Purpose: The purpose of this historical prospective study was to compare the pre- and post-operative Quality of Life (QOL) outcomes 12 months post-operatively between Articular Tears (AT) and Bursal Tears (BT) of patients with partial thickness tear of the rotator cuff. Methods: Data of 93 consecutive patients diagnosed with Partial Thickness Tear (PTT) who had undergone decompression, acromiploasty, or repair were used to compare outcome between patients with Articular Tears and Bursal Tears. The QOL outcome measures included one disease specific outcome measure, the Western Ontario Rotator Cuff Index (WORC) and two shoulder specific measures, the American Shoulder & Elbow Surgeons standardized shoulder assessment form (ASES) and the Constant-Murley score. A statistical paired t-test (pre vs. 12 months) and an independent t-test analysis (Articular vs. Bursal) were conducted to examine the impact of the tear site. Results: Forty-four Articular and 49 Bursal tears (48 females and 45 males) were included in the analysis. The mean age was 55.5 (SD: 13) and 53.3 (SD: 12) for the AT and BT groups respectively. There was no statistically significant difference between two groups in pre-operative QOL outcome scores. Both groups showed significant improvement in the above outcomes (p< 0.0001) one year following surgery. However, the AT group was significantly less improved than the BT group in the ASES scores (p=0.005), and Constant-Murley scores (p=0.035). The WORC was not sensitive in differentiating between the two groups (p=0.11). Conclusion: The intent of this study was to compare the pre-operative and rate of improvement in two groups of patients suffering from different site of rotator cuff pathology. The results indicate that the quality of life improves significantly regardless of the tear site. The pattern of recovery however is different indicating that patients with Bursal tear show a higher degree of improvement in their functional measures, possibly due to reduced mechanical compression on rotator cuff

The purpose of this historical prospective study was to compare the pre and post-operative Quality of Life (QOL) outcomes twelve months post-operatively in patients with partial thickness rotator cuff tears. Data of ninety-three consecutive patients diagnosed with Partial Thickness Tear (PTT) who had undergone decompression, acromioplasty, or repair were used to compare the outcome between patients with Articular Tears (AT) and Bursal Tears (BT). The QOL outcome measures included one disease specific outcome measure, the Western Ontario Rotator Cuff Index (WORC) and two shoulder specific measures, the American Shoulder & Elbow Surgeons standardised shoulder assessment form (ASES) and the Constant-Murley score. A statistical paired t-test (pre vs. twelve months) and an independent t-test analysis (Articular vs. Bursal) were conducted to examine the impact of the tear site. Forty-four Articular and forty-nine Bursal tears (forty-eight females and forty-five males) were included in the analysis. The mean age was 55.5 (SD: 13) and 53.3 (SD: 12) for the AT and BT groups respectively. There was no statistically significant difference between the two groups in pre-operative QOL outcome scores. Both groups showed significant improvement in the above outcomes (p< 0.0001) one year following surgery. However, the AT group was significantly less improved than the BT group in the post-op ASES scores (p=0.04), Constant-Murley scores (p=0.006) and WORC (p=0.01). The intent of this study was to compare the pre and post operative scores and rate of improvement in two groups of patients suffering from rotator cuff pathology at different sites. The results indicate that the quality of life improves significantly regardless of the tear site. The pattern of recovery however is different indicating that patients with Bursal tears show a higher degree of improvement in their functional measures. The findings suggest that two types of tears are different in their etiology and pathomechanics

Poor shoulder function may complicate the non-operative treatment of a humeral diaphyseal fracture. This has often been regarded as an unavoidable consequence of the relative immobility of the shoulder during brace treatment. Tears of the rotator cuff have not previously been recognised as an underlying cause of persistent shoulder pain and stiffness in this situation. In this report, we identified six patients, from a consecutive series of 294 patients with humeral fractures treated in our Institution over a five-year period, who were found to have symptomatic rotator cuff tears following non-operative treatment of their humeral diaphyseal fracture. All had normal pre-injury upper limb function, but had persistent pain and loss of active shoulder movement after their fracture had united. Large, retracted cuff tears, affecting the cuff muscles attached to the greater tuberosity, were identified pre-operatively from imaging of the rotator cuff and intra-operatively at open surgery. Surgical reconstruction of the cuff was carried out in all cases and yielded satisfactory return of shoulder function, on assessment at least eighteen months after injury

Hip abductor tears(AT) have long been under-recognized, under-reported and under-treated. There is a paucity of data on the prevalence, morphology and associated factors. Patients with “rotator cuff tears of the hip” that are recognized and repaired during total hip arthroplasty(THA) report comparable outcomes to patients with intact abductor tendons at THA.

The study was a retrospective review of 997 primary THA done by a single surgeon from 2012–2022. Incidental findings of AT identified during the anterolateral approach to the hip were documented with patient name, gender, age and diagnosis. The extent and size of the tears of the Gluteus medius and Minimus were recorded. Xrays and MRI's were collected for the 140 patients who had AT and matched 1:1 with respect to age and gender against 140 patients that had documented good muscle quality and integrity. Radiographic measurements (Neck shaft angle, inter-teardrop distance, Pelvis width, trochanteric width and irregularities, bodyweight moment arm and abductor moment arm) were compared between the 2 groups in an effort to determine if any radiographic feature would predict AT.

The prevalence of AT were 14%. Females had statistically more tears than males(18vs10%), while patients over the age of 70y had statistically more tears overall(19,7vs10,4%), but also more Gluteus Medius tears specifically(13,9vs5,3%). Radiographic measurements did not statistically differ between the tear and control group, except for the presence of trochanteric irregularities. MRI's showed that 50% of AT were missed and subsequently identified during surgery.

Abductor tears are still underrecognized and undertreated during THA which can results in inferior outcomes. The surgeon should have an high index of suspicion in elderly females with trochanteric irregularities and although an MRI for every patient won't be feasible, one should always be prepared and equipped to repair the abductor tendons during THA.

Meniscal tears commonly co-occur with ACL tears, and many studies address their side, pattern, and distribution. Few studies assess the patient's short-term functional outcome concerning tear radial and circumferential distribution based on the Cooper et al. classification. Meniscal tears require primary adequate treatment to restore knee function. Our hypothesis is to preserve the meniscal rim as much as possible to maintain the load-bearing capacity of the menisci after meniscectomy.

The purpose of this study is to document the location and type of meniscal tears that accompany anterior cruciate ligament (ACL) tears and their effect on patient functional outcomes following arthroscopic ACL reconstruction and meniscectomy.

This prospective cross-sectional observational study was conducted at AL-BASRA Teaching Hospital in Iraq between July 2018 and January 2020 among patients with combined ipsilateral ACL injury and meniscal tears. A total of 28 active young male patients, aged 18 to 42 years, were included. All patients were subjected to our questionnaire, full history, systemic and regional examination, laboratory investigations, imaging studies, preoperative rehabilitation, and were followed by Lysholm score 6 months postoperatively.

All 28 patients were males, with a mean age of 27 ± 0.14 years. The right knee was the most commonly affected in 20/28 patients (71.4%). The medial meniscus was most commonly injured in 11 patients, 7 patients had lateral meniscal tears, and 10 patients had tears in both menisci. The most common tear pattern of the medial meniscus was a bucket handle tear (36.4%), while longitudinal tears were the most frequent in the lateral meniscus (71.4%) (P-value = 0.04). The most common radial tear location was zone E-F (5/28, 17.8%), and the most common circumferential zone affected was the middle and inner third, reported in 50% of tears. Good and excellent outcomes using the Lysholm score after 6 months were obtained in 42.9% and 17.9% of patients, respectively. Better functional scores were associated with lateral meniscal tears, bucket handle tears, tears extending to a more peripheral vascular area, and if no more than one-third of the meniscus was resected (P-value = 0.002). Less favourable outcomes were reported in smokers, posterior horn tears, and when surgery was delayed more than 1 year (P-value = 0.03).

We conclude that there is a negative correlation between the amount of meniscus resected and functional outcome. Delayed ACL reconstruction increases the risk of bimeniscal tears. Bucket handle tears are the most common tears, mostly in the medial meniscus, while longitudinal tears are most common in the lateral meniscus. We recommend performing early ACL reconstruction within 12 months to reduce the risk of bimeniscal injuries.

Magnetic resonance imaging (MRI) is the gold standard for the diagnosis of the pathologies affecting the glenohumeral joint and the rotator cuff diseases. MRI allows to highlight anatomic discontinuities of both muscles and tendons. However, MRI diagnostic accuracy has not proven to be highly sensitive in distinguishing between a partial-thickness tear and a full-thickness rotator cuff tear. The purpose of this study was to determine if MRI under axial traction can be helpful in increasing MRI sensitivity to identify partial-thickness rotator cuff tears.

The study included 10 patients (4 males and 6 females) who had clinical examination and MRI suggesting a partial-thickness rotator cuff tear. They were candidates for shoulder arthroscopy because of persistent symptoms after at least three months of conservative treatment. The patients underwent a new MRI (under axial traction: MRI-AT) with a 4-kg weight applied to the affected arm. Then the patients underwent arthroscopy to confirm the diagnosis. Patients with a suspected full-thickness rotator cuff tear were excluded from the study.

Patients’ average age was 52.4 years, and the dominant side was affected in 77.7% of the cases. Preoperative Constant-Murley Score was 57. MRI-AT showed that 3 patients were affected by a complete tear of the rotator cuff, 3 patients by a partial-thickness rotator cuff tear and 4 patients had no lesion. The analysis of data showed that: under axial traction the subacromial space increased by 0,2 mm (P value = 0,001075), the superior glenohumeral space decreased by 2.4 mm (P value = 0,07414), the inferior glenohumeral space increased by 0.3 mm (P value = 0,02942), the acromial angle decreased by 1.9° (P value = 0,0002104) and the acromion-glenohumeral angle decreased by 0.3° (P-value = 0,01974). Two experienced evaluators analyzed previous standard MRI and MRI-AT scans in a double-blinded fashion, with inter-rater evaluation of all the images and measures. Intraclass correlation coefficient (ICC) has been utilized to assess the reliability of the measures performed by different operators. ICC always resulted in more than 0.7, showing a high concordance among values in the same group. A comparative evaluation between standard MRI and MRI-AT has been conducted to highlight possible discrepancies and this has been compared to intraoperative findings. Concordance of the values was 89% between standard MRI and MRI-AT and 100% between MRI under axial traction and intraoperative findings.

This study showed a high correlation between the diagnosis achieved with MRI-AT and the intraoperative arthroscopic findings. The use of MRI-AT in clinical practice may improve the diagnostic sensitivity of this method to detect a partial-thickness rotator cuff tear.

Rotator cuff tears are common, with failure rates of up to 94% for large and massive tears¹. For such tears, reattachment of the musculotendinous unit back to bone is problematic, and any possible tendon-bone repair heals through scar tissue rather than the specially adapted native enthesis. We aim to develop and characterise a novel soft-hard tissue connector device, specific to repairing/bridging the tendon-bone injury in significant rotator cuff tears, employing decellularised animal bone partially demineralised at one end for soft tissue continuation.

Optimisation samples of 15×10×5mm³, trialled as separate cancellous and cortical bone samples, were cut from porcine femoral condyles and shafts, respectively. Samples underwent 1-week progressive stepwise decellularisation and a partial demineralisation process of half wax embedding and acid bathing. Characterisations were performed histologically for the presence/absence of cellular staining in both peripheral and central tissue areas (n=3 for each cortical/cancellous, test/PBS control and peripheral/central group), and with BioDent reference point indentation (RPI) for pre- and post-processing mechanical properties.

Histology revealed absent cellular staining in peripheral and central cancellous samples, whilst reduced in cortical samples compared to controls. Cancellous samples decreased in wet mass after decellularisation by 45.3% (p<0.001). RPI measurements associated with toughness (total indentation depth, indentation depth increase) and elasticity (1st cycle unloading slope) showed no consistent changes after decellularisation. X-rays confirmed half wax embedding provided predictable control of the mineralised-demineralised interface position.

Initial optimisation trials show proof-of-concept of a soft-hard hybrid scaffold as an immune compatible xenograft for irreparable rotator cuff tears. Decellularisation did not appreciably affect mechanical properties, and further biological, structural and chemical characterisations are underway to assess validity before in vivo animal trials and potential clinical translation.

Data were collected on patients undergoing subacromial decompression (SAD) in our routine practice from 1998 to 2004. All patients had clinical signs of subacromial pain and had failed conservative treatment. Tears were not repaired. Data on age, gender, arm dominance and presence of cuff tear at operation were recorded. At six months post-operatively, patients were assessed with the Constant Score (CS). Data were analysed using multiple linear regression. Data on 427 patients were collected, 168 having rotator cuff tears. The mean age was 55.41 years (SD 12.00). There were 233 women and 191 men. There were no significant gender differences between the two groups (x2=2.34, df=1, p=0.13). The group with cuff tears were significantly older by 10.24 years (p< 0.001, 8.10 to 12.38). Power of the study was 90% at the 5% significance level. Multiple linear regression showed that gender, age and presence of a cuff tear all had a significant effect on the CS. Gender B = 5.52 (1.99 to 9.06) p = 0.002 Age B = −0.31 (−0.48 to −0.15) p < 0.001 Cuff tear B = −5.51 (−9.48 to −1.55) p = 0.007 Hand dominance and the side operated upon had no significant effect. We found that in patients with symptomatic shoulders, who had failed conservative treatment and undergone an SAD, the CS at six months follow up was lower in those who had a cuff tear. There was increased tear prevalence in slightly older patients, and these scored on average 5.5 (1.5 to 9.5) points less than expected on the CS, p = 0.007, after allowing for age and gender. We believe that the surgeon should discuss with the patient whether a 5.5 points lower score is enough of a difference to warrant a formal rotator cuff repair rather than debridement and SAD alone, and a joint decision should be made

16 to 34% of the population suffer from shoulder pain, the most common cause being rotator cuff tears. NICE guidance recommends using ultrasound scan (USS) or MRI to assess these patients, but does not specify which is preferable. This study assesses the accuracy of USS and MRI in rotator cuff tears in a DGH, to establish the most appropriate imaging modality.

Patients who had at least two of shoulder ultrasound, MRI or arthroscopy within a seven month period (n=55) were included in this retrospective study. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were calculated using arthroscopy as the true result, and kappa coefficients calculated for each pairing.

