Revisiting the Anterior Glenoid: An Analysis of the Calcified Cartilage Layer, Capsulolabral Complex, and Glenoid Bone Density.

PURPOSE: In this cadaveric study, we aim to define the basic anatomy of the anterior glenoid with attention to the relationships of calcified cartilage, capsulolabral complex, and osseous morphology of the anterior glenoid. METHODS: Seventeen cadaveric glenoid specimens (14 male, 3 female, mean age 53.9 ± 10) were imaged with micro-computed tomography (CT) and embedded in poly-methyl-methacrylate. Specimens were included for final analysis only if the entire glenoid articular cartilage, labrum, capsule, and biceps insertion were pristine and without evidence of injury, degeneration, or damage during the preparation process. Group 1 members (n = 9) were axially sectioned through 3 to 9 o'clock and 4 to 8 o'clock; group 2 members (n = 8) were radially sectioned through 3, 4, 5, and 9 o'clock. A scanning electron microscope (SEM) analysis quantified the percentage of bone within a 5 × 2.5 mm region at the glenoid rim. Micro-CT, SEM, and light microscopy evaluated the capsulolabral complex and calcified fibrocartilage. RESULTS: A 7 ± 2.1 mm region of calcified fibrocartilage at 4 o'clock was identified from the articular face to the medial glenoid neck supporting the overlying capsulolabral footprint and was >3× thicker at the articular attachment (316 ± 153 µm) versus the glenoid neck (92 ± 66 µm). At 3 to 9 o'clock and 4 to 8 o'clock 79.2% ± 5.4% and 75.2% ± 7.8% of the glenoid osseous width was covered with articular cartilage. The labrum accounted for 13.1% ± 3.4% of the glenoid width at 4 o'clock. SEM analysis demonstrated decreased glenoid bone density at 3, 4, and 5 o'clock (P ≤ .015) and no difference (P = .448) at 9 o'clock versus central subchondral bone. CONCLUSIONS: The capsulolabral footprint contributes significantly to the glenoid face, inserts directly adjacent to the articular cartilage, and extends medially along the glenoid neck. A layer of calcified fibrocartilage lies immediately beneath the capsulolabral footprint and is 3× thicker at the articular insertion compared with the glenoid neck. Lastly, there is a bone density gradient at the anterior-inferior rim versus the central subchondral bone. CLINICAL RELEVANCE: Arthroscopic Bankart repair has been reported to have a significant failure rate in many settings. It is felt that reproducing anatomy with the repair could help improve outcomes. Based on this study's findings, an arthroscopic Bankart technique that most closely reproduces native anatomy and potentially optimizes soft-tissue healing could be performed. This includes removal of 1 to 2 mm of articular cartilage from the glenoid face with anchor placement at this location to appropriately reposition the capsulolabral complex.

Factors influencing direct clinical costs of outpatient arthroscopic rotator cuff repair surgery.

BACKGROUND: Very limited information exists about factors affecting direct clinical costs of rotator cuff repair surgery. The purpose of this study was to determine the direct cost of outpatient arthroscopic rotator cuff repair surgery using a unique value-driven outcomes tool and to identify patient- and treatment-related variables affecting cost. METHODS: Cost data were derived for arthroscopic rotator cuff repairs performed by 3 surgeons from March 2014 to June 2015 using the value-driven outcomes tool. Costs included overall total direct cost, which included facility utilization costs, medication costs, supply costs, and other ancillary costs. Univariate and multivariate regressions were performed to determine the effect of various patient-related and surgical-related factors on costs. RESULTS: There were 170 arthroscopic rotator cuff repairs performed during the study period. Multivariate analysis showed significant correlations between higher total direct cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors used (P < .0001). Higher body mass index, severe systemic illness, 1 of the 3 surgeons, biceps tenodesis using an anchor, and total sum of anchors were correlated with higher facility utilization costs (P < .04). Severe systemic illness, addition of a subscapularis repair, 1 of the 3 surgeons, and additional subacromial decompression were correlated with higher pharmacy costs (P < .006). The addition of a subscapularis repair, total sum of anchors, and severe muscle changes to the supraspinatus were correlated with higher supply costs (P < .015). CONCLUSIONS: From a direct cost perspective, implementation of strategies to reduce overall costs should focus on reducing overall anchor quantity or price.

Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy.

