Does Capsular Closure Affect Clinical Outcomes in Hip Arthroscopy? A Prospective Randomized Controlled Trial.

BACKGROUND: There is increasing concern of iatrogenic hip instability after capsulotomy during surgery. Greater emphasis is now being placed on capsular closure during surgery. There are no prospective studies that address whether capsular closure has any effect on outcomes. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate patient outcomes after interportal capsulotomy repair compared with no repair. We hypothesized that restoration of normal capsular anatomy with interportal repair will achieve clinical outcomes similar to those for no repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Adult patients with femoral acetabular impingement indicated for hip arthroscopy were randomized into either the capsular repair (CR) or the no repair (NR) groups. All patients underwent standard hip arthroscopy with labral repair with or without CAM/pincer lesion resection. Clinical outcomes were measured via the Hip Outcome Score-Activities of Daily Living (HOS-ADL) subscale, Hip Outcome Score-Sport Specific (HOS-SS) subscale, modified Harris Hip Score (mHHS), visual analog scale for pain, International Hip Outcome Tool, and Veterans RAND 12-Item Health Survey (VR-12). RESULTS: A total of 54 patients (56 hips) were included (26 men and 30 women) with a mean age of 33 years. The HOS-ADL score significantly improved at 2 years in both the NR group (from 68.1 ± 20.5 to 88.6 ± 20.0; P < .001) and the CR group (from 59.2 ± 18.8 to 91.7 ± 12.3; P < .001). The HOS-SS score also significantly improved in both the NR group (from 41.1 ± 25.8 to 84.1 ± 21.9; P < .001) and the CR group (from 32.7 ± 23.7 to 77.7 ± 23.0; P < .001). Improvement was noted for all secondary outcome measures; however, there was no significant difference between the groups at any time point. Between 1 and 2 years, the NR group showed significant worsening on the HOS-ADL (-1.21 ± 5.09 vs 4.28 ± 7.91; P = .044), mHHS (1.08 ± 10.04 vs 10.12 ± 11.76; P = .042), and VR-12 Physical (-2.15 ± 5.52 vs 4.49 ± 7.30; P = .014) subsets compared with the CR group. CONCLUSION: There was significant improvement in the VR-12 Physical subscale at 2 years postoperatively in the capsular CR group compared with the NR group. Capsular closure appears to have no detrimental effect on functional outcome scores after hip arthroscopy. We recommend restoration of native anatomy if possible when performing hip arthroscopy.

Osteochondritis Dissecans Lesion of the Radial Head.

This case shows an atypical presentation of an osteochondritis dissecans (OCD) lesion of the radial head with detachment diagnosed on plain radiographs and magnetic resonance imaging (MRI). OCD lesions are rather uncommon in the elbow joint; however, when present, these lesions are typically seen in throwing athletes or gymnasts who engage in activities involving repetitive trauma to the elbow. Involvement of the radial head is extremely rare, accounting for <5% of all elbow OCD lesions. Conventional radiographs have low sensitivity for detecting OCD lesions and may frequently miss these lesions in the early stages. MRI, the imaging modality of choice, can detect these lesions at the earliest stage and provide a clear picture of the involved articular cartilage and underlying bone. Treatment options can vary between nonoperative and operative management depending on several factors, including age and activity level of the patient, size and type of lesion, and clinical presentation. This case represents a radial head OCD lesion managed by arthroscopic débridement alone, resulting in a positive outcome.

Prevention of Venous Thromboembolism after Arthroscopic Knee Surgery in a Low-Risk Population with the Use of Aspirin. A Randomized Trial.

