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Clinical Relevance: Eight Shoulders and a Knee

2009; Elsevier BV; Volume: 25; Issue: 6 Linguagem: Inglês

10.1016/j.arthro.2009.03.012

1526-3231

James H. Lubowitz, Gary G. Poehling,

Trauma Management and Diagnosis

Historically and since our inception, Arthroscopy, like the articles we have published, has had strengths and limitations. Throughout this history, a strength of the journal as measured by reader surveys has been clinical relevance. In recent years, we have strived to improve the scientific quality of the journal, but above all, we have emphasized that we must maintain our strength because clinically relevant articles, which we define as those containing information so compelling that it might change clinical practice, may have an immediate impact on our patients.1Lubowitz J.H. Poehling G.G. Clinically relevant articles of high levels of evidence are required to change surgical practice.Arthroscopy. 2007; 23: 803Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 2Lubowitz J.H. Poehling G.G. Do basic science articles have clinical relevance?.Arthroscopy. 2008; 24: 249-250Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 3Lubowitz J.H. Poehling G.G. Two on the fast track: Arthroscopic rotator cuff repair and subacromial decompression with coracoacromial ligament excision.Arthroscopy. 2009; 25: 2-3Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar In this issue, we celebrate a high note of clinically relevant shoulder articles. In the past, we suggested that “It's a good time to have a bad shoulder” because there were so many techniques available to treat shoulder problems.4Lubowitz J.H. Poehling G.G. “Good time for a bad shoulder.”.Arthroscopy. 2007; 23: 1006-1011Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar The purpose of this editorial is to highlight eight clinically relevant shoulder articles in the current issue. Yet before we entice the shoulder arthroscopists, we must note that among the other fine articles in this issue is an important and extremely well-prepared knee case report. Eichinger et al., from Tacoma, Washington, and Greeley, Colorado,5Eichinger J.K. Bluman E.M. Sides S.D. Arrington E.D. Surgical management of septic arthritis of the knee with a coexistent popliteal cyst.Arthroscopy. 2009; 25: 696-700Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar report that in cases of the unfortunate but not rare diagnosis of knee joint sepsis, consideration should be given to the possibility of a coexistent popliteal cyst, a condition which also, notably, is not rare. In such cases, knee sepsis may be difficult to eradicate without cyst irrigation and debridement or removal. The point, once made, seems obvious—perhaps classic material for an orthopaedic in-training or Board examination answer—yet to our knowledge, this observation has never before been published. Readers should note the carefully considered treatment algorithm included in the report. And now to preview the clinically relevant shoulder articles: Yoo et al.6Yoo J.C. Ahn J.H. Yang J.H. Koh K.H. Choi S.H. Yoon Y.C. Correlation of arthroscopic repairability of large to massive rotator cuff tears with preoperative magnetic resonance imaging scans.Arthroscopy. 2009; 25: 573-582Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar from Seoul, Korea, describe how MRI predicts the repairability of rotator cuff tears. This sophisticated analysis should aid in preoperative planning for this common arthroscopic procedure. Ko et al.7Ko S.-H. Friedman D. Seo D.-K. Jun H.-M. Warner J.J.P. A prospective therapeutic comparison of simple suture repairs to massive cuff stitch repairs for treatment of small- and medium-sized rotator cuff tears.Arthroscopy. 2009; 25: 583-589Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar of Ulsan, Korea, and Boston, report that massive cuff stitch shows no clinical improvement over simple stitch for small- and medium-size rotator cuff tears. This is in contrast to the findings of a similar study by the same authors, which compared simple and modified mattress locking stitch for supraspinatus repair and showed that simple suture was simply not as good.8Ko S.-H. Warner J.J.P. Friedman D. Park K.-B. Lee C.-C. Arthroscopic single row supraspinatus tendon repair with a modified mattress locking stitch: A prospective randomized controlled comparison to a simple stitch.Arthroscopy. 2008; 24: 1005-1012Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 9Lubowitz J.H. Poehling G.G. Diagnosis, safety, efficacy: Hip and shoulder arthroscopy.Arthroscopy. 2008; 24: 973Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Of interest is that, while Ko et al. report no clinical difference between groups, repair integrity as measured using ultrasound was found to be superior with massive cuff stitch. This calls into question the meaning of ultrasound evaluation of repair integrity; what matters to patients is their clinical outcome, not their ultrasound result. Future, long-term follow-up studies are required to explain the clinical significance of imaging evaluation after rotator cuff repair. Lee et al.10Lee G.H. Busfield B.T. Carrillo M. Ortega R. Kharrazi F.D. The supraspinatus distension sign: An indicator of supraspinatus integrity.Arthroscopy. 2009; 25: 617-619Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar from Los Angeles show that the supraspinatus distention sign indicates arthroscopic evidence of an intact rotator cuff. While preoperative planning using history, physical examination, and imaging studies6Yoo J.C. Ahn J.H. Yang J.H. Koh K.H. Choi S.H. Yoon Y.C. Correlation of arthroscopic repairability of large to massive rotator cuff tears with preoperative magnetic resonance imaging scans.Arthroscopy. 