Friday, July 29, 2011

ORTHOPEDICS TODAY July 2011

Iatrogenic labral punctures did not affect clinical result of hip arthroscopy
Badylak JS. Arthroscopy. 2011;27:761-767.

Iatrogenic labral punctures had no effect on the 1- and 2-year clinical results of hip arthroscopy, according to case-control study results.

John S. Badylak, MD, and James S. Keene, MD, identified 50 patients with iatrogenic labral punctures (ILPs) from a database of 250 hip arthroscopy patients. The senior surgeon performed all of the arthroscopies. The researchers compared the results of these 50 patients with a matched group of 50 patients who did not have an ILP. They evaluated all of the hips with Byrd’s 100-point modified Harris hip score before the operation and at 3, 6, 12 and 24 months postoperatively.

In the ILP group, mean patient age was 40 years; for the comparison group it was 36 years. The average preoperative score was 36 points. Mean joint distraction was 13 mm in the ILP group and 15 mm in the NLP group. The researchers saw a positive Byrd’s sign in both the puncture (84%) and non-puncture (42%) groups.

There were no significant differences between the groups at all follow-up intervals. At 6 months postoperatively, the ILP group averaged 85 points and the comparison group averaged 88 points. At 12 months, the average score was 88 for the ILP and 90 for the comparison group, and at 24 months, it was 88 for the ILP group and 89 for the group.

Perspective

The authors performed a well thought out, well controlled, case-control study. The data presented in this paper is timely given the increased numbers of hip arthroscopic procedures being performed in the United States.

However, it is important to note that almost all of the patients in this study underwent hip arthroscopy with labral debridement/excision of labral tears. Although historically, this has been the treatment of choice for most labral tears, new data in the last several years, particularly by Chris Larson, MD, has shown that arthroscopic labral debridement yields inferior clinical results to arthroscopic labral repair/refixation.

The importance of the labral seal on the femoral head has been delineated and reinforces the need to repair the labrum to the acetabular rim. So, although iatrogenic labral punctures may not affect the clinical outcome at 2 years in the setting of labral debridement, there may in fact be a clinically significant difference when compared in the setting of labral repair or at longer term follow-up with labral debridement. The treating hip arthroscopist should be careful not to generalize the results of this study to the labral repair population.

These iatrogenic labral punctures do occur, but one should give thought to repairing these punctures if they disrupt the labral seal on dynamic examination intraoperatively.

— John E. McDonald Jr., MD
The Steadman Philippon Research Institute
Vail, Colorado

For further information: http://www.orthosupersite.com/view.aspx?rid=84761



Posted on the ORTHOSuperSite July 21, 2011
Study finds arthroscopy, open surgery equally efficacious in treatment of FAI

Researchers at Hospital for Special Surgery have found that arthroscopic treatment offemoroacetabular impingement yields outcomes similar to open surgery in terms of structural repair.

The study was published in the July issue of the American Journal of Sports Medicine.

“For the majority of patients with more typical hip impingement, arthroscopic approaches should be just as effective at adequately restoring the mechanics as the open surgical technique,” study co-author Bryan T. Kelly, MD, stated in a Hospital for Special Surgery press release.

Study methods and findings

Kelly’s team performed surgical treatment on 60 male patients younger than 40 years with symptomatic femoroacetabular impingement. Thirty patients were treated with arthroscopic cam and/or rim osteoplasty in addition to labral debridement and/or refixation. The other 30 patients were treated with open surgical dislocation, as well as cam and/or rim osteoplasty and labral debridement or refixation.

The team took preoperative and postoperative radiographs that measured depth and arc of resection as measured by assessment of the anterior femoral head-neck offset, anteroposterior and lateral alpha angle and beta angle.

Comparing the results, Kelly’s team found the arthroscopic group displayed a mean reduction in extended-neck lateral alpha angle of 28.3% and a mean anteroposterior alpha angle reduction of 16.8%. They also reported an improvement in anterior head-neck offset of 111% and a mean beta angle increase of 23.1°.

The open dislocation group, meanwhile, displayed a mean reduction in extended-neck lateral alpha angle of 30.7%, a mean anteroposterior alpha angle reduction of 25.7%, a 108% improvement in anterior head-neck offset and an 18.35° increase in mean beta angle.

Similar mechanical correction

The results, the authors noted, point toward arthroscopic osteoplasty being capable of restoring head-neck offset and achieving similar depth, arc and proximal-distal resection to those results seen through open surgical dislocation in cases of anterior and anterosuperior cam and focal rim impingement deformity.

