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Background: The medial patellofemoral ligament (MPFL) is the primary soft tissue restraint to lateral patellar translation and is often disrupted by lateral patellar dislocation. Surgical management for recurrent patellar instability focuses on restoring the MPFL function with repair or reconstruction techniques. Recent studies have favored reconstruction over repair; however, long-term comparative studies are limited. Purpose: To compare long-term clinical outcomes, complications, and recurrence rates of isolated MPFL reconstruction and MPFL repair for recurrent lateral patellar instability. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 55 patients (n = 58 knees) with recurrent lateral patellar instability were treated between 2005 and 2012 with either MPFL repair or MPFL reconstruction. The exclusion criteria were previous or concomitant tibial tubercle osteotomy or trochleoplasty and follow-up of <8 years. Pre- and postoperative descriptive, surgical, imaging, and clinical data were recorded for each patient. Results: MPFL repair was performed on 26 patients (n = 29 knees; 14 women, 15 men), with a mean age of 18.4 years. MPFL reconstruction was performed on 29 patients (n = 29 knees; 18 women, 11 men), with a mean age of 18.2 years. At a mean follow-up of 12 years (range, 8.3-18.9 years), the reconstruction group had a significantly lower rate of recurrent dislocation compared with the repair group (14% vs 41%; P = .019). There were no differences in the number of preoperative dislocations or tibial tubercle-trochlear groove distance. The reconstruction group had significantly more time from initial injury to surgery compared with the repair group (median, 1460 days vs 627 days; P = .007). There were no differences in postoperative Tegner, Lysholm, or Kujala scores at the final follow-up. In addition, no statistically significant differences were detected in return to sport (RTS) rates (repair [81%] vs reconstruction [75%]; P = .610) or reoperation rates for recurrent instability (repair [21%] vs reconstruction [7%]; P = .13). Conclusion: MPFL repair resulted in a nearly 3-fold higher rate of recurrent patellar dislocation (41% vs 14%) at the long-term follow-up compared with MPFL reconstruction. Given this disparate rate, the authors recommend MPFL reconstruction over repair because of the lower failure rate and similar, if not superior, clinical outcomes and RTS.
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BACKGROUND: Gluteus maximus tendon transfer has recently been described as a treatment option for irreparable abductor tendon tears. The purpose of this study was to systematically review outcomes following gluteus maximus tendon transfer for hip abductor deficiency. METHODS: The published literature was queried for outcomes following gluteus maximus transfer in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes of interest included preoperative and postoperative functional scores, resolution of pain and gait abnormalities, postoperative rehabilitation protocols, surgical complications, reoperation rates, and postoperative magnetic resonance imaging. In total, 10 studies with a total of 125 patients (76% women) with a mean age of 67 years (range, 30 to 87) were identified for inclusion. RESULTS: Modified Harris Hip Score (+30.1 ± 6.6 [95% confidence interval: +15.5 to +46.5]) and Visual Analog Scale for pain (-4.1 ± 1.1 [95% confidence interval: -7.1 to -1.0]) were improved following gluteus maximus transfer, compared to preoperative levels. No significant improvement was noted in abduction strength and 33% of patients demonstrated a residual Trendelenburg gait postoperatively. The overall complication rate was 5.6% (7 of 125), with a reoperation rate of 1.6% (2 of 125). CONCLUSIONS: Gluteus maximus tendon transfer for abductor insufficiency has demonstrated reliable outcomes at 3 years, with improvement in hip function and pain. However, patients demonstrate modest improvements in abduction strength, and a significant subset will continue to demonstrate a Trendelenburg gait postoperatively.
