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ABSTRACT: To characterize the distribution of vascularity of the postoperative rotator cuff tendon using a maximum intensity projection technique after contrast-enhanced sonography.
We retrospectively evaluated image data on 23 patients (11 male and 12 female) with intact rotator cuff repairs who had previously undergone contrast-enhanced sonography of their shoulders using lipid microspheres before and after a standardized exercise protocol. The patients were on average 3 months out from their surgery. Using offline image analysis software, a maximum intensity projection image was obtained for each patient, reflecting the regional vascular distribution within the repair and adjacent soft tissue. Subjective analysis was performed in 4 regions of interest: peribursal, articular medial, articular lateral, and suture anchor, independently by 2 musculoskeletal radiologists using a semiquantitative scale ranging from 0 to 4 for each region (0, no enhancement; 1, 1%-25% enhancement; 2, 26%-50%; 3, 51%-75%; and 4, 76%-100%). A combined vascularity score (0-8) was produced for each region and formed the basis for the subjective analysis.
Using a Mann-Whitney nonparametric test, the data showed significantly higher regional enhancement in the peribursal and suture anchor regions compared to the tendon (P < .001). Exercise resulted in a statistically significant increase in the extent of enhancement in all regions (P < .002). Inter-rater reliability analysis using a weighted κ statistic showed strong agreement (0.63-0.64) for the suture anchor site and moderate agreement for the others (peribursal, 0.35-0.39; articular medial, 0.45-0.55; and articular lateral 0.32-0.33).
The maximum intensity projection technique after contrast-enhanced sonography provides a topographic map of rotator cuff vascularity; the latter has been implicated as an important factor in promoting bone-tendon healing. Approximately 3 months after rotator cuff repair, the suture anchor and peribursal regions showed the most robust vascularity. Maximum intensity projection imaging further establishes that there is a global increase in vascular response at the repair site after exercise.
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 08/2011; 30(8):1103-9. · 1.25 Impact Factor
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ABSTRACT: The objectives of this study were to characterize and compare the vascularity of arthroscopically repaired rotator cuff tendons at short-term and intermediate-term follow-up.
Nineteen patients who underwent arthroscopic rotator cuff repair were prospectively monitored for an average of 21.2 months. Initial baseline, grayscale ultrasound images of the operated-on shoulder were obtained on all patients at 3 months and at a minimum of 10 months postoperatively. Perflutren-lipid microsphere contrast (DEFINITY, Lantheus Medical Imaging, North Billerica, MA, USA) was injected after baseline grayscale images and after exercise to obtain contrast-enhanced images of the repair. Three regions of interest--supraspinatus tendon, peribursal tissue, and bone anchor site--were evaluated before and after rotator cuff-specific exercises.
The peribursal tissue demonstrated the greatest blood flow, followed by the bone anchor site and tendon, in pre-exercise and postexercise states. Significantly less blood flow was observed in all regions of interest before exercise (P < .05) and only at the bone anchor site after exercise (P < .001) at latest follow-up compared with the 3-month values. Intratendinous blood flow remained relatively low at both evaluation points after surgical repair.
Preliminary findings suggest that the peribursal tissue and bone anchor site are the main conduits of blood flow for the rotator cuff tendon after arthroscopic repair, with the supraspinatus tendon being relatively avascular. Blood flow of the repaired rotator cuff tendon decreases with time. Furthermore, exercise significantly enhances blood flow to the repaired rotator cuff.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2011; 21(5):597-603. · 1.93 Impact Factor
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ABSTRACT: Glenoid component loosening is one of the most common causes of failed total shoulder arthroplasty. Previous reports indicate that it is desirable to reimplant the glenoid component during revision shoulder arthroplasty. The purpose of our study was to retrospectively evaluate the satisfaction of patients undergoing glenoid revision (reimplantation or resection) following total shoulder replacement specifically for symptomatic glenoid loosening. Twenty-eight shoulders that developed symptomatic glenoid loosening following primary total shoulder arthroplasty were included in the study. Patients were retrospectively evaluated at a minimum of 2 years postoperatively. Patients either underwent resection followed by reimplantation of the glenoid component (13) or resection of the component with or without bone grafting (15). Each patient was evaluated with the UCLA Shoulder Scale and the Constant-Murley Shoulder Assessment. There were seven excellent, 13 good, five fair and three poor results on the UCLA score. Functional outcome scores trended higher in the reimplantation group but were not statistically significant. Both groups reported equal pain relief and satisfaction. Five out of 15 patients underwent arthroscopic resection of the glenoid, and these patients scored as well on the UCLA and Constant scores as the reimplantation group. When symptomatic glenoid loosening is the indication for revision total shoulder replacement, patients tend to achieve good to excellent results. Though functional scores were slightly higher in the reimplantation group, satisfaction was equally high in both groups. Resection, when indicated, should be performed arthroscopically as this improved functional outcome in our series.
