bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effect of Glenoid Version and Width on Outcomes of Arthroscopic Posterior Shoulder Stabilization
Authors: Mauro Craig S. , McClincy Michael P. , Bradley James P.
Published: September 2013

Objectives:

Posterior shoulder instability has become more widely recognized and recent studies have demonstrated improved outcomes with arthroscopic treatment. Chondrolabral version has been postulated to be an important contributor to posterior shoulder stability. Further, while glenoid bone loss has been shown to be an important predictor of the outcomes of anterior shoulder stabilizations, the effect of glenoid shape and size is less clear in the setting of posterior instability. We hypothesized that anatomical variations of the glenoid, specifically in its size and version, affect the patient outcomes following arthroscopic posterior shoulder stabilization.

Methods:

Two-hundred athletes were prospectively followed after undergoing an arthroscopic repair of unidirectional posterior instability by a single surgeon. They were followed for a mean of 24 months post-operatively, and outcome measures included the ASES and standardized pain, function, and stability scores. MRI arthrogram measurements of the glenoid were performed on an axial image at the inferior one-third level. They included measurements of labral, chondral, and glenoid bone version and glenoid and labral width. Simple linear regressions were performed to determine relationships between MRI measurements and outcome scores.

Results:

One-hundred eighteen MRI arthrograms were performed at our institution and were available for review. Glenoid bone width and bone version both predicted pre-operative pain and ASES scores, with patients with wider (slope 1.3, p<.05) and more retroverted glenoids (slope.94, p<.05) having better average pre-operative pain and ASES scores than subjects with smaller and more anteverted glenoids. At final post-operative follow-up, no significant differences in outcome scores were detected among subjects with regard to glenoid bone version. However, patients with wider glenoids continued to have better pain and ASES scores (slope 1.0, p<.05). There was no correlation between chondral and labral version and any outcome measure pre-operatively or post-operatively.

Conclusion:

Glenoid anatomy may play an important role in the outcomes of patients undergoing arthroscopic stabilization of posterior capsulolabral injuries. While decreased glenoid retroversion and bony width both portended lower shoulder function pre-operatively, only decreased bony width was predictive of poorer outcomes postoperatively. Patients with posterior shoulder instability and a smaller glenoid width identified on MRI may warrant further investigation of glenoid bone morphology by CT scan. Further investigation of the effect of glenoid, chondral, and labral version and glenoid width on posterior shoulder stability and outcomes following posterior shoulder stabilization is warranted.
The Cost-Effectiveness Of Arthroscopic Bankart Repair Versus Non-Operative Treatment For First-time, Traumatic, Anterior Shoulder Dislocations
Authors: Donegan Ryan Patrick , Davis Garrett , Genuario James , Bell John
Published: September 2013

Objectives:

Prior studies have demonstrated excellent results after acute arthroscopic stabilization of first-time, traumatic, anterior shoulder dislocations in young patients. However, this treatment has not been widely accepted as first line management of this injury. Surgeons may point to the initial direct costs of surgical management as one rationale for conservative management of these injuries. The purpose of this study is to determine whether surgical stabilization of first time traumatic anterior shoulder dislocation represents a cost effective treatment alternative when compared to non-operative treatment with physical therapy.

Methods:

A decision-analytic model was constructed to assess the cost-effectiveness of arthroscopic bankart repair compared with non-operative treatment with physical therapy based on the incremental cost-effectiveness ratio (ICER). A threshold ICER of less than $100,000/quality adjusted life year gained was set to define a cost-effective treatment modality. Health state utilities for treatment outcomes of a recurrently dislocating shoulder and a stable shoulder were collected prospectively by surveying fifty patient volunteers using a time trade-off

Method:

The probabilities of the various treatment outcomes and the costs associated with treatment were derived from the orthopaedic literature and adjusted Medicare reimbursement rates.

Results:

The incremental cost-effectiveness ratio (ICER) for arthroscopic bankart versus non-operative treatment was $43,500. The estimated cost of surgical treatment must increase from approximately $11,000 to over $24,000 for surgery to no longer be cost-effective. The one-year probability of dislocation after bankart repair must increase from approximately 4% to 7%, or the probability of dislocation after non-operative treatment must decrease from 17% to approximately 11% for surgery to no longer be cost-effective

Conclusion:

Using currently available probabilities, estimated costs, and prospectively collected health state utilities, arthroscopic bankart repair represents a cost-effective treatment alternative for first-time, traumatic anterior shoulder dislocations in young patients. These results are robust when the costs, probabilities, and utilities are widely varied. Further studies should focus on identifying patient populations who fall within the threshold values identified in this analysis.
Glenohumeral Passive Range Of Motion And The Correlation To Elbow Injuries In Professional Baseball Pitchers
Authors: Wilk Kevin E. , Macrina Leonard , Fleisig Glenn S. , Aune Kyle , Porterfield Ron , Harker Paul , Andrews James R.
Published: September 2013

Objectives:

The purpose of this study was to determine whether GIRD and/or bilateral difference in total rotational motion (TRM) of the glenohumeral joint (external rotation + internal rotation) correlated with elbow injuries in professional baseball pitchers.