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Músculo Esquelético , Tendones , Humanos , Nalgas/cirugía , Músculo Esquelético/cirugía , Dolor , MusloRESUMEN
BACKGROUND: Arthrofibrosis (AF) after anterior cruciate ligament reconstruction (ACLR) remains a challenge. There is a paucity of data on arthroscopic interventions for AF after ACLR. PURPOSE: To (1) describe the patient, injury, and surgical characteristics and patient-reported outcomes (PROs) of those requiring an arthroscopic intervention for loss of motion after ACLR and (2) compare outcomes between patients undergoing an early intervention (within 3 months) versus those undergoing a late intervention (after 3 months). STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Patients with a history of ACLR and a subsequent operative procedure for postoperative AF at a single institution between 2000 and 2018 were retrospectively identified. Arthroscopic interventions included lysis of adhesions, capsular release with or without manipulation under anesthesia, and excision of cyclops lesions. Patients were excluded if they had a knee dislocation or multiple-ligament injury, a periarticular fracture, or less than 2-year follow-up from the arthroscopic intervention. PROs including the Tegner activity score, visual analog scale pain score, and International Knee Documentation Committee score as well as knee range of motion (ROM) were recorded. RESULTS: A total of 40 patients were included with a mean age of 27.2 years (range, 11.0-63.8 years) at surgery and a mean follow-up of 10.0 years (range, 2.9-20.7 years). The mean preoperative flexion and extension were 102° (range, 40°-150°) and 8° (range, 0°-25°), respectively. The mean postoperative flexion and extension were 131° (range, 110° to 150°) and 0° (range, -10° to 5°), respectively. After the arthroscopic intervention, the mean ROM improved from 94° (range, 40°-140°) preoperatively to 131° (range, 107°-152°) at final follow-up (P < .001), and the visual analog scale pain score improved from 3.0 preoperatively to 1.2 postoperatively (P = .001). Overall, 13 patients (32.5%) underwent an intervention within 3 months and 27 (67.5%) after 3 months. The early intervention group had a higher postoperative International Knee Documentation Committee score compared with the late intervention group (86.8 vs 71.7, respectively; P = .035). CONCLUSION: An arthroscopic intervention for AF after ACLR successfully improved knee ROM and pain. Patients who underwent either early or late surgery obtained satisfactory motion and function, although improved PROs were observed when the intervention occurred within 3 months of the primary procedure.
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Lesiones del Ligamento Cruzado Anterior , Reconstrucción del Ligamento Cruzado Anterior , Artropatías , Humanos , Adulto , Estudios Retrospectivos , Articulación de la Rodilla , Artropatías/etiología , Artropatías/cirugía , Escala de Puntuación de Rodilla de Lysholm , Adherencias Tisulares/etiología , Adherencias Tisulares/cirugía , Reconstrucción del Ligamento Cruzado Anterior/métodos , Resultado del TratamientoRESUMEN
Hip abductor deficiency resulting from gluteus medius and minimus pathology is increasingly recognized as a generator of lateral-sided hip pain. In the setting of a failed gluteus medius repair or in patients with irreparable tears, transfer of the anterior portion of the gluteus maximus muscle can be performed to treat gluteal abductor deficiency. The classic description of the gluteus maximus transfer technique relies solely on bone tunnel fixation. This article describes a reproducible technique that incorporates the addition of a distal row to the tendon transfer, which may improve fixation by both compressing the tendon transfer to the greater trochanter and providing improved biomechanical strength to the transfer.
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Purpose: To compare the clinical outcomes of operative and nonoperative management, identify risk factors for recurrent instability, and identify risk factors for progression to surgery after failed nonoperative management for patients with first-time anterior shoulder dislocation after the age of 50 years. Methods: An established geographic medical record system was used to identify patients who experienced a first-time anterior shoulder dislocation after the age of 50 years. Patient medical records were reviewed to identify treatment decisions and outcomes of interest, including rates of frozen shoulder and nerve palsy, progression to osteoarthritis, recurrent instability, and progression to surgery. Outcomes were evaluated using Chi-square tests and survivorship curves were generated using Kaplan-Meier methods. A Cox model was developed to evaluate for potential risk factors of recurrent instability and progression to surgery after an initial trail of at least 3 months of nonoperative treatment. Results: 179 patients were included with a mean follow-up of 11 years. 14% (n = 26) underwent early surgery within 3 months and 86% (n = 153) were initially treated nonoperatively. Mean age (59 years), was similar for both groups, but those that underwent early surgery had an increased rate of full-thickness rotator cuff tears (82% vs 55%; P = .01), labral tears (24% vs 8.0%; P = .01), and humeral head fracture (23% vs 8.5%; P = .03). When comparing the early surgery group to the nonoperative group, there were similar rates of persistent moderate-severe pain (19% vs 17%; P = .78) and frozen shoulder (8 vs 9%, respectively; P = .87) at final follow-up. Although nerve palsy (19% vs 8%; P = .08) and progression to osteoarthritis (20% vs 14%; P = .40) were more common in surgical patients, they experienced lower rates of recurrent instability after surgical intervention (0% vs 15%; P = .03) compared to nonoperatively treated patients. Increasing number of instability events prior to presentation was the greatest risk factor for recurrent instability (HR 232; P < .01). Fourteen percent (n = 21) failed initial nonoperative treatment and proceeded to surgical intervention at an average of 4.6 years after the initial instability event, and the greatest risk factors for progression to surgery were recurrent instability (HR 3.41; P < .01). Conclusions: Although the majority of patients >50 years that experience ASI are treated nonoperatively, those that require surgery tend to have more significant injury pathology, a lower risk of recurrent instability after surgery, but a higher progression to osteoarthritis compared to patients that do not require surgical intervention. There was no difference in pain severity at final follow-up, rates of frozen shoulder or nerve palsy between patients who underwent initial nonoperative treatment after instability and those who underwent surgery. A history of multiple instability episodes prior to presentation was the greatest predictor of recurrent instability and failure of nonoperative treatment and progression to surgery. Level of Evidence: Level III, retrospective cohort study.