INTRODUCTION: Historically, venous thromboembolism (VTE) in the setting of elective knee arthroscopy has been considered rare. However, more recently, the rate of deep vein thrombosis (DVT) has been reported to be approximately 10%. With increasing recognition of the potential for the development of thromboembolic events, several randomized trials have evaluated the efficacy of chemoprophylaxis in reducing the risk of VTE following knee arthroscopy. However, all of these studies have evaluated the efficacy of low molecular weight heparins (LMWH), with reductions in the risk of DVT ranging from 65% to 93%, but with the potential side effect of bleeding. At the present time, there have been no randomized studies reported evaluating the utility of aspirin, an agent with a reportedly lower bleeding risk than LMWH, as pharmacologic prophylaxis against VTE after arthroscopic knee surgery. METHODS: In a single-center, randomized, single-blind prospective trial, the efficacy of aspirin as postoperative pharmacologic VTE prophylaxis was evaluated in a low risk population undergoing knee arthroscopy. One hundred seventy patients were randomized to a treatment group of 325 mg of aspirin daily for 14 days postoperatively (66 patients) or to the control group with no intervention (104 patients). Bilateral, whole leg, compression venous duplex ultrasonography was performed 10 to 14 days postoperatively to document the incidence of DVT. The primary endpoint of the current study was the development of DVT or pulmonary embolism (PE), and the secondary endpoint was the development of a postoperative complication. RESULTS: The study cohort was comprised of 104 males (61%) and 66 females (39%) with a mean age of 44.4 ± 14.4 years (range: 18 to 75 years). Within both the aspirin treatment and control groups, the surgical procedures included meniscectomy, ACL reconstruction, chondroplasty, and meniscus repair. No cases of postoperative deep vein thrombosis (DVT) or pulmonary embolism (PE) were identified in either arm of the study during the observation period. Twenty-three patients experienced a complication, including pain or swelling (9%), residual joint line tenderness (3%), arthrofibrosis (0.6%), and instability after a fall (0.6%). Three patients developed knee swelling, two of them in the aspirin group and one of whom required a knee aspiration. However, there was no difference in the development of complications between the two patient populations (p = 0.76, odds ratio [OR] 1.14, 95% confidence interval [CI] 0.5-2.56). CONCLUSIONS: With no cases of VTE identified in our patient population, the use of aspirin in a low-risk population undergoing arthroscopic knee surgery is not warranted.

Alternative Therapeutic Modalities in Sports Medicine.

Bone marrow aspirate, prolotherapy, platelet-rich plasma,and autologous conditioned serum represent alternative treatment options that have emerged to address various musculoskeletal ailments. We have reviewed the basic science, physiology, and clinical evidence of each of these modalities and discovered that each treatment has its individual place in the management of common orthopaedic pathologies. Bone marrow aspirates are successful in treating early arthritis and cartilage defects. Prolotherapy and platelet-rich plasma have demonstrated good efficacy in treating inflammatory processes and early arthritis. Finally, autologous conditioned serum (Orthokine) represents a promising treatment option for chronic joint arthritis. The clinical evidence supporting these alternative treatment modalities is insufficient and further level 1 evidence is needed before we can begin to employ these techniques in our daily orthopaedic practice.

The incidence of venous thromboembolism (VTE)--after hip arthroscopy.

PURPOSE: The purpose of this study was to determine the incidence of venous thromboembolism (VTE) after hip arthroscopy. METHODS: Over the course of 13 months, four surgeons that routinely perform hip arthroscopy participated in a protocol to screen all patients postoperatively for deep venous thrombosis (DVT) using bilateral venous duplex ultrasound at or about the 2 week postoperative time point. All patients were assessed and stratified for VTE risk prior to surgery. Mechanical intraoperative and postoperative chemoprophylaxis were not administered. Perioperative factors, such as weightbearing status after surgery, traction time, and anesthesia type, were recorded. RESULTS: We identified 139 eligible patients (average age 37.7, SD = 12.0) that underwent hip arthroscopy. The incidence of symptomatic VTE was 1.4 percent (2/139). Of the entire patient pool, 81 obtained a follow-up ultrasound. There were no cases of asymptomatic deep vein thrombosis (DVT). There were two symptomatic venous thromboembolic events noted; one DVT and one pulmonary embolus. One patient had no risk factors; the other was overweight and routinely took oral contraceptives. Amongst the patient cohort, the mean BMI was 25.9 (SD = 4.8). The mean traction time was 58.9 minutes (SD = 23.1). Most patients (71%) were partial weightbearing after the procedure. CONCLUSION AND CLINICAL RELEVANCE: In patients undergoing hip arthroscopy, the rate of postoperative VTE was low, despite the use of prolonged axial traction and surgical proximity to the pelvic veins. Although patients should be counseled preoperatively regarding the risk of VTE, we believe that routine use of pharmacologic prophylaxis is not indicated following hip arthroscopy if patients are properly risk stratified prior to surgery and found to be at low risk for VTE.

