Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 468 | Issue 6 | Jun, 2010

Strategies in Biologic Augmentation of Rotator Cuff Repair: A Review

Emilie V. Cheung MD, Luz Silverio BA, John W. Sperling MD

Degenerative rotator cuff tears are increasing with the aging population, and healing is not uniform after surgery. Rotator cuffs may show improved healing when biologic factors are added during surgery.

Tendon Properties Remain Altered in a Chronic Rat Rotator Cuff Model

LeAnn M. Dourte BS, Stephanie M. Perry PhD, Charles L. Getz MD, Louis J. Soslowsky PhD

Chronic rotator cuff tears are often associated with pain or poor function. In a rat with only a detached supraspinatus tendon, the tendon heals spontaneously which is inconsistent with how tears are believed to heal in humans.

The Effect of Hypercholesterolemia on Rotator Cuff Disease

Joseph A. Abboud MD, Jae S. Kim MS

The causes of rotator cuff tendon rupture are multifactorial and still unclear. Intrinsic and extrinsic factors have been implicated as predisposing risk factors for rotator cuff rupture. Previous studies have suggested a relationship between elevated serum lipid profiles and tendon ruptures, although not rotator cuff tears specifically.

Natural History of Fatty Infiltration and Atrophy of the Supraspinatus Muscle in Rotator Cuff Tears

Barbara Melis MD, Michael J. DeFranco MD, Christopher Chuinard MD, Gilles Walch MD

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.

Isokinetic Muscle Performance Test Can Predict the Status of Rotator Cuff Muscle

Joo Han Oh MD, PhD, Jong Pil Yoon MD, Jae Yoon Kim MD, Chung Hee Oh MD

The isokinetic muscle performance test (IMPT) is a validated and objective method used to evaluate muscle function but it is unknown whether it correlates with severity of rotator cuff tears.

Partial-thickness Articular Surface Rotator Cuff Tears: An All-inside Repair Technique

Edwin E. Spencer MD

Treatment of partial-thickness articular surface rotator cuff tears varies from simple débridement with or without an acromioplasty to various repair techniques. These repair techniques have included in situ transtendinous methods, as well as completion of the tear and repairing the full-thickness defect. The transtendinous techniques can be associated with stiffness and completing the tear takes down normal intact tissue. Therefore, a technique was developed that repairs the articular-side partial- thickness rotator cuff tears with an all-inside approach that does not violate the intact bursal tissue and does not complete the tear.

Healed Cuff Repairs Impart Normal Shoulder Scores in Those 65 Years of Age and Older

Edward V. Fehringer MD, Junfeng Sun PhD, Jonathon Cotton MD, Michael J. Carlson MD, Erica M. Burns MD

It is unclear whether repaired rotator cuffs heal in older patients and whether the function in those shoulders compares with those of similarly aged patients with untreated tears.

Indications for Reverse Total Shoulder Arthroplasty in Rotator Cuff Disease

Gregory N. Drake DO, Daniel P. O’Connor PhD, T. Bradley Edwards MD

Reverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA’s approval in 2004, the appropriateness in patients with rotator cuff disease is unclear.

Cigarette Smoking Increases the Risk for Rotator Cuff Tears

Keith M. Baumgarten MD, David Gerlach MD, Leesa M. Galatz MD, Sharlene A. Teefey MD, William D. Middleton MD, Konstantinos Ditsios MD, Ken Yamaguchi MD There is little available evidence regarding risk factors for rotator cuff tears. Cigarette smoking may be an important risk factor for rotator cuff disease. The purpose of this study was to determine if cigarette smoking correlates with an increased risk for rotator cuff tears in patients who present with shoulder pain. A questionnaire was administered to 586 consecutive patients 18 years of age or older who had a diagnostic shoulder ultrasound for unilateral, atraumatic shoulder pain with no history of shoulder surgery. Three hundred seventy-five patients had a rotator cuff tear and 211 patients did not. Data regarding cigarette smoking were obtained for 584 of 586 patients. A history of smoking (61.9% versus 48.3%), smoking within the last 10 years (35.2% versus 30.1%), mean duration of smoking (23.4 versus 20.2 years), mean packs per day of smoking (1.25 versus 1.10 packs per day), and mean pack-years of smoking (30.1 versus 22.0) correlated with an increased risk for rotator cuff tear. We observed a dose-dependent and time-dependent relationship between smoking and rotator cuff tears. We observed a strong association between smoking and rotator cuff disease. This may indicate smoking is an important risk factor for the development of rotator cuff tears.,[object Object]

