Partial-thickness rotator cuff tears: clinical and imaging outcomes and prognostic factors of successful nonoperative treatment.

PURPOSE: The purpose of this study was to determine the clinical success rate of nonoperative treatment of partial-thickness rotator cuff tears (PT-RCTs), to determine baseline clinical factors predictive of outcome of nonoperative treatment of PT-RCTs, and to determine the imaging outcome of nonoperative treatment of PT-RCTs. PATIENTS AND METHODS: All patients with a primary diagnosis of a PT-RCT were eligible for inclusion. Seventy-six patients (48 males, 28 females) with an average age of 52±10 years were included in the study. Patients were evaluated using a standardized format including clinical, imaging, and shoulder specific quality-of-life outcomes. Patients were assessed and treated either successfully nonoperatively or consented to undergo surgical intervention of their PT-RCT. Patients treated nonoperatively underwent follow-up by MRI arthrogram. RESULTS: Thirty-seven patients (49%) underwent nonoperative treatment. Logistic regression analysis indicated that the baseline variables of side (dominant or nondominant side involved), onset (traumatic or atraumatic), and thickness of tendon tear (<50% or >50%) were significant predictors of outcome. At a mean 46±7 months of follow-up, nonoperatively treated patients demonstrated a mean American Shoulder and Elbow Surgeons score of 85.1±16.0, and a Simple Shoulder Test score of 10.0±2.5. Overall, 76% of tears treated nonoperatively did not show a tear progression on anatomic imaging. Nine patients (24%) demonstrated tear progression, of which three patients (8%) demonstrated full-thickness tearing. CONCLUSION: Nonoperative treatment was utilized in ~50% of the patients and resulted in improved clinical outcomes. Onset, shoulder involved, and thickness of the tear were predictive of the success of nonoperative treatment.

What happens to patients when we do not repair their cuff tears? Five-year rotator cuff quality-of-life index outcomes following nonoperative treatment of patients with full-thickness rotator cuff tears.

BACKGROUND: The purpose of this study was to examine 5-year outcomes in a prospective cohort of patients previously enrolled in a nonoperative rotator cuff tear treatment program. METHODS: Patients with chronic (>3 months), full-thickness rotator cuff tears (demonstrated on imaging) who were referred to 1 of 2 senior shoulder surgeons were enrolled in the study between October 2008 and September 2010. They participated in a comprehensive, nonoperative, home-based treatment program. After 3 months, the outcome in these patients was defined as "successful" or "failed." Patients in the successful group were essentially asymptomatic and did not require surgery. Patients in the failed group were symptomatic and consented to undergo surgical repair. All patients were followed up at 1 year, 2 years, and 5 or more years. RESULTS: At 5 or more years, all patients were contacted for follow-up; the response rate was 84%. Approximately 75% of patients remained successfully treated with nonoperative treatment at 5 years and reported a mean rotator cuff quality-of-life index score of 83 of 100 (SD, 16). Furthermore, between 2 and 5 years, only 3 patients who had previously been defined as having a successful outcome became more symptomatic and underwent surgical rotator cuff repair. Those in whom nonoperative treatment had failed and who underwent surgical repair had a mean rotator cuff quality-of-life index score of 89 (SD, 11) at 5-year follow-up. The operative and nonoperative groups at 5-year follow-up were not significantly different (P = .11). CONCLUSION: Nonoperative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some clinicians may argue that nonoperative treatment delays inevitable surgical repair, our study shows that patients can do very well over time.

Long-term outcomes of the Bankart and Latarjet repairs: a systematic review.

The most common surgical techniques for the treatment of recurrent anterior shoulder instability include the arthroscopic Bankart repair, the open Bankart repair and the open Latarjet procedure. The purpose of this study was to evaluate and compare the long-term outcomes following these procedures. A systematic review of modern procedures with a minimum follow-up of 5 years was completed. The objective outcome measures evaluated were post-operative dislocation and instability rate, the Rowe score, radiographic arthritis and complications. Twenty-eight studies with a total of 1652 repairs were analyzed. The estimated re-dislocation rate was 15.1% following arthroscopic Bankart repair, 7.7% following open Bankart repair and 2.7% following Latarjet repair, with the comparison between arthroscopic Bankart and open Latarjet reaching statistical significance (p<0.001). The rates of subjective instability and radiographic arthritis were consistently high across groups, with no statistical difference between groups. Estimated complication rates were statistically higher in the open Latarjet repair (9.4%) than in the arthroscopic Bankart (0%; p=0.002). The open Latarjet procedure yields the most reliable method of stabilization but the highest complication rate. There are uniformly high rates of post-operative subjective instability symptoms and radiographic arthritis at 5 years regardless of procedure choice.

