RELIABILITY OF THE GOUTALLIER CLASSIFICATION SYSTEM IN THE EVALUATION OF THE MULTIFIDUS MUSCLE

ABSTRACT Introduction: The paravertebral musculature is essential for the biomechanics and stability of the spine, and its involvement in the pathophysiology of spinal diseases has been demonstrated. Qualitative evaluation of muscle degeneration is usually performed by analyzing the fat infiltration rate proposed by the Goutallier classification system. Objective: The objective of this study is to analyze the intra- and interobserver agreement of the Goutallier Classification for the evaluation of fatty degeneration of the multifidus muscle, using magnetic resonance imaging exams. Methods: The study included 68 patients, all diagnosed with symptomatic disc hernia and indicated for surgery. Preoperative magnetic resonance images were used for the analyses. The images were initially evaluated by two orthopedists and two medical students, and then re-evaluated after two weeks. Intra- and inter-observer reliability analysis was performed using the Fleiss Kappa test and the Landis and Koch criteria. All the analyses were performed using the R statistical environment (R Development Core Team, version 3.3.1, 2016) and the significance level was set at 5%. Results: The percentages of intra- and inter-observer agreement were 86.76% and 61.03%, respectively. The intraobserver agreement was near perfect and the interobserver agreement was moderate. Conclusion: The Goutallier Classification System showed moderate interobserver and intraobserver agreement, being a relevant tool for the evaluation of paravertebral musculature fat replacement. Level of evidence II; Prospective study for diagnostic purposes.

Primary versus revision arthroscopic bridging reconstruction using dermal allograft: a clinical and radiographic analysis (243)

Objectives: Large or massive rotator cuff tears make up between 10-40% of all rotator cuff tears, yet there is no agreement on the best treatment. Previous studies have shown that acellular human dermal allograft (AHDA) can be used for bridging reconstruction with positive patient outcomes. The use of this surgical technique has not been extensively studied in the primary or revision surgical setting. The main objective of this study was to compare the clinical and radiographic outcomes of patients who received primary or revision arthroscopic bridging reconstruction. Methods: This study is a retrospective review of a sequential series of patients who underwent arthroscopic bridging reconstruction (ABR) using AHDA by the primary author (IW). A total of 130 patients underwent ABR between 2010 and 2018. The inclusion criteria were patients with completed Western Ontario Rotator Cuff (WORC) questionnaire, Disabilities of the Arm, Shoulder, and Hand (DASH) score, or both pre-operatively and at multiple post-operative timepoints. Patients with missing WORC scores were excluded from the study. Eighty-three patients were included following chart review. Patients with available post-operative MRIs were also used for radiological assessment by an independent MSK-trained radiologist. Post-operative MRIs were reviewed to assess for graft integrity and changes to rotator cuff muscle atrophy (using the Warner classification) and fatty degeneration (using the Goutallier classification). Results: There were 46 patients who received primary ABR and 37 who received revision ABR. Forty-eight patients had a post-operative MRI available for review (Primary: 25; Revision: 23). The demographics are summarized in Table 1. Both groups showed a significant improvement in WORC score post-operatively (p<0.001). Primary ABR resulted in higher post-operative WORC scores as compared to revision ABR (p=0.015; Figure 1). The incidence of complete re-tears in the primary group was 8% and 17.4% in the revision group. More than 35% of patients in the primary group showed improvement in fatty infiltration of the infraspinatus and supraspinatus muscles. There was a higher progression in muscle atrophy in the revision group as compared to the primary group (74% and 30%, respectively). Conclusions: Arthroscopic primary arthroscopic bridging reconstruction for large/massive rotator cuff tears using acellular human dermal allograft had better improvement in their WORC scores compared to revision group at the final follow-up. Although the revision group had improved at the two-year follow-up, these changes in WORC score were not sustained at the final follow-up while the improvements were maintained for the primary group. The primary group had a smaller re-tear rate, better fatty infiltration and muscle atrophy as compared to the revision group. This suggests that primary bridging reconstruction provides better outcomes than a revision surgery.

