Osteochondral lesions of the talus vary both in terms of patient symptoms and treatment options. ... more Osteochondral lesions of the talus vary both in terms of patient symptoms and treatment options. Patient presentation is variable, commons symptoms include minor previous trauma with persistent pain, recurrent ankle swelling, and mechanical symptoms. Treatment often depends on the stability of the cartilage fragment and typically includes a course of conservative treatment. Surgical options include simple arthroscopy with loose body removal with or without microfracture, open reduction and internal fixation of the lesion, autologous chondrocyte implantation with structural allograft, or an osteochondral autograft transplant (OAT), typically using the knee as a donor site. Although a range of successful surgical treatments has been published, OATs demonstrates reliable functional outcomes and is a good option for large osteochondral lesions (>1.5 cm2), after a failed microfracture or in situations with cystic lesions. In this article, we aim to provide a comprehensive description of OAT of the talus. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate co... more To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. Methods: Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and c 2 analysis was used to compare surgery rates between divisions. Results: A total of 445 shoulder instability injuries
Case: A 21-year-old collegiate baseball pitcher presented with transient lateral arm pain and wri... more Case: A 21-year-old collegiate baseball pitcher presented with transient lateral arm pain and wrist extension weakness after pitching more than 1 inning. Physical examination was unremarkable at rest. Ultrasound-guided injection of the radial nerve at the level of the lateral intramuscular septum improved his symptoms. After decompression of the radial nerve, the patient noted resolution of his symptoms while pitching. Conclusion: Atraumatic radial neuropathy is a rare but documented phenomenon. As far as we know, this is the first reported case of a transient exertional radial neuropathy in an athlete at the level of the lateral intermuscular septum.
Medicine and Science in Sports and Exercise, May 1, 2015
TEST AND RESULTS: X-ray wrist-increased sclerosis of the distal radius and ulnar metaphysis adjac... more TEST AND RESULTS: X-ray wrist-increased sclerosis of the distal radius and ulnar metaphysis adjacent to the growth plate. MRI wrist-signal abnormality and focal irregularity in the distal radial metaphysis and physis most suggestive of stress reaction. Small ganglion cyst along the radiocarpal joint in the volar aspect of the wrist. No evidence of a Salter fracture. Contents of the carpal tunnel are normal. FINAL WORKING DIAGNOSIS: Distal radial physeal stress reaction (gymnast's wrist) TREATMENT AND OUTCOMES: Patient was placed in a short arm cast for 4 weeks. As it was hockey season when the cast came off, he was placed in a formfit wrist splint for hockey and started a gradual return to sports. So far the patient has had minimal pain with hockey, but further outcomes will be discussed at the conference. Since this is an injury which typically occurs in adolescent gymnasts, we will discuss the possible mechanism of this injury with tennis.
Advertisement. Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for Cu... more Advertisement. Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for Current Orthopaedic Practice. Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information ...
Surgical treatment of early avascular necrosis of the femoral head remains controversial. The tec... more Surgical treatment of early avascular necrosis of the femoral head remains controversial. The technique presented here involves drilling of the femoral head followed by injection of autologous, concentrated bone marrow stem cells. Preliminary reports using similar techniques show lower rates of collapse when compared with core decompression. This technique is simple, minimally invasive, requires only overnight hospital admission, does not require a period of postoperative nonweightbearing, and is well tolerated by patients. It is important to select patients carefully (ie, those with Association Research Circulation Osseous stage I and II disease). We believe that the mesenchymal stem cells in the concentrated bone marrow are essential for the regeneration of bone within the avascular necrosis lesions but the presence of other hematopoetic lineage cells may also be important to optimize the physiological and cellular milieu for the promotion of both osteogenesis and angiogenesis.
Patellofemoral disorders can be divided into those that primarily cause pain and those that cause... more Patellofemoral disorders can be divided into those that primarily cause pain and those that cause instability. Lateral tracking, malalignment, and a tight lateral retinaculum are anatomic factors that can increase joint reactive forces resulting in pain and chondral damage. Patella alta, trochlear dysplasia, lateral tracking vector, and MPFL deficiency can be associated with patella instability. Tibia tubercle osteotomy can be used to treat pain and instability in cases that demonstrate malalignment and a lateral tracking vector. This chapter will define indications for tibia tubercle transfer, review anatomic and biomechanical factors associated with the technique, and highlight important technical considerations.
