Alex J. Kline

Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder A Prospective Study of 100 Shoulders

Background There are few reports in the literature detailing arthroscopic treatment of unidirectional posterior shoulder instability. Hypothesis Arthroscopic capsulolabral reconstruction is effective in restoring stability and function and alleviating pain in athletes with symptomatic unidirectional posterior instability. This population has significant differences in glenoid and chondrolabral versions when compared with controls. Study Design Cohort study; Level of evidence, 2. Methods Ninety-one athletes (100 shoulders) with unidirectional recurrent posterior shoulder instability were treated with an arthroscopic posterior capsulolabral reconstruction and evaluated at a mean of 27 months postoperatively. A subset of 51 shoulders in contact athletes were compared with the entire group of 100 shoulders. Patients were evaluated prospectively with the American Shoulder and Elbow Surgeons scoring system. Stability, strength, and range of motion were evaluated preoperatively and postoperatively with standardized subjective scales. Forty-eight shoulders had magnetic resonance arthrograms performed and were available for review. The posterior inferior chondrolabral and bony glenoid versions were measured and compared with controls. Results At a mean of 27 months postoperatively, the mean American Shoulder and Elbow Surgeons score improved from 50.36 to 85.66 (P < .001). There were significant improvements in stability, pain, and function based on standardized subjective scales (P < .001). The contact athletes did not demonstrate any significant differences when compared with the entire cohort for any outcome measure. The results in the 71 shoulders followed for at least 2 years were similar to the overall group. On magnetic resonance arthrography, the shoulders with posterior instability were found to have significantly greater chondrolabral and osseous retroversion in comparison with controls (P < .001 and P = .008, respectively). Conclusion Arthroscopic capsulolabral reconstruction is an effective, reliable treatment for symptomatic unidirectional recurrent posterior glenohumeral instability in an athletic population. Overall, 89% of patients were able to return to sport, with 67% of patients able to return to the same level postoperatively.

The Management of Ankle Fractures in Patients with Diabetes

Patients with diabetes mellitus have higher complication rates following both open and closed management of ankle fractures. Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients. Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques. Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome. Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.

Minimally invasive technique versus an extensile lateral approach for intra-articular calcaneal fractures.

Background: The optimal method for treating intra-articular fractures of the calcaneus remains controversial. Extensile approaches allow excellent fracture exposure, but high rates of wound complications are seen. Newer minimally invasive techniques for calcaneus fracture fixation offer a potentially lower wound complication rate, but long-term clinical results are not available. The aim of this study was to compare the outcomes of intra-articular calcaneus fractures treated with open reduction and internal fixation via an extensile approach versus those with a minimally invasive sinus tarsi approach. Methods: We performed a retrospective review of all intra-articular calcaneal fractures treated operatively between October 2005 and December 2008. A total of 112 fractures were found that met our inclusion criteria; 79 were treated with an extensile lateral approach and 33 via a minimally invasive approach based on surgeon preference. Chart and radiographic results were thoroughly reviewed on all 112 fractures, specifically for wound healing complications and the need for further surgeries within the study period. Additionally, all patients were contacted and asked to return for a research visit that included radiography, clinical examination, and quality of life questionnaires (Short Form 36 [SF-36], foot function index [FFI], visual analog scale [VAS] pain). A total of 47 of 112 (42%) patients returned for a research visit (31 extensile, 16 minimally invasive). Results: The 2 groups were comparable with regard to demographics (age, follow-up, male to female ratio, tobacco use, diabetes, workers’ compensation status). In the extensile group, 53% of fractures were Sanders II and 47% were Sanders III, whereas in the minimally invasive group 61% were Sanders II and 39% were Sanders III. The overall wound complication rate was 29% in the extensile group (9% required operative intervention) versus 6% in the minimally invasive group (P = .005) (none required operative intervention). Overall, 20% of the extensile group required a secondary surgery within the study period versus 2% in the minimally invasive group (P = .007). In the group of patients who returned for research visits, the average FFI total score was 31 in the extensile group versus 22 in the minimally invasive group (P = .21). The average VAS pain score with activity was 36 in the extensile group versus 31 in the minimally invasive group (P = .48). Overall, 84% of patients in the extensile group were satisfied with their result versus 94% in the minimally invasive group (P = .32). Both groups had 100% union rates, and no differences were noted in the final postoperative Bohler’s angle and angle of Gissane. Conclusion: Clinical results were similar between calcaneal fractures treated with an extensile approach and those treated with a minimally invasive approach. However, the minimally invasive approach had a significantly lower incidence of wound complications and secondary surgeries. The minimally invasive approach was a valuable method for the treatment of intra-articular calcaneal fractures, with low complication rates and results comparable to those treated with an extensile approach. Level of Evidence: Level III, retrospective comparative case series.