59 comparisons were made in total. Sensitivity for MRI in full supraspinatus tears was 0.83, and for USS 0.75. Specificity for MRI in these tears was 0.75, and for USS 0.83. Values were much lower in other tears, which occurred less frequently. USS and MRI completely agreed with each other 61.3% of the time. Both modalities were only completely accurate 50% of the time. Kappa coefficient between arthroscopy and MRI for supraspinatus tears was 0.658, and for USS was 0.615.

There was no statistical difference between MRI and USS sensitivity or specificity (p=1), suggesting that one modality cannot be recommended over the other for full supraspinatus tears. They also do not tend to corroborate one another, suggesting that there is no benefit from doing both scans. Further research is needed to see how both modalities can be improved to increase their accuracy.

Introduction. Superior Labral Anterior Posterior Tears are being treated surgically in increasing numbers. Stiffness is the most common complication. We reviewed 115 cases of SLAP repairs to try and identify preoperative risk factors if any for stiffness. Methods. Retrospective cohort study of 115 patients who underwent SLAP repair. All patients failed attempts at conservative therapy including NSAIDS, Physical Therapy and cortisone injections. Results. Age ranged from 16–71 years, with an average age of 46. Male 84, Female 31. patient charts and operative notes were examined from 2004–2009. We used an average of 1.64 anchors per case; we performed arthroscopic Mumford on 15 patients, subscap repair (4), 19 cases with concomitant SLAP repair and Arthroscopic rotator cuff repair Other procedures included Biceps tenotomy and tenodesis, chondroplasty, Microfracture, removal of loose bodies, synovectomy and lysis of adhesions. Twelve patients underwent revision surgery(10%) We had 5 cases of stiffness which required lysis of adhesions and synovectomy, 4 cases had previous SLAP and concomitant rotator cuff repair done at the index surgery, 4 cases had arthrosis noted at index surgery and underwent chondroplasty and 2 of them underwent micro fracture. During the revision surgery 4 had also a concomitant cuff tear (new) which required repair Average time from index surgery to revision was 11 months, the patients who developed adhesive Capsulitis and stiffness the average age was 56 years. We had 2 titanium metal anchors pull out and present as loose bodies with one of the anchor causing chondral damage, we stopped using metal anchors and we have not had this problem recur since.5 cases had Mumford procedure done during the revision surgery.5 cases needed repeat SLAP repairs and by increasing use of biceps tenotomy this incidence should decrease. Conclusions. Our large retrospective case series shows an acceptable complication rate. Stiffness (5%) is still the most common complication especially in patients older than 50, withpreexisting Glenohumeral arthritis and concomitant rotator cuff tears. Hopefully our early aggressive mobilization will decrease this incidence

Objective: Various tear types and patterns of meniscus injuries have been described. We record meniscus tear type and pattern in a standard manner for every knee arthroscopy in our database of more than 17,000 knee surgeries. We determined if meniscus tear type and pattern correlate with function and activity levels at least two years after partial meniscectomy. Methods: Two hundred six (206) patients underwent partial medial meniscectomy and 117 underwent partial lateral meniscectomy by a single surgeon (average age=49 years; range, 18 to 80). At index surgery, the type and pattern of meniscus tear was recorded. Tears were designated as bucket handle/vertical longitudinal (BV), flap/radial (FR), or complex (CH) which includes horizontal cleavage tears. Patients not in neutral or near-neutral alignment and those undergoing concurrent procedures for microfracture or ACL reconstruction were excluded. Patients were followed for a minimum of two years (average=4.6 yrs) after partial meniscectomy. Patients completed questionnaires including Lysholm and Tegner scores to assess function and activity. Results: For the medial meniscus, there was significant correlation between tear type and patient age. The BV lesion group (n=35) was significantly younger (41 years) than the FR (n=65) (50 years) and CH (n=193) (53 years) groups (p=0.01). The BV group had significantly higher Lysholm (89) scores versus FR (80) and CH (77) (p=0.04). The BV group also had higher Tegner activity levels (5.8) than FR (4.6) and CH (4.5) (p=0.04). For lateral meniscus, the BV (n=15) (40 years) and FR (n=37) (48 years) groups were significantly younger than the CH group (n=45) (56 years); p=0.03. FR patients had higher Lysholm and Tegner scores, but not significantly different. Twenty-five percent (25%) of BV medial meniscus tears required further surgery while less than 15% of other types of medial or lateral tears required further surgery. Average time to second surgery for all patients was 2.4 years, with medial being 2.6 years and lateral being 1.5 years. Conclusions: In this series, BV medial meniscus tears had better function and activity levels at least two years post-meniscectomy, perhaps due to younger age. This group also required more reoperations during the first two years after index meniscectomy than any other group, perhaps as a result of higher activity levels. Overall, partial lateral meniscectomy patients required reoperation sooner than medial meniscectomies. Tear type did not significantly influence outcomes after lateral meniscectomy. Therefore, meniscus tear type and pattern correlated with function and activity levels for medial but not lateral > 2 years after partial meniscectomy

Abstract

Abstract

Partial thickness abductor tendon tears are a significant source of recalcitrant laterally based hip pain. For those that fail conservative treatment, the results of endoscopic repair are highly successful with minimal morbidity. The principal burden is the protracted rehabilitation that is necessary as part of the recovery process. There is a wide gap between failed conservative treatment and successful surgical repair. It is hypothesized that a non-repair surgical strategy, such as a bioinducitve patch, could significantly reduce the burden associated recovery from a formal repair. Thus, the purpose of this study is to report the preliminary results of this treatment strategy.

Symptomatic partial thickness abductor tendon tears are treated conservatively, including activity modification, supervised physical therapy and ultrasound guided corticosteroid injections. Beginning in January 2022, patients undergoing hip arthroscopy for intraarticular pathology who also had persistently symptomatic partial thickness abductor tendon tears, were treated with adjunct placement of a bioinducitve (Regeneten) patch over the tendon lesion from the peritrochanteric space. The postop rehab protocol is dictated by the intraarticular procedure performed. All patients are prospectively assessed with a modified Harris Hip Score (mHHS) and iHOT and the tendon healing response examined by ultrasound.

Early outcomes will be presented on nine consecutive cases.

Conclusions - Will be summarized based on the preliminary outcomes to be reported.

A larger radial tuberosity, and therefore a smaller radioulnar space, may cause mechanical impingement of the DBT predisposing to tear. We sought to investigate anatomic factors associated with partial DBT tears by retrospectively reviewing 3-T MRI scans of elbows with partial DBT tears and a normal elbow comparison group

3-T MRI scans of elbows with partial DBT tears and elbows with no known pathology were reviewed retrospectively by two independent observers. Basic demographic data were collected and measurements of radial tuberosity length, radial tuberosity thickness, radio-ulnar space, and radial tuberosity-ulnar space were made using simultaneous tracker lines and a standardised technique. The presence or absence of enthesophytes and the presence of a single or double DBT were noted.

26 3-T MRI scans of 26 elbows with partial DBT tears and 30 3-T MRI scans of 30 elbows without pathology were included. Basic demographic data was comparable between the two groups. The tear group showed statistically significant larger mean measurements for radial tuberosity length (24.3mm vs 21.3mm, p=0.002), and radial tuberosity thickness (5.5mm vs 3.7mm, p=<0.0001. The tear group also showed statistically significant smaller measurements for radio-ulnar space (8.2mm vs 10.0mm, p=0.010), and radial tuberosity-ulnar space (7.2mm vs 9.1mm, p=0.013). There was a statistically significant positive correlation between partial DBT tears and presence of enthesophytes (p=0.007) as well as between partial DBT tears and having two discrete DBTs rather than a single or interdigitating tendon (p=<0.0001).

Larger radial tuberosities, and smaller radio-ulnar and radial tuberosity-ulnar spaces are associated with partial DBT tears. This may be due to chronic impingement, tendon delamination and consequent weakness which ultimately leads to tears. Enthesophytes may be associated with tears for the same reason. Having two discrete DBTs that do not interdigitate prior to insertion is also associated with partial tears.

Aims

We studied the outcomes following arthroscopic primary repair of bucket handle meniscus tears to determine the incidence of re-tears and the functional outcomes of these patients.

The function of the upper extremity is highly dependent on correlated motion of the shoulder. The shoulder can be affected by several diseases. The most common are: rotator cuff tear (RCT), shoulder instability, shoulder osteoarthritis and fractures. Rotator cuff disease is a common disorder. It has a high prevalence rate, causing high direct and indirect costs. The appropriate treatment for RCT is debated. The American Academy Orthopaedic Surgeons guidelines state that surgical repair is an option for patients with chronic, symptomatic full-thickness RCT, but the quality of evidence is unconvincing. Thus, the AAOS recommendations are inconclusive. We are performing a randomized controlled trial to compare surgical and conservative treatment of RCT, in term of functional outcomes, rotator cuff integrity, muscle atrophy and fatty degeneration. Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The Thomas and Matsen classification, which is currently the most commonly utilized classification, divides shoulder instability events into the traumatic, unidirectional, Bankart lesion, and surgery (TUBS) and the atraumatic, multidirectional, bilateral, rehabilitation, and capsular shift (AMBRI) categories. The acquired instability overstress surgery (AIOS) category was then added. Surgical procedures for shoulder instability includes arthroscopic capsuloplasty, remplissage, bone block procedure or Latarjet procedure. Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with osteoarthritis or fracture of the proximal humerus, with associated severe osteoporosis and RC dysfunction.

Massive posterosuperior cuff tears (mRCT) retracted to the glenoid are surgically challenging and often associated with high retear rates. Primary repair is a less-favourable option and other salvage procedures such as SCR and tendon transfers are used. This study presents clinical and radiological outcomes of muscle advancement technique for repair of mRCT.

Sixty-one patients (mean age 57±6, 77% males and 23% females) (66 shoulders) underwent all-arthroscopic rotator cuff repair that included supraspinatus and infraspinatus subperiosteal dissection off scapular bony fossae, lateral advancement of tendon laminae, and tension-free double-layer Lasso Loop repair to footprint.

Pre-and post-operative range of motion (ROM), cuff strength, VAS, Constant, ASES, and UCLA scores were assessed. Radiologic assessment included modified Patte and Goutallier classifications. All patients had MRI at 6 months to evaluate healing and integrity of repair was assessed using Sugaya classification with Sugaya 4 and 5 considered retears.

Advanced fatty degeneration (Goutallier 3-4) was present in 44% and 20% of supraspinatus and infraspinatus. Tendon retraction was to the level of or medial to glenoid in 22%, and just lateral in 66%. 50.8% mRCT extended to teres minor. Subscapularis was partially torn (Lafosse 1-3) in 46% and completely torn (Lafosse 4-5) in 20%.

At mean follow-up (52.4 weeks), a significant increase in ROM, Relative Cuff Strength (from 57% to 90% compared to contralateral side), VAS (from 4 ±2.5 to 1±1.7), Constant (50±17.8 to 74 ±13.0), ASES (52 ±17.5 to 87 ±14.9), and UCLA (16± 4.9 to 30 ±4.9) scores were noted. There were six retears (10%), one failure due to P. acnes infection. 93% returned to pre-injury work and 89% of cases returned to pre-injury sport. Satisfaction rate was 96%.

Muscle advancement technique for mRCT is a viable option with low retear rates, restoration of ROM, strength, and excellent functional outcomes.

Abstract

We performed this systematic overview on the overlapping meta-analyses that analyzed autologous platelet-rich plasma (PRP) as an adjuvant in the repair of rotator cuff tears and identify the studies which provide the current best evidence on this subject and generate recommendations for the same.

We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Scopus, Embase, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects on September 8, 2021, to identify meta-analyses that analyzed the efficacy of PRP as an adjuvant in the repair of rotator cuff tears. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades and used the Jadad decision algorithm to generate recommendations.

20 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of the included studies varied from 6–10 (mean:7.9). All the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The initial size of the tear and type of repair performed do not seem to affect the benefit of PRPs. Among the different preparations used, leucocyte poor (LP)-PRP possibly offers the greatest benefit as a biological augment in these situations.

Based on this systematic overview, we give a Level II recommendation that intra-operative use of PRPs at the bone-tendon interface can augment the healing rate, reduce re-tears, enhance the functional outcomes and mitigate pain in patients undergoing arthroscopic rotator cuff repair.

To analyse the efficacy and safety of cellular therapy utilizing Mesenchymal Stromal Cells (MSCs) in the management of rotator cuff(RC) tears from clinical studies available in the literature.

We conducted independent and duplicate electronic database searches including PubMed, Embase, Web of Science, and Cochrane Library on August 2021 for studies analyzing the efficacy and safety of cellular therapy (CT) utilizing MSCs in the management of RC tears. VAS for pain, ASES Score, DASH Score, Constant Score, radiological assessment of healing and complications and adverse events were the outcomes analyzed. Analysis was performed in R-platform using OpenMeta [Analyst] software.

Purpose: Short-term results of surgical repair of subscapularis tears are well known. The purpose of this study was to assess long-term outcome after surgical repair of 21 full-thickness tears of the subscapularis.

Material and methods: Inclusion criteria were subscapularis tear (n=21) which were isolated (n=9) or associated with a supraspinatus tear (n=11) without intraspinatus tears. The subscapularis was reinserted by transosseous fixation in fifteen cases and with a trapezeal flap in six. The supraspinatus was repaired by transosseous suture. Function (Constant score) was assessed preoperatively, at one and three years, and at last follow-up (nine years, range six to fifteen years). We also noted radiographic changes (subacromial height, osteoarthritis using the Samilson classification, anterior dislocation of the humeral head). Fatty degeneration (FD) of the cuff was assessed on pre-operative scans and at last follow-up. Arthroscan, performed at one year and ultrasonography performed at last follow-up were used to assess cuff continuity.

Results: The rough Constant score was 45.2 (12–93.5) preoperatively, 67.5 (20–95) at one and three years and 59.45 (20–95) at last follow-up. At last follow-up, the Constant score was significantly better than preoperatively (improved pain score). There was only one case of repeated tear (repaired supraspinatus). At last follow-up we noted six anterior dislocations. The subacromial space remained unchanged (9.5 mm). Glenohumeral osteoarthritis developed in fourteen cases (2 Samilson class 3) including eight de novo degenerations. FD of repaired subscapularis tendons was 0.8 (0–4) preoperatively and 1.64 (1–4) at last follow-up. FD of unrepaired subscapularis tendons treated with a trapezeal flap worsened (2.2 to 2.7). FD of the supraspinatus and infraspinatus (0.5 preoperatively) worsened one stage. At last follow-up, the Constant score was lower in the presence of anterior dislocation of the humeral head (p=0.013). Development of anterior dislocation of the humeral head was correlated with major preoperative FD of the subscapularis (cut-off between 1.5 and 2, p=0.01). There was a correlation between more FD of the infraspinatus and the presence of anterior dislocation of the humeral head. Among the trapezeal flaps, there were only two good results (Constant scores 74 and 75) in patients with FD of the subscapularis scored 1.5 preoperatively.