HSS Journal 02/2010; 6(1):52-6.
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ABSTRACT: There has been limited in-vivo assessment of rotator cuff vascularity following repair. This study aims to characterize the vascularity of the shoulder 3 months following supraspinatus tendon repair.
Twenty-nine patients (average age, 61.4 years) underwent Perflutren lipid microsphere contrast-enhanced shoulder ultrasound examinations 3 months after arthroscopic rotator cuff repair. Each shoulder was scanned at rest and following exercise using linear phased array 9-MHz transducer optimized to detect the contrast agent. Blood flow was quantified off-line using ultrasound imaging quantification and analysis software (QLAB, Philips, Andover, MA). Peak enhancement (vascular volume) and rate of rise (perfusion) were determined for 3 regions of interest: peribursal area, supraspinatus tendon, and anchor site.
Peak enhancement and rate of rise were greatest in the peribursal soft tissue and anchor site. Resting peak enhancement and rate of rise were significantly lower within the tendon compared to the other 2 regions (P < .001). Exercise resulted in increased enhancement and rate-of-rise to all 3 regions, but had a significant predilection towards increasing vascular volume within the peri-bursal region (P = .026).
At 3 months following repair, the majority of blood flow to the repair is derived from the peribursal soft tissues and the anchor site. The tendon, particularly those with a defect at 3 months, is relatively avascular. Though limited by inclusion of only a single time point, this study introduces a new technique to quantify vascularity following supraspinatus repairs and suggests that the surrounding vascular milieu may play a role in tendon healing.
Basic Science.
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 07/2009; 19(1):73-80. · 1.93 Impact Factor
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ABSTRACT: To test the hypothesis that regional variations in supraspinatus tendon vascularity exist and can be imaged and quantified in asymptomatic individuals by using contrast material-enhanced ultrasonography (US).
After institutional review board approval and informed consent were obtained, 31 volunteers aged 22-65 years (mean age, 41.5 years) underwent lipid microsphere contrast-enhanced shoulder US performed with an L8-4 transducer operating in contrast harmonic mode and a mechanical index of 0.07 in a HIPAA-compliant protocol. Images were obtained in the volunteers at rest and after exercise. Quantitative analysis was performed by using the time-enhancement postcontrast data derived from four regions of interest (ROIs): bursal medial, articular medial, bursal lateral, and articular lateral. Two 2-minute acquisitions were performed after each contrast material bolus. Baseline enhancement and peak enhancement for each ROI were estimated from these acquisitions. Baseline gray-scale and power Doppler US images of the supraspinatus tendon were obtained by using an L12-5 transducer. The Mann-Whitney nonparametric test was used to test for significant differences between ROIs in all volunteers.
In the volunteers at rest before exercise, significant variations in regional enhancement between the articular medial zone and both the bursal medial zone (P = .002) and the bursal lateral zone (P = .003) were observed. Differences in enhancement between the articular medial and articular lateral zones approached significance. Greater differentiation (P < .001) was observed after exercise, with a significant increase in apparent enhancement in each ROI in all volunteers.
This study revealed the spatial distribution of the blood supply to the supraspinatus tendon in asymptomatic individuals. The addition of exercise to the protocol resulted in a significantly increased level of enhancement compared with that at rest and enabled more sensitive assessment of intratendinous and peritendinous vascularity.
http://radiology.rsnajnls.org/cgi/content/full/2483071400/DC1.