Cat peptide antigen desensitisation for treating cat allergic rhinoconjunctivitis.

INTRODUCTION: Allergic rhinoconjunctivitis is an increasingly common source of morbidity with sensitivity to cats accounting for 10-15% of the disease burden. Allergy to cats is a major risk factor for the development of asthma. AREAS COVERED: Within the present manuscript, the current data on a novel therapeutic approach to treat cat allergy is reviewed. Cat Peptide Antigen Desensitisation (Cat-PAD) is a mixture of seven small peptides developed for the treatment of cat allergy. It is designed to induce immunological tolerance via binding to MHC class II on antigen presenting cells and interacting with regulatory T cells without triggering the cross-linking of IgE on mast cells and basophils. The peptide sequences are derived from the major cat allergen Fel d 1. The peptides have been selected to ensure a similar T cell response to that generated to whole cat dander in ex-vivo PBMC derived from cat allergic individuals. The size of the peptides is insufficient to induce cross-linking of IgE. Clinical data from a series of studies shows that Cat-PAD is able to significantly reduce allergic rhinoconjunctivitis symptoms after a short course of four injections over 12 weeks, and that the treatment effect is persistent lasting 2 years after the start of treatment. EXPERT OPINION: Taken together Cat-PAD is a novel, well tolerated and promising therapeutic approach to treat cat allergic patients. Data from the current international Phase III study will unravel whether the concept is also efficient and tolerable under daily life circumstances.

Comparison of ultrasound-guided versus blind glenohumeral injections: a cadaveric study.

BACKGROUND: Intra-articular glenohumeral (GH) injections are important for diagnostic and therapeutic purposes. It has been suggested that ultrasound guided injections are more accurate than blind or freehand injections. This study assessed the accuracy of ultrasound-guided GH injections compared with freehand injections in fresh cadavers. METHODS: The study used 80 shoulder specimens from fresh cadavers. Ultrasound guidance was used to inject radiopaque contrast in 40 shoulders, and freehand technique was used in the remaining 40. All injections were performed by 2 surgeons (A and B) through a posterior approach. After the injections, radiographs were obtained of the specimens to assess the accuracy of the injections. RESULTS: Sixty-six of 80 (82.5%) injections were accurately administered into the GH joint. Ultrasound-guided injections were accurate in 37 of 40 specimens (92.5%) compared with freehand injections, which were accurate in only 29 of 40 specimens (72.5%; P = .02). Both surgeons independently had higher accuracy using ultrasound-guidance compared with the freehand technique (surgeon A: 90% vs 65%, P = 0.058; surgeon B: 95% vs 80%, P = 0.15). The average time for injections was 52 seconds by the freehand technique and 166 seconds using ultrasound guidance (P < 0.001). CONCLUSIONS: The data from this cadaveric study suggest that ultrasound-guided injections are more accurate at reaching the GH joint than freehand injections. The ultrasound-guided injections took substantially longer to administer. Once familiar with the technique, surgeons can expect improved accuracy and efficacy of GH joint injections using ultrasound guidance in the clinical setting.

Reverse total shoulder arthroplasty for failed shoulder arthroplasty.

INTRODUCTION: Shoulder arthroplasty provides excellent outcomes for most patients; however, a subset of these patients with a failed arthroplasty will require revision. Recently, the reverse total shoulder arthroplasty (rTSA) has been used in these difficult clinical situations. Therefore, we sought to examine our initial experience using rTSA as a treatment for failed shoulder arthroplasty. METHODS: During a 5-year period, 31 patients (mean age, 68.7 years) underwent rTSA for treatment of a failed shoulder arthroplasty and their presurgical and operative data were analyzed. Of the 31 patients, 28 were available for an average follow-up of 40.7 months. Their outcomes were assessed with American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA), and Simple Shoulder Test (SST) scores, and the visual analog scale (VAS) for pain. RESULTS: Compared with preoperative status, there were statistically significant improvements in all outcome measurements, including the ASES (24.0 to 66.2), UCLA (7.4 to 23.5), SST (1.5 to 7.6), and VAS (7.0 to 2.6). Active forward elevation improved from 44° preoperatively to 108° postoperatively (P < .001). Results were rated as good or excellent by 19 patients (67.9%), satisfactory by 4 (14.3%), and unsatisfactory by 5 (17.8%). Among the types of failed arthroplasty, patients with failed TSA noted the greatest improvement in their outcome, but this improvement was not statistically significant. CONCLUSIONS: The data suggest that patients can expect improved functional outcome and decreased pain after revision of previous arthroplasty to rTSA and that this procedure can provide a reliable salvage option for a challenging clinical problem.

