Background Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive overhead sports and can profoundly affect ability to return to ...play and long-term elbow function. Treatment of large, unstable defects in the elbow with osteochondral autograft plug transfer has not been adequately studied. Methods We retrospectively identified 11 teenaged patients with large (>1 cm2 ) capitellar OCD treated with osteochondral autograft plug transfer. Average age at the time of surgery was 14.5 years (range, 13-17 years). Outcome measures obtained included return to play, preoperative and postoperative elbow range of motion, Disabilities of Arm, Shoulder and Hand (DASH; Institute for Work and Health, Toronto, ON, Canada) by telephone interview, and osseous integration on radiographs. All 11 patients were available for evaluation at an average of 22.7 months (range, 6-49 months) postoperatively. Results All patients were involved in competitive high school athletics and returned to at least their preinjury level of play. Average return to play was 4.4 months (range 3-7 months). The average final DASH was 1.4 (95% confidence interval, 0.6-2.1), and the average final sport-specific DASH was 1.7 (95% confidence interval −1.8 to 5.2). Elbow range of motion significantly improved, including improvement in flexion from a preoperative average of 126° to a postoperative average of 141° ( P = .009) and improvement in extension from a preoperative average of 21° to a postoperative average of 5° ( P = .006). Conclusions Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK
Background Although the risk of venous thromboembolism (VTE) following elective shoulder arthroscopy is low, the large volume of procedures performed each year yields a significant annual burden of ...patients with thromboembolic complications. The purpose of this study was to evaluate the association of high procedural altitude with the incidence of postoperative VTE following arthroscopic rotator cuff repair. Methods A Medicare database was queried for all patients undergoing arthroscopic rotator cuff repair from 2005 to 2012. All patients with procedures performed at an altitude of 4000 feet or higher were grouped into the “high-altitude” study cohort. Patients with procedures performed at an altitude of 100 feet or lower were then matched to patients in the high-altitude cohort on the basis of age, gender, and medical comorbidities. The rate of VTE was then assessed for both the high-altitude and matched low-altitude cohorts within 90 days postoperatively. Results The rates of combined VTE (odds ratio OR, 2.6; P < .0001), pulmonary embolism (OR, 4.3; P < .0001), and lower extremity deep venous thrombosis within 90 days (OR, 2.2; P = .029) were all significantly higher in patients with procedures performed at high altitude compared with matched patients with the same procedures performed at low altitude. Conclusions Procedural altitude >4000 feet is associated with significantly increased rates of postoperative VTE, including deep venous thrombosis and pulmonary embolism, compared with age-, gender-, and comorbidity-matched patients undergoing the same procedures at altitudes <100 feet.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK
Background Outcomes of arthroscopic superior labral anterior-posterior (SLAP) repairs have been well reported with generally favorable outcomes. Unfortunately, a percentage of patients remain ...dissatisfied or suffer further injury after SLAP repair and may seek additional treatment. The purpose of this study was to evaluate the surgical outcomes of biceps tenodesis for failed SLAP repairs. Methods A retrospective review of all patients undergoing biceps tenodesis was completed. Inclusion criteria were previous SLAP repair and subsequent revision biceps tenodesis. Exclusion criteria were additional shoulder procedures including rotator cuff repair, instability procedures, and preoperative frozen shoulder. Objective outcomes were postoperative assessments with Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Veterans RAND 36-Item Health Survey. Physical examination was conducted to determine postoperative range of motion and strength compared with the nonoperative shoulder. Results A cohort of 24 patients was identified, and of these, 17 patients (71%) completed the study at 2 years' follow-up. The average postoperative Constant score was 84.4; American Shoulder and Elbow Surgeons score, 75.5; Single Assessment Numeric Evaluation score, 73.1%; Simple Shoulder Test score, 9.2; and Veterans RAND 36-Item Health Survey score, 76.1. Postoperative range of motion of the operative shoulder returned to near that of the asymptomatic nonoperative shoulder. Workers’ compensation status led to inferior results. Conclusions Options for patients with a failed prior SLAP repair are limited. As a salvage operation for failed SLAP repair, biceps tenodesis serves the majority of patients well, with favorable outcomes by validated measures and excellent shoulder range of motion and elbow strength at 2 years’ follow-up. Workers’ compensation status may predispose patients to poorer outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK
Purpose To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non–skill position collegiate football ...athletes and report minimum 2-year clinical outcomes in this population. Methods For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand ( Quick DASH) outcomes. Results A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average Quick DASH score for the entire cohort was 1 out of 100; Quick DASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non–skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non–skill position players. There was no difference in average Quick DASH overall scores or subgroup scores between cohorts. Conclusions Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non–skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player’s football position. Type of study/level of evidence Therapeutic IV.