Radiology 09/2008; 248(3):954-61. · 5.73 Impact Factor
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ABSTRACT: The optimal operative management of anterior cruciate ligament (ACL) injury continues to be debated. Many complications can occur, but fracture is often not routinely discussed. We present a complex intra-articular tibia fracture in a patient who had an autologous, ipsilateral bone-patellar-bone ACL reconstruction. While still advocating early, aggressive physical therapy, this case reminds us of the inherent susceptibility to injury in the immediate post-operative period.
HSS Journal 03/2008; 4(1):20-4.
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ABSTRACT: We sought to evaluate clinical and functional outcome in a cohort of patients who underwent transfer of the long head of the biceps tendon (LHBT).
Patients who were diagnosed with biceps pathology or instability underwent an arthroscopic assisted or all arthroscopic transfer LHBT as either an isolated procedure or part of another shoulder procedure by the senior author. The procedure was performed using a new arthroscopic subdeltoid technique. Forty shoulders in 39 patients were examined at a minimum of 2 years. Patients underwent complete shoulder evaluation and clinical outcomes were scored based on American Society of Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA), and L'Insalata questionnaires. Ipsilateral and contralateral metrics were also evaluated.
Forty shoulders (13 female, 26 male, 1 bilateral; average age, 38.5 years) were evaluated with L'Insalata, UCLA, and ASES questionnaires, scoring 75.57, 27.32, and 78.72, respectively. In the 25 patients who had an isolated LHBT transfer, the L'Insalata, UCLA, and ASES scores were 85.2, 29.5, and 84.8, respectively. Three patients had early traumatic failure related to noncompliance with postoperative rehabilitation protocol. This included the only 2 patients who had a Popeye sign at follow-up during active elbow flexion. There was not a statistically significant side-to-side strength difference using a 10-pound weight. Eighty percent of patients were self-rated as good to excellent, and 20% of patients were self-graded as fair or poor, which includes the 3 failures mentioned above. All of the patients reported no arm pain at rest with regard to the biceps. Ninety-five percent of patients reported no biceps tenderness upon palpation of the bicipital groove. Five patients complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion.
Arthroscopic subdeltoid transfer of the LHBT is an appropriate and reliable intervention for active patients with chronic, refractory biceps pathology. There was no loss of strength for biceps curls. All patients reported no pain isolated to biceps muscle at rest. Ninety-five percent of patients had resolution of their preoperative biceps symptoms.
Level IV, therapeutic case series.
Arthroscopy The Journal of Arthroscopic and Related Surgery 03/2008; 24(2):217-23. · 3.02 Impact Factor
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ABSTRACT: We sought to evaluate the functional and radiographic outcome of osteochondral lesions involving the femoral condyle that were arthroscopically repaired via a bioabsorbable fixation device made of self-reinforced poly-L-lactic acid.
A retrospective clinical and radiographic evaluation of 9 patients (8 male and 1 female) with a mean age of 18 years at the time of surgery was carried out. Of these patients, 8 were diagnosed with osteochondritis dissecans and 1 had a traumatic chondral fracture. All patients underwent arthroscopic repair of a discrete osteochondral lesion involving the femoral condyle with a bioabsorbable fixation implant. All patients were evaluated at a mean of 33 months postoperatively. All patients had preoperative magnetic resonance imaging (MRI) documenting the integrity and location of the fragment. Patients were evaluated at follow-up with a physical examination, Lysholm questionnaire, and repeated MRI with specific cartilage pulse sequencing.
At surgery, the mean size of the fragment was 2 x 2 cm. A mean of 4 nails was used in each case (range, 2 to 10). All patients were treated with a postoperative rehabilitation protocol of non-weight-bearing for a minimum of 6 weeks. The mean postoperative Lysholm score was 94 (range, 78 to 100). The outcomes were excellent in 7 patients, good in 1, and fair in 1. After surgery, MRI evaluation of the osteochondral lesion and overlying cartilage was graded as healed in 7 patients and of questionable integrity in 2.
This report documents the efficacy of a bioabsorbable nail to internally fix osteochondral lesions. It supports the use of MRI for both preoperative planning and postoperative assessment of fragment healing.
Level IV, therapeutic case series.
