Brian C. Werner

Trends in pediatric and adolescent anterior cruciate ligament injury and reconstruction

Background: With the increasing involvement in organized athletics among children and adolescents, more anterior cruciate ligament (ACL) injuries are being recognized in the skeletally immature population. The goal of the present study is to utilize a national database to characterize the recent epidemiologic trends of ACL injuries, ACL reconstruction, and treatment of associated meniscal and chondral pathology in the pediatric and adolescent populations. Methods: A national database was queried for ACL tear (ICD-9 844.2) and arthroscopic reconstruction of an ACL tear (CPT 29888) from 2007 to 2011. Searches were limited by age group to identify pediatric and adolescent cohorts: (1) ages 5 to 9 years old, (2) ages 10 to 14 years old, and (3) ages 15 to 19 years old. A comparative cohort of adult patients from ages 20 to 45 was also created. The database was also queried for concomitant procedures at the same time as ACL reconstruction for each age group, including partial meniscectomy, meniscus repair, microfracture, osteochondral autograft or allograft transfer, and shaving chondroplasty. The &khgr;2 analysis was used to determine statistical significance. Results: A total of 44,815 unique pediatric or adolescent patients with a diagnosis of an ACL tear and 19,053 pediatric or adolescent patients who underwent arthroscopic ACL reconstruction were identified. Significant increases in pediatric and adolescent ACL tear diagnosis and reconstruction compared with adult patients were noted. Significant increases in many concomitant meniscus and cartilage procedures in pediatric and adolescent patients compared with adult patients were also noted. Conclusions: The present study demonstrates a significant increase in the overall diagnosis of ACL injury and ACL reconstruction in both pediatric and adolescent patients, rising at a rate significantly higher than adults. In addition, pediatric and adolescent patients who undergo ACL reconstruction had significant increases in incidences of concomitant meniscal and cartilage procedures. Level of Evidence: Level III—retrospective cohort study.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Minimum Two Year Clinical Outcomes

Objectives: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. The goal of this study is to compare the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral tenodesis. Our null hypothesis is that both methods yield satisfactory results with regards to shoulder and biceps function, postoperative shoulder scores, pain relief and complications. Methods: Retrospective cohort study. Patients who underwent either arthroscopic suprapectoral or open subpectoral biceps tenodesis for superior labral or long head biceps pathology with a minimum follow-up of 2 years were included in the study. Patients were excluded if they underwent significant additional shoulder procedures, including rotator cuff repair or procedures to address glenohumeral instability, if there was significant pre-operative range of motion deficits due to frozen shoulder or glenohumeral arthritis, or if they had significant contralateral shoulder pathology or surgery. Subjects were evaluated with several clinical outcome measures and physical examination including range of motion and strength. Range of motion and strength measurements were normalized to the asymptomatic contralateral limb. Power analysis indicated that a minimum of 17 subjects were required in each group (34 total) to determine a clinically meaningful difference in the outcome measures. Results: Between 2007 and 2011, 79 patients met all inclusion and exclusion criteria, which included 30 arthroscopic suprapectoral tenodesis (ASPBT) patients and 49 open subpectoral biceps tenodesis (OSPBT) patients. 23 of 30 (76.7%) ASPBT and 28 of 49 (57.1%) OSPBT patients completed clinical follow-up at an average of 3.1 year postoperative (range 2.2 - 4.3 years). The cohorts were similar in terms of age, gender, BMI, smoking and workers compensation status. Overall outcomes for both procedures were satisfactory. No significant differences were noted in post-operative Constant Murley (ASPBT: 89, OSPBT: 92, p = 0.567), ASES (ASPBT: 89, OSPBT: 88, p = 0.845), SANE (ASPBT: 86, OSPBT: 86, p = 0.982), SST (ASPBT: 10, OSPBT: 10, p = 0.597), LHB Score (ASPBT: 91, OSPBT: 94, p = 0.329), or VR-36 (ASPBT: 80, OSPBT: 79, p = 0.833). No significant range of motion or strength differences (expressed as percent of asymptomatic contralateral limb) were noted between procedures. (Table I). Conclusion: Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology. No significant differences in clinical outcomes as determined by several validated outcomes measures were found between the two tenodesis methods, nor were any range of motion or strength deficits noted at minimum two-years post-operatively.