Archives of Orthopaedic and Trauma Surgery, Oct 21, 2021
Introduction Femoral nerve block (FNB) is a routinely used regional analgesic technique for anter... more Introduction Femoral nerve block (FNB) is a routinely used regional analgesic technique for anterior cruciate ligament (ACL) reconstruction. One method to balance the analgesic effect and functional impairment of FNBs may be to control the concentration of local anesthetics utilized for the block. Materials and methods Retrospective chart review was performed on 390 consecutive patients who underwent ACL reconstruction between June 2014 and May 2017. Patients were divided into those who received a standard (0.5%-bupivacaine) or low (0.1-0.125%-bupivacaine) concentration single-shot FNB performed with ultrasound guidance. Maximum postoperative VAS, Post-Anaesthesia Care Unit (PACU) time prior to discharge, need for additional 'rescue' block, and intravenous postoperative narcotic requirements were recorded. Results A total of 268 patients (28.4 ± 11.9 years) were included for final analysis, with 72 patients in the low-concentration FNB group and 196 patients receiving the standard concentration. There were no differences in the maximum postoperative VAS between the low (6.4 ± 2.5) and standard (5.7 ± 2.9) concentration groups (P = 0.08). Similarly, the time from PACU arrival to discharge was not different between groups (P = 0.64). A sciatic rescue block was needed in 22% of patients with standard-dose FNB compared to 30% of patients receiving the low-concentration FNB (P = 0.20). Patients with a hamstring autograft harvest were more likely to undergo a postoperative sciatic rescue block compared to a bone-patellar tendon autograft (P = 0.005), regardless of preoperative block concentration. Quadriceps activation was preserved with low-concentration blocks. Conclusions Using 1/5th to 1/4th the standard local anesthetic concentration for preoperative femoral nerve block in ACL reconstruction did not significantly differ in peri-operative outcomes, PACU time, need for rescue blockade, or additional immediate opioid requirements. Level of Evidence III.
Detailed anatomic dissections of the deep medial knee retinaculum have shown a consistent promine... more Detailed anatomic dissections of the deep medial knee retinaculum have shown a consistent prominent anatomic structure extending from the distal deep quadriceps tendon to the adductor tubercle region, forming a distinct medial quadriceps tendonefemoral ligament (MQTFL). Reconstruction of this anatomic structure has yielded consistent medial stabilization of the patellofemoral joint without drilling into the patella over more than 3 years in patients with recurrent patella instability and dislocation. Results are similar to those of MPFL reconstruction but with reduced risk of patella fracture, a known and serious complication of MPFL reconstruction. The reconstruction graft is secured at the anatomic femoral origin of the MQTFL and brought under the vastus medialis such that it may be woven and attached to the deep distal medial quadriceps tendon to provide a secure, reliable reproduction of the MQTFL and excellent stabilization of the patellofemoral joint without risk of patella fracture.
Journal of Shoulder and Elbow Surgery, Jul 1, 2021
BACKGROUND Superior capsular reconstruction (SCR) treatment of massive, symptomatic, irreparable ... more BACKGROUND Superior capsular reconstruction (SCR) treatment of massive, symptomatic, irreparable rotator cuff tears (RCT) has become a more recently utilized procedure. However, there is a lack of consensus surrounding optimal graft choice for the SCR technique and current dermal grafts have increased cost and are technically challenging due to a need for multiple implants. The purpose of this study was to biomechanically investigate a biological lower-cost alternative as a support for the superior capsule reconstruction concept; an isolated semitendinosus tendon allograft (STT) and a combination graft with the tendon of the long head of the biceps (LHBT) in an established massive posterosuperior RCT cadaver model. METHODS Ten fresh-frozen cadaveric shoulders (53.3 ± 12.4 years: range: 26 - 65) were tested on an established dynamic shoulder simulator using dynamic muscle loading. Cumulative deltoid forces, maximum abduction angle, and superior humeral head translation were compared across four testing conditions: (1) intact state, (2) massively retracted (Patte III), irreparable posterosuperior RCT, (3) SCR repair using a STT allograft, (4) SCR repair using a combined STT-LHBT repair. RESULTS Intact shoulders required a mean deltoid force of 154.2 ± 20.41N to achieve maximum glenohumeral abduction (55.3 ± 2.3°). Compared to native shoulders, maximum abduction angle decreased following a massively retracted posterosuperior RCT by 52% (28.3 ± 8.4°; p<.001), while cumulative deltoid forces increased by 48 % (205.3 ± 40.9N; p=0.001). The STT repair and STT-LHBT repair improved shoulder function when compared to the tear state, with mean maximum abduction angle of 30.6 ± 9.0o and 31.8 ± 7.7o and mean deltoid force of 205.3 ± 40.9 N, and 201.0 ± 34.0 N respectively, but this was not statistically significant (P > 0.05). The STT-LHBT repair significantly improved range of motion compared to the tear state (P = .04). CONCLUSIONS In a dynamic shoulder simulator model, both the SST and the SST-LHBT repair techniques improved glenohumeral joint kinematics in an amount similar to previously reported "traditional" SCR techniques for treatment of an irreparable posterosuperior RCT.
