Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality. Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys. Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8). Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management. Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

Results from a United States Investigational Device Study of Adhesive Capsulitis Embolization in the Treatment of Shoulder Pain: The Adhesive Capsulitis Embolization Study.

PURPOSE: To evaluate the safety and efficacy of arterial embolization to relieve shoulder pain secondary to adhesive capsulitis (AC). MATERIALS AND METHODS: In total, 20 patients (18 females, 2 males; mean age, 51 years) with AC resistant to >30 days of conservative treatment were enrolled in a multicenter prospective study. Adhesive capsulitis embolization was performed with 75-µm or 200-µm spherical particles. Subjects were assessed before and after the procedure with magnetic resonance imaging, visual analog scale (VAS; 0-100 mm) scores, Single Assessment Numeric Evaluation (SANE; 0-100) scores, and American Shoulder and Elbow Surgeons (ASES; 0-100) scores. Adverse events were recorded at all follow-up time points. RESULTS: Hypervascularity was identified and embolization was technically successful in all patients, with 83 arteries embolized in 20 patients. Baseline VAS, SANE, and ASES scores before the procedure were 89.2 mm, 27.2, and 30.9, respectively. The 1-month (n = 19), 3-month (n = 18), and 6-month (n = 12) follow-ups demonstrated significant improvements. At the 1-month follow-up, VAS score decreased by 31.8 (P = 1.2E-11), SANE score increased by 22.1 (P = 1.8E-8), and ASES score increased by 14.2 (P = 4.3E-5). At the 6-month follow-up, VAS score decreased by 62.1 (P = 7.0E-11), SANE score increased by 55.4 (P = 4.1E-10), and ASES score increased by 44.5 (P = 1.8E-6). Due to the coronavirus pandemic, the study ended early; 6 patients did not complete the 6-month follow-up. No major adverse events were noted. CONCLUSIONS: Interim findings suggest that arterial embolization is safe and effective for patients with AC refractory to conservative treatment.

Biomechanical Comparison of Anatomic Restoration of the Ulnar Footprint vs Traditional Ulnar Tunnels in Ulnar Collateral Ligament Reconstruction.

BACKGROUND: Current techniques for ulnar collateral ligament (UCL) reconstruction do not reproduce the anatomic ulnar footprint of the UCL. The purpose of this study was to describe a novel UCL reconstruction technique that utilizes proximal-to-distal ulnar bone tunnels to better re-create the anatomy of the UCL and to compare the biomechanical profile at time zero among this technique, the native UCL, and the traditional docking technique. HYPOTHESIS: The biomechanical profile of the anatomic technique is similar to the native UCL and traditional docking technique. STUDY DESIGN: Controlled laboratory study. METHODS: Ten matched cadaveric elbows were potted with the forearm in neutral rotation. The palmaris longus tendon graft was harvested, and bones were sectioned 14 cm proximal and distal to the elbow joint. Specimen testing included (1) native UCL testing performed at 90° of flexion with 0.5 N·m of valgus moment preload, (2) cyclic loading from 0.5 to 5 N·m of valgus moment for 1000 cycles at 1 Hz, and (3) load to failure at 0.2 mm/s. Elbows then underwent UCL reconstruction with 1 elbow of each pair receiving the classic docking technique using either anatomic (proximal to distal) or traditional (anterior to posterior) tunnel locations. Specimen testing was then repeated as described. RESULTS: There were no differences in maximum load at failure between the anatomic and traditional tunnel location techniques (mean ± SD, 34.90 ± 10.65 vs 37.28 ± 14.26 N·m; P = .644) or when including the native UCL (45.83 ± 17.03 N·m; P = .099). Additionally, there were no differences in valgus angle after 1000 cycles across the anatomic technique (4.58°± 1.47°), traditional technique (4.08°± 1.28°), and native UCL (4.07°± 1.99°). The anatomic group and the native UCL had similar valgus angles at failure (24.13°± 5.86° vs 20.13°± 5.70°; P = .083), while the traditional group had a higher valgus angle at failure when compared with the native UCL (24.88°± 6.18° vs 19.44°± 5.86°; P = .015). CONCLUSION: In this cadaveric model, UCL reconstruction with the docking technique utilizing proximal-to-distal ulnar tunnels better restored the ulnar footprint while providing valgus stability comparable with reconstruction with the docking technique using traditional anterior-to-posterior ulnar tunnel locations. These results suggest that utilization of the anatomic tunnel location in UCL reconstruction has similar biomechanical properties to the traditional method at the time of initial fixation (ie, not accounting for healing after reconstruction in vivo) while keeping the ulnar tunnels farther from the ulnar nerve. Further studies are warranted to determine if an anatomically based UCL reconstruction results in differing outcomes than traditional reconstruction techniques. CLINICAL RELEVANCE: Current UCL reconstruction techniques do not accurately re-create the ulnar UCL footprint. The UCL is a dynamic constraint to valgus loads at the elbow, and a more anatomic reconstruction may afford more natural joint kinematics. This more anatomic technique performs similarly to the traditional docking technique at time zero, and the results of this study may offer a starting point for future in vivo studies.