Clinical, Radiographic, and Genetic Analyses in a Population-Based Cohort of Adult Spinal Deformity in the Older Population

Objective: This study aimed to identify the sagittal parameters associated with health-related quality of life and genetic variations that increase the risk of adult spinal deformity (ASD) onset in the older population.Methods: We recruited 120 participants who had a sagittal vertical axis > 50 mm in a sagittal imbalance study. Sagittal radiographic parameters, cross-sectional area, and intramuscular fatty infiltration using the Goutallier classification in the paraspinal lumbar muscles were evaluated. Functional scales included the self-reported Oswestry Disability Index (ODI), 36-item Short Form Health Survey (SF-36), and visual analogue scales (VAS) for back and leg pain. We performed whole-exome sequencing and an exome-wide association study using the 100 control subjects and 63 individuals with severe phenotypes of sagittal imbalance.Results: Pelvic incidence minus lumbar lordosis (PI–LL) mismatch was negatively associated with the SF-36 and positively correlated with ODI and VAS for back and leg pain. PI–LL was related to the quality and size of the paraspinal muscles, especially the multifidus muscle. We identified common individual variants that reached exome-wide significance using single-variant analysis. The most significant single-nucleotide polymorphism was rs78773460, situated in an exon of the SVIL gene (odds ratio, 9.61; p = 1.15 × 10-9).Conclusion: Older age, higher body mass index, and a more significant PI–LL mismatch were associated with unfavorable results on functional scales. We found a genetic variation in the SVIL gene, which has been associated with the integrity of the cytoskeleton and the development of skeletal muscles, in severe ASD phenotypes. Our results help to elucidate the pathogenesis of ASD.

Assessing Fatty Infiltration of Paraspinal Muscles in Patients With Lumbar Spinal Stenosis: Goutallier Classification and Quantitative MRI Measurements

Objective: Fatty infiltration of paraspinal muscle is associated with spinal disorders. It can be assessed qualitatively (i.e., Goutallier classification) and quantitatively using image processing software. The aims of this study were to compare paraspinal muscle fatty infiltration as assessed using the Goutallier classification vs. quantitative magnetic resonance images (MRI) measurements and to investigate the association between anthropometric parameters and paraspinal muscle morphology and fatty infiltration in patients with symptomatic lumbar spinal stenosis (LSS).Methods: Patients affected by symptomatic LSS scheduled for surgery with available MRI of the lumbar spine were included in this retrospective cross-sectional study. Fatty infiltration at each lumbar level was rated qualitatively according to the Goutallier classification and quantified based on the cross-sectional area (CSA) of the paraspinal muscle, of its lean fraction (LeanCSA), and the ratio between LeanCSA and CSA and the CSA relative to the CSA of vertebral body (RCSA). Considering the muscle as a single unit, overall fatty infiltration according to Goutallier, overall CSA, LeanCSA, LeanCSA/CSA, and RCSA were computed as averages (aGoutallier, aCSA, aLeanCSA, aLeanCSA/aCSA, and aRCSA). Associations among parameters were assessed using Spearman's respective Pearson's correlation coefficients.Results: Eighteen patients, with a mean age of 71.3 years, were included. aGoutallier correlated strongly with aLeanCSA and aLeanCSA/aCSA (R = −0.673 and R = −0.754, both P &lt; 0.001). There was a very strong correlation between values of the left and right sides for CSA (R = 0.956, P &lt; 0.001), LeanCSA (R = 0.900, P &lt; 0.001), and LeanCSA/CSA (R = 0.827, P &lt; 0.001) at all levels. Among all anthropometric measurements, paraspinal muscle CSA correlated the most with height (left: R = 0.737, P &lt; 0.001; right: R = 0.700, P &lt; 0.001), while there was a moderate correlation between vertebral body CSA and paraspinal muscle CSA (left: R = 0.448, P &lt; 0.001; right: R = 0.454, P &lt; 0.001). Paraspinal muscle CSA correlated moderately with body mass index (BMI; left: R = 0.423, P &lt; 0.001; right: R = 0.436, P &lt; 0.001), and there was no significant correlation between aLeanCSA or aLeanCSA/CSA and BMI.Conclusions: The Goutallier classification is a reliable yet efficient tool for assessing fatty infiltration of paraspinal muscles in patients with symptomatic LSS. We suggest taking body height as a reference for normalization in future studies assessing paraspinal muscle atrophy and fatty infiltration.