Graft Augmentation Versus Bridging for Large to Massive Rotator Cuff Tears: A Systematic Review.

PURPOSE: To systematically review the literature on the healing rates and clinical outcomes of the 2 different graft indications (i.e., augmentation vs bridging) during rotator cuff repair. METHODS: A systematic literature review was performed for clinical studies of rotator cuff repair using grafts for large to massive tears. The primary outcome was tendon healing on either magnetic resonance imaging or ultrasound. The secondary outcomes included visual analog scale for pain, American Shoulder and Elbow Surgeons score, and University of California at Los Angeles score, and forward elevation. Studies were divided into augmentation and bridging groups, and outcomes were compared statistically. RESULTS: Twelve studies with 13 study groups were included: 167 repairs in the augmentation group and 247 repairs in the bridging group. For augmentation and bridging groups, the mean age was 62.2 and 62.8 years and the mean follow-up was 28.5 and 37.7 months, respectively. The estimated healing rates were 64.0% for augmentation and 77.9% for bridging. Although both procedures had improved clinical outcomes, no statistical difference between groups was detected except lower visual analog scale in the bridging group at follow-up. CONCLUSIONS: Bridging grafts had no significant difference in healing or clinical outcomes when compared with a graft used for augmentation. Bridging grafts may be considered for this difficult patient population with large to massive rotator cuff tears. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Arthroscopic Repair of Articular Surface Partial-Thickness Rotator Cuff Tears: Transtendon Technique versus Repair after Completion of the Tear-A Meta-Analysis.

Articular surface partial-thickness rotator cuff tears (PTRCTs) are commonly repaired using two different surgical techniques: transtendon repair or repair after completion of the tear. Although a number of studies have demonstrated excellent clinical outcomes, it is unclear which technique may provide superior clinical outcomes and tendon healing. The purpose was to evaluate and compare the clinical outcomes following arthroscopic repair of articular surface PTRCT using a transtendon technique or completion of the tear. A systematic review of the literature was performed following PRISMA guidelines and checklist. The objective outcome measures evaluated in this study were the Constant Score, American Shoulder and Elbow Surgeons score, Visual Analogue Scale, physical examination, and complications. Three studies met our criteria. All were prospective randomized comparative studies with level II evidence and published from 2012 to 2013. A total of 182 shoulders (mean age 53.7 years; mean follow-up 40.5 months) were analyzed as part of this study. Both procedures provided excellent clinical outcomes with no significant difference in Constant Score and other measures between the procedures. Both procedures demonstrated improved clinical outcomes. However, there were no significant differences between each technique. Further studies are required to determine the long-term outcome of each technique.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology.

BACKGROUND: Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm. METHODS: A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark "agree" or "disagree" beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting. RESULTS: In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic. CONCLUSION: This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Can Grafts Provide Superior Tendon Healing and Clinical Outcomes After Rotator Cuff Repairs?: A Meta-analysis.

BACKGROUND: Arthroscopic repair of large to massive rotator cuff tears commonly retear. To improve healing rates, a number of different approaches have been utilized, including the use of grafts, which may enhance the biomechanical and biologic aspects of the repair construct. However, the outcomes after the use of grafts are diverse. PURPOSE: To systematically review the literature for large to massive rotator cuff tears to determine whether the use of grafts generally provides superior tendon healing and clinical outcomes to the repairs without grafts. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A systematic review of the literature was performed. Clinical studies comparing the repairs with (graft group) and without grafts (control group) were included and analyzed. The primary outcome was tendon healing on either magnetic resonance imaging or ultrasound. The secondary outcome measures included visual analog scale for pain, University of California at Los Angles (UCLA) score, and forward elevation range. Differences between groups in all outcome measures were statistically analyzed. RESULTS: Six comparative studies (level of evidence 2 or 3) with 13 study groups were included. A total of 242 repairs in the graft group (mean age, 62.5 ± 4.6 years) and 185 repairs in the control group (mean age, 62.5 ± 5.0 years) were analyzed. The graft types utilized included autograft (fascia lata) in 1 study, allograft (human dermis) in 2 studies, xenograft (bovine pericardium, porcine small intestine submucosa) in 2 studies, synthetic graft (polypropylene) in 1 study, and a combination of autograft (the long head of biceps) and synthetic graft (polypropylene) in 1 study. The overall mean follow-up time was 28.4 ± 9.0 months. When 1 or 2 studies/study groups were excluded due to practical or statistical reasons, the graft group demonstrated significantly improved healing (odds ratio, 2.48; 95% CI, 1.58-3.90; P < .0001) and all clinical outcome measures at final follow-up (P ≤ .02). CONCLUSION: The use of grafts generally provides superior tendon healing and clinical outcomes compared to repairs without grafts, except for some specific graft types (eg, porcine small intestine submucosa, bovine pericardium). Further investigations are required to determine the benefits of the use of grafts.