Classification and Clinical Significance of Acromial Spur in Rotator Cuff Tear: Heel-type Spur and Rotator Cuff Tear

Joo Han Oh MD, PhD, Jae Yoon Kim MD, Ho Kyoo Lee MD, Jung-Ah Choi MD, PhD Acromial spurs reportedly relate to the impingement syndrome and rotator cuff tears. We classified the morphologic characteristics of the acromion (shape and thickness) and acromial spurs and determined whether they correlated with rotator cuff tears. We measured acromial shape and thickness using simple radiography and MR arthrography or CT arthrography in 106 patients with full-thickness rotator cuff tears and in 102 patients without tears. Acromial spurs could be classified morphologically into six types: heel, lateral/anterior traction, lateral/anterior bird beak, and medial. We found acromial spurs in 142 of the 208 patients (68%), and their incidence increased with age. The acromial spur was more common in the cuff tear group. The heel type was most common and detected in 59 patients (56%) in the cuff tear group and in 36 patients (35%) in the control group. The flat acromion was more common (60%) than curved and hooked acromion; however, there was no major difference between acromial shape and cuff tear. The mean acromial thickness was 8.0 mm, and the cuff tear group had thicker acromion. These data suggest acromial spurs can be classified according to the distinct morphology, and the most common heel-type spur might be a risk factor for full-thickness rotator cuff tears.,[object Object]

Internal Rotation Deficits Affect Scapular Positioning in Baseball Players

Stephen J. Thomas MEd, ATC, Kathleen A. Swanik PhD, ATC, Charles B. Swanik PhD, ATC, John D. Kelly MD

Anecdotal evidence suggests an association between glenohumeral internal rotation deficits (GIRD) and scapular dysfunction, an observable alteration in the normal position or motion of the scapula in relation to the thoracic cage.

Reliability of the Grading System for Fatty Degeneration of Rotator Cuff Muscles

Joo Han Oh MD, PhD, Sae Hoon Kim MD, Jung-Ah Choi MD, PhD, Yeoju Kim MD, Chung Hee Oh MD Fatty degeneration of the rotator cuff muscles is considered one of the most important factors for the outcomes of cuff repair. However, the reliability of the grading system is not well validated. Two specialists in musculoskeletal radiology and three shoulder fellowship-trained orthopaedic surgeons reviewed the fatty degeneration grades of each cuff muscle of consecutive 75 full-thickness cuff tears. Fatty degeneration grades were assessed according to the systems of Goutallier et al. and Fuchs et al. using preoperative MR and postoperative CT arthrographies. The interclass correlation coefficient was analyzed to assess interobserver and intraobserver reliabilities. For interobserver reliability using the system of Goutallier et al. the interclass correlation coefficient was higher in MR arthrography (0.6–0.72) than in CT arthrography (0.43–0.6) and higher for radiologists (0.58–0.78) than for orthopaedic surgeons (0.32–0.68). There was no difference between the systems of Goutallier et al. and Fuchs et al. Intraobserver reliabilities showed a similar pattern (0.26–0.81), but the level of experience should be considered. Although the system of Goutallier et al. is most widely used in orthopaedics, reported data should be interpreted carefully because of the relatively low reliability.,[object Object]

Reliability of Shoulder Abduction Strength Measure for the Constant-Murley Score

Michael Tobias Hirschmann MD, Björn Wind MD, Felix Amsler MSc, Thomas Gross MD [object Object]

Modified L’Episcopo Tendon Transfers for Irreparable Rotator Cuff Tears: 5-year Followup

Christian Gerhardt MD, Lars Lehmann MD, Sven Lichtenberg MD, Peter Magosch MD, Peter Habermeyer PhD

