The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion.

PURPOSE: The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion. METHODS: Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament. RESULTS: Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion. CONCLUSIONS: The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy. CLINICAL RELEVANCE: Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.

The Comma Sign: An Anatomic Study.

The "comma sign" is a comma-shaped arc of tissue located at the superolateral edge of the subscapularis at its insertion on the humeral head. It consists of the coracohumeral ligament (CHL) and the superior glenohumeral ligament (SGHL). It was recently recognized as an important landmark to aid surgeons in identifying the edge of a torn subscapularis tendon. The exact proportion of CHL and SGHL has not been precisely defined. The goal of this study was to dissect and more accurately define the composition of the comma tissue and its exact relationship to the subscapularis tendon. A total of 8 fresh frozen cadaveric shoulder specimens (mean age, 74 years; 5 male, 3 female) were dissected via a wide deltopectoral approach. Anatomic landmarks were identified, and measurements were taken with a digital caliper. The midpoint width of the SGHL and CHL and the composite insertion width of the subscapularis were measured. Measurements were taken 3 times each and averaged to calculate mean width. Mean midpoint width of the SGHL, CHL, and composite insertion was 5.99 mm (range, 5.25-6.91 mm), 5.13 mm (range, 4.28-5.72 mm), and 9.93 mm (range, 6.69-12.05 mm), respectively. The comma sign consists of approximately half SGHL (54%) and half CHL (46%) at its insertion to the subscapularis tendon, with an approximate width of 1 cm. With the increase in arthroscopic subscapularis repairs, knowledge of these dimensions will aid surgeons in discerning the comma tissue from other capsular elements and ultimately help in surgical restoration of native anatomy. [Orthopedics. 2021;44(4):e546-e548.].

Long-term Patient-Reported Outcome Measures Following Particulated Juvenile Allograft Cartilage Implantation for Treatment of Difficult Osteochondral Lesions of the Talus.

BACKGROUND: Conventional methods are not suitable for difficult to treat osteochondral lesions of the talus (OCLTs). The role of particulated juvenile allograft articular cartilage implantation is not well elucidated for long-term patient outcomes. METHODS: Thirteen patients with difficult-to-treat OCLTs underwent arthroscopy-assisted implantation of particulated juvenile articular cartilage graft into defects from 2010 to 2012 by the same surgeon. "Difficult to treat" was defined as having at least 3 of the following features or 2 if both variables described lesion characteristics: (1) lesions size of 107 mm2 or greater, (2) shoulder lesions, (3) patients who failed microfracture, (4) patient aged ≥40 years, or (5) patient body mass index (BMI) >25. Patients were evaluated using physical examination, patient interviews, and outcome score measures. Patients had follow-up at 2 years, 4 years, and between 6 and 10 years at their most recent follow-up. Differences in functional outcome scores were compared before and after surgery. RESULTS: Patients (age: 46.5 ± 11.8 years, BMI: 28.5 ± 6.1) had, on average, most recent follow-up of 8.0 years (range 72-113 months). Average visual analog scale for pain score decreased for patients by 3.9 points (95% confidence interval [CI] 2.18-5.60), when compared to preoperative assessment. Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports subscale scores also improved from 46.5 to 80.9 (95% CI 21.35-47.43), and from 18.8 to 57.9 (95% CI 21.05-57.10), respectively. Short Form-36 Health Survey physical component scores showed significant improvement by an average of 45.5 points (95% CI 32.42-58.50). American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Scale scores improved from 55.2 to 80.3 (95% CI 12.459-37.741). CONCLUSION: These results demonstrate positive patient-reported long-term outcomes for a cohort of patients with difficult OCLTs, followed over the course of 6-10 years after treatment with arthroscopy-assisted particulated juvenile articular cartilage implantation. LEVEL OF EVIDENCE: Level II, prospective cohort study.

The Angular Relationships Between the Coracohumeral Ligament and Adjacent Shoulder Structures Are Variable.

PURPOSE: To describe the arthroscopic anatomy of the coracohumeral ligament (CHL) in relation to visible anatomic reference points to aid in the execution of a more effective arthroscopic medial-lateral rotator interval closure. METHODS: Detailed dissection to identify the CHL was performed in 4 shoulders from 2 fresh-frozen donor cadavers with a deltopectoral approach. The angular relationship between the CHL and the superior border of the subscapularis tendon was determined via gross dissection. Arthroscopic images were used to determine the angular position of the CHL in relation to both the glenoid articular surface and the intraarticular segment of the tendon of the long head of the biceps brachii (LHB). RESULTS: Analysis of 4 cadaveric shoulders via gross dissection demonstrated the CHL to subtend a mean angle of 29° (range 16° to 39°) with respect to the superior border of the subscapularis tendon. Arthroscopic analysis of 4 cadaveric shoulders demonstrated the CHL to subtend a mean angle of 59° (range 38° to 77°) with respect to the glenoid articular surface. Additionally, arthroscopic analysis of 2 cadaveric shoulders demonstrated the CHL to subtend a mean angle of 29° (range 11° to 47°) with respect to the LHB tendon. CONCLUSION: Although the position of the CHL in relation to the subscapularis tendon, glenoid articular surface, and LHB tendon demonstrates a moderate degree of anatomic variability, these structures provide valuable anatomic reference points for the identification of the course of this significant static shoulder stabilizer. CLINICAL RELEVANCE: Comprehensive understanding of the angular relationships between the CHL and adjacent shoulder structures may assist with the execution of a more effective arthroscopic rotator interval closure.

Osteochondral Lesions of the Talus Revisited Emerging Technologies.

Osteochondral lesions of the talus are becoming an increasingly recognized source of chronic ankle pain following injury. Although, once thought to be attributed to ischemic necrosis, acute or repetitive trauma is the contemporary theory regarding their etiology. Presently, there is no clear-cut consensus among surgeons on the best algorithm to manage these challenging injuries. Arthroscopic techniques along with emerging technologies in the field of cartilage repair are becoming increasingly popular treatment modalities. These innovative methods have potential to provide a new direction for the future and deliver improved clinical outcomes. The current review discusses opinions regarding the development of these lesions and also the approach to management, including the latest surgical modalities, such as osteochondral grafts and juvenile chondrocyte implantation.

Potocki-Lupski syndrome in conjunction with bilateral clubfoot.

Potocki-Lupski syndrome (PTLS) is a rare chromosomal microduplication syndrome resulting in multiple congenital abnormalities including developmental delays, autistic features, and certain structural anomalies, with cardiovascular being the most common. The phenotype of this contiguous gene duplication syndrome is quite variable and may include musculoskeletal abnormalities. Given the infrequency and novelty of this disorder, full phenotypic characterization of PTLS has not yet been fully elucidated. We present a case of severe bilateral clubfoot in a patient with PTLS. Diagnosis was made by array-based comparative genomic hybridization and confirmed by fluorescence in-situ hybridization. Because clubfoot was also present in an apparently unaffected brother, the presence of PTLS may have acted as a modifier of the phenotype. This report highlights the complex interaction of chromosomal and familial factors that contribute to musculoskeletal birth defects.