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Background: There is a paucity of research on the management of partial-thickness tears of the distal bicep tendon, and even less is known about the long-term outcomes of this condition. Purpose: To identify patients with partial-thickness distal bicep tendon tears and determine (1) patient characteristics and treatment strategies, (2) long-term outcomes, and (3) any identifiable risk factors for progression to surgery or complete tear. Study Design: Case-control study; Level of evidence, 3. Methods: A fellowship-trained musculoskeletal radiologist identified patients diagnosed with a partial-thickness distal bicep tendon tear on magnetic resonance imaging between 1996 and 2016. Medical records were reviewed to confirm the diagnosis and record study details. Multivariate logistic regression models were created using baseline characteristics, injury details, and physical examination findings to predict operative intervention. Results: In total, 111 patients met inclusion criteria (54 treated operatively, 57 treated nonoperatively), with 53% of tears in the nondominant arm and a mean follow-up time after surgery of 9.7 ± 6.5 years. Only 5% of patients progressed to full-thickness tears during the study period, at a mean of 35 months after the initial diagnosis. Patients who were nonoperatively treated were less likely to miss time from work (12% vs 61%; P < .001) and missed fewer days (30 vs 97 days; P < .016) than those treated surgically. Multivariate regression analyses demonstrated increased risk of progression to surgery with older age at initial consult (unit odds ratio [OR], 1.1), tenderness to palpation (OR, 7.5), and supination weakness (OR, 24.8). Supination weakness at initial consult was a statistically significant predictor for surgical intervention (OR, 24.8; P = .001). Conclusion: Clinical outcomes were favorable for patients regardless of treatment strategy. Approximately 50% of patients were treated surgically; patients with supination weakness were 24 times more likely to undergo surgery than those without. Progression to full-thickness tear was a relatively uncommon reason for surgical intervention, with only 5% of patients progressing to full-thickness tears during the study period and the majority occurring within 3 months of initial diagnosis.
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PURPOSE: Prior studies of enhanced recovery protocols (ERP) have been conducted at large institutions with abundant resources. These results may not apply at institutions with less resources directed to quality improvement efforts. The purpose of this study was to assess the value of a minimalistic enhanced recovery protocol in reducing length of stay (LOS) following PSF for adolescent idiopathic scoliosis. We hypothesized that accelerated transition to oral pain medications and mobilization alone could shorten hospital length of stay in the absence of a formal multimodal pain regimen. METHODS: AIS patients aged 10-18 who underwent PSF at a tertiary pediatric hospital between January 1, 2014 and December 31, 2017 were reviewed. The study population was further narrowed to consecutive patients from a single surgeon's practice that piloted the modified ERP. Reservation from key stakeholders regarding the feasibility of implementing widespread protocol change led to the minimal alterations made to the postoperative protocol following PSF. Patients were divided into either the Standard Recovery Protocol (SRP) or Enhanced Recovery Protocol (ERP). Primary variables analyzed were hospital LOS, complications, readmissions, and total narcotic requirement. RESULTS: A total of 92 patients met inclusion criteria. SRP and ERP groups consisted of 44 (47.8%) and 48 (52.2%) patients. There was no difference between the two groups with regard to age, sex, and ASA score (p > 0.05). Fusion levels and EBL did not differ between treatment groups (p > 0.05). PCA pumps were discontinued later in the SRP group (39.5 ± 4.3 h) compared to the ERP group (17.4 ± 4.1 h, p < 0.0001). Narcotic requirement was similar between groups (p = 0.94) Patients in the SRP group had longer hospital stays than patients in the ERP group (p < 0.0001). 83% of the ERP group had LOS ≤ 3 days compared to 0% in the SRP group, whose mean LOS was 4.2 days. There was no difference in complications between the groups (2.2% vs 6.0%, p = 0.62). Readmission to the hospital within 30 days of surgery was rare in either group (2 SRP patients: 1 superior mesenteric artery syndrome, 1 bowel obstruction vs 0 ERP patients, p = 0.23). CONCLUSION: In this cohort, minor changes to the postoperative protocol following surgery for AIS led to a significant decrease in hospital length of stay. This minimalistic approach may ease implementation of an ERP in the setting of stakeholder apprehension.
