Clinical outcomes following open anterior shoulder stabilization for glenohumeral instability in the young collision athlete.

BACKGROUND: Anterior glenohumeral instability occurs most commonly in those aged 15-29, with 72% of individuals younger than 22 years suffering recurrent episodes; collision athletes are at particular risk. In the setting of subcritical glenoid bone loss, arthroscopic Bankart repair is widely used despite concerns of recurrent dislocations when compared with open techniques. Furthermore, indications for bone-block procedures are evolving with the Latarjet procedure being favored amongst recent authors as a primary stabilization method in elite and contact athletes. OBJECTIVE: To determine the efficacy of open modified Bankart stabilization in treating anterior glenohumeral instability in young collision athletes. METHODS: This was a retrospective review of outcomes of consecutive patients aged 15-20 years who underwent unilateral or bilateral open stabilization for recurrent anterior glenohumeral instability over a 7-year period (2007-2015). The cohort was selected as recent literature suggests that this is the group with the highest redislocation rate and poorest outcomes. Outcome assessments included redislocation rate, return to sport, pain score, patient-related satisfaction scores, and the Western Ontario Shoulder Instability Index. RESULTS: A total of 60 patients (55 male: 5 female) of mean age 18 years (range: 15-20 years) were available for follow-up at 7 years. All but 3 were competitive athletes with 18 competing regionally and 9 internationally; rugby union and rugby league represent the most common sports. Fifty-five of 60 (92%) have returned to their desired level of sport with 62% of athletes returning to their previous level of competition sport and 1 retuning at a higher level. The mean postoperative pain score was 2.5/10. The mean time to return to play was 14 months (range: 5-48 months). Eight of 60 shoulders reported redislocation (13%), 7 of these being traumatic dislocations after return to high-impact sporting activities. At 7 years of follow-up, 4 of 60 shoulders (7%) had undergone revision surgery. CONCLUSION: Young collision athletes represent a challenging cohort of instability patients. This study of open modified Bankart in young collision sport athletes revealed excellent outcomes with 92% return to sport and a low revision rate. The results from this cohort rival those of arthroscopic repair. The open procedure described here in this 7-year series represents a robust, reliable technique that could be considered as an alternative to arthroscopic Bankart due to concern for recurrence, while avoiding potential morbidity and complication of bone-block procedures. There is still a role for the open modified Bankart procedure in treating traumatic anterior instability.

Functional Outcomes After the Surgical Management of Isolated Anterolateral Leg Chronic Exertional Compartment Syndrome.

BACKGROUND: Failure rates of up to 20% have been reported after fasciotomy for chronic exertional compartment syndrome (CECS). There is some evidence that postoperative failure and complication rates are higher in the posterior compartments of the lower leg than the anterolateral compartments. Isolated compartment surgery may put patients at risk of requiring revision surgery because of the risk of developing posterior compartment disease. HYPOTHESIS: Isolated anterolateral fasciotomy for CECS, in the absence of posterior compartment symptoms, produces satisfactory functional outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 2006 and 2012, patients who had positive intracompartment pressure-testing findings and who underwent isolated anterolateral fasciotomy release for CECS were given a self-administered questionnaire. The minimum follow-up was 3 years. The questionnaire addressed time to return to sport and ongoing symptoms. A visual analog scale was used to assess pain during exercise before and after surgery (score: 0, no pain; 10, worst pain imaginable); overall satisfaction with the procedure was assessed as well. Of 31 eligible patients, 20 patients (36 legs operated on) were assessed. RESULTS: Postoperatively, 90% of participants returned to the same or higher level of sport. The mean pain score during exercise before surgery was 8.17, whereas it was 1.74 after surgery. The overall mean patient satisfaction score was 8.64. Only 1 leg (2.8%) went on to develop posterior compartment syndrome. CONCLUSION: Isolated anterolateral fasciotomy for CECS produced excellent functional outcomes. Our rate of recurrence was low compared with those found in the literature, and 90% of participants returned to their same or higher level of sport postoperatively.