PURPOSE: The purpose of this study was to evaluate the utility of multimodal analgesia with fascia iliaca blockade and for acute pain control in patients undergoing hip arthroscopy. METHODS: Thirty consecutive patients undergoing primary hip arthroscopy were prospectively studied. All patients were treated preoperatively with ultrasound-guided single injection fascia iliaca blockade and multimodal analgesia. Data collected included post-operative nausea, numeric rating scale (NRS) pain scores during rest and activity, opioid consumption during the first five days (recorded as tablets of 5 mg hydrocodone/500 mg acetaminophen) and overall patient satisfaction with analgesia. RESULTS: This study included 23 female and 7 male patients with a median age of 35 years (range 14-58). No patient required medication for post-operative nausea. The overall NRS scores were an average of 3.9 on day 0, 3.6 on day 1, 3.4 on day 2, 2.9 on day 3, 3.0 on day 4 and 2.7 on day 5. The average tablets of opioid taken were 1.5 on day 0, 1.2 on day 1, 1.3 on day 2, 1.0 on day 3, 1.1 on day 4 and 0.9 on day 5. Overall, 20 patients rated their post-operative pain control as very satisfied (67 %), and 10 patients as satisfied (33 %). There were no complications or side effects from the fascia iliaca blockade. CONCLUSION: In this prospective study, multimodal analgesia with fascia iliaca blockade following hip arthroscopy was safe and effective. The quality of early post-operative analgesia provided by the fascia iliaca blockade was excellent and resulted in low opioid consumption, high quality of pain relief and high overall patient satisfaction.

Diagnosing joint infections: synovial fluid differential is more sensitive than white blood cell count.

In order to identify the predictive value of synovial fluid white blood cell (WBC) count and differential white blood cell count in identifying nonprosthetic joint infection in immunocompetent and immunosuppressed populations, we retrospectively reviewed 96 adult patients who underwent hip or knee aspiration because of symptoms suggesting a possible nonprosthetic joint infection. Medical history, including immunosuppressive disease or drugs, was recorded, and synovial fluid cell count, differential, and culture results were compared. There were 44 patients with positive synovial cultures. Of 36 patients who had a synovial WBC ≥50,000/mm³, 89% had positive cultures. The sensitivity to synovial WBC ≥50,000/mm³ was 0.727 (95% CI 0.570-0.845), and specificity was 0.923 (95% CI 0.806-0.975). There were 12 patients with a synovial WBC <50,000/mm³ that had positive cultures. The sensitivity of percentage polymorphonuclear cells (%PMNs) to predict positive cultures when the %PMNs were at least 80, 85, and 90% was 0.932, 0.886, and 0.818, respectively. The specificity when the %PMNs was at least 80, 85, and 90% was 0.598, 0.577, and 0.673, respectively. Among the 29% of immunocompromised patients, the sensitivity to synovial WBC ≥50,000/mm³ was 0.714 (95% CI 0.420-0.904), and specificity was 1.000 (95% CI 0.732-1.000). Twenty-nine percent of patients with a synovial WBC <50,000/mm³ had positive cultures. The sensitivity of %PMNs to predict positive cultures when the %PMNs was at least 80, 85, and 90% was 1.000, 0.929, and 0.786, respectively. The specificity when the %PMNs were at least 80, 85, and 90% was 0.500, 0.643, and 0.714, respectively. We found that the synovial WBC differential (percentage synovial fluid PMNs) is a more sensitive predictor for nonprosthetic adult joint infection than the synovial absolute WBC count. This was true in both the general population and the immunosuppressed population.

Functional and Radiographic Outcomes After Allograft Anatomic Coracoclavicular Ligament Reconstruction.

OBJECTIVES: To analyze the functional and radiographic outcomes of anatomic coracoclavicular ligament reconstruction (ACCR) using allograft tendon without interference screw fixation. DESIGN: Retrospective nonrandomized study. SETTING: Level I trauma center (University Hospital). PATIENTS: Seventeen patients (mean age of 44 years) with Rockwood III through V acromioclavicular joint disruptions. Twelve of 17 patients had a primary reconstruction, including 4 patients sustaining their injuries as part of a polytrauma incident. Five of 17 patients were revisions of a previously failed acromioclavicular reconstruction procedure. INTERVENTION: Open ACCR using hamstring allograft with high-strength suture augmentation and knotted graft fixation without interference screws. MAIN OUTCOME MEASURES: Clinical and patient reported outcome measures including Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and visual analog scale scores for pain and radiographic outcomes. RESULTS: The average final postoperative Simple Shoulder Test and American Shoulder and Elbow Surgeons scores were 10.8 and 80.5, respectively. The average final postoperative visual analog scale pain was 1.8. All patients demonstrated clavicle tunnel widening on final postoperative radiographs compared with immediate postoperative radiographs. The overall complication rate was 36%, with no clavicle or coracoid fractures. CONCLUSIONS: Open ACCR using hamstring allograft tendon secured with a square knot and high-strength suture augmentation yields equivalent outcomes to those repairs requiring an additional interference screw. Clavicle tunnel widening predictably occurs, but the clinical significance is undetermined. It appears therefore that an interference screw is not needed. Larger comparison studies are needed. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Comprehensive Evaluation of Factors Affecting Healing, Range of Motion, Strength, and Patient-Reported Outcomes After Arthroscopic Rotator Cuff Repair.