Protocol for a multicenter, randomised controlled trial of surgeon-directed home therapy vs. outpatient rehabilitation by physical therapists for reverse total shoulder arthroplasty: the SHORT trial.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has emerged as a successful surgery with expanding indications. Outcomes may be influenced by post-operative rehabilitation; however, there is a dearth of research regarding optimal rehabilitation strategy following RTSA. The primary purpose of this study is to compare patient reported and clinical outcomes after RTSA in two groups: in one group rehabilitation is directed by formal, outpatient clinic-based physical therapists (PT group) as compared to a home therapy group, in which patients are instructed in their rehabilitative exercises by surgeons at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care and quality of life between the two groups. METHODS: This randomised controlled trial has commenced at seven sites across the United States. Data is being collected on 200 subjects by clinical research assistants pre-operatively and post-operatively at 2, 6, and 12 weeks, 6 months, 1 and 2 year visits. The following variables are being assessed: American Shoulder and Elbow Surgeons (ASES), pain level using the numeric pain scale, the Single Assessment Numeric Evaluation (SANE) score, and shoulder active and passive range of motion for analysis of the primary aim. Chi square and t-tests will be used to measure differences in baseline characteristics of both groups. Repeated measures linear mixed effects modeling for measurement of differences will be used for outcomes associated with ASES and SANE and scores, and range of motion measures. Secondary aims will be analyzed for comparison of complications, cost, and quality of life assessment scores using data obtained from the PROMIS 29 v. 2, questionnaires administered at standard of care post-operative visits, and the electronic health record. Subjects will be allowed to crossover between the PT and HT groups, and analysis will include both intention-to-treat including patients who crossed over, and a second with cross-over patients removed, truncated to the time they crossed over. DISCUSSION: RTSA is being performed with increasing frequency, and the optimal rehabilitation strategy is unclear. This study will help clarify the role of formal physical therapy with particular consideration to outcomes, cost, and complications. In addition, this study will evaluate a proposed rehabilitation strategy. TRIAL REGISTRATION: This study is registered as NCT03719859 at ClincialTrials.gov .

Surgical treatment for recurrent shoulder instability: factors influencing surgeon decision making.