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Escoliosis , Fusión Vertebral , Adolescente , Humanos , Niño , Escoliosis/cirugía , Dolor , Tiempo de Internación , Narcóticos , Fusión Vertebral/métodosRESUMEN
Background: Biomechanical studies support the use of suture tape reinforcement for limiting graft elongation and increasing strength in knee ligament reconstructions. Purpose: To compare posterior cruciate ligament (PCL) laxity, complication and reoperation rates, and patient-reported outcomes (PROs) after all-inside single-bundle PCL reconstruction (PCLR) with versus without independent suture tape reinforcement. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study of consecutive patients who underwent primary, all-inside allograft single-bundle PCLR with and without independent suture tape reinforcement at a single academic institution from 2012 to 2019. Medical records were reviewed for patient characteristics, additional injuries, and concomitant procedures. PRO scores (including the International Knee Documentation Committee [IKDC], Tegner activity scale, and Lysholm scores), bilateral comparison kneeling radiographs, and physical examination findings were collected at a minimum of 2 years postoperatively. Results: Included were 50 patients: 19 with suture tape reinforcement (mean age 30.6 ± 2.9 years) and 31 without suture tape reinforcement (control group; mean age 26.2 ± 1.6 years). One PCLR graft in the suture tape group failed. Posterior drawer examination revealed grade 1+ laxity in 4 of 19 (21%) of the suture tape cohort versus 6 of 31 (19%) of the control cohort (P > .999). Bilateral kneeling radiographs showed similar side-to-side differences in laxity between the groups (suture tape vs control: mean, 1.9 ± 0.4 vs 2.6 ± 0.6 mm; P = .361). There were no statistically significant differences between the groups in postoperative IKDC (suture tape vs control: 79.3 vs 79.6; P = .779), Lysholm (87.5 vs 84.3; P = .828), or Tegner activity (5.6 vs 5.7; P = .562) scores. Conclusion: All-inside single-bundle PCLR with and without independent suture tape reinforcement demonstrated low rates of graft failure, complications, and reoperations, with satisfactory PROs at a minimum 2-year follow-up. Radiographic posterior tibial translation was comparable between the 2 groups.
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Background: There is a dearth of knowledge on anterior shoulder instability in older patients. Purpose/Hypothesis: The purposes of this study were to describe the incidence and epidemiology, injury characteristics, and treatment and outcomes in patients ≥50 years old with first-time anterior shoulder instability. We also describe the historical trends in diagnosis and treatment. It was hypothesized that the rates of obtaining a magnetic resonance imaging (MRI) scan and surgical intervention have increased over the past 20 years. Study Design: Descriptive epidemiology study. Methods: An established geographic database was used to identify 179 patients older than 50 years who experienced new onset anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient characteristics, imaging characteristics, and surgical treatment and outcomes, including recurrent instability. Comparative analysis was performed to identify differences between age groups. Mean follow-up time was 11 years. Results: The incidence of first-time anterior shoulder dislocation in our study population was 28.8 per 100,000 person-years, which is higher than previously reported. Full-thickness rotator cuff tears were found in 62% of the 66 patients who underwent MRI scans. Of all patients, 26% progressed to surgery at a mean time of 1.6 years after injury; 57% of all surgical procedures involved a rotator cuff repair, and 17% included anterior labral repair. All patients who underwent a labral repair also underwent concomitant rotator cuff repair. The rate of recurrent instability for the cohort was 15% at a median of 176 days after the initial instability event. There were no instances of recurrent instability after operative intervention. At an average of 7.5 years after the initial instability event, 14% of patients developed radiographic progression of glenohumeral arthritis. The rate of surgical intervention within 1 year of initial dislocation increased from 5.1% in 1994 to 1999 to 52% in 2015 to 2016. Conclusion: The incidence of first-time anterior shoulder instability in patients aged ≥50 years was 28.8 per 100,000 person-years. Full-thickness rotator cuff tears (62%) were the most common condition associated with anterior shoulder instability, followed by Hill-Sachs lesions (56%). The rate of recurrent instability for the entire cohort was 15%, with no instances of recurrent instability after operative intervention.