Alternative bearing surface options for revision total hip arthroplasty.

Despite the overall success of total hip arthroplasty (THA), there has been an increase in the rate of revision hip surgeries performed each year in the United States. These revision surgeries result in several billion dollars in health care costs. Bearing surface wear can result in the need for revision surgery through a variety of mechanisms. Many implant failures necessitating the need for revision surgeries occur secondary to dislocations, which are often related to prothesis wear and eventual loosening of the components. Wear also can lead to osteolysis and may play a role in aseptic loosening. Specific concerns regarding the wear rates of metal-on-polyethylene (the most common bearing surface) have encouraged the manufacture of newer polyethylene implants with improved wear properties, as well as alternative bearing surfaces. The goal is to improve the durability of revision implants and/or reduce the incidence of revision THAs. Revision arthroplasty involves using alternative surfaces, such as replacing the metal femoral head with a ceramic component or changing the entire prosthesis to a metal-on-metal or ceramic-on-ceramic articulation. It is important to review the characteristics of these alternative bearing surface options and their contributions to improved THA tribology and prolonged prosthesis longevity. The choice of a bearing surface for a revision THA should consider factors such as the patient's age and activity level, the cost of the implant, and both the surgeons' and patients' preferences. Although laboratory studies and small clinical trials have generated optimistic results for these alternative implants in vitro and in vivo, much still needs to be learned about the long-term performance of these materials in patients after total hip revision surgery.

Luxatio erecta: case series with review of diagnostic and management principles.

We reviewed 11 cases of luxatio erecta (inferior shoulder dislocation) managed acutely at our institutions to gain insight into the diagnostic and management principles of this condition. We then compared our findings with those in the current literature. Luxatio erecta requires careful clinical and radiographic evaluation and a high index of suspicion for associated injuries, as they occur frequently and can be significant given their tendency to be associated with higher energy trauma. Our results indicate that the majority of patients return to preinjury level of shoulder function, despite associated injuries. Closed reduction constituted definitive management in 100% of the cases in our series, and there was no recurrent instability at follow-up.

Spinal epidural abscess mimicking lymphoma: a case report.

We describe a case of epidural thoracic abscess presenting similar to epidural lymphoma on imaging and review the imaging findings and clinical characteristics of both to help differentiate the two. Typical magnetic resonance imaging characteristics for epidural abscess are a heterogeneously enhancing epidural collection, which is isointense/hypointense on T1 images and hyperintense on T2 images with granulation tissue typically having a rim of enhancement with gadolinium. In contrast, typical imaging characteristics for an epidural lymphoma include an isointense/hypointense appearance on T1-weighted magnetic resonance imaging (MRI) and a hyperintense or even hypointense appearance on T2 images. Lymphomas tend to enhance uniformly and diffusely with contrast. The patient's MRI revealed a compressive thoracic epidural mass at T8-T10. The mass was hypointense on T1- and T2-weighted images and enhanced intensely and uniformly on T1 images after gadolinium injection. Additionally, abnormal hyperintense signal within the left T9-T10 facet joint was identified on T2 images. The imaging findings were felt to be most consistent with lymphoma, but the possibility of epidural abscess, and less likely, epidural hematoma were also considered. Although the patient's abscess presented similar to lymphoma on MRI, possibly the most revealing clue on imaging that infection was the likely diagnosis was hyperintense signal within the left facet joint seen on T2-weighted images. This is important as primary radiation treatment based on imaging characteristics alone, without a tissue diagnosis, is often suggested in cases of lymphoma. This mode of treatment would be contraindicated in the setting of infection. A diagnosis that is not conclusive by needle biopsy or imagine may require an open procedure for definitive diagnosis.

