Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors.

PURPOSE: The purpose of this study was to establish and analyze a simplified scoring system based on anatomic imaging measurements to predict recurrent instability after primary arthroscopic shoulder capsulolabral repair. METHODS: All patients undergoing primary arthroscopic anterior capsulolabral repair of the shoulder were reviewed. Patients were contacted and charts were reviewed for endpoint of recurrent instability and return to prior level of activity. Predictive variables for recurrent instability studied included age, sex, amount of glenoid bone loss, intact anterior articular arc (IAAA), glenohumeral tracking (off-track), contact sports and overhead sports participation. RESULTS: 540 patients met inclusion criteria and follow-up data with magnetic resonance imaging data were available for 337 shoulders. Average follow-up was 6.2 years(range 3.4-9.3 years). Symptomatic recurrent instability occurred in 102 patients (30.3%) and 68% of contacted patients returned to pre-injury activities. In univariate analysis, age under 21 years, off-track lesions, IAAA <150°, and glenoid bone loss (GBL) of 10% or greater displayed an increased risk of recurrent instability. Multivariable analysis showed these factors remained significant: age <21 (odds ratio [ratio] 2.37), off-track glenoid (OR 2.86), IAAA <150 (OR 3.90), and GBL ≥10% (OR 7.47). A scoring system assigning 1 point each for age and off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10% yielded 79% sensitivity, 75% specificity, 58% positive predictive value, and 89% negative predictive value using a probability value of 20 percent for recurrent instability. CONCLUSION: At mid-term follow-up, recurrent shoulder instability following primary arthroscopic anterior capsulolabral repair was 30% in this series. Younger age, glenoid bone loss of 10% or more, IAAA <150° and off-track glenoid lesion conferred the greatest risk for postoperative instability. We propose a scoring system assigning 1 point for age, 1 point for off-track lesions, 2 points for IAAA <150, and 4 points for GBL >10%. This schema demonstrated moderate accuracy for predicting recurrent instability when using a cutoff threshold score above 2 points for failure. LEVEL OF EVIDENCE: Level III, Retrospective Cohort Study.

Operative Management of Acute Triceps Tendon Ruptures: Review of 184 Cases.

BACKGROUND: Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair. HYPOTHESIS: No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3. METHODS: All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded. RESULTS: 184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age ( P = .18), sex ( P = .51), completeness of tears ( P = .74), tourniquet time ( P = .455), and prevalence of smokers ( P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911). CONCLUSION: Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Anterior deltoid reeducation for irreparable rotator cuff tears revisited.

BACKGROUND: A previous study introduced a method of conservative treatment of irreparable rotator cuff tears (RCTs) using a rehabilitation program (anterior deltoid reeducation [ADR]). The purposes of this study were to present our experience with ADR and to compare our results with those of the previous study. METHODS: Thirty consecutive elderly patients with irreparable RCTs were prospectively enrolled and taught how to perform the home-based ADR program for a period of 3 months. Clinical and radiographic evaluations were determined at the first visit. Clinical follow-up was available after 9 and 24 months. Failure of the ADR program was defined as abandonment of the ADR program because of pain and/or a patient's decision to undergo surgery at any time or a less than 20-point improvement in the American Shoulder and Elbow Surgeons score at last follow-up. RESULTS: Of the 30 patients, 9 did not complete the 3-month ADR program because of pain. Of the 21 patients who completed the ADR program, 3 were not satisfied with the outcome and went on to undergo surgery. Eighteen of the 30 patients completed the program and had a follow-up at 24 months. Among these 18 cases, there were significant mean improvements between pre-ADR and follow-up outcome scores among all variables (P < .005). However, 6 of these 18 patients did not have an improvement in the American Shoulder and Elbow Surgeons score by at least 20 points. Overall, the ADR program had a success rate of only 40%. CONCLUSION: A 3-month ADR program had limited success to treat irreparable RCTs. We could not reproduce the high rate of satisfactory results of 82% found in a previous study.

Biomechanical effects of anterior capsular plication and rotator interval closure in simulated anterior shoulder instability.