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Purpose: To investigate the incidence of anteroinferior glenoid rim fractures (AGRFs) after anterior shoulder instability (ASI) in patients aged 50 years or older, identify risk factors for surgical intervention for AGRFs, compare initial treatment strategies, and compare clinical outcomes of patients with and without associated AGRFs. Methods: An established geographic medical record system was used to identify patients aged 50 years or older with ASI between 1994 and 2016. Patients with radiographic evidence of AGRFs were identified and matched 1:1 to patients without AGRFs. Outcome measures included recurrent instability, recurrent pain events, conversion to arthroplasty, and osteoarthritis graded with the Samilson-Prieto classification for post-instability arthritis. Results: Overall, 177 patients were identified, with a mean follow-up period of 10.8 years. Of these patients, 41 (23.2%) had AGRFs and were matched to 41 control patients without AGRFs. The average age was 58.6 and 58.2 years for the AGRF and control groups, respectively. Rates of surgical intervention (27% vs 49%), recurrent instability (12% vs 20%), progression of osteoarthritis (34% vs 39%), and conversion to arthroplasty (2% vs 5%) were similar between AGRF patients and controls. For patients with AGRFs, increased bone fragment size (odds ratio, 1.1) and increased body mass index (odds ratio, 1.2) correlated with an increased risk of surgery. The cutoff value for an increased risk of surgery in patients with AGRFs was a fragment size 33% of the glenoid width or greater. Conclusions: Of patients aged 50 years or older at presentation of ASI, 23.2% presented with an associated AGRF. A fragment size 33% of the glenoid width or greater and a higher patient body mass index were significant factors for surgical intervention; however, most patients did not require surgery and still showed acceptable clinical outcomes, and the most common reason for surgical intervention was a rotator cuff tear. Overall, the presence of an AGRF did not portend a worse prognosis as treatment strategies and long-term outcomes including recurrent instability, progression of osteoarthritis, and conversion to arthroplasty were similar to those in patients without AGRFs. Level of Evidence: Level III, retrospective comparative study.
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Purpose: To 1) evaluate the clinical efficacy of arthroscopic posterior capsular release for improving range of motion (ROM) in cases of recalcitrant flexion contracture and 2) determine patient-reported outcomes (PROs) postoperatively. Methods: Retrospective chart review was performed to identify patients who underwent arthroscopic posterior capsular release due to persistent extension deficit of the knee despite comprehensive nonoperative physical therapy between 2008 and 2021. Knee ROM and PROs (International Knee Documentation Committee [IKDC], Tegner, and visual analog scale [VAS]) were collected at final follow-up. Results: Overall, 22 patients were included with a median age of 37 years (interquartile range [IQR]: 20.5-44.3). Of these, 8 (36%) were male and 14 (64%) were female, and average follow-up was 3.7 ± 3.3 years. The most common etiology was knee flexion contracture after anterior cruciate ligament (ACL) reconstruction (59%). All patients failed a minimum of 3 months of nonoperative management. Prior to operative intervention, 100% of patients received physical therapy, 64% received extension knee bracing or casting, and 36% received corticosteroid injection. Median preoperative extension was 15° (IQR: 10-25) compared to 2° (IQR: 0-5) postoperatively (P < .001). At final follow-up, median extension was 0° (IQR: 0-3.5). Postoperative VAS pain scores at rest (2 vs 0; P = .001) and with use (5 vs 1.8; P = .017) improved at final contact, and most (94%) patients reported maintaining their extension ROM. Patients with ACL-related extension deficit reported better IKDC (81 vs 51.3; P = .008), Tegner (5.8 vs 3.6; P = .007), and VAS pain scores (rest: 0.2 vs 1.8; P = .008; use: 1.3 vs 5; P = .004) compared to other etiologies. Conclusion: Arthroscopic posterior capsular release for recalcitrant flexion contracture provides an effective means for reducing pain and restoring terminal extension. The improvement in extension postoperatively was maintained for most (94%) patients at final follow-up with a 14% reoperation rate.