“This is the first study in patients to show that we can achieve similar mechanical correction arthroscopically,” Kelly stated in the release.

For further information: http://www.orthosupersite.com/view.aspx?rid=85873


Tuesday, July 26, 2011

From Reuters Health Information

Meniscal Damage Tied to Knee Arthritis After ACL Repair

NEW YORK (Reuters Health) Jul 06 - Meniscal injury is a key factor in the progression of chondral injury among patients undergoing anterior cruciate ligament (ACL) reconstruction, according to a June 6th online report in the American Journal of Sports Medicine.

In fact, the authors suggest that meniscal damage could be more important in the progression of chondral damage and osteoarthritis than the ACL injury itself.

Dr. James R. Borchers of The Ohio State University in Columbus and his colleagues write that patients who undergo ACL reconstruction typically have damage to the meniscal and articular cartilage, but there's little information on how this damage may differ between patients undergoing primary ACL reconstruction and those having revision surgery.

To investigate, they studied data from the Multicenter Orthopedic Outcomes Network (MOON) and the Multicenter ACL Revision Study (MARS) on 508 patients who received primary ACL reconstruction and 281 patients who had revision surgery.

The likelihood of new, untreated medial meniscal tears was the same in both groups, although new untreated lateral meniscal tears were 46% less common in patients undergoing revision surgery.

Severe cartilage damage in the lateral compartment and the patellar-trochlear compartment (Outerbridge grade 3 and 4) was more common with revision surgery, with odds ratios of 1.73 and 1.70, respectively, compared to primary surgery. However, the likelihood of damage in the medial compartment was the same in both groups.

Having had a prior medial meniscectomy on the medial femoral condyle increased the risk of articular cartilage injury in both the primary and revision groups 1.44-fold, while prior meniscectomy on the medial tibial plateau increased articular injury risk 1.63-fold.

Prior lateral meniscectomy also increased risk of severe articular cartilage damage in both groups, 1.65-fold for the lateral femoral condyle and 1.56-fold for the lateral tibial plateau.

When the researchers controlled for meniscal status, they found an increased risk of chondral injury to the lateral and patellofemoral compartments in the patients undergoing revision surgery compared to those having primary surgery. This finding suggests, they say, that chondral damage likely progresses after failed primary ACL reconstruction.

"While our current study cannot identify all risks after primary reconstruction for the progression of chondral damage, it suggests the need to closely examine the early time period after primary ACL reconstruction and the prevention of further chondral damage," Dr. Borchers and his colleagues write.

For further information: http://www.medscape.com/viewarticle/745931?src=mp&spon=8


ORTHOPEDICS July 2011;34(7):267.
Surgical Outcome Following Arthroscopic Fixation of Acromioclavicular Joint Disruption With the TightRope Device
by Eric Thiel, MD; Amar Mutnal, MD; Gregory J. Gilot, MD

Abstract

The objective of this study was to evaluate the preliminary radiographic and clinical results of grade IV and V acromioclavicular joint disruption repair using the arthroscopic Arthrex acromioclavicular TightRope (Naples, Florida) fixation technique. Numerous procedures have been described for surgical management of acromioclavicular joint disruption. The TightRope device involves an arthroscopic technique that allows nonrigid anatomic fixation of the acromioclavicular joint. A cohort of 10 men and 2 women with a mean age of 43 years (range, 25–61 years) underwent the acromioclavicular joint TightRope procedure between April 2007 and October 2009. Eleven patients had either Rockwood grade IV or V disruptions and 1 sustained a distal third clavicle fracture with acromioclavicular joint disruption. Data was collected from a chart review. Patients were evaluated clinically, radiographically, by the simple shoulder test, and by overall satisfaction. There were 2 failures of reduction and 1 loss of reduction at final radiographic follow-up. The rate of fixation failure was 16.6%. All patients had >110° of total elevation. The majority of patients obtained satisfactory functional results according to the Simple Shoulder Test averaging 11 of 12 questions answered positively (range, 7–12; standard deviation, 1.50) and 11 of 12 patients were satisfied with the procedure. At final phone interview at approximately 2 years postoperatively, 6 patients were lost to follow-up. The remaining patients were all satisfied with the procedure and no patients reported subjective loss of reduction or deterioration of function. Simple Shoulder Test average was maintained with 11 of 12 positively answered questions (range, 7–12; standard deviation, 2.0) This case series revealed a high rate of fixation failure with the TightRope system. Still, most patients were satisfied with the procedure and achieved high functional shoulder results.

Drs Thiel, Mutnal, and Gilot are from the Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida.

