Venous thromboembolism: Exploring incidence and utility of screening in spinal cord injury.

OBJECTIVE: To assess the incidence and possible risk factors for venous thromboembolism (VTE) in patients admitted to a SCI rehabilitation center. DESIGN: Retrospective review. SETTING: Acute neurorehabilitation hospital specializing in SCI. METHODS: Records of 228 consecutive admissions were reviewed. All patients received screening four limb ultrasounds on admission. Charts were reviewed to determine whether VTE was diagnosed at the acute care hospital or in the rehabilitation center; either on admission screening or later in the rehabilitation stay. Charts were reviewed to identify potential risk factors for VTE as well as the incidence of bleeding complications in patients on full anticoagulation. RESULTS: In this cohort, 115 deep venous thromboses (DVTs) were identified in the following settings: 27% in acute care [n = 31], 70% on admission to rehabilitation [n = 80], and 24% during the rehabilitation stay [n = 28]. Of those on therapeutic anticoagulation due to admission diagnosis of VTE [n = 63], 12.7% developed recurrent DVT and 9.5% had bleeding complications. Of those who were initiated and continued on therapeutic anticoagulation, there was zero incidence of PE. Risk factors for the development of VTE included age, body mass index (BMI), rehabilitation length of stay, injury etiology, spinal cord-related surgery, and history of inferior vena cava filter. CONCLUSIONS: DVT was identified in 70% of this cohort with screening ultrasound on admission to rehabilitation and of those initiated and continued on therapeutic anticoagulation, none developed PE, while 9.5% had bleeding complications. Given the findings of this study, prospective research in noninvasive vascular ultrasound screening for VTE should be considered.

Venous Thromboembolism: Exploring Incidence and Utility of Screening in Individuals With Brain Injury.

OBJECTIVE: To determine the incidence of VTE in the population with brain injuries (BIs) using ultrasonography, and to assess the risk of pulmonary embolism (PE) development and/or bleeding complications related to anticoagulation. DESIGN: Retrospective study. SETTING: Acute rehabilitation hospital. PARTICIPANTS: 238 individuals with moderate to severe BI who were routinely screened for VTE with ultrasonography on admission to rehabilitation (N=238). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Retrospective chart review was performed to identify individuals who were diagnosed with VTE at the following 3 time points: in acute care prior to admission to rehabilitation, at the time of admission diagnosed via screening examination, and after admission to rehabilitation. Additionally, risk factors for VTE, PE, and incidence of bleeding complications related to therapeutic anticoagulation were assessed. RESULTS: 123 deep vein thromboses (DVTs) were identified with 38.2% in acute care (n=47), 69.1% on admission to rehabilitation (n=85), and 7.3% during the course of rehabilitation stay (n=9). Risk factors for development of VTE included age at injury, body mass index, injury etiology, history of neurosurgical procedure, and surgery during inpatient rehabilitation. Of those who were placed on therapeutic anticoagulation due to admission diagnosis of VTE (n=50), 2% developed recurrent DVT and 2% had bleeding complications. There was zero incidence of PE. CONCLUSION: We demonstrated a high prevalence of VTEs identified on screening ultrasonography on admission to inpatient rehabilitation among individuals with moderate to severe BIs, and low complications related to anticoagulation. Given the findings of this study, prospective research in ultrasonography screening for VTE in moderate to severe BI is needed.

A systematic review of suicidal ideation and behaviors among adults with spinal cord injury.