Early Complications Following the Operative Treatment of Pilon Fractures with and without Diabetes

Background: An increased rate of complications has been clearly shown in diabetic patients undergoing operative treatment for displaced ankle fractures. To date, no studies have specifically looked at the complication rates following the operative management of pilon fractures in this difficult patient population. We performed a retrospective review to determine the rates of complications in diabetic patients undergoing operative fixation of tibial pilon fractures compared with a control group of patients without diabetes. Materials and Methods: The trauma registry was utilized to identify all patients who underwent primary treatment for a tibial pilon fracture between January 2005 and June of 2007 at a single Level 1 trauma center. A minimum of 6-month followup was required for inclusion. A chart and radiographic review was completed to identify the complications seen in each patient population. Specifically, we looked at the rate of infection (superficial and deep), the rate of nonunion or delayed union, and the rate of surgical wound complications. Results: A total of 14 fractures in 13 diabetic patients, and 69 fractures in 68 non-diabetic patients met inclusion criteria. In the diabetic patient group, the average age was 48 years, the average BMI was 35, and 36% of the fractures were open. In the non-diabetic group, the average age was 47 years, the average BMI was 29, and 35% of the fractures were open. Only the difference in BMI was statistically significant. The infection rate was 71% for diabetic patients (43% deep infection), and 19% for non-diabetic patients (9% deep infection) [p < 0.001, odds ratio 10.719 (95% confidence interval 2.914 to 39.798)]. Overall, the rate of non-union/delayed union was 43% in the diabetic group versus 16% in the non-diabetic group [p = 0.02, odds ratio 3.955 (95% confidence interval 1.145 to 13.656)]. The rate of surgical wound complications was 7% in both the non-diabetic and diabetic patient groups. Conclusion: The management of tibial pilon fractures in diabetic patients is difficult, with a high rate of complications compared to non-diabetic patients. These results mirror those previously reported for ankle fractures in diabetic patients. Level of Evidence: IV, Retrospective Case Series

Arthroscopic Treatment of Multidirectional Shoulder Instability in Athletes: A Retrospective Analysis of 2- to 5-Year Clinical Outcomes

Background There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. Hypothesis Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures. Study Design Case series; Level of evidence, 4. Methods Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales. Results The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation. Conclusion Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population.

BMP-14 deficiency inhibits long bone fracture healing: a biochemical, histologic, and radiographic assessment.

Objectives: Bone morphogenetic proteins (BMPs) represent a distinct subset of the transforming growth factor-β family best known for their role in joint formation and bone growth, and several recent clinical trials have begun to look at their efficacy in the augmentation of fracture healing. The goal of this research is to examine the effect of BMP-14, also known as growth differentiation factor-5 and cartilage- derived morphogenetic protein-1 (GDF-5, CDMP-1) on fracture healing by studying the long bone repair process in mice with a deficiency in this signaling peptide. Methods: The animal model used for these studies was the BMP-14 (−/−) brachypodism (bp) mouse. Phenotypically normal heterozygous (±) littermates were used as controls. Closed mid shaft femur fractures were created and stabilized with intramedullary fixation in 8-week-old female mice. Forty-eight mice per genotype group were examined. On postoperative days 4, 7, 10, 14, 21, 28, 35, and 42, the mice were killed and the femurs and repair tissue were harvested for analysis. At each time point, the fracture sites were analyzed radiographically, histologically, and biochemically. For all quantitative analyses, the data were normalized and analyzed statistically using a 2-factor ANOVA test. Results: Biochemically, peak values of normalized proteoglycan content were approximately 3 times less in the mutant fractures early in the time course of healing compared with the controls (P < 0.05). Histologically, BMP-14-deficient fractures exhibited a delay in peak area cell density, callus organization, and bone formation compared with controls. Radiographic analysis demonstrated that the peak callus was 2 weeks delayed and approximately 2 times less in the mutants compared with controls (P < 0.05). Radiographic grading of callus also demonstrated a significant difference after day 14. Conclusions: Based on histologic, radiographic, and biochemical analysis, BMP-14-deficient mice display a short-term delay in healing of approximately 1 to 2 weeks. The observed abnormalities seem to be the result of a delay in cellular recruitment and chondrocyte differentiation in the early stages fracture repair in the absence of BMP-14. These results support the hypothesis that BMP-14 deficiency leads to a delay in fracture healing. Further studies are warranted to more closely examine the role of BMP-14 in normal fracture healing and the mechanism by which it works.

The effect of nonsteroidal anti-inflammatory agents on spinal fusion.