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Background: Wrestling is a physically demanding sport, with young athletes prone to anterior cruciate ligament (ACL) injuries. There is a paucity of data evaluating the results of ACL reconstruction (ACLR) in this cohort. Purpose: To assess return to sport (RTS), patient-reported outcomes, reoperation rates, and graft survival after ACLR in a large cohort of competitive wrestlers at midterm follow-up. Study Design: Case series; Level of evidence, 4. Methods: We identified all competitive wrestlers (club, high school, collegiate, or professional) with a history of an ACLR at a single institution between 2000 and 2019. Graft failure was defined as a retear (as determined via clinical or advanced imaging evaluation) and/or revision ACLR. All patients were contacted for determination of reinjury rates; current sport status; and pain visual analog scale, International Knee Documentation Committee, and Tegner activity scores. Results: Included were 107 knees in 103 wrestlers, with a median follow-up time of 5.9 years (interquartile range [IQR], 3.9-10.3 years). The median age was 17 years (IQR, 15-18 years), with 106 (99%) male patients, and the distribution of bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts was 64 (60%) and 43 (40%), respectively. At final follow-up, 80% of athletes were able to RTP at a median of 280 days (IQR, 212-381 days). Graft failure occurred in 14 (13%) knees at a median time of 1.8 years (IQR, 0.7-5.3 years) after the index ACLR. BTB autograft demonstrated a lower failure rate compared with HT autograft (8% vs 21%; P = .044) and was associated with better survival compared with HT autograft up to 15 years after the index ACLR (90.4% vs 76.3%; P = .030). When compared by graft diameter, HT autografts of at least 7.5 mm were not associated with a lower graft failure than BTB constructs of all sizes (P = .205). Conclusion: Return to competitive wrestling was observed in 80% of athletes after ACLR, with 14% of wrestlers experiencing graft failure. BTB autograft was associated with better survival than HT autograft.
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BACKGROUND: Prospective evaluation of clinical outcomes after posterior meniscal root repair utilizing a transtibial pullout technique is limited, and factors that may contribute to outcomes are unclear. HYPOTHESIS: It was hypothesized that there would be an overall significant improvement in outcomes after root repair and that differences in clinical outcomes would correlate with age, body mass index (BMI), sex, and meniscal extrusion. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Consecutive patients undergoing transtibial medial or lateral meniscal root repair were enrolled prospectively at 2 orthopaedic centers between March 2017 and January 2019. Pre- and postoperative magnetic resonance imaging (MRI) were obtained to assess for meniscal healing, quantification of extrusion, articular cartilage grade, and subchondral bone changes. Patient-reported outcomes including International Knee Documentation Committee (IKDC) scores, Tegner activity scale, and visual analog scale (VAS) for pain were collected preoperatively and 2 years postoperatively. Patients were then subdivided by clinical and demographic characteristics to determine factors associated with clinical outcomes. RESULTS: Included were 45 patients (29 female, 16 male; mean age, 42.3 ± 12.9 years; mean BMI, 31.6 kg/m2) who underwent 47 meniscal root repairs (29 medial and 16 lateral; 2 had both). Significant improvements at 2-year follow-up were seen in IKDC score (41.1 vs 78.4; P < .001), Tegner activity level (3 vs 4; P < .001), and VAS pain (2.8 vs 0.7; P < .001). BMI, preoperative malalignment, cartilage status, and progressive meniscus extrusion (Δ = 0.7 mm) did not have a negative impact on IKDC and Tegner scores 2 years postoperatively. Age greater than or equal to 50 years and extrusion pre- and postoperatively were associated with decreased Tegner scores. Progressive meniscal extrusion was associated with a decreased overall improvement in Tegner scores. CONCLUSION: Transtibial root repair for medial and lateral posterior meniscal root tears demonstrated significantly improved clinical outcomes at 2 years postoperatively. Increased age, increased BMI, cartilage status, and meniscal extrusion did not have a negative impact on short-term functional outcomes (IKDC), but age greater than or equal to 50 years and extrusion negatively influenced patient activity level (Tegner). REGISTRATION: NCT03037242 (ClinicalTrials.gov identifier).
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Arthrofibrosis (AF) is an exaggerated immune response to a proinflammatory insult leading to pathologic periarticular fibrosis and symptomatic joint stiffness. The knee, elbow, and shoulder are particularly susceptible to AF, often in the setting of trauma, surgery, or adhesive capsulitis. Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss. Reliable nonoperative modalities exist and outcomes are improved when etiology, joint involved, and level of dysfunction are considered in the clinical decision making process. Surgical procedures should be reserved for cases recalcitrant to nonoperative measures. The purpose of this review is to provide an overview of the current understanding of AF pathophysiology, identify common risk factors, describe prevention strategies, and outline both nonoperative and surgical treatment options. This manuscript will focus specifically on sterile AF of the knee, elbow, and shoulder.