Patients with posterosuperior cuff tears lose functional external rotation of the shoulder. Latissimus dorsi and teres major transfer is performed to restore external rotation. Twenty patients with a mean age was 55.8 ± 6 years underwent this procedure and were examined at averages of 24.7 (n = 17) and 70.6 (n = 13) months. Two patients did not improve presumably because of failure of the transfer. The Constant and Murley score increased from 55.6 to 90.4 after 2 years and to 87.9 after 5 years. The mean active flexion increased from 119.4° to 169.3° and reached 170° after 5 years, and mean external rotation increased from 12° to 35°, finally reaching 23°. The grade of cuff arthritis progressed from initially Grade 1 in 17% and Grade 2 in 28% to Grade 2 in 8%, Grade 3 in 69%, and Grade 4 in 15% at final followup. The acromiohumeral distance increased from 4.5 mm to 6 mm and decreased to 3.8 mm after 5 years. Electromyographic analysis showed activity during isometric internal and external rotation in the transferred muscle in all patients. The L’Episcopo procedure can restore shoulder function, but cuff arthropathy may progress.,[object Object]

Does an Arthroscopic Suture Bridge Technique Maintain Repair Integrity?: A Serial Evaluation by Ultrasonography

Jin-Young Park MD, Hawa Tahir Siti MD, Jung-Sup Keum MD, Sung-Gyu Moon MD, Kyung-Soo Oh MD Biomechanical studies suggest a suture bridge technique enhances rotator cuff tendon footprint contact area, holding strength, and mean contact pressure. Based on these studies, we asked whether (1) the suture bridge technique would provide a high rate of cuff integrity after surgery, (2) the status of the repaired cuff would change with time, (3) preoperative factors could predict postoperative cuff integrity, and (4) patients with retears had less favorable pain, functional scores, range of motion (ROM), and muscle strength compared with those with intact repairs. We prospectively followed 78 patients with arthroscopic repairs in whom we used the suture bridge technique. The integrity of the rotator cuff repair was determined using ultrasonographic evaluation at 4.5 and 12 months after surgery. Ultrasonography revealed intact cuffs in 91% at 4.5 months postoperatively, all of which were maintained at the 12-month followup. Failure rates were 17.6% (three of 17) for massive tears, 11.1% (two of 18) for large tears, 6.3% (two of 32) for medium tears, and no failures for small tears. Preoperative fatty degeneration of the supraspinatus muscle was a strong predictor of cuff integrity. We found no correlation between the integrity and clinical outcomes except for a temporary decrease of abduction strength at 6 months. Arthroscopic repair using suture bridge technique can achieve a low retear rate in shoulders treated for rotator cuff tears, but the occurrence of retear did not influence the outcome.,[object Object]

Distribution of Lubricin in the Ruptured Human Rotator Cuff and Biceps Tendon: A Pilot Study

Tadanao Funakoshi MD, PhD, Scott D. Martin MD, Thomas M. Schmid PhD, Myron Spector PhD

Lubricin is a lubricant for diarthrodial joint tissues and has antiadhesion properties; its presence in the (caprine) rotator cuff suggests it may have a role in intrafascicular lubrication.

Muscone Protects Vertebral End-plate Degeneration by Antiinflammatory Property

Qian-Qian Liang PhD, Min Zhang PhD, Quan Zhou MD, PhD, Qi Shi MD, Yong-Jun Wang MD, PhD Most chronic neck pain is the result of degeneration of the cervical spine. IL-1β may play an important role in intervertebral disc degeneration. This being the case, inhibiting IL-1β could provide a therapeutic approach for reducing or preventing disc degeneration. Muscone reportedly relieves pain and suppresses inflammation. Therefore, we asked whether muscone, a potent antiinflammatory agent, could reduce proinflammatory cytokines in vitro (end-plate cartilage cultures) and end-plate degeneration in vivo (a rat model that induces intervertebral disc degeneration). In vitro, muscone reversed IL-1β-induced upregulation of IL-1β, tumor necrosis factor α, cyclooxygenase 2, inducible nitric oxide synthase, matrix metalloproteinase 13, aggrecanase 2, and nitric oxide and downregulation of Col2α1 and aggrecan. Pretreatment with muscone (6.25, 12.5, 25 μmol/L) inhibited the IL-1β-induced phosphorylation of extracellular signal-regulated kinases 1/2 and c-Jun N-terminal kinase in a dose-dependent manner. In vivo, muscone inhibited the expression of prostaglandin E2, 6-keto-prostaglandin F1α, IL-1β, and tumor necrosis factor α and recovered the structural distortion of the degenerative disc. Our findings suggest muscone is a promising agent for treating intervertebral disc degeneration through its antiinflammatory effects.

