bluuebunny/crossref_metadata_2025 huggingface dataset:
Randomized Prospective Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-reported Outcomes at Long-term Follow-up
Authors: Waterman Brian Robert , Newgren Jonathan , Gowd Anirudh K. , Cabarcas Brandon C. , Bach Bernard R. , Cole Brian J. , Romeo Anthony A. , Verma Nikhil N.
Published: July 2018

Objectives:

To evaluate long-term clinical outcomes after arthroscopic rotator cuff repair with and without acromioplasty.

Methods:

Between 2007-2011, prospectively-enrolled patients undergoing arthroscopic repair for full-thickness rotator cuff tears were previously randomized into either acromioplasty or non-acromioplasty groups. Patients with death, advanced neurologic conditions, or subsequent shoulder arthroplasty were excluded. Baseline and long-term follow-up questionnaires, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (SST), University of California-Los Angeles (UCLA), Visual Analog Scale (VAS) for pain, and Constant scores were obtained. Rates of revision rotator cuff surgery, or secondary reoperation were recorded. Averages with standard deviation (SD) were calculated, and t-tests were utilized to compare outcomes of interest between cohorts.

Results:

After exclusion of 5 additional patients from the short-term follow-up study, 66 of 90 patients (73.3%) were available at 92.4 months (±10.5). Comparison of baseline demographics and intraoperative information revealed no significant differences, including age, gender, workers compensation, acute mechanism of injury, tear size, degree of retraction, and surgical technique (e.g. single- vs. double-row). At final follow-up, there were no statistically significant differences according to ASES (p=0.33), VAS pain (p=0.79), Constant (p=0.17), SST (p=0.05), UCLA (p=0.19), and SF-12 (p=0.79) in patients with and without acromioplasty (Figure 1). One patient with acromioplasty (2.9%) and two patients without acromioplasty (6.3%) sustained atraumatic recurrent rotator cuff tear with secondary repair (p=0.99).

Conclusion:

Combined acromioplasty and rotator cuff repair offer no significant long-term benefits in patient-reported outcomes or secondary surgery when compared to arthroscopic rotator cuff repair alone. [Figure: see text]
Incidence and Clinical Significance of Posterior Glenoid Deficiency in Patients with Posterior Glenohumeral Instability
Authors: Elsenbeck Michael , Wolfe Jared , Nappo Kyle E. , Christensen Daniel , Waltz Robert A. , LeClere Lance E. , Dickens Jonathan F.
Published: July 2018

Objectives:

Posterior glenohumeral instability accounts for 10-40% of instability repairs yet the degree posterior bone deficiency contributing to labral repair failure is unclear. The purpose of this study is to determine the incidence, characteristics, and clinical impact of posterior glenohumeral bone deficiency in patients undergoing posterior shoulder stabilization.

Methods:

All consecutive patients undergoing isolated soft tissue only posterior labral repairs from 2008-2016 at our institution were identified via review of surgical case logs. Posterior bone deficiency was calculated using the best fit circle method along the inferior 2/3 s of the glenoid by two independent observers. The intra-observer and inter-observe reliability ICC of this method was .96 and .86, respectively. Patients were divided into three groups, no bone loss (0-5%), minimal bone loss (5-13.5%) and moderate posterior bone deficit (>13.5%). Our primary outcome, was reoperation for any reason, secondary outcomes were military separation due to the operative shoulder, and placement on permanent restricted duty due to the operative shoulder. Additional comparisons between the groups were made on the basis of preoperative clinical and radiographic characteristics.

Results:

We identified 66 patients that met our inclusion and exclusion criteria. Our median follow up time was 22 months (range 7-144months). 39 of the 66 patients had no measureable bone deficiency while 18 patients had between 5 and 13.5%, and 9 patients had greater than 13.5%. The greatest amount of bone deficiency in a patient was 27%. The reoperation rates were 7.7% in the no bone deficiency group, 16% in the minimal bone deficiency group, and 33% in the moderate group, this difference was statistically significant (p=.036). There was no difference in rates of military separation, or restricted duty between groups. Additionally, patients with posterior glenoid bone deficiency, were more likely to complain of instability instead of pain on initial presentation (p=.002), and were more likely to have a positive posterior load shift test (p=.027).

Conclusion:

Posterior glenoid bone deficiency is common and potentially under recognized in patients undergoing surgery for posterior glenohumeral instability with over one-third of our patients having some degree of bone deficiency. In patients with moderate glenoid bone deficiency (>13.5%), soft tissue only stabilization procedures may have higher reoperation rates then in patients without bone deficiency. On preoperative evaluation the primary complaint of instability instead of pain and a positive posterior load shift were predictive of the presence of posterior glenoid bone deficiency.
Automated 3D MRI Allows for Accurate Evaluation of Glenoid Bone Loss as Compared to 3D CT
Authors: Lansdown Drew A. , Dawe Robert , Cvetanovich Gregory L. , Verma Nikhil N. , Cole Brian J. , Bach Bernard R. , Nicholson Gregory P. , Romeo Anthony A. , Yanke Adam Blair
Published: July 2018

Objectives:

Glenoid bone loss is frequently present in the setting of recurrent shoulder instability. The magnitude of bone loss is an important determinant of the optimal surgical treatment. The current gold-standard for measurement of glenoid bone loss is three-dimensional (3D) reconstruction of a computed tomography (CT) scan. CT scans, however, carry an inherent risk of radiation and increased cost for a second modality. Magnetic resonance imaging (MRI) offers excellent soft tissue contrast and may allow resolution of bony structures to generate 3D reconstructions without a risk of ionizing radiation. We hypothesized that automated 3D MRI reconstruction would offer similar measurements of glenoid bone loss as recorded from a 3D CT scan in a clinical setting.