Operative Techniques in Sports Medicine, Mar 1, 2015
Rotator cuff tears are among the most common causes of pain and disability in the upper extremity... more Rotator cuff tears are among the most common causes of pain and disability in the upper extremity. Despite significant advances in repair techniques and instrumentation, re-tear rates after surgery remain high. Numerous avenues of structural and biological augmentation have been explored to increase healing potential and achieve successful outcomes particularly in patients with massive cuff tears and/or those undergoing revision surgery. The purpose of this paper is to present and discuss various techniques currently published that are designed to augment this process through variable methodologies. One common methodology is the use of graft tissue to "load share" with the repair and/or facilitate placement of pluripotential stem cell or growth factors at the site of needed healing. Although this field remains in development, this paper attempts to explain the concepts currently employed and summarize the current FDA approved options.
Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is hi... more Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is high. The Latarjet procedure has been well described for restoring glenohumeral stability in patients with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss. However, the treatment for patients with combined humeral head and mild (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;25%) glenoid bone loss remains unclear. This study reports on the outcomes of the modified Latarjet for patients with combined humeral and glenoid defects and compares the results for patients with ≤25% glenoid bone loss versus patients with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss. The hypothesis was that the 2 groups would have equivalent subjective outcomes and recurrence rates. Cohort Study; Level of evidence, 3. Modified Latarjet was performed in 40 patients with recurrent anterior shoulder instability, engaging Hill-Sachs by examination confirmed with arthroscopy, and ≤25% anterior glenoid bone loss (group A). A second group of 12 patients were identified to have &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss with an engaging Hill-Sachs lesion (group B). The mean follow-up time was 3.5 years. All patients were assessed for their risk of recurrence using the Instability Severity Index score and Beighton score and had preoperative 3-dimensional imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), recurrence rate, radiographs, range of motion, and dynamometer strength were used to assess outcomes. A multivariate analysis was performed. Glenoid bone loss averaged 15% in group A compared with 34% in group B. Both groups had comparable WOSI scores (356 vs 475; P = .311). In multivariate analysis, the number of previous surgeries and Beighton score were directly correlated with WOSI score in Latarjet patients. The SANE score was better in group A (86 vs 77; P = .02). Group B experienced more loss of external rotation (9.2° vs 15.8°; P = .0001) and weaker thumbs-down abduction and external rotation strength (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .032). Subscapularis, abduction, and external rotation strength averaged at least 75% of the contralateral shoulder in both groups. Graft resorption was similar in both groups (32% vs 33%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .999). The overall recurrent instability rate for the study, defined as any subsequent subluxations or dislocation, was 15%; recurrent instability rates (15% vs 17%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; .999) were similar for both groups. The complication rate was 25% for both groups. The modified Latarjet procedure provides satisfactory outcomes for patients with combined bone loss, which is known to have high recurrence rates with traditional arthroscopic stabilization. Previous surgical stabilization procedures and the Beighton score adversely affect outcome after modified Latarjet. Furthermore, the number of previous surgeries and Beighton score can be used to predict WOSI score in Latarjet patients. Further study is needed to determine if these results hold true in the long term.
