Bipolar Osteochondral Allograft Transplantation of the Patella and Trochlea.

OBJECTIVE: To evaluate clinical, functional, and radiographic outcomes of patients who underwent bipolar osteochondral allograft transplantation (OCAT) of the patellofemoral joint (PFJ). DESIGN: Prospectively collected data on 18 knees who underwent fresh osteochondral allograft transplantation of the patella and trochlea by a single surgeon were reviewed. Inclusion criteria were: high-grade chondral lesions of PFJ (5 knees), or recurrent patella dislocations with trochlear dysplasia and chondral injury to the patella and/or trochlea (13 knees). Functional scores were obtained preoperatively and at follow-up appointments included Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC), Oxford, Cincinnati, Tenger-Lysholm, visual analogue scale (VAS)-pain, and Single Assessment Numeric Evaluation (SANE). Grafts were also evaluated using Osteochondral Allograft MRI Scoring System (OCAMRISS). RESULTS: Three patients were lost to follow-up, leaving 4 knees in group 1, and 11 knees in group 2. Average age was 28.9 years (range 16-52 years). The average follow-up was 33.2 months (range 12-64 months). There was significant improvement of KOOS (from 38.7 to 83.1), IKDC (from 28.2 to 76.6), Tegner-Lysholm (from 38.3 to 88.3), Oxford (from 22.7 to 42.9), Cincinnati (from 35.1 to 83.6), VAS (from 71 to 17.9.), and SANE (from 43.3 to 83) (P < 0.0001). The OCAMRISS score for patella was 2.23 and for trochlea 4.69. There were no revisions or conversions to arthroplasty. CONCLUSION: Bipolar OCAT of the patella and trochlea provide significant improvement in functional outcomes, relief from pain, activity level, and prevent recurrent instability.

Single Assessment Numeric Evaluation (SANE) is a reliable metric to measure clinically significant improvements following shoulder arthroplasty.

BACKGROUND: Single Assessment Numeric Evaluation (SANE) offers a simple method of evaluating patients' sense of functional improvement after shoulder arthroplasty. METHODS: Patients receiving total shoulder arthroplasties were retrospectively queried between 2014 and 2017. Patients completed questionnaires involving SANE, American Shoulder and Elbow Surgeons (ASES) score, and Constant scores at the 1-year interval. Minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were calculated using the anchor-based methodology. RESULTS: A total of 207 patients with an average age of 66.7 ± 10.3 years and a body mass index of 31.5 ± 7.3 were available for analysis. The SANE score was the only score to have acceptable area under curve (AUC) (70.5%) for achieving MCID with a cutoff of 28.8. In terms of SCB, ASES (88%) and SANE (70.5%) had acceptable AUC with cutoffs of 20.7 and 50.2, respectively. All 3 scores had excellent AUC (>80%) for PASS with cutoffs of 81.9, 75.5, and 24.5 for ASES, SANE, and Constant scores, respectively. Normalized SANE scores were weakly correlated with ASES and Subjective Constant after normalizing for scale (R2 < 0.4). Achieving MCID by SANE was correlated with achieving MCID by Constant (P < .001). Achieving SCB and PASS by SANE was correlated with achieving SCB and PASS by ASES and Constant (ASES: P = .007, P < .001; Constant: P < .001, P < .001). CONCLUSION: The present study establishes clinically significant outcomes for SANE. Achievement of clinically significant outcomes in SANE was correlated with achieving meaningful outcomes with legacy measures of ASES and Constant scores. SANE may be used as a simple and efficient measure of patient outcome after total shoulder arthroplasty.

Outpatient shoulder arthroplasty: outcomes, complications, and readmissions in 2 outpatient settings.

BACKGROUND: There is currently a paucity of non-database studies looking at safety and outcomes after outpatient shoulder arthroplasty. The purpose of this study was to report our initial safety experience with outpatient shoulder arthroplasty including 90-day complications and readmissions. Our hypothesis was that the rate of early complications after outpatient shoulder arthroplasty would be low and similar to that of inpatient procedures regardless of outpatient setting. METHODS: We analyzed 50 consecutive patients who underwent outpatient shoulder arthroplasties (44 anatomic total shoulder arthroplasties, 4 reverse total shoulder arthroplasties, and 2 hemiarthroplasties) from 2014-2017. The readmission rate and complications were recorded. All patients were available for minimum 3-month follow-up. Preoperative and postoperative Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and visual analog scale scores were recorded. RESULTS: The average age was 56.9 ± 6.9 years; average body mass index, 29.75 ± 5.9; and average Charleston Comorbidity Index, 1.6 ± 1.2. There were 6 complications (12%) (hematoma, deep venous thrombosis, axillary nerve injury, acute infection, and 2 subscapularis failures). Only 4 occurred within the 90-day global period, and only 1 patient required readmission. Our subscapularis failures occurred after 3 months postoperatively and required additional surgery (arthroscopic repair and revision to reverse total shoulder arthroplasty). At last follow-up, all had significant improvements (P < .001) in range of motion and functional scores (American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, and visual analog scale scores). No difference in the complications and functional outcomes was found between the patients based on their surgical setting. CONCLUSION: Outpatient shoulder arthroplasty is a safe option for appropriately selected patients. No difference in complications and outcomes occurs regardless of outpatient setting.