CONTEXT: Suicide is a public health crisis within the United States. Individuals with spinal cord injury (SCI) are vulnerable to negative outcomes such as suicide. OBJECTIVE: This systematic review describes frequency of suicidal ideation (SI) and behaviors (suicide attempt [SA] and deaths) among samples of adults living with SCI. Associated risk and protective factors of SI and suicidal behaviors were also explored. METHODS: On July 7, 2021, OVID Medline, EMBASE, OVID PsycINFO, Web of Science Core Collection, CINAHL, Cochrane Library, and Google Scholar databases were searched for SI, SA, and deaths by suicide among adults with a history of SCI. Risk of bias (RoB) was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool. Results were synthesized descriptively considering the likely impact of RoB. The updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting method was used. RESULTS: Sixty-nine articles were included. Frequency of SI and SAs within study samples ranged from 4% to 67%, and 0% to approximately 66%, respectively. While assessment methods for SI and SA widely varied, suicide deaths data sources were more consistent. Studies assessing SI and SA generally had high RoB and the overall strength of evidence was low. Stronger observational study designs assessing death by suicide had low RoB and the overall strength of evidence was high. Very few studies examined protective factors. DISCUSSION: Findings support previous work. Quality of evidence, and therefore confidence in the frequency of these outcomes, was impacted by the use of assessment measures without sufficient psychometric properties. The field will benefit from use of psychometrically sound measures to assess for SI, SA and suicide deaths. Furthermore, additional work is needed to elucidate risk and protective factors and to clearly characterize samples to increase generalizability of findings to the larger SCI community, including standardized reporting of SCI characteristics (e.g. use of American Spinal Injury Association classification system). Ultimately, improved suicide assessment and risk management is expected to prevent suicide among those living with SCI. REGISTRATION: CRD42020164686.

Long-Term Follow-Up of Patients With Ventilator-Dependent High Tetraplegia Managed With Diaphragmatic Pacing Systems.

OBJECTIVE: To explore participants' experiences after implantation of a diaphragmatic pacing system (DPS). DESIGN: Cross-sectional, observational study using self-report questionnaires. SETTING: Participants were recruited from 6 Spinal Cord Injury Model System centers across the United States (Craig Hospital, CO; Jefferson/Magee Rehabilitation Hospital, PA; Kessler Rehabilitation Center, NJ; University of Miami, FL; The Shirly Ryan Ability Lab, IL; Shepherd Center, GA). INTERVENTIONS: Not applicable. PARTICIPANTS: Men and women (N=28) with tetraplegia were enrolled in the study between November 2012 and January 2015. MAIN OUTCOME MEASURES: Participants completed self-report questionnaires focused on their DPS usage and mechanical ventilation, as well as their experiences and satisfaction with the DPS. RESULTS: DPS is a well-tolerated and highly successful device to help individuals living with spinal cord injury who are dependent on ventilators achieve negative pressure, ventilator-free breathing. A small percentage of participants reported complications, including broken pacing wires and surgery to replace or reposition wires. CONCLUSIONS: This study provides insight into the usage patterns of DPS and both the potential negative and positive effects that DPS can have on the life of the user. Knowledge gained from this study can provide a foundation for further discussion about the benefits and potential risks of using a DPS to inform an individual's decision to pursue a DPS implant.

Physical activity behavior change for older veterans after dysvascular amputation.

OBJECTIVE: Determine the feasibility of using a physical-activity behavior-change (PABC) intervention for increasing physical activity and reducing disability in Veterans 1-5years following dysvascular lower-limb amputation (LLA). DESIGN: Cross-over, feasibility trial SETTING: VA Geriatric Research Education and Clinical Center and Veterans Homes PARTICIPANTS: 32 Veterans with dysvascular LLA (1-5years after major LLA) INTERVENTION: The home-based study, using telerehabilitation technology, is intended to reduce participant burden by removing transportation and time barriers. Participants will be randomized into two participation periods of three months (Months 1-3 and 4-6). PABC intervention will occur Months 1-3 for GROUP1 and Months 4-6 for GROUP2. During PABC Intervention, participants engage in weekly video interaction with a physical therapist, who uses a collaborative approach to develop self-monitoring, barrier identification, problem solving and action planning skills to improve physical activity. GROUP2 will participate in a no physical activity intervention, attention control in Months 1-3. GROUP1 will have a no contact, intervention "wash-out" period in Months 4-6. MAIN OUTCOME MEASURES: Feasibility will be determined using measures of 1) participant retention, 2) dose goal attainment, 3) participant acceptability, 4) safety, and 5) initial effect size. Effect size will be based on accelerometer-based physical activity and self-report disability using the Late-Life Function and Disability Index. CONCLUSIONS: This study focuses on a prevalent and understudied population with low physical activity and high levels of disability due to dysvascular LLA. The results of this study will guide future development of targeted rehabilitation research to improve long term physical activity and disability outcomes.