Nonoperative treatment of symptomatic spondylolysis.

SUMMARY OF BACKGROUND DATA: Symptomatic spondylolysis resulting from a stress fracture of the pars interarticularis is a cause of low back pain in the juvenile and adolescent patient. Treatment is conservative in the majority of cases. OBJECTIVE: To analyze the outcome of patients with symptomatic isthmic spondylolysis treated nonoperatively with a custom fit thoracolumbar orthosis and activity cessation for 3 months followed by an organized physical therapy program. STUDY DESIGN: Retrospective case series. PATIENT SAMPLE: Four hundred thirty-six juvenile and adolescent patients with spondylolysis. OUTCOME MEASURES: Pain improvement, hamstring flexibility, range of motion, resolution of back spasms, and return to previous activities. METHODS: Retrospective review of 436 juvenile and adolescent patients with symptomatic spondylolysis confirmed by single-photon emission computed tomography or computed tomography. Clinical outcomes were assessed through patient history and physical examination. RESULTS: Ninety-five percent of patients achieved excellent results according to a modified Odom's Criteria. The remaining 5% of patients achieved good results as they required occasional nonsteroidal anti-inflammatory drugs to relieve pain. Back spasms were resolved and hamstring tightness and range of motion returned to normal in all patients. All patients returned to their preinjury activity level. No patients went on to surgery. CONCLUSIONS: Symptomatic juvenile and adolescent patients with an isthmus spondylolysis may be effectively managed with a custom fit thoracolumbar orthosis brace and activity cessation for approximately 3 months followed by an organized physical therapy program.

The use of thoracoscopy in the management of adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective case cohort series. OBJECTIVE: To analyze the outcomes of thoracoscopy in the surgical treatment of adolescent idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Traditionally, progressive idiopathic scoliosis has been treated surgically with either an open posterior, anterior, or combined surgical approach. Surgical methods are being explored to minimize the extent of soft tissue disruption such as thoracoscopy followed spinal release, bone grafting, and instrumentation. Several authors have reported good results using thoracoscopy in the treatment of spinal deformity following a requisite learning curve. METHODS: A consecutive case cohort series of 45 adolescent patients with idiopathic scoliosis evaluated and treated at a single institution. Patients with a progressive deformity underwent a thoracoscopically assisted curve correction, fusion, and instrumentation procedure. After surgery, patients were assessed at 1, 3, 6, and 12 months and then annually. RESULTS: All patients underwent successful thoracoscopic instrumentation and fusion without the need for an open conversion. The average preoperative thoracolumbar Cobb measurement of the major curve was 51.6 degrees . The thoracolumbar levels instrumented anteriorly ranged from T7 to L3 and had an average postoperative Cobb angle of 6.58 degrees , with an overall improvement of 87.3%. To date, at a mean follow up of 4.6 years, all curves have maintained correction. Sagittal balance was recreated or maintained through the application of interbody femoral ring allografts. Operative times averaged 5 hours and 46 minutes, with a range of 3 hours, 48 minutes to 6 hours, 55 minutes. Hospital stays averaged 2.9 days, with a range of 2 to 7 days. All patients were completely off pain medication before their first postoperative visit at 4 weeks. Children were back to school between 2 and 4 weeks on average. There were a total of 3 complications. One patient experienced transient chest wall numbness, which resolved by 3 months. Two patients developed postoperative mucus plugging in the ventilated lung. CONCLUSION: Endoscopic thoracoscopic spinal deformity correction, fusion, and instrumentation is a safe and feasible method of surgical management of an adolescent patient with progressive scoliosis. The key to successful fusion is a total discectomy and complete endplate removal. This method appears to be comparable to open procedures in terms of curve correction with significantly shorter hospitalization and rehabilitation due to less surgical discomfort. The thoracoscopic correction of adolescent scoliosis warrants continued development and evaluation as a surgical method of scoliosis correction.