Magnetic resonance imaging arthrography following type II superior labrum from anterior to posterior repair: interobserver and intraobserver reliability.

BACKGROUND: Arthroscopic repair of type II superior labrum from anterior to posterior (SLAP) lesions is a common surgical procedure. However, anatomic healing following repair has rarely been investigated. The intraobserver and interobserver reliability of magnetic resonance imaging arthrography (MRA) following type II SLAP repair has not previously been investigated. This is of particular interest due to recent reports of poor clinical results following type II SLAP lesion repair. PURPOSE: To evaluate the MRA findings following arthroscopic type II SLAP lesion repair and determine its intraobserver and interobserver reliability. STUDY DESIGN: Cohort study (diagnosis), Level of Evidence, 2. METHODS: Twenty-five patients with an isolated type II SLAP lesion (confirmed via diagnostic arthroscopy) underwent standard suture anchor-based repair. At a mean of 25.2 months post-operatively, patients underwent a standardized MRA protocol to investigate the integrity of the repair. MRAs were independently reviewed by two radiologists and a fellowship trained shoulder surgeon. The outcomes were classified as healed SLAP repair or re-torn SLAP repair. RESULTS: On average, 54% of MRAs were interpreted as healed SLAP repairs while 46% of MRAs were interpreted as having a re-torn SLAP repair. Overall, only 43% of the studies had 100% agreement across all interpretations. The intraobserver reliability ranged from 0.71 to 0.81 while the interobserver reliability between readers ranged from 0.13 to 0.44 (Table 1). CONCLUSION: The intraobserver agreement of MRA in the evaluation of type II SLAP repair was substantial to excellent. However, the interobserver agreement of MRA was poor to fair. As a result, the routine use of MRA in the evaluation of type II SLAP lesion repair should be utilized with caution. A global evaluation of the patient, including detailed history and physical examination, is paramount in determining the cause of failure and one should not rely on MRA alone.

Arthroscopic repair of type II SLAP lesions: Clinical and anatomic follow-up.

AIMS: The aim was to evaluate the clinical and anatomic outcome of arthroscopic repair of type II SLAP lesions. MATERIALS AND METHODS: The senior author performed isolated repairs of 25 type II SLAP lesions in 25 patients with a mean age of 40.0 ± 12 years. All tears were repaired using standard arthroscopic suture anchor repair to bone. All patients were reviewed using a standardized clinical examination by a blinded, independent observer, and using several shoulder outcome measures. Patients were evaluated by magnetic resonance imaging arthrogram at a minimum of 1-year postoperatively. STATISTICAL ANALYSIS USED: Two-tailed paired t-test were used to determine significant differences in preoperative and postoperative clinical outcomes scores. In addition, a Fisher's exact test was used. RESULTS: At a mean follow-up of 54-month, the mean American Shoulder and Elbow Surgeons Shoulder Index (ASES) scores improved from 52.1 preoperatively to 86.1 postoperatively (P < 0.0001) and the Simple Shoulder Test (SST) scores from 7.7 to 10.6 (P < 0.0002). Twenty-two out of the 25 patients (88%) stated that they would have surgery again. Of the 21 patients who had postoperative magnetic resonance imaging arthrographys (MRAs), 9 patients (43%) demonstrated dye tracking between the labrum bone interface suggestive of a recurrent tear and 12 patients (57%) had a completely intact repair. There was no significant difference in ASES, SST, and patient satisfaction scores in patients with recurrent or intact repairs. CONCLUSIONS: Arthroscopic repair of type II SLAP lesions demonstrated improvements in clinical outcomes. However, MRA imaging demonstrated 43% of patients with recurrent tears. MRA results do not necessarily correlate with clinical outcome.

