Glenohumeral Instability Related to Special Conditions: SLAP Tears, Pan-labral Tears, and Multidirectional Instability.

Glenohumeral instability is one of the more common conditions seen by sports medicine physicians, especially in young, active athletes. The associated anatomy of the glenohumeral joint (the shallow nature of the glenoid and the increased motion it allows) make the shoulder more prone to instability events as compared with other joints. Although traumatic dislocations or instability events associated with acute labral tears (ie, Bankart lesions) are well described in the literature, there exists other special shoulder conditions that are also associated with shoulder instability: superior labrum anterior/posterior (SLAP) tears, pan-labral tears, and multidirectional instability. SLAP tears can be difficult to diagnose and arthroscopic diagnosis remains the gold standard. Surgical treatment as ranged from repair to biceps tenodesis with varying reports of success. Along the spectrum of SLAP tears, pan-labral tears consist of 360-degree injuries to the labrum. Patients can present complaining of either anterior or posterior instability alone, making the physical examination and advanced imaging a crucial component of the work up of the patients. Arthroscopic labral repair remains a good initial option for surgical treatment of these conditions. Multidirectional instability remains one of the more difficult conditions for the sports medicine physician to diagnose and treat. Symptoms may only be reported as vague pain versus frank instability making the diagnoses particularly challenging, especially in a patient with overall joint laxity. Conservative management to include physical therapy is the mainstay initial treatment in patients without an identifiable structural abnormality. Surgical management of this condition has evolved from open to arthroscopic capsular shifts with comparable results.

Operative management of complex lumbosacral dissociations in combat injuries.

BACKGROUND CONTEXT: As war injury patterns have changed throughout Operations Iraqi and Enduring Freedom (OIF and OEF), a relative increase in the incidence of complex lumbosacral dissociation (LSD) injuries has been noted. Lumbosacral dissociation injuries are an anatomical separation of the spinal column from the pelvis, and represent a manifestation of severe, high-energy trauma. PURPOSE: This study aimed to assess the clinical outcomes of combat-related LSD injuries at a mean of 7 years following operative treatment. STUDY DESIGN: This is a retrospective review. PATIENT SAMPLE: We identified 20 patients with operatively managed LSDs. OUTCOME MEASURES: Time from injury to arrival in the United States, operative details, fixation methods, postoperative complications, time to retirement from military service, disability, and ambulatory status at latest follow-up. METHODS: We performed a retrospective review of outcomes of all patients with operatively managed combat-related LSD from January 1, 2003 to December 31, 2011. RESULTS: Twenty patients met inclusion criteria and were treated as follows: posterior spinal fusion (12, 60%), sacroiliac screw fixation (7, 35%), and combined anterior-posterior fusion for associated L3 burst fracture (1, 5%). The mean age was 28.2±6.4 years old. The most common mechanism of injury was mounted improvised explosive device (IED, 55%). On average, 2.2 spinal regions were injured per patient. Neurologic dysfunction was present in 15 patients. Three patients underwent operative stabilization of their injuries before evacuation to the United States. Four patients had a postoperative wound infection and two patients underwent reoperation. Mean follow-up was 85.9 months (range: 39.7-140.8 months). At most recent follow-up, seventeen patients were no longer on active duty military service. Eight patients had persistent bowel dysfunction and nine patients had persistent bladder dysfunction. Fifteen patients reported chronic low back pain. Seventeen were ambulating and five had documentation of running following surgery. CONCLUSIONS: This is the largest series of operatively managed LSD in patients currently reported. Our series suggests that combat-related LSD injuries frequently result in persistent, long-term neurologic dysfunction, disability, and chronic pain. Operative management carries a high postoperative risk of infection. However, a select group of patients are highly functional at latest follow-up.

Persistent axial neck pain after cervical disc arthroplasty: a radiographic analysis.

BACKGROUND CONTEXT: There is very little literature examining optimal radiographic parameters for placement of cervical disc arthroplasty (CDA), nor is there substantial evidence evaluating the relationship between persistent postoperative neck pain and radiographic outcomes. PURPOSE: We set out to perform a single-center evaluation of the radiographic outcomes, including associated complications, of CDA. DESIGN: This is a retrospective review. PATIENT SAMPLE: Two hundred eighty-five consecutive patients undergoing CDA were included in the review. OUTCOME MEASURES: The outcome measures were radiological parameters (preoperative facet arthrosis, disc height, CDA placement in sagittal and coronal planes, heterotopic ossification [HO] formation, etc.) and patient outcomes (persistent pain, recurrent pain, new-onset pain, etc.). METHODS: We performed a retrospective review of all patients from a single military tertiary medical center from August 2008 to August 2012 undergoing CDA. Preoperative, immediate postoperative, and final follow-up films were evaluated. The clinical outcomes and complications associated with the procedure were also examined. RESULTS: The average radiographic follow-up was 13.5 months and the rate of persistent axial neck pain was 17.2%. For patients with persistent neck pain, the rate of HO formation per level studied was 22.6%, whereas the rate was significantly lower for patients without neck pain (11.7%, p=.03). There was no significant association between the severity of HO and the presence of neck pain. Patients with a preoperative diagnosis of cervicalgia, compared to those without cervicalgia, were significantly more likely to experience continued neck pain postoperatively (28.6% vs. 13.1%, p=.01). There were no differences in preoperative facet arthrosis, pre- or postoperative disc height, segmental range of motion, or placement of the device relative to the posterior edge of the vertebral body.However, patients with implants more centered between the uncovertebral joints were more likely to experience posterior neck pain (p=.03). CONCLUSIONS: We found that posterior axial neck pain is relatively frequent after CDA, and patients with persistent neck pain were significantly more likely to have preoperative cervicalgia and develop HO postoperatively. We also found that patients with implants that were placed off-centered were less likely to also complain of neck pain, although the reasons for this finding remain unclear.