Methods:

A retrospective review was performed for fourteen patients who had both pre-operative MRI scan and CT scan of the shoulder. All MR scans were performed on a 1.5 T scanner (Siemens) utilizing a Dixon chemical shift separation sequence and the out-of-phase images with 0.90 mm slice thickness. Reconstructions of the glenoid were performed from axial images (Figure 1A) using an open-platform image processing system (3D Slicer; slicer.org). A single point on the glenoid was selected and a standard threshold was used to build a 3D model (Figure 1B). High-resolution CT scans underwent 3D reconstruction in Slicer based on Houndsfield Unit thresholding. Glenoid bone loss on both scans was measured with the Pico method by defining a circle of best fit using the inferior 2/3 of the glenoid and determining the percent area missing from this circle. Pearson’s correlation coefficient was utilized to determine the similarity between MR and CT based measurements. Statistical significance was defined as p<0.05.

Results:

The correlation between 3D MR and CT-based measurements of glenoid bone loss was excellent (r = 0.95, p<0.0001). The mean bone loss as measured by the 3D MR was 13.2 +- 7.2% and was 12.5 +- 8.6% for the 3D CT reconstruction (p=0.32). Bone loss in this cohort ranged from 3.7-25.4% on 3D MR and 1.4-26.0% on 3D CT. The root-mean-square difference between measurements was 2.7%.

Conclusion:

There was excellent agreement between automated 3D MR and 3D CT measurements of glenoid bone loss and minimal differences between these measurements. This reconstruction method requires minimal post-processing, no manual segmentation, and is obtained with widely-available MR sequences. This method has the potential to decrease the utilization for CT scans in determining glenoid bone loss. [Figure: see text]
90-Day Complications Following the Distal Tibia Allograft Procedure
Authors: Frank Rachel M. , Richardson Catherine , Gregory Bonnie , Sumner Shelby , O’Brien Michael C. , Bernardoni Emon , Verma Nikhil N. , Cole Brian J. , Nicholson Gregory P. , Provencher Matthew T. , Romeo Anthony A.
Published: July 2018

Objectives:

To describe complications occurring within 90-days following the distal tibia allograft (DTA) procedure.

Methods:

Consecutive patients undergoing DTA for anterior glenohumeral instability by fellowship-trained surgeons were included for analysis. Indications for DTA included primary or recurrent anterior instability with clinically significant anterior glenoid bone loss, failed prior arthroscopic stabilization, and/or failed prior Latarjet. All complications that occurred within 90-days of surgery were analyzed and correlated with demographic factors.

Results:

A total of 63 consecutive patients (average age 26.4±8.2 years, 90% male) were included. Fifty patients (79%) had undergone prior ipsilateral shoulder surgery, including 8 undergoing prior Latarjet (13%). The average glenoid bone loss prior to DTA was 29±7%. There were 5 total complications within 90 days of surgery, for an overall short-term complication rate of 7.9%. The 58 patients without complications had an average age of 26.2±7.9 years (95% male), with 45 (78%) having had prior shoulder surgery. Three of these 5 required subsequent surgery, including 1 revision DTA for hardware failure, 1 subscapularis repair, and 1 debridement for retained foreign body. The remaining 2 complications were transient and resolved with non-operative treatment, including 1 patient with postoperative pain requiring a subacromial injection, and 1 patient with a stitch abscess treated with oral antibiotics. The 5 patients experiencing complications had an average age of 29.0±11.5 years (40% male), with all 5 (100%) having had prior shoulder surgery. There were no episodes of recurrent instability.

Conclusion:

The overall 90-day complication rate following DTA is 7.9%, substantially lower than the previously described rate of 25% in patients undergoing Latarjet, despite the majority of patients having had at least 1 prior ipsilateral shoulder surgery. This information can be used to counsel patients on the risks of early complications following DTA.
Radiographic Analysis of Glenoid Morphology after Arthroscopic Latarjet vs Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability
Authors: Wong Ivan H. , King JP , Boyd Gordon , Mitchell Michael , Coady Catherine M.
Published: July 2018

Objectives:

The Latarjet procedure for autograft transposition of coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, there is concern for decreased healing and increased resorption using an allograft bone. The purpose of this study was to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of autograft coracoid vs allograft distal tibia.

Methods:

A retrospective review of 50 consecutive patients who had an arthroscopic boney reconstruction of the glenoid (13 coracoid; 37 distal tibial), diagnosed with anterior shoulder instability, and CT confirmed glenoid bone loss >20%. Pre-and post-operative CT scans were reviewed by two fellowship trained musculoskeletal radiologists for: graft position, glenoid concavity, cross sectional area, width, version, total area, osseous union, and graft resorption.

