Brian D. Busconi

Hip Arthroscopy: Applications and Technique

Hip arthroscopy is infrequently performed in North America. The anatomic constraints of the joint and the lack of equipment specifically designed for this application have contributed to the lack of surgical experience. Because of the potential for significant neurovascular injury, familiarization with precise portal placement is essential. In properly selected patients, hip arthroscopy allows diagnosis of a variety of disorders. The authors believe this technique has a significant role in the treatment of acetabular labral tears, loose bodies, chondral injuries to the joint, and septic arthritis.

Medial patellofemoral ligament injury patterns and associated pathology in lateral patella dislocation: an MRI study

BackgroundLateral Patella dislocations are common injuries seen in the active and young adult populations. Our study focus was to evaluate medial patellofemoral ligament (MPFL) injury patterns and associated knee pathology using Magnetic Resonance Imaging studies.MethodsMRI studies taken at one imaging site between January, 2007 to January, 2008 with the final diagnosis of patella dislocation were screened for this study. Of the 324 cases that were found, 195 patients with lateral patellar dislocation traumatic enough to cause bone bruises on the lateral femoral trochlea and the medial facet of the patella were selected for this study. The MRI images were reviewed by three independent observers for location and type of MPFL injury, osteochondral defects, loose bodies, MCL and meniscus tears. The data was analyzed as a single cohort and by gender.ResultsThis study consisted of 127 males and 68 females; mean age of 23 yrs. Tear of the MPFL at the patellar attachment occurred in 93/195 knees (47%), at the femoral attachment in 50/195 knees (26%), and at both the femoral and patella attachment sites in 26/195 knees (13%). Attenuation of the MPFL without rupture occurred in 26/195 knees (13%). Associated findings included loose bodies in 23/195 (13%), meniscus tears 41/195 (21%), patella avulsion/fracture in 14/195 (7%), medial collateral ligament sprains/tears in 37/195 (19%) and osteochondral lesions in 96/195 knees (49%). Statistical analysis showed females had significantly more associated meniscus tears than the males (27% vs. 17%, p = 0.04). Although not statistically significant, osteochondral lesions were seen more in male patients with acute patella dislocation (52% vs. 42%, p = 0.08).ConclusionPatients who present with lateral patella dislocation with the classic bone bruise pattern seen on MRI will likely rupture the MPFL at the patellar side. Females are more likely to have an associated meniscal tear than males; however, more males have underlying osteochondral lesions. Given the high percentage of associated pathology, we recommend a MRI of the knee in all patients who present with acute patella dislocation.