PURPOSE: The purpose of this study was to determine the effect of a stepwise arthroscopic anterior plication and arthroscopic-equivalent rotator interval (RI) closure on glenohumeral range of motion, kinematics, and translation in the setting of anterior instability. METHODS: Six cadaveric shoulders were stretched to 10 % beyond maximum external rotation (ER) to create an anterior shoulder instability model. Range of motion, kinematics, and glenohumeral translations were recorded for the following conditions: (1) intact, (2) stretched, (3) after anterior capsular plication, and (4) after RI closure. RESULTS: The total range of motion after capsular stretching increased significantly in the 60° abduction position (p = 0.037). Average ER and total rotation were significantly decreased from the intact and stretched conditions by both repair conditions at 60° and 0° of glenohumeral abduction (p < 0.05), with no significant difference between plication and additional RI closure. At 0° abduction and 0° ER, glenohumeral translation decreased significantly from the stretched condition after RI closure with 10 and 15 N anterior and 10 N posterior loads (p < 0.05). At 30° ER, translation after RI closure was significantly less than both the intact and stretched conditions with 10 N anterior loads (p = 0.009; p = 0.004). These changes in translational stability were not seen with plication alone. CONCLUSIONS: Anterior capsular plication reduced glenohumeral range of motion back to the intact state, and often tighter. RI closure did not contribute significantly to the reduction in the range of motion, but had implications regarding glenohumeral translation. Caution should be taken when performing anterior plication and combined repairs to avoid overtightening. Intraoperative translations could be useful when debating RI closure in patients with unidirectional anterior glenohumeral instability.

Effects of glycemic control on prevalence of diabetic frozen shoulder.

BACKGROUND: There is controversy regarding the influence of glycemic control in diabetic patients with frozen shoulder. To determine the relationship between glycemic control and the prevalence of frozen shoulder in diabetic patients, we hypothesized that increased glycosylated hemoglobin A1c (HbA1c) levels would correlate with an increased prevalence of frozen shoulder. METHODS: A retrospective analysis with statistical review of 201,513 diabetic patients enrolled in a regional health maintenance organization in 2007 was performed. Analysis included determining the relationship between the prevalence of frozen shoulder and the following factors: HbA1c level, type of diabetes treatment, duration of diabetes treatment, and presence of end-stage diabetic manifestations. RESULTS: There were 1150 diabetic patients with a diagnosis of frozen shoulder. There was no significant relationship between HbA1c level and the prevalence of frozen shoulder. Insulin-dependent patients who used or did not use oral hypoglycemics were 1.93 times more likely than non-insulin-dependent diabetic patients to have frozen shoulder, and that rate increased to 1.96 times more likely when the results were adjusted for HbA1c level. Patients who were taking oral hypoglycemic drugs were 1.5 times more likely to develop frozen shoulder than those who did not use insulin or take oral hypoglycemic drugs. Duration of diabetes was also associated with the development of frozen shoulder, after controlling for insulin use (odds ratio: 1.85 for duration of more than ten years of use compared with less than five years of use). The prevalence of end-stage diabetic manifestations was increased in patients with frozen shoulder as compared with those without frozen shoulder (p < 0.0001). CONCLUSION: There was no association found between HbA1c level and the prevalence of frozen shoulder in this diabetic population.

Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures.

Although hemiarthroplasties are an important treatment for femoral neck fractures, the literature does not provide a clear approach for selecting the implant fixation method. Therefore, we performed a systematic search of the medical literature and identified 11 prospective and retrospective studies that compared results between cemented and uncemented femoral implant fixation methods. After independent blind data extraction, we compared variables between cemented and uncemented cohorts using two different meta-analysis models. Pooled data represented 1632 cemented and 981 uncemented hemiarthroplasties (average age of patients, 78.9 and 77.5 years, respectively). The average operating room times and blood loss volumes were 95 minutes and 467 mL, respectively, for the cemented and 80 minutes and 338 mL for the uncemented cohorts. Postoperative mortality rates, overall complications, and pain were similar between the two cohorts. Despite a few potential trends, we found few statistical differences between cemented and uncemented techniques based on reported outcome measurements. In addition, inspection of this literature underscored the lack of and need for consistent and standardized reporting of outcome variables regarding these procedures.

Traumatic myositis ossificans as a result of college fraternity hazing.