Primary Total Knee Arthroplasty in Super-obese Patients: Dramatically Higher Postoperative Complication Rates Even Compared to Revision Surgery

This study utilized a national database to evaluate 90 day postoperative complication rates after total knee arthroplasty (TKA) in super obese (BMI > 50 kg/m(2)) patients (n = 7666) compared to non-obese patients (n = 1,212,793), obese patients (n = 291,914), morbidly obese patients (n = 169,308) and revision TKA patients (n = 28,812). Super obese patients had significantly higher rates of local and systemic complications compared to all other BMI groups as well as those undergoing revision TKA with higher rates of venous thromboembolism (VTE), infection, and medical complications. Super obesity is associated with dramatically increased rates of postoperative complications after TKA compared to non-obese, obese, and morbidly obese patients as well as those undergoing revision TKA.

Validation of an innovative method of shoulder range-of-motion measurement using a smartphone clinometer application

BACKGROUND An accurate and reliable measurement of shoulder range of motion (ROM) is important in the evaluation of the shoulder. A smartphone digital clinometer application is a potentially simpler method for measuring shoulder ROM. The goal of this study was to establish the reliability and validity of shoulder ROM measurements among varying health care providers using a smartphone clinometer application in healthy and symptomatic adults. METHODS An attending surgeon, fellow, resident, physician assistant, and student served as examiners. Bilateral shoulders of 24 healthy subjects were included. Fifteen postoperative patients served as the symptomatic cohort. Examiners measured ROM of each shoulder, first using visual estimation and then using a goniometer and smartphone clinometer in a randomized fashion. RESULTS The interobserver reliability among examiners showed significant correlation, with average intraclass correlation coefficient [ICC(2,1)] values of 0.61 (estimation), 0.69 (goniometer), and 0.80 (smartphone). All 5 examiners had substantial agreement with the gold standard in healthy subjects, with average ICC(2,1) values ranging from 0.62 to 0.79. The interobserver reliability in symptomatic patients showed significant correlation, with average ICC(2,1) values of 0.72 (estimation), 0.79 (goniometer), and 0.89 (smartphone). Examiners had excellent agreement with the gold standard in symptomatic patients, with an average ICC(2,1) value of 0.98. CONCLUSION The smartphone clinometer has excellent agreement with a goniometer-based gold standard for measurement of shoulder ROM in both healthy and symptomatic subjects. There is good correlation among different skill levels of providers for measurements obtained using the smartphone. A smartphone-based clinometer is a good resource for shoulder ROM measurement in both healthy subjects and symptomatic patients.

Ultra-Low Velocity Knee Dislocations: Patient Characteristics, Complications, and Outcomes