Suture locking of isolated internal locking knotless suture anchors is not affected by bone quality.

PURPOSE: The purpose of this study was to evaluate the mechanical performance of different suture locking mechanisms including: i) interference fit between the anchor and the bone (eg, 4.5 mm PushLock, 5.5 mm SwiveLock), ii) internal locking mechanism within the anchor itself (eg, 5.5 mm SpeedScrew), or iii) a combination of interference fit and internal locking (eg, 4.5 mm MultiFIX P, 5.5 mm MultiFIX S). METHODS: Anchors were tested in foam blocks representing normal (20/8 foam) or osteopenic (8/8 foam) bone, using standard suture loops pulled in-line with the anchor to isolate suture locking. Mechanical testing included cyclic testing for 500 cycles from 10 N to 60 N at 60 mm/min, followed by failure testing at 60 mm/min. Displacement after 500 cycles at 60 N, number of cycles at 3 mm displacement, load at 3 mm displacement, and maximum load were evaluated. RESULTS: Comparing 8/8 foam to 20/8 foam, load at 3 mm displacement and maximum load were significantly decreased (P<0.05) with decreased bone quality for anchors that, even in part, relied on an interference fit suture locking mechanism (ie, 4.5 mm PushLock, 5.5 mm SwiveLock, 4.5 mm MultiFIX P, 5.5 mm MultiFIX S). Bone quality did not affect the mechanical performance of 5.5 mm SpeedScrew anchors which have an isolated internal locking mechanism. CONCLUSION: The mechanical performance of anchors that relied, even in part, on interference fit were affected by bone quality. Isolated internal locking knotless suture anchors functioned independently of bone quality. Anchors with a combined type (interference fit and internal locking) suture locking mechanism demonstrated similar mechanical performance to isolated internal locking anchors in osteopenic foam comparing similar sized anchors. CLINICAL RELEVANCE: In osteopenic bone, knotless suture anchors that have an internal locking mechanism (isolated or combined type) may be advantageous for secure tendon fixation to bone.

Partial Thickness Rotator Cuff Tears: Current Concepts.

Partial thickness rotator cuff tears are a common cause of pain in the adult shoulder. Despite their high prevalence, the diagnosis and treatment of partial thickness rotator cuff tears remains controversial. While recent studies have helped to elucidate the anatomy and natural history of disease progression, the optimal treatment, both nonoperative and operative, is unclear. Although the advent of arthroscopy has improved the accuracy of the diagnosis of partial thickness rotator cuff tears, the number of surgical techniques used to repair these tears has also increased. While multiple repair techniques have been described, there is currently no significant clinical evidence supporting more complex surgical techniques over standard rotator cuff repair. Further research is required to determine the clinical indications for surgical and nonsurgical management, when formal rotator cuff repair is specifically indicated and when biologic adjunctive therapy may be utilized.

Complications following arthroscopic fixation of acromioclavicular separations: a systematic review of the literature.

PURPOSE: Over the past decade, a number of arthroscopic or arthroscopically assisted reconstruction techniques have emerged for the management of acromioclavicular (AC) separations. These techniques provide the advantage of superior visualization of the base of the coracoid, less soft tissue dissection, and smaller incisions. While these techniques have been reported to provide excellent functional results with minimal complications, discrepancies exist within the literature. This systematic review aims to assess the rate of complications following these procedures. METHODS: Two independent reviewers completed a search of Medline, Embase, PubMed, and the Cochrane Library entries up to December 2013. The terms "Acromioclavicular Joint (MeSH)" OR "acromioclavicular* (text)" OR "coracoclavicular* (text)" AND "Arthroscopy (MeSH)" OR "Arthroscop* (text)" were used. Pooled estimates and 95% confidence intervals were calculated assuming a random-effects model. Statistical heterogeneity was quantified using the I(2) statistic. LEVEL OF EVIDENCE: IV. RESULTS: A total of 972 abstracts met the search criteria. After removal of duplicates and assessment of inclusion/exclusion criteria, 12 articles were selected for data extraction. The rate of superficial infection was 3.8% and residual shoulder/AC pain or hardware irritation occurred at a rate of 26.7%. The rate of coracoid/clavicle fracture was 5.3% and occurred most commonly with techniques utilizing bony tunnels. Loss of AC joint reduction occurred in 26.8% of patients. CONCLUSION: Arthroscopic AC reconstruction techniques carry a distinct complication profile. The TightRope/Endobutton techniques, when performed acutely, provide good radiographic outcomes at the expense of hardware irritation. In contrast, graft reconstructions in patients with chronic AC separations demonstrated a high risk for loss of reduction. Fractures of the coracoid/clavicle remain a significant complication occurring predominately with techniques utilizing bony tunnels.