Relationship Between the Superior Gluteal Vessels and Nerve at the Greater Sciatic Notch.

Bleeding from the superior gluteal (SG) blood vessels at the greater sciatic notch is frequently encountered during acetabular fracture surgery. The purpose of this study is to define the positional anatomy of the superior gluteal vessels and nerve (SGVAN) at the greater sciatic notch. Twenty-three hemipelvi were dissected in whole human cadavers. The greater sciatic notch and SGVAN were visualized via a posterior surgical approach, identified deep in the greater sciatic notch, and traced superficially. Branches of the SGVAN and their anatomical relationship to each other were recorded. In the notch, SG arteries comprised a single vessel in 18 (78%) of 23 specimens, with all of these dividing at varying distances (1-3.5 cm) along the lateral ilium after dividing into superior and inferior branches. The SG artery branches were contiguous with periosteum of the bony notch in all specimens. More than 1 SG nerve branch was seen in the greater sciatic notch of all specimens, including an inferior branch that exited caudal or caudal-superficial to the SG vessels. The caudal-most SG nerve branch was directly adjacent to the bony notch's periosteum in 15 (65%) of 23 specimens. The SGVAN are at risk in patients undergoing acetabular fracture surgery. Individuals performing surgery along the acetabulum's posterior column would expect to encounter a major SG nerve branch (deep inferior) before encountering the SG vessels in all cases. Iatrogenic injuries to the SGVAN might be prevented by avoiding use of cautery in this area if hemorrhage is encountered.

Evaluation of a commercial bovine colostrum replacer for achieving passive transfer of immunity in springbok calves (Antidorcas marsupialis).

Failure of passive transfer (FPT) occurs in ruminant species when there is inadequate absorption of immunoglobulins from the colostrum. In zoologic establishments, FPT can be a common occurrence in hand-raised ruminant neonates fed insufficient amounts of colostrum replacer (CR) and/or poor-quality CR. The goals of this study were to investigate the efficacy of a commercial bovine CR at achieving adequate passive transfer of immunity and evaluate tests to assess FPT in nondomestic ruminant species. In the past several years, research in dairy calves has shown that passive transfer rates can be dramatically improved if the CR dose is doubled. The treatment group (n = 10) consisted of springbok (Antidorcas marsupialis) calves fed Land O'Lakes bovine commercial CR at a dose of > or = 4.68 g of immunoglobulin G (22 g of CR powder) per kilogram of animal's body weight divided into five feedings over 24 hr. The control group (n=7) consisted of calves that nursed from their dams. This study reported no significant difference between the proportion of calves with adequate passive transfer in the treatment (80%) and control (71%) groups (P= 1.00). Morbidity and mortality rates until weaning were 0% in both groups. The study also determined the sensitivity and specificity values (n = 37) for five serum tests (y-glutamyl-transferase [GGT], globulin, glutaraldehyde coagulation [GC], sodium sulfite turbidity test, and total protein) used to determine passive transfer status in springbok calves. This study recommends the following serum tests and cutoff ranges for determining FPT in springbok calves: globulin < or = 1.85 mg/dl, GGT < or = 228.5 IU/ L, and GC > or = 28 min.

Comparison of colostrum feeding by nipple bottle versus oroesophageal tubing in Holstein dairy bull calves.