Methods:

This study was conducted over eight competitive seasons (2005-2012). Each year during spring training, the same examiners assessed passive range of motion (PROM) of both the dominant and non-dominant shoulders of professional pitchers using a bubble goniometer. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral joint motion was assessed in supine with the arm at 90 degrees of abduction and in the plane of the scapula for ER and IR. During ER and IR ROM assessment, the scapula was stabilized per methods previously established. Elbow injuries and days missed due to injury were assessed and recorded by the medical staff of the team.

Results:

Significant differences were noted during side-to-side comparisons (p<0.0001) within subjects. Amongst this cohort, there were 50 shoulder injuries in 38 players accounting for a total of 2294 days missed. GIRD did not correlate to elbow injuries (p= 0.5507). Pitchers with a deficit of more than 5 degrees in TRM between shoulders had a 2.3x higher risk of injury (p = 0.0214).

Conclusion:

Based on these results, pitchers with bilateral differences in total rotational motion had a significant impact on the risk of elbow injuries. This information can help guide the clinician during the evaluation and progression of the professional baseball pitcher.
Treatment Of Chronic Lateral Ankle Instability With ATLF And CFL Fibular Advancement: Surgical Technique And Clinical Outcome
Authors: Dwyer Tim , Petrera Massimo , Ogilvie-Harris Darrell
Published: September 2013

Objectives:

To report the 2 to 5 year outcome of ATFL and CFL fibular advancement for the treatment of lateral ligament instability of the ankle.

Methods:

Fifty-five patients presenting with chronic lateral ankle instability who had failed non-operative management (bracing, taping, physiotherapy) underwent a lateral ligament fibular advancement between 2005 and 2008. In each case the ATLF and CFL were released from the fibula and advanced using two double loaded metallic suture anchors (3.5mm). The senior author DJOH) performed all the cases. Patients were allowed to full weight bear in a walking boot for 6 weeks after surgery. Patients were assessed pre-operatively and post-operatively using the Foot and Ankle Outcome Score (FAOS). Data were prospectively collected and retrospectively reviewed by an independent author.

Results:

Six patients (11%) were lost at follow-up, leaving a study group of 49 patients (23 male and 26 female). The mean patient age at the time of surgery was 25 years old (range, 18-37 years old), with a mean duration of symptoms of 1.8 years (range, 6 months - 5 years). The mean follow-up was 42 months (range, 24 - 60 months). Significant improvement was seen in the FAOS score from a mean value of 36 pre-op to 75.4 post-op (p<0.001). Pain subscale improved from 35 to 75 (p<0.001); symptoms from 29 to 77 (p=0.01); function from 45 to 77 (p<0.001); function in sports and recreation from 38 to 70 (p<0.001); foot and ankle related quality of life from 35 to 78 (p<0.001). The failure rate was 6%, with three patients complaining of residual instability secondary to re-tear. Two cases of superficial infections were seen. One patient complained of temporary nerve irritation and numbness.

Conclusion:

This study demonstrates that ATFL and CFL advancement with suture anchor fixation and early, protected weight bearing is an effective procedure for the treatment of chronic lateral ankle instability.
The Demographics And Epidemiology Of Osteochondritis Dissecans Of The Ankle, Elbow, Foot, And Shoulder In Children
Authors: Kessler Jeffrey I. , Nikizad Hooman , Shea Kevin G. , Jacobs John C. , Weiss Jennifer
Published: September 2013

Objectives:

To assess the demographics and epidemiology of osteochondritis dissecans (OCD) of the ankle, elbow, foot, and shoulder in patients age 2-19.

Methods:

A retrospective chart review was done on OCD between 2007 and 2011. Inclusion criteria included OCD of the ankle, elbow, foot, or shoulder, and patients aged 2-19. Exclusion criteria included the co-existence of any other intra-articular lesions. Joint involvement, laterality, and all patient demographics were recorded. The incidence of OCD in 2010 was determined for the ankle, elbow, and foot.

Results:

125 patients with a total of 128 OCD lesions fit the inclusion criteria. 60.2% of lesions were right sided and 39.8% left sided. Males had 53.9% and females 46.1% of all lesions. Lesions of the ankle, elbow, foot, and shoulder represented 66.4%, 31.3%, 0.8%, and 1.6% of all joints, respectively. No OCD lesions were found in the 2-5 year-olds. The incidence of ankle OCD for patients aged 6-19 was 4.7 per 100,000 for all patients, and 3.5, and 6.0 per 100,000 for males and females, respectively. The incidence of elbow OCD was 2.2 per 100,000 for all patients, and 3.8 and 0.6 per 100,000 for males and females, respectively. The incidence of OCD in the foot was 0.15 per 100,000 for all patients. The male/female ratio for elbow OCD was 6.4/1, and 1/1.6 for ankle OCD. In the ankle joint, the vast majority involved the medial talus (71.8%), with most of the rest involving the lateral talus (22.4%). Females had 28.8% of lesions in the lateral talus while males had only 12.1%. Almost all elbow lesions (97.5%) involved the capitellum. In the shoulder, both lesions involved the glenoid, and in the foot, the single lesion involved the metatarsal head.