BACKGROUND: Rotator cuff repair (RCR) leads to improved patient outcomes, which may or may not coincide with biological healing of the tendon. Many patient factors may play a role in subjective and objective patient outcomes of surgery. PURPOSE: To evaluate the effect of various patient factors and tendon healing on range of motion, strength, and functional outcomes after arthroscopic RCR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We reviewed patients who underwent arthroscopic RCR. Postoperative endpoints included physical examination, repeat magnetic resonance imaging (MRI), and patient-reported outcome measures. The Short Form-36 (SF-36) was also completed at enrollment. Physical examination included range of motion and strength testing. Preoperative tear characteristics and postoperative healing on MRI were recorded. Associations between these characteristics and rotator cuff healing were determined. Multivariate models investigated factors affecting healing and final outcomes. RESULTS: A total of 81 patients had MRI before and a minimum of 1 year after RCR. Patient-reported outcomes were available for all patients at mean 2.7 years (range, 1-7.7 years) after RCR. Seventy-five patients had physical examination data. Patients were less likely to heal if they had tears involving multiple tendons (P = .037), tears >2.2 cm (P = .037), tears retracted >2.0 cm (P = .006), and tears with cumulative Goutallier grade ≥3 (P = .003). Patients who healed were stronger on manual muscle testing in forward elevation (P < .001) and external rotation (P = .005) and on forward elevation isometric testing (P = .033), and they reported better patient-reported outcomes (P ≤ .01) at final follow-up. In multivariate models, tendon healing was associated with less pain (P = .019) and better patient-reported outcomes (all P ≤ .006). Lower SF-36 mental component summary (MCS) score was associated with increased pain (P = .025) and lower final American Shoulder and Elbow Surgeons score (P = .035), independent of healing status. CONCLUSION: Larger, more retracted tears with greater fatty infiltration are less likely to heal per MRI. Patients who do not heal are weaker and have worse patient-reported outcome measures. Lower SF-36 MCS score was associated with poorer patient-reported outcomes independent of tendon healing.

Isolated arthroscopic rotator interval closure for shoulder instability.

We present our technique for isolated arthroscopic rotator interval closure in the treatment of mild symptomatic glenohumeral instability in the absence of a labral tear. A careful history, physical examination, and imaging help to identify a select subset of atraumatic instability patients who may benefit from this procedure, and diagnostic arthroscopy can provide further evidence. By use of a posterior viewing portal with anterior and anterolateral working portals, the anterior capsuloligamentous complex is mobilized, and the rotator interval is closed with carefully placed sutures to advance the capsule superiorly and provide tension through decreased capsular volume.

Arthroscopic repair of the floating posterior-inferior glenohumeral ligament lesion.

We present our technique for diagnosis and arthroscopic repair of a floating posterior-inferior glenohumeral ligament avulsion injury. A high degree of suspicion based on the patient's history, along with careful examination, should alert the surgeon to the existence of this lesion. By use of an anterolateral viewing portal and precisely placed posterior working portals, the lesion is repaired through suture anchor fixation to the humeral head and glenoid rim in a carefully sequenced fashion to achieve appropriate tension and restore the anatomy.

Sacral fractures: current strategies in diagnosis and management.

Sacral fractures are commonly associated with pelvic ring fractures due to high-energy mechanisms of injury. An understanding of the anatomic relation of the sacrum to the lumbar spine, pelvis, and surrounding neurovascular structures is critical in evaluating functional deficits that may be associated with sacral fractures. While displaced fractures can be easily diagnosed on high quality plain radiographs, nondisplaced or transverse fracture patterns may be difficult to diagnose without a computed tomography scan. Once identified, correct classification of a sacral fracture can facilitate ideal treatment strategies. Stable nondisplaced fractures are usually treated nonoperatively, while significantly displaced fractures require reduction and internal fixation. Surgical fixation techniques include percutaneously placed iliosacral screws, posterior sacral "tension band" fixation, and for certain fracture patterns osteosynthesis that incorporates the lower lumbar spine (lumbopelvic or triangular fixation). This article reviews the approach to sacral fracture diagnosis and management.

An 8 nt RNA triggers a rate-limiting shift of RNA polymerase II complexes into elongation.

To better understand the critical conversions that RNA polymerase II complexes undergo during promoter escape, we determined in vitro the precise positions of the rate-limiting step and the last step requiring negative superhelicity or TFIIE and TFIIH. We found that both steps occur after synthesis of an 8 nt RNA during the stage encompassing translocation of the polymerase active site to the ninth register. When added to reactions just before this step, TFIIE and TFIIH overcame the requirement for negative superhelicity. The positions at which both steps occur were strictly dependent on RNA length as opposed to the location of the polymerase relative to promoter elements, showing that the transcript itself controls transformations during promoter escape. We propose a model in which completion of promoter escape involves a rate-limiting conversion of early transcribing complexes into elongation complexes. This transformation is triggered by synthesis of an 8 nt RNA, occurs independent of the general transcription factors, and requires under-winding in the DNA template via negative superhelicity or the action of TFIIE and TFIIH.