Drs Thiel, Mutnal, and Gilot have no relevant financial relationships to disclose.

This investigation was performed at the Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, Florida.

Correspondence should be addressed to: Gregory J. Gilot, MD, Department of Orthopedic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL 33331 (gilotg@ccf.org).
Posted Online: July 07, 2011

Acromioclavicular joint disruption is a common injury about the shoulder, representing 40% to 50% of athletic shoulder injuries. 1,2 Sequelae range from an asymptomatic shoulder to one that is painful with significant loss of strength. Management of acromioclavicular joint disruption is dependent on the grade of injury. Williams et al 3 developed the most widely used classification system after modifying the original system described by Tossy et al. 4,5 The literature supports conservative management of Rockwood type I and II acromioclavicular joint disruption and operative management of type IV, V, and VI injuries. 6 The management of type III injuries, however, remains controversial, with authors advocating both operative and nonoperative treatment. 7–10

Over 60 different procedures have been described for the surgical management of acromioclavicular joint disruption. 11,12 The 4 main surgical options include: (1) primary acromioclavicular joint fixation (with pins, screws, sutures, wires, plates, hook plates) with or without ligament repair or reconstruction; (2) primary coracoclavicular internal fixation (with Bosworth screw, wire, fascia, conjoint tendon, or synthetic sutures) with or without incorporation of acromioclavicular ligament repair/reconstruction 13,14 ; (3) excision of the distal clavicle with or without coracoclavicular ligament repair with fascia or suture, or coracoacromial ligament transfer 12,15,16 ; and (4) dynamic muscle transfers with or without excision of the distal clavicle. 17

The modified Weaver-Dunn reconstruction, which consists of both transfer of the coracoacromial ligament and suture augmentation, is the most commonly performed procedure for acromioclavicular disruption. Multiple studies have shown this technique to be an effective option. 11,18–21 Some authors, however, have noted residual subluxation with this procedure. 22,23 Other reconstructions, as well as the native coracoclavicular ligaments, have been shown to have higher biomechanical strength than the modified Weaver-Dunn technique. 24–26

With no 1 technique serving as the gold standard for surgical management of acromioclavicular joint disruption, the treatment of acromioclavicular disruptions continues to evolve. Several novel procedures have been designed to reconstruct the acromioclavicular joint in an anatomic manner. Anatomic reconstructions attempt to reproduce the coracoclavicular ligaments with either allograft or autograft tissue. Studies have reported improved biomechanical strength with this technique, but no clinical studies report improved outcome. 24,27–29 Arthroscopic techniques involve anatomically reconstructing a disrupted acromioclavicular joint by replacing the coracoclavicular ligaments with sutures. Ideally, the patient’s own coracoclavicular ligaments and periosteal sleeve, including the acromioclavicular joint capsule, will subsequently heal when held in a reduced position. 30–35

We describe our experience using an arthroscopically assisted procedure (TightRope; Arthrex, Naples, Florida) (Figures , ) in the surgical management of 12 patients with grade IV or V acromioclavicular joint disruption.

Arthrex TightRope.

Figure 1:. Arthrex TightRope.

Schematic of the positioned TightRope.

Figure 2:. Schematic of the positioned TightRope.

Materials and Methods

Between April 2007 and October 2009, 12 patients with acute acromioclavicular joint disruption were managed surgically by the senior author (G.J.G.) at Cleveland Clinic Florida Hospital. A chart review of patient demographic data, mechanism of injury, surgical technique/complications, postoperative range of motion, and postoperative visual analog pain scale was performed. For the purpose of our study, we defined total elevation as 120° with any motion beyond 120° being secondary to scapulothoracic substitution. 36 The patients were examined at 48 hours and 6 and 12 weeks postoperatively. Patients were evaluated during the follow-up period by physical examination, radiographic evaluation, and telephone interview.

Radiographic data consisting coracoclavicular distance measurements were obtained preoperatively and postoperatively at 6, 12, and 24 weeks and 1 year (Table ). In the radiological evaluation, the coracoclavicular distance was measured as the vertical distance between the superior border of the coracoid to the superior edge of the clavicle on standard anteroposterior radiographs (Figures –). This measurement was the least vulnerable projection errors. 37 The radiographic outcome was defined and classified as (1) maintained reduction (when the postoperative coracoclavicular distance remained constant), (2) loss of reduction (when the final coracoclavicular distance was less than half the difference between the preoperative and immediate postoperative coracoclavicular distance), and (3) failure of reduction (when the final coracoclavicular distance was greater than or equal to half the difference between the preoperative and immediate postoperative coracoclavicular distance).