BACKGROUND: The optimal surgical approach for recurrent anterior shoulder instability remains controversial, particularly in the face of glenoid and/or humeral bone loss. The purpose of this study was to use a contingent-behavior questionnaire (CBQ) to determine which factors drive surgeons to perform bony procedures over soft tissue procedures to address recurrent anterior shoulder instability. METHODS: A CBQ survey presented each respondent with 32 clinical vignettes of recurrent shoulder instability that contained 8 patient factors. The factors included (1) age, (2) sex, (3) hand dominance, (4) number of previous dislocations, (5) activity level, (6) generalized laxity, (7) glenoid bone loss, and (8) glenoid track. The survey was distributed to fellowship-trained surgeons in shoulder/elbow or sports medicine. Respondents were asked to recommend either a soft tissue or bone-based procedure, then specifically recommend a type of procedure. Responses were analyzed using a multinomial-logit regression model that quantified the relative importance of the patient characteristics in choosing bony procedures. RESULTS: Seventy orthopedic surgeons completed the survey, 33 were shoulder/elbow fellowship trained and 37 were sports medicine fellowship trained; 52% were in clinical practice ≥10 years and 48% <10 years; and 95% reported that the shoulder surgery made up at least 25% of their practice. There were 53% from private practice, 33% from academic medicine, and 14% in government settings. Amount of glenoid bone loss was the single most important factor driving surgeons to perform bony procedures over soft tissue procedures, followed by the patient age (19-25 years) and the patient activity level. The number of prior dislocations and glenoid track status did not have a strong influence on respondents' decision making. Twenty-one percent glenoid bone loss was the threshold of bone loss that influenced decision toward a bony procedure. If surgeons performed 10 or more open procedures per year, they were more likely to perform a bony procedure. CONCLUSION: The factors that drove surgeons to choose bony procedures were the amount of glenoid bone loss with the threshold at 21%, patient age, and their activity demands. Surprisingly, glenoid track status and the number of previous dislocations did not strongly influence surgical treatment decisions. Ten open shoulder procedures a year seems to provide a level of comfort to recommend bony treatment for shoulder instability.

The value of shoulder replacement and rotator cuff surgery: the patients' perspective.

BACKGROUND: With the continued rise in health care costs, value-based care in orthopedics is more important than ever. Health care providers, policymakers, and insurance companies all have input into defining and setting the level of this value. The purpose of this study was to evaluate patient perception of value in rotator cuff repair (RCR) and total shoulder replacement (TSA) using a population composed only of patients who underwent the procedure. METHODS: We were able to obtain complete data from 191 of the 250 patients in the RCR cohort and 211 of the 250 patients in the TSA cohort. Patients were asked what they believe a surgeon should be reimbursed for performing RCR or TSA, what they would be willing to pay for the procedure, and to rate the importance of each aspect of their care. Patients then estimated what Medicare reimbursed for the procedure they underwent. RESULTS: The mean result for patients surveyed regarding a reasonable fee for surgeons was $9870 for RCR and $14,231 for TSA. The mean patient estimate for actual Medicare reimbursement was $5705 for RCR and $9372 for TSA. Fifty-seven percent thought that payment for RCR was too low, and 76% thought that it was too low for TSA. When asked to rate the importance of each aspect of their care, RCR patients felt that 46% should go to the surgeon. TSA patients felt that surgeons should receive 47%. CONCLUSION: In agreement with prior studies, patients perceived the monetary value of RCR and TSA to be much higher than current Medicare schedules.

A prospective study assessing the political advocacy of American Shoulder and Elbow Surgeons members.

BACKGROUND: This study assessed the current political standings and active political engagement of American Shoulder and Elbow Surgeons (ASES) members along with the political process as it relates to health care policy. METHODS: This survey study involved 552 ASES members. The survey was open for 2 weeks. Responses were received from 254 of the 552 members (46%), and their answers were analyzed. RESULTS: Six (2%) of the responding members were solo practitioners, 100 (39%) belonged to a private practice, 106 (42%) were providers at academic institutions or residency training programs, 25 (10%) were employed by a hospital, and 17 (7%) categorized themselves as other. Email was the preferred method of communication. Of all responding members, 110 (43%) stated they had contributed to the American Academy of Orthopaedic Surgery Political Advocacy Committee in the last 12 months. Four (10%) of the responding members have a relationship with an elected official, and 220 (87%) would be willing to become a key contact and reach out to a legislator. CONCLUSION: Moving forward, this survey can be used to better shape the political advocacy efforts of the ASES and potentially other subspecialty societies. The response that "a high percentage of members would like to be more involved" suggests the need for a program to help further educate and facilitate the membership on political advocacy.