Results:

Graft nonunion was seen in 3 (23.07%) of the coracoid patients, and in 2 (5.4%) of the tibial allograft patients (OR 5.25; 95% CI: 0.768-35.89). Odds ratios comparing allograft to coracoid for overall resorption was 5.00 (CI: 1.276-19.597). Graft resorption greater than 50% was seen in 3 (8.11%) of the allografts and was absent within the coracoid patients. Graft resorption lesser than 50% was greater in both groups with 27 (72.97%) allograft and 6 (46.15%) coracoid patients. However, no statistically significant difference was found between the two procedures regarding AP diameter of graft (p=0.818) or graft cross sectional area (p=0.797).

Conclusion:

Arthroscopic anatomic glenoid reconstruction using distal tibial allograft showed greater boney union but higher resorption compared to coracoid autograft. Even so, there was no statistically significant difference between the two procedures regarding final graft surface area and size of grafts. These short-term results suggest distal tibial allograft as an alternative to coracoid autograft in the recreation of glenoid boney morphology.
Correlation of Patient Reported Outcome Measurement Information System Computer Adaptive Test (PROMIS-CAT) and Knee Injury and Osteoarthritis Outcome Score (KOOS) in Knee Osteotomy and Cartilage Procedures
Authors: Sherman Seth L. , Garrone Andrew James , Voss Elliott E.
Published: July 2018

Objectives:

PROMIS-CAT is a novel and efficient method for obtaining patient reported outcomes. Since its inception in 2007, PROMIS has been validated for several body joints, but correlations between PROMIS and orthopaedic legacy measures (i.e., KOOS) have not been evaluated for many knee procedures. The purpose of this study was to determine whether the PROMIS-CAT tool demonstrates correlation with KOOS for patients undergoing either osteotomy or cartilage procedures of the knee.

Methods:

After obtaining IRB approval, patients were identified who had undergone elective osteotomy (Tibial Tubercle Osteotomy [TTO], High Tibial Osteotomy [HTO], Distal Femoral Osteotomy [DFO]) and/or cartilage restoration (microfracture, DeNovo NT, Osteochondral Allograft Implantation [OCA], Autologous Chondrocyte Implantation [ACI], and meniscal transplant) procedures performed by a single surgeon. Eligible patients completed a series of outcome questionnaires including same day PROMIS-CAT for pain, mobility, physical function and KOOS domains for daily living, pain and sports and recreation. The scores were collected prospectively. Statistical analysis was performed using Spearman’s rank correlations.

Results:

A total of 212 data points (97 osteotomy, 53 cartilage, 62 combined) were identified to be used in the statistical analysis. Spearman’s rank correlations of all patient scores collected between PROMIS Pain and KOOS Pain (for Pain), PROMIS Mobility and KOOS Daily Living (for Mobility and Living), and PROMIS Physical Function and KOOS Sports and Recreation (for Activity) produced rho values of -0.841, 0.816 and 0.715, respectively. Among osteotomy only patients, Pain scores, Mobility and Living scores and Activity scores correlated with a rho value of -0.828, 0.776, and 0.701, respectively. In patients undergoing cartilage procedures who did not have an osteotomy procedure performed, Pain scores, Mobility and Living scores and Activity scores correlated with a rho value of -0.784, 0.860, and 0.651, respectively. Patients undergoing both osteotomy and cartilage procedures had Pain scores, Mobility and Living scores and Activity scores correlate with rho values of -0.826, 0.830, and 0.732, respectively.

Conclusion:

The PROMIS-CAT tool was found to correlate well with KOOS domains for patients undergoing osteotomy and/or cartilage procedures of the knee. PROMIS-CAT can be considered as an efficient and reliable method of collecting patient outcomes in this patient population. Advantages include reduced collection time and less of a ceiling effect than legacy outcome scores.
Demonstrating the Value of an ACL Registry
Authors: Maletis Gregory B. , Funahashi Tadashi Ted , Love Rebecca , Wyatt Ronald , Prentice Heather A. , Burfeind William , Paxton Liz
Published: July 2018

Objectives:

One purpose of a registry is to identify procedures or devices that have either good or poor outcomes and improve treatment outcomes through feedback to surgeons. In 2010 we initially reported the influence of graft choice on the risk of early revision after ACL Reconstruction (ACLR). In 2012 we reported a three times higher risk of revision if allograft was used rather than bone-patellar tendon-bone (BPTB) autograft. In subsequent studies of allografts, we have identified poorer results with BPTB allografts compared to soft tissue allografts and with soft tissue allografts irradiated with > 1.8 Mrads or processed with chemical methods. Patients < 21 years of age were also identified to be at particularly high-risk for revision if allograft tissue was employed. These registry findings were disseminated to surgeons within and outside our integrated healthcare system. The purpose of this study was to evaluate the impact of registry feedback on surgeon graft type selection.

Methods:

Feedback to surgeons on graft performance was presented through a variety of mechanisms including (1) peer-reviewed publications, (2) internal and external meetings and conferences (3) newsletters of study findings, (4) Risk calculators and (5) confidential individualized reports of surgeon’s outcomes. In addition, surgeon champions set a quality improvement goal to reduce allograft usage overall and specifically to decrease the use of high risk grafts and usage in high-risk patient groups. Allograft usage was monitored on a quarterly basis to determine if the target was achieved. Annual graft utilization from 2008-2015 is reported here as proportions, for the overall cohort and for high-risk subgroups.