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Bursitis , Artropatías , Sueños , Humanos , Articulación de la Rodilla , Rango del Movimiento ArticularRESUMEN
BACKGROUND: There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. METHODS: A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. CONCLUSIONS: Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. LEVEL OF EVIDENCE: Level IV.
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Moldes Quirúrgicos , Fracturas del Fémur , Niño , Preescolar , Estudios de Factibilidad , Fracturas del Fémur/diagnóstico por imagen , Fracturas del Fémur/cirugía , Fémur/diagnóstico por imagen , Humanos , Lactante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US-geographic population-based cohort of patients with anterior shoulder instability. METHODS: An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient-specific risk factors were individually incorporated into the 10-point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. RESULTS: The study population consisted of 405 patients with a mean follow-up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high-risk group were more likely to fail nonoperative management than those in the low-risk group (60.3% vs 48.9%; P = .028). CONCLUSIONS: The NISIS has been proposed as a potentially useful tool in clinical decision-making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US-geographic population-based cohort consisting of competitive and recreational athletes under the age of 40 with longer-term follow-up, the NISIS high-risk cutoff was able to predict overall failure with 60.3% accuracy. LEVEL OF EVIDENCE: III, retrospective observation trial.
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Inestabilidad de la Articulación , Luxación del Hombro , Articulación del Hombro , Adolescente , Estudios de Seguimiento , Humanos , Inestabilidad de la Articulación/diagnóstico , Masculino , Recurrencia , Estudios Retrospectivos , Hombro , Luxación del Hombro/diagnósticoRESUMEN
BACKGROUND: Meniscal tears are common in active patients, but treatment trends and surgical outcomes in young patients with lateral meniscal tears are lacking. PURPOSE: To evaluate treatment trends, outcomes, and failure rates in young patients with lateral meniscal tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients aged ≤25 years treated surgically for isolated lateral meniscal tears from 2001 to 2017 were identified. Treatment trends were compared over time. International Knee Documentation Committee (IKDC) scores and failure rates were compared by treatment modality (meniscectomy vs meniscal repair). Failure was defined as reoperation, symptomatic osteoarthritis, or a severely abnormal IKDC score. Univariate regression analyses were performed to predict failure and IKDC scores based on treatment, type and location of tear, or extent of meniscectomy. RESULTS: Included were 217 patients (226 knees) with a mean age of 17.4 years (range, 7-25 years); of these patients, 144 knees (64%) were treated with meniscectomy and 82 knees (36%) with meniscal repair. Treatment with repair increased over time compared with meniscectomy (P < .001). At a minimum 2-year follow-up (mean, 6.1 ± 3.9 years), 107 patients (110 knees) had IKDC scores, and analysis indicated that although scores in both groups improved from pre- to postoperatively (repair: from 69.5 ± 13.3 to 97.4 ± 4.3; meniscectomy: from 75.7 ± 9.0 to 97.3 ± 3.9; P < .001 for both), improvement in IKDC score was greater after repair (27.9 ± 13.9) versus meniscectomy (21.6 ± 9.4) (P = .005). Included in the failure analysis were 184 patients (192 knees) at a mean follow-up of 8.4 ± 4.4 years. The rates of reoperation, symptomatic osteoarthritis, and failure were not significantly different between the meniscectomy and repair groups. CONCLUSION: An increase was seen in the rate of isolated lateral meniscal tear repair in young patients. IKDC score improvement was greater after repair than meniscectomy, although postoperative IKDC scores were similar. Symptomatic arthritis, reoperation, and failure rates were similar between groups; however, there was a trend for increased arthritis symptoms in patients treated with meniscectomy, especially total meniscectomy. Treatment modality, type and location of tear, and amount of meniscus removed were not predictive of final IKDC scores or failure.