Conclusion: Functional and radiographic outcome after cuff repair or palliation with a trapezeal flap for subscapularis tears associated or not with supraspinatus tears is not satisfactory unless the fatty degeneration of the subscapularis is low preoperatively (δ 1.5).

The purpose of this study was to examine five-year outcomes of patients previously enrolled in a non-operative rotator cuff study.

Patients with chronic, full-thickness rotator cuff tears (demonstrated on imaging) who were referred to one of two senior shoulder surgeons were enrolled in the study between October 2008 and September 2010. Patients participated in a comprehensive non-operative, home-based treatment program. After three months patients were defined as “successful” or “failed”. “Successful” patients were essentially asymptomatic and did not require surgery. “Failed” patients were symptomatic and consented to surgical repair. All patients were followed up at one year, two years, and five-plus years.

Original results of our study showed that 75% of patients were treated successfully with non-operative treatment, while 25% went on to surgery. These numbers were maintained at two-year follow-up (previously reported) and five-year follow-up. At five+ years, 88 patients were contacted for follow-up. Fifty-eight (66%) responded. The non-operative success group had a mean RC-QOL score of 80 (SD 18) at previously reported two-year follow-up. At five-year follow-up this score did not decrease (RCQOL = 82 (SD 16)). Furthermore, between two and five years, only two patients who had previously been defined as “successful” became more symptomatic and underwent surgical rotator cuff repair. From the original cohort of patients, those who failed non-operative treatment and underwent surgical repair had a mean RC-QOL score of 89 (SD 12) at five-year follow-up. The operative and non-operative groups at five-year follow-up were not significantly different (p = 0.07).

Non-operative treatment is an effective and lasting option for many patients with a chronic, full-thickness rotator cuff tear. While some may argue that non-operative treatment delays inevitable surgical fixation, our study shows that patients can do extremely well over time.

Critical shoulder angle (CSA), lateral acromial angle (LAA), and acromion index (AI) are common radiologic parameters used to distinguish between patients with rotator cuff tears (RCT) and those with an intact rotator cuff. This study aims to assess the predictive power of these parameters in degenerative RCT.

This retrospective study included data from 92 patients who were divided into two groups: the RCT group, which included 47 patients with degenerative full-thickness supraspinatus tendon tears, and a control group of 45 subjects without tears. CSA, AI, and LAA measurements from standardized true anteroposterior radiographs were independently derived and analyzed by two orthopedic surgeons. Receiver operating characteristic (ROC) analyses were performed to determine the cutoff values.

No significant differences were found between patients in the RCT and control groups in age (p = 0.079), gender (p = 0.804), or injury side (p = 0.552). Excellent inter-observer reliability was seen for CSA, LAA, and AI values. Mean CSA (38.1°) and AI (0.72) values were significantly larger in the RCT group than in the control group (34.56° and 0.67°, respectively, p < 0.001) with no significant difference between groups for LAA (RCT, 77.99° vs. control, 79.82°; p = 0.056). ROC analysis yielded an area under the curve (AUC) of 0.815 for CSA with a cutoff value of 37.95°, and CSA was found to be the strongest predictor of the presence of a RCT, followed by AI with an AUC of 0.783 and a cutoff value of 0.705.

We conclude that CSA and AI may be useful predictive factors for degenerative RCT in the Turkish population.

When compared to magnetic resonance imaging (MRI), ultrasound (US) performed by experienced users is an inexpensive tool that has good sensitivity and specificity for diagnosing rotator cuff (RC) tears. However, many practitioners are now utilizing in-office US with little to no formal training as an adjunct to clinical evaluation in the management of RC pathology. The purpose of our study was to determine if US without formal training is effective in managing patients with a suspected RC tear.

This was a single centre prospective observational study. Five fellowship-trained surgeons each examined 50 participants referred for a suspected RC tear (n= 250). Patients were screened prior to the consultation and were included if ≥ 40 years old, had an MRI of their affected shoulder, had failed conservative treatment of at least 6 months, and had ongoing pain and disability. Patients were excluded if they had glenohumeral instability, evidence of major joint trauma, or osteonecrosis. After routine clinical exam, surgeons recorded their treatment plan (“No Surgery”, “Uncertain”, or “Surgery”). Surgeons then performed an in-office diagnostic US followed by an MRI and documented their treatment plan after each imaging study. Interrater reliability was analyzed using a kappa statistic to compare clinical to ultrasound findings and ultrasound findings to MRI, normal and abnormal categorization of biceps, supraspinatus, and subscapularis.

Following clinical assessment, the treatment plan was recorded as “No Surgery” in 90 (36%), “Uncertain” in 96 (39%) of cases, “Surgery” in 61 (25%) cases, and incomplete in 3 (2%). In-office US allowed resolution of 68 (71%) of uncertain cases with 227 (88%) of patients having a definitive treatment plan. No patients in the “No Surgery” group had a change in treatment plan. After MRI, 16 (6%) patients in the “No Surgery” crossed-over to the “Surgery” group after identification of full-thickness tears, larger than expected tears or alternate pathology (e.g., labral tear).

The combination of clinical examination and in-office US may be an effective method in the initial management of patients with suspected rotator cuff pathology. Using this method, a definitive diagnosis and treatment plan was established in 88% of patients with the remaining 12% requiring an MRI. A small percentage (6%) of patients with larger than expected full-thickness rotator cuff tears and/or alternate glenohumeral pathology (e.g., labral tear) would be missed at initial evaluation.

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery.

Cite this article: Bone Joint Res 2014;3:155–60.

The treatment of massive chronic tears is problematic. The re-tear rate following surgery for extensive cuff tears remains high, and there is little consensus regarding optimum treatment. To investigate the outcome of a cohort of patients who had open repair of an extensive cuff tear using the Leeds Kuff patch as an augment. A retrospective cohort study of consecutive patients with a massive cuff tear who had surgery in our regional elective orthopaedic centre over a two year period from January 2015 to Dec 2016. All patients followed identical rehabilitation protocols, supervised by physiotherapists with an interest in the shoulder. Outcomes assessment was undertaken at a minimum of 12 months by a registrar or physiotherapist who was not part of the treating team. Pre-op data collection included; range of motion, pain score, Oxford shoulder score (OSS), assessment of muscle atrophy on MRI. Data collection was completed in 15 patients. The mean age was 62 yrs (56 – 75). The mean pre-op OSS was 22, improving to a mean of 43. The range of motion and pain score improved. There were no intra-operative complications. One patient required a second surgery for evacuation of a haematoma at 10 days post op. One patient had an obvious re-tear at 4 months. Open rotator cuff repair with synthetic Kuff patch augmentation for chronic degenerative tears appears worthwhile when assessed at 12 months and they continuous to improve even at 18 months. This treatment method may be a useful option for patients > 70 years old.

Deficiency of the abductor mechanism is a well-recognised cause of pain and limping after total hip replacement (THR). This can be found incidentally at the time of surgery, or it may arise as a result of damage to the superior gluteal nerve intra-operatively, or after surgery owing to mechanical failure of the abductor muscle repair or its detachment from the greater trochanter. The incidence of abductor failure has been reported as high as 20% in some studies. The management of this condition remains a dilemma for the treating surgeon. We review the current state of knowledge concerning post-THR abductor deficiency, including the aetiology, diagnosis and management, and the outcomes of surgery for this condition.

Cite this article: Bone Joint J 2013;95-B:343–7.

Rotator cuff disease encompasses a spectrum from partial to full thickness tears. Despite being 2–3 times more common than full–thickness tears, effective non-operative treatment for partial thickness tears has remained elusive. Platelet enriched plasma (PRP) has been proposed to enhance rotator cuff healing by enhancing the natural healing cascade. However, its utility in rotator cuff disease remains controversial. The purpose of this study was to compare the patient reported outcomes between PRP and corticosteroid injection in patients with symptomatic partial thickness tears.

This double blind randomized controlled trial enrolled patients with symptomatic, partial thickness rotator cuff tears or rotator cuff tendinopathy proven on ultrasound or MRI. Patients were randomized to either corticosteroid or PRP ultrasound-guided injection of the affected shoulder. Patients completed patient reported outcomes at 6 weeks and 12 weeks. The primary outcome was Visual Analog Scale (VAS) pain scores. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) index, American Shoulder and Elbow Surgeons (ASES) score, and failure of non-operative management as determined by consent for surgery or progression to operative intervention.

Ninety-nine patients were enrolled in the study with equal demographics between the two groups. Taking into account pre-injection scores, patients with PRP injections demonstrated a statistically significant improvement in VAS scores compared to patients receiving corticosteroid injections at 12 weeks (p=0.045) but not at 6 weeks (p=0.704). There was no difference in other outcome measures or progression of the two groups to surgical intervention.

The use of PRP in the management of partial thickness rotator cuff tears demonstrates significant improvement of pain scores at 12 week follow up compared to corticosteroid injections. However, this did not affect the rate of progression to surgical intervention. Continued study is required to determine the utility of PRP in this patient population.

The treatment of massive rotator cuff tears remains controversial. There is lack of studies comparing patient-reported outcomes (PROM) of arthroscopic massive rotator cuff repairs (RCR) against large, medium and small RCRs. Our study aims to report the PROM for arthroscopic massive RCR versus non-massive RCR.

Patients undergoing an arthroscopic RCR under a single surgeon over a 5-year period were included. Demographic data were recorded. Pre-operative Quick-DASH and Oxford Shoulder Score (OSS) were prospectively collected pre-operatively and at final review (mean of 18 months post-operatively). The scores were compared to a matched cohort of patients who had large, medium or small RCRs. A post-hoc power analysis confirmed 98% power was achieved.

82 patients were included in the study. 42 (51%) patients underwent massive RCR. The mean age of patients undergoing massive RCR was 59.7 and 55% (n=23) were female. 21% of massive RCRs had biceps augmentation. Quick-DASH improved significantly from a mean of 46.1 pre-operatively to 15.6 at final follow-up for massive RCRs (p<0.001). OSS improved significantly from a mean of 26.9 pre-operatively to 41.4 at final follow up for massive RCRs (p<0.001). There was no significant difference in the final Quick-DASH and OSS scores for massive and non-massive RCRs (p=0.35 and p=0.45 respectively). No revision surgery was required within the minimum one year follow up timescale.

Arthroscopic massive rotator cuff repairs have no functional difference to non-massive rotator cuff repairs in the short term follow up period and should be considered in appropriate patient groups.

Introduction

Glenoid inclination, defined as the angle formed by the intersection of a line made of the most superior and inferior points of the glenoid and a line formed by the supraspinatus fossa, has been postulated to impact the mechanical advantage of the rotator cuff in shoulder abduction. An increase in glenoid inclination has previously been reported in patients with massive rotator cuff tears and multiple studies have correlated rotator cuff tears to an increase of the critical shoulder angle, an angle comprised of both the glenoid inclination and acromical index. Glenoid inclination is best measured by the B-angle as it has been shown to be both an accurate and reliable. The purpose of this study was to determine the correlation of glenoid inclination and the presence of degenerative rotator cuff tears.

Meniscus tears in adult patients do not heal spontaneously and represent a risk factor for OA development. PDGF is well known as an enhancer of meniscal cell biosynthetic activity and also has chemotactic activity for mesenchymal cells. PDGF incorporation into scaffolds should be efficient for recruitment of cells to initiate repair in the injured meniscus. We recently developed decellularized meniscus sheet for use in the treatment of meniscus tears. The aim of this study is to examine the potential of PDGF-coated decellularized meniscus scaffold in mediating integrative healing by endogenous cell migration.

Fresh bovine meniscus was chemically decellularized. Round sheets were made from the decellularized tissue. Heparin was covalently conjugated with decellularized meniscus scaffold (DMS). PDGF-BB was immobilized by binding to the heparin-conjugated DMS. In vitro, PDGF release kinetics was analyzed by ELISA. DMS was transplanted into the injured meniscus explants and cultured for 2 and 4 weeks. The numbers of migrated cells at the border between DMS and injured explant were counted on DAPI stained sections and PDGFRb expressing cells were counted after immunohistochemical staining. The newly produced ECM and collagen fiber alignment was detected by histology on Safranin-O and picrosirius red stained sections. The explants were also tested for tensile properties.

PDGF release kinetics showed sustained slow release in heparin-conjugated DMS, with 11.2% release at day- 16th compared to 26.1% release from the DMS without heparin. Insertion of the PDGF-treated DMS into the meniscus tears in bovine meniscus explants led to the migration of endogenous meniscus cells to the defect zone. The migrated cells expressed PDGFRb and produced new ECM in the defect area. Safranin-O and pircrosirius red staining showed tissue integration between DMS and injured explants. Moreover, the higher concentration of PDGF promoted cell integration into the DMS. Tensile properties of injured explants treated with PDGF coated DMS were significantly higher than in DMS without PDGF.

Heparin-conjugated DMS showed strong immobilization of PDGF, which was released slowly. PDGF coated DMS promoted migration of endogenous meniscus cells to the defect area and into the scaffold. New matrix was formed that bridged the space between the native meniscus and the scaffold and this was associated with improved biomechanical properties. The PDGF coated DMS is a novel, feasible and efficient approach for the treatment of meniscus tears.

There has been very little documented regarding the impact of meniscal injuries on knee proprioception. The aim of this study was to investigate the proprioceptive function of patients with meniscal tears and asses the influence that arthroscopic partial menisectomy has on knee proprioception.

One hundred subjects were recruited comprising an Arthroscopy group (50 patients) and a Normal Control group (50 subjects). The Biodex Balance SD System was used to assess proprioception. This equipment measures knee proprioception on an electronic platform. The balance of the subject is computed producing an Overall Stability Index (OSI). Lower scores reflect better proprioception. Knee stability was assessed clinically and with the Rolimeter knee arthrometer. The Lysholm and IKDC scoring systems were used to evaluate all the subjects.

Of the 50 subjects within the Arthroscopy group (all of whom had a normal ACL confirmed) 34 were found to have meniscal tears. Twenty-nine of the 34 patients with meniscal tears returned for their follow-up review 3 months post-operatively.