Results:

Our integrated healthcare system’s ACLR registry currently includes over 35,000 patients. Beginning in 2008, the annual proportion of ACLR cases using an allograft increased with a peak of 45% in 2010. Allograft use has decreased in the ensuing years and was 33% in 2015, a decrease of 27%. High-risk graft usage decreased from 8% in 2011 to 5% in 2015 which is a 38% decrease. Allograft use in patients < 21 years of age decreased 68% from a high of 28% in 2009 to 9% in 2015. (see Figure)

Conclusion:

Translating registry findings into evidence-based clinical practice is the goal of a registry. In this study, we found that information derived from an ACL Registry and disseminated to the participants can directly influence the use of specific procedures or implants that are associated with poor outcomes. Registries can provide useful information that may ultimately be used to improve patient care.
Prospective Validation of Patient-Reported Outcomes Measurement Information Systems (PROMIS) CAT Scores in a Hip Preservation Population
Authors: Kollmorgen Robert , Lewis Brian , Mather Richard C. , Olson Steven
Published: July 2018

Objectives:

Current Hip Patient Reported Outcome Scores (PROs) are not universally obtained, centers use different forms to try to interpret treatment outcomes, and are limited by floor and ceiling effects. Legacy scores of Modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT), and Hip Outcomes Score (HOS) are common place and used in the literature. Patient compliance for legacy PROs have been shown to limit proper data collection. PROMIS measures were developed through NIH funding, vetted against a population norm and PROMIS Computer Adaptive Testing (CAT) has been shown in recent literature to compare well with knee and shoulder legacy scores, and are completed in a quicker amount of time. We hypothesize that in a hip preservation population, the CAT PROMIS Profile V2.0 and PROMIS physical function (PF) would show high correlation with legacy scores of (mHHS, iHOT, and HOS).

Methods:

After obtaining IRB approval, power analysis revealed 86 patients were needed to detect a significant difference. 100 patients were prospectively enrolled. Patients were asked to complete the iHOT-12, mHHS, HOS and then complete the CAT PROMIS Profile v 2.0. Inclusion criteria for the current study included all Initial encounter and single follow-up patients that have completed the CAT portion and started the legacy scores before opting out. Exclusion criteria will be any patient with a repeat encounter, patients under the age of 18 or a patient that did not complete the legacy or CAT scores. Repeat encounters were excluded due to statistical analysis assuming independence among observers. Correlation between instruments was defined as excellent (>0.7), excellent-good (0.7-0.61), good (0.6-0.4), and poor (0.3-0.2).

Results:

Demographics of 75 females and 25 males, mean BMI 26.3, and mean age 36.1 (range 18-67). The PROMIS Physical function, Pain Intensity, and Ability to Participate in Social Roles showed excellent correlation with the iHOT-12 (r=0.71 P<0.001), mHHS (r=0.8 P<0.001) and HOS (r=0.82 P<0.001). Patients averaged 21.6 questions to complete all seven arms of the PROMIS Profile. No patient experienced a ceiling effect utilizing the PROMIS Profile CAT.

Conclusion:

The PROMIS Profile allows for an in-depth look at patients’ dysfunction, not asked in current legacy scores. The PROMIS Physical function and Pain Intensity show excellent correlation with iHOT-12, mHHS and HOS. The CAT PROMIS Profile, shows no observed ceiling effect and can be considered to replace current legacy measures in hip preservation.
Arthroscopic SLAP IIb Repair Using Knot-tying Versus Knotless Suture Anchors: Is There a Difference?
Authors: Arner Justin W. , De Groot Joseph , Bradley James P.
Published: July 2018

Objectives:

SLAP IIb surgical outcomes have traditionally been less predictable when compared to other shoulder injuries. Traditional knotted anchors may partially be to blame by abrading the rotator cuff leading to tearing and pain.

Methods:

Seventy-four athletes who underwent arthroscopic SLAP IIb repair with traditional (n=42) and knotless anchors (n=32) at minimum 2-year follow-up were evaluated. Demographic, surgical data, return to play (RTP), KJOC, ASES, stability, ROM, strength, and pain scores were compared.

Results:

Knotless anchors had slightly higher RTP (93.5%, 58.1% same level) vs. traditional (90.2%, 53.7% same level), but was not statistically significant. Knotless anchors were less likely to require revision surgery (9%) compared to traditional anchors (17%), but was not statistically significant. There was no difference in KJOC, ASES, stability, ROM, strength, and pain between the two anchor types (Table 1). Pain was the only variable linked to decreased RTP (p < 0.0001). Younger patients had significantly poorer KJOC (p = 0.02) and ASES scores (p = 0.02) but no difference in RTP. No difference in outcome measures or RTP was found with gender, age, overhead athletes, number of anchors, or sport type (Table 2). Average follow-up was 6.5 years.