2009; 25: 573-582Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar suggests the diagnosis of rotator cuff tear, arthroscopy is the gold standard for diagnosis, and the supraspinatus distention sign is worthy of consideration. Strauss et al.11Strauss E.J. Frank D. Kubiak E. Kummer F. Rokito A. The effect of the angle of suture anchor insertion on fixation failure at the tendon-suture interface after rotator cuff repair: Deadman's angle revisited.Arthroscopy. 2009; 25: 597-602Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar of New York reconsider the importance of the deadman's angle (≤45°) for arthroscopic rotator cuff repair anchor insertion. We recall the memorable and classic 1995 article by Burkhart highlighting his observations along a South Texas fence line:12Burkhart S. The deadman theory of suture anchors: Observations along a South Texas fence line.Arthroscopy. 1995; 11: 119-123Abstract Full Text PDF PubMed Scopus (209) Google Scholar anchor-bone pull-out strength increases at the deadman's angle. Yet Strauss et al.11Strauss E.J. Frank D. Kubiak E. Kummer F. Rokito A. The effect of the angle of suture anchor insertion on fixation failure at the tendon-suture interface after rotator cuff repair: Deadman's angle revisited.Arthroscopy. 2009; 25: 597-602Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar found that soft tissue–anchor pull-out strength decreases at the deadman's angle. Future research must consider both modes of failure, as well as anchor, soft tissue, and bone variability, and other variables including tear pattern and stitch and suture configuration. In the interim, surgeons should carefully consider both of these studies in preparation for their next arthroscopic rotator cuff repair. Seyahi and Demirhan13Seyahi A. Demirhan M. Arthroscopic removal of intraosseous and intratendinous deposits in calcifying tendinitis of the rotator cuff.Arthroscopy. 2009; 25: 590-596Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar of Istanbul, Turkey, report truly excellent results of arthroscopic treatment of calcific rotator cuff tendonitis. Let us hope we can achieve similar Constant and VAS pain scores in our own patients. Turning to shoulder instability, Rispoli et al.14Rispoli D.M. Athwal G.S. Sperling J.W. Cofield R.H. The macroscopic delineation of the edge of the glenoid labrum: An anatomic evaluation of an open and arthroscopic visual reference.Arthroscopy. 2009; 25: 603-607Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar from Lackland, Texas, and Rochester, Minnesota, performed an arthroscopic and open anatomic analysis and report that reliance on arthroscopic visualization of the glenoid labral edge can result in placement of shoulder anchors on the glenoid articular surface. During shoulder stabilization, the bony edge of the glenoid rim must be properly identified to avoid this potentially harmful complication. Bhatia et al.15Bhatia D.N. DeBeer J.F. van Rooyen K.S. The “subscapularis-sparing” approach: A new mini-open technique to repair a humeral avulsion of the glenohumeral ligament lesion.Arthroscopy. 2009; 25: 686-690Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar of Cape Town, South Africa, describe a subscapularis-sparing approach to humeral avulsion of the glenohumeral ligament. This concise technical note is beautifully illustrated, and should aid surgeons in reducing arthroscopic morbidity during HAGL repair. Finally, Busfield and Romero16Busfield B.T. Romero D.M. Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis.Arthroscopy. 2009; 25: 647-652Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar of Los Angeles review shoulder chondrolysis, a vital topic in our journal.17Chu C.R. Izzo N.J. Papas N.E. Fu F.H. In vitro exposure to 0.5% bupivacaine is cytotoxic to bovine articular chondrocytes.Arthroscopy. 2006; 22: 693-699Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar, 18Gomoll A.H. Kang R.W. Williams J.M. Bach B.R. Cole B.J. Chondrolysis after continuous intra-articular bupivacaine infusion: An experimental model investigating chondrotoxicity in the rabbit shoulder.Arthroscopy. 2006; 22: 813-819Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 19Lubowitz J.H. Poehling G.G. Glenohumeral thermal capsulorrhaphy is not recommended—Shoulder chondrolysis requires additional research.Arthroscopy. 2007; 23: 687Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 20Anz A. Smith M.J. Stoker A. et al.The effect of bupivacaine and morphine in a coculture model of diarthrodial joints.Arthroscopy. 2009; 25: 225-231Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 21Lubowitz J.H. Poehling G.G. Keeping it short: Evidence-based international systematic reviews, rotator cuff, knee posterolateral corner, and bupivacaine chondrocytotoxicity.Arthroscopy. 2007; 23: 687Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar As previously noted, glenohumeral thermal capsulorrhaphy is not recommended. Shoulder chondrolysis requires additional research. In addition, intra-articular pain pumps may result in chondrolysis. Subacromial pain pumps with bupivacaine have yet to be implicated as a cause of glenohumeral chondrolysis. In sum, we preview clinically relevant articles: eight shoulders and a knee. We imagine readers will carefully study these as well as the other excellent articles contained herein. Finally, we continue to aggressively solicit your letters to the editor. We invite controversy as a means to ultimately achieving meaningful consensus.