The proprioceptive function of the injured knee of the Arthroscopy group with meniscal tears (mean OSI 0.86) was significantly poorer compared to that of their uninjured knee (mean OSI 0.62, p< 0.001, 95%CI 0.14, 0.34) and to the Normal Control group (mean OSI 0.49, p< 0.001, 95%CI 0.21, 0.54). There was no significant improvement in their proprioceptive function following menisectomy (mean OSI 0.75, p=0.23, 95%CI −0.07, 0.28). There was a significant improvement of both the Lysholm (p=0.004) and IKDC (p=0.021) scores postoperatively.

Conclusion: These results indicate that there is a demonstrable proprioceptive deficit in patients with meniscal tears even in the presence of a normal ACL. This deficiency in proprioception did not improve within three months following arthroscopic partial menisectomy despite the improvement in functional outcome measures.

Purpose of the study: When repairing rotator cuff tears, injury to the infraspinatus is generally a posterior extension of a supraspinatus tear. The description of isolated tears of the infraspinatus has not been to our knowledge reported in the literature. We report a series of 13 cases with more than one year follow-up.

Material and methods: Thirteen patients underwent surgery for an isolated tear of the infraspinatus between 1995 and 2004. There were ten men and three women. Mean age at surgery was 47 years (range 34–62). The right shoulder was involved in seven of the thirteen cases, and the dominant shoulder in eight. A progressive onset was observed in eleven patients and nine had a history of treated calcified tendinopathy. Clinically, pain was the predominant symptom. The Jobe test was deficient in all patients as was external rotation (except one patient). The preoperative Constant score was 70 (range 62–87). X-rays revealed type C posterior calcification in nine patients. A full-thickness tear was observed in seven cases, a partial deep tear in three, and a partial superficial tear in three. Isolated fatty degeneration of the infraspinatus noted Goutallier grade 2 or greater was observed in seven patients. Open surgical repair was preformed in all patients.

Results: Mean time to revision was 29 months (range 12–82). Subjectively, six patients were very satisfied, six were satisfied, and one was disappointed (failure by secondary tear). Two shoulder-hand syndromes were noted in the postoperative period. At last follow-up, the Constant score was 83.5 (range 64–97). All patients except one were satisfied with pain relief but the lack of force was significant.

Discussion and conclusion: Isolated tears of the infra-spinatus are rare, but there is a notable relationship with calcifying tendinopathy of the same tendon. Repair should be undertaken before the development of fatty degeneration in order to improve the chances of force recovery.

Background: Muscle tears and injuries are a huge problem throughout the world. Ways of reducing these injuries are welcome, with warm-up and stretching of muscles prior to use established methodologies. Forces associated with muscles can be thought of as active (stimulated muscle: actin-myosin) and passive (relaxed muscle: elastic proteins and connective tissue). In muscle tears, the connective tissue component is damaged, but there is very little information in the literature on this component of the muscle.

Objective: To examine passive (elastic) components in muscle during impact loading at differing temperatures. In particular to test the hypothesis that the connective tissue component fails at different loads according to the temperature.

Methods: Gastrocnemius and Soleus were isolated from 36 male rat limbs, clamped and exposed to increasing impact loads, by dropping a known weight from increasing heights. Muscle was given one minute to recover before an increased force was applied. Temperature was varied from 17 C to 42 C (to encompass the physiological range) in 5 C increments. The height of drop causing non-recoverable deformation, and the maximum deceleration of the weight (measured using an accelerometer attached to a picoscope) at a constant height was recorded for each temperature.

Results: The energy to failure, i.e. the point at which non-recoverable deformation occurred was found to increase above 32 C (p < 0.01) and the maximum deceleration at impact found to have a downward trend with increasing temperatures. At 17 C, the energy to failure was 317.7 ± 20 mJ, At 22 C, the energy to failure was 301.8 ± 29 mJ, At 27 C, the energy to failure was 317.7 ± 40 mJ, At 32 C, the energy to failure was 333.5 ± 21.2 mJ, At 37 C, the energy to failure was 460.2 ± 15.8 mJ, At 42 C, the energy to failure was 619.5 ± 21.2 mJ,

Conclusions: Muscle was shown to act in an increasingly elastic nature with temperature. At higher temperatures a larger energy is required to deform the muscle permanently, and the muscle decelerates more slowly, both in keeping with elastic properties. The same energy at a lower temperature causes significant deformation within the muscle. This has numerous clinical implications, as the temperature at which this change occurs is encountered during surgery and also by sportsmen on outdoor pitches. More research is required to look at the passive components within muscles in humans.

Purpose: Bilateral tears of the ACL are classically described as occurring after a first tear. Few reports have examined the underlying mechanism and the frequency and predisposing morphological factors

Material and methods: We reviewed retrospectively a series of 3722 ACL plasties performed from 1984 to 2001, including 148 patients who underwent bilateral repair. In this group, we detailed the demographic features, the time from tear to repair, the type of sports activity and focused on the radiological measurement of tibial tilt.

Results: The estimated frequency of bilateral tears was 4%. We noted that these bilateral tears were associated with: male predominance (60%), mean age 21 years (±5.5) at first tear, younger age for females, second tear at 24.5±6.5 years, predominant practice of pivot sports without contact (56%), and competition sports. The time between the two tears was 48 months on average. The rate of contralateral tears during the first postoperative year was 16%, it was 60% at three years. The mean tibial tilt was 9.91±2.87° versus 6.8±1.87° in the control population.

Discussion: Our findings were in agreement with the literature for frequency, young age at first tear, particularly for women, short time between the two tears, and type of sports activity. The high rate of contralateral tears during the first year is a significant finding. Hypotheses put forward include loss of confidence in the operated knee leading to more stress on the contralateral knee, but also poorly adapted use of the healthy knee in sports activity. Rehabilitation exercises focusing on bilateral proprioception, respecting sufficient time after the first repair before resuming sports activities, and good control of knee laxity with an ‘anatomic’ plasty appear to be important elements of prevention. The favouring role of a narrow intercondylar notch has been established in the literature. We found that tibial tilt should also be taken into consideration.

Conclusion: Careful search for predisposing factors is important because of the frequency of bilateral tears of the ACL. The rehabilitation program should be well adapted and the patient should be informed of the risk. These measures should help decrease the incidence of this relatively frequent complication.

The purpose of this study was to evaluate the results of selective anatomic augmentation of partial anterior cruciate (ACL) ligament tears in 36 consecutive patients with mean 3years follow-up. Our hypothesis is that this selective augmentation of partial ACL tears could restore knee stability and function. In a consecutive series of 314 ACL reconstructions, 40 patients in which intact ACL fibers remained in the location corresponding to the anteromedial or posterolateral bundle were diagnosed perioperatively. All patients underwent selective augmentation of the torn bundle, while keeping the remaining fibers intact using autogenous hamstring graft. 38 patients (28 males, 10 females) were available with minimum 3 year follow- up. 26 cases had AM bundle tears and 12 cases had PL bundle tears respectively. Patients were assessed with International Knee Documentation Committee (IKDC) 2000 Knee Evaluation Form, Lysholm score; instrumented knee testing was performed with the arthrometer (KT 2000).

Statistical analysis was performed to compare the preoperative and postoperative objective evaluation. At 3 year follow-up, 12 (31.6%) patients were graded A, 25 (65.8%) graded B and 1 C (2.6%) at IKDC objective evaluation. Lysholm's score and mean side to side instrumental laxity improved significantly. The results of anatomic single bundle augmentation in partial ACL tears are encouraging with excellent side to side laxity.

Acute peroneal tendon tears present as a relatively sudden onset of lateral ankle or hindfoot pain, frequently in conjunction with a traumatic episode or injury. Underlying or causative factors, including recurrent ankle sprains, hindfoot varus leading to ankle instability, or dislocating peroneal tendons may be associated and can often lead to peroneal tendon tears being overlooked as a cause of persistent lateral ankle or foot pain. Some apparently acute peroneal tendon tears may represent an acute manifestation of an underlying chronic or subclinical abnormality.

The spectrum of peroneal tendinopathies includes tenosynovitis, tendinosis, subluxation or dislocation, stenosing tenosynovitis, disorders of the os peroneum, and conditions related to accessory peroneal tendons, as well as acute and chronic tendon tears. These abnormalities of the peroneal tendons may coexist, and one may lead to another, as evidenced by the significant incidence of tears in the presence of dislocating peronei and ankle instability.

Suspicion of the possibility of peroneal tendon injury, coupled with careful clinical examination and appropriate investigation, allows the clinician to identify the extent of damage and to implement a successful management plan. Because peroneal tears signify a mechanical abnormality, this management often entails surgical intervention.

1. Radiographs of both shoulders were performed on 106 unselected necropsy subjects and those found to be abnormal were examined pathologically.

2. Radiological abnormalities were found in sixty-eight shoulders of thirty-eight subjects. Pathological examination showed rotator cuff tears and associated abnormalities in thirty-five of these, rheumatoid arthritis in one, a previous fracture in one, and one was not examined.

3. The criteria for radiological diagnosis of rotator cuff tears are examined and discussed.

4. The radiological changes give little indication of the severity of the tears or associated abnormalities except in the case of complete rupture of the cuff when acromio-humeral articulation occurs.

5. The lesions are all explicable on a traumatic basis. There is no correlation with the presence or absence of osteoarthritic disease of the joint.

6. The biceps tendon may become damaged or even ruptured in this condition.

7. Villous synovial proliferation was found in fourteen cases, in five of which it was pigmented with histological appearances resembling pigmented villonodular synovitis. The significance of this finding is briefly discussed.

Introduction and purpose: Achilles tendon tears with a surgical indication can be approached by means of either a standard open surgery or an alternative technique, namely a percutaneous suture of the tendon rupture. This study compares the functional results and complications of both techniques in order to assess the differences between them. The purpose of the paper is to determine whether percutaneous sutures are a valid option for the treatment of these kinds of lesions.

Materials and methods: A prospective randomized study was carried out of two groups of patients. One included 26 patients where the Achilles tendon tear was repaired by means of a percutaneous suture; the other was a control group where the classical open surgery technique was used. The mean patient age was 41 years. 92% were male. 54% of lesions were on the left side. A comparison was made of functional results and of the complications which appeared in both groups.

Results: Both groups were homogeneous regarding age, laterality and relevant antecedents. Functional results and the complications’ rate were similar in both groups.

Conclusions: Although the percutaneous suture is not a widespread technique, the study shows it as a valid alternative for the treatment of Achilles tendon ruptures since it leads to a level of function similar to that of open surgery.

The results of arthroscopic repair of tears of the sub-scapularis tendon in nine men and six women, ranging in age from 53 to 73 years, were followed up at a mean of 14 months (6 to 24). Three were complete tears, six 50%-tears and six 30%-tears. In seven patients there were associated tears of the supraspinatus and infraspinatus tendons, which were repaired arthroscopically during the same procedure.

In each case the subscapularis tear was identified. In most patients a biceps tenotomy was necessary. The subscapularis footprint was prepared and the tendon was repaired using one or two anchors, each with two sutures, depending on the size of the tear. The mean pre-operative and postoperative Constant scores were 48 and 88 respectively.

In most patients, power returned to almost normal and pain was almost completely relieved. Arthroscopic subscapularis repair is a relatively new procedure and seems to give good results.

Introduction

Massive rotator cuff tears in the patient who is too young for a reverse shoulder replacement are a challenging situation. A technique using a ‘Grammont osteotomy’ of the acromion has been developed to allow a comprehensive approach, the so called “Full Monty”.

Massive tears of the supraspinatus of the rotator cuff lead to painful loss of movement. The literature supports repair of these tears for young healthy individuals, however they present a surgical challenge with historically poor results from both athroscopic and standard open techniques.

Prof Bunker has developed a surgical technique for massive rotator cuff tears with a Grammont Osteotomy of the spine of the acromion, when standard surgical techniques will not allow the necessary exposure: the so called “Full Monty”.

Patients were entered in to a prospective study to obtain the functional benefit of this procedure. Each patient had a pre-operative American Shoulder Elbow Score (ASES) Oxford Shoulder score (OSS), pain score, range of movement. Post-operatively these measures were repeated along with a patient questionnaire on function and satisfaction.

The mean American Shoulder score (ASS) preoperatively was 7 (out of a possible 30) and improved postoperatively to 23(P = 0.00011). The improvement in the Oxford Shoulder Score was 22 (out of a possible 48) preoperatively to 43 postoperatively (0.0001) and 80% patients stated their treatment was “successful”.

We believe this a successful surgical option for a patient with “massive” rotator cuff tear that is not amenable to standard surgical techniques.

Aim: Chronic rotator cuff tears raise a difþcult problem for treatment. The purpose of the study is to evaluate the results of surgical treatment of 96 full thickness rotator cuff tears. Method: There were 59 males and 37 females with average age of 56 years (35–78). The dominant shoulder was involved in 70% of the cases. Most of the patients had weakness and all of them had pain during the night. The duration of symptoms was more than 4months. 22 tears were small, 38 medium, 28 large and 8 massive. All of the patients had positive arthrogram or MRI. Surgical management consisted of deltoid splitting approach, anterior Neerñs acromioplasty modiþed by Rockwood and repair of the tear. In 6 cases dislocation long head of the biceps was found and repaired. In two cases the long head of biceps was incorporated in the repair. In 5 cases full coverage of the head could not be achieved. Results: F.U. averaged six years. The results were granted according to Wolfgang scale. There were 46 excellent, 39 good, 7 fair and 4 poor. Signiþcant improvement in pain achieved in 90% of the cases and strength improved in 78%. Postoperatively three patients had drop arm sign and one had developed ectopic ossiþcation. Negative prognostic factor was the dislocation of long head of biceps in combination with irreparable tears. The quality of the repair correlated with þnal outcome. Conclusions: The results of this study conþrm the view that operative management of rotator cuff tears offers reliable results and indicated in relatively young patients. Release of coracohumeral ligament and mobilization of supraspinatus decreased the need for tendon transfer.

Summary Statement

In this study, massive rotator cuff tears were treated using an absorbable collagen-based patch or a non-absorbable synthetic patch. Results demonstrated the efficacy of the use of the synthetic prolene patch especially for elderly patients

Background: The purpose of this study was to evaluate the mid and long-term results of the open repair of the rotator cuff tears in patients where pain of the shoulder was the primary and function the secondary consideration.