Conclusion:

Knotless anchors required less revision surgery, had higher RTP, ASES, and KJOC scores; however, statistical significance was not achieved in this relatively small cohort. Further evaluation, such as case matching and assessment of a larger sample size should be done. Possible other advantages such as tensioning and surgical time may also be important when considering lower profile knotless fixation.
Outcomes After Arthroscopic Management of Subspinous Impingement in Borderline Hip Dysplasia
Authors: Feghhi Daniel , Bharam Srino , Shearin Jonathan
Published: July 2018

Objectives:

Arthroscopic management of femoroacetabular impingement in the setting of borderline hip dysplasia is controversial. There is concern for iatrogenic hip instability with rim-resection in an already structurally compromised acetabulum. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement. The purpose of this study was to report on the outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia.

Methods:

An IRB approved retrospective study of patients with symptomatic hip impingement, borderline dysplasia (LCEA 18-24°) and prominent AIIS who failed conservative management and subsequently underwent arthroscopic subspinous decompression was conducted. Eighteen patients, 19 hips (4 male and 14 female, average age 28) were identified from 2012 to 2015. 3D-CT imaging was used to categorize AIIS morphology into Type 1, 2 or 3 (Hetsroni classification). Alpha angle and femoral version were determined as well. Patient-reported outcome scores (PROs) consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperative (range, 23-61 months).

Results:

There were no postoperative complications or symptoms of instability. Fourteen hips were of Type 2 AIIS morphology and 6 were categorized as type 1. Femoral osteoplasty was performed in 17 hips (average alpha angle 66°). Repeated measures ANOVA revealed a significant improvement in all PROs from preop to latest follow-up; (mHHS 64.7, 93.4, p< .001; HOS-ADL 62.1, 94.6, p< .001; HOS-SSS 26.5, 93.4 p< .001). An ANCOVA revealed patients with type 2 AIIS had a significantly higher post-op mHHS than those with a type 1 morphology; (88.3, 95.6, p< .01).

Conclusion:

Arthroscopic AIIS decompression in patients with co-existing borderline dysplasia and subspinous impingement leads to favorable outcomes without compromising hip stability.
Incidence of Heterotopic Ossification Among NFL Athletes Following Platelet-Rich Plasma (PRP) for Treatment of Core Muscle Injuries (CMI)
Authors: Poor Alexander Edward , Roedl Johannes B. , Zoga Adam C. , Meyers William C.
Published: July 2018

Objectives:

Platelet-rich plasma (PRP) therapy is an increasingly-popular treatment to promote healing in damaged tendons, ligaments, cartilage and muscles. Few studies analyze long-term effects of PRP. The authors have a busy practice treating core muscle injuries (CMI) and, in the last several years, have noticed an unusually high incidence of HO among patients with previous PRP injections for these injuries. The purpose of this study is to investigate PRP and heterotopic ossification in core muscle injuries.

Methods:

NFL players with core muscle injuries treated at a single institution during the 2015 season filled out questionnaires and were included in retrospective analysis. Heterotopic ossification was observed on MRI and intraoperatively and confirmed pathologically.

Results:

Five NFL players had previous PRP injections for core muscle injuries and 4/5 (80%)had HO. These were 2 linebackers and 2 cornerbacks. The fifth, a kicker, had no ossification but extensive fibrosis around the distal rectus abdominis and proximal adductors. These results are similar for all athletes with previous PRP injections treated around the same time period, 87% (13/15). The incidence of HO among all athletes without a previous PRP injection was 2/1088 (0.18%).

Conclusion:

Retrospective analysis may be overestimating the true incidence and we have yet to identify patterns related to the variations in PRP technique. But these preliminary results suggest the need for further research and a cautious approach to using PRP in the treatment of CMI.
Complete Radiographic Healing and Related Factors in Juvenile Osteochondritis Dissecans of the Talus
Authors: Gandhi Jigar S. , Park Kunbo , Talwar Divya , Lawrence John Todd R.
Published: July 2018

Objectives:

Rates of healing following treatment of juvenile osteochondritis dissecans (OCD) of the talus remain scarce. Additionally, there is a paucity of research into the outcomes associated with the treatment of these lesions. The purpose of this study was to evaluate radiographic healing of talar dome OCDs in adolescents.

Methods:

This was a retrospective review of patients ≤18 years of age with talar OCD from a single pediatric institution within a 12-year period. Charts and radiographs were reviewed for demographics and clinical data, lesion’s location and dimensions, and physeal status. The final radiologic healing was evaluated at 1-year follow-up. Complete and incomplete healing groups were compared using multivariable logistic regression models to examine the predictive effects for the independent variables. A nomogram was produced from the study sample to allow predictions to be made in individual patients.

Results:

Ninety-two lesions in 74 patients with mean age of 13.1 years (range 7.1 to 18.0 years) were analyzed. 60.8% of the patients were female. Thirty-three (41.8%) lesions were treated conservatively, and 59 (58.2%) were treated surgically (drilling, debridement, microfracture, bone grafting, or loose body removal). Thirty-nine (42.4%) lesions demonstrated complete healing. Patients with complete healing were younger ( p 0.032) and had lower BMIs ( p 0.006) compared to those with incomplete healing. In a multivariate regression model, the factors that correlated significantly were the age, BMI, Berndt and Harty’s stage at presentation and type of treatment (observation vs. surgical). Location and dimension of the lesion, physeal status (open vs. closed), presenting symptoms, and type of surgical procedure showed no association with likelihood of healing. A nomogram was developed using the independent variables that correlated significantly with the likelihood of complete radiographic healing (Figure 1).