High Long-term Survival of Bulk Femoral Head Autograft for Acetabular Reconstruction in Cementless THA for Developmental Hip Dysplasia

Mitsunari Kim MD, Toru Kadowaki MD

Deficient acetabula associated with acetabular dysplasia cause difficulty achieving adequate coverage of the acetabular component during THA. Autografting with the removed femoral head has been used for several decades to achieve better coverage, but the long-term benefits of this technique remain controversial, with some series reporting high rates of graft resorption and collapse.

Cerebral Microembolization during Primary Total Hip Arthroplasty and Neuropsychologic Outcome: A Pilot Study

Rahul V. Patel MRCS (Eng), MD, FRCS (Tr&Orth), Jan Stygall MSc, Jane Harrington PhD, Stanton P. Newman DPhil, Fares S. Haddad BSc, MCh (Orth), FRCS (Ed), FRCS (Orth)

Intraoperative cerebral microembolization occurs in a substantial proportion of patients undergoing THA. Historically, postoperative cognitive dysfunction has been attributed to different factors, including anesthesia, but the influence of the surgery has not been thoroughly examined.

Trochanteric Slide Osteotomy on Previously Osteotomized Greater Trochanters

Dror Lakstein MD, Yona Kosashvili MD, MHA, David Backstein MD, MEd, FRCSC, Oleg Safir MD, FRCSC, Allan E. Gross MD, FRCSC The sliding trochanteric osteotomy is a useful and safe technique facilitating exposure of the hip in a complex arthroplasty. The modified sliding trochanteric osteotomy preserves the posterior capsule and short external rotators, allows anterior dislocation of the hip, and is associated with a lower dislocation rate. With the increased incidence of failed THAs and need for revision, there is an increased need for better exposure of challenging hips. Therefore, trochanteric osteotomies in hips that previously had osteotomies are not uncommon and likely will become frequent in the future. We evaluated use of the modified trochanteric slide osteotomy on greater trochanters that previously had osteotomies and were healed. We reviewed 38 patients with repeated osteotomies and 38 matched control patients with osteotomies on greater trochanters that did not have previous osteotomies. The minimum followup was 13 months (mean, 37 months; range, 13–73 months). Thirty-three osteotomies (87%) healed with bony union, four (11%) had fibrous union, and one (3%) had nonunion. Two (5%) patients had a new onset abductor lurch develop. Two (5%) patients had persistent trochanteric pain and two (5%) had dislocations. The bony union, fibrous union, and nonunion rates, and the abductor lurch, persistent trochanteric pain, and dislocation rates, were similar to those of the control patients. Repeated osteotomy on a previously healed greater trochanter osteotomy is a reliable procedure with similar clinical outcome and complication rates as a primary osteotomy.,[object Object]

Does Minimally Invasive Surgery Improve Short-term Recovery in Total Knee Arthroplasty?

Tao Cheng MD, PhD, Tao Liu MD, PhD, Guoyou Zhang MD, PhD, Xiaochun Peng MD, PhD, Xianlong Zhang MD, PhD

Concerns have been raised regarding minimally invasive surgery (MIS) and its possible effect on postoperative functional recovery, complications, and survival rate after TKA.

Is Sclerotherapy Better than Intralesional Excision for Treating Aneurysmal Bone Cysts?