Material – Method: the study includes 48 patients, out of a total 64, operated on during the period 1985–2001 for full-thickness massive tears of the rotator cuff. The average age was fifty-two years. In all but six the main symptom was persistent pain resulting from a chronic tear. This group had clinical evidence of a rotator cuff defect in the form of weakness and limited range of active motion. The six additional patients suffered from acute tears following trauma and were led to early surgical repair. Their characteristic sign was extensive limitation of active motion, whereas the passive movements were near normal. The operation performed was the anterior acromioplasty with cuff repair through an anterosuperior incision. Several techniques were employed to advance the retracted tendons to their insertions, in the large and massive chronic tears. No patient had transfer of the latissimus dorsi tendon to bridge the gap in the rotator cuff.

Results: The clinical evaluation according to the rating system of UCLA showed 36 excellent, 9 good and 3 fair results. There was no poor result after an average follow-up 7,4 years.

Conclusions: The present series indicates that reconstruction of a torn rotator cuff can be successful in the majority of patients. Careful preoperative evaluation and planning is of great value in arranging the surgical technique. In large and massive chronic tears the retracted infl exible muscles do not allow easy advancement of their tendons in order to be securely fixed to the greater tubercle. Therefore the surgeon should be familiar with special techniques to achieve a so-called watertight repair, which is necessary for a long-lasting good result.

To report the long term outcome of patients with a partial tear of the anterior cruciate ligament (ACL).

We reviewed 26 of 31 athletes who had a diagnosis of acute, incomplete tear of the anterior cruciate ligament (ACL) between November 1986 and December 1991. All patients had arthroscopy and examination under anaesthesia within 8 weeks of acute knee injury, and were included in the study if there were still ACL fibres remaining which resisted anterior tibial translation. We excluded patients with associated major ligamentous lesions. Patients were reviewed by a combination of questionnaire and clinical examination at a mean of 38 months after the index injury (range 18 to 66).

At review, 20 patients (77%) had developed some symptoms of knee instability. The number of patients with a positive Lachman’s test had increased from 17 to 18, and those with a positive pivot shift had increased from 9 to 13. Seven patients (27%) had undergone ACL reconstruction, 7 other patients (27%) had been unable to return to sport, and 6 patients (23%) continued to participate in sport, but at a reduced level. Only 6 patients (23%) were able to continue in sport at their pre-injury level without reconstructive surgery. Patients with a tear of the anteromedial bundle of the ACL were more likely to have signs of instability at review and to require ACL reconstructive surgery than patients with a tear mainly affecting the posterolateral bundle.

Partial lesions of the ACL, especially when involving the AM bundle, should not be regarded as benign injuries. They often result in symptomatic instability necessitating intra-articular reconstruction of the ACL, and, in the long run, in marked decrease in the level of sports participation.

Increasingly often diagnosed by sophisticated investigation, rotator cuff disease may be treated conservatively or surgically. Surgical options are decompression alone, decompression and debridement, partial rotator cuff repair, full reconstruction, tendon transfer and prosthetic replacement.

Emphasising the quality of the repair rather than the classification of the injury, this paper details the criteria used in reaching a decision about the type of surgical treatment. Clinical, radiological, ultrasonographic and arthroscopic findings are used. The prognosis is directly related to the repair.

The aim is to evaluate the effectiveness of pericardium patch as a tendon augmentation graft in the repair of massive rotator cuff tear. This is prospective study analysis of a consecutive series of 60 patients who underwent open repair of a massive rotator cuff tear with patch between 1999 and 2007. The inclusion criteria were: symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size (massive: 2 or more tendons), minimum follow-up of 2 years since surgery, active and motivated patients. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views), ultrasound and NMR of the shoulder. The study group consistent of 60 patients (39 men and 21 women) with the mean age of was 66 years (range, 46–81). The mean duration of symptoms before repair was 18 months (range 3–48). Patients were assessed with UCLA score, visual analog scale (Vas scale) and ultrasound preoperatively, at 1 year, and at 3 years. The change in UCLA scores, Vas scale were analyzed with the paired Student's test, assuming a normal distribution of the total score. Satisfactory results were achieved in 49 patients: mean preoperative UCLA score improved from 9.3 to 16.9 at final follow-up.

For pain, the mean preoperative value of Vas scale was 9,1, postoperative mean value was 4.9. Range of motion and abduction power improved not significantly after surgery, although patients satisfaction levels were high. Imaging studies identified intact patch in 15 patients and patch detachment in 45. No adverse side effects (infection, rejection, allergy) were reported during the study period.

The results of our study suggest that patients (appropriately selected) with a massive full-thickness rotator cuff tear can be expected to have a pain relief after repair, but not a significantly improved of functional outcome.

1. The end-results of conservative treatment of supraspinatus tears have been studied in a series of 109 patients graded on a clinical basis, and in a further series of twenty-seven patients assessed initially by procaine infiltration.

2. In 87 per cent. of patients with mild lesions, full function was regained in an average period of five and a half weeks. In more than 50 per cent. of patients with apparently severe lesions, there was full functional recovery in eleven to thirteen weeks.

3. Clinical assessment, other than as mild or apparently severe, is unreliable in the early stages.

4. Procaine infiltration of recent tears, by abolishing pain and spasm, allows more accurate assessment of supraspinatus function and gives a more clear indication as to the advisability of conservative or early operative treatment. If such infiltration of the torn segment of tendon fails to restore voluntary abduction power, early operative repair is indicated.

5. Six patients with negative procaine tests, in whom the shoulder cuff was subsequently explored, all showed extensive tears.

Background

The mechanical disadvantage and detrimental effect to articular cartilage following meniscectomy has been well documented in the literature. Meniscal repair in the avascular (white on white zone) is controversial and would be deemed inappropriate by many.

Background: It is commonly believed that rotator cuff tears do progress in size over time. Recent reports suggest that tear progression may not be necessarily true. It was the purpose of this study to review non-operatively treated isolated supraspinatus tears especially in terms of tear size progression.

Methods: Inclusion criteria were non-operatively treated isolated full-thickness tears of the supraspinatus, MRI at time of diagnosis available, and patients willing to undergo an additional MRI after more than 2 years after diagnosis. Twenty-four patients (20 men, 4 women) with an average at time diagnosis of 51 years identified and reviewed with MRI and clinically based on the Constant score.

Results: The average follow-up was 46 (27–87) months. The Constant score (not available at time of diagnosis) at follow-up averaged 75 points (relative Constant score 86%). Overall the average tear size did not change significantly over time (366mm2 at follow-up versus 393mm2 at time of diagnosis, p > 0.05). In 2 patients the tear was not detectable any longer on MRI suggesting that it was healed, in 7 patients the tear was smaller, in 10 patients it did not change over time and only in 5 patients it progressed.

Discussion and Conclusion: Non-operatively treated isolated supraspinatus tears were unchanged, smaller or even healed in 79% of the patients after a follow-up period of more than 4 years. This suggests that supra-spinatus tears do not necessarily progress over time and even have a potential to heal.

Hypothesis

Avascular meniscal tears can be repaired with good clinical outcomes.

Aims

To describe the distribution and clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Purpose of the study: Data concerning the teres minor in the context of rotator cuff tears is scarce despite the fact that this muscle plays a crucial role in the event of an infraspinaus tear. The purpose of this study was to analyse the computed tomography and magnetic resonance images of the teres minor muscle in rotator cuff tears.

Material and method: The aspect of the teres minor muscle was studied in 1624 shoulders with rotator cuff tears. The axial and sagittal CT or MRI aspect was noted as normal, hypertrophic, atrophic or absent (Walch classification). We searched for correlations with the tendon torn, tear mechanism (trauma, degeneration, mixed), gender, dominance, time to imaging, age at imaging, and fatty infiltration of the supraspinatus, infraspinatus and subscapularis.

Results: The teres minor was noted normal in 90.9% of the shoulder, hypertrophic in 5.2%, atrophic in 3.2% and absent in 0.2%. The type of cuff tear had a significant impact (p< 0.0005). Regarding the aspect of the teres minor muscle, the highest percentages were as follows: normal for isolated supraspinatus tears, hypertrophic for supraspinatus and subscapularis tears, atrophic for posterosuperior (supraspinatus, infraspinatus ± teres minor) tears and absent for massive tears involving the supraspinatus, the infraspinatus ± the subscapularis (p< 0.0005). The correlation was statistically significant between the aspect of the teres minor and the grade of fatty infiltration of the infraspinatus (p< 0.0005) and the subscapularis (p< 0.0005).

Discussion: The aspect of an atrophic or absent teres minor, which correlates with the trumpet sign in massive tears, was only found in 3.5% of the tears. There would thus be few indications for latissimus dorsi transfer to restore active external rotation.

Purpose of the study: This work examined the clinical, radiological, and videoarthroscopic features of partial tears of the anterior cruciate ligament (ACL) and analysed results of ligament plasties.

Material and method: Mean age was 32 years. Patients complained of instability accidents in 70% of cases. The Lachman test was noted soft endpoint to + or ++ in 90%. A palpable click was found in 60% but was considered severe in two cases only. Telos laxity was moderate (about 5 mm) in 80%. Mean time to surgery was relatively short (9 months). Arthroscopic exploration revealed rupture of the anteromedial head of the ACL with preservation of the posterolateral component. There was a meniscal injury in nine knees. Early in our experience we performed a total plasty for nine patients (six using hamstring tendons and three with the patellar tendon). At the present time, we spare the posterolateral head and make a partial plasty of the anteromedial head (11 knees: 3 harvesting a single tendon [gracilis] and eight using the gracilis and the semitendious) associated with lateral reinforcement in five.

Results: Mean follow-up was 30 months; 30% of patients had knee pain. Three knees exhibited a soft endpoint (+) all after a total plasty. There were no cases of quadriceps motion deficit or amyotrophy.

Discussion: The existence of partial tears of the ACL were confirmed in this series. This type of tear corresponds to an objective condition seen arthroscopically and also to precise clinical presentations and biological findings: minor signs of instability with moderate objective anterior instability to the order of 5 mm.

Conclusion: Considering this work and a review of the literature, the diagnosis of partial tears of the ACL could be established from the physical examination and measurements of anterior knee laxity. Reconstruction of a single head provides better results than complete reconstruction which would sacrifice an intact portion of the ACL.

Magnetic resonance imaging (MRI) is a useful diagnostic tool in evaluating meniscus pathology in the knee. Data from available literature suggests sensitivity and specificity rates around 90% when compared to the gold standard findings at knee arthroscopy. We sought to evaluate the sensitivity, specificity and precision rate (positive predictive value) of MRI at diagnosing meniscus tears within our unit.

A retrospective audit of a total of 79 MRI reports and arthroscopic findings spanning a one year period was carried out. There were 66 positive MRI reports and 13 negative reports. There were 6 false positives 4 false negatives when compared to arthroscopic findings. The sensitivity of MRI for detecting meniscus tears was 93.7% with 60 out of 64 tears detected. All 4 false negatives also had at least grade III osteoarthritic changes at arthroscopy. Specificity was rather low at 60% with MRI reporting 6 tears (false positives) out of 15 patients who had no tears found at arthroscopy. The positive predictive value (precision rate) of MRI detecting tears was 90.9%.

This data shows that MRI in our unit has a comparable high sensitivity to that in various literature making it a useful tool at ruling out disease with a negative result in the clinical setting. A more useful parameter in the clinical setting is its high precision rate when faced with a positive result. However, its specificity is much lower than that in most published data. A total of 6 tears on MRI turned out not to be on arthroscopy meaning patients could have been subjected to an avoidable invasive procedure in the absence of any other indication. This highlights the importance of obtaining reports from experienced musculoskeletal radiologists and the need for surgeons to review MRI images and match them to clinical information prior to subjecting patients to surgery.

Introduction

An additional pathology should be considered for Achillodynia differentials – the intratendinous tear (ITT) – for which we describe symptoms, ultrasound findings and co-presenting pathology.

Introduction: The Constant Score Functional Assessment (CS) is now the standard method of assessing shoulder disability in Europe. Previous studies have indicated that the CS values associated with a full-thickness rotator cuff tear (RCT) are lower than for normal shoulders. This study was designed to investigate which parameters of the CS were most influenced by the presence of a RCT. As ultrasonograpy has now been shown to have a high accuracy for diagnosing full-thickness RCTs it was used to establish the diagnosis.

Methods: 28 patients attending the Shoulder Clinic were invited to take part in this study for which Local Ethics Committee approval had been obtained. The majority of patients had a painful shoulder on at least one side. All patients had a CS carried out with the “Strength” measurement made in 3 ways – 1) maximum force using a fixed spring balance – FSB(max); 2) maximum force using a commercial myometer – M(max); 3) mean force from 2 to 4 seconds using a commcercial Myometer – M(mean). The CS was measured with no knowledge of the patient’s history or diagnosis and blinded to the state of the rotator cuff. The patients were then assessed using ultrasonograpy of the shoulder (Diasus with an 8–16MHz head) to establish the presence of a full-thickness RCT.

Results: The CS Values for the left and right shoulders have been analysed separately.

The results have also been analysed for each part of the Constant Score – Pain, Activities of Daily Living, Range of Movement and Strength and these will be presented.

Discussion: It was anticipated that subjects with a RCT would be found to be weaker and have a reduced CS in an affected shoulder. This was found to be the case for the left shoulder but not for the right. The reasons for this will be discussed. The abnormally low CS for the normal right shoulders (Group 1) will also be explored.

Conclusion: The CS may be a valuable method of identifying those patients with a RCT. This study indicates that a more careful evaluation of “Strength” measurements still needs to be undertaken.

Introduction and Aims: A prospective analysis of the sonographic findings of asymptomatic shoulders in black patients over 40 years of age, to determine the prevalence of rotator cuff lesions in this group.

Method: Physical examination and bilateral sonograms were performed on 106 black patients, who visited the Trauma Clinic. Patients with shoulder trauma were excluded. Scans were made of sub-scapularis, supra-spinatus and infra-spinatus insertions. The size of the tears were measured in millimetres and divided in partially and full thickness tears.

Results: There were 66 male and 50 female patients. Mean age 52.8 years. Thirty-three patients had a history of previous trauma, but were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of five, which means that pain is present now and then, but no medication is necessary. Forty-two cuff lesions were present in 34 patients. The biggest lesion (3.5 cm) was in a 73-year old patient. In 17 shoulders, the tear was more than one cm and in 13 shoulders it was a partial tear. There was almost no weakness of sub-scapularis, supra-spinatus and infra-spinatus.