Management of Midshaft Clavicle Fractures in Adults.

Fractures of the clavicle are common injuries that occur across all age groups but are most frequently seen in the young, active patient population. Among the different types of clavicle fractures, those occurring in the middle third of the clavicular shaft are the most common. Historically, most of these fractures were treated by closed means even when notable displacement was present. Recently, there has been a renewed interest in assessing the best treatment option for these patients. Although nonsurgical treatment is a reliable method for treating many of these fractures, more recent data suggest that fractures with notable displacement (>2 cm of shortening or >100% displacement) and/or comminution have better short-term outcomes and lower rates of nonunion with surgical management. Current surgical options include superior plating, anterior-inferior plating, dual plating, and intramedullary nail fixation.

Patient perception of physician reimbursement in elective shoulder surgery.

BACKGROUND: A previous study revealed that patients perceived physician reimbursement to be much higher than current Medicare schedules for hip and knee replacement. The purpose of this study was to evaluate patient perception of surgeon reimbursement for total shoulder replacement (TSA) and rotator cuff repair (RCR). METHODS: The study surveyed 250 patients. Patients were asked what they believe a surgeon should be reimbursed for performing TSA and RCR. Patients were then asked to estimate what Medicare reimbursed for each of these procedures. We then revealed the Medicare reimbursement rate for TSA and RCR, and patients were asked to comment. Finally, patients were asked whether surgeons with advanced shoulder training should receive additional payments. RESULTS: Patients thought that surgeons should receive $13,178 for TSA and $8459 for RCR. Patients estimated actual Medicare reimbursement was $7177 for TSA and $4692 for RCR. Eighty percent of patients stated that Medicare reimbursement was too low for TSA, 75% thought that payment for RCR was lower than what it should be. Less than 1% of patients felt that it was higher than it should be. A total of 87% of patients thought that surgeons with advanced shoulder training should be reimbursed at a higher rate. CONCLUSION: Patients perceived the values of TSA and RCR were much higher than current Medicare schedules. This is in agreement with prior surveys. Continued decreases in Medicare reimbursements may force surgeons to not participate in Medicare and create a potential access issue. Further investigation should focus on identifying how many surgeons may opt out.

Technical pitfalls of shoulder hemiarthroplasty for fracture management.

Although most proximal humerus fractures can be treated nonoperatively, 4-part fractures and 3-part fractures/dislocations in elderly patients often require management with prosthetic arthroplasty. Reverse arthroplasty is gaining in popularity, but hemiarthroplasty still has a role in the management of 4-part and some 3-part fractures and dislocations. The 2 most important technical factors influencing functional outcome in hemiarthroplasty patients are the restoration of the patient's correct humeral head height and version, and healing of the greater and lesser tuberosities in an anatomic position. Hemiarthroplasty for proximal humerus fracture provides predictable pain relief, but functional recovery is much less predictable.

Pulmonary embolism after shoulder arthroscopy.