OBJECTIVE: To compare the apparent efficiency of absorption of IgG and failure of passive transfer of immunity rates between calves fed colostrum by nipple bottle (NB) and oroesophageal tubing (OET). DESIGN: Randomized controlled study. ANIMALS: 26 Holstein bull calves (age, 4 to 8 hours). PROCEDURES: Calves were randomly assigned to receive colostrum by either NB or OET. Pooled colostrum was used for feeding each group of calves. Calves received either a maximum of 4 L of colostrum fed through an NB over a period of 20 minutes or an equivalent volume of colostrum fed by OET. Subsequently, a pair of similarly aged calves received similar volumes of colostrum with similar immunoglobulin concentrations. Colostrum was fed only once. Thereafter, calves were fed 2 L of milk replacer every 12 hours. All calves survived to at least 48 hours of age. Serum samples were collected prior to feeding colostrum and at 48 hours of age for determination of serum immunoglobulin concentrations. RESULTS: There were no differences in failure of passive transfer of immunity rates and apparent efficiency of absorption of IgG between calves fed by NB or OET. Volume of colostrum fed was the only significant variable in determining failure of passive transfer of immunity in calves at 48 hours. CONCLUSIONS AND CLINICAL RELEVANCE: Reported advantages and disadvantages of either feeding method are likely to be of minimal practical relevance in achieving adequate passive transfer of immunity in calves when calves are fed a similar volume of colostrum with comparable immunoglobulin concentrations.

Cyclic load testing and ultimate failure strength of biodegradable glenoid anchors.

PURPOSE: The purpose of this study was to compare biodegradable glenoid suture anchors by cyclic loading and load to failure testing. METHODS: Seven different suture anchors (BioKnotless and Lupine Loop [DePuy-Mitek, Norwood, MA]; BioPushLock, BioSutureTak, and BioFasTak [Arthrex Corp, Naples, FL]; BioAnchor [Conmed Linvatec, Largo FL]; and BioRaptor [Smith & Nephew, Andover, MA]) were tested in 8 matched pairs of human cadaver fresh-frozen glenoids. The anchors were inserted in rotation into different glenoid rim positions. Sutures attached to the anchors were fixed to an Instron 8871 machine (Instron, Canton, MA) and cyclic loading and destructive testing were performed. The cyclic displacement at 100 and 500 cycles, stiffness, ultimate failure strength, and mode of failure were determined. RESULTS: No statistical difference was found in the ultimate failure load for any of these anchors. The Lupine Loop and BioAnchor had greater 100 cycle and 500 cycle mean displacements than the BioPushLock and BioSutureTak. The Lupine Loop also had greater 100 cycle and 500 cycle mean displacement than the BioFasTak (P < .05). The BioAnchor had greater mean 500 cyclic displacement than the BioFasTak (P < .05). Mean BioSutureTak stiffness was greater than the Lupine Loop, BioAnchor, BioKnotless, and BioRaptor (P < .05). CONCLUSIONS: No differences in ultimate failure strength after cyclic loading were found in these seven biodegradable glenoid anchors (BioKnotless, Lupine Loop, BioPushLock, BioSutureTak, BioFasTak, BioAnchor, and BioRaptor). Most displacement occurred in the first 100 cycles. Displacement at 500 cycles was greater for the Lupine Loop and the BioAnchor than the BioPushLock, BioSutureTak, and BioFasTak. Failure was principally by the anchor pulling out of bone except for the BioSutureTak, which also failed by the suture loop eyelet pulling out of the anchor body, and the BioPushLock which failed by the suture slipping past anchor. CLINICAL RELEVANCE: Biodegradable glenoid anchors did not show statistical difference in ultimate failure load after cyclic loading.

Cyclic load testing of biodegradable suture anchors containing 2 high-strength sutures.