Conclusion: Asymptomatic rotator cuff tears were as common in the black population as in the Caucasian population. The symptoms present are mild and the patients experienced it as normal. Weakness as such may not be a problem in patients with a rotator cuff tear. Weakness may become a problem if the tear increases in size. Pain may become a problem when the shoulder becomes unstable.

Rotator cuff tendon healing has proven to be a substantial clinical challenge. There is significant interest in finding biologic augmentation methods to improve this healing process. Two currently available products include platelet rich plasma/platelet rich fibrin matrix and several commercially available extra cellular matrix (ECM) patches. Platelet rich plasma is a sample of an autologous blood which has been centrifuged to a concentration of platelets three to four times that of normal. Platelets contain multiple growth factors, many of which have been shown to be involved in all phases in tendon healing. An alternative is platelet rich fibrin matrix. This forms a fibrin matrix with the platelets embedded within. Growth factors are subsequently released as the fibrin is reabsorbed. There are only a few studies which look at the effectiveness of platelet rich plasma and fibrin matrix. Overall, there is no strong evidence to support its routine use in the setting of rotator cuff repair. Extra cellular matrix patches are used to reinforce the strength of the repair and offload the tendon. They also provide the potential to form a scaffold for new growth and differentiation and may at some point be a delivery vehicle for cells and growth factors. There are currently two prospective randomised studies evaluating ECM patches – one showed that the patch studied was actually harmful to repair and the second suggested there was some benefit in larger tears. While there is not a lot of strong evidence to support routine use, further research and development is necessary to maximise this strategy.

Introduction The annulus fibrosus of the intervertebral disc is composed of a series of concentric collagenous lamellae that constrain the highly pressurised fluid of the nucleus pulposus. With advancing age and even after physical injury in youth the disc almost invariably becomes progressively degenerate due to the combined effects of dehydration of the nucleus and disruption of the annulus. There is conjecture however, about which of the two compartments shows degenerate changes first.

Methods A histological and biochemical review is presented, based on a review of the literature and work carried out in our laboratories.

Results Three distinct types of annulus tears are seen histologically. Rim tears are formed by detachment of the peripheral annular fibres from the vertebral rim. Autopsy studies show that these lesions are rare in subjects younger than 30 years but the incidence increases significantly with advancing age. Although granulation tissue grows into the outer layers of the annulus in a normal healing response, these lesions frequently extend deeper into the disc. Radiating tears course radially across several lamellae, most often extending from the vertebral rim across the nucleus to involve the posterior side of the disc. These lesions are seen mostly between the ages of 30 and 50 years. Concentric tears are characterised by separation of adjacent lamellae and may appear as early as the second decade of life. In advanced degeneration nuclear changes may be seen with any combination of annular lesions. Biochemical changes, including dehydration and reduced proteoglycan content of the nucleus, parallel the morphologic changes to the disc. Altered biochemistry is further reflected by MRI studies in which some scanning sequences can detect even modest loss of fluid from the nucleus as early as three months after experimental annular incision. Annular lesions also compromise the biomechanical properties of the disc. While internal fixation that aims to immobilise the injured disc may promote some recovery of the mechanical integrity, degeneration nevertheless advances in the long term. Attempts to seal peripheral annular defects in experimental studies using biocompatible glue have also failed to promote healing and to prevent progression of even minor structural defects.

Conclusions Technological developments such as gene transfer into disc cells and direct implantation of either stem cells or more mature cells are emerging as potential candidates for the treatment of disc degeneration.

Introduction: This study was designed to investigate which parameters of the Constant Score are most influenced by the presence of a Rotator Cuff Tear (RCT).

Methods: 28 patients attending the Shoulder Clinic took part in this study for which Ethics approval had been obtained. Strength measurements were assessed in three ways: 1) maximum force using a fixed spring balance (FSB) 2) maximum force using the Nottingham Mecmesin Myometer 3) mean force during 2nd to 4th seconds using Nottingham Myometer. The CS assessor was blind to the volunteer’s history and state of their rotator cuff. Ultrasonography was used to establish the presence of a full-thickness RCT.

Results: The CS values for the left and right shoulders were analysed separately. No statistically significant difference (p> 0.05) was found between shoulders with a RCT and without a RCT in the pain, ADL and ROM parameters. Left shoulders with a RCT scored significantly different strength scores to those without (p< 0.05) but this significance was not seen in the right shoulders (p> 0.05). Shoulder strength measurements were highest with the FSB and lowest when measured using the mean force.

Discussion: The results obtained so far suggest that a shoulder with a full-thickness tear of the RC may obtain a significantly lower strength score than a normal shoulder. It does not suggest that any of the other three parameters of the CS can indicate the presence of a tear.

Conclusion: A reduction of shoulder strength alone might be a good indicator of a full-thickness RCT. However, this study indicates the importance of standardising the method of shoulder strength assessment for the Constant Score.

In this prospective analysis of the sonographic findings of asymptomatic shoulders to determine the prevalence of rotator cuff lesions in black patients over the age of 40 years, we examined 106 black patients.

Patients with shoulder trauma were excluded. Bilateral sonography was done on the subscapularis, supra-spinatus and infraspinatus insertions of 66 men and 50 women (mean age 52.8 years). The tears were measured and classed as partial or full thickness tears. In 33 patients, there was a history of previous trauma, but they were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of 5, which means that pain is present intermittently but no medication is necessary. In 34 patients there were 42 cuff lesions. The largest (3.5 cm) was in a 73-year-old. In 17 shoulders the tear measured more than 1 cm, and in 13 shoulders the tear was partial. There was almost no weakness of subscapularis, supra-spinatus and infraspinatus muscles.

We concluded that asymptomatic rotator cuff tears are as common in the black population as in the Caucasian population.

To the best of our knowledge, this prospective study is the first to investigate the prevalence of acetabular labrum tears in athletes presenting with groin pain.

Eighteen consecutive athletes who presented to our sports clinic with groin pain, underwent Magnetic Resonance Arthrography (MRA). Presence or absence of acetabular labrum tears, were reported on by a Consultant Radiologist, who has an interest in musculoskeletal radiology.

In 4 out of 18 athletes with groin pain (22.2%), the Magnetic Resonance Arthrography demonstrated the presence of acetabular labrum tear. Two underwent hip arthroscopy and treatment

Acetabular labrum tears can be a common cause of groin pain in athletes. Sports clinicians have to be well aware of the condition. Magnetic resonance arthrography of the hip can be a valuable tool in diagnosing this pathology.

The absence of menisci in the knee leads to early degenerative changes. Complete radial tears of the meniscus are equivalent to total meniscectomy and repair should be performed if possible. The purpose of this study was to biomechanically compare the cross suture, hashtag and crosstag meniscal repairs using all-inside implants for radial tears.

Radial tears were created at the mid-body of 36 fresh-frozen lateral human menisci and then repaired, in randomiSed order, with Fast-Fix™ 360s (Smith & Nephew, Andover, MA) using the cross suture, hashtag and crosstag techniques. The repaired menisci were tested using an Instron Electropuls E10000 (Instron, Norwood, MA). The tests consisted of cyclic loading from 5 to 30N at 1Hz for 500 cycles, then a load to failure test. Displacement following cyclic loading, load at 3mm of displacement, load to failure, and stiffness were recorded. Any differences between repairs were assessed using Kruskal-Wallis and Mann Whitney tests (p<0.05).

Cross suture repairs displaced more following cyclic loading and resisted less load to failure than both the hashtag and crosstag repairs. However, these differences were not statistically significant. The average displacement following cyclic loading of cross suture, hashtag, and crosstag repairs was 4.34 mm (±2.02 mm), 3.46 mm (±2.12 mm), and 3.24 mm (±1.52 mm) respectively (p=0.33). Maximal load to failure was 64.83 N (±17.41 N), 74.52 N (±9.03 N), and 74.98N (±10.50N), respectively (p=0.419).

All-inside cross suture, hashtag and crosstag repairs all displaced >3mm with cyclic loading, which is the threshold for meniscal insufficiency. This contrasts previous studies using inside-out sutures, where crosstag and hashtag repairs resisted cyclic loading (< 3mm). Inside-out suturing for radial tears of the lateral meniscus currently remains the gold standard.

Introduction: Rotator cuff tears are a common injury which affects both the young athlete and the sedentary elderly alike. This condition is commonly treated with glucocorticoid injections as part of initial management. The effects, however, of these injections on the histology of collagen and the metabolism of tendon fibroblasts are still controversial.

Materials and methods: In this study, samples from 19 patients with rotator cuff tears were taken during definitive surgery to manage these tears. There was a history of glucocorticoid injections in all of the patients. The samples were examined in terms of histopathology using light microscopy, in situ hybridization to detect the presence of glucocorticoid receptor mRNA and TUNEL assay to determine the incidence of apoptosis.

Results: Light microscopy of hematoxylin-eosin stained samples from the study group showed marked cellularity although there were no signs of inflammation. The nuclei were noted to be rounded and a significant number showed pyknosis. Angiogenesis was also noted in the sections, consistent with previous finding of angio-fibroblastic hyperplasia as a characteristic of tendinosis. Collagen structure was noted to be abnormal, with longitudinal clefts and focal areas of marked disorganization of fibers. In situ hybridization showed a strong signal for glucocorticoid receptor mRNA in all of the samples. TUNEL assay also showed a strong signal for apoptosis of the tendon fibroblasts in the study group as compared to the control group which showed almost no signal.

Conclusion: Our results suggest that although an overall picture of hypercellularity is seen in cases of tendinosis and tendon tears, a high percentage of these cells are undergoing apoptosis. This may reflect a natural high rate of turnover of cells during the process of repair or may be due to exogenous factors. Glucocorticoids almost certainly affect metabolism of tendon fibroblasts and subsequently collagen structure as seen by the abundant expression of the receptor mRNA. However, a causal relationship between glucocorticoids and apoptosis of tenocytes is yet to be established.

PURPOSE

We performed an anatomical study to clarify humeral insertions of coracohumeral ligament (CHL) and superior glenohumeral ligament (SGHL) and their relationship with subscapularis tendon. The purpose of our study was to explain the « Comma Sign » observed in retracted subscapularis tears treated by arthroscopy.

Purpose

Management of massive, degenerative, and irreparable rotator cuff tears is challenging. Excessive re-tear rates and poor clinical outcome after standard repair have led to alternative methods of treatment. Tendon transfers and shoulder arthroplasty have had mixed results; both are invasive procedures with high potential morbidity. We began performing rotator cuff augmentation and replacement using GraftJacket allograft acellular human dermal matrix as a biologic minimally invasive alternative in this difficult population almost 6 years ago. This article highlights our preferred arthroscopic technique and early results.

Shoulder pain or loss of normal range of motion is a frequent complaint in the outpatient clinic. Of these presentations, rotator cuff injury is a common cause. This can range from mild, transient inflammation of the tendons, to partial tears of tendons, or even full thickness tears. Disruption of the tendons can occur from forceful forward throwing actions undertaken in some sports, for example baseball pitching, more commonly in the UK however, chronic impingement can lead eventually to a tendon tear-usually seen in an older population. Current methods of investigation of such injuries after clinical history and examination, includes plain film radiography, ultrasonography, magnetic resonance imaging and arthrography. We decided to look at how ultrasound can be used in the district general hospital for investigation of such injuries.

Purpose of study: The diagnosis of meniscal tears is usually based on the patient’s history and on specific physical tests. Magnetic resonance imaging (MRI) and arthroscopy is often necessary for diagnosis.

Theofilos Karachalios et al. described the new ‘Thessaly test’ and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery (Ref: J Bone Joint Surg Am. 2005 May; 87(5):955–62). Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test.

Methods & Results: We examined 109 patients [(80 male, 29 female), average age 39.11 years, range (16–66)] who presented with a history suggestive of a meniscal tear. Joint line tenderness,

McMurray’s test and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated.

Our study showed a much lower diagnostic accuracy for the Thessaly test (61.25 % for medial meniscus and 80 % for lateral meniscus) It is comparable to McMurray’s test (57.14 % for medial meniscus and 77.38 % for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (80.95 %for medial meniscus and 90.48 % for lateral meniscus). Combining the joint line tenderness test with McMurrays test or the Thessaly test further increased the diagnostic accuracy. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Arthroscopy was diagnostic and therapeutic in all cases.

Conclusion: Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations. In our study the Thessaly test in isolation did not have the highest diagnostic accuracy for the detection of meniscal tears but helps increase diagnostic certainty when combined with standard tests.

Massive, irreparable rotator cuff tears occur in about 15% of patients with ruptures of the rotator cuff tendons. There is no consistently agreed management for irreparable rotator cuff tears, however, latissimus dorsi tendon transfer is a recognised technique. We aimed to review the functional outcome of patients undergoing this operation at a single tertiary referral centre.

Fourteen latissimus dorsi transfer procedures in thirteen patients from May 2007 to May 2008 were retrospectively reviewed. The mean age of patients undergoing the procedure was fifty nine years. All patients were confirmed to have massive, irreparable (>5cm) rotator cuff tears as determined by MRI or ultrasound. Modified Constant scores (assessing shoulder pain, functional activity and movement) determined pre-operatively and post latissmus dorsi transfer were compared. The mean duration of follow up was 12 months.

The mean Modified Constant Score (maximum = 75) improved from 23 points pre-operaively to 52 points post latissimus dorsi transfer (p < 0.05). All patients had improvement in shoulder pain following the operation. There was a trend for younger patients to have greater improvement in functional activity and shoulder movement.

From our series, latissimus dorsi transfer is effective at improving functional outcomes in patients with massive, irreparable rotator cuff tears, especially in younger age groups.

Purpose

Chronic massive rotator cuff tears are challenging to repair completely because of the development of tendon retraction with inelasticity, muscle atrophy and fatty infiltration. The objective of this study was to investigate the clinical outcome and MRI findings after arthroscopic superior capsule reconstruction (ASCR) for symptomatic irreparable rotator cuff tears.

We reviewed 87 patients who underwent revision anterior cruciate ligament (ACL) reconstruction. The incidence of meniscal tears and degenerative change was assessed and related to the timing from primary ACL graft failure to revision ACL reconstruction. Patients were divided into either an early group (revision surgery within 6 months of graft failure) or a delayed group. Degenerative change was scored using the French Society of Arthroscopy system. There was a significantly higher incidence of articular cartilage degeneration in the delayed group compared to the early group (53.2% vs 24%, p < 0.01, Mann- Whitney U test). No patients in the early group had advanced degenerative change (SFA grades 3 or 4), compared with 12.9% of patients in the delayed group. There was no significant difference in the incidence of meniscal tears between the two groups. In conclusion, the findings of the study support the view that patients with a failed ACL reconstruction and symptomatic instability should have an early revision reconstruction procedure carried out to minimise the risk of articular degenerative change.