Deep venous thrombosis and pulmonary embolism events are common complications following lower-extremity orthopedic surgery. Conversely, deep venous thrombosis and pulmonary embolism events are rare following upper-extremity surgery, specifically shoulder arthroscopy. The purpose of this article is to emphasize the necessity of performing a thorough preoperative workup to uncover possible risk factors for deep venous thrombosis/pulmonary embolism despite the rare occurrence of developing a pulmonary embolism following shoulder arthroscopy. This article describes 3 patients who developed a nonfatal pulmonary embolism following elective shoulder arthroscopy. All 3 surgeries were performed with the patient in the lateral decubitus position. No complications were noted intraoperatively. Symptoms appeared at postoperative days 14, 29, and 2, respectively. One patient demonstrated no risk factors for developing a pulmonary embolism, whereas the other 2 exhibited risk factors for deep venous thrombosis and pulmonary embolism. Pulmonary embolism is a rare but serious complication following shoulder arthroscopy. Shoulder surgeons should be aware of the presenting signs and symptoms. Mechanical or chemical prophylaxis should be administered for patients with identified coagulopathic risk factors. Although it is rare for patients to develop a pulmonary embolism following upper-extremity shoulder arthroscopy, orthopedic surgeons must be aware of the possibility that a pulmonary embolism can occur after elective, uncomplicated shoulder arthroscopy. Surgeons should consider prophylactic measures for patients with identified coagulopathy disorders.

Defining functional shoulder range of motion for activities of daily living.

INTRODUCTION: The range of motion (ROM) in the wrist and elbow required for daily activities has been reported to be less than the normal anatomic ROM. This functional ROM has not been defined for the shoulder. Many shoulder outcome assessment tools use specific functional tasks of daily living to score functional results of treatment. This study quantified the total shoulder ROM required to perform the functional tasks of the American Shoulder and Elbow Surgeon (ASES), Simple Shoulder Test (SST), and University of Pennsylvania (U-Penn) Shoulder Score (PSS). MATERIALS AND METHODS: The FASTRAK electromagnetic tracking system (Colchester, VT, USA) was used to test 40 shoulders in 20 volunteers with no shoulder pathology found on physical examination. Three sensors were used: 1 each on the T3 spinous process, the scapular spine, and the arm over the distal humerus. Subjects performed each functional task of the ASES, SST, and PSS while flexion, extension, abduction, adduction, external rotation, and internal rotation were recorded. RESULTS: Average shoulder motions required to perform the 10 functional tasks were flexion, 121° ± 6.7°; extension, 46° ± 5.3°; abduction, 128° ± 7.9°; cross-body adduction, 116° ± 9.1°; external rotation with the arm 90° abducted, 59° ± 10°; and internal rotation with the arm at the side, 102° ± 7.7°. CONCLUSION: Although attaining full motion is a reasonable goal of all shoulder treatment, our results indicate that less ROM is required to perform the functional tasks used in common outcome tools.

Management and outcomes of latissimus dorsi and teres major injuries in professional baseball pitchers.

BACKGROUND: Very little data exist on latissimus dorsi (LD) and teres major (TM) injuries in professional baseball pitchers. PURPOSE: This review was undertaken to report on the management and outcomes of baseball pitchers with injury to 1 or both of these muscles. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of 16 professional baseball pitchers diagnosed and treated for an LD and/or TM tear between 2002 and 2008 was performed. Magnetic resonance imaging confirmed the diagnosis in all cases. The mean age was 28.1 years. All were treated nonoperatively with rest, rehabilitation, and return to pitching after a throwing program. The injuries included tendon avulsions in 6 athletes and strains in 10. Length of disabled time, return to prior level of pitching, and recurrences were noted. RESULTS: Fifteen of 16 pitchers (94%) returned to the same or higher level of play. The mean time to throwing was 35.6 days. Mean time to pitching was 61.9 days. Nine of 16 injuries (56%) were season-ending. Mean total time lost for athletes returning the same season was 82.4 days. Two of 16 pitchers (13%) sustained recurrent injuries. Prior shoulder and elbow injuries were noted in 75% (12 of 16). CONCLUSION: Injury of the LD and/or TM can occur in pitchers. Nonoperative treatment is successful in allowing a return to high-level pitching.

Open luxatio erecta: a case report and literature review.

Luxatio erecta humeri is a rare clinical entity, comprising 0.5% of all glenohumeral dislocations. Even more uncommon, open luxatio erecta has only been described three times dating back to the 1800s. These cases report poor results including death from sepsis, avascular necrosis, and severely limited motion. We now report a fourth case of open luxatio erecta secondary to a work-related injury.

