Arthroscopic versus open distal clavicle excision: comparative results at six months and one year from a randomized, prospective clinical trial.

The purpose of this report is to compare outcomes after arthroscopic versus open distal clavicle excision in the treatment of refractory acromioclavicular joint pain. A randomized, prospective clinical trial comparing the 6-month and 1-year outcomes of patients undergoing open distal clavicle excision (group 1) with those undergoing arthroscopic distal clavicle excision (group 2) was carried out. The Modified American Shoulder and Elbow Surgeons form, visual analog scale pain score, Short Form 36, and satisfaction questions were assessed preoperatively and at 6 months and 1 year postoperatively. Seventeen patients were enrolled. There was a trend across all measures for earlier or better outcomes (or both) after arthroscopic over open treatment. The improvement in visual analog scale pain score from preoperatively to 1 year postoperatively was significant for group 2 but not group 1 (P = .006 vs P = .13). Occult intra-articular pathology was detected and treated in 50% of group 2 patients. Arthroscopic and open distal clavicle excisions both provide significant pain reduction at 1 year. Both are effective surgeries for the treatment of refractory acromioclavicular joint pain. The ability to diagnosis and treat subtle concomitant shoulder pathology is a unique advantage of the arthroscopic approach.

Return to Play After Shoulder Instability Surgery in National Collegiate Athletic Association Division I Intercollegiate Football Athletes.

BACKGROUND: Recent attention has focused on the optimal surgical treatment for recurrent shoulder instability in young athletes. Collision athletes are at a higher risk for recurrent instability after surgery. PURPOSE: To evaluate variables affecting return-to-play (RTP) rates in Division I intercollegiate football athletes after shoulder instability surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Invitations to participate were made to select sports medicine programs that care for athletes in Division I football conferences (Pac-12 Conference, Southeastern Conference [SEC], Atlantic Coast Conference [ACC]). After gaining institutional review board approval, 7 programs qualified and participated. Data on direction of instability, type of surgery, time to resume participation, and quality and level of play before and after surgery were collected. RESULTS: There were 168 of 177 procedures that were arthroscopic surgery, with a mean 3.3-year follow-up. Overall, 85.4% of players who underwent arthroscopic surgery without concomitant procedures returned to play. Moreover, 15.6% of athletes who returned to play sustained subsequent shoulder injuries, and 10.3% sustained recurrent instability, resulting in reduction/revision surgery. No differences were noted in RTP rates in athletes who underwent anterior labral repair (82.4%), posterior labral repair (92.9%), combined anterior-posterior repair (84.8%; P = .2945), or open repair (88.9%; P = .9362). Also, 93.3% of starters, 95.4% of utilized players, and 75.7% of rarely used players returned to play. The percentage of games played before the injury was 49.9% and rose to 71.5% after surgery ( P < .0001). Athletes who played in a higher percentage of games before the injury were more likely to return to play; 91% of athletes who were starters before the injury returned as starters after surgery. Scholarship status significantly correlated with RTP after surgery ( P = .0003). CONCLUSION: The majority of surgical interventions were isolated arthroscopic stabilization procedures, with no statistically significant difference in RTP rates when concomitant arthroscopic procedures or open stabilization procedures were performed. Athletes who returned to play often played in a higher percentage of games after surgery than before the injury, and many played at the same or a higher level after surgery.

Repair of the adult acetabular labrum.

Although hip arthroscopy is a new technique, indications for its use are rapidly expanding. With better utilization and understanding of both radiologic assessment of hip pathology and clinical examination, specific intra-articular derangement is being identified. Longitudinal, peripheral, and intrasubstance anterior hip labral tears can be repaired using anterior paratrochanteric and anterior portals with standard hip arthroscopy equipment. Repair of the torn labrum may help re-establish the anatomic function of the labrum, thereby preventing biomechanical compromise through surgical debridement, which may lead to degenerative changes associated with osteoarthritis. Although long-term results are still unknown, results of short-term follow-up are positive.

Autologous hamstring anterior cruciate ligament reconstruction in patients older than 40.

The primary objective in this retrospective review was to assess the patient-specific outcomes and clinical utility of anterior cruciate ligament (ACL) reconstruction using the autologous quadruple-band hamstring technique in patients older than 40. Study results agree with the recent literature and demonstrate the effectiveness of an alternative to the bone-patellar tendon-bone (BPB) technique-an alternative with potentially decreased postoperative morbidity. Results also support the recent conclusion that age alone should not be a limiting factor in whether ACL reconstruction should be performed. We found that appropriately selected patients may experience significant improvements in stability, function, and pain after ACL reconstruction with the quadruple-band hamstring autograft technique. For outcomes after ACL reconstruction, there seems to be no significant difference between the sexes or between patients with and without associated injuries in this population. This study also supports use of the autologous hamstring technique as a viable option for older patients-with results similar to those of the BPB technique. The autologous hamstring technique was associated with excellent patient satisfaction and excellent functional outcome with limited postoperative morbidity. This technique may become the preferred approach for the older athlete, given its limited morbidity and equivalent clinical stability.

Transforaminal lumbar interbody fusion: unilateral versus bilateral disk removal--an in vivo study.

We conducted a study to quantify the attainable cross-sectional area available for fusion and the mean volume of disk removed with a unilateral transforaminal lumbar interbody fusion (TLIF). Starting with the unilateral approach and completing the procedure with a bilateral approach, we removed the maximal amount of disk material. Postoperative computed tomography (CT) images were used to estimate the cross-sectional area/vertebral endplate available for bone grafting and fusion. Results showed that, using the unilateral approach, we removed 11.8 cm3 (range, 7-25 cm3) of disk material--or more than 69% of the total volume of resected disk. Postoperative CT images confirmed that more than 56% of the endplate cross-sectional area is available for fusion using the unilateral approach. We conclude that unilateral TLIF removes sufficient disk material for achieving a solid and stable arthrodesis while minimizing neural retraction and dural exposure.

Acetabular labral tears: diagnostic accuracy of clinical examination by a physical therapist, orthopaedic surgeon, and orthopaedic residents.

BACKGROUND: Previous studies have shown military physical therapists (PT) to have comparable clinical diagnostic accuracy (CDA) and interobserver agreement to orthopaedic surgeons (OS). However, no studies have examined hip pathology or used intraoperative findings as the reference standard for diagnosis. OBJECTIVE: To compare the CDA of physical examination findings among a PT, an OS, and two surgical orthopaedic residents (ORs) for hip labral tears. METHODS: Thirty-six patients (15 males, 21 females) aged 18-47 (mean + SD, 31.4 + 8.1 years) with 37 symptomatic hips were enrolled in a prospective study and underwent a standardized clinical examination followed by hip arthroscopy. A PT, an OS, and two ORs independently performed history and examinations with the emphasis of diagnosis on the results of six special tests. RESULTS: Thirty-two of 37 individuals (86%) had labral tears to the hip at arthroscopy. Analysis of agreement between clinical diagnosis and intra-operative findings of a labral tear produced a CDA of 85.3% (29/34 correct) for the PT, 84.4% (27/32 correct) for the OS, and 80.0% (24/30 correct) for ORs. No significant difference in CDA occurred in comparing the PT, OS, and ORs. CONCLUSIONS: Using arthroscopy as the reference standard, hip labral tears were clinically suspected with 80-85% accuracy. The clinical diagnostic accuracy of the PT, OS, and ORs was high with no significant difference between examiners. In this study, an experienced PT, an OS, and two ORs demonstrated similarly high diagnostic skills.