The Use of the Comma Sign and Tissue for Recognition, Reduction, and Stability During Arthroscopic Repair of Combined Anterosuperior Cuff Tears

Background: The comma sign is a useful marker for combined retracted supraspinatus and subscapularis tears. It was first described by the group of Burkhart as a “composite ligamentous structure” of the rotator interval attached to the retracted subscapularis. However, Neyton and coworkers suggested that the ruptured superior part of subscapularis is pulled upward by supraspinatus retraction. This video illustrates the value of “comma” recognition for reduction and repair stability. We feel that the comma tissue can be a composition of rotator interval ligaments with or without superior subscapularis contribution depending on an associated cleavage tear. Indications: Patients with retracted anterosuperior tears, unless muscle quality is poor (Goutallier classification ≥3). Understanding of the comma tissue is difficult but of crucial importance to assess complex anterosuperior cuff tears for reduction and repair with stability by maintaining and integrating this comma link into the repair construct. Technique Description: Arthroscopic setup includes beach chair position, armholder, cerebral saturation monitoring (target mean arterial blood pressure of about 70 mm Hg). Previously described circumferential portals were used for a repair with a double row construct (4 medial anchors: 2.5 for subscapularis; 1.5 for supraspinatus) and 2 lateral anchors. The superior boarder of subscapularis as well as the retracted capsular layer of supraspinatus was reduced and fixed using a lasso loop technique. Key stages are (1) tendon manipulation with 2 traction sutures; (2) tendon release; (3) comma reduction; (4) footprint preparation (burr, microfracture); (5) retrograde suture passing; (6) knot tying, knotless lateral row; and (7) a close surgeon to physiotherapist rehabilitation link (6 weeks passive to 90°, no resistance training for 3-6 months). Results: Senior author’s (S.B.) series: 32 anterosuperior tears over 4 years (mean age: 62 years, 48-73 years), minimum follow-up 1 year showed good results (mean SSV: 85% [preop. 35%], range: 40%-95%; mean Constant: 82 [preop. 30], range: 40-90). One major complication (cutibacterium infection; brick layer; workers compensation; invalidity demand; Constant/Subjective Shoulder Value both 40) and minor temporary stiffness at 3 months (8 patients; 22%). Conclusion: Adequate reduction and comma integration into a solid repair construct, as well as responsible rehabilitation surveillance, deliver successful results after technically intricate anterosuperior repairs.

Association of Recurrent Tear After Arthroscopic Rotator Cuff Repair and Superoxide-Induced Oxidative Stress

Background: Recurrent tears after arthroscopic rotator cuff repair (ARCR) remain a significant clinical problem. Oxidative stress contributes to the degeneration of the rotator cuff, and a degenerative rotator cuff can lead to recurrent tear after ARCR. However, the correlation between oxidative stress and retear after ARCR is unclear. Purpose: To investigate the correlation between superoxide-induced oxidative stress and recurrent tear after ARCR. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 68 patients who underwent ARCR using a suture-bridge technique participated in this study. Specimens were collected from the edge of the torn tendon during surgery. The modified Bonar score was used to evaluate degeneration of the rotator cuff on histological specimens, and fluorescence intensity on dihydroethidium (DHE) staining was used to detect oxidative stress. Superoxide dismutase (SOD) enzyme activity was also measured. The following were used for clinical evaluation: age, tear size on magnetic resonance imaging (MRI) before surgery, Goutallier classification on MRI before surgery, and Japanese Orthopaedic Association score before and 6 months after surgery. After the repaired rotator cuffs were evaluated on MRI 6 months after surgery, the patients were divided into groups: those with a healed rotator cuff (healed group; n = 46) and those with a recurrent tear (retear group; n = 22). The significant differences between the groups were determined with regard to clinical evaluation, modified Bonar score, DHE intensity, and SOD activity. In addition, multivariate logistic regression analysis was performed to investigate risk factors for recurrent tear. Results: Age, tear size, Goutallier classification, modified Bonar score, DHE intensity, and SOD activity were significantly greater in the retear group than in the healed group, although the Japanese Orthopaedic Association score was not significantly different. Multiple logistic regression analysis demonstrated that age, tear size, and SOD activity were significantly correlated with recurrent tear. Conclusion: In addition to tear size and age, superoxide-induced oxidative stress may be an exacerbating factor for retear after ARCR.