Fracture healing is dependent on the concurrent processes of proteolytic degradation and in growt... more Fracture healing is dependent on the concurrent processes of proteolytic degradation and in growth of new blood vessels that allow osteogenic and osteoclastic cells to facilitate the primary resorption of the calcified cartilage. Thus the expression and activation of selective metalloproteinases (MMP’s) that cleave the extracellular matrix are essential for both the remodelling and induction of new bone formation. Our previous investigations have shown that TNF-α is a key mediator at multiple steps during fracture healing. The aims of this study were to identify metalloproteinases that are temporally expressed during fracture healing and determine if TNF-α functionally affects these processes. RNA expression was examined over a 28-day period following the generation of simple transverse fractures in mouse tibiae of TNF-α receptor null (p55−/− p75−/−) and strain matched control mice. The effects of TNF-α on the expression of specific MMPs was also examined ex vivo in cultures of cells prepared from eight day post fracture callous tissues. Using microarray analysis we examined the expression of 20 MMPs and their associated inhibitors during murine fracture healing. These data identify those MMPs that are expressed uniquely during both the period of endochondral resorption and later times during osteogenic tissue formation. Multiple members of these two families of factors were delayed and showed altered levels of expression in the absence of TNF-α signaling. In summary the pattern of MMP expression during fracture repair shows unique temporal spatial and quantitative variations in the expression.
Combined injuries to the anterior cruciate ligament (ACL) and lateral knee ligaments are an incre... more Combined injuries to the anterior cruciate ligament (ACL) and lateral knee ligaments are an increasingly well-documented injury pattern. ACL reconstruction is one of the most commonly performed procedures in orthopedic surgery, but the reconstruction is at risk of failure if existing concomitant pathology, such as a lateral ligament injury, is not addressed. Studies have suggested that lateral or posterolateral knee instability occurs concomitantly with ACL injuries in 11–19.7% of patients. This combined injury pattern is important for orthopedic surgeons to recognize and treat appropriately in order to optimize patient outcomes. The purpose of this chapter is to discuss the current state of combined anterior and lateral knee instability. It will begin with a brief overview of the pertinent anatomy, pathophysiology, and biomechanics of the ACL and lateral knee ligaments. Then, a discussion of clinical evaluation including history, physical examination, imaging studies, and diagnostic arthroscopy findings will assist the clinician in the appropriate evaluation of these injuries. Finally, the treatment options for combined ACL and lateral knee injuries in both the acute and chronic setting will be reviewed.
Purpose: To measure the patellofemoral contact pressure in early flexion after a tibial tubercle ... more Purpose: To measure the patellofemoral contact pressure in early flexion after a tibial tubercle distalization osteotomy. Methods: Ten matched-pair fresh-frozen cadaveric knees were studied. The average Blackburne-Peel ratio of the native knees was 0.91. The knees were placed on a testing rig, with a fixed femur and tibia mobile through 90 of flexion. Individual quadriceps heads and the iliotibial band were separated and loaded with 205 N in anatomic directions using a weighted pulley system. A straight tubercle distalization osteotomy of 1 cm was performed and fixed with screws, with and without a lateral release. Patellofemoral contact pressures were measured at 0 , 10 , 20 , 30 , 45 , 60 , and 90 of flexion using pressure-sensitive films on the medial trochlea and lateral trochlea. Contact force, area, and pressure were measured in the following states: (1) in the native knee, (2) after distalization, and (3) after distalization with lateral release. Results: The average Blackburne-Peel ratio after distalization was 0.64. Tibial tubercle distalization resulted in a 6-fold increase in mean contact pressure at 0 (0.15 MPa vs 0.90 MPa, P < .001) and a 55% increase at 10 of flexion (0.70 MPa vs 1.09 MPa, P ¼ .02). Mean contact pressure was similar from 20 to 90 of flexion (P > .1). After distalization, the total contact area was significantly higher at 0 of flexion (17.7 mm 2 vs 58.4 mm 2 , P ¼ .02). Lateral release after distalization did not significantly change contact pressure (P > .21). Conclusions: Our results suggest that patella baja, as a result of excessive patellar distalization, can cause increased patellofemoral contact pressures during early flexion at 0 and 10. No changes were seen in contact pressure from 20 to 90. Clinical Relevance: Care should be taken to prevent excessive distalization of the patella to avoid patella baja and increased patellofemoral contact pressures during early flexion.