PURPOSE: The purpose of this study was to test 4 different biodegradable suture anchors threaded with 2 high-strength sutures under cyclic loading conditions in humeral cadaveric specimens divided into 2 different age groups. METHODS: Thirty-two paired human cadaveric humeri were stripped of all soft tissue. Two groups were studied: group 1, in which the mean age was 54 years, and group 2, in which the mean age was 70 years. We placed 1 suture anchor at 3 humeral sites per bone (anterior, middle, and posterior greater tuberosity). We tested 24 specimens using each of 4 anchors: TwinFix AB (Smith & Nephew Endoscopy, Andover, MA), BioZip (Stryker Endoscopy, San Jose, CA), Bio-Corkscrew FT (Arthrex, Naples, FL), and SpiraLok (DePuy Mitek, Raynham, MA). The anchor's sutures were grasped with an Instron clamp (Instron, Canton, MA), preloaded, and cycled from 10 to 60 N 500 times, followed by destructive testing. The mean displacement at 500 cycles, yield loads, failure modes, and ultimate loads were recorded. RESULTS: Most cyclic motion occurred during the first 100 cycles. More motion occurred in older bones than in younger bones (P < .05). The mean yield loads were greater for the young group for the SpiraLok anchors than for Bio-Corkscrew FT anchors in the young and old groups (P < .001), TwinFix anchors in the old group (P < .05), and BioZip anchors in the old group (P < .05). The ultimate failure loads for SpiraLok anchors in the young group were greater than for Bio-Corkscrew FT anchors in the young and old groups and BioZip anchors in the old group (P < .05). In group 1 TwinFix AB (P = .01) and BioZip (P = .02) ultimate loads were statistically greater than that for Bio-Corkscrew FT. The TwinFix AB failed by anchor pullout. The Bio-Corkscrew FT failed by eyelet pullout. The BioZip and SpiraLok pulled out in older bone and experienced eyelet breakage in younger bone. None of the 4 anchors reached 5 mm of displacement even after 500 loading cycles. CONCLUSIONS: Most of the displacement occurred in the first 100 cycles. Of all anchors tested, the Bio-Corkscrew FT recorded the lowest displacement after 500 cycles (P < .05). The SpiraLok had the highest ultimate load of all anchors tested (P < .01). CLINICAL RELEVANCE: Rotator cuff anchors perform differently in younger humeral bone than in older humeral bone. Most displacement with cyclic loading occurring between the anchor and bone takes place in the first 100 cycles. Anchors in older bones can be expected to fail at lower loads.

Tendon graft substitutes-rotator cuff patches.

Over the past few years, many biologic patches have been developed to augment repairs of large or complex tendon tears. These patches include both allograft and xenografts. Regardless of their origins, these products are primarily composed of purified type I collagen. Many factors should be considered when choosing an augmentation patch including tissue origin, graft processing, cross-linking, clinical experience, and physical properties. The purpose of this article is to familiarize the sports medicine community with several tendon augmentation grafts: GraftJacket (Wright Medical Technology, Arlington, TN), CuffPatch (Organogenesis, Canton, MA, licensed to Arthrotek, Warsaw, IN), Restore (Depuy, Warsaw, IN), Zimmer Collagen Repair (Permacol) patch (Tissue Science Laboratories Covington, GA, licensed to Zimmer, Warsaw, IN), TissueMend (TEI Biosciences, Boston, MA, licensed to Stryker Howmedica Osteonics, Kalamazoo, MI), OrthoADAPT (Pegasus Biologics, Irvine, CA), and BioBlanket (Kensey Nash, Exton, PA).

Triple-loaded single-anchor stitch configurations: an analysis of cyclically loaded suture-tendon interface security.