Manish Kumar Varshney MS, DNB, MNAMS, MRCS (Glasgow), Shishir Rastogi MS, DNB (PMR), Shah Alam Khan MS, DNB (Orth), MRCS, FRCS, Vivek Trikha MS

Minimally invasive approaches such as sclerotherapy have been introduced to treat aneurysmal bone cysts. Sclerotherapy has been associated with reasonable healing rates during the past two decades. However, it is unclear whether sclerotherapy compares with the more traditional extended curettage and bone grafting.

Staged Lengthening Arthroplasty for Pediatric Osteosarcoma around the Knee

Chang-Bae Kong MD, Soo-Yong Lee MD, Dae-Geun Jeon MD

Orthopaedic oncologists often must address leg-length discrepancy after resection of tumors in growing patients with osteosarcoma. There are various alternatives to address this problem. We describe a three-stage procedure: (1) temporary arthrodesis, (2) lengthening by Ilizarov apparatus, and (3) tumor prosthesis.

Proximal Tibial Metaphyseal Fractures with Severe Soft Tissue Injury: Clinical and Functional Results at 2 Years

James S. Starman MD, Renan C. Castillo PhD, Michael J. Bosse MD, Ellen J. MacKenzie PhD

Controversy exists regarding management of proximal tibial metaphyseal fractures with severe soft tissue injury. It is unclear whether limb salvage or early amputation results in the best functional and clinical outcomes.

Septic Arthritis in Adults with Sickle Cell Disease Often is Associated with Osteomyelitis or Osteonecrosis

Philippe Hernigou MD, Gildasio Daltro MD, Charles-Henri Flouzat-Lachaniette MD, Xavier Roussignol MD, Alexandre Poignard MD

Septic arthritis is a known complication of sickle cell disease (SCD) in children, and the association with osteomyelitis and osteonecrosis has been described. However, it is unclear whether this association applies to adults.

Origins of Eponymous Orthopaedic Equipment

Clifton Meals BA, Jeffrey Wang MD

Orthopaedists make great use of eponymous equipment, however the origins of these tools are unknown to many users. This history enriches, enlightens, and enhances surgical education, and may inspire modern innovation.

Case Report: Absent C6 Cervical Pedicle in a Collegiate Football Player

John R. Fowler MD, Ray A. Moyer MD Congenital absence of a cervical pedicle is a rare clinical finding with only 70 reported cases in the literature from 1946 until present. The congenitally absent pedicle has clinical importance owing to the frequency of misdiagnosis and inappropriate invasive treatments. We present the case of a 21-year-old college football player who experienced neck and shoulder pain after violent twisting of his neck by the face mask. The player walked off the field under his own power. He was sent to the locker room, where he underwent right shoulder and cervical spine radiographs. Initial review of the radiographs raised concern for a jumped right C6 facet. The patient then underwent CT and MRI of the cervical spine, confirming the diagnosis of an absent cervical pedicle. He was treated nonoperatively for a short time and completed the season. He had no symptoms at last followup at 8 months. The most frequent location of the absent cervical pedicle is at the C6 level, and the next most common is at the C5 level. Neural compression or instability is uncommon and nonsurgical treatment is the mainstay of treatment. Misdiagnosis can lead to inappropriate treatment such as halo or tong application with traction, which occurred in seven of 57 cases in one series, and exploratory surgery, which occurred in four of 57 cases.

Case Report: Reconstruction of the Distal Tibia with Porous Tantalum Spacer after Resection for Giant Cell Tumor

K. Economopoulos MD, L. Barker PA-C, C. Beauchamp MD, R. Claridge MD Treatment options for giant cell tumors of the distal tibia include curettage and cement packing, curettage and bone grafting, or resection and reconstruction for aggressive tumors. Curettage of aggressive tumors often leads to severe bone loss requiring reconstruction. Allograft and autograft may be effective options for reconstruction, but each is associated with drawbacks including the possibility of infection and collapse. We present a case of giant cell tumor of the distal tibia treated with curettage and arthrodesis using a porous tantalum spacer. Complete removal of the tumor and successful arthrodesis of the ankle were accomplished using the spacer. The patient returned to pain-free walking along with eradication of the giant cell tumor. We believe porous tantalum spacers are a reasonable option for reconstructing the distal tibia after curettage of a giant cell tumor with extensive bone loss.
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