +), or not, tenotomy (-). Clinical and functional outcomes were performed using the American Shoulder and Elbow Surgeons (ASES), the University of California-Los Angeles (UCLA) scoring system. Radiological evaluation was performed in X-rays and magnetic resonance imaging (MRI), measuring the acromiohumeral distance (AHD), humeral migration (HM) and upper migration index (UMI). RESULTS: There was no significant difference between the groups in terms of patient characteristics. The follow-up period was 30.9 ± 8.7 months in the tenotomy ( +) group and 34.9 ± 8.2 months in the tenotomy (-) group with no significant difference. Postoperative ASES score improved significantly in the tenotomy ( +) group compared to the tenotomy (-) group (91.2 ± 4.7, 80.8 ± 18.7, respectively, p = 0.005). There was a significant difference in postoperative AHD, HM and UMI values (MRI; p = 0.003, p = 0.017, p = 0.025; X-ray; p = 0.049, p = 0.002, p = 0.010, respectively). The post-pre difference increase of AHD [MRI for tenotomy( +): 0.14 ± 0.86 and tenotomy(-): 0.91 ± 0.85, p = 0.001; X-ray for tenotomy( +): 0.61 ± 0.43 and tenotomy(-): 1.12 ± 0.7, p = 0.001] and UMI [MRI for tenotomy( +): 0.005 ± 0.05 and tenotomy(-): 0.04 ± 0.06, p = 0.006; X-ray for tenotomy( +): 0.01 ± .064 and tenotomy(-): 0.12 ± 0.37, p = 0.110] values were higher in the tenotomy (-) group compared to the tenotomy ( +) group while HM values decreased more in the tenotomy (-) group. [MRI for tenotomy ( +): -0.19 ± 1.07 and tenotomy (-): -0.79 ± 1.52, p = 0.079; X-ray for tenotomy ( +): -0.27 ± 0.54 and tenotomy (-): -1.006 ± 1.83, p = 0.040]. CONCLUSION: After short-term follow-up, the humeral head was positioned higher in patients who underwent LHBT tenotomy compared to patients without tenotomy. However, it seems to affect clinical outcomes during this period positively. LEVEL OF EVIDENCE: Level 3.

Factors Affecting Prolonged Postoperative Pain and Analgesic Use After Arthroscopic Full-Thickness Rotator Cuff Repair.

BACKGROUND: Postoperative pain and analgesic use after arthroscopic rotator cuff repair remain important issues that affect rehabilitation and overall outcomes. PURPOSE: To evaluate the pre- and intraoperative factors that may cause prolonged duration of postoperative pain and analgesic use. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We included 443 patients who underwent arthroscopic rotator cuff repair and subacromial decompression. Visual analog scale (VAS) scores for pain were obtained preoperatively and at 30 and 90 days postoperatively. Patients were divided into a group who had prolonged postoperative pain (duration ≥1 and <3 months; n = 86 patients) and a group with nonprolonged pain (duration <1 month; n = 357 patients). The following factors were compared between groups: age, sex, body mass index, repair technique, tear size, retraction amount, repair tension, tendon degeneration, preoperative pseudoparesis, symptom duration, application of microfracture to the rotator cuff footprint for marrow stimulation, smoking, degree of fatty degeneration, preoperative narcotic analgesic use, diabetes, acromioclavicular joint degeneration, and preoperative Douleur Neuropathique 4 (DN4) and American Shoulder and Elbow Society (ASES) scores. RESULTS: Significant differences were seen between the prolonged and nonprolonged groups regarding the median duration of pain (54 vs 27 days, respectively; P < .001) and analgesic use (42 vs 28 days, respectively; P < .001). Significant differences were noted between the groups for symptom duration (P = .007), smoking status (P = .001), degree of fatty degeneration (P = .009), preoperative narcotic analgesic use (P < .001), preoperative DN4 and ASES scores, 30-day VAS score (P < .001), duration of opioid and nonopioid analgesic use (P < .001), tear size (P = .026), and retraction stage (P = .032). Tear size (P = .009), retraction amount (P = .005), preoperative narcotic analgesic use (P < .001), degree of fatty degeneration (P < .001), and preoperative DN4 score (P = .024) were factors independently associated with prolonged postoperative pain and analgesic use. CONCLUSION: Patients with larger size tears, retracted tendons, preoperative use of narcotic analgesics, higher tensioned tendon after repair, and Goutallier grade 3 or 4 fatty degeneration faced an increased risk of prolonged postoperative pain and analgesic use after arthroscopic rotator cuff repair. These factors might be mitigated by psychosocial support; gentle, controlled, and individualized postoperative rehabilitation approaches; detailed preoperative evaluation; and closer follow-up of patients who are treated operatively.

Factors associated with the development of re-tear following arthroscopic rotator cuff repair: A retrospective comparative study.