Flexor hallucis longus augmentation for Achilles tendon – is pre-operative evaluation of flexor hallucis longus by MRI required?

Objectives: Flexor hallucis longus (FHL) tendon transfer is the method of choice in reconstructing chronic neglected Achilles tendon rupture. We performed a retrospective study to assess the incidence and degree of fatty degeneration of FHL. Material and Methods: Two hundred and twenty-five consecutive MR of ankles were reviewed retrospectively and assessed for fatty atrophy based on Goutallier classification. Results: About 42.7% had Grade 1, 8.4% had Grade 2, 3.1% had Grade 3, and 1.8% had Grade 4 fatty atrophy of FHL. Other lesions identified included posterior ankle impingement, tenosynovitis, loose bodies, and giant cell tumors of the tendon sheath. Conclusion: We suggest pre-operative radiological assessment of the FHL to establish that the FHL muscle and tendon are normal and intact and suitable for transfer surgery. We also discuss the spectrum of pathologies affecting FHL.

Complete and partial repair of massive rotator cuff tears provide sustainable long term improvement in clinical scores

Objectives: The aim was to report results of arthroscopic repair of 86 massive cuff tears and decided to assess whether or not clinical scores were maintained 5 years later. Methods: Of the initial series of 86 shoulders, 2 patients died, 16 were lost to follow-up and 4 had a repeat surgery. Therefore, it was possible to reevaluate 64 patients. Repairs were complete in 44 cases and partial in 20 cases. Seventeen shoulders were pseudoparalytic. Tears with fatty degeneration at stage 4 or higher according to the Goutallier classification were not eligible for repair. Preoperatively, the Constant Score (CS), shoulder strength, location of the tear, tendon retraction and degree of fatty infiltration were assessed. Patients were assessed at 8.1±0.6 years [7.1-9.3] using absolute and age- and sex-adjusted CS, the subjective shoulder value (SSV) and the simple shoulder test (SST). Results: The absolute CS was 80.0±11.7 at the first follow-up (at 2-5 years) and decreased to 76.7±10.2 at the last follow-up (at 7-10 years) (p<0.001). The adjusted CS was 99.7±15.9 at the first follow-up and remained at 98.8±15.9 at the last follow-up (ns.). In terms of the other criteria, strength decreased over time (p<0.001) but pain, SSV and SST remained the same. Partial repairs had less strength at the first and last follow-up (p<0.05). Pseudoparalytic shoulders had a lower absolute and adjusted CS at the last follow-up (p<0.05) but the improvement in CS was greater (p=0.014). Conclusion: Partial and complete arthroscopic repair provide good long-term results in patients with massive rotator cuff tears, regardless of the location of the tear, the degree of fat infiltration (I to III according to the Goutallier classification) and even in case of a pseudoparalytic shoulder.

The experience with the use of a subacromial balloon in the treatment of patients with large, massive, irreparable rotator cuff tears

Background. Large, massive irreparable rotator cuff tears lead to a significant decrease in the function of the shoulder joint together with the development of a pronounced pain syndrome. Such injuries are difficult to treat, and the number of relapses, when trying to restore them, is quite high. The installation of a subacromial balloon is the method of choice for this group of patients and allows restoring the function of the shoulder joint fairly successfully. Aim: to evaluate the results of the treatment of patients with massive irreparable rotator cuff tears injuries in a prospective study from 2016 to 2018. Methods. The results of the arthroscopic treatment of large, irreparable rotator cuff injuries in 25 patients (with the average age of 67 5 years) with the installation of a subacromial balloon are presented. In all the clinical cases, there was a pronounced (grades 34, according to the Goutallier classification) fatty dystrophy of the rotator cuff muscles (supraspinatus or in combination with subaspinatus). All the patients underwent the subacromial space release with a thorough bursectomy and subsequent installation of a subacromial balloon. Results. The average score on the UCLA scale was 14 3 points (1117) before the operation and 312 points (2933) 12 months after the operation, the results were considered good and excellent. Conclusion. The results obtained allow us to evaluate the described technique as low-traumatic, simple and fast in its accomplishment, aimed at the reduction of the pain syndrome and restoration of the upper extremity function.