Osteochondral lesions of the talus vary both in terms of patient symptoms and treatment options. ... more Osteochondral lesions of the talus vary both in terms of patient symptoms and treatment options. Patient presentation is variable, commons symptoms include minor previous trauma with persistent pain, recurrent ankle swelling, and mechanical symptoms. Treatment often depends on the stability of the cartilage fragment and typically includes a course of conservative treatment. Surgical options include simple arthroscopy with loose body removal with or without microfracture, open reduction and internal fixation of the lesion, autologous chondrocyte implantation with structural allograft, or an osteochondral autograft transplant (OAT), typically using the knee as a donor site. Although a range of successful surgical treatments has been published, OATs demonstrates reliable functional outcomes and is a good option for large osteochondral lesions (>1.5 cm2), after a failed microfracture or in situations with cystic lesions. In this article, we aim to provide a comprehensive description of OAT of the talus. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.
To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate co... more To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III. Methods: Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and c 2 analysis was used to compare surgery rates between divisions. Results: A total of 445 shoulder instability injuries
Case: A 21-year-old collegiate baseball pitcher presented with transient lateral arm pain and wri... more Case: A 21-year-old collegiate baseball pitcher presented with transient lateral arm pain and wrist extension weakness after pitching more than 1 inning. Physical examination was unremarkable at rest. Ultrasound-guided injection of the radial nerve at the level of the lateral intramuscular septum improved his symptoms. After decompression of the radial nerve, the patient noted resolution of his symptoms while pitching. Conclusion: Atraumatic radial neuropathy is a rare but documented phenomenon. As far as we know, this is the first reported case of a transient exertional radial neuropathy in an athlete at the level of the lateral intermuscular septum.
Medicine and Science in Sports and Exercise, May 1, 2015
TEST AND RESULTS: X-ray wrist-increased sclerosis of the distal radius and ulnar metaphysis adjac... more TEST AND RESULTS: X-ray wrist-increased sclerosis of the distal radius and ulnar metaphysis adjacent to the growth plate. MRI wrist-signal abnormality and focal irregularity in the distal radial metaphysis and physis most suggestive of stress reaction. Small ganglion cyst along the radiocarpal joint in the volar aspect of the wrist. No evidence of a Salter fracture. Contents of the carpal tunnel are normal. FINAL WORKING DIAGNOSIS: Distal radial physeal stress reaction (gymnast's wrist) TREATMENT AND OUTCOMES: Patient was placed in a short arm cast for 4 weeks. As it was hockey season when the cast came off, he was placed in a formfit wrist splint for hockey and started a gradual return to sports. So far the patient has had minimal pain with hockey, but further outcomes will be discussed at the conference. Since this is an injury which typically occurs in adolescent gymnasts, we will discuss the possible mechanism of this injury with tennis.
Advertisement. Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for Cu... more Advertisement. Close Window. Close Window. Thank you for choosing to subscribe to the eTOC for Current Orthopaedic Practice. Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information ...
Surgical treatment of early avascular necrosis of the femoral head remains controversial. The tec... more Surgical treatment of early avascular necrosis of the femoral head remains controversial. The technique presented here involves drilling of the femoral head followed by injection of autologous, concentrated bone marrow stem cells. Preliminary reports using similar techniques show lower rates of collapse when compared with core decompression. This technique is simple, minimally invasive, requires only overnight hospital admission, does not require a period of postoperative nonweightbearing, and is well tolerated by patients. It is important to select patients carefully (ie, those with Association Research Circulation Osseous stage I and II disease). We believe that the mesenchymal stem cells in the concentrated bone marrow are essential for the regeneration of bone within the avascular necrosis lesions but the presence of other hematopoetic lineage cells may also be important to optimize the physiological and cellular milieu for the promotion of both osteogenesis and angiogenesis.
Patellofemoral disorders can be divided into those that primarily cause pain and those that cause... more Patellofemoral disorders can be divided into those that primarily cause pain and those that cause instability. Lateral tracking, malalignment, and a tight lateral retinaculum are anatomic factors that can increase joint reactive forces resulting in pain and chondral damage. Patella alta, trochlear dysplasia, lateral tracking vector, and MPFL deficiency can be associated with patella instability. Tibia tubercle osteotomy can be used to treat pain and instability in cases that demonstrate malalignment and a lateral tracking vector. This chapter will define indications for tibia tubercle transfer, review anatomic and biomechanical factors associated with the technique, and highlight important technical considerations.