OBJECTIVE: The aim of this study was to analyze the risk factors for the development of re-tear following Arthroscopic Rotator Cuff Repair (aRCR). METHODS: This retrospective clinical study included 196 consecutive aRCRs with a minimum 3-year follow-up. Pre- and postoperative clinical and functional outcomes were measured using the Visual Analog Scale (VAS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the University of California at Los Angeles Shoulder Rating Scale (UCLA), the Constant-Murley Score (CMS), and the Douleur Neuropathique (DN4) questzionnaire. The Goutallier staging of fatty infiltration, Occupational Ratio (OR), the Acromiohumeral Interval (AHI), Acromioclavicular Joint (ACJ) arthritis, acromion type, Critical Shoulder Angle (CSA), and tangent sign (tan- sign) were evaluated as radiological parameters. Different subgroup parameters were evaluated after dividing the patients into re-tear (-) and re-tear (+) groups, according to clinical and radiological outcomes as well as patient and intraoperative characteristics. RESULTS: The mean follow-up period was 72.0 ± 15.8 months. The mean age at the time of surgery was 58.4 ± 8.9 years. A significant improvement was found in clinical and functional scores in the re-tear (-) group (P < 0.001 for all). However, the retear (+) group had poorer outcome scores than the re-tear (-) group. Twenty patients (10.2%) had re-tear at the last follow-up. There was a significant difference between groups regarding pre-and postoperative clinical scores, with worse scores in the retear (+) group (P < 0.001 for all). Also, pre-and postoperative pseudoparalysis (P = 0.001 for both), acromioclavicular joint arthritis (ACJ) (P = 0.001), intraoperative rotator cuff wear (P = 0.007) or stiffness (P = 0.025), a longer time period between symptom onset and surgery (P = 0.031), larger tear size (P = 0.010), preoperative shoulder stiffness (P = 0.001), higher duration of postoperative analgesia use (P < 0.001), higher degrees of preoperative Occupational Ratio (OR) (P < 0.001), and higher degrees of fatty degeneration (P < 0.001) were found to be associated with re- tear development. CONCLUSION: Surgeons should consider the preoperative degree of fatty degeneration, clinical and functional scores, presence of ACJ arthritis, intraoperative tendon quality, tear size and chronicity as well as postoperative prolong analgesic requirement, and development of pseudoparalysis as factors regarding re-tear development risk following aRCR. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Factors associated with the development of early- to mid-term cuff-tear arthropathy following arthroscopic rotator cuff repair.

BACKGROUND: Few studies have specifically evaluated the development of cuff-tear arthropathy (CTA) after a rotator cuff repair in the postoperative early to mid-term. This study aimed to identify the factors associated with the development of CTA, to evaluate the effect of arthropathy on functional outcomes, and to evaluate the incidence of CTA 3-10 years after an arthroscopic rotator cuff repair. METHODS: A total of 312 patients who underwent an arthroscopic repair of a large or massive full-thickness rotator cuff tear with a minimum follow-up of 3 years were retrospectively divided into 2 groups for analysis: those with postrepair CTA (arthritic glenohumeral changes due to rotator cuff insufficiency) and those without. CTA was assessed using the Seebauer and modified Hamada-Fukuda classification systems. Pre-, intra-, and postoperative patient characteristics; characteristics of the rotator cuff tear; clinical and radiological parameters; and pre- and postoperative functional scores were compared. RESULTS: The rate of development of CTA was 11.5% (36 of 312 patients, 13 centric and 23 eccentric arthropathy). CTA was more frequently associated with the poor integrity of the supraspinatus tendon after repair (P < .001) and massive tears (P = .006). Postoperative pseudoparalysis (P < .001), symptomatic retear (P < .001), tear size (P = .026), critical shoulder angle (P = .001), preoperative acromiohumeral interval (P = .046), and the humeral head superior migration (P = .001) were found to be associated with the development of CTA. However, only postoperative pseudoparalysis was found to be an independent risk factor (P < .001, odds ratio: 2.965). Patients with postrepair CTA had significantly worse functional outcome scores. CONCLUSION: The postoperative development of pseudoparalysis may be a marker of CTA in the future and that closer follow-up may be necessary.

Chronic Achilles Tendon Rupture Reconstruction Using the Lindholm Method and the Vulpius Method.

BACKGROUND: We investigated the clinical and functional outcomes of chronic Achilles tendon rupture reconstruction via the Lindholm technique and via the Vulpius' lengthening of the gastrocnemius. METHODS: We evaluated 15 patients with chronic Achilles tendon rupture (Lindholm technique in eight patients and primary repair with the Vulpius technique in seven patients). In the final follow-up, the Hooker scale was used to measure the ankle functional capacity in all patients. The patients were evaluated on the basis of their capability to stand on tiptoe on the affected limb and the time required to return to pre-injury daily activities. RESULTS: The mean follow-up time was 19.6 months (range, 12 - 38 months). The mean time to return to work and daily activity was 3.2 months. The mean calf atrophy at the end of follow-up was 1.2 cm (range, 0 - 2.5 cm). At the last follow-up visit, no patient had any limitation in the activities of daily living and the active and passive ankle range of motion was good. All patients were able to perform single-leg heel rises at the end of follow-up and the Hooker scores were excellent for 11 patients and satisfactory for four patients. CONCLUSION: The reconstruction of chronic Achilles tendon ruptures via the Lindholm technique or via the Vulpius technique is associated with good clinical and functional outcomes.