A 10-year Retrospective Review of Functional Outcomes of Adolescent Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is an increasingly prevalent sporting injury in adolescents. Surgical reconstruction of the ACL in adolescents has been controversial and there has been little reported on functional outcomes after surgery.The aim of this study was to undertake a retrospective notes review and questionnaire survey of a group of adolescents who had their ACL surgically reconstructed over the previous 10 years, assessing delay to surgery, levels of meniscal damage, reoperation rates, and functional outcomes. METHODS: A retrospective chart review was performed on 100 adolescent patients who underwent arthroscopic ACL reconstruction using a transphyseal technique. These patients were also contacted and completed the Knee Osteoarthritis Outcome Score (KOOS). RESULTS: One hundred patients had their records reviewed. The average age at follow-up was 20.5 (SD, 2.4) years. There were 49 females and 51 males. Meniscal tears were present in 76% of patients at the time of surgery. The rate of medial meniscal tears increased with delay to surgical intervention beyond 3 months. Reoperation rate for these patients was 24%.Eighty patients completed the KOOS questionnaire. Patients were a mean of 4 (SD, 2.2) years postsurgery. The main findings indicate that in the 5 key KOOS domains patients scored a mean of 60 (SD, 13) for symptoms, 65 (SD, 10) for pain, 70 (SD, 6.4) for activities of daily living, 54 (SD, 17.6) for sport and recreation, and 47.2 (SD, 20.1) for quality of life. CONCLUSIONS: This study demonstrates that young people with ACL injuries have a very high associated incidence of meniscal pathology at the time of surgery. There is a high reoperation rate for meniscal surgery and graft failure. Four years post-ACL reconstruction many have not yet returned to a fully functional state.Further research to understand why functional outcomes are modest is required. LEVEL OF EVIDENCE: Level IV-retrospective case series.

The Value of Accurate Magnetic Resonance Characterization of Posterior Cruciate Ligament Tears in the Setting of Multiligament Knee Injury: Imaging Features Predictive of Early Repair vs Reconstruction.

Multiligament knee injury (MLKI) represents a complex set of pathologies treated with a wide variety of surgical approaches. If early surgical intervention is performed, the disrupted posterior cruciate ligament (PCL) can be treated with primary repair or reconstruction. The purpose of our study was to retrospectively identify a critical length of the distal component of the torn PCL on magnetic resonance imaging (MRI) that may predict the ability to perform early proximal femoral repair of the ligament, as opposed to reconstruction. A total of 50 MLKIs were managed at Harborview Medical Center from May 1, 2013, through July 15, 2014, by an orthopedic surgeon. Following exclusions, there were 27 knees with complete disruption of the PCL that underwent either early reattachment to the femoral insertion or reconstruction and were evaluated using preoperative MRI. In a consensus fashion, 2 radiologists measured the proximal and distal fragments of each disrupted PCL using preoperative MRI in multiple planes, as needed. MRI findings were correlated with what was performed at surgery. Those knees with a distal fragment PCL length of ≥41mm were capable of, and underwent, early proximal femoral repair. With repair, the distal stump was attached to the distal femur. Alternatively, those with a distal PCL length of ≤32mm could not undergo repair because of insufficient length and as such, were reconstructed. If early surgical intervention for an MLKI involving disruption of the PCL is considered, attention should be given to the length of the distal PCL fragment on MRI to plan appropriately for proximal femoral reattachment vs reconstruction. If the distal PCL fragment measures ≥41mm, surgical repair is achievable and can be considered as a surgical option.

Arthroscopic treatment of anterior ankle impingement: a prospective study of 46 patients with 5-year follow-up.

BACKGROUND: Midterm outcomes after arthroscopic debridement in patients with anterior ankle impingement without osteoarthritis are currently unclear. PURPOSE: To assess the functional and radiological outcomes after arthroscopic treatment of anterior ankle impingement with a minimum 5-year follow-up in patients without osteoarthritis. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From September 1999 to March 2006, a consecutive series of eligible patients without ankle osteoarthritis and with anterior ankle impingement, who had persistent ankle pain and activity restrictions despite at least 6 months of nonoperative management, underwent standardized arthroscopic debridement and followed uniform postoperative management. Patients were assessed preoperatively and at 6 weeks, 6 months, and 12 months and then at 1-year intervals after surgery until a minimum of 5 years' follow-up had been achieved, with weightbearing ankle dorsiflexion, Foot Functional Index (FFI), and plain radiography including Scranton and McDermott classification (SMC) grade and tibial osteophyte size. RESULTS: A total of 46 patients (42 male, 4 female) were prospectively assessed, with a mean age at surgery of 29 years (range, 16-44 years) and a mean follow-up duration of 5.1 years (range, 5.0-7.5 years). Preoperative ankle radiographs demonstrated a median SMC grade of 2 and a mean tibial osteophyte size of 5.1 mm. At a minimum of 5 years postoperatively, patients demonstrated limited improvement in ankle dorsiflexion (mean, 24.7° [preoperatively] vs 27.0° [final follow-up]; P = .049); however, they demonstrated substantial improvement in the FFI (mean, 20.5 [preoperatively] vs 2.7 [final follow-up]; P < .001). Postoperatively, 84% of patients showed a recurrence of radiological osteophytes, with plain radiographs at final follow-up demonstrating no significant difference in the SMC grade (P = .107) or tibial osteophyte size (P = .212) compared with preoperative imaging. There was no significant effect of patient age, sex, body mass index, or SMC grade at the time of surgery on any of the postoperative outcome measures. CONCLUSION: In this prospective outcome study of 46 patients without osteoarthritis managed arthroscopically for anterior ankle impingement, the functional outcome scores had significantly improved at 5 years postoperatively despite a recurrence of radiographic osteophytes.

Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study.

BACKGROUND: Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture. HYPOTHESIS: There is no difference in the outcome of acute Achilles tendon rupture treated nonoperatively or operatively if controlled early motion is allowed as part of the rehabilitation program. STUDY DESIGN: Randomized, controlled clinical trial; Level of evidence, 1. METHODS: Patients with acute rupture of the Achilles tendon were randomized to surgery or no surgery, with both groups receiving early motion controlled in a removable orthosis, progressing to full weightbearing at 8 weeks from treatment. Both groups were followed prospectively for 12 months with measurements of range of motion, calf circumference, and the Musculoskeletal Functional Assessment Instrument (MFAI) outcome score; any reruptures and any complications were noted. RESULTS: Both groups were comparable for age and sex. There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups. CONCLUSION: This study supports early motion as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. There appears to be no difference between the 2 groups, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon.

Does the priority scoring system for joint replacement really identify those in most need?

The Priority Criteria for Major Joint Replacement Scoring System was introduced to prioritise patients on the basis of clinical and social need for surgery. The purpose of this study was to assess its correlation with the Western Ontario and McMasters Universities Arthritis Index (WOMAC) and musculoskeletal functional assessment questionnaires. Fifty patients placed on the waiting list for total joint arthroplasty were surveyed comparing the physician derived priority score and the patient-derived WOMAC and musculoskeletal functional assessment questionnaires. Results demonstrate a poor correlation between the priority scoring system and the WOMAC and musculoskeletal functional assessment. In addition, the results indicates that the priority scoring system for major joint replacement does not differentiate between severity of impairment secondary to joint disease in patients placed on the surgical waiting list for joint replacement.

Knee dislocations: where are the lesions? A prospective evaluation of surgical findings in 63 cases.

OBJECTIVE: To evaluate soft-tissue injury patterns in a large series of patients with knee dislocations to identify frequency and associations that may aid in surgical planning. DESIGN: Prospective clinical study. SETTING: Two institutions, both level I trauma centers. PATIENTS: Sixty patients with 63 dislocatable knees. RESULTS: Cause of injury was motor vehicle injury in 34 patients, sports in 23 patients, and falls in 3 patients; 71% of knees studied had bicruciate injuries. Eight knees had associated major intraarticular fractures. Vascular disruption occurred in 14% of knees. Peroneal nerve palsies occurred in 14% of knees. All injured knees with complete peroneal nerve palsies had anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament disruptions. The incidence of vascular injury was the same for patients injured in sports as for those injured in road trauma. Reattachable ligamentous avulsions occurred in 19% for anterior cruciate ligament, 51% for posterior cruciate ligament, 64% for medial collateral ligament, and 84% for lateral collateral ligament injuries. Certain injury patterns also had a high association of tendon and capsule avulsions. Proximal lateral collateral ligament injuries were commonly associated with popliteus tendon avulsions and seldom with distal biceps avulsions. Distal lateral collateral ligament injuries were commonly associated with distal biceps avulsions and seldom with popliteus tendon avulsions. Reattachable meniscal capsular avulsions off the tibia occurred predominantly when the collateral ligament injury was a distal avulsion. CONCLUSIONS: This study showed a wide variety of injury patterns. Knees had to have at least two ligaments injured to be dislocatable but not necessarily both cruciate ligaments. Sports injuries have the same pattern of injury as motor vehicle accidents, suggesting similar forces of injury. The study demonstrates a high incidence of reattachable avulsion injuries to ligaments and soft tissues in dislocatable knees. These may not be as easily dealt with if surgery is delayed beyond 3-4 weeks.