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1.  Isolated Arthroscopic Rotator Interval Closure for Shoulder Instability 
Arthroscopy Techniques  2013;3(1):e35-e38.
We present our technique for isolated arthroscopic rotator interval closure in the treatment of mild symptomatic glenohumeral instability in the absence of a labral tear. A careful history, physical examination, and imaging help to identify a select subset of atraumatic instability patients who may benefit from this procedure, and diagnostic arthroscopy can provide further evidence. By use of a posterior viewing portal with anterior and anterolateral working portals, the anterior capsuloligamentous complex is mobilized, and the rotator interval is closed with carefully placed sutures to advance the capsule superiorly and provide tension through decreased capsular volume.
PMCID: PMC3986479  PMID: 24749020
2.  Technique for Margin Convergence in Rotator Cuff Repair 
HSS Journal  2011;7(3):208-212.
The purpose of the present study is to describe the technique of margin convergence for U-shaped rotator cuff tears and report the clinical outcomes and ultrasonography with a minimum of 2 years follow-up. Three hundred eleven patients with a rotator cuff tear were prospectively enrolled in a registry at one institution. Inclusion criteria included any patient undergoing arthroscopic margin convergence for a rotator cuff tear. Exclusion criteria included open or mini-open rotator cuff repairs or suture anchor fixation to the cuff insertion without margin convergence. The outcome measurements included physical examination, manual muscle testing, the American Shoulder and Elbow Surgeons (ASES) score, and ultrasonography. Nineteen patients met the study criteria and 13 were available for 2-year follow-up (68.4%). The mean age of this cohort was 62.2 ± 7.5 years with a mean pre-operative rotator cuff tear size of 4.0 ± 1.6 cm. The ASES score increased significantly from 50.0 ± 17.7 before surgery to 83.3 ± 19.5 at 2 years (P = 0.01). The active forward elevation also improved from 156.2 ± 11.9° before surgery to 168.0 ± 12.1 at 2 years (P = 0.03). The active external rotation 54.4 ± 14.5 at baseline and improved to 57.1 ± 19.1 at 2 years (P = 0.04). The strength also increased significantly from 6.7 ± 6.4 to 10.6 ± 4.9 lb at 1 year (P = 0.048). The post-operative ultrasound demonstrated that 46.2% of rotator cuff tears were healed at 2 years. In conclusion, margin convergence is a useful technique for U-shaped tears that are difficult to mobilize.
PMCID: PMC3192885  PMID: 23024615
margin convergence; rotator cuff; shoulder arthroscopy
3.  Full-thickness supraspinatus tears are associated with more synovial inflammation and tissue degeneration than partial-thickness tears 
The objective of this study was to determine whether the tear size of a supraspinatus tendon correlated with synovial inflammation and tendon degeneration in patients that underwent shoulder arthroscopy for rotator cuff repair. We hypothesized that increased synovial inflammation would correlate with greater tear size of the supraspinatus tendon at the time of surgery.
Materials and Methods
Tissue from the synovium, bursa, torn supraspinatus tendon and subscapularis tendon were obtained from patients during shoulder arthroscopy in order to evaluate the mRNA expression of pro-inflammatory cytokines, tissue remodeling and angiogenesis factors in the tendon, bursa, and synovium. Additional tissue was fixed to determine histological changes including inflammation, vascular ingrowths, and collagen organization.
Increased expression of IL-1β, IL-6, COX-2, MMP-9, and VEGF was found in the synovium of patients with full-thickness tears versus partial-thickness tears (p<0.05). In the supraspinatus tendon, increased expression of MMP-1, -9, and -13 and VEGF was found in the full-thickness group. The upregulation of these genes in the full-thickness group was consistent with enhanced synovium inflammation, greater vascular ingrowth and the loss of collagen organization in both supraspinatus and subscapularis tendons as determined by histology.
Increased synovium inflammation and tissue degeneration correlates with the tear size of the supraspinatus tendon. A better understanding of the relationship between synovial inflammation and the progression of tendon degeneration can help design novel and effective treatments to limit the advance of rotator cuff diseases and to improve their clinical outcomes.
Level of evidence
Basic Science, Molecular and Cell Biology Study
PMCID: PMC3156316  PMID: 21612944
Rotator cuff tear; synovial inflammation; pro-inflammatory cytokines; matrix metalloproteinase
4.  Iliopsoas Impingement: A Newly Identified Cause of Labral Pathology in the Hip 
HSS Journal  2011;7(2):145-150.
Labral tears typically occur anterosuperiorly in association with femoroacetabular impingement or dysplasia. Less commonly, labral pathology may occur in an atypical direct anterior location adjacent to the iliopsoas tendon in the absence of bony abnormalities. We hypothesize that this pattern of injury is related to compression or traction on the anterior capsulo-labral complex by the iliopsoas tendon where it crosses the acetabular rim. In a retrospective review of prospectively collected data, we identified 25 patients that underwent isolated, primary, unilateral iliopsoas release and presented for at least 1 year follow-up (mean 21 months). Pre-operative demographics, clinical presentation, intra-operative findings, and outcome questionnaires were analyzed. The injury was treated with a tenotomy of the iliopsoas tendon at the level of the joint line and either labral debridement or repair. Mean post-operative outcome scores were 87.17, 92.46, and 78.8 for the modified Harris Hip Score, activities of daily living Hip Outcome Score, and sports-related score, respectively. The atypical labral injury identified in this study appears to represent a distinct pathological entity, psoas impingement, with an etiology which has not been previously described.