Cost analysis of outpatient anterior cruciate ligament reconstruction: autograft versus allograft.

BACKGROUND: Prior studies suggest the cost of allograft anterior cruciate ligament (ACL) reconstruction is less than that for autograft reconstruction. Charges in these studies were influenced by patients requiring inpatient hospitalization. QUESTION/PURPOSE: We therefore determined if allograft ACL reconstruction would still be less costly if all procedures were performed in a completely outpatient setting. METHODS: We retrospectively reviewed 155 patients who underwent ACL reconstruction in an ambulatory surgery center between 2001 and 2004; 105 had an autograft and 50 had an allograft. Charges were extracted from itemized billing records, standardized to eliminate cost increases, and categorized for comparison. Surgeon and anesthesiologist fees were not included in the analysis. Groups were compared for age, gender, mean total cost, mean cost of implants, and several other cost categories. RESULTS: The mean total cost was $5465 for allograft ACL reconstruction and $4872 for autograft ACL reconstruction. There were no differences in complications between the two groups. CONCLUSIONS: Allograft ACL reconstruction was more costly than autograft ACL reconstruction in the outpatient setting. The cost of the allograft outweighs the increased surgical time needed for harvesting an autograft. LEVEL OF EVIDENCE: Level II, economic and decision analyses. See Guidelines for Authors for a complete description of levels of evidence.

Neer Award 2005: Peripheral nerve function during shoulder arthroplasty using intraoperative nerve monitoring.

The incidence of neurologic injury after shoulder arthroplasty has been reported to be 1% to 4%. However, the true incidence may be higher, because injury is identified only clinically and examination of the post-arthroplasty shoulder is difficult. This study used intraoperative nerve monitoring to identify the incidence, pattern, and predisposing factors for nerve injury during shoulder arthroplasty. Continuous intraoperative monitoring of the brachial plexus was performed in 30 consecutive patients undergoing shoulder arthroplasty. Impending intraoperative compromise of nerve function was signaled by sustained neurotonic electromyographic activity or greater than 50% amplitude attenuation of transcranial electrical motor evoked potentials (or both). Arm and retractor positions were recorded and adjusted to relieve tension. Patients with intraoperative nerve alerts underwent diagnostic electromyography at least 4 weeks postoperatively. Of the patients, 17 (56.7%) had 30 episodes of nerve dysfunction (ie, nerve alerts) during surgery. None of these 30 nerve alerts returned to baseline with retractor removal alone. Of the 30 alerts, 23 (76.7%) returned to baseline after repositioning of the arm into a neutral position. Postoperative electromyography results were positive in 4 of 7 patients (57.1%) who did not have a return to baseline transcranial electrical MEPs intraoperatively and in 1 of 10 (10%) whose nerve function did return to baseline. In all cases of positive postoperative electromyographic results, the pattern of nerve involvement matched the pattern of intraoperative nerve dysfunction. The affected nerves included the following: combined (ie, mixed plexopathy) (46.7%), musculocutaneous (20%), axillary (16.7%), ulnar (10%), and radial (6.7%). Prior shoulder surgery and passive external rotation of less than 10 degrees were associated with an increased incidence of nerve dysfunction (P < .05). The incidence of nerve injury during shoulder arthroplasty is likely greater than reported. Positioning of the arm at the extremes of motion should be minimized. Patients with decreased motion (<10 degrees passive external rotation with the arm at the side) and a history of prior open shoulder surgery are at higher risk for nerve injury and should be counseled on the increased risk. This patient population may also be considered for routine nerve monitoring.

Heterotopic ossification in a throwing athlete after elbow arthroscopy.