Patient Demographics

Table 1. Patient Demographics

AP radiograph of a Rockwood IV acromioclavicular joint dislocation.

Figure 1:. AP radiograph of a Rockwood IV acromioclavicular joint dislocation.

Three-month postoperative AP radiograph of the TightRope. Note the calcification in the coracoclavicular interval.

Figure 3:. Three-month postoperative AP radiograph of the TightRope. Note the calcification in the coracoclavicular interval.

At a minimum of 6 months from the date of surgery, a follow-up telephone interview was conducted during which patients were asked to express global satisfaction on the procedure by responding either satisfied or not satisfied and were also asked to complete the Simple Shoulder Test questionnaire. This was repeated at a minimum of 16 months postoperatively. The Simple Shoulder Test is a standardized, 12-question patient self-assessment outcome measure instrument used to determine shoulder function (Table ). It provides a practical method for evaluating success of a treatment in terms of the percent of patients gaining (and losing) each function after treatment was instituted. It is valid, reliable, responsive, and has high positive predictive value. 20,38,39 For our study the pre-surgical Simple Shoulder Test score was not calculated. It has been shown, however, that patients with no prior or current history of shoulder problems were able to physically accomplish the questioned tasks and answered yes to >95% of all questions. 39

Measurements of Coracoclavicular Distance of All 12 cases

Table 2. Measurements of Coracoclavicular Distance of All 12 cases

To facilitate outcome assessment, the data from the Simple Shoulder Test was converted to a scoring scale. This has been described by previous authors when comparing shoulder scoring scales rotator cuff repair evaluation. 39 The 12 questions were weighted equally on a 100-point percentage scale, with 100 points representing the best result or 12 positive answers. Seventeen points (2 questions) are related to the effect that pain has on the patient’s shoulder function. The functional range of motion achieved by the shoulder can be awarded a maximum of 33 points (4 questions). Strength characteristics account for 25 points (3 questions), and complex functional activities for the shoulder account for the final 25 points (3 questions).

Final clinical follow-up involved 10 men and 2 women with a mean age of 43 years (range, 25–61 years), who were included in this study (Table ). These 12 patients were followed radiographically for a minimum of 3 months (average, 5.75 months; range, 3–18 months). Clinical follow-up was for a minimum of 6 months (average, 19.4 months; range, 6–36 months). Final telephone interview was for a minimum of 16 months (average 22.8 months; range, 16–31 months). Of the 12 disruptions, 6 were sustained during a sporting activity, 5 in a motor vehicle accident, and 1 following a fall. Nine of the injuries were on the left side and three were on the right side. According to Rockwood classification, 8 (66.6%) patients had type V lesions and 3 (25%) had type IV lesions. One (8.3%) patient sustained a distal third clavicle fracture with disruption of the acromioclavicular joint.

For our surgical technique, we used both general and regional anesthesia. The patient is placed in the beach-chair position. Arthroscopic access to the shoulder is gained through a standard posterior portal approximately 2 cm inferior and medial from the posterolateral corner of the acromion. A diagnostic examination is then performed paying special attention to the articular cartilage, biceps tendon, biceps anchor, and rotator cuff tendons. An anterolateral working portal just above the subscapularis tendon, in the lateral most aspect of the rotator interval, is established using an outside-in technique. A 3-cm sagittal incision is made over the clavicle approximately 3 cm medial to the acromioclavicular joint. The deltotrapezia fascia is incised in the same direction. With the aid of a small periosteal elevator, the superior surface of the clavicle is cleared of soft tissue.

With the 70° scope in the posterior portal, the subcoracoid space is arthroscopically dissected using a radiofrequency ablation device and/or shaver introduced through the anterolateral portal. The goal is to obtain clear visualization of the undersurface of the coracoid arch through which drill holes will be made. The drill entry points were based upon anatomical parameters reported by Rios et al 40 and Salzmann et al. 41 Fluoroscopy is used for correct placement of drill holes during the procedure. An acromioclavicular drill guide and marking hook (Arthrex) is introduced through the anteroinferior portal under direct vision and placed under the medial part of the coracoid arch near its base while its other end (the drill sleeve) is placed over the desired entry point approximately 4.5 cm from the lateral end of the clavicle. With the drill guide held in this position, and the acromioclavicular marking guide clearly visualized arthroscopically, a 2.4-mm guide pin is drilled through the clavicle and the base of the coracoid. The guide is removed while the pin is maintained in its position through the clavicle and coracoid base. The guide pin is then overdrilled with a 4.0-mm cannulated drill bit transclavicular and transcoracoidal. A nitinol suture passer is inserted into the subcoracoid space through the drill. The nitinol wire is retrieved via the anteroinferior portal. The cannulated drill bit is removed. The TightRope is attached to the nitinol suture passer and advanced through the drill hole from superior to inferior until the metal button is flipped beneath the coracoid arch.