PMCID: PMC3145856  PMID: 22754415
psoas impingement; hip arthroscopy; labral tears
5.  Traumatic Osteochondral Injury of the Femoral Head Treated by Mosaicplasty: A Report of Two Cases 
HSS Journal  2010;6(2):228-234.
The increased risk of symptomatic progression towards osteoarthritis after chondral damage has led to the development of multiple treatment options for cartilage repair. These procedures have evolved from arthroscopic lavage and debridement, to marrow stimulation techniques, and more recently, to osteochondral autograft and allograft transplants, and autogenous chondrocyte implantation. The success of mosaicplasty procedures in the knee has led to its application to other surfaces, including the talus, tibial plateau, patella, and humeral capitellum. In this report, we present two cases of a chondral defect to the femoral head after a traumatic hip dislocation, treated with an osteochondral autograft (OATS) from the ipsilateral knee, and the inferior femoral head, respectively, combined with a surgical dislocation of the hip. At greater than 1 year and greater than 5 years of follow-up, MRI studies have demonstrated good autograft incorporation with maintenance of articular surface conformity, and both patients clinically continue to have no pain and full active range of motion of their respective hips. In our opinion, treatment of osteochondral defects in the femoral head surface using a surgical dislocation combined with an OATS procedure is a promising approach, as full exposure of the femoral head can be obtained while preserving its vasculature, thus enabling adequate restoration of the articular cartilage surface.
PMCID: PMC2926357  PMID: 21886541
hip dislocation; osteochondral autograft transplant; femoral head; osteochondral defect; osteochondral injury; mosaicplasty
6.  Arthroscopic Anterior and Posterior Labral Repair After Traumatic Hip Dislocation: Case Report and Review of the Literature 
HSS Journal  2010;6(2):223-227.
With the improvements in flexible instrumentation, hip arthroscopy is being increasingly used to treat a variety of hip pathology, including labral tears. However, up to this point, there has not been a case report of an anterior and a posterior labral tear successfully repaired arthroscopically. We present a case report of a 27-year-old male firefighter who presented to our institution with an anterior and posterior labral tear, as well as a cam lesion and loose body, following a traumatic hip dislocation. The purpose of this case report is to illustrate that both anterior and posterior labral tears can be repaired using hip arthroscopy. Anterior and posterior labral tears can be caused by a traumatic hip dislocation, and both can be successfully repaired using arthroscopic techniques.
PMCID: PMC2926365  PMID: 21886540
anterior; posterior; hip; labral tear; traumatic dislocation; arthroscopy repair
7.  One- Versus Two-Incision Technique for Distal Biceps Tendon Repair 
HSS Journal  2008;4(2):117-122.
There are several techniques that have been described for distal biceps tendon repair but there is still controversy regarding the optimal technique. Our hypothesis is that the single-incision technique will have a similar complication rate and functionally equivalent restoration of function compared with the two-incision approach. A retrospective review of consecutive biceps tendon repairs was performed at one institution over a 5-year period. Thirty-six patients met the inclusion criteria and 26 were available for follow-up including subjective assessment, physical examination, and strength testing. Patients were divided into two groups based on the surgical approach utilized: 12 patients underwent single-incision repair and 14 had a two-incision repair. The average follow-up was 33 months (minimum 13; maximum 75). There were no statistically significant differences in regards to flexion strength or endurance, supination strength or endurance, or complication rates between the two techniques. In conclusion, both surgical techniques led to adequate restoration of strength with a low complication rate. Both techniques are safe to perform and should be guided by surgeon comfort with the approach.
PMCID: PMC2553175  PMID: 18815854
8.  Osteoporosis and Skeletal Fractures 
HSS Journal  2006;2(1):62-69.
Osteoporosis affects millions of individuals worldwide, rendering them susceptible to fragility fractures of the spine, hip, and wrist and leading to significant morbidity, mortality, and economic cost. Given the substantial impact of osteoporosis on both patients and the medical community, it is imperative that physicians improve awareness and knowledge of osteoporosis in the setting of low-energy fractures. In this review, we provide information on effective means of preventing fragility fractures and introduce clinicians to issues pertinent to the patient who suffers an osteoporotic fracture. Prevention of fragility fractures centers around adequate mineral nutrition, including daily calcium and vitamin D supplementation, as well as prescription antiresorptive medications such as bisphosphonates or teriparatide therapy in severe cases, both of which have been shown to decrease future fracture risk. Balance and strength training also play important roles in the management of the osteoporotic patient, particularly following a low-energy fracture, and external hip protectors may be useful for certain patients. Kyphoplasty and vertebroplasty are two minimally invasive techniques that show great promise in the treatment of vertebral compression fractures, although questions regarding long-term biomechanical effects still exist. Traditionally, osteoporosis has been underdiagnosed and undertreated following a low-energy fracture in an elderly patient. Although treatment rates may be improving through public health initiatives, the majority of patients with osteoporosis remain inadequately treated. Perioperative intervention programs that focus on patient education about osteoporosis and treatment options lead to significant increases in intervention and treatment. Reducing the risk of skeletal fractures in patients susceptible to osteoporosis involves improved physician education on the risk factors and management of osteoporosis, as well as informing patients on the significance of dual-energy X-ray absorptiometry testing and medical treatment so that they may serve as their own healthcare advocates in this often-undertreated disease.
PMCID: PMC2504115  PMID: 18751849

Results 1-8 (8)