Evaluation of the lateral instability of the ankle by inversion simulation device and assessment of the rehabilitation program.

OBJECTIVES: To assess the correctibility of the muscle atrophy, proprioceptive loss, and slowing of the reflex arc around the ankle after ankle sprain with rehabilitation. METHODS: The study group consisted of 20 cases with chronic instability who had at least two episodes of ankle sprains (mean 20.6 years, range 16-32 years); control group consisted of 20 patients with same demographic characteristics but without instability. Isokinetic muscle strength measurements and proprioceptive evaluations were made using the Cybex device before and 1.5-month after rehabilitation period. Additionally, the inversion simulation device, which was developed together with the mechanical engineering department of our university, was correlated with the EMG device, and response periods of muscles to stimulation were measured. RESULTS: The proprioceptive loss present in all cases with ankle instability before treatment significantly improved after effective rehabilitation (p=0.001). It was detected that lengthened peroneal latent periods shortened with effective rehabilitation (p=0.001). Cross-interaction of rehabilitation was shown with the preservation of the difference between the pathologic and normal sides regarding proprioception and peroneal latent periods before and after treatment, without any difference between the control group and the pathologic sides. CONCLUSION: After ankle sprains, especially in patients with chronic instability, strengthening of the muscles around the ankle with well-planned proprioceptive exercises helps the patients return to normal living and sports activities, and prevents unnecessary surgery, especially in cases with functional instability.

Anatomic evaluation and relationship between the lumbar pedicle and adjacent neural structures: an anatomic study.

OBJECTIVE: Transpedicular spinal fixation has recently been the focus of increased attention in several institutions throughout the world, but its safety and efficacy are still important questions for orthopedic surgeons. Accurate screwing through the pedicle will avoid neurologic complications and increase the stability of the instrumentation. In this study, it was aimed to analyze the anatomic relations quantitatively between the lumbar pedicle and the adjacent dural sac and nerve roots, to determine the risky areas for neural injury during transpedicular screw placement. METHODS: Ten adult cadavers were used for observation of the lumbar pedicle and its relations. After removal of the laminas and facets, the lumbar pedicles, dural sac, and nerve roots were exposed. Interpedicular distance (IPD), pedicle-inferior nerve root distance (PIRD), pedicle-superior nerve root distance (PSRD), and pedicle-dural sac distance (PDSD) were measured. RESULTS: Average distance from the lumbar pedicle to the dural sac medially and to the adjacent nerve roots superiorly and inferiorly through the cranial to caudal lumbar levels ranged from 1.29 to 1.56, from 4.12 to 5.52, and from 1.10 to 1.06 mm, respectively. The mean IPD ranged from 32.77 to 41.24 mm. There were statistically significant differences between the L5 level and other lumbar levels for IPD, PSRD, and PDSD measurements. CONCLUSIONS: These results indicate that although L5 is safer than other lumbar levels for pedicle screw insertion, an improper medial and caudal placement of a pedicular screw will carry a great risk of injury to the dural sac and inferior nerve root.

Arthroscopic treatment of anterolateral soft tissue impingement of the ankle: evaluation of factors affecting outcome.

PURPOSE: To evaluate the results for patients treated arthroscopically for anterolateral soft tissue impingement syndrome, to determine the factors affecting the outcome, and to report on a synovial shelf. TYPE OF STUDY: Retrospective clinical review. METHODS: Forty-one patients underwent operative arthroscopy for anterolateral impingement of the ankle between 1990 and 2001; the mean follow-up was 83.7 months (range, 21 to 152 months). There were 25 men and 16 women with an average age of 33.2 years (range, 15 to 63 years). All patients reported a history of inversion injury to the ankle. The most frequent preoperative complaints were tenderness localized to the anterolateral aspect of the ankle, swelling, crepitation, and pain at weight-bearing. All patients had failed to respond to at least 3 months of conservative treatment. The results were assessed according to Meislin's criteria and the American Orthopaedics Foot and Ankle Society (AOFAS) scoring table. For statistical analysis, the Mann-Whitney U test was used where appropriate and the significance was set at P < .005. RESULTS: According to Meislin's criteria, there were excellent results in 21 patients, good in 16, fair in 2, and poor in 2. The mean AOFAS score was 89.6 points (range, 60-100) at follow-up. Four different soft tissue pathologies causing impingement were described. It has been statistically shown that cartilage damage located at the anterolateral region of the ankle and not advanced to the subchondral bone, and repeated inversion injuries had negative effects on clinical results at long-term follow-up. CONCLUSIONS: The arthroscopic diagnosis and treatment of anterolateral soft tissue impingement is a safe and effective method. Any combination of associated intra-articular pathologies, such as a chondral lesion or a new inversion injury of the ankle, after the arthroscopic procedure resulted in a poor outcome. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.