PURPOSE: This study evaluated the strength and suture-tendon interface security of different suture configurations from triple-suture-loaded anchors. METHODS: A juvenile bovine infraspinatus tendon was detached and repaired by use of 4 different suture combinations from 2 suture anchors: 3 simple sutures in each anchor (ThreeVo anchor; Linvatec, Largo, FL); 2 peripheral simple stitches and 1 central horizontal mattress suture passed deeper into the tendon, creating a larger footprint (bigfoot-print anchor); 2 peripheral simple stitches with 1 central horizontal mattress stitch passed through the same holes as the simple sutures (stitch-of-Burns); and 2 simple stitches (TwoVo anchor; Linvatec). The constructs were cyclically loaded between 10 N and 180 N for 3,500 cycles and then destructively tested. The number of cycles required to create a 5-mm gap and a 10-mm gap and the ultimate load to failure and failure mode were recorded. RESULTS: The ThreeVo anchor was strongest and most resistant to cyclic loading (P < .01). The TwoVo anchor was least resistant to cyclic loading. The stitch-of-Burns anchor was more resistant to cyclic loading than both the bigfoot-print anchor and the TwoVo anchor (P < .03). The ThreeVo, stitch-of-Burns, and TwoVo anchors were stronger than the bigfoot-print anchor (P < .05). CONCLUSIONS: Three simple sutures in an anchor hold better than two simple sutures. Three simple sutures provide superior suture-tendon security than combinations of one mattress and two simple stitches subjected to cyclic loading. A central mattress stitch placed more medially than two peripheral simple stitches (bigfoot-print anchor) configured to enlarge the tendon-suture footprint was not as resistant to cyclic loading or destructive testing as three simple stitches (ThreeVo anchor). CLINICAL RELEVANCE: Placing a central mattress stitch more medially than 2 peripheral simple stitches to enlarge the tendon-suture footprint was not as resistant to cyclic loading or destructive testing as 3 simple stitches.

Sutures and suture anchors--update 2006.

PURPOSE: To evaluate recently introduced sutures and suture anchors for single pull load to failure strength and failure mode. METHODS: Suture anchors were tested in fresh porcine metaphyseal cortex and cancellous troughs with the use of an established protocol. An Instron machine applied tensile loads parallel to the axis of insertion at a rate of 12.5 mm/sec until failure, and mean anchor failure strengths were calculated. The mode of failure (anchor pull-out, suture eyelet cut-out, or suture failure) was recorded. Anchors tested included the BioRaptor 2.9, BioZip, Super Revo, Impact, Allograft cortical anchor, SpiraLok, Herculon, AxyaLoop titanium anchors 3, 5, and 6.5 mm, AxyaLoop bioabsorbable anchors 3, 5, and 6.5, ParaFix titanium anchors 3, 5, and 6.5, ParaSorb BioAnchors 3, 5.5, and 6.5, and Bio-Corkscrew FT. Sutures were also tested through an established protocol for load to failure. Sutures tested consisted of Orthocord, Ultrabraid (White and CoBraid), ForceFiber, Hi-Fi, MagnumWire, and Maxbraid Polyethylene Plus. RESULTS: Mean failure loads were as follows: BioRaptor 238 N, BioZip 366 N, double-loaded Super Revo 486 N, triple-loaded Super Revo 362 N, Impact 202 N, Allograft cortical anchor 240 N, SpiraLok 289 N, Herculon 819 N, AxyaLoop titanium anchors 3.0 (335 N), 5.0 (485 N), and 6.5 mm (465 N), AxyaLoop bioabsorbable anchors 3 (143 N), 5 (395 N), and 6.5 (369 N), ParaFix titanium anchors 3 (335 N), 5 (485 N), and 6.5 (465 N), ParaSorb BioAnchors 3 (143 N), 5.5 (395 N), and 6.5 (369 N), and Bio-Corkscrew FT (260 N). The sutures all broke at the mid point of their tested strands away from the grips. Mean suture strength for No. 2 Orthocord was 92 N; for No. 2 Ultrabraid CoBraid and White, strengths were 265 N and 280 N, respectively; strength for No. 2 Force Fiber was 289 N, for No. 2 Hi-Fi 250 N, for No. 2 MagnumWire 303 N, and for No. 2 Maxbraid Polyethylene Plus 256 N. CONCLUSIONS: Newer suture products showed significant improvements in load to failure values when compared with braided polyester sutures. Higher load to failure values continue to be seen in metal versus biodegradable anchors and in screw-type versus nonscrew designs. CLINICAL RELEVANCE: Surgeons who prefer stronger sutures now have several high-strength suture options from which to choose. Most of the new anchors tested performed very well.

Meniscal repair with the RapidLoc meniscal repair device.