Conclusion:

In this population-based cohort study of pediatric OCD in nearly 1 million children, males had a greater incidence of OCD and most were right sided. Females had nearly twice the incidence of ankle OCD, while males had over 6 times the incidence of elbow OCD. To our knowledge, this is the largest epidemiologic/demographic study of pediatric OCD of the ankle, elbow, foot, and shoulder reported.
Baseline Neurocognitive Test Results In Non-concussed Athletes: Does Sleep Matter?
Authors: McClure D. Jake , Zuckerman Scott L. , Kutscher Scott J. , Gregory Andrew , Solomon Gary S.
Published: September 2013

Objectives:

When managing sport-related concussions (SRC), sports medicine physicians utilize serial neurocognitive assessments and self-reported symptom inventories when evaluating athlete recovery and safety for returning to play (RTP). Since post-concussive RTP goals include symptom resolution and return to neurocognitive baseline, clinical decisions rest on an understanding of modifiers of baseline performance. Several studies have reported the influence of age, gender and sport on baseline neurocognitive performance, but few have assessed the potential effect of sleep. We hypothesized that: 1) athletes receiving less sleep prior to baseline testing would perform worse on neurocognitive metrics; and 2) decreased sleep would have no association with the quantity of reported symptoms.

Methods:

We retrospectively reviewed 3,704 non-concussed athletes, 2,385 male, 3,321 high school and 383 college-aged, with baseline symptom and neurocognitive scores on Immediate Post-concussion Assessment and Cognitive Testing (ImPACT). Subjects were stratified into three groups based on self-reported sleep duration the night prior to testing; 1) short < 7 hrs, 2) intermediate 7−9 hrs; and 3) long ≥ 9 hrs). Multivariate analysis assessed the influence of categorical sleep duration on the baseline number of reported symptoms and ImPACT performance, with alpha level of 0.05.

Results:

When controlling for age, gender and sport as covariates, the multivariate analysis of covariances showed a significant association between shorter sleep duration and poorer verbal memory scores (p=0.019), visual memory scores (p=0.035), and reaction time scores (p=0.044), but not for visual-motor scores. Significance was found between shorter sleep duration and increased number of reported symptoms (P < 0.0001). Subsequent pairwise comparisons revealed these associations to be most significant when specifically comparing the short and intermediate sleep groups.

Conclusion:

Our results indicate that athletes sleeping less than 7 hours prior to testing perform worse on 3 out of 4 neurocognitive ImPACT scores and endorse more symptoms. Because concussion management and RTP decisions hinge on the comparison to a reliable baseline evaluation, sports medicine physicians should strongly consider amount of sleep prior to neurocognitive testing in the assessment of athletes’ recovery.
SUMMIT Prospective, Randomized, Controlled Trial: Response Rates To Matrix-induced Autologous Chondrocyte Implant (MACI) Versus Microfracture (MFX) By Lesion Characteristics
Authors: Saris Daniel , Price Andrew , Drogset Jon Olav , Podškubka Ales , Tsuchida Anika , Bezuidenhoudt Mauritz , Kili Sven , Levine David W. , Brittberg Mats
Published: September 2013

Objectives:

To compare the response rates of patients treated with the MACI implant with those treated with MFX for the repair of symptomatic articular cartilage defects of the knee, based on lesion characteristics, in the phase 3 SUMMIT (Superiority of Matrix-induced autologous chondrocyte implant versus Microfracture for Treatment of symptomatic articular cartilage defects) trial (sponsored by Sanofi/Genzyme Biosurgery).

Methods::

Patients with ≥1 symptomatic focal articular cartilage defect of the femoral condyles (MFC/LFC) and/or trochlea and baseline Knee Injury and Osteoarthritis Outcome Score (KOOS) pain score ≤55 participated in this prospective, randomized, controlled trial (NCT00719576). The co-primary endpoint was improvement in KOOS pain and function (sports/recreational activities) at 2-year follow up. A patient was considered a responder if they had at least a 10-point improvement over baseline in KOOS pain and function scores. The Cochran-Mantel-Haenszel χ2 (α=0.05) was used to analyze differences in response rates between groups by lesion size (>4 cm2, >5 cm2), lesion location (MFC/LFC/trochlea), and osteochondritis dissecans (OCD) etiology (yes/no).

Results::

Patients (N=144) had a mean age of 33.8 years and 51% were male. The mean lesion size was 4.8 cm2, and most lesions were on the MFC (74%). The KOOS pain and function (sports/recreational activities) co-primary endpoint improvement was clinically and statistically significantly better in patients treated with the MACI implant versus MFX ( P=0.001) at 2-year follow up. Significantly better improvements were also observed for KOOS activities of daily living ( P<0.001), quality of life ( P=0.029) and symptoms ( P<0.001) with the MACI implant compared with MFX. Response rates for the overall and subgroup analyses are shown in the Table. The incidence of adverse events was similar between the treatment groups and no unexpected safety findings were reported. Based on the small patient numbers in the subgroups, further research on response predictors is warranted.

Conclusion::

Clinically and statistically significantly better results in KOOS pain and function co-primary scores were observed with the MACI implant versus MFX for treating cartilage defects of the knee 2 years following surgery. More patients responded with the MACI implant compared with MFX when their lesions were >4 cm2, on the MFC, and not of OCD origin.
Magnetic Resonance Imaging and Clinical Evaluation of Chondral lesions treated with Allografts Juvenile Cells
Authors: Pascual-Garrido Cecilia , Gold Stephanie L. , Snikeris Jaclyn , Burge Alissa , Nguyen Joseph , Potter Hollis G. , Warren Russell F. , Williams Riley J. , Rodeo Scott A.
Published: September 2013

Objectives:

The De Novo NT graft (®)(natural tissue) (Zimmer, Warsaw, IN) is a new technique that consists of a scaffold free allogeneic juvenile cartilage. The purpose of this study is to describe the first cases performed in our institution with De Novo NT (®) assessing both clinical outcomes and magnetic resonance imaging.