Following the same technique, a second TightRope device is placed 2 cm from the lateral end of the clavicle and adjacent to the lateral part of the coracoid arch near its base. For our first 3 patients, only 1 TightRope device was used. An assistant supports the weight of the ipsilateral arm and the surgeon tightens the TightRope devices on the clavicle, thereby reducing the acromioclavicular disruption anatomically. Reduction is assessed with palpation of the acromioclavicular joint. The TightRope devices are knotted securely once satisfactory reduction is achieved. The final construct consists of 2 TightRope devices spanning the coracoclavicular space anatomically reproducing the coracoclavicular ligaments. The clavicular wound is closed in layers and the portals are closed in standard fashion. Postoperatively, the shoulder is protected in a sling for 6 weeks. During that time, only passive range-of-motion exercises are permitted. Shoulder motion and muscle strengthening exercises are delayed up to 10 to 12 weeks.

All statistical analyses were run on Stata 10.0 (Stata Corporation, College Station, Texas).

Results

Patients treated by the TightRope device obtained satisfactory functional results for the shoulder as assessed by the Simple Shoulder Test (Table ). An average of 11 of 12 questions were answered positively (range, 7–12; standard deviations, 1.5 and 2.0 and first and second phone interviews, respectively). The responses were then converted to a 100 point scale, which had an average score of 95 (standard deviation, 12.61). The question receiving the least positive response was “Does your shoulder allow you to sleep comfortably?” with 82% of the patients answering yes. When responding to global satisfaction of the procedure, 11 patients responded that they were satisfied while one patient was unavailable for follow-up telephone interview. At the second interview, approximately 2 years postoperatively, 100% satisfaction was reported from the 6 of 12 patients available for follow-up, with none reporting any subjective loss of reduction.

Simple Shoulder Test

Table 3. Simple Shoulder Test

At their final office follow-ups, all patients had >110° active forward flexion. With respect to the visual analog pain scale, 8 patients were pain free, 3 patients reported pain of <3/10, and 1 patient reported pain of 8/10 (Table ).

Regarding radiographic assessment of reduction and maintenance of reduction, 2 patients had failure of reduction and 1 patient had loss of reduction (Table ). The 2 patients with failure of reduction both had only one TightRope device placed. Failure of reduction occurred at sometime between the second and 12th postoperative week in both patients. The patient who experienced a loss of reduction had it occur sometime between 6 months and 1 year from surgical date. None of the patients who had a failure or loss of reduction experienced a new injury. They also did not report an acute onset of pain or audible snap. The overall rate of fixation failure was 16.6%.

In 2 patients who had either a failure or loss of reduction, the Simple Shoulder Test score was 100 and final range of motion was 120° of forward flexion. One patient with failure of reduction was not available for follow-up Simple Shoulder Test scoring (Table ).

No postoperative complications related to the procedure were found (Table ). During regular follow-up, we observed no other complications such as osteolysis, cut-through phenomena, fracture non-union, neurovascular injuries, deep infection, or frozen shoulder.

Discussion

The management of acromioclavicular joint disruptions has continued to evolve over the last decade with arthroscopic and tendon-transfer techniques, termed anatomic reconstructions, arising to challenge the standard modified Weaver-Dunn reconstruction. These novel techniques are designed to improve biomechanical strength and to be less invasive. 24,30,35,40,42

Multiple arthroscopic techniques have been described both in the acute and chronic setting. Techniques include: (1) harvesting the native coracoacromial ligament arthroscopically followed by an arthroscopic distal clavicle resection and transfer of the ligament; (2) suture augmentation using bone anchors arthroscopically placed into the base of the coracoid; (3) suture augmentation looped under the coracoid using direct arthroscopic visualization; or, (4) reduction of the clavicle into its anatomic position using the TightRope technique (Arthrex) to recreate the coracoclavicular ligaments. 30,31,33,34

The goal of anatomic reconstruction is to provide a stable and functional construct through reconstruction of the conoid and trapezoid ligaments. 6,18,24,27,29 Biomechanical studies, however, have shown that described anatomic procedures do not restore the strength and stiffness of the native acromioclavicular joint complex. 27,28,43

Walz et al 21 studied the biomechanical properties of the TightRope device. The authors compared cyclic loading and load to failure between native coracoclavicular ligaments and an anatomic reconstruction using 2 TightRope devices in cadavers. The mean vertical force in static load until failure measured 598 N and 982 N for the coracoclavicular ligaments and TightRope model, respectively. The mean anterior force in static load until failure was 338 N in the coracoclavicular ligament model compared to 627 N in the TightRope model. The TightRope model had more repetitions until failure during cyclic loading. The study showed that the TightRope reconstruction technique led to favorable in vitro results with forces greater than or equal to those of the native coracoclavicular ligaments.

