Three- and 4-part proximal humeral fracture fixation with an intramedullary cage: 1-year clinical and radiographic outcomes.

BACKGROUND: Reverse total shoulder arthroplasty is a treatment option for 3- and 4-part proximal humeral fractures in elderly patients. However, arthroplasty has drawbacks in younger patients because of their greater activity level and more likely need for revision surgery. In such patients, an intramedullary cage may allow for reconstruction of the proximal humerus. METHODS: We reviewed the outcomes of patients with proximal humeral fractures treated with expandable intramedullary cages from 2016 to 2017. We included patients with closed 3- or 4-part fractures (Neer classification), no osteoarthritis of the glenohumeral joint, and minimum 12-month follow-up. We assessed range of motion, pain, the American Shoulder and Elbow Surgeons score, and the Subjective Shoulder Value. RESULTS: Eleven patients (mean follow-up, 54 weeks [range, 49-61 weeks]) were included. Two patients had 3-part fractures, and nine had 4-part fractures. At final follow-up, the mean visual analog scale score for pain was 1.4 (range, 0-6), the mean Subjective Shoulder Value was 69 (range, 20-90), and the mean American Shoulder and Elbow Surgeons score was 80 (range, 27-98). Mean forward flexion was 123° (range, 45°-160°), mean abduction was 82° (range, 30°-90°), and mean external rotation in 90° of abduction was 71° (range, 30°-90°). At final radiographic evaluation, all fractures were healed. No wound-related or neurologic complications were noted. Avascular necrosis developed in 1 patient; conversion to shoulder arthroplasty was performed. CONCLUSION: Treatment of 3- and 4-part proximal humeral fractures with an expandable intramedullary cage produced good clinical outcomes and a 100% union rate.

Platelet-Rich Plasma Activates Proinflammatory Signaling Pathways and Induces Oxidative Stress in Tendon Fibroblasts.

BACKGROUND: Tendon injuries are one of the most common musculoskeletal conditions in active patients. Platelet-rich plasma (PRP) has shown some promise in the treatment of tendon disorders, but little is known as to the mechanisms by which PRP can improve tendon regeneration. PRP contains numerous different growth factors and cytokines that activate various cellular signaling cascades, but it has been difficult to determine precisely which signaling pathways and cellular responses are activated after PRP treatment. Additionally, macrophages play an important role in modulating tendon regeneration, but the influence of PRP on determining whether macrophages assume a proinflammatory or anti-inflammatory phenotype remains unknown. PURPOSE: To use genome-wide expression profiling, bioinformatics, and protein analysis to determine the cellular pathways activated in fibroblasts treated with PRP. The effect of PRP on macrophage polarization was also evaluated. STUDY DESIGN: Controlled laboratory study. METHODS: Tendon fibroblasts or macrophages from rats were cultured and treated with either platelet-poor plasma (PPP) or PRP. RNA or protein was isolated from cells and analyzed using microarrays, quantitative polymerase chain reaction, immunoblotting, or bioinformatics techniques. RESULTS: Pathway analysis determined that the most highly induced signaling pathways in PRP-treated tendon fibroblasts were TNFα and NFκB pathways. PRP also downregulated the expression of extracellular matrix genes and induced the expression of autophagy-related genes and reactive oxygen species (ROS) genes and protein markers in tendon fibroblasts. PRP failed to have a major effect on markers of macrophage polarization. CONCLUSION: PRP induces an inflammatory response in tendon fibroblasts, which leads to the formation of ROS and the activation of oxidative stress pathways. PRP does not appear to significantly modulate macrophage polarization. CLINICAL RELEVANCE: PRP might act by inducing a transient inflammatory event, which could then trigger a tissue regeneration response.

Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear.

PURPOSE: Intra-articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. METHODS: At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre-injection, during post-injection anaesthetic phase, and at 14 days post-injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. RESULTS: Fifty-four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre-injection NRS score was 7.0 (range 2.5-10.0), post-injection anaesthetic phase was 1.0 (range 0.0-5.0), and 14 day post-injection was 5.0 (range 0.0-10.0). As a group, NRS scores significantly diminished from post-injection anaesthetic phase to 14 days post-injection (p < 0.001). At 14 days post-injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. CONCLUSION: In patients with symptomatic FAI and labral tear, intra-articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic-only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool.

Modest mid-term outcomes after isolated arthroscopic debridement of acetabular labral tears.

PURPOSE: Currently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2-year follow-up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI). METHODS: The records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan-Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2-year follow-up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes. RESULTS: Fifty-nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow-up of 5 (range 2-14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6-60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores. CONCLUSIONS: Isolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.

Allograft versus autograft in posterior cruciate ligament reconstruction: an evidence-based systematic review.

Controversy exists as to the superior graft source for posterior cruciate ligament (PCL) reconstruction. Allogeneic and autogeneic tissue have unique advantages and disadvantages, but little is known about the performance of one versus the other. This study is an evidence-based, systematic literature review comparing clinical and functional outcomes of allograft and autograft PCL reconstruction. A search was conducted via the Cochrane and MEDLINE databases for all relevant studies meeting the following inclusion criteria: (1) English language, (2) human subjects, (3) between the years 1980 and 2011, (4) minimum 24-month follow-up, (5) measures of clinical and functional outcomes, and (6) patients with isolated grade II/III PCL injuries who had failed nonoperative management and were deemed clinically and functionally unstable. Excluded studies were (1) technique articles, (2) case reports, and (3) patients with additional ligamentous or bony injuries. A total of 19 relevant studies were identified (2 direct comparison, 5 allograft, and 12 autograft). No appreciable differences between allograft and autograft PCL reconstruction were identified. A paucity of data exists comparing allogeneic and autogeneic PCL reconstruction, but satisfactory clinical and functional results have been obtained with both graft sources.

Treatment of anterior cruciate ligament injury in skeletally immature patients.

The incidence of ACL tears is rising in the pediatric and adolescent populations as these individuals succumb to traumatic and nontraumatic athletic injuries. Management of this condition in the skeletally immature patient poses a challenge and is controversial. Operative reconstruction carries the concern for damage to the physis with resultant limb length inequality and angular joint deformity but provides stability to the knee and allows return of function in most patients. On the other hand, nonoperative treatment has been shown to carry an increased risk of meniscal and articular cartilage damage and is difficult from a compliance standpoint in this demographic. For the majority of skeletally immature patients, operative treatment is recommended as it has shown good clinical and functional results with minimal risk of growth disturbance. This paper aims to address the natural course of ACL injuries in the skeletally immature patient, treatment options with associated complications, and current preventative strategies.