Background: Knee dislocations resulting in multiligament knee injuries (MLIs) are usually associated with high-energy mechanisms such as motor vehicle accidents or sports injuries; however, obese patients are at risk of MLIs from simple falls. Termed “ultra-low velocity” (ULV) dislocations, these injuries occur in obese patients during activities of daily living and may be associated with higher associated risks and complications. Hypothesis: Ultra-low velocity knee dislocations occur more commonly in obese female patients, are associated with higher risks of neurovascular injuries, and have more significant perioperative complications compared with other MLIs. Study Design: Case series; Level of evidence, 4. Methods: The records of 215 consecutive patients with MLIs were identified over a 12-year period. Their charts were reviewed to identify a cohort of patients with mechanisms consistent with ULV dislocations (n = 23). This cohort was compared with all patients with MLIs. Additionally, ULV patients with neurovascular injuries were compared with those without neurovascular injuries. Results: The average body mass index (BMI) was significantly higher in the ULV cohort (49.1 kg/m2) compared with all patients with MLIs (34.1 kg/m2). Injuries occurred more commonly in female patients in the ULV cohort (69.6%) compared with all patients with MLIs (24.3%). Peroneal nerve injuries occurred more commonly in the ULV cohort (39.1%) compared with all patients with MLIs (8.4%), as did vascular injuries (28.1% vs 4.7%, respectively). Postoperative complications were common among all ULV-MLI patients regardless of neurovascular injury status. Seventeen patients (6/12 in the intact group and 11/11 in the neurovascular injury group) had significant complications postoperatively. A significantly higher overall complication rate was noted in the ULV-MLI group (73.9%) compared with the entire MLI cohort (21.4%). Additionally, the ULV-MLI cohort had a higher reoperation rate, wound infection rate, deep venous thrombosis rate, and presence of vascular claudication. Conclusion: Ultra-low velocity knee injuries occur in patients with a greater BMI, more frequently in female patients, and with higher rates of concomitant neurovascular injuries compared with other MLIs. Additionally, a significantly greater incidence of postoperative complications can be expected after ligament reconstruction in this population compared with other MLIs.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Restoration of Length-Tension and Mechanical Strength Between Techniques

Objectives: The approach to biceps tenodesis remains controversial, as the procedure can be performed open or arthroscopically. Little data exists directly comparing the arthroscopic suprapectoral and open subpectoral techniques, particularly in terms of location, restoration of the long head biceps length-tension relationship, and the mechanical strength of the tenodesis. The purpose of this study was to (1) determine the in-vivo tenodesis location using arthroscopic suprapectoral (ASPBT) and open subpectoral techniques (OSPBT) for long head biceps tenodesis and compare this to the location achieved in a separate clinical cohort, (2) evaluate the in-vivo restoration of the long head biceps length-tension relationship for both ASPBT and OSPBT techniques and (3) assess how location in the proximal humerus (suprapectoral or subpectoral) and method of fixation affects pull-out strength for biceps tenodesis using an interference screw implant. Our null hypothesis was that no difference existed between ASPBT and OSPBT with regards to location, restoration of the length-tension relationship, and pull-out strength. Methods: 18 matched cadaveric shoulder specimens were randomized to either open subpectoral or arthroscopic suprapectoral tenodesis groups (9 open, 9 arthroscopic.) Tenodesis was performed by two sports fellowship-trained surgeons using identical clinical techniques. Prior to surgery, a metallic bead was sutured in place, 1 cm distal to the musculotendinous junction of the long head of the biceps, and a pre-operative fluoroscopic image was obtained. Post-operatively, an additional fluoroscopic image was obtained to evaluate the location of the tenodesis and the metallic bead, which was compared to the pre-operative image to determine tensioning (Fig 1). Biomechanical testing was then performed using a MTS machine with 2.5kN load cell. Constructs were cycled for 100 cycles, then load to failure testing was performed. Results: The average tenodesis location in the ASPBT group of cadaveric specimens was 4.68 cm ± 0.97 cm distal to the top of the humerus, compared with 7.46 cm ± 1.7 cm (p < 0.0001) in the OSPBT group. This was very similar to the location observed in a separate clinical cohort. The ASPBT technique resulted in an average of 2.15 ± 0.62 cm of biceps over-tensioning compared with 0.78 ± 0.35 cm (p < 0.001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared to 197 ± 38.6 N (p = 0.002) in the OSPBT group. Implant pullout was significantly more frequent in the ASPBT (7/9) compared to the OSPBT (1/9) group. Conclusion: This study revealed several notable differences between the arthroscopic suprapectoral and open subpectoral biceps tenodesis techniques. The described ASPBT technique using an interference screw implant results in a more proximal tenodesis location, has the tendency to over-tension the biceps and has a significantly decreased ultimate load to failure compared with an open subpectoral technique in matched cadaver specimens. Modification of currently published arthroscopic suprapectoral techniques is necessary to improve restoration of the physiologic length-tension relationship of the biceps. Improved implants are likely necessary to achieve equivalent construct strength to the open subpectoral technique, although the clinical ramifications of this strength discrepancy have not been established.