Arthroscopic repair of massive, contracted, immobile tears using interval slides: clinical and MRI structural follow-up.

PURPOSE: The purpose of this study was to determine clinical and structural outcomes of arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slides. METHODS: Eleven patients who had rotator cuff tears that were irreparable using standard mobilization techniques, but were repaired using interval slides were reviewed. Patients were evaluated at mean 25.2 months (±10.3) post-operatively utilizing a standardized clinical examination and by magnetic resonance imaging (MRI). RESULTS: American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test (SST) scores improved significantly (ASES p = 0.0001; SST p = 0.0001) from pre- to post-operative. Range of motion in forward elevation and external rotation increased from pre- to post-operative, though not significantly. Strength via manual muscle testing improved on forward elevation (p = 0.001) and external rotation (p = 0.007) from pre- to post-operative. Post-operative MRI demonstrated massive re-tearing to the original size in 6 patients (55 %) and intact rotator cuffs with tissue spanning the defects in 5 (45 %) patients. CONCLUSIONS: In patients with massive, contracted, immobile tears, an interval slide technique may be utilized as a salvage procedure. Arthroscopic repair of massive, contracted, immobile rotator cuff tears using interval slide techniques can lead to good clinical and satisfactory structural outcomes. LEVEL OF EVIDENCE: IV.

The rotator cuff quality-of-life index predicts the outcome of nonoperative treatment of patients with a chronic rotator cuff tear.

BACKGROUND: Chronic rotator cuff tears are prevalent and can be disabling. The existing literature is unclear regarding the effectiveness of nonoperative treatment. The purposes of this study were to determine whether the outcome of nonoperative treatment can be predicted on the basis of the presenting clinical characteristics and whether the outcome achieved at three months after treatment can be maintained at two years. METHODS: The prospective cohort included ninety-three patients with a documented chronic full-thickness rotator cuff tear. Patients underwent a three-month supervised program of nonoperative treatment and were then evaluated by an orthopaedic surgeon. The treatment outcome was defined as a success if surgical treatment was no longer deemed appropriate by both patient and surgeon because the patient had improved considerably and was predominantly asymptomatic. The outcome was defined as a failure if the patient elected to have surgery after failing to improve and remaining symptomatic. The presenting clinical characteristics that were analyzed included age, sex, smoking status, hand dominance, duration of symptoms, onset (traumatic etiology or insidious onset), shoulder motion, external rotation strength, tear size as documented by ultrasonography or magnetic resonance imaging, and the Rotator Cuff Quality-of-Life Index (RC-QOL). RESULTS: Seventy (75%) of the patients were successfully treated. Logistic regression analysis showed that the baseline RC-QOL score was a significant predictor of outcome (p = 0.017). Eighty-nine percent of patients maintained their three-month outcome at two years of follow-up. CONCLUSIONS: The RC-QOL was predictive of the outcome of nonoperative treatment of patients with a chronic full-thickness rotator cuff tear. Patients in whom the nonoperative treatment was deemed successful at the conclusion of three months of treatment had a very high chance of ongoing success at two years after the initiation of treatment.

Transtendon rotator-cuff repair of partial-thickness articular surface tears can lead to medial rotator-cuff failure.

PURPOSE: The purpose of this study was to evaluate clinical and anatomic outcomes of patients following transtendon rotator-cuff repair of partial articular supraspinatus tendon avulsion (PASTA) lesions. PATIENTS AND METHODS: Patients in the senior author's practice who had isolated PASTA lesions treated by transtendon rotator-cuff repair were included (n=8) and retrospectively reviewed. All patients were evaluated preoperatively and at a mean of 21.2 months (±9.7 months) postoperatively using standardized clinical evaluation (physical exam, American Shoulder and Elbow Surgeons, and Simple Shoulder Test). All patients underwent postoperative imaging with a magnetic resonance imaging arthrogram. RESULTS: There was a significant improvement in American Shoulder and Elbow Surgeons (42.7±17.5 to 86.9±25.2) and Simple Shoulder Test (4.6±3.2 to 10.1±3.8) scores from pre- to postoperative, respectively. Postoperative imaging demonstrated full-thickness medial cuff tearing in seven patients, and one patient with a persistent partial articular surface defect. CONCLUSION: Transtendon repair of PASTA lesions may lead to improvements in clinical outcome. However, postoperative imaging demonstrated a high incidence of full-thickness rotator-cuff defects following repair.