Methods:

17 patients with focal patella femoral cartilage lesions treated with De Novo NT (®) were prospectively followed. The mean age at the time of surgery was 30 years. Clinical assessment was performed with the International Knee Documentation Committee (IKDC), KOOS and MARX at baseline and most recent follow up. Magnetic resonance imaging, including T2 relaxation time maps and T1 rho in six patients, was used to evaluate the cartilage repair morphologic characteristics in 12 patients.

Results:

Fifteen patients met the study criteria with a mean follow up of 12 months (±3). The mean defect size was 217±100 mm. In 11 cases the lesion was in the patella, 3 in the trochlea and one in both patella and trochlea. Mean improvement in preoperative to postoperative score was significant for the IKDC objective score 45.8 (±28) to 73.3 (±24) (p=.009), IKDC pain score 49.1 (±20) to 69.8 (±23) (p=.003), KOOS 53.5 (±21) to 75.5 (±15) (p=.001), IKDC subjective 41.3 (±21.7) to 72.7 (±15) (p=.004). MRI demonstrated only two cases (16%) with graft hypertrophy. There was only one case with a detached graft. Mild and moderate subchondral edema was present in 90% (11 patients) of the cases. At the interface between the repaired tissue and the native cartilage, there were only two cases with a fissure of more than 2mm. Very good (66 to 100%) and good (between 33-66%) cartilage fill was present in 54% of the cases. Mild synovial reaction was present in 58% of the cases. From the 6 patients with T2 mapping, all repairs showed significantly different prolongation of quantitative T2 values in both the superficial and deep components of the repair tissue (47.18 for repair vs 28.3 for native (p=0.005) in the deep area and 58.6 for repair vs 37.4 for native in the superficial area (p=0.02). (Figure 1).

Conclusion:

De Novo NT® appears to be an effective treatment for patello-femoral chondral lesions, with significant improvement in the short-term clinical follow up. The MRI indicated implant stability with peripheral integration in most cases. As the implanted cells are allogeneic, synovial reaction is a parameter that should be considered. Only 5 patients had moderate synovial reaction, which did not affect the graft. Quantitative T2 mapping showed stratification of T2 values suggesting maturation to hyaline cartilage.
Are Articular Cartilage Lesions and Meniscus Tears Predictive of IKDC, KOOS, and Marx Activity Level Outcomes after ACL Reconstruction? A 6-Year MOON Cohort Study
Authors: Cox Charles L. , Huston Laura J. , Dunn Warren R. , Parker Richard D. , Wright Rick W. , Kaeding Christopher C. , Marx Robert G. , Amendola Annunziato , McCarty Eric C. , Spindler Kurt P.
Published: September 2013

Objectives:

Identifying risk factors for inferior outcomes after ACL reconstruction (ACLR) is important for prognosis and future treatment. Study goal: analyze a sufficiently large enough cohort to evaluate whether articular cartilage and meniscal variables are predictive of three validated sports outcome instruments. We hypothesized that articular cartilage lesions and meniscus tears/treatment would be predictors of IKDC, KOOS (all 5 subscales), and Marx Activity Level at 6 years after ACLR.

Methods:

From 2002-2004, 1411 ACLR subjects were prospectively enrolled and followed longitudinally with the IKDC, KOOS, and Marx completed at entry, 2 and 6 years. A logistic multivariable model consisted of patient demographics, surgical technique variables, and articular cartilage injuries and meniscus tears/treatment for determining predictors (risk factors) of IKDC, KOOS, and Marx at 6 years.

Results:

We completed a minimum follow-up on 93% (1307/1411) of our cohort at 6 years. Baseline results: 56% male, median age 23 years, 75% with non-contact injury mechanism, articular cartilage pathology (MFC-25%, LFC-20%, MTP-6%, LTP-12%, patella-20%, and trochlear-9%), and meniscal pathology (medial-38%, lateral-46%). Both articular cartilage lesions and meniscal tears significantly predicted 6 year outcomes on IKDC and KOOS (Table 1). Grade 3 or 4 articular cartilage lesions (excluding patella) significantly reduced IKDC and KOOS scores at 6 years. Figure 1 focuses on IKDC and demonstrates worse outcomeswith chondral injuries on the MFC, MTP, and LFC. Likewise, KOOS was negatively affected by cartilage injury. The sole significant predictor of reduced Marx activity was the presence of a grade 4 lesion on the MFC. Lateral meniscus repairs did not correlate with inferior results, but medial meniscus repairs predicted worse IKDC and KOOS scores. Lateral meniscus tears left alone significantly improved prognosis. Small partial meniscectomies (<33%) on medial meniscus fared worse, but conversely, larger excisions on lateral meniscus (>50%) improved prognosis. Analogous to previous studies, other significant predictors of worse outcome scores were lower baseline scores, higher BMI, lower education level, smoking, and revisions.