Patellar Instability Redziniak, Daniel E., MD; Diduch, David R., MD; Novicoff, Wendy M., PhD ...
Journal of bone and joint surgery. American volume,
2009-September-01, Volume:
91, Issue:
9
Journal Article
Background:
Horizontal meniscal cleavage tears often occur in older individuals and have a degenerative component. Commonly, these are managed with partial meniscectomy. However, this results in ...significantly decreased contact area and increased peek contact forces. Arthroscopic repair has shown comparable results with repairs of other tear types.
Indications:
Cerclage repair is performed for a horizontal cleavage tear in individuals without significant arthritis and in whom partial meniscectomy would remove an unacceptably large portion of meniscal tissue.
Technique Description:
Using standard arthroscopy portals, a self-retrieving suture passing device is used to pass a #0 high-strength suture through the periphery of the meniscus. Arthroscopic knots are tied on the superior surface of the meniscus and pushed as far posteriorly as possible. A small 1-cm incision is made just through skin on the proximal, posteromedial border of the tibia. Through this a spinal needle is placed percutaneously to pass a Chia into the joint just posterior to the knot. A curved spinal needle from an outside-in meniscal repair kit may be used as this provides a better trajectory to tears closer to the root attachment. The Chia and suture limbs are retrieved out the front of the knee, and then the suture tails are shuttled out the back of the knee. This is repeated until the repair is complete. The suture limbs are then cut below skin.
Results:
After arthroscopic all-inside repair of horizontal cleavage tears, patients do well. Outcomes are similar to repairs of other meniscal tear types. In all, 80% of patients are satisfied with their results, and there is an 11% to 12% failure rate which is comparable to other types of tear repairs.
Discussion:
All-inside cerclage repair should be considered for individuals sustaining a horizontal cleavage tear. This preserves meniscal tissue compared to partial meniscectomy and yields good healing rates and outcomes.
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Graphical Abstract
This is a visual representation of the abstract.
Background:
A uniplanar, varus-producing distal femur osteotomy (DFO) may improve patellar tracking by effectively medializing the tibial tubercle, decreasing the Q-angle, and reducing the ...dislocation vector on the patella.
Indications:
A 17-year-old female with 8° of genu valgum presented with 18 months of symptomatic left knee patellar instability episodes that limit her function.
Technique Description:
A lateral subvastus approach to the distal femur was performed. Medial patellofemoral ligament reconstruction (MPFL-R) was conducted up to the point of femoral-sided graft fixation. A lateral opening wedge DFO was made with a sagittal saw and osteotomes, with care taken to maintain the medial cortical hinge. After distraction of the osteotomy site and femoral head allograft wedge placement, the osteotomy was secured with a lateral distal femoral locking plate. Finally, femoral-sided graft fixation for the MPFL-R was completed.
Results:
There were no immediate complications after surgery. Surgical management led to improvement of the patient's patellar instability, which allowed return to the prior baseline level of function.
Discussion/Conclusion:
The senior author's preferred technique for a lateral opening wedge DFO in association with an MPFL-R is presented. A varus-producing DFO is a surgical option for patients with genu valgum and recurrent patellar instability who have failed conservative management. This case demonstrates the efficacy of a lateral opening wedge DFO in improving patellar tracking and improving knee function by resolving recurrent patellar instability episodes.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Graphical Abstract
This is a visual representation of the abstract.
Background:
Recognizing and repairing a lateral meniscus complete radial tear is critical, as this tear pattern makes the meniscus nonfunctional for load sharing of axial forces, and the convex shape ...of the lateral tibial plateau increases contact pressure.
Indications:
The diagnosis of a lateral meniscus complete radial tear was supported by joint effusion, lateral joint line tenderness, positive McMurray test, and magnetic resonance imaging findings. Arthroscopy confirmed the complete radial tear.