A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes.

BACKGROUND: The literature comparing open and arthroscopic repair for glenohumeral instability is conflicting. We performed a prospective, expertise-based, randomized clinical trial to compare open shoulder stabilization with arthroscopic shoulder stabilization by measuring quality-of-life outcomes and recurrence rates at two years among patients treated for traumatic anterior shoulder instability. METHODS: Computer-generated, variable-block-size, concealed randomization allocated 196 patients to either the open-repair group (n = 98) or the arthroscopic-repair group (n = 98). An expertise-based randomization design was employed to avoid a differential bias in terms of physician experience. Outcomes were measured at baseline, at three and six months postoperatively, and at one and two years postoperatively with use of the Western Ontario Shoulder Instability Index (WOSI) and the American Shoulder and Elbow Surgeons (ASES) functional outcome scale. Recurrent instability was also analyzed. RESULTS: There were no significant differences in outcome scores at baseline. At two years, seventy-nine patients in the open group and eighty-three patients in the arthroscopic group were available for follow-up. There was no significant difference in mean WOSI scores between the groups; the mean WOSI score (and standard deviation) for the open group was 85.2 ± 20.4 (95% confidence interval [CI] = 80.5 to 89.8), and for the arthroscopic group, 81.9 ± 19.8 (95% CI = 77.4 to 86.4); p = 0.31. There was also no significant difference in mean ASES scores: 91.4 ± 12.7 (95% CI = 88.5 to 94.4) for the open group and 88.2 ± 15.9 (95% CI = 84.6 to 91.8) for the arthroscopic group; p = 0.17. Recurrence rates at two years were significantly different: 11% in the open group and 23% in the arthroscopic group (p = 0.05). Recurrent instability was more likely in patients with a preoperative Hill-Sachs lesion and in male patients who were twenty-five years old and younger. There was no significant difference in shoulder motion between the groups at two years. CONCLUSIONS: There was no difference between open and arthroscopic repair in terms of patient quality of life. Open repair resulted in a significantly lower risk of recurrence. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion.

The interobserver reliability of classification systems for radial head fractures: the Hotchkiss modification of the Mason classification and the AO classification systems.

BACKGROUND: Radial head fractures are common injuries, and there is little information on the reliability of classification systems for such injuries. The purpose of our study was to report the interobserver reliability of 2 commonly used classification systems: the Hotchkiss modification of the Mason classification and the AO classification systems. METHODS: We compiled the radiographs from a cohort series of 43 patients with radial head fractures, and 5 observers classified the radiographs according to both classification systems. Additionally, we collapsed the systems, with types II and III combined for the Hotchkiss classification and the final digit dropped for the AO classification. We calculated percent agreement, the kappa statistic and the associated 95% confidence intervals (CIs). RESULTS: The mean percent agreement was 72.3% (95% CI 65.8%-78.9%) for the Hotchkiss classification and 37.7% (95% CI 30.5%-44.9%) for the AO classification. The kappa statistic was 0.585 (0.541-0.661) for the Hotchkiss classification and 0.261 (0.240-0.350) for the AO classification. The mean percent agreement was 89.3% (86.6%-92.0%) for the consolidated Hotchkiss classification and 67.4% (54.6%-80.3%) for the consolidated AO classification. The kappa statistic was 0.760 (0.691-0.805) for the consolidated Hotchkiss classification and 0.455 (0.372-0.521) for the consolidated AO classification. CONCLUSION: The interobserver reliability for the Hotchkiss modification of the Mason classification was moderate, and that for the AO classification was fair according to the criteria of Landis and Koch. Collapsing the Hotchkiss classification improved the reliability to substantial, and collapsing the AO system improved reliability to the lower end of moderate.

Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.