Aims To describe the distribution, clinical presentation of SLAP tears in rugby players, and time taken for return to sport.

Method A retrospective review of 51 shoulder arthroscopies performed on professional rugby players over a 35 month period was carried out. All patients diagnosed with a SLAP lesion at arthroscopy were identified. Each patient’s records were reviewed to record age, injury side, mechanism of injury, clinical diagnosis, investigations and results, management, and return to play.

Results The incidence of SLAP tears was 35%. All 18 patients were male with an average age of 27yrs. There were 11 isolated SLAP tears (61%), 3 SLAP tears associated with a Bankart lesion (17%), 2 SLAP tears associated with a posterior labral lesion (11%) and 2 SLAP tears associated with an anterior and posterior labral injury (11%). Of the 18 SLAP tears, 14 (78%) were Type 2, 3(17%) were Type 3 and 1(5%) was Type 4. All patients recalled a specific heavy tackle with fall onto the lateral aspect of shoulder. No patient sustained a complete dislocation. None of the patients presented with symptoms of instability. MR Arthrograms were performed in 17 of the 18 patients. SLAP tears were detected in 13 patients (76%). All patients underwent arthroscopic reconstruction within 6 months post injury. At Arthroscopy 7 patients (39%) were found to have associated injuries. Preoperatively 11% of patients were satisfied with their shoulder. By 6 months post surgery 89% of patients were satisfied and 95% were back to their previous activity level. Patients with isolated SLAP tears returned to sports at an average of 2.6 months post surgery.

Conclusion SLAP tears are a common injury in rugby players with shoulder pain following injury. These can often be diagnosed with MR arthrography. Arthroscopic repair is associated with excellent results and early return to sports.

Introduction: Neglected Achilles tendon ruptures are a management challenge. Several surgical techniques have been described. A two centre, two surgeon, two year longitudinal study was undertaken to report the results of reconstruction of neglected Achilles tendon rupture using a free autologous gracilis tendon graft

Methods: Fourteen patients underwent surgery for a neglected rupture of the Achilles tendon occurring between 65 days and nine months before the operation. All were prospectively followed up for two years.

Results: No patients experienced any problems in the wound used to harvest the tendon of gracilis. Four patients were managed conservatively following a superficial infection of the achilles tendon surgical wound. No patients developed a deep vein thrombosis or sustained a re-rupture. All patients were able to walk on tiptoes, and no patient used a heel raise or walked with a visible limp. The maximum calf circumference remained significantly decreased in the operated leg at latest follow up. The operated limb was significantly less strong than the non-operated one.

Conclusions: The management of neglected subcutaneous tears of the Achilles tendon by free gracilis tendon grafting is safe but technically demanding. It affords good recovery, even in patients with a neglected rupture of nine months’ duration. These patients should be warned that they are at risk of post-operative complications, and that their ankle plantar flexion strength can remain reduced.

The purpose of this study was to test the null hypothesis that patients with partial thickness rotator cuff tears do not suffer more pain or stiffness than those with full thickness tears. A power study determined that 68 partial thickness tears were required in the study in order to prove a clinically important difference (± = 0.05 and ² = 0.2). Consecutive patients undergoing arthroscopy and bursoscopy for rotator cuff related problems were assessed using a pain analogue scale and their shoulder movements were measured. Information was gained both pre- and intra-operatively about possibly relevant confounders including age, site size and thickness of tears, and endocrine disorders. Exclusion criteria included glenohumeral arthropathy, frozen shoulder, instability and major traumatic injuries, as well as the inability to understand the pain score. 439 shoulders (428 patients) were included in the study; 216 shoulders had no cuff tear, 95 had partial thickness tears (75 joint side, 1 intrasubstance, 19 bursal side), and 128 shoulders had full thickness tears. There was no significant difference (p< 0.05) in the pain scores or range of movement between full and partial thickness tears. Age was the only independent variable to have an effect on pain score.

The null hypothesis has been upheld. This study contradicts the findings of previous research and challenges commonly held assertions on this topic. Neither pain nor stiffness can be used clinically as discriminators between partial and full thickness rotator cuff tears.

Purpose of the study: Four elements differentiate myotendinous tears of the infraspinatus from other rotator cuff tears: the tendon insertion on the trochiter and the joint capsule are spared; the onset in characterized by intense muscle oedema followed at 6 to 12 months by severe and definitive fatty degeneration.

Material and method: Fifty-nine myotendinous tears of the infraspinatus were collected prospectively from 1993 to 2007. Female gender predominated (58%); trauma was noted at onset in 22% of the shoulders and the mean age of discovery was 48.9 years. Twenty-nine shoulders were seen at the acute phase with significant muscle oedema recognized on the MRI T2 Fat Sat sequence. A second group of 30 patients had grade 4 fatty infiltration of the infraspinatus without full thickness cuff tears. The EMG was available for 23 shoulders and was normal in all, ruling out a neurological cause. Associated lesions of the supraspinatus and infraspinatus tendons were: tendon calcification (61%) and partial tears at the acute phase (21%) and chronic phase (70%) suggesting a degenerative cause.

Results: Twenty-four patients underwent surgery and 35 had a medical treatment. At mean 46 months follow-up (range 12–125) the Constant score improved from 51.7 to 69.4 points (p< 0.0001). There was no different statistically between the operated and non-operated patients (p=0.325). All patients seen at the acute phase of the oedema progressed to complete grade 4 fatty degeneration of the muscle, irrespective of the treatment delivered.

Discussion: Early diagnosis of this lesion can be achieved with T2 Fat Sat MRI sequences. Arthroscopic repair to tighten the infraspinatus muscle could avoid the irremediable degeneration with total loss of muscle function.

Labral tears are increasingly recognized as a source of hip pain. These rarely occur in normal hips, but in individuals with subtle femoral deformities. Anterior impingement of the femoral neck on the acetabulum due to loss of anterior offset results in a labral tear in active individuals. Future surgeries should be directed at this anterior offset deficiency in order to completely alleviate pain and prevent further recurrences.

To determine the incidence of anterior hip impingement and femoral pathology in patients undergoing hip arthroscopy for labral tear.

Anterior labral tears occur in the presence of abnormal femoral anatomy, which results in anterior hip impingement.

Future treatment of labral tears should include addressing the hip impingement.

Labral tears of the hip are increasingly being recognized as a source of hip pain in young, active individuals. Athroscopic labral debridement is commonly associated with poor results. As a result, it is likely that other hip pathology is present at the time of labral tear. The purpose of this study was to determine the incidence of anterior hip impingement secondary to a pistol grip deformity in patients undergoing hip arthroscopy for labral tears.

The charts and radiographs of forty consecutive patients who underwent hip arthroscopy were evaluated. X-rays were evaluated for presence of acetabular or femoral pathology. Femoral pathology was then graded based on degree of slip and posterior slip angle.

All patients who underwent hip arthroscopy for labral tears had abnormal femoral or acetabular anatomy. In those patients without acetabular dysplasia, a pistol grip deformity of the femoral head was present in all cases. Evidence of anterior hip impingement with osteophyte formation was present in ninety-two percent. In these patients, hip arthroscopy results in complete resolution of mechanical symptoms, but hip pain was still present.

Labral tears of the hip appear to be secondary to anterior femoral impingement. This is analogous to a rotator cuff tear in the presence of shoulder impingement. Anterior impingement of the femoral neck on the acatabulum due to an anterior femoral offset deformity results in both pain and labral tears. Future surgeries should be directed at this anterior offset deficiency in order to prevent recurrent injuries or residual pain.

Purpose: A prospective investigation to define the syndrome associated with symptomatic labral tears definitively diagnosed at hip arthroscopy.

Methods: 66 consecutive patients that had an arthroscopically documented labral tear were evaluated. Demographics, symptomatology, examination, previous treatments, functional limitations, were assessed prospectively. Onset/duration of symptoms to diagnosis of tears, other diagnoses offered by healthcare providers, and non-labral procedures that patients had undergone for the symptoms were analyzed. Radiographic abnormalities and MR arthrography findings were recorded.

Results: There were 47 female and 19 male patients with a mean age of 38 years. Initial presentation: insidious in 61%, acute injury in 30%, and trauma in 9% hips. Moderate to severe pain occurred in 86% of patients, with groin pain predominating (92%). Fifty three percent had true mechanical symptoms - catching/locking. Walking, pivoting, impact activity aggravated patient symptoms (p< 0.05). Pain was characterized as a combination of dull aching pain with intermittent episodes of sharp pain in 70%(p=0.001). Pain was frequently activity related (p< 0.05) and night pain occurred in 71% of patients (p=0.0006). The majority of patients (98%) with a labral tear reported being active/athletic. On examination 39% patients had a limp, 38% a positive Trendelenburg sign, and 95% a positive impingement sign. The mean time to diagnosis of labral tear from the onset of symptoms was 21 months. A mean of 3.3 healthcare providers were seen prior to a definitive diagnosis. Surgery on another anatomic site was recommended in 11 patients and 4 of these underwent an unsuccessful surgery prior to diagnosis of the labral tear. Radiographic data indicated that 38% of hips had an underlying structural abnormality consistent with mild development dysplasia or anterior femoroacetabular impingement. Preoperative MRA detected 73% of the labral tears.

Conclusions: The clinical presentation of a labral tear may vary, with duration of symptoms often greater than 12 months prior to diagnosis. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected, and investigated, as radiographs and history may be nonspecific for this diagnosis.

Various arthroscopic techniques using differing graft materials have been described and present a potential alternative to arthroplasty for rotator cuff arthropathy. We describe the short-term outcomes of allograft reconstruction, having evolved of our surgical technique from graft interposition to superior capsule reconstruction (SCR). All patients with an irreparable tear, in the absence of clinical and radiograph evidence of osteoarthritis, who underwent an allograft (Graft Jacket^TM) reconstruction with either an arthroscopic interposition or SCR technique within our institution were included. A retrospective case note analysis was performed to ascertain perioperative details including total operating and consumable implant costs. 15 patients were in the interposition group, mean age 66 years (48–77). Mean postoperative follow-up time was 17 months (1.9 −27.8). The mean OSS improved from 30.6 to 35.7 (p<0.05). Additionally, mean pain scores out of 10 improved from 7.7 to 1.5 (p<0.01). Mean satisfaction for the surgery was 7.8 out of 10. Complications included 2 re-ruptures (13.3%), 1 infection (6.7%) and 1 case of no improvement (6.7%). In the SCR group, there were 10 patients, mean age 64.5 (56– 68 years). Half of these patients had previous rotator cuff surgery. Mean postoperative follow-up time was 8.7 months (1.9 – 16.3). The mean OSS improved from 24 to 32.9 (p<0.01). Similarly, pain scores decreased from 7.9 to 3.5 (p<0.01). Mean satisfaction was 7.2. Complications included 1 case of no improvement (10%) resulting in a reverse TSR and 1 re-rupture (10%). A formal, prospective comparison trial is advocated to determine if SCR is superior.

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most frequent cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn’t settle and warrants further investigation and treatment. Between July 2006 and February 2008, 28 patients underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors.

There were 15 females and 1 male. They had a mean age of 62. All patients completed a self-administered questionnaire pre-operatively and 1 year postoperatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.

Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant (p< 0.05) improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10. The mean change of Oxford hip score was 20.5. The mean improvement in SF-36 PCS was 8.5 and MCS 13.7. 6 patients who had a Trendelenberg gait pre-surgery had normal gait 1 year following surgery.

We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

Reverse shoulder arthroplasty (RSA) was released into the United States market in 2004 for the indication of Rotator Cuff Tear Arthropathy. Since that time the indications have widened and now include massive rotator cuff tears that are not deemed to be surgically repairable. This diagnosis includes patients that are considered young in terms of shoulder replacement surgery. These patients do not have the radiographic changes of arthropathy, but most have undergone multiple surgical procedures in the past to attempt to repair the rotator cuff deficiency. These younger patients have a different post-op expectation than the patient with advanced arthropathy over the age of 70.

The complication rate seen in this younger patient population is higher than seen in the older population undergoing RSA. The post-operative survey for satisfaction is also considerably lower in the younger population group.

RSA for massive rotator cuff tears in a younger population under the age of 65 years gives a lower patient satisfaction result and a higher complication rate than age-matched patients older than 65 years. Although this is still the best procedure available for this difficult diagnosis, patients younger than 65 years should be consulted as to what their expectations are post-operatively. Pain relief is still the main reason to undergo an RSA.

Summary

When a TFCC tear is diagnosed, practitioners should maintain a high level of suspicion for the presence of a concomitant SL or LT ligament tear.

Background: Cam-type femoroacetabular impingement (FAI) is becoming more recognized. Cartilage lesions of the acetabulum and labral tears are frequently encountered. The goal of this study was to accurately describe and communicate these injuries and thus providing a standard for reporting injury, management, and outcome.

Methods: We evaluated acetabular cartilage lesions and labral tears found during hip arthroscopy in 52 patients with radiological signs of cam-type FAI. They were graded according to the morphology and extent of the lesion. The labral tears were described according to the classification by Lage.

Results: Eleven patients (21.2%) had normal cartilage, 14 (26.9%) had a grade 1, 17 (32.7%) a grade 2, 6 (11.5%) a grade 3, and 4 (7.7%) a grade 4 lesion. Labral tears were found in 31 patients (59.6%). There was a high correlation between age and the presence and extent of acetabular cartilage and labral lesions (r=0.70; p< 0.0001 and r=0.45; p< 0.001 respectively). There was also a high correlation between the extent of the acetabular cartilage lesion and the presence of labral lesions (r=0.62; p< 0.0001).

Conclusion: In our study there was a high prevalence of associated injuries (86.5%) in cam-type FAI. Despite the recognized consequences of associated lesions on treatment and outcome, no classification system includes this aspect of FAI. Based on our findings, we developed a system to grade acetabular cartilage lesions according to their morphology and extent. This should provide the surgeon with a standardized tool to better describe the full extent of the injury and treat it accordingly.

Purpose: This work revealed the advantages of percutaneous suture of the Achilles tendon using an improved technique with entirely resorbable material.