RESUMEN
BACKGROUND: Osteochondromas are the most common benign bone tumor, accounting for 36% of benign bone tumors. Often found within the appendicular skeleton, osteochondromas of the spine are rare, comprising 4% to 7% of primary benign spinal tumors. CASE SUMMARY: We report a case of a solitary lumbar osteochondroma in an 18-year-old male with a history of a suprasellar pineal germinoma treated with combined chemotherapy and radiation. He underwent mass excision and partial laminectomy with the ultrasonic bone scalpel (Misonix, Farmingdale, NY, United States) at the L5 Level without the use of adjuvants. The patient returned to work and full activities without back pain at 3 mo postoperatively. CONCLUSION: Osteochondromas are common tumors of the appendicular skeleton but rarely occur within the spine. This case discussion supplements current osteochondroma literature by describing an unusual presentation of this tumor.
RESUMEN
BACKGROUND: Obesity rates continue to rise among children and adolescents across the globe. A multicenter research consortium composed of institutions in the Southern US, located in states endemic for childhood obesity, was formed to evaluate the effect of obesity on pediatric musculoskeletal disorders. This study evaluates the effect of body mass index (BMI) percentile and socioeconomic status (SES) on surgical site infections (SSIs) and perioperative complications in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). METHODS: Eleven centers in the Southern US retrospectively reviewed postoperative AIS patients after PSF between 2011 and 2017. Each center contributed data to a centralized database from patients in the following BMI-for-age groups: normal weight (NW, 5th to <85th percentile), overweight (OW, 85th to <95th percentile), and obese (OB, ≥95th percentile). The primary outcome variable was the occurrence of an SSI. SES was measured by the Area Deprivation Index (ADI), with higher scores indicating a lower SES. RESULTS: Seven hundred fifty-one patients were included in this study (256 NW, 235 OW, and 260 OB). OB and OW patients presented with significantly higher ADIs indicating a lower SES (P<0.001). In addition, SSI rates were significantly different between BMI groups (0.8% NW, 4.3% OW, and 5.4% OB, P=0.012). Further analysis showed that superficial and not deep SSIs were significantly different between BMI groups. These differences in SSI rates persisted even while controlling for ADI. Wound dehiscence and readmission rates were significantly different between groups (P=0.004 and 0.03, respectively), with OB patients demonstrating the highest rates. EBL and cell saver return were significantly higher in overweight patients (P=0.007 and 0.002, respectively). CONCLUSION: OB and OW AIS patients have significantly greater superficial SSI rates than NW patients, even after controlling for SES. LEVEL OF EVIDENCE: Level III.
Asunto(s)
Cifosis , Obesidad Infantil , Escoliosis , Adolescente , Índice de Masa Corporal , Niño , Humanos , Obesidad Infantil/complicaciones , Obesidad Infantil/epidemiología , Estudios Retrospectivos , Escoliosis/epidemiología , Escoliosis/cirugía , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Children who are prohibited from returning to daycare (RTD) after treatment with cast immobilization place an increased burden on parents and caregivers. The purpose of this study was to assess the impact of cast immobilization on RTD. Specifically, we sought to determine the prevalence of RTD after orthopaedic immobilization based on daycare facility policy. METHODS: This was a survey study of randomly selected daycare facilities servicing a total of 6662 children within 10 miles of a major metropolitan city center. The 40-question survey included information on daycare policies and experience caring for children treated with orthopaedic immobilization. The survey also included questions about daycare type, enrollment, and geographic location. Photographs of the types of immobilization were embedded in the survey to facilitate understanding. Daycare facilities were randomly selected based on a power analysis to estimate a 50% prevalence of RTD after spica casting within 10% margin of error. RESULTS: Seventy-three daycare facilities completed the survey study. The average child-staff ratio was 5:1 and most daycare facilities (78%) did not have a nurse on staff. Predetermined policies regarding RTD after injury were available at 81% of daycares. Twenty-eight (38.5%) facilities had encountered a child with a cast in the previous year. The rate of RTD for children with upper limb injuries was 90.5% compared with 79% for lower limb injuries (P=0.003). Spica casts showed the lowest RTD rate: single leg (22.5%), 1 and a half leg (18%), and 2 leg (16%) (P<0.0001). Experienced daycare facilities (>5 y) had a higher RTD rate compared with less experienced facilities (P=0.026). CONCLUSIONS: The ability to RTD is dependent on immobilization type. Children with long leg and spica casts are disproportionately restricted when compared with other cast types. At minimum, surgeons should consider the socioeconomic implications of orthopaedic immobilization. There is also a need for orthopaedic involvement in policy formation at the local level to provide standardized guidelines for re-entry into childcare facilities following orthopaedic immobilization. LEVEL OF EVIDENCE: Level IV.