Persistent tendon defects after rotator cuff repair are not uncommon. Recently, the senior author has identified a subset of 5 patients (mean age, 52 years; range, 42 to 59 years) after arthroscopic double-row rotator cuff repair who showed an unusual mechanism of tendon failure. In these patients the tendon footprint appears well fixed to the greater tuberosity with normal thickness. However, medial to the intact footprint, the tendon is torn with full-thickness defects through the rotator cuff. All patients were involved in Workers' Compensation claims. Magnetic resonance arthrography showed an intact cuff footprint but dye leakage in all patients. Revision surgery was performed at a mean of 8.6 months after the index procedure and showed an intact rotator cuff footprint but cuff failure medial to the footprint. Four patients had repair of the defects by tendon-to-tendon side-to-side sutures, whereas one did not undergo repair. Medial-row failure of the rotator cuff is a previously unreported mechanism of failure after double-row rotator cuff repair. Given the small number of patients in this study, it is unclear whether these defects are symptomatic. However, repair of these defects resulted in improvement in pain in 4 of 5 patients.

The location-specific healing response of damaged articular cartilage after ACL reconstruction: short-term follow-up.

Although many different interventions have been proposed for treating cartilage lesions at the time of ACL reconstruction, the normal healing response of these injuries has not been well documented. To address this point, we compared the arthroscopic status of chondral lesions at the time of ACL reconstruction with that obtained at second-look arthroscopy. We hypothesized that there might be a location-specific difference in the healing response of damaged articular cartilage. Between September 1998 and March 2000, 383 patients underwent arthroscopically-assisted hamstring ACL reconstruction without any intervention to the articular cartilage. Among these patients, 84 patients underwent second-look arthroscopy (ranging from 6 to 52 months following initial surgery) and make up the population of the present study. Chondral injuries, left untreated at ACL reconstruction, were arthroscopically evaluated using the Outerbridge classification, and were again evaluated at second-look arthroscopy. At second-look arthroscopy, there was significant recovery of chondral lesions by Outerbridge grading on both the medial and lateral femoral condyles. Among the recovered chondral lesions, 69% of cases of the medial femoral condyle, 88% of cases of the lateral femoral condyle were partial thickness injuries (grade I and II). Conversely, there was no significant recovery of chondral lesions observed at the patello-femoral joint or tibial plateaus. Our study revealed that there was a location-specific difference in the natural healing response of chondral injury. Untreated cartilage lesions on the femoral condlyes had a superior healing response compared to those on the tibial plateaus, and in the patello-femoral joint.

A randomized pilot validation of educational measures in teaching shoulder arthroscopy to surgical residents.

BACKGROUND: Injuries to the shoulder joint commonly require the attention of an orthopedic surgeon. Shoulder arthroscopy plays an increasingly important role in the diagnosis and repair of shoulder pathology; however, the most effective manner in which to teach orthopedic residents fundamental knowledge of diagnostic shoulder arthroscopy before entering the operating room is unclear. We aimed to compare the existing cadaver-based teaching of diagnostic shoulder arthroscopy knowledge with a method that combines model- and video-based teaching to orthopedic surgery residents in a randomized pilot trial. METHODS: A composite (model/video teaching) method was designed, using prepared teaching videos and the commercially available ALEX shoulder arthroscopy model. First- and second-year orthopedic surgery residents from the University of Calgary were consented, surveyed for their arthroscopy experience and randomized to either cadaver or composite teaching. Subjects wrote a pretest before their teaching session and a posttest afterwards to assess their knowledge of diagnostic arthroscopy. The tests were multiple choice, containing text and pictorial-based questions. The posttest was modified to minimize recall bias. Subjects were also surveyed for their comments regarding the teaching sessions. RESULTS: Nine of 10 subjects increased their test scores after the teaching sessions, with 4 of 5 in the cadaver-based and 5 of 5 in the composite groups. There were no differences between the teaching groups on their mean pre- or posttest scores. The composite group, but not the cadaver-based group, had a statistically significant increase in posttest scores. When the text- and pictorial-based question sections were analyzed separately, both groups significantly improved their mean text-based score, whereas only the composite group increased their mean pictorial-based questions score. Surveying the residents elicited positive comments regarding both manners of teaching. CONCLUSION: This pilot trial suggests that a composite teaching curriculum is at least as effective as a cadaver-based environment for teaching orthopedic surgery residents fundamental knowledge of diagnostic shoulder arthroscopy.