Clinical studies on the TightRope device are limited, with only a few case reports and 2 case series available in the literature. 31,44–47 To our knowledge, the largest series to date is by Salzmann et al. 46 In their study, 23 patients with acute acromioclavicular joint disruptions underwent reduction and implantation of 2 TightRope devices. At a mean follow-up of 30 months, significant improvements in the visual analog scale and Constant scores were noted. Postoperative radiographic acromioclavicular joint alignment was unsatisfactory in 8 cases, although the authors noted no difference in clinical outcome compared to the patients who maintained reduction.

In a study by Lim et al, 45 eight patients with an acute acromioclavicular joint injury were managed with implantation of one TightRope device. The patients were followed for a minimum of 6 months. They noted a 50% fixation failure rate, with loss of reduction occurring between the second and sixth postoperative weeks. Retrieved specimens revealed suture abrasion that was postulated to be the mechanism of failure. At final follow-up, 4 of the 8 patients had uneventful recovery with no pain and resumption of full duties.

Despite reportedly having biomechanical properties comparable to the native coracoclavicular ligaments, the TightRope device still had a high fixation failure rate, both in Lim et al’s 45 (50%) and Salzmann et al’s 46 (34%) studies, as well as in our study (16.6%). This is consistent with other available techniques such as the modified-Weaver Dunn, which has been reported to have subluxation or disruption in the chronic setting as high as 30%. 21–23 The 2 failures in our study occurred in patients who had only 1 TightRope device implanted. During the study period, we changed our technique so that 2 TightRope devices were used. We began using 2 TightRope devices because we felt this model was a better anatomic recreation of the coracoclavicular ligaments in accordance with Walz et al’s 21biomechanical study. We also felt that if 1 device should fail then the second device would serve as a back-up to prevent complete fixation failure. The use of only 1 TightRope device may explain the high rate of fixation failure in Lim et al’s 45 study.

The patients in our study reported being satisfied with the procedure and achieved satisfactory functional results of the shoulder, with an average score of 95 on the initial Simple Shoulder Test, including the patients that had failure or loss of reduction. This is consistent with the study findings of other techniques, in which loss of reduction has not been shown to lead to symptoms or reoperation in the majority of patients. 46,48

Despite half of the initial group being unavailable for final telephone interview, the results were consistent with the initial phone interview with 11 of 12 questions answered positively and 6 of 6 patients satisfied with the procedure. The patients available for this final interview were comprised of those who underwent the reconstruction more recently. When asked why they did not return for their last scheduled follow-up, they cited not having any significant problems as the main reason. This response could be extrapolated to the remainder of the initial group. Given that most of the patients from the initial group were local, it could also be assumed that any catastrophic failures would have likely presented to our clinic. Of note, a patient who recently underwent reconstruction who was not in the initial group, reported 12/12 on the Simple Shoulder Test, was satisfied with the procedure at interview 8 months postoperatively and the final radiograph revealing maintenance of reduction.

To date, there is only 1 report in the literature of a complication using the TightRope device for acromioclavicular joint disruptions. The authors reported a clavicle fracture through a drill hole following a repeat trauma 8 months after the index surgery. They suggest removal of the device following healing to prevent a stress riser and potential clavicle fracture. 44 We noted no complication in our study and currently do not advocate removal of the device following healing.

This study has several key limitations, which include the small number of cases, limited clinical and radiographic follow-up, number of patients lost to follow-up at final phone interview, lack of a control group, and possibility of intraobserver error with respect to radiographic measurements.

Conclusion

The proposed advantage of the TightRope device is that it allows for nonrigid anatomic fixation of the acromioclavicular joint, thus maintaining reduction while allowing normal rotation of the clavicle. 45Although clinical studies are limited, our series, as well as those of Lim et al 45 and Salzman et al, 46revealed a high rate of fixation failure with the TightRope system. Despite the high failure rate, the majority of patients in our study reported being satisfied with the procedure and achieved high functional results of the shoulder.