Conclusion:

Both articular cartilage injury and meniscal tears/treatment at the time of ACLR were significant predictors of both IKDC and KOOS scores at 6 year follow-up. Similarly, having a grade 4 MFC lesion significantly reduced a patient’s Marx activity level score at 6 years.
Joint Space Loss after Arthroscopic Partial Meniscectomy: Data from the Osteoarthritis Initiative
Authors: Rothy Alexander , Cherney Steven , Fening Stephen D. , Duryea Jeffrey , Winalski Carl S. , Jones Morgan H. , Miniaci Anthony
Published: September 2013

Objectives:

Knee osteoarthritis (OA) is a prevalent disease that causes substantial disability and use of medical resources, and knee arthroscopy is frequently performed in patients with OA or at risk of developing OA. While meniscectomy has been associated with progression of OA in multiple studies, none have assessed progression of joint space width (JSW) loss compared to matched controls. The Osteoarthritis Initiative (OAI) provides a unique cohort to enable this evaluation. We hypothesize that JSW significantly decreases in meniscectomy patients versus matched controls within a one-year period, and that joint space loss continues to be more rapid in subsequent years.

Methods:

A prospective cohort study with matching was conducted using records from the OAI public use data sets. The cohort (n=4796) is contains the incidence subcohort (normal radiographs with risk of developing OA) and the progression subcohort (radiographic evidence of OA). Subjects have fixed-flexion radiographs taken at yearly intervals and validated measurements of JSW are performed. Additional details about the OAI and study design are publicly accessible at http://oai.epi-ucsf.org/datarelease/About.asp. 141 meniscectomy knees were identified and 141 controls were randomly selected while matching for subcohort, gender, study site, age, knee side, and year. Paired t-test was used to evaluate change in JSW over the first year in the 141 matched pairs. Repeated measures MANOVA with adjustment for age, gender, race, and BMI was used to assess longitudinal changes in JSW in a subset of 33 matched pairs with 4 years of JSW measurements available.

Results:

Meniscectomy and control groups were balanced with respect to age, gender, race, BMI, and baseline JSW. The JSW decrease overa 1-year period was 0.948 mm in meniscectomy knees and 0.137 mm in controls p<0.0001). Table 1 shows similar results when stratifying by subcohort. In the crude and adjusted analyses of knees with 4 years of follow-up, the rate of JSW loss after the first year was not significantly different between meniscectomy knees and controls as shown in Figure 1.

Conclusion:

Arthroscopic partial meniscectomy is associated with increased loss of JSW during the first year after surgery in knees with OA and knees at risk of developing OA; however, the rate of JSW loss is not accelerated over the next 3 years. Immediate JSW narrowing may occur due to loss of the interposed meniscus, due to morphologic changes such as flattening and extrusion, or due to rapid degeneration of articular cartilage in response to increased tibiofemoral contact stress. Significance among both subcohorts suggests that meniscectomy causes progression of osteoarthritis independent of disease stage. Future investigation of change in cartilage and meniscal volumes on MR imaging may further explain the cause of this joint space loss.
Locked Intramedullary Fixation vs Anatomically Contoured Locked Plating Of Clavicle Shaft Fractures – A Prospective Randomized Controlled Trial
Authors: King Reggie Paul
Published: September 2013

Objectives:

The treatment of displaced clavicle shaft fractures has evolved due to complications experienced by conservatively treated patients. Numerous operative modalities are available with various positive and negative aspects associated with each technique. This prospective randomized controlled trial compares the outcome of patients treated operatively with a novel locked intramedullary device and patients treated by traditional anatomically contoured locked plating.

Methods:

Patients with displaced and shortened clavicle shaft fractures were randomized according to presentation into 2 groups - intramedullary fixation and anatomically contoured locked plating. All patients were operated by the same surgeon with similar post-operative regimes for both groups. Outcomes accessed were DASH and Constant Shoulder scores at 6 weeks, 3 months and 6 months, scar size and quality, operative time, union rate and incidence of supraclavicular nerve injury at the time of surgery. Patients were assessed by the operative surgeon, a physiotherapist and an occupational therapist. Progression to union was assessed by a radiologist.

Results:

40 patients with 6 months follow-up were available for review - 20 in each group. No statistically significant difference in average DASH and Constant Shoulder scores at 6 weeks, 3 months and 6 months for the two groups were found. The surgical scars were smaller and the cosmetic result better in the intramedullary group. Operative time was significantly shorter in the intramedullary group. Both groups achieved a 100% union rate at 6 months post-op. The rate of supraclavicular nerve injury in the plating group was higher and most patients complained of prominent hardware.

Conclusion:

Locked intramedullary fixation of clavicle shaft fractures using the Sonoma CrX system was found to be a reliable method of achieving fracture reduction and fracture union. Shoulder function was restored and union achieved with a good cosmetic result. Supraclavicular nerve injury is rare and a second operation to remove prominent hardware is not necessary. Patient outcomes were found to be similar to that achieved by anatomically contoured locked plating - the current accepted gold standard method of treatment.
Trends In The Volume Of Operatively Treated Mid-shaft Clavicle Fractures In Children And Adolescents
Authors: Heyworth Benton E. , Suppan Catherine A. , Kocher Mininder S. , Bae Donald S.
Published: September 2013

Objectives:

Clavicle fractures are common in children and adolescents and are traditionally treated nonoperatively. With youth sports participation increasing in popularity, including contact sports, the frequency of such injuries may be increasing. The purpose of this study was to examine institutional trends in the volume of operative plate fixation for mid-shaft clavicle fractures in children and adolescents.