Material and methods: Thirty cases of subcutaneous tears were operated on two to ten days after the accident (range 24 hr – 7 weeks). We used a 4-thread resorbable V-suture anchored in the calcaneum and, after blocking the ankle in the equine position, on the proximal fragment using two bioresorbable buttons. Postoperatively, immediate weight bearing was progressive using an adjustable and removable orthesis. Active-passive rehabilitation was initiated immediately. The material was left in place indefinitely and was resorbed after three months.

Results: We followed these patients for 24 – 8 months. Wound healing was excellent and material tolerance was exceptional (only one complaint of transient calcaneal pain). Objective outcome was comparable with that obtained with conventional suture, with a significant reduction in the risk of skin and neurological complications. There were no cases of recurrent tears. CT and MRI controls confirmed the early healing, the quality of the tendon repair, and material resorption within the expected delay. Subjective outcome was excellent.

Discussion: While the results obtained in this series are comparable to those with prior percutaneous techniques, the important improvement was the very significant reduction in skin and neurological complications often reported in other series. It is also noteworthy that there were no recurrent tears. The advantages are even more remarkable compared with surgery. The greater solidity authorises very rapid rehabilitation, similar to protocols advocated for nonoperative care. The limitations on indications appear to be tears seen after three weeks and true calcaneal de-insertions.

Conclusion: This technique improves patient comfort and follow-up while allowing safer rehabilitation.

Aim: The description of technique and early results of arthroscopic rotator cuff tears (RCT) reconstruction.

Patients-Methods: Âetween 01/2001 and 02/2003 26 patients, ranging in age from 33–82 (mean age 61,5 y.) – 17 males, 9 females – with RCT underwent arthroscopic reconstruction including debridement, sub-acromial decompression and mobilization of the rotator cuff. The RCT was then repaired with the arm in neutral position using “side to side” suturing technique and rotator cuff anchors when needed. Postoperatively, rehabilitation program included initially passive, active kinisiotherapy while exercises under resistance were finally performed..

Results: All patients were evaluated using ASES and UCLA scores pre-and postoperatively. Pain relief postoperatively was noticed in almost all reconstructed patients. In order to indentify functional improvement range of motion and strength were seperately evaluated. Range of motion just as pain remission was notably improved in almost all patients while strength ameliorate most in patients with complete restoration of rotator cuff tear. The interval between reconstruction and full patients’ recovery ranged between 3 months – pat. < 60 years – to 6–8 months – pat. > 60 years.

Conclusions: Arthroscopic RCT reconstruction although a demanding technique achieves satisfactory early results—mainly regarding pain relief and range of motion improvement- comparable to those of open repair reducing also postoperative morbidity.

Introduction: Large chronic tears of the supra and infraspinatus tendons lead to pain and dysfunction of the shoulder. If conservative treatment fails and repair is impossible, transfer of the latissimus dorsi (LD) muscle can be attempted to substitute for lost of supero-posterior cuff function.

Method: In 2003 nad 2004, twenty five patients with an average age of 54,8 years (range, 51 to 62 years) who had ongoing pain and impaired function underwent the LD transfer after ultrasonographic examination and diagnostic arthroscopy as a primary surgery. The patients were examined at an average of fourteen months (range, twelve to twenty six months) after the operation. The results were assessed with use of Constant-Murley score pre–and postoperatively.

Results: The mean Constant-Murley score increased from 32,50 points preoperatively to 78,75 points postoperatively. The mean score for pain improved of 8,75 points (from 3,75 to 12,50), activities of daily living improved of 10,00 points (from 6,00 to 16,00), range of motion of 15,00 points (from 14,00 to 29,00) and strengh improved of 11,50 points (from 8,75 to 21,25). 20 patients (80%) were very satisfied and 5 patients (20%) were satisfied. The postoperative pain relief was left as the predominant improvement. No patient was disappointed. All patients stated that they would have the operative procedure again under similar circumstances. There was only one complication – subcutaneous haematoma treated with revision and drainage.

Conclusions: Our results indicate that LD transfer is a reasonable approach for salvage of a massive tear of the supero-posterior rotator cuff. Despite the difficult operation technique and long rehabilitation phase, this procedure improves the subjective and objective findings.

Arthroscopic labral debridement has become and accepted mode of treatment for acetabular labral tears (ALTs) and yet results in literature are few and conflicting especially with regards presence of cartilage damage and its influence on outcome.

Aim of our prospective cohort study was to look at outcome of ALTs post arthroscopic limbectomy using validated questionnaires at average of 2 years. We also looked at the sensitivity of MR arthrography in detecting ALTs and cartilage damage.

Consecutive cohort of 82 patients who were suspected of having ALTs by senior author had MR arthrography followed by hip arthroscopy. All patients filled out a WOMAC, NAHS scores before and after the operation. All patients who were followed up also filled an especially designed five-point functional questionnaire. At time of arthroscopy the presence of labral tear, its position in the acetabulum and degree of cartilage damage (based on Outerbridge classification) were recorded and correlated with Mra and patient outcome.

Seventy six patients were found to have a labral tear, with majority of these lesions in the anterior or antero-superior quadrant. 59% of patients were shown to have an associated degree of cartilage damage. Although overall all patients showed significant improvement in their functional scores, those with high grade cartilage damage had poorer results in comparison. We also found that patients with older age are at higher risk of requiring a THJR in the first 2 years following arthroscopy. MRa proved to a sensitive tool at detecting labral pathology but not so at identifying presence of cartilage damage.

Arthroscopic debridement of ALTs in patients presenting with mechanical hip symptoms provides good functional outcome, however it should be used with caution in those with high grade articular cartilage damage and older age group where there is higher likelihood of failure.

Background: A common complication of lumbar spine surgery is incidental tear of the dural sac and subsequent leakage of the cerebrospinal fluid intraoperatively. Studies have reported a wide variation in the rates of dural tears in spine surgery (1%–17%). The rates were higher after revision surgery.

Objective: To establish a baseline rate of incidence of dural tears after lumbar surgery in Morriston Hospital Neurosurgical Unit and to compare it with the results reported in the literature.

Methods and Results: A prospective review of the operation notes of 65 consecutive patients who had undergone lumbar surgery (Primary lumbar discectomy, primary lumbar laminectomy and revision lumbar discectomy) over a period of 3 months from Jan 2008. Patients were operated on by different neurosurgical consultants.

40 patients had primary lumbar discectomy of which 2 (5%) had dural tears. 20 patients had primary lumbar laminectomy of which 1 (5%) had a dural tear and 5 patients had revision lumbar discectomy of which 1 (20%) had a dural tear. All dural tears were repaired intraoperatively.

Conclusion: This study shows that the highest percentage of incidental durotomy was in revision lumbar surgery which was also slightly higher than the reported rates (8.1%–17.4%). The percentage of dural tears after primary discectomy and primary laminectomy was within range of the percentages reported in the literature (1%–7.1%) and (3.1%–13%) respectively. A multicentre prospective larger study which includes all different surgical procedures performed on the lumbar spine is needed to establish a more accurate incidence rate for this common complication.

Aim: The common anatomic pathology responsible for the recurrent dislocation of the shoulder is in younger patients a trauma causes the Bankart lesion. Contrary to that, the common cause for recurrent instability in older patients, which is far more rare, is the massive tear of the rotator cuff tendons. During that the shoulder loose the of the posterior-upper stabilizing element (posterior mechanism according to Neer), and present a secondary anterior-inferior recurrent instability. This paper presents the results of the operative treatment for the above-mentioned rare and complex lesion.

Material – Method: Seven (7) patients, three (3) male and four (4) female with a mean age of 71 years developed recurrent shoulder instability as a result of trauma or preceding infection, which destroyed the rotator cuff. The initial injury was associated with dislocation in 2 cases and without dislocation in 3. The other 2 had a prior infection of the glenohumeral joint, which was treated conservatively. The patients who suffered injury were initially treated with a sling for 2 to 4 weeks. All cases presented with instability, pain and weakness, and in 2 cases the subluxation was obvious in every attempt to raise the arm. The radiological findings consisted of subacromial space narrowing, sclerosis and spur formation of the inferior part of the acromion and diffuse osteoporosis. All of the patients had tears in at least two tendons of the rotator cuff. The cases were treated operatively with a combination of the Boytchev anterior stabilization procedure (osteotomy of the coracoid process, transfer of the conjoined tendon under the subscapularis tendon and repositioning of the coracoid process) with an attempt to close the rotator cuff tear. A complete closure was achieved in 3 cases (in one the long head of the biceps was used), and a partial closure in 2. In the remaining 2 cases the closure of the tear was impossible. All of the patients postoperatively underwent an early mobilization regime.

Results: The mean follow-up was 30 months. Stabilization of the shoulder was achieved in 6 cases. Constant score varied from 50 to 85. One patient had a recurrent of the subluxation. All of the patients presented marked improvement in pain and in muscle strength. Two (2) of them developed almost full range of motion and satisfactory muscle strength. Four (4) patients presented decreased range of motion and muscle strength 50% of the unaffected arm, while one patient developed inability to raise his arm above 70 degrees. Five cases out of seven showed a satisfactory response to daily life activities.

Conclusions: The combination of recurrent anterior instability with massive rotator cuff tears presents great difficulty in treatment especially in the cases where an infection had preceded. A complete closure of the rotator cuff tear is usually very difficult to achieve, while the treatment of the instability alone leads to dubious results as far as pain and range of motion is concerned. For the management of the above complex lesion the existing literature is rather poor, and the combination of the Boytchev procedure with an repair of the rotator cuff tear, yielded satisfactory results mainly in regard to pain control, and secondly in achieving a good postoperative range of motion.

Two dimensional ultrasound of the shoulder joint has become a well established diagnostic tool. Difficult interpretation of ultrasonographic findings, however, suggests that ultrasound appears not to be an always reliable method, especially in partial thickness tears. The present study was performed to determine whether the use of three dimensional (3D) sonography further increases the diagnostic yield of ultrasound.

On a total of 22 externally intact appearing rotator cuffs of cadaveric shoulder joints 7 full thickness and 15 partial thickness incisions were carried out on the M. supraspinatus, subscapularis and infraspinatus tendon. The specimens included the humeral head, the glenoid, the joint capsule and periarticular tendons.

Ultrasound was performed on the shoulder specimens in a water basin with a 8.5 MHz curved array transducer (Combison 530D, Kretztechnik, Zipf, Austria).

With three dimensional ultrasound rotator cuff lesions were more often correctly diagnosed (sensitivity of 77 %) than with conventional 2D sonography (sensitivity of 64 %). Specificity was 85 % and 69 %, respectively. In partial thickness tears in particular, 3D imaging was the superior method reaching a sensitivity and specifity of 73% and 77%, respectively compared to 53% and 61%, respectively with 2D ultrasound.

The use of three dimensional ultrasound appears to have a higher diagnostic yield in partial thickness tears. One advantage is that the examiner must not move the transducer to obtain other planes. Changes in echogenicity can be observed in the complete volume and in any plane. In the diagnosis of partial tears these changes enabled the examiner to distinguish intact from ruptured tissue.

Background

Labral tears are now recognised as a common pathology especially in young adults. With advancement of arthroscopic techniques, most recent published literature is focused on short- or mid-term results of labral repair or re-fixation. There is limited data regarding long-term results of labral debridement and effect of co-existing pathology on outcomes. We investigated long-term results after arthroscopic labral debridement, the predictors of outcomes and correlation with any co-existing hip pathology.

Meniscal tears commonly occur after a traumatic twisting injury to the knee (acute) or can form over time (degenerate). Symptoms include pain, swelling, and ‘locking’ of the knee. These symptoms are also commonly associated with osteoarthritis (OA). In some cases of OA, degenerative meniscal tears can also be present making it difficult to determine the cause of symptoms. Furthermore, acute meniscal lesions may be associated with early stage OA but often no radiological signs are evident. Many metabolites associated with joint disorders are released into the synovial fluid providing a real-time snap shot of joint pathology. The ability to examine concentrations of specific metabolites within synovial fluid could provide invaluable clinical information about the cause and stage of joint pathology. We have tested the hypothesis that ‘high resolution 1H-NMR can discriminate between osteoarthritic and meniscal tear-related metabolites within human synovial fluids and aid in clinical diagnosis.’

We measured the isokinetic strength of abduction, adduction, internal rotation, and external rotation in ten patients with full-thickness tears of the supraspinatus and ten with partial-thickness tears. The measurements were repeated after intra-articular or intrabursal injection of local anaesthetic.

Pain blocks produced significant increases in strength in both full and partial-thickness tears. After the block, the strength in full-thickness tears compared with the opposite side was 67% to 81% in abduction and 67% to 78% in external rotation, both significantly smaller than those on the uninvolved side (p = 0.0064, p = 0.0170). In partial-thickness tears the strength after the block ranged from 82% to 111%, with no significant differences between the involved and uninvolved sides.

The decreases in strength of 19% to 33% in abduction and 22% to 33% in external rotation after full-thickness tears appear to represent the contribution of supraspinatus to the strength of the shoulder.

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42).

The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction.

We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff.

Purpose of the study: Fatty infiltration and atrophy of rotator cuff muscles is an important prognostic factor for anatomic healing and function after repair. The purpose of this study was to analyse factors influencing the development and progression of the supraspinatus muscle and to search for correlation between infiltration and atrophy.

Material and method: Preoperative arthroscans and MRI series for 1688 patients with rotator cuff tears were reviewed. We searched for correlations between fatty infiltration of the supraspinatus muscle and gender, age at imaging, size of the tear, onset (trauma or not), and time from symptom onset to imaging. Fatty infiltration was noted according to the Goutallier classification and on the MRI using the classification adapted by Fuchs. For the statistical analysis, fatty infiltration was considered minor for grades 0 and 1, moderate for grade 2 and severe for grades 3 and 4. Muscle atrophy was assessed using the tangent sign.

Results: Fatty infiltration of the supraspinatus increased significantly with the size of the tendon tear (p< 0.0005), time from symptom onset to imaging (lp< 0.0005) and patient age (p< 0.0005). Atrophy increased with number of torn tendons, positive tangent sign was correlated with the grade of fatty infiltration of the supraspinatus (p< 0.0005) and the infraspinatus (p< 0.0005). Moderate and severe fatty infiltration developed a mean 3 and 5 years, respectively, after symptom onset.

Discussion: Surgical treatment should be undertaken before the appearance of moderate (grade 2) fatty infiltration and atrophy (positive tangent sign).

Conclusion: Moderate fatty infiltration of the supraspinatus develops on average three years after onset of symptoms.