Reoperation after in-theater combat spine surgery.

BACKGROUND CONTEXT: The ideal timing of surgical decompression or stabilization following combat-related spine injury remains unclear. PURPOSE: The study aims to determine the etiology and factors related to reoperation following evacuation to the United States after undergoing in-theater spine surgery. STUDY DESIGN: This is a retrospective analysis. PATIENT SAMPLE: The sample includes 13 patients with combat-related spine injuries undergoing revision spine surgery. OUTCOME MEASURES: The outcome measures were time to arrival in the United States, time to reoperation, indications for revision, operative details, further revision surgery, infection rate, complications after reoperation, and most recent clinical follow-up information. METHODS: This is a retrospective analysis of patients undergoing spine surgery designated as injured during the Global War on Terrorism between July 2003 and July 2013. Inpatient and outpatient medical records, operative reports, and imaging studies were reviewed. RESULTS: The mean time to index surgery was 1.6 days. The mechanisms of injury included five gunshot wounds, three improvised explosive devices (IED), two helicopter crashes, one motor vehicle accident, and two other mechanisms (fall and crush injury). The mean injury severity score (ISS) was 22.7 (range: 13-45). There were six cervical, seven thoracic, eight lumbar, and two sacral injuries, with a mean of 1.8±1.0 spinal regions injured per patient. Twelve patients had a spinal cord injury, four of which were AIS (American Spinal Association Impairment Scale). Three patients underwent spinal stabilization on the date of injury, and one patient had three separate spine surgeries while downrange before arrival. Four patients underwent fixation in theater. There was a mean of 5.5 days from injury to arrival in the United States, and the mean time to revision fixation was 11.2 days post-index surgery (range: 4-14 days). Revision indications included instability or progressive kyphosis (N=6), and two of these patients had decompression without instrumentation downrange. Other indications included inadequate decompression (N=4), infection, persistent drainage, and epidural hematoma. At a mean of 5.5-year follow-up, all patients were medically retired from service, with minimal neurologic improvement. CONCLUSIONS: Our study found that instability or progressive kyphosis and incomplete decompression were the most common indications for reoperation after evacuation to the United States. Our data provide additional understanding of the potential etiologies of failure and reoperation following in-theater combat spine surgery, and may help avoid such complications.

The Use of Intravenous Tranexamic Acid in Patients Undergoing Total Hip or Knee Arthroplasty: A Retrospective Analysis at a Single Military Institution.

OBJECTIVE: To describe a single institution's experience after initiation of a protocol in which all primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients were administered intravenous tranexamic acid (TXA) intraoperatively to decrease perioperative blood loss. METHODS: A retrospective review of medical records at a single institution from February 2012 to April 2014. The TXA treatment group was compared to a control group. We reviewed intraoperative blood loss, preoperative hemoglobin (Hb) levels, postoperative day 0 to 2 Hb levels, transfusion rates, postoperative venous thromboembolism, and other complication rates. RESULTS: 259 patients underwent either TKA (165) or THA (94). 121 received perioperative intravenous TXA and 138 did not. There was a statistically decreased rate of allogeneic blood transfusion (0 vs. 10, p = 0.003) as well as a higher postoperative day 2 Hb level (10.8 ± 1.1 vs. 10.2 ± 2.6 g/dL, p = 0.02) in the treatment group. There was no statistical difference in any variable measured in the THA group, though there was a trend toward higher postoperative Hb levels at all-time points measured. CONCLUSION: Intravenous TXA is a safe and effective drug to decrease perioperative blood loss and allogeneic transfusion in THA and TKA. There was no increased risk of venous thromboembolism or other complications in our review.

An Analysis of Research from Faculty at U.S. Adult Reconstruction Fellowships.

We reviewed all articles published in three major orthopaedic journals from January 2010 to December 2014. Any article focusing on adult reconstruction of the hip or knee was reviewed for first and last authorship, institution, and level of evidence. Three institutions had authored work from arthroplasty faculty that fell within the top five most published institutions in all three journals, while one institution ranked first in all three journals. 43 of 67 (64.2%) reconstruction fellowships had at least one publication included in this study. The majority of the adult reconstruction literature published by faculty at U.S. reconstruction fellowships stems from a few academic centers with the ten most prolific institutions accounting for 65.9% of all U.S. fellowship publications.