Arthroscopy The Journal of Arthroscopic and Related Surgery 02/2008; 24(1):62-8. · 3.02 Impact Factor
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ABSTRACT: The coronal plane high tibial osteotomy is a novel technique that is used to treat tibiofemoral malalignment. The authors hypothesize that the coronal plane high tibial osteotomy is (1) efficacious in treating both varus and valgus tibiofemoral malalignment; (2) does not alter the slope of the proximal tibia; and (3) does not alter the relationship between the patella and tibial tubercle. A retrospective review of 25 patients with tibiofemoral malalignment (19 varus/6 valgus) treated with a coronal plane osteotomy with a minimum of 2-year follow-up was performed. A Kaplan-Meyer survival curve was performed using knee arthroplasty and a Hospital for Special Surgery (HSS) knee score <70 as failure criteria. The Insall-Salvati ratio and the proximal tibial slope were measured. A p value of 0.05 was considered significant. At 60-month follow-up, knees with initial varus malalignment had an 84% survival rate using both knee arthroplasty and the HSS score as endpoints. Knees with initial valgus malalignment had an 84 and 60% survival rate using knee arthroplasty and the HSS score as endpoints, respectively. There was no statistically significant change in the Insall-Salvati ratio and proximal tibial slope after coronal plane osteotomy. The coronal plane osteotomy is efficacious in treating varus and valgus tibiofemoral malalignment and does not alter the patellar-tibial tubercle relationship or the posterior tibial slope [case series (level of evidence: IV)].
HSS Journal 10/2007; 3(2):147-54.
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ABSTRACT: The amount of axial rotation in the tibia caused by high tibial osteotomy is relatively unknown. The authors hypothesize that the coronal plane high tibial osteotomy, a novel technique used to treat varus malalignment, alters the axial rotation of the tibia less than the opening wedge high tibial osteotomy. Eight, embalmed, stripped cadaveric tibia-fibula constructs with intact interosseous membranes were randomized to either opening wedge or coronal plane high tibial osteotomies. Sequential valgus corrections of 5 degrees, 10 degrees, and 15 degrees were performed. The Qualisys Track Manager motion capture system was used to measure axial rotation. Student's t test was used to compare axial rotation between the two groups. A p value of 0.05 was determined to be significant. The coronal plane technique produced rotations about the tibial axis that were statistically significantly smaller than those of the opening wedge technique for all correction angles (1.2 degrees internal rotation (IR) vs 16 degrees external rotation (ER), respectively, at 5 degrees correction; p = 0.02) (3.5 degrees IR vs 21.2 degrees ER at 10 degrees correction; p = 0.04) (4.5 degrees IR vs 23.0 degrees ER at 15 degrees correction; p = 0.01). The coronal plane high tibial osteotomy alters axial rotation of the tibia significantly less than the opening wedge high tibial osteotomy.
HSS Journal 10/2007; 3(2):155-8.
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ABSTRACT: Humeral head osteonecrosis is a progressive disease that requires prompt diagnosis and treatment. Core decompression is a viable treatment option for early-stage cases. Most surgeons perform core decompression by arthroscopically visualizing the necrotic area of bone and using a cannulated drill to take a core. Several attempts are frequently needed to reach the proper location. In the hip multiple passes are associated with complications. We describe the use of an anterior cruciate ligament (ACL) tibial drill guide to precisely localize the area of necrotic bone. Diagnostic arthroscopy is performed to assess the areas of osteonecrosis. Core decompression is performed by use of an ACL tibial guide, brought in through the anterior or posterior portal to precisely localize the necrotic area in preparation for drilling. Under image intensification, Steinmann pins are advanced into the area of osteonecrosis. Once positioned, several 4-mm cores are made. We treated 3 patients with this technique, and all had immediate pain relief. The use of the ACL guide allows precise localization of the area of humeral head involvement and avoids multiple drillings into unaffected areas. Initial indications are that arthroscopic-assisted core decompression with an ACL guide is an effective alternative to previously used methods.
Arthroscopy The Journal of Arthroscopic and Related Surgery 02/2007; 23(1):103.e1-4. · 3.02 Impact Factor
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ABSTRACT: The number of total shoulder arthroplasties has increased exponentially over the last ten years, creating a more prominent role for revision shoulder arthroplasty in the future. The main reasons for failure of shoulder arthroplasty can be classified as soft-tissue deficiencies, osseous deficiencies, component wear, or infection. We hypothesized that, despite appropriate surgical techniques, the outcome of revision total shoulder replacement can be predicted on the basis of the indication for the revision procedure.