BACKGROUND: The RapidLoc is an all-inside, self-adjusting, flexible meniscal repair device that combines a suture with an anchor component and, by using a reinforced sliding knot, allows for tightening to compress and hold the repaired meniscal segments. The purpose of this study was to evaluate the clinical success of the RapidLoc device. METHODS: A prospective consecutive series of meniscal repairs performed with the RapidLoc device was studied. Lysholm, Tegner, Cincinnati, IKDC (International Knee Documentation Committee) activity scores, clinical examination findings, and adverse events were recorded on all patients. Associated procedures were recorded. An accelerated postoperative rehabilitation program was followed, independent of whether anterior cruciate ligament (ACL) surgery was also performed. RESULTS: A total of 32 patients underwent 32 meniscal repairs, with an average follow-up of 31 months (18 to 48 months). In all, 23 repairs were done in conjunction with ACL reconstruction, and 9 repairs were carried out in stable knees. Repairs were made to 25 medial menisci and 7 lateral menisci. Tears repaired consisted of peripheral longitudinal tears with an average length of 2 cm (range, 15 to 30 mm). Four failures (12.5%) were arthroscopically documented. Clinical success occurred in 87.5% at the time of last follow-up. At follow-up, mean Tegner score was 5.1 (2.8 preoperative), IKDC activity score was 3.1 (1.8 preoperative), Lysholm score was 93.6 (48.4 preoperative), and mean Cincinnati score was 88.1 (43.7 preoperative). The most common adverse event was cutting of the suture during RapidLoc insertion. One patient had excoriation and grooving of the medial femoral condyle associated with failed repair. Another patient developed a postoperative infection. CONCLUSIONS: The early clinical success rate was 87.5% with the RapidLoc device. Chondral grooving was observed in a single case. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Shoulder arthritis in the young adult: arthroscopy to arthroplasty.

Young adult patients with shoulder arthritis present challenging treatment decisions for the orthopaedic surgeon. Patients treated with shoulder arthroplasty have the youngest average age of all patients who undergo joint arthroplasty. However, in the young, active patient or in those without advanced disease, joint arthroplasty may not be appropriate. Arthroscopic treatment or interposition arthroplasty may provide symptomatic relief without radically compromising future procedures.

Tendon augmentation grafts: biomechanical failure loads and failure patterns.

PURPOSE: The purpose of this study was to determine the load to failure strengths and modes of failure of various commercially available tendon augmentation xenografts and allografts. TYPE OF STUDY: Experimental laboratory study. METHODS: GraftJacket (Wright Medical Technology, Arlington, TN), CuffPatch (Arthrotek, Warsaw, IN), Restore (Depuy, Warsaw, IN), Permacol (Tissue Science Laboratories, Covington, GA; licensed to Zimmer, Warsaw, IN), and TissueMend (TEI Biosciences, Boston, MA; licensed to Stryker Howmedica Osteonics, Kalamazoo, MI) measuring 2 x 5 cm were hydrated according to manufacturers guidelines, a horizontal mattress stitch 5-mm wide was placed 5 mm from the narrow edge of the graft. Tensile loads to failure were applied on the suture while an Instron machine held the graft material and mean loads to failure of the suture graft construct were obtained and modes of graft failure noted. RESULTS: The mean loads to failure were obtained: GraftJacket thin (157 N), GraftJacket MaxForce (182 N), GraftJacket Extreme (229 N), CuffPatch (32 N), Restore (38 N), Permacol (128 N), and TissueMend (70 to 76 N). Failure occurred principally by suture pull-through in all specimens and patterns tended to vary by implant type. CuffPatch and TissueMend tended to fail by isthmus pullout, whereas Restore and Graft jacket failed by end pullout. The tissues were statistically stratified into four groups depending on the material. Human skin (GraftJacket) was the strongest followed by porcine skin (Permacol) and bovine skin (TissueMend). Both in turn were stronger than the porcine small intestine submucosa (Restore and CuffPatch) (P < 0.001). CONCLUSIONS: Suture retention can be reliably tested with a narrow range of standard error utilizing this testing methodology. Skin has higher loads to failure than intestine submucosa. Failure modes differed significantly among the implant types, suggesting that suturing methods for each implant should be considered independently before use. These data cannot be interpreted to suggest that one graft material is clinically superior to another. Rather, each has different properties that the surgeon should recognize when considering their use. CLINICAL RELEVANCE: These grafts have been used as augmentations and substitutions in tendon repairs and as a material for interpositional arthroplasty. These data show that the successful use of these materials requires adequate separation of the fixation sutures and provides an understanding of how each material will fail if subjected to excessive loading during the rehabilitation period.