Trends in Long Head Biceps Tenodesis

Background: Tenodesis of the long head of the biceps tendon has become a popular surgical treatment option for patients with pain or instability attributed to a diseased or unstable biceps tendon. No previous studies have characterized the practice patterns of surgeons performing biceps tenodesis in the United States. Purpose: To investigate current trends in both arthroscopic and open biceps tenodesis across time, sex, age, and region of the United States as well as associated charges. Study Design: Descriptive epidemiology study. Methods: Patients who underwent biceps tenodesis (Current Procedural Terminology [CPT] codes 23430 and 29828) for the years 2008 through 2011 were identified using the PearlDiver Patient Record Database, including both private-payer and Medicare data. These cohorts were then assessed for associated diagnoses using International Classification of Diseases, 9th Revision, codes and concomitant procedures using CPT codes. These searches yielded procedural volumes, sex and age distribution, regional volumes, and average per-patient charges. A χ2 linear-by-linear association analysis, Student t test, and linear regression were used for comparisons, with P < .05 considered significant. Results: A total of 44,932 biceps tenodesis procedures were identified from 2008-2011. The incidence of biceps tenodesis procedures per 100,000 database patients increased 1.7-fold over the study period, from 8178 in 2008 to 14,014 in 2011 (P < .0001). An increase in the overall percentage volume was noted in patients aged 60-69 years (P = .039) and 20-29 years (P = .016). The overall charges for arthroscopic tenodesis increased at a rate significantly greater than that of open tenodesis (P < .0001). Rotator cuff tear or sprain, bicipital tenosynovitis, biceps tendon rupture, superior labral lesion, and osteoarthritis were the most common diagnoses associated with biceps tenodesis procedures. A significant increase in isolated biceps tenodesis was also observed over the study period, from 1967 patients in 2008 to 3565 patients in 2011, representing a 1.8-fold increase. Conclusion: The incidence of biceps tenodesis has increased yearly from 2008-2011. Arthroscopic tenodesis has emerged as a more popular technique. Charges associated with the procedure have increased significantly. Significant regional variations in procedural incidences exist.

What Change in American Shoulder and Elbow Surgeons Score Represents a Clinically Important Change After Shoulder Arthroplasty