Methods:

Medical records, identified through a departmental database and cross-referenced for accuracy against billing records using ICD-9 codes, were retrospectively reviewed to identify otherwise healthy 10-18 years-olds who presented with a clavicle shaft fracture between 1999-2011 at a single tertiary-care pediatric hospital. Demographic data, fracture characteristics and treatment details were analyzed. Radiographic review of operative cases was used to confirm fracture location and surgical implant. Annual volumes were determined for the overall number of clavicle fractures, mid-shaft clavicle fractures, and mid-shaft fractures that underwent operative plate fixation. Additionally, the annual rate was determined for the number of operative cases among all mid-shaft fractures. Kendall’s Tau-b was used to assess the relationship between case volume and time.

Results:

From 1999-2011, a total of 882 patients were seen at our institution with a diaphyseal clavicle fracture (mean age: 14.3), 644 (73%) of which were mid-shaft. Of these 644, 111 were treated with operative plate fixation (mean age: 15.9). There was a significant increase in the number of mid-shaft clavicle fractures seen annually over that period, from 20/yr to 85/yr (r=0.80, p<0.0001). The percent of mid-shaft clavicle fractures treated with plate fixation also increased significantly from 5% to 25% (r=0.84, p<0.0001) while the rate of mid-shaft fractures among all diaphyseal fractures remained more stable. Among the mid-shaft fracture cases that received operative plate fixation, 53.2% presented with fractures received during a competitive sporting event.

Conclusion:

The volumes of clavicle fractures and of mid-shaft clavicle fractures treated operatively appear to be increasing. Additionally, despite a lack of evidence based support, the frequency of operative plate fixation of mid-shaft clavicle fractures appear to be increasing in the pediatric population. Many of these fractures are of a sports-based etiology.
Normal Parameters Of Skeletally Immature Knees
Authors: Bathen Mary , Bastrom Tracey P. , Edmonds Eric W.
Published: September 2013

Objectives:

A child’s knee undergoes significant morphologic changes during development. Age-specific normal parameters have not been previously described. The purpose of this study was to delineate the changes that occur with growth utilizing magnetic resonance imaging (MRI).

Methods:

A retrospective review of a radiologic database of MRI knees, ages 4 to 18 years, was undertaken using “normal” diagnosis codes, including: knee pain, plicae, septic arthritis, jumper’s knee, growing pains, benign neoplasm, and osteomyelitis. 19 osseous parameters were measured, plus their cartilaginous counterparts, if different. Spearman’s rho correlations were calculated between age and MRI measures.

Results:

132 MR images were reviewed. Significant correlation with age was observed in all but MPFL insertion on the sagittal view for the osseous measurements (p<0.05). Similarly, the cartilage measures all demonstrated significant correlation with age except MPFL insertion on the sagittal view, but also the Notch-Width index, and trochlear morphology. The magnitude of correlation was significantly different between the osseous and cartilage measures for all but 3 of the variables: osseous and cartilage Insall-Salvati ratios, and insertion of MPFL on the femur. Osseous patella height stabilizes by age 10 with values ranging from 0.9-1.2 until age 18. Cartilage patella height demonstrates a modest linear increase with age (rho=0.352). MPFL insertion on the sagittal view remains stable with age (rho=0.036, p>0.05) and the mean insertion remains below the growth plate (11.5 mm to 4.9 mm). On the coronal view, MPFL insertion modestly increases with age (rho=0.33, p<0.001) starting below the growth plate on average (4.3 mm to 2.6 mm), until age 7 when the mean insertion appears to be at or above the growth plate.

Conclusion:

Most of the studied parameters follow a clear trend of growth and change in size that correlates with maturity. However, the normal Insall-Salvati ratio that delineates patella alta does not appear to be within the normal range until age 10. Furthermore, the discrepancy in the literature concerning the location of the MPFL insertion on the femur in relation to the physis may be attributed to migration of the insertion site during maturation, with the MPFL insertion being below the physis until age 7 when it migrates to insert at or above the physis.
CT And MRI Measurements Of Tibial Tubercle To Trochlear Groove Distances (TT-TG) Are Not Equivalent
Authors: Camp Christopher L. , Bond Jeffrey R. , Collins Mark S. , Stuart Michael J. , Krych Aaron John , Levy Bruce A. , Dahm Diane Lynn
Published: September 2013

Objectives:

TT-TG distance is a commonly used measurement for surgical decision-making in patients with patellofemoral malalignment and instability. This measurement has historically been performed utilizing axial CT scans. More recently, MRI has been proposed as an equivalent test for measurement of TT-TG distance. We sought to determine the reliability of TT-TG measurements on both MRI and CT, and to determine whether the measurements can be used interchangeably.

Methods:

All patients diagnosed with patellar instability who had received both CT and MRI of the knee between 2003 and 2011 were included (n=59 knees in 54 patients). Two fellowship trained musculoskeletal radiologists measured the TT-TG distances for each patient by CT and MRI in a randomized, blinded fashion for a total of 236 measurements. Inter-observer reliability was calculated between radiologists for both imaging modalities and inter-methods reliability was calculated between the two imagining modalities. The results are reported using intraclass correlation coefficients (ICC) and Bland Altman analysis (BAA).