Midterm results of meniscal repair using the BioStinger meniscal repair device.

PURPOSE: The purpose of this study was to evaluate the midterm healing rate and any adverse events from meniscus repair using the BioStinger meniscus repair device (Linvatec, Largo, FL). METHODS: A retrospective review of a consecutive series of meniscal repairs performed by a single surgeon using the BioStinger was conducted. The BioStinger is cannulated, made of molded poly L-lactic acid, and inserted over a needle into the meniscus tissue. Clinical results and adverse events were noted, and Lysholm, Tegner, Cincinnati, and International Knee Documentation Committee (IKDC) activity scores were obtained on all patients. RESULTS: Forty-one patients underwent 41 meniscal repairs with an average follow-up of 38.6 months (range, 24 to 69 months); 35 meniscus repairs were performed in conjunction with anterior cruciate ligament reconstruction and 6 in stable knees. Tears repaired were peripheral, posterior horn tears with an average length of 2 cm. Clinical evidence of meniscal healing was observed in 95% at the time of last follow-up. Six second-look arthroscopies were performed and 2 failures were found. All other patients were symptom free. At follow-up, the mean Tegner score was 6.1 (2.8 preoperative), IKDC activity score was 3.3 (2.1 preoperative), Lysholm score was 90.6 (48.7 preoperative), and the mean Cincinnati score was 86.7 (41.3 preoperative). Four patients had peripheral migration of the device without skin tenting or perforation; 3 underwent removal of the BioStinger from the soft tissues and the other resolved after 12 months. CONCLUSIONS: The midterm clinical success rate was 95% using the BioStinger device. Adverse events were observed in few cases. LEVEL OF EVIDENCE: Level IV, cases series.

Thermal medial retinaculum shrinkage and lateral release for the treatment of recurrent patellar instability.

PURPOSE: To study a technique of medial retinacular thermal shrinkage and evaluate the clinical effectiveness of this technique. TYPE OF STUDY: Nonrandomized prospective case series. METHODS: A consecutive series of patients with recurrent patellar instability treated with arthroscopic lateral release and medial thermal retinaculum shrinkage using a monopolar radiofrequency probe was assessed subjectively by visual analog scale and both preoperatively and postoperatively by physical examination and Lysholm and Fulkerson knee scores. RESULTS: We evaluated 53 knees with an average follow-up of 53 months (range, 24 to 88 months). The mean Lysholm and Fulkerson scores improved from 45 and 41 to 81 and 82, respectively. Subjectively, 48 of 53 knees (90%) were reported as excellent or good. The average visual analog scale score was 8 out of 10. Five patients failed because of recurrent dislocation (9% recurrence). Additional stabilization procedures were performed in 4 patients. CONCLUSIONS: Medial shrinkage using monopolar thermal energy is effective in treating recurrent patellar instability. Our results were comparable with prior studies using suture plication. The technique avoids additional incisions and decreases operative time. LEVEL OF EVIDENCE: Level IV, therapeutic prospective cohort study.

Arthroscopic osteochondral autografting.

Arthroscopic osteochondral autografting is indicated for unipolar, full thickness articular cartilage lesions between 1 and 2.5 cm in diameter. A stable properly aligned knee is important to a good outcome. This procedure should not be performed in the presence of generalized osteoarthritis. Arthroscopic osteochondral autografting allows the restoration of hyaline articular cartilage with zonal matching of the graft. It is cost-effective, can be performed on an outpatient basis, and results in durable resurfacing with excellent long-term results.