Conclusion:

Complete radiologic healing of juvenile OCDs was more likely in patients with younger age and lower BMI. Although the difference in outcome between various surgical treatment types was not statistically significant, initial management with surgery was more likely to result in a complete healing compared to observation alone. To our knowledge, this is the first time a nomogram predicting outcome in terms of complete radiographic healing has been developed for juvenile OCD lesions of the talus. Besides its potential role in treatment decision making process, this nomogram can be used to counsel patients and their families with regard to the prognosis for healing. [Figure: see text]
Long-term Follow Up of Arthroscopically Repaired Meniscal Tears in a Pediatric Population
Authors: Hagmeijer Michella , Kennedy Nicholas I. , Tagliero Adam J. , Stuart Michael J. , Dahm Diane L. , Krych Aaron John
Published: July 2018

Background:

Meniscal repair is desirable over resection to prevent post-meniscectomy arthritis, especially in young and active patients. However, long-term data is currently lacking following meniscus repair, particularly in the pediatric population.

Purpose:

To report long-term follow-up of isolated meniscus tears treated by meniscal repair in a pediatric population, and to compare those results to previous mid-term follow-up data reported. We hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up.

Methods:

Patients less than 18 that had a meniscal repair procedure performed between 1990 and 2005 were included. Concomitant ACL reconstructions were excluded from the present study. At the time of final follow-up, recurrent meniscus tear, reoperation rates, and IKDC and Tegner scores were determined. Wilcoxin signed ranks tests were performed to calculate the differences in clinical outcome for the 3 time points (pre-operative, average 7 years post-op, and average 18 years post-op) and Spearman coefficients were calculated for Tegner and IKDC with different variables.

Results:

At an average follow-up of 18 years (range 13.2 - 25.9 years), 34 patients with 35 isolated meniscus repairs (4F: 30 M) with an average age of 16 (9.9 - 18.7) were included in this study. Of the 35 knees (34 patients), none had “failed” or re-injured their affected meniscus since mid-term follow-up in 2008. The average IKDC score was 92.1 which was found to be significantly increased when compared to both preoperative IKDC 64.7 (P<.0001) and mid-term IKDC scores, 89.8 (p=.02). However, the average Tegner score (6.5) was significantly lower than both pre-operative 8.28 (p<.0001) and the mid-term Tegner average 8.25 (p<.0001). Patients with a meniscus re-tear and subsequent partial meniscectomy had lower IKDC scores than clinically successful repairs (88.9 vs 94.0), but this did not reach statistical significance (p=.09). There was no correlation for Tegner or IKDC values with 1) rim width, 2) current age, 3) time elapsed since surgery, or 4) time from injury to surgery. There were also no differences in Tegner or IKDC scores when comparing; medial versus lateral, left versus right, tear types, surgical repair technique, or male vs female.

Conclusion:

This study demonstrates very good clinical long-term outcomes following meniscal repair in a pediatric population.
The Latarjet Procedure for Anterior Shoulder Instability in Pediatric and Adolescent Athletes
Authors: Heyworth Benton E. , Wu Mark , Kramer Dennis E. , Bae Donald S.
Published: July 2018

Objectives:

To investigate surgical outcomes of the Latarjet procedure in the pediatric and adolescent athletic population compared to alternative techniques used to treat anterior shoulder instability with glenoid bone loss.

Methods:

This retrospective comparative cohort study involved a review of 40 patient records with a mean age of 16.7 years (range: 14.3 to 19.2) with anterior shoulder instability and glenoid bone loss (mean: 19%). Demographic and clinical features were recorded pre- and post-operatively, with mean follow up of 26.3 months (sd, 22.8). Advanced imaging and arthroscopic assessment were used to quantify concomitant pathology. Percent glenoid bone loss was calculated using the “glenoid rim distances” method. Glenoid track width and Hill-Sachs interval (HSI) were measured to determine if shoulders were on-track or off-track. Patients were contacted to obtain validated functional outcome questionnaires, including Quick-DASH, ASES, and Marx shoulder activity scale.

Results:

Of the 40 patients, 18 underwent the Latarjet procedure and 22 underwent alternative stabilization procedures. At presentation, both groups were statistically similar with regard to presence of HS (overall 92%), and mechanism of initial dislocation. However, patients who underwent the Latarjet procedure were slightly older at surgery (p=0.045), had longer symptom duration (p=0.015), and had failed more arthroscopic Bankart repair procedures (p=0.002). Additionally, more patients had “off-track” glenohumeral bone loss in the Latarjet group (38%) compared to the control group (9%), (p=0.049). Post-operatively, the Latarjet and control groups had comparable minimal loss of external rotation (47% vs .45%, p=0.768) and high rates of return to sports (94% vs 100%) at a similar time (5.3 vs. 5.4 months, p=1.0). There was a 17% recurrent instability rate in the Latarjet cohort similar to 23% in the control cohort (p=0.709). There were no cases of post-operative nerve palsy or coracoid non-union in those who underwent the Latarjet, compared to one non-union following bony Bankart ORIF in the control group. Functional outcome scores were similarly high across both groups (Table 1).