Archives of Orthopaedic and Trauma Surgery, Oct 21, 2021
Introduction Femoral nerve block (FNB) is a routinely used regional analgesic technique for anter... more Introduction Femoral nerve block (FNB) is a routinely used regional analgesic technique for anterior cruciate ligament (ACL) reconstruction. One method to balance the analgesic effect and functional impairment of FNBs may be to control the concentration of local anesthetics utilized for the block. Materials and methods Retrospective chart review was performed on 390 consecutive patients who underwent ACL reconstruction between June 2014 and May 2017. Patients were divided into those who received a standard (0.5%-bupivacaine) or low (0.1-0.125%-bupivacaine) concentration single-shot FNB performed with ultrasound guidance. Maximum postoperative VAS, Post-Anaesthesia Care Unit (PACU) time prior to discharge, need for additional 'rescue' block, and intravenous postoperative narcotic requirements were recorded. Results A total of 268 patients (28.4 ± 11.9 years) were included for final analysis, with 72 patients in the low-concentration FNB group and 196 patients receiving the standard concentration. There were no differences in the maximum postoperative VAS between the low (6.4 ± 2.5) and standard (5.7 ± 2.9) concentration groups (P = 0.08). Similarly, the time from PACU arrival to discharge was not different between groups (P = 0.64). A sciatic rescue block was needed in 22% of patients with standard-dose FNB compared to 30% of patients receiving the low-concentration FNB (P = 0.20). Patients with a hamstring autograft harvest were more likely to undergo a postoperative sciatic rescue block compared to a bone-patellar tendon autograft (P = 0.005), regardless of preoperative block concentration. Quadriceps activation was preserved with low-concentration blocks. Conclusions Using 1/5th to 1/4th the standard local anesthetic concentration for preoperative femoral nerve block in ACL reconstruction did not significantly differ in peri-operative outcomes, PACU time, need for rescue blockade, or additional immediate opioid requirements. Level of Evidence III.
Detailed anatomic dissections of the deep medial knee retinaculum have shown a consistent promine... more Detailed anatomic dissections of the deep medial knee retinaculum have shown a consistent prominent anatomic structure extending from the distal deep quadriceps tendon to the adductor tubercle region, forming a distinct medial quadriceps tendonefemoral ligament (MQTFL). Reconstruction of this anatomic structure has yielded consistent medial stabilization of the patellofemoral joint without drilling into the patella over more than 3 years in patients with recurrent patella instability and dislocation. Results are similar to those of MPFL reconstruction but with reduced risk of patella fracture, a known and serious complication of MPFL reconstruction. The reconstruction graft is secured at the anatomic femoral origin of the MQTFL and brought under the vastus medialis such that it may be woven and attached to the deep distal medial quadriceps tendon to provide a secure, reliable reproduction of the MQTFL and excellent stabilization of the patellofemoral joint without risk of patella fracture.
Journal of Shoulder and Elbow Surgery, Jul 1, 2021
BACKGROUND Superior capsular reconstruction (SCR) treatment of massive, symptomatic, irreparable ... more BACKGROUND Superior capsular reconstruction (SCR) treatment of massive, symptomatic, irreparable rotator cuff tears (RCT) has become a more recently utilized procedure. However, there is a lack of consensus surrounding optimal graft choice for the SCR technique and current dermal grafts have increased cost and are technically challenging due to a need for multiple implants. The purpose of this study was to biomechanically investigate a biological lower-cost alternative as a support for the superior capsule reconstruction concept; an isolated semitendinosus tendon allograft (STT) and a combination graft with the tendon of the long head of the biceps (LHBT) in an established massive posterosuperior RCT cadaver model. METHODS Ten fresh-frozen cadaveric shoulders (53.3 ± 12.4 years: range: 26 - 65) were tested on an established dynamic shoulder simulator using dynamic muscle loading. Cumulative deltoid forces, maximum abduction angle, and superior humeral head translation were compared across four testing conditions: (1) intact state, (2) massively retracted (Patte III), irreparable posterosuperior RCT, (3) SCR repair using a STT allograft, (4) SCR repair using a combined STT-LHBT repair. RESULTS Intact shoulders required a mean deltoid force of 154.2 ± 20.41N to achieve maximum glenohumeral abduction (55.3 ± 2.3°). Compared to native shoulders, maximum abduction angle decreased following a massively retracted posterosuperior RCT by 52% (28.3 ± 8.4°; p<.001), while cumulative deltoid forces increased by 48 % (205.3 ± 40.9N; p=0.001). The STT repair and STT-LHBT repair improved shoulder function when compared to the tear state, with mean maximum abduction angle of 30.6 ± 9.0o and 31.8 ± 7.7o and mean deltoid force of 205.3 ± 40.9 N, and 201.0 ± 34.0 N respectively, but this was not statistically significant (P > 0.05). The STT-LHBT repair significantly improved range of motion compared to the tear state (P = .04). CONCLUSIONS In a dynamic shoulder simulator model, both the SST and the SST-LHBT repair techniques improved glenohumeral joint kinematics in an amount similar to previously reported "traditional" SCR techniques for treatment of an irreparable posterosuperior RCT.