Results:

The 59 knees had a mean TT-TG distance of 16.9 mm (range: 8.3-25.8) by CT and 14.7 mm (range: 1.5-25.1) by MRI. Eighteen patients (31%) had a TT-TG ≥ 20 mm by CT, and only 9 (15%) had a TT-TG ≥ 20 mm by MRI. Inter-observer reliability between the radiologists was considered excellent for both CT and MRI (ICC = 0.777 and 0.843 respectively). When comparing CT to MRI, however, the ICC was considered only fair for each of the two raters (0.532 and 0.539). A total of 11 patients (19%) had a TT-TG ≥ 20 mm on CT preoperatively and underwent distal realignment by tibial tubercle osteotomy (TTO). In this surgical subgroup, the mean TT-TG on CT was 22.5 mm (range 19.8-25.8) while the mean TT-TG on MRI was only 18.7 mm (range 14.4-22.8).

Conclusion:

TT-TG distance can be measured with excellent inter-rater reliability on both MRI and CT scans; however, the values derived from these two tests may not be interchangeable. This observation should be taken into consideration when MRI is used for surgical planning since MRI may underestimate TT-TG distance when compared to CT.
Conflict of Interest in Sports Medicine
Authors: Tjoumakaris Fotios P. , Tucker Bradford S. , Pepe Matthew D. , Hammoud Sommer , Cohen Steven B. , Ciccotti Michael C.
Published: September 2013

Objectives:

The American Academy of Orthopaedic Surgeons (AAOS) and other orthopaedic societies require members who present original research to disclose conflicts so that audiences can make informed decisions when interpreting data. To what degree members use this information when interpreting studies has never been investigated. The purpose of our study was to evaluate how a reported conflict of interest by the primary research team can influence the perceived value of data presented in original research.

Methods:

We devised a hypothetical prospective study (https://www.surveymonkey.com/s/MPCCLCX) and asked orthopaedic surgeons and non operative sports medicine specialists to rate the perceived clinical value of the data that was obtained based upon variations of study design, statistical significance of outcomes between treatment groups, and characteristics of the research setting (academic v. private institution). The research team in question was disclosed to have the following conflict of interest: the project was funded by a pharmaceutical company and that all authors received compensation for consulting services.

Results:

750 sports medicine physicians were sent a survey request to participate in this IRB approved study. 522 responses were obtained for an overall response rate of 70%. 99% of respondents were orthopaedic surgeons. The majority of respondents were from the Northeastern U.S. (32%) and male (96%). Most have been in practice for over 20 years (40%) and were from private practice single specialty groups (58%). 80% of respondents strongly agreed with the statement that conflict disclosure is important when interpreting study results. 62% of respondents reported always reading the disclosure slide during academy or other meeting presentations. 41% of respondents reported always using this information when deciding how to interpret scientific data. Using a case series design with significant positive results at an academic center, 24% reported that the study was likely trustworthy. When the setting of the study was changed to a community hospital, this number decreased to 5%. When no significant difference was found between the groups, 42% believed the study to be trustworthy. When the study design was Level I evidence (RCT trial) and at an academic center, 57% believed the study to be trustworthy. With the same criteria but at a community hospital, this number decreased to 39%. When the results of this design showed no difference among groups, the majority of respondents believed the study to be trustworthy (62%).

Conclusion:

Although the majority of orthopaedic surgeons in our analysis believed that disclosure of conflict of interest is important, less than half used this information when interpreting studies. Changing the study design from a case series to a randomized controlled trial improved the perceived reliability of the data, but was not as important as the reporting of “negative” results.
Complications Following Arthroscopic Knee Surgery
Authors: Salzler Matthew J. , Miller Chealon Dain , Lin Albert , Herold Sara , Irrgang James J. , Harner Christopher D.
Published: September 2013

Objectives:

The purpose of the study was to examine the nature and frequency of complications following the most common arthroscopic knee procedures, with particular attention to fellowship training, geographic location of practice, and age and sex of the patient.

Methods:

Data were obtained from the ABOS database for orthopaedic surgeons who sat for the part II examination from 2003-2009. The database was queried to determine the type and frequency of complications for patients who underwent knee arthroscopy and for those who underwent sports medicine knee arthroscopy including arthroscopic partial meniscectomy, meniscal repair, chondroplasy, microfracture, anterior cruciate ligament reconstruction, or posterior cruciate ligament reconstruction. Factors affecting complication rates that were investigated included type of procedure, fellowship training status, geographic location of practice and age and sex of the patient.

Results:

There were 4435 complications out of 92,565 knee arthroscopic procedures obtained from the ABOS database for an overall candidate-reported complication rate of 4.8%. The complication rate was highest for PCL reconstruction (20.1%) and ACL reconstruction (9.7%). The complication rates for meniscectomy, meniscal repair, and chondroplasty were 2.8%, 7.7%, and 3.5%, respectively. The complication rate for sports fellowship trained candidates was higher than for non-sports trained candidates (5.1%: sports, 4.1%: no sports) and for male patients (4.9% vs. 4.3%). The complication rate was highest for surgeons in the Northwest (4.9%) and lowest in the South (4.2%). Younger patients (60, 3.6%). The overall rate of pulmonary embolus was 0.11%. Surgical complications were more common than medical or anesthetic complications (Table 1), and infection was the most common complication overall (0.84%).