Conclusion:

Despite being a technically challenging, salvage-type, open reconstructive shoulder procedure, the Latarjet procedure yielded low complication rates and comparably good outcomes in an adolescent cohort with more risk factors for recurrence than a control group of adolescents undergoing other procedures. For young, athletic patients with multiple instability recurrences, previous surgeries, long symptom duration, and glenohumeral bone loss—including severe, ‘off track’ variations—the Latarjet procedure provides a high rate of return to sports, good/excellent functional outcome scores, and low rates of recurrent instability and complications.
A Cam Shaped Femur Might Be A Risk Factor for ACL Injuries
Authors: Pfeiffer Thomas Rudolf , Burnham Jeremy M. , Kanakamedala Ajay C. , Hughes Jonathan Daniel , Irrgang James J. , Debski Richard , Musahl Volker
Published: July 2018

Objectives:

Bony morphologic characteristics have been demonstrated to increase the risk of anterior cruciate ligament (ACL) injury. While posterior femoral condyle condylar offset is an aspect of distal femoral bony morphology that has been reported to influence range of motion and other aspects of knee joint kinematics, it remains unclear whether this characteristic influences the risk of ACL injury. The purpose of the study was to examine the relationship between distal femoral morphology and risks of ACL injury, reconstruction failure, and contralateral ACL injury. It was hypothesized that increased posterior femoral condylar depth, quantified as the cam ratio, would correlate with increased risk of primary ACL injuries, ACL reconstruction failures, and contralateral ACL injuries.

Methods:

Consecutive patients undergoing evaluation for knee complaints at an academic medical center from 2012-2016 with minimum 24-month follow-up were retrospectively reviewed. Subjects were stratified into four groups: a control group consisting of patients with no ACL injuries and three groups of patients with a primary ACL injury, failed ACL reconstruction, or previous ACL injury with subsequent contralateral ACL injury. Using lateral radiographs, the ratio of posterior condylar depth over total condylar distance was defined as the cam ratio. Analysis-of-variance (ANOVA) and post-hoc testing were used to test for differences in the mean tomahawk ratio between study groups (p<0.05). Receiver Operating Characteristic (ROC) analysis was performed to determine the optimal cam ratio cut-off for detecting increased risk for ACL injury.

Results:

One hundred and seventy-five patients met inclusion criteria. The mean cam ratios in the control, primary ACL injury, failed ACL reconstruction, and contralateral ACL injury groups were 61.1% (± 2.1), 64.2% (± 3.8), 64.4% (± 3.6), and 66.9% (± 4.0), respectively. Patients with a primary ACL injury, failed ACL reconstruction, or contralateral ACL injury had a significantly higher cam ratio compared to the control group (p<0.008). ROC analysis demonstrated a cam ratio of 63% or greater to be associated with an increased risk for ACL injury with a sensitivity of83% and a specificity of 71%.

Conclusion:

The data from this study show that an increased posterior femoral condylar depth, or cam ratio, might be associated with increased risk of ACL injury, including primary ACL injury, failed ACL reconstruction, and contralateral ACL injury. The data from this study may help clinicians identify patients at greater risk of ACL injury and re-injury. Future prospective studies will be helpful in investigating the mechanism by which an increased cam ratio increases ACL injury risk and potential strategies to mitigate the increased risk posed by this bony characteristic.
Patient-Specific Parameters Associated with Traction Stiffness in Primary and Revision Hip Arthroscopy
Authors: Kapron Ashley L. , Karns Michael , Aoki Stephen Kenji , Adeyemi Temitope F. , Baillargeon Elizabeth A. , Hartley Melissa K. , Todd Jocelyn N. , Maak Travis
Published: July 2018

Objectives:

To quantify the force of traction required for adequate distraction of the hip during arthroscopy and explore the relationship between hip joint stiffness and patient-specific demographics, flexibility, and anatomy.

Methods:

101 primary arthroscopy patients (61 females) and 23 patients undergoing revision arthroscopy for capsular repair (all female) were prospectively enrolled. A load cell attached to the traction boot continuously measured traction force. Fluoroscopy images were obtained before and after traction to measure joint displacement. The stiffness coefficient was calculated as the force of traction divided by joint displacement. Primary patients were analyzed in a univariable regression model and re-analyzed separately by gender. Variables significant at p<0.05 were included in a multivariable regression model. Stiffness was compared between female primary and revision patients using independent t-tests.

Results:

For primary arthroscopy, instantaneous peak force averaged 80 ± 18 kgf, after which the force required to maintain distraction decreased to 57 ± 13 kgf. In univariable regression analysis, gender, alpha angle, hamstring flexibility and Beighton hypermobility score were each correlated to stiffness. However, gender was the only significant variable in the multivariable regression model. Intragender analysis demonstrated increased hamstring flexibility correlated with decreased stiffness in males and higher Beighton scores correlated with decreased stiffness in females. Stiffness was significantly less in the revision cases than the primary cases (p=0.006).