We conducted a retrospective review of seventy-eight shoulders that had undergone revision shoulder arthroplasty. The shoulders were divided into two categories: (1) those with osseous or component-related problems and (2) those with soft-tissue deficiency. Category 1 consisted of four cohorts of shoulders: twenty-two treated with revision of the glenoid component, sixteen treated with conversion of a hemiarthroplasty to a total shoulder arthroplasty because of glenoid arthrosis, eight treated with revision of the humeral stem, and four treated for a periprosthetic fracture. Category 2 consisted of five cohorts of shoulders: ten treated with rotator cuff repair following total shoulder replacement, four with a failed tuberosity reconstruction, four with cuff tear arthropathy, five with instability, and five with infection. Patients were evaluated with the UCLA subjective outcome instrument, the L'Insalata shoulder questionnaire, and a subjective satisfaction scale (maximum score of 5 points).
The average UCLA score was 21.4 points and the average L'Insalata score was 68.73 points for the seventy-eight shoulders that were analyzed. The average score on the subjective satisfaction questionnaire was 2.91 points. According to the UCLA scores, twenty-four revisions were considered to have had an excellent result; fifteen, a good result; twenty-four, a fair result; and fifteen, a poor result. The average scores for the category-1 shoulders were significantly better than those for the category-2 shoulders (p < 0.05). Of the different types of operations, revision or implantation of a glenoid component and open reduction and internal fixation of a periprosthetic fracture provided the best outcomes. Tuberosity reconstruction, hemiarthroplasty for treatment of cuff tear arthropathy, and revision due to infection had uniformly poor outcomes.
In general, these results indicate that the outcome of revision shoulder arthroplasty can be predicted on the basis of the indication for the procedure. Component revisions, excluding humeral head revision for salvage, provide the best results, whereas soft-tissue reconstructions can be expected to yield poorer results overall.
Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.
The Journal of Bone and Joint Surgery 08/2006; 88(7):1494-500. · 3.27 Impact Factor
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ABSTRACT: The effect of contact area between tendon and bone on ultimate pullout strength of a repaired tendon is not known. The purpose of this study was to test whether the strength of a healed bone-tendon interface is related to the amount of tendon that is in contact with bone at the time of repair.
A total of 20 mature goats underwent bilateral open rotator cuff repair of the infraspinatus tendon. The tendon edge was repaired to bleeding cancellous bone in each case with the use of suture anchors. The tendon was repaired with 2 anchors (contact area A; n = 20) on 1 shoulder and 4 anchors (contact area B; n = 20) on the contralateral shoulder. Ten goats were euthanized at 4 weeks (group 1) and 10 goats at 8 weeks (group 2) postoperatively. Twelve specimens were evaluated with ultrasound in the sagittal and coronal planes in a saline bath before mechanical testing was conducted. Ultimate load to failure was reported for each shoulder. Data were analyzed by means of a paired t test and Wilcoxon signed-rank test.
Ultrasound evaluation revealed several instances in groups 1/2 and contact areas A/B in which clear gap formation occurred without scar (collagen) interdigitation at the bone-tendon interface. Failures occurred at the bone-tendon repair site in all specimens during biomechanical testing. The mean load to failure for all specimens in group 1 was 350.7 N; it was 619.4 N for specimens in group 2 (P = .0002). In group 1, specimens with contact area A had a mean load to failure of 317.3 N; specimens with contact area B had a mean load to failure of 375.5 N (P = .15). In group 2, specimens repaired with contact area A had a mean ultimate load to failure of 635.8 N, whereas contact area B specimens had an ultimate failure strength of 688.5 N (P = .45; Wilcoxon signed-rank).
Increasing the number of suture anchors and the surface area of the tendon that is in contact with bone at the repair site increased the ultimate load to failure of the repaired tendon at both 4 and 8 weeks postoperatively by less than 10% at both intervals. This was not a statistically significant increase in failure strength in this model.
This animal model shows no statistically significant differences in strength at the repair site between a 2-anchor and a 4-anchor rotator cuff repair. This information may have direct clinical applications for the surgical technique employed in the repair of rotator cuffs.