Operative Techniques in Sports Medicine, Mar 1, 2015
Rotator cuff tears are among the most common causes of pain and disability in the upper extremity... more Rotator cuff tears are among the most common causes of pain and disability in the upper extremity. Despite significant advances in repair techniques and instrumentation, re-tear rates after surgery remain high. Numerous avenues of structural and biological augmentation have been explored to increase healing potential and achieve successful outcomes particularly in patients with massive cuff tears and/or those undergoing revision surgery. The purpose of this paper is to present and discuss various techniques currently published that are designed to augment this process through variable methodologies. One common methodology is the use of graft tissue to "load share" with the repair and/or facilitate placement of pluripotential stem cell or growth factors at the site of needed healing. Although this field remains in development, this paper attempts to explain the concepts currently employed and summarize the current FDA approved options.
Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is hi... more Recurrent anterior glenohumeral dislocation in the setting of an engaging Hill-Sachs lesion is high. The Latarjet procedure has been well described for restoring glenohumeral stability in patients with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss. However, the treatment for patients with combined humeral head and mild (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;25%) glenoid bone loss remains unclear. This study reports on the outcomes of the modified Latarjet for patients with combined humeral and glenoid defects and compares the results for patients with ≤25% glenoid bone loss versus patients with &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss. The hypothesis was that the 2 groups would have equivalent subjective outcomes and recurrence rates. Cohort Study; Level of evidence, 3. Modified Latarjet was performed in 40 patients with recurrent anterior shoulder instability, engaging Hill-Sachs by examination confirmed with arthroscopy, and ≤25% anterior glenoid bone loss (group A). A second group of 12 patients were identified to have &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;25% glenoid bone loss with an engaging Hill-Sachs lesion (group B). The mean follow-up time was 3.5 years. All patients were assessed for their risk of recurrence using the Instability Severity Index score and Beighton score and had preoperative 3-dimensional imaging to assess humeral and glenoid bone loss. Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), recurrence rate, radiographs, range of motion, and dynamometer strength were used to assess outcomes. A multivariate analysis was performed. Glenoid bone loss averaged 15% in group A compared with 34% in group B. Both groups had comparable WOSI scores (356 vs 475; P = .311). In multivariate analysis, the number of previous surgeries and Beighton score were directly correlated with WOSI score in Latarjet patients. The SANE score was better in group A (86 vs 77; P = .02). Group B experienced more loss of external rotation (9.2° vs 15.8°; P = .0001) and weaker thumbs-down abduction and external rotation strength (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .032). Subscapularis, abduction, and external rotation strength averaged at least 75% of the contralateral shoulder in both groups. Graft resorption was similar in both groups (32% vs 33%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .999). The overall recurrent instability rate for the study, defined as any subsequent subluxations or dislocation, was 15%; recurrent instability rates (15% vs 17%; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; .999) were similar for both groups. The complication rate was 25% for both groups. The modified Latarjet procedure provides satisfactory outcomes for patients with combined bone loss, which is known to have high recurrence rates with traditional arthroscopic stabilization. Previous surgical stabilization procedures and the Beighton score adversely affect outcome after modified Latarjet. Furthermore, the number of previous surgeries and Beighton score can be used to predict WOSI score in Latarjet patients. Further study is needed to determine if these results hold true in the long term.