BackgroundThe American Shoulder and Elbow Surgeons (ASES) questionnaire was developed to provide a standardized method for evaluating shoulder function. Previous studies have determined the clinical responsiveness of this outcome measure for heterogenous populations or patients with nonoperatively treated rotator cuff disease. Currently, to our knowledge, no studies exist that establish the clinically relevant change in the ASES score after shoulder arthroplasty.Questions/purposesWe asked: (1) What are the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the ASES score after primary and reverse shoulder arthroplasties? (2) Are the MCID and SCB for the ASES score different between primary and reverse shoulder arthroplasties? (3) What patient-related factors are associated with achieving the MCID and SCB after total shoulder arthroplasty and reverse shoulder arthroplasty?MethodsA longitudinally maintained institutional shoulder arthroplasty registry was retrospectively queried for patients who underwent primary shoulder arthroplasty, including anatomic or reverse total shoulder arthroplasty from 2007 to 2013, with a minimum 2-year followup. Seven hundred ninety-four patients were identified and eligible; 304 of these patients did not have 2 years of followup or complete datasets, resulting in a study cohort of 490 patients (62% of the 794 potentially eligible). The MCID and SCB of the ASES score for these patients was calculated using an anchor-based method, using four different anchors measuring satisfaction with work, activities, overall, and activity from the SF-36. The MCID (anchored to somewhat satisfied) and SCB (very satisfied) of the ASES score were calculated for the entire cohort and stratified by arthroplasty type. Multivariate logistic regression of patient-related factors that influence the MCID and SCB achievement was performed.ResultsThe MCID for all patients combined ranged from 6.3 to 13.5; for the overall satisfaction anchor, the MCID was 13.5 ± 4.5 (95% CI, 4.8–22.3). The SCB for the overall cohort ranged from 12.0 to 36.6; for the overall satisfaction anchor, the SCB was 36.6 ± 3.8 (95% CI, 29.1–44.1). There were no differences in the MCID of the ASES score between anatomic and reverse shoulder arthroplasty for any of the anchors (p = 0.159–0.992) or the SCB for any of the anchors (p = 0.467–0.977). Combining anatomic and reverse shoulder arthroplasty in one group, higher preoperative ASES score (odds ratio [OR], 0.96; 95% CI, 0.94–0.98; p < 0.001), having a reverse shoulder arthroplasty (OR, 0.36; 95% CI, 0.16–0.85; p = 0.016), and having rheumatoid arthritis were independent predictors of not achieving an MCID for the ASES 2 years after surgery. Higher preoperative ASES score (OR, 0.91; 95% CI, 0.89–0.92; p < 0.001), a diagnosis of rotator cuff tear arthropathy (OR, 0.14; 95% CI, 0.07–0.30; p < 0.001), a diagnosis of back pain (OR, 0.42; 95% CI, 0.24–0.71); p = 0.002), and living alone (OR, 0.36; 95% CI, 0.19–0.69; p = 0.002) were all independent predictors of not achieving SCB after shoulder arthroplasty.ConclusionsPatients with glenohumeral arthritis or rotator cuff tear arthropathy who undergo primary conventional total or reverse shoulder arthroplasty and have at least a nine-point improvement in their ASES score experience a clinically important change, whereas those who have at least a 23-point improvement in their ASES score experience a substantial clinical benefit. High preoperative function was associated with a decreased likelihood of achieving clinically important change after total shoulder arthroplasty.Level of EvidenceLevel III, therapeutic study.

Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures

BACKGROUND Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database. METHODS Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated. RESULTS From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications. CONCLUSIONS Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.

Increased Incidence of Postoperative Stiffness After Arthroscopic Compared With Open Biceps Tenodesis

PURPOSE To determine the incidence of postoperative stiffness after open and arthroscopic biceps tenodesis, compare the incidence between each method, and determine relevant risk factors for its occurrence. METHODS A consecutive series of patients who underwent biceps tenodesis during a 3-year period were retrospectively reviewed. RESULTS We evaluated 249 patients, which included 143 who underwent open subpectoral tenodesis and 106 who underwent arthroscopic suprapectoral tenodesis. The mean overall follow-up period for the arthroscopic group was 9.9 months (range, 5.1 to 33.5 months). The mean overall follow-up period for the open group was 9.5 months (range, 4.7 to 49.2 months). There was no significant difference in overall follow-up duration between groups (P = .627). A significantly increased incidence of postoperative stiffness was found in the arthroscopic group compared with the open group (17.9% v 5.6%, P = .002). Within the arthroscopic group, patients with postoperative stiffness were more frequently female patients than those without stiffness (63.2% v 33.3%, P = .016) and were more likely to be smokers than those without stiffness (36.8% v 16.1%, P = .040). The tenodesis site was located significantly more proximal in the arthroscopic group of patients with postoperative stiffness compared with patients without postoperative stiffness (32.44 ± 7.8 mm from the top of the humeral head v 50.34 ± 7.8 mm, P < .0001). CONCLUSIONS Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. This appears to occur more commonly in female patients and smokers and may have a relation to the position of the tenodesis, with a more superiorly placed tenodesis site being a potential influencing factor. On the basis of this series, this complication most commonly will improve over time and with symptom-based management. LEVEL OF EVIDENCE Level III, therapeutic case-control study.