Arthroscopy The Journal of Arthroscopic and Related Surgery 07/2006; 22(6):595-602. · 3.02 Impact Factor
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ABSTRACT: It has been assumed that a robust vascular response at the tendon to bone interface during rotator cuff repairs is an integral part to the healing process. There are few studies that have explored this in an in-vivo prospective fashion.
To prospectively characterize vascular and anatomical patterns in repaired rotator cuff tendons using Power Doppler sonography in a double-blinded fashion.
Case control study; Level of evidence, 3.
Fifty patients undergoing rotator cuff repair were enrolled: 28 mini-open, 14 open, and 8 arthroscopic repairs; 20 patients were controls. Patients underwent Power Doppler sonography at 6 weeks, 3 months, and 6 months postoperatively. Power Doppler sonography analysis examined 6 areas of the rotator cuff repair: discretely marginated intrasubstance, partial-thickness defects, full-thickness defects, focal thinning of repair, presence of bursal or joint fluid, and location of anchors. A subjective scoring system assessed blood flow in each region.
There was a predictable, significant decrease in vascular scores after rotator cuff repair over time. The mean vascular score was 11.6 at 6 weeks, 8.3 at 3 months, 7.0 at 6 months, and 2.4 for controls. There was a significant difference (P < .05) in vascular recruitment scores between each time period, with the most robust flow at the peritendinous region. The lowest vascular score was at the anchor site or cancellous trough. Forty-eight percent of the patients had a rotator cuff repair defect postoperatively. These findings did not correlate with functional assessment and outcome at 6 months. There was no significant difference in vascular scores between the defect and no-defect groups. Mean University of California, Los Angeles; L'Insalata; and American Shoulder and Elbow Surgeons scores at 6 months were 28.6, 86.3, and 81.5, respectively. Thirty-three percent of asymptomatic controls had a rotator cuff tear that averaged 7.6 x 7.1 mm.
The robust vascular response dropped with time, which is not seen in asymptomatic shoulders. Nearly half of the patients demonstrated persistent rotator cuff defects after rotator cuff repair that did not correlate with functional outcome and physical findings at 6 months.
The American Journal of Sports Medicine 02/2006; 34(1):120-7. · 3.79 Impact Factor
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ABSTRACT: Patients who present with global capsular laxity and glenohumeral instability frequently can be treated successfully with shoulder girdle musculature strengthening exercises and activity modification. When such injury is caused by a paralytic shoulder, a rehabilitation program may not be a viable treatment option. Presented in this article are 3 patients with global capsular laxity and glenohumeral instability as a result of shoulder paralysis. We also describe an arthroscopic technique of thermal capsulorrhaphy. In our experience, arthroscopic thermal capsulorrhaphy used to treat global capsular laxity and glenohumeral instability resulting from a paralytic shoulder has decreased symptoms of shoulder instability and has significantly reduced shoulder pain.
Arthroscopy The Journal of Arthroscopic and Related Surgery 06/2005; 21(5):636. · 3.02 Impact Factor
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ABSTRACT: Treatment of chronic, refractory biceps tendinitis remains controversial. The authors sought to evaluate clinical and functional outcomes of arthroscopic release of the long head of the biceps tendon.
In specific cases of refractory biceps tendinitis, site-specific release of the long head of the biceps tendon may yield relief of pain and symptoms.
Case series; Level of evidence, 4.
Fifty-four patients diagnosed with biceps tendinitis underwent arthroscopic release of the long head of the biceps tendon as an isolated procedure or as part of a concomitant shoulder procedure over a 2-year period. Patients were not excluded for concomitant shoulder abnormality, including degenerative joint disease, rotator cuff tears, Bankart lesions, or instability. Nine of 40 patients had an isolated arthroscopic release of the biceps tendon. At a minimum of 2 years, the American Shoulder and Elbow Surgeons; the University of California, Los Angeles; and the L'Insalata shoulder questionnaires as well as ipsilateral and contralateral metrics were used for evaluation.
The L'Insalata; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 77.6, 27.6, and 75.6, respectively. Seventy percent had a Popeye sign at rest or during active elbow flexion; 82.7% of men and 36.5% of women had a positive Popeye sign (P < .05); 68% were rated as good, very good, or excellent. No patient reported arm pain at rest distally or proximally; 38% of patients complained of fatigue discomfort (soreness) isolated to the biceps muscle after resisted elbow flexion.
Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. Cosmetic deformity presenting as a positive Popeye sign and fatigue discomfort were the primary complaints.
Although tenotomy is not the ideal intervention for patients of all ages with various shoulder abnormalities, data suggest that it may be an acceptable surgical intervention for a specifically selected cohort of individuals.
The American Journal of Sports Medicine 03/2005; 33(2):208-13. · 3.79 Impact Factor
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The Journal of Bone and Joint Surgery 02/2005; 87(1):168-71. · 3.27 Impact Factor
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Techniques in Shoulder and Elbow Surgery 05/2004; 5(2):66-75.
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ABSTRACT: Most rotator cuff surgery is performed on chronic tears. As there is no animal model in which to examine the physiology of muscle and tendon injury and repair in this setting, we developed a chronic rotator cuff injury model in sheep.
The infraspinatus tendon was released in thirty-six female sheep. Biopsy specimens were obtained from the muscle and were analyzed for fat content. The force generated by the muscle with supramaximal stimulation was recorded intraoperatively. A control group (twelve sheep) underwent an immediate tendon repair. In the remaining twenty-four sheep, the tendon was wrapped in a dura substitute to prevent scarring and was repaired at six weeks (eight sheep) and eighteen weeks (sixteen sheep) after release. In the immediate repair group, four animals were killed at six weeks; four, at twelve weeks; and four, at twenty weeks. In the six-week delayed repair group, four animals were killed at twelve weeks and four were killed at twenty weeks after the repair. In the eighteen-week delayed repair group, eight animals were killed at twelve weeks; four, at twenty weeks; and four, at thirty weeks after the repair. Muscle biopsies and testing were repeated prior to killing of the animals.
The average force of muscle contraction decreased 3.6 lb (1.6 kg) by six weeks after the injury and 3.9 lb (1.8 kg) by eighteen weeks after the injury. After the repair, the force of contraction in the six-week group improved by 0.8 lb (0.4 kg) at twelve weeks postoperatively and by 1.3 lb (0.6 kg) at twenty weeks postoperatively. In contrast, no improvement occurred in the eighteen-week group until thirty weeks after the repair, at which time a 0.9-lb (0.4-kg) improvement was noted. There was a twelvefold increase in intramuscular fat concentration; this lipid infiltration was partially reversed after the tendon repair. Isolated tendon samples demonstrated an increase in the modulus of elasticity after chronic detachment that partially corrected after the tendon repair in the earlier (six-week) repair group.
We found that earlier repair of the tendon results in a more rapid recovery of both muscle function and tendon elasticity compared with a more delayed repair. We concluded that there may be a "point of no return" in rotator cuff injury after which the elasticity of the muscle-tendon unit does not return to normal.
The Journal of Bone and Joint Surgery 01/2004; 85-A(12):2391-402. · 3.27 Impact Factor
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ABSTRACT: The shoulder is among the most difficult joints to image well using ultrasound, likely contributing to the wide range of reported success of ultrasound in diagnosing rotator cuff tears. Using well defined techniques and criteria, recent studies have demonstrated very favorable results in detecting rotator cuff pathology using ultrasound. Special attention must be given to the potential pitfalls due to tendon curvature and the complex anatomy of the rotator cuff, as well as to using appropriate equipment. Current literature demonstrates a sensitivity of 91 to 95% and approximately 90% specificity and accuracy in the assessment of both partial‐ and full‐thickness tears using ultrasound.
Technical advances in ultrasound imaging are expected to further expand the role of ultrasound in the evaluation of rotator cuff pathology by offering improved image quality and reducing its inherent operator dependence. These include tissue harmonic imaging, extended field‐of‐view imaging, and 3‐dimensional imaging. The real‐time nature of ultrasound permits dynamic assessment of shoulder stability, tendon subluxations, as well as allowing accentuation of cuff tears. This review will covers the sonographic anatomy, scanning techniques, and pathology of the rotator cuff and long head of biceps tendons, emphasizing recent advances in ultrasound technology as these apply to the rotator cuff. Examples of the sonographic appearances following cuff repair and in the presence of a shoulder replacement will also be included.
Techniques in Shoulder and Elbow Surgery 08/2003; 4(3):121–132.