Fracture healing is dependent on the concurrent processes of proteolytic degradation and in growt... more Fracture healing is dependent on the concurrent processes of proteolytic degradation and in growth of new blood vessels that allow osteogenic and osteoclastic cells to facilitate the primary resorption of the calcified cartilage. Thus the expression and activation of selective metalloproteinases (MMP’s) that cleave the extracellular matrix are essential for both the remodelling and induction of new bone formation. Our previous investigations have shown that TNF-α is a key mediator at multiple steps during fracture healing. The aims of this study were to identify metalloproteinases that are temporally expressed during fracture healing and determine if TNF-α functionally affects these processes. RNA expression was examined over a 28-day period following the generation of simple transverse fractures in mouse tibiae of TNF-α receptor null (p55−/− p75−/−) and strain matched control mice. The effects of TNF-α on the expression of specific MMPs was also examined ex vivo in cultures of cells prepared from eight day post fracture callous tissues. Using microarray analysis we examined the expression of 20 MMPs and their associated inhibitors during murine fracture healing. These data identify those MMPs that are expressed uniquely during both the period of endochondral resorption and later times during osteogenic tissue formation. Multiple members of these two families of factors were delayed and showed altered levels of expression in the absence of TNF-α signaling. In summary the pattern of MMP expression during fracture repair shows unique temporal spatial and quantitative variations in the expression.
Combined injuries to the anterior cruciate ligament (ACL) and lateral knee ligaments are an incre... more Combined injuries to the anterior cruciate ligament (ACL) and lateral knee ligaments are an increasingly well-documented injury pattern. ACL reconstruction is one of the most commonly performed procedures in orthopedic surgery, but the reconstruction is at risk of failure if existing concomitant pathology, such as a lateral ligament injury, is not addressed. Studies have suggested that lateral or posterolateral knee instability occurs concomitantly with ACL injuries in 11–19.7% of patients. This combined injury pattern is important for orthopedic surgeons to recognize and treat appropriately in order to optimize patient outcomes. The purpose of this chapter is to discuss the current state of combined anterior and lateral knee instability. It will begin with a brief overview of the pertinent anatomy, pathophysiology, and biomechanics of the ACL and lateral knee ligaments. Then, a discussion of clinical evaluation including history, physical examination, imaging studies, and diagnostic arthroscopy findings will assist the clinician in the appropriate evaluation of these injuries. Finally, the treatment options for combined ACL and lateral knee injuries in both the acute and chronic setting will be reviewed.
Purpose: To measure the patellofemoral contact pressure in early flexion after a tibial tubercle ... more Purpose: To measure the patellofemoral contact pressure in early flexion after a tibial tubercle distalization osteotomy. Methods: Ten matched-pair fresh-frozen cadaveric knees were studied. The average Blackburne-Peel ratio of the native knees was 0.91. The knees were placed on a testing rig, with a fixed femur and tibia mobile through 90 of flexion. Individual quadriceps heads and the iliotibial band were separated and loaded with 205 N in anatomic directions using a weighted pulley system. A straight tubercle distalization osteotomy of 1 cm was performed and fixed with screws, with and without a lateral release. Patellofemoral contact pressures were measured at 0 , 10 , 20 , 30 , 45 , 60 , and 90 of flexion using pressure-sensitive films on the medial trochlea and lateral trochlea. Contact force, area, and pressure were measured in the following states: (1) in the native knee, (2) after distalization, and (3) after distalization with lateral release. Results: The average Blackburne-Peel ratio after distalization was 0.64. Tibial tubercle distalization resulted in a 6-fold increase in mean contact pressure at 0 (0.15 MPa vs 0.90 MPa, P < .001) and a 55% increase at 10 of flexion (0.70 MPa vs 1.09 MPa, P ¼ .02). Mean contact pressure was similar from 20 to 90 of flexion (P > .1). After distalization, the total contact area was significantly higher at 0 of flexion (17.7 mm 2 vs 58.4 mm 2 , P ¼ .02). Lateral release after distalization did not significantly change contact pressure (P > .21). Conclusions: Our results suggest that patella baja, as a result of excessive patellar distalization, can cause increased patellofemoral contact pressures during early flexion at 0 and 10. No changes were seen in contact pressure from 20 to 90. Clinical Relevance: Care should be taken to prevent excessive distalization of the patella to avoid patella baja and increased patellofemoral contact pressures during early flexion.
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