Conclusion:

A substantial force is required to achieve and maintain hip distraction, with males requiring higher forces. Males with increased hamstring flexibility and females with higher Beighton scores are less stiff than their same gender counterparts. Patients indicated for revision capsule repair were less stiff, supporting the importance of the hip capsule on hip stability. These data may be used to identify patients with microinstability and patients where specific focus on capsular repair and/or plication may be warranted.
Surgical Repair of Distal Triceps Tendon Injuries: Short-Term Clinical Outcomes and Re-Rupture Rate
Authors: Waterman Brian Robert , Dean Robert , Veera Shreya S. , Cole Brian J. , Romeo Anthony A. , Wysocki Robert , Cohen Mark S. , Fernandez John , Verma Nikhil N.
Published: July 2018

Objectives:

The purpose of this study is to describe the clinical, functional, and patient-reported outcomes of distal triceps tendon repairs, as well as to describe perioperative risk profile and re-rupture rates among those with or without pre-existing enthesopathy.

Methods:

Patients who underwent surgical repair of traumatic triceps tendon injuries between 2008 and 2016 were identified from the surgical database at a single institution. The electronic medical records were queried to determine demographic information, time from injury, mechanism of injury, extent of tear, pre-existing enthesopathy, and postoperative complications. Patients with arthritis, concomitant ligament surgery, and/or secondary rupture following previous elbow surgery were excluded. Follow-up outcome measures included the Mayo Elbow, Disabilities of the Arm, Hand, and Shoulder (QuickDASH), Veterans RAND (VR/SF-12), and Kerlan-Jobe Orthopaedic Clinic (KJOC) scores with a minimum of 1-year follow up.

Results:

A total of 88 patients (83 males, 5 females) with mean age of 47 years (range, 14-74) were identified with distal triceps tendon repairs at an average of 49 days (range, 1 to 3650 days) after injury. Sixty-nine patients (76.1%) returned for follow-up at average 3.99 years post-operatively (SD, 2.51). The most common mechanisms of injury were direct elbow trauma (45.4%), extension/lifting exercises (18.1%), overuse (13.6%), and hyperflexion or hyperextension (14.8%). Twenty patients were identified with pre-existing, symptomatic enthesophytes, and 68 tears were caused by acute injury; A total of 42 and 46 partial tendon tears were identified (Table 1). Bone tunnels were most commonly used (n=42, 47.7%), while direct sutures (n=31, 35.2%) and suture anchors (n=12, 13.6%) were also used. Postoperative complications occurred in 23.9% of patients, but no patients experienced re-rupture at time of final follow-up. Final postoperative patient-reported outcome measures are noted in Table 1. No statistically significant correlation was found between patient age (p=0.750), degree of tear (p=0.870), or surgical technique (p=0.740) and presence of perioperative complications.

Conclusion:

Despite heightened risk of perioperative complications after primary repair of distal triceps tendon injuries, the current series identifies favorable functional outcomes and no cases of re- rupture at short- to mid-term follow-up. Furthermore, age, surgical technique, and extent of tear were not associated with adverse patient outcomes in this investigation. [Table: see text]
Release Location in a Risk Factor for Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers
Authors: Portney Daniel Aaron , Buchler Lucas T. , Lazaroff Jake Michael , Gryzlo Stephen , Saltzman Matthew
Published: July 2018

Objectives:

Medial ulnar collateral ligament reconstruction (UCLR) is a common procedure performed for Major League Baseball (MLB) pitchers. The etiology of UCL injury is complex and not entirely understood. The purpose of this study was to use publically available pitch tracking technology (PITCHf/x) to compare the pre-injury throwing mechanics of MLB pitchers who require UCL reconstructive surgery with those of pitchers who have never undergone UCL reconstruction.

Methods:

Pitch tracking and demographic data on MLB pitchers who had undergone UCL reconstruction between the 2010 and 2017 seasons was gathered. Pitchers were excluded if they did not throw 100 total pitches in each of the three years prior to surgery. Furthermore, only pitch types that a given pitcher utilized more than 25 times in each of the three years prior to surgery were included for individual analysis. Pitch type, release location, and velocity were compared between the UCL reconstructive surgery cohort and a matched-control cohort.

Results:

The average pitch release location for pitchers who required UCL reconstruction was more lateral in the two years immediately preceding surgery than the control cohort (p=0.001 and p=0.023). Furthermore, a time-based comparison between the year immediately preceding surgery and two years prior showed a more lateral release immediately prior to surgery (p=0.036). Pitchers who required UCL reconstruction throw similar rates of fastballs as the control cohort and the average pitch velocity and fastball velocity were similar between the UCL group and the control group. The control pitchers displayed a significant decrease in average pitch velocity (p=0.005) and average fastball velocity (p=0.012) over the period of the study.

Conclusion:

Pitch tracking indicates pitch selection and pitch velocity are similar before that the average release point is more lateral preceding UCL reconstruction as compared to the control cohort suggesting that pitch release location might be an independent risk factor for UCL injury and reconstruction. On the other hand, pitch selection and pitch velocity are similar between these cohorts. Powerful technology including PITCHf/x allows for accurate monitoring of factors such as arm position and could potentially be used to identify pitchers at risk for UCL rupture. [Figure: see text]