We present a case of a 20-year-old college student who had myositis ossificans traumatica develop after a fraternity hazing. The patient was struck repeatedly on both of his thighs while standing at attention, and he presented with bilateral thigh pain and stiffness 6 weeks after the incident. Physical examination revealed 130 degrees flexion of his right knee and 50 degrees flexion of his left knee, which had a firm end point. Radiographs showed extensive new bone located adjacent to the anterior and lateral aspects of his left femur with less involvement of his right thigh. Magnetic resonance imaging revealed considerable edema involving much of the rectus femoris and vastus lateralis of both thighs. The patient was treated with physical therapy and indomethacin for pain and inflammation control. At his 1.5-year followup, the patient's left knee flexion had improved to 130 degrees . Nonoperative treatment with careful followup resulted in a favorable outcome in this patient despite considerable formation of bilateral thigh myositis ossificans traumatica.

Mastication causing segmental spinal motion in common cervical orthoses.

STUDY DESIGN: In vivo fluoroscopic quantification of segmental cervical spinal motion in asymptomatic volunteers during mastication. OBJECTIVE: To quantify the degree of segmental cervical spine motion in patients during mastication and while wearing several commonly used cervical orthoses. SUMMARY OF BACKGROUND DATA: Cervical orthoses are routinely used to stabilize the cervical spine after trauma or cervical fusion and are, in some cases, prescribed to be worn at all times, including during eating. METHODS: Seven volunteers with an average age of 31 years (range, 26-42 years) had 5 seconds of continuous lateral cervical fluoroscopic imaging while they chewed gum without any cervical orthosis (control) and while wearing a soft collar turned forward then backward, a Philadelphia collar, a Miami J collar, or a two-poster brace. Still images were created from the fluoroscopy video, which allowed for quantification of the amount of segmental motion. RESULTS: All cervical collars produced statistically greater motion at occiput-C1 and C1-C2 when compared with no collar. The motion was greatest at the occiput-C1 junction and decreased to the C4 level. No motion was detected in any subject in any brace below C4. The two-poster brace produced the most segmental motion at occiput-C1 (6.3 degrees +/- 2.0 degrees) compared with the soft collar turned backwards (1.9 degrees +/- 1.9 degrees). No subject had any segmental motion below C2 in the soft collar. No segmental spinal motion was observed without a cervical brace. CONCLUSIONS: To limit upper cervical spine segmental motion during mastication, for patients with unstable cervical spines, we propose a two-poster brace with removal of the mandibular component to allow for free mandibular action. For stable spines, we propose a soft collar turned backwards. Patients should be educated with this information.

Infrapatellar fat pad disruption: a radiographic sign of patellar tendon rupture.

UNLABELLED: After knee trauma, radiographs showing patella alta supercede other signs that suggest patellar tendon rupture. However, without patella alta the diagnosis may be missed. A standard lateral radiograph with the knee flexed showed the infrapatellar fat pad as a dark band with a smooth contour. Our pilot study identified a disruption of the fat pad contour as a radiographic sign of tendon rupture. Two blinded reviewers independently analyzed randomly selected lateral radiographs of the knees of 14 patients with knee injuries. Seven patients had confirmed ruptures diagnosed at surgery, and the other patients had different diagnoses. There were 12 men and two women with an average age of 49 years (range, 20-81 years). One observer detected five of the seven disrupted tendons and six of the seven intact tendons. The other observer detected six of the seven disrupted tendons and all seven intact tendons. Disruption in the contour of the infrapatellar fat pad on routine lateral view radiographs was a reasonably reliable sign of patellar tendon rupture. Diagnostic accuracy should increase when used with the patient's history, physical examination, and other radiographic signs. Absence of this sign should not supersede other suggestive signs of patella tendon rupture. LEVEL OF EVIDENCE: Diagnostic study, Level II (development of diagnostic criteria on consecutive patients--with universally applied reference "gold" standard). See the Guidelines for Authors for a complete description of levels of evidence.

Development and use of a wrist fusion plate for children and adolescents.

Arthrodesis is a widely accepted treatment for several destructive disorders of the wrist joint. Previous literature has shown that compression plating is a reliable technique for achieving rigid fixation and fusion in adults. The goal of this study was to apply similar principles of adult wrist fusion to children, using a custom-designed fusion plate sized for children. Five children underwent wrist fusion using rigid fixation and dorsal plate application. Mean age at time of surgery was 16.4 years. The indication for surgery was paralysis (spinal cord injury) in three and spasticity (cerebral palsy and traumatic brain injury) in two. Surgery was performed through a dorsal approach and combined with carpectomy in the two patients with spasticity. Follow-up averaged 2.2 years and radiographs showed solid fusion and proper alignment of plate and screws. Improved stability and limb function were noted by patients and family. There were no instances of hardware failure, and plate removal has not been required.