A case of heterotopic ossification occurring after elbow arthroscopy in a young, healthy, throwing athlete is reported. The heterotopic bone caused a loss of motion post-arthroscopy in the patient and was confirmed with plain radiographs and bone scan. Twenty-two months after elbow arthroscopy, the patient underwent an open excision of the heterotopic bone. He returned to competitive throwing the next season. While this complication is rare after such minimally invasive procedures, this entity should be considered in the differential diagnosis in the throwing athlete who is unable to recover full range of motion after elbow arthroscopy.

Thermal modification of partial tears of the anterior cruciate ligament.

PURPOSE: Partial tears of the anterior cruciate ligament (ACL) are common, representing 10% to 28% of all ACL tears. Untreated partial tears of the ACL may go on to complete rupture in up to 42% of cases, and as few as 30% of patients return to their preinjury activity level. The purpose of this study was to evaluate the effectiveness of thermal modification for the treatment of partial tears of the ACL. TYPE OF STUDY: A prospective, nonrandomized consecutive case series. METHODS: Thirteen patients with a partial tear of a native ACL were treated with thermal modification of the ACL. All patients had a preoperative office examination significant for an end-point to Lachman examination and pivot-glide. All patients had bilateral preoperative KT-1000 measurements. All tears were confirmed by arthroscopy to constitute a 50% or less loss of structural integrity of the ligament. The ACL underwent thermal modification using the Oratec thermal probe (Oratec Interventions, Menlo Park, CA), and was examined by intraoperative KT-1000 testing. Patients were evaluated postoperatively at 6 weeks, and at 3, 6, 12, and 24 months by office examination and functional outcome scoring. RESULTS: KT-1000 arthrometer testing revealed a mean side-to-side difference of 4.35 mm preoperatively (SD = 1.1 mm). At the most recent follow-up, averaging 23 months (range, 18 to 28 months), 10 patients had a negative Lachman examination and no pivot-shift. Two patients had persistent grade II Lachman and complaints of giving way 3 months postoperative. Both patients underwent ACL reconstruction. One patient was lost to follow-up. Of the remaining 10 patients, all patients achieved full extension, and the average flexion range of motion was 131 degrees (SD = 5.6). Compared with the preoperative KT-1000 arthrometer testing, the most recent evaluation revealed a decrease in mean side-to-side difference to 1.9 mm (SD = 1.5 mm). At most recent follow-up, the mean Lysholm score was 96.3 (SD = 4.4), the mean Tegner score was 6.1 (SD = 1.2), and the mean Cincinnati score was 94 (SD = 3.0). CONCLUSIONS: With cautious application, thermal modification may be a viable treatment option for partial tears of the ACL in a select subset of patients. Further investigation is necessary to determine the long-term effectiveness of this procedure. LEVEL OF EVIDENCE: Level IV, Therapeutic Case Series Study (no or historical control group).

Gamma probe assisted biopsy of suspected metastatic rib lesions.

Retrieving diagnostic tissue from a rib lesion can be challenging. Using a hand-held intraoperative gamma probe to target and biopsy the areas of increased radioisotope uptake has been limited largely to use by thoracic surgeons and interventional radiologists. Such techniques also have been used by orthopaedic oncologists in localizing osteoid osteomas. We pursued a similar technique in localizing the rib lesion. During the 10 months, two patients with a history of cancer and recent bone scans indicative of possible rib metastasis required biopsies for definitive tissue diagnosis. Both patients had gamma-probe localization of their rib lesions intraoperatively using minimally invasive techniques. The operation of the probe was simple with a short learning curve. Both patients had biopsies that yielded diagnoses verifying the abnormality on the staging bone scan. Localization was sensitive and accurate with histologic confirmation in both patients. The length and extent of surgery were markedly reduced with no complications. These results match those reported in the literature by thoracic surgeons and radiologists. The hand-held gamma probe assisted biopsy of suspicious rib abnormalities can be an effective surgical technique that the orthopaedic surgeon should consider. Additional experience with the technique will allow an assessment of the sensitivity and specificity.