A large body of information suggests NSAIDS have a negative impact on the healing of bone. Although each clinical healing scenario presents a slightly different level of challenge, the healing of a posterolateral spinal fusion is one of the most difficult challenges in bony healing. Clinically, this results in a relatively high rate of nonunions using traditional fusion techniques. Spinal fusion models have confirmed NSAIDS have a definite inhibitory effect on healing of the fusion. Although data are limited, it appears this effect is most severe when NSAIDS are administered in the early postoperative period. Moreover, the effect may be worse with certain types initial inflammatory, subsequent reparative, and final remodeling phases. Because of the anti-inflammatory activity of NSAIDS, one might assume their effects would be worse when administered in the inflammatory phase. Indeed, the study by Riew et al suggests the inhibitory effects are more significant when NSAIDS are administered earlier following fusion. Other studies conducted with non-spinal models also suggest early administration of NSAIDS results in greater inhibition of bone formation (Goodman et al). Unfortunately, the length of the inflammatory phase in humans is not well known. This leaves the clinician unsure about the safe time to allow resumption of NSAID usage clinically. It appears likely NSAID use following a spinal fusion procedure will increase the rate of pseudarthrosis. The literature suggests that avoidance of NSAIDS in the postoperative period may avoid nonunion. Additionally, we propose that chronic NSAID usage should be addressed in a similar manner to cigarette smoking. While neither are absolute contraindications to elective spinal fusion, patients should be counseled to discontinue the use of NSAIDS in the peri- and postoperative period to maximize their chance for a successful fusion.

Metatarsal Head Resurfacing for Advanced Hallux Rigidus

Background: Advanced stages of first metatarsophalangeal (MTP) arthritis have traditionally been treated with various arthroplasties or arthrodesis. Studies suggest the outcomes of arthrodesis are superior to those of metallic joint replacement; however, complications and suboptimal outcomes in active patients still remain with arthrodesis of the first MTP joint. This study reports results of patients with advanced MTP arthritis who underwent metallic resurfacing of the metatarsal side of the MTP joint. Methods: From 2005 to 2006, 26 patients (30 implants) with stage II or III hallux rigidus underwent resurfacing with the HemiCAP® implant and consented to participate in a study comparing pre- and postoperative radiographs, range of motion (ROM), American Orthopedic Foot and Ankle Society, and Short Form 36 Health Survey (SF-36) scores. Average age of these patients was 51 years. Patients were assessed at a mean of 27 months with outcome measures and contacted at 60 months to assess current symptoms and satisfaction. Results: Assessment at 27 months demonstrated statistically significant improvements in ROM, AOFAS, and SF-36 scores (P < .05) when compared to baseline. Mean preoperative AOFAS scores improved from 51.5 to 94.1. Mean active ROM improved from 19.7 to 47.9 degrees. Mean passive ROM improved from 28.0 to 66.3 degrees. Mean RAND SF-36 physical component score improved significantly from 66.7 to 90.6. Average time for return to work was 7 days. At 60 months, all patients reported excellent satisfaction with their current state and would repeat the procedure. Implant survivorship was 87% at 5 years. Of the 30 implants, 4 were revised at 3 years. Conclusion: The results at 5 years were very promising. Preservation of joint motion, alleviation of pain, and functional improvement data were very encouraging. Because minimal joint resection was performed, conversion to arthrodesis or other salvage procedures would be relatively simple if further intervention became necessary. Level of Evidence: Level IV, prospective case series.

Resurfacing of the Metatarsal Head to Treat Advanced Hallux Rigidus.

Advanced stages of hallux rigidus are usually treated with various arthroplasties or arthrodesis. Recent results with resurfacing of the metatarsal head have shown promising results and outcomes similar or superior to those of arthrodesis. In this article, the authors show their preoperative decision making, surgical techniques, postoperative management, results, and a comparative literature review to identify metatarsal head resurfacing as an acceptable technique for the treatment of advanced hallux rigidus in active patients. Key points in this article are adequate soft tissue release, immediate rigid fixation of the components, and appropriate alignment of the components.

Subtalar Coalitions in the Adult

Tarsal coalitions, while relatively uncommon, are typically identified in adult patients during an evaluation for ankle instability, sinus tarsus pain, and/or pes planovalgus. The true incidence of tarsal coalition is unknown with estimates ranging from 1% to 12% of the overall population. The most common area of involvement of the subtalar joint is the middle facet, and heightened awareness should be present in adult patients with limited motion of the subtalar joint. Standard radiographic imaging, to include a Harris heel view, is recommended initially, although computerized tomography scan and MRI are often necessary to confirm the diagnosis.