An Age and Activity Algorithm for Treatment of Type II SLAP Tears.

BACKGROUND: Type II SLAP tears predominantly occur in males between their third and fifth decades of life. The mechanism of injury is often repeated overheard activity but can also occur due to direct compression loads and traction injuries. The treatment options have changed over the years and include non-operative therapy, direct labral-biceps complex repair, and labral debridement with biceps tenodesis or tenotomy. OBJECTIVE: To review the existing literature on the management of Type II SLAP tears and provide clinical recommendations based on patient age and activity level. METHODS: A review of the existing literature through October 2017 investigating the management of Type II SLAP tears was performed. Emphasis was placed on distinguishing the outcomes based on age and activity level to provide an appropriate treatment algorithm. RESULTS: Patients with Type II SLAP tears should first be trialed with non-operative management and many patients will have a successful result with ability to return to their respective sports or activities. Surgical management should be considered if non-operative management does not provide symptomatic relief. Young, athletic, or high-demand patients should be treated with a SLAP repair while biceps tenodesis should be considered for older or worker's compensation patients. Patients undergoing revision surgery for a failed SLAP repair should be managed with biceps tenodesis. CONCLUSION: Type II SLAP tears remain a difficult pathology to manage clinically, but the treatment indications are narrowing. The age and activity algorithm described in this review provides an effective method of managing this complex clinical condition.

The Role of Biologic Therapy in Rotator Cuff Tears and Repairs.

PURPOSE OF REVIEW: The purpose of this review was to establish the foundation of the major biologic adjuvants to rotator cuff repairs and review recent scientific findings. RECENT FINDINGS: Platelet-rich plasma (PRP) overall has no significant impact on functional outcomes and repair integrity, but may be more advantageous in small to medium tears. Further studies should focus on leukocyte-rich versus poor preparations and the use of PRP in patients that are high risk for repair failure. Biologic and synthetic patches or augments provide mechanical stability for large and massive rotator cuff tears and decrease re-tear rates. Mesenchymal stem cells have demonstrated improved healing rates without an impact on outcomes. Cytokines and growth factors show promise in animal models, but require human trials to further evaluate. In massive or revision repairs, allograft or synthetic patch augmentation should be considered. Platelet-rich plasma may have benefit in smaller tears. Further studies are needed to evaluate the value of mesenchymal stem cells and various cytologic chemical signals.

Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes.

PURPOSE OF REVIEW: To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears. RECENT FINDINGS: Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best. Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

Magnetic resonance imaging-based topographical differences between control and recurrent patellofemoral instability patients.

BACKGROUND: Plain films and computed tomography (CT)-based imaging were the first to establish measurements that evaluated patellar instability. Limited research has shown the efficacy of magnetic resonance imaging (MRI) in evaluating these established measurements. PURPOSE: To identify morphological differences between normal knees and those with patellofemoral instability on MRI to determine what measurements are significant and how MRI-based means differ from historical means based on radiograph and CT imaging. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: Eighty-one controls and 40 patients with recurrent patellar instability between 2006 and 2010 were reviewed. The control patients had a history and an examination negative for patellofemoral symptoms. Patients with patellar instability had a history of at least 2 frank patellofemoral joint dislocations (PFJDs). The MRI images were obtained on the nonweightbearing knee in full extension. Measurements of patellar tilt, trochlear morphologic characteristics, and tibial tuberosity-trochlear groove (TTTG) distance were evaluated on axial slices, and patellar height was measured on sagittal images. Trochlear shape was assessed at the proximal and distal trochlea. RESULTS: All measurements of patellar tilt (mean ± SD) were found to be significantly different between the 2 groups. For patellar height, the Insall-Salvati ratio (control, 1.08 ± 0.02; PFJD, 1.26 ± 0.03) and Caton-Deschamps ratio (control, 1.13 ± 0.02; PFJD, 1.29 ± 0.03) proved to be significantly different. Trochlear morphologic characteristics had numerous measurements prove to be significantly different proximally and distally. These included classic measurements such as sulcus angle (control, 148.48° ± 0.94°; PFJD, 165.57° ± 2.65°) and lateral trochlear inclination (control, 21.27° ± 0.66°; PFJD, 13.31° ± 1.36°) proximally and less established measurements such as the ratio of external (lateral) trochlea to internal (medial) trochlea (control, 1.51 ± 0.05; PFJD, 2.11 ± 0.17), a measurement of facet asymmetry. CONCLUSION: The MRI-based patellar tilt measures proved to be an excellent group of measurements for delineating between controls and those with instability. Patella alta ratios, such as Insall-Salvati and Caton-Deschamps, demonstrated a statistically significant difference between normal and recurrent dislocators. Trochlear measurements proved significantly different at the proximal and distal trochlea. Our findings demonstrate that MRI is appropriate to help discern recognized pathologic abnormalities that characterize patellofemoral instability.