Conclusion:

The overall self-reported complication rate for arthroscopic knee procedures was 4.7%, which may be even higher given that the data are self-reported. PCL and ACL reconstruction had the highest complication rate amongst arthroscopic procedures in this study. The increased risk of complications for sports fellowship trained surgeons may be explained by a higher percentage of complex procedures being performed by fellowship trained surgeons. Knee arthroscopy is not a benign procedure and patients should be aware of the risk of complications. In order to reduce the number of complications, surgeons should be aware of the complexity of the procedure, patient factors, and regional differences in care. Limitations of the study include self-reporting of data, which may underestimate their actual complication rate, and that surgeons in their board collection period are more likely to be earlier in their career, which may overestimate the complication rate for more experienced surgeons.
Complications after Hip Arthroscopy
Authors: Larson Christopher M. , Clohisy John C. , Beaule Paul , Kelly Bryan T. , Giveans Russell , Stone Rebecca M. , Samuelson Kathryn M.
Published: September 2013

Objectives:

There is very little published literature looking at comprehensive complication rates after hip arthroscopy with current techniques and indications.

Methods:

Between 01/2011 and 11/2012, 1,026 consecutive hips (507 males, 519 females) with a mean age of 31.2 years (range 12 - 73) underwent hip arthroscopy at three institutions. The diagnosis, demographic information, and procedures were recorded, and a validated complications grading classification for hip joint surgery (Clavian classification) was utilized for all patients prospectively.

Results:

There were 951 primary hip arthroscopies and 75 revision hip arthroscopies. Arthroscopy was performed for FAI in 936 hips (91.2%), and 760 hips (74.1%) had a labral repair and 229 hips (22.3%) had a labral debridement. The most common event (18.7% of hips) noted was post-operative sensory disturbance adjacent to the portals or involving the distal anterolateral thigh consistent with LFC nerve disturbance. This was typically not noticed by patients and found on physical examination and only persisted beyond 6 months in 7 hips (0.7%). Iatrogenic chondral injury was noted for 20 hips (1.9%), iatrogenic labral puncture in 11 hips (1.1%), superficial portal infection in 6 hips (0.6%), sensory deficit about the foot in 9 hips (0.9%), deep venous thrombosis in 3 hips (0.3%), pulminary embolism in 1 hip (0.1%), pulmonary edema in 1 hip (0.1%), wound hematoma in 2 hips (0.2%), perineal numbness (pudendal nerve) in 9 hips (0.9%), heterotopic ossification in 4 hips (0.4%), reflex sympathetic dystrophy in 1 hip (0.1%) and wound/skin (traction) dehiscence in 1 hips (0.1%). There were no femoral neck fractures, iatrogenic instability, AVN, or extra-abdominal fluid extravasation in this cohort. The overall complication rate not including temporary periportal and thigh numbness (sequalae) was 6.9% (71 hips). Overall 88.7% had a grade 1, 5.6% Grade 2, 4.2% grade 3, and 1.4% grade 4 complication. There was no difference in the rate of complications between males and females (p=.221), primary vs revision cases (p=.159) or labral repair vs debridement (p=.173), and BMI had no effect on complication rate.

Conclusion:

The overall complication rate after hip arthroscopy was 6.9% and higher than previously reported in the literature. This rate of complications is in line with complication rates after open surgical dislocation using the same classification system.
Injury to the Suprascapular Nerve During SLAP repair
Authors: Morgan Ryan , Henn Ralph Frank , Dreese James C.
Published: September 2013

Objectives:

The suprascapular nerve is potentially at risk during superior labrum repair. We compared risk of injury to the suprascapular nerve during suture anchor placement through an anterosuperior versus a rotator interval portal. Our hypothesis was that the rotator interval portal provides a safer and more reproducible method for repair of Type-II SLAP tears.

Methods:

Each pair of ten bilateral fresh human cadaveric shoulders was randomized to suture anchor placement through an anterosuperior portal on one shoulder and a rotator interval portal on the contralateral shoulder. Suture anchors were placed into the glenoid rim (one o’clock, eleven o’clock, and ten o’clock positions for right shoulder; eleven o’clock, one o’clock, and two o’clock for left shoulder). Standard 3 × 14 mm suture anchors were placed, and the suprascapular nerve was carefully dissected. When glenoid perforation occurred, the distance from the suture anchor tip to the suprascapular nerve was measured. The anchors were removed, and the distance from the glenoid rim to the suprascapular nerve and drill hole depth at each suture anchor entry site was recorded.

Results:

All far posterior suture anchors (ten o’clock anchor for right shoulders, two o’clock anchor for left shoulders) perforated the glenoid rim using the anterosuperior or rotator interval portal. For the far posterior anchor, distance from anchor tip to suprascapular nerve averaged 8.02 mm (range, 3.4 to 14 mm) using the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) using the rotator interval portal, a statistically significant difference of 5.92 mm (95% confidence interval [CI]: −7.81 to −4.04; p ≤ 0.001).

Conclusion:

Using an anterosuperior or rotator interval portal results in consistent penetration of one o’clock and two o’clock posterior suture anchors and may place the suprascapular nerve at risk of iatrogenic injury. Based on the high likelihood of glenoid perforation and closer proximity of the suture anchor tip to the suprascapular nerve, the risk of injury is significantly greater with a rotator interval portal for superior labrum anterior and posterior repair.

Clinical Relevance:

It is important to recognize the high rate of glenoid perforation and risk of injury to the suprascapular nerve when placing anchors in the posterior glenoid from either portal.