Outcomes After Operative Management of Combat-Related Low Lumbar Burst Fractures.

STUDY DESIGN: Retrospective review. OBJECTIVE: Report the 2-year operative and clinical outcomes of these service members with low lumbar fractures. SUMMARY OF BACKGROUND DATA: The majority of spinal fractures occur at the thoracolumbar level, with fractures caudal to L2 accounting for only 1% of spine fractures. A previous report from this institution regarding combat-related spine burst fractures documented an increased incidence of low lumbar burst fractures in injured service members. METHODS: Review of inpatient and outpatient medical records in addition to radiographs for all patients treated at our institution with combat-related burst fractures occurring at the L3-L5 levels. RESULTS: Twenty-four patients with a mean age of 28.1± 7.2 underwent surgery for low lumbar (L3-L5) burst fractures. The mean number of thoracolumbar levels injured was 2.9 ± 1.4. Eleven patients had neurological injury, 4 of which were complete. The mean days to surgery were 16.8 ± 24.5. The mean number of levels fused was 4.3 ± 2.1, with fixation extending to the pelvis in 4 patients (17%). Fourteen (61%) patients had at least 1 postoperative complication, with 7 (30%) requiring reoperation. Five patients had a postoperative wound infection. Five patients had deep venous thromboses, 3 had pulmonary emboli. Mean clinical follow-up was 3.3± 2.2 years. At latest follow-up, all were separated from military service, 10 experienced persistent bowel/bladder dysfunction, 15 had lower extremity motor deficits, and 10 had documented persistent low back pain. Nineteen had chronic pain with 18 patients still taking pain medications and/or muscle relaxers. CONCLUSION: Low lumbar burst fractures are a rare injury with an increased incidence in combat casualties engaged in the wars in Iraq and Afghanistan. We found a high rate of acute postoperative complications (61%), as well as a high reoperation rate (30%). At approximately 3 years of follow-up, most of these patients had persistent neurological symptoms and chronic pain. LEVEL OF EVIDENCE: 4.

Operative treatment of new onset radiculopathy secondary to combat injury.

We set out to describe combat-related spine trauma over a 10-year period, and thereby determine the frequency of new onset radiculopathy secondary to injuries sustained in support of combat operations. We performed a retrospective analysis of a surgical database at three military institutions. Patients undergoing spine surgery following a combat-related injury in Afghanistan or Iraq between July 2003 and July 2013 were evaluated. We identified 105 patients with combat-related (Operations Enduring and Iraqi Freedom) spine trauma requiring operative intervention. Of these, 15 (14.3%) patients had radiculopathy as their primary complaint after injury. All patients were diagnosed with herniated nucleus pulposus. The average age was 39 years, with 80% injured in Iraq and 20% in Afghanistan. The most common mechanism of injury was mounted improvised explosive device (33%). The cervical spine was most commonly involved (53%), followed by lumbar spine (40%). Average time from injury to surgery was 23.4 months; 53% of patients had continued symptoms following surgery, and two patients had at least one revision surgery. Two patients were medically retired because of their symptoms. This study is the only of its kind evaluating the operative treatment of traumatic radiculopathy following combat-related trauma. We identified a relatively high rate of radiculopathy in these patients.

Systematic review and meta-analysis of minimally invasive transforaminal lumbar interbody fusion rates performed without posterolateral fusion.

The need for posterolateral fusion (PLF) in addition to interbody fusion during minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) has yet to be established. Omitting a PLF significantly reduces overall surface area available for achieving a solid arthrodesis, however it decreases the soft tissue dissection and costs of additional bone graft. The authors sought to perform a meta-analysis to establish the fusion rate of MIS TLIF performed without attempting a PLF. We performed an extensive Medline and Ovid database search through December 2010 revealing 39 articles. Inclusion criteria necessitated that a one or two level TLIF procedure was performed through a paramedian MIS approach with bilateral posterior pedicle screw instrumentation and without posterolateral bone grafting. CT scan verified fusion rates were mandatory for inclusion. Seven studies (case series and case-controls) met inclusion criteria with a total of 408 patients who underwent MIS TLIF as described above. The mean age was 50.7 years and 56.6% of patients were female. A total of 78.9% of patients underwent single level TLIF. Average radiographic follow-up was 15.6 months. All patients had local autologous interbody bone grafting harvested from the pars interarticularis and facet joint of the approach side. Either polyetheretherketone (PEEK) or allograft interbody cages were used in all patients. Overall fusion rate, confirmed by bridging trabecular interbody bone on CT scan, was 94.7%. This meta-analysis suggests that MIS TLIF performed with interbody bone grafting alone has similar fusion rates to MIS or open TLIF performed with interbody supplemented with posterolateral bone grafting and fusion.