Based on the biomechanical study by Walz et al, 21 we recommend that 2 TightRope devices be implanted. We believe that using 2 devices more closely replicate the function of the native coracoclavicular ligaments. There is a question regarding the long-term stability of the implant. Do the coracoclavicular ligaments, periosteum, and acromioclavicular joint capsule reconstitute themselves with reduction of the clavicle alone? Several of our patients showed evidence of increased radiodensity at the coracoclavicular interval on postoperative films (Figure ). In addition, other authors have noted tissue complexes around the TightRope device at the time of second-look arthroscopy. 21 Additionally, we believe this study warrants further investigation into this method of acromioclavicular joint reconstruction. Adequately powered, multicenter, prospective, randomized, controlled studies with long-term follow-up are needed to better determine the efficacy and role of the TightRope device in the management of acute acromioclavicular joint disruptions.

For further information: http://www.orthosupersite.com/view.aspx?rid=85241
Posted on the ORTHOSuperSite July 14, 2011
Patients with full range of motion after ACL surgery have lower osteoarthritis incidence

SAN DIEGO — The incidence of osteoarthritis after ACL reconstruction is less when normal knee range of motion is achieved and maintained through follow-up, according to a presenter at the 2011 Annual Meeting of the American Orthopaedic Society for Sport Medicine here.

“Our results show little change of range of motion loss during the follow-up time. The data lead us to believe the range of motion deficits that patients have early after surgery persist throughout time and will contribute to osteoarthritis in the long-run,” K. Donald Shelbourne, MD said.

Shelbourne and colleagues prospectively followed patients after ACL reconstruction for a minimum of 5 years. Rehabilitation was refined through the years with the goal being to obtain full knee range of motion as quickly as possible after surgery and maintain it for the long-term. Range of motion and radiographs were evaluated according to IKDC objective criteria. Normal extension was considered to be within 2· of the opposite knee including hyperextension, and normal knee flexion was considered to be within 5·. Investigators rated radiographs as abnormal if they saw any sign of joint space narrowing of sclerosis or if osteophytes were present.

Postoperative follow-up was obtained for 780 patients at a mean of 10.5 ± 4.2 years with normal radiographs for 71% of those with normal extension and flexion and 55% of those with any range of motion deficit.

Of the patients with intact menisci, normal radiographs were found in 77% of cases with normal range of motion vs. 67% of cases with abnormal range of motion. For patients with medial meniscectomy, normal radiographs were found for 56% of patients with normal motion vs. 38% of patients with abnormal motion. For patients with lateral meniscectomy, normal radiographs were found for 74% of patients with normal range of motion vs. 41% for those with abnormal range of motion. For patients with both medial and lateral meniscectomy, normal radiographs were found for 56% of patients with normal motion compared to 24% of patients w

ho had abnormal range of motion.

“Patients with abnormal range of motion at follow-up after ACL reconstruction have twice the chance of developing osteoarthritis. Proper rehabilitation to achieve normal knee range of motion can reduce the effect of partial meniscectomy or articular cartilage damage for developing osteoarthritis after surgery,” Shelbourne said.

For further information: http://www.orthosupersite.com/view.aspx?rid=85682


Saturday, July 16, 2011

Study Identifies Patients Who Should Not Undergo Surgery for a Snapping Hip Tendon

Released: 7/8/2011 3:55 PM EDT
Embargo expired: 7/10/2011 12:00 AM EDT
Source: Hospital for Special Surgery

Newswise — Researchers at Hospital for Special Surgery have identified a group of patients who may have increased difficulty for surgical treatment of a snapping psoas, a condition that usually develops because a teenager or young adult has a pelvis that grows faster than their psoas tendon. The study will be presented at the annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM), held July 7-11 in San Diego.

“The conclusion from this study is that you should be cautious about releasing the psoas tendon, particularly in cases where there is some structural instability in the hip, specifically increased femoral anteversion, because although the tendon may be causing pain, it is also providing some dynamic support to the hip so it can cause problems if it is released,” said Bryan T. Kelly, M.D., who led the study and is co-director of the Center for Hip Pain and Preservation (www.hss.edu/hippain) at Hospital for Special Surgery (HSS) in New York.

The study received the 2011 Herodicus Award given annually by the Herodicus Society at the AOSSM meeting for the best paper submitted by an orthopedic resident or sports medicine fellow.