Technique Description:
During the procedure, a self-capturing suture passer was used to pass a size 0 high-strength suture through the meniscus. To start the repair, the free ends of the suture were passed from top to bottom on both sides of the tear. These free ends were then crossed on the bottom of the meniscus to create an X configuration and passed from the bottom to top slightly further back from the first suture passes. A spinal needle and a chia were used from outside-in to create a side-to-side suture across the tear to reinforce the repair, and a knot was then tied on the outer capsule. The chia was used once again to shuttle the size 0 sutures to the exterior portion of the knee and the knots were tied on top of the capsule.
Results:
Postoperatively, patients are 25% weightbearing with a 0° to 90° range of motion restriction for 6 weeks, with no deep squatting for 3 months. With an isolated radial tear repair, the patient can expect to return to sport by 5 months. Radial tear repair outcomes demonstrate reduced lateral meniscus extrusion, complete meniscus healing in 86.4% of patients, and significantly improved International Knee Documentation Committee, Lysholm, and Tegner scores.
Discussion/Conclusion:
Repairing a complete radial tear of the lateral meniscus restores the function of the meniscus. This surgical technique provides a high rate of complete meniscus healing and excellent patient satisfaction.
Graphical Abstract
This is a visual representation of the abstract.
Background:
Reinjury rates following anterior cruciate ligament (ACL) reconstruction remain high, and the cause is often multifactorial. There is growing literature supporting asymmetric ...biomechanical deficits leading to increased risk of reinjury. Neuromuscular training during postoperative rehabilitation may mitigate risk of reinjury by addressing these biomechanical deficits.
Indications:
Neuromuscular training is supported in the literature to reduce primary ACL injury risk and modify biomechanical risk factors. Incorporating neuromuscular training into postoperative rehabilitation following ACL reconstruction may reduce the risk of reinjury.
Technique Description:
The Landing Error Scoring System, or LESS test, is an assessment tool utilized to detect biomechanical asymmetries following ACL reconstruction. Video analysis allows for observation of subtle biomechanical differences. Neuromuscular training programs help improve these deficits through stepwise gradual and individualized progressions that are specific to each patient’s needs and desired athletic return.
Results:
A patient who participates in neuromuscular training as a component of postoperative rehabilitation should demonstrate improvements in their individual biomechanical deficits at the completion of the program described.
Discussion/Conclusion:
Biomechanical assessment following ACL reconstruction, such as the LESS test, can identify deficits that may increase risk of reinjury. Neuromuscular training following ACL reconstruction can address these deficits and potentially mitigate risk of reinjury.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
Graphical Abstract
This is a visual representation of the abstract.
Background:
Tibial tubercle osteotomy and distal realignment allows for adjustment to the patellofemoral articulation in order to improve patellar tracking and redistribute patellar contract ...pressures.
Indications:
A healthy, active 39-year-old woman status post right knee tibial tubercle osteotomy presented with >2 years of patellar instability symptoms in the left knee. Imaging revealed a tibial tubercle to trochlear groove (TT-TG) distance of 21 mm and patellar tendon lateral trochlear ridge (PT-LTR) distance of 14 mm.
Technique Description:
After knee arthroscopy is performed, an open incision is made along the inferomedial patellar tendon. Two pilot holes are created before a sagittal saw is used to make the tibial tubercle osteotomy, before completing it with an osteotome. Anteromedialization and/or distalization of the osteotomy is performed relative to templated values in order to improve patellar articulation. After correction, 3 bicortical screws are placed to achieve stable fixation.
Results:
There were no immediate complications following surgery. Surgical management led to improvement of the patient’s patellofemoral pain, which allowed return to prior baseline level of function.
Discussion/Conclusion:
The preferred technique for an anteromedialzing tibial tubercle osteotomy is presented. An anteromedializing tibial tubercle osteotomy is an effective surgical option for patients with evidence of patellar maltracking or central or lateral patellar chondromalacia whom have failed conservative management. This case demonstrates the efficacy of an anteromedializing tibial tubercle osteotomy to provide pain relief by improving patellar tracking and offloading patellar contact pressures on areas of prominent chondral wear.
Graphical Abstract
This is a visual representation of the abstract.
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