The hip is a ball-and-socket joint where the head of the femur (thigh bone) rotates within the cup-shaped socket of the pelvis. The head of the femur is supported by an angled neck which joins to the long thigh bone. At the base of the femoral neck is a boney protrusion. The psoas tendon is one of two hip flexor tendons that attaches to this protrusion. When the pelvis grows faster than the psoas tendon, this tendon becomes tight and snaps over the pelvis during walking or other activity. This condition, which can be painful, is known as a snapping psoas tendon.

“The reason that it snaps usually has to do with the anatomy of the pelvis. We usually see it in adolescent hips where the pelvis is growing at a faster rate than the tendon can accommodate for the growth,” said Dr. Kelly. “Structurally the tendon is not long enough to accommodate the bony anatomy.”

Doctors usually treat a snapping psoas tendon with physical therapy that involves stretching and strengthening, anti-inflammatories and corticosteroids, but if this doesn’t work, doctors resort to surgically lengthening the tendon. Because the tendon does not have the ability to stretch, surgeons cut slits in the tendon in what is called a partial release of the tendon or a fractional lengthening. “You cut it in a way that allows the muscle to elongate,” Dr. Kelly said.

Studies have shown that arthroscopic and open surgery can achieve similar outcomes for this condition. Few studies, however, have studied whether abnormalities in hip structure, specifically femoral anteversion, can impact outcomes. In most people, the center of the femoral neck points toward the center of the hip socket. Femoral anteversion is a condition in which the center of the femoral neck leans toward the front of the socket. This causes the knee and foot on the affected side to rotate internally or twist toward the midline of the body.

In December 2006, HSS researchers started a prospective registry of all hip arthroscopy procedures performed during a three-year period, 2006 to 2009, by a single, high-volume arthroscopic hip surgeon, Dr. Kelly. The study presented at AOSSM included all patients who underwent a psoas tendon lengthening at the time of surgery, a minimum of six months follow-up, and a preoperative high-resolution computed tomography (CT) scan to detect femoral anteversion. Patients were not included in the study if they had previous tendon hip surgery or hip trauma.

Sixty-seven patients underwent arthroscopic lengthening of a symptomatic psoas tendon, either in isolation or in conjunction with treatment for hip impingement. CT scans showed that 19 of 67 patients had high anteversion. The researchers assessed clinical outcomes both before and after surgery with modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS) questionnaires. These are commonly used to evaluate a patient’s ability to carry out specific activities that involve the hip: activities of daily living, such as climbing stairs, and athletic activities, such as running and jumping.

Prior to surgery, patients who had high anteversion scored significantly worse in terms of athletic activities on the HOS, but there was no difference in either questionnaire scores in terms of daily living activities. After surgery, patients who had high anteversion scored significantly worse on the MHHS questionnaire with regard to athletic and daily living activities, but the HOS scores were similar between the two groups. Twice as many patients who had high anteversion had to undergo revision surgery.

The researchers say the psoas tendon may be an important stabilizer in the hips of patients with high anteversion, and the tendon’s release in these patients may result in a delayed return to activities after surgery and inferior outcomes.

“The results of this study indicate that there are certain groups of patients that respond very favorably to surgical treatment of the psoas tendon, but there are other groups of patients that due to mechanical reasons, surgeons should exercise extreme caution in proceeding with any tendon release around the hip,” Dr. Kelly said. He said these patients should be considered for alternative treatment strategies.

Other authors of the study are lead author and orthopedic surgery resident Peter D. Fabricant, M.D., and Katrina Dela Torre, R.N., M.Sc., at HSS, and Asheesh Bedi, M.D., former HSS fellow now at the University of Michigan.

About Hospital for Special Surgery
Founded in 1863, Hospital for Special Surgery (HSS) is a world leader in orthopedics, rheumatology and rehabilitation. HSS is nationally ranked No. 1 in orthopedics, No. 3 in rheumatology, No. 16 in neurology and No. 18 in geriatrics by U.S. News & World Report (2010-11), has received Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center, and has one of the lowest infection rates in the country. From 2007 to 2011, HSS has been a recipient of the HealthGrades Joint Replacement Excellence Award. A member of the NewYork-Presbyterian Healthcare System and an affiliate of Weill Cornell Medical College, HSS provides orthopedic and rheumatologic patient care at NewYork-Presbyterian Hospital at New York Weill Cornell Medical Center. All Hospital for Special Surgery medical staff are on the faculty of Weill Cornell Medical College. The hospital's research division is internationally recognized as a leader in the investigation of musculoskeletal and autoimmune diseases. Hospital for Special Surgery is located in New York City and online atwww.hss.edu.

For further information:

http://www.newswise.com/articles/study-identifies-patients-who-should-not-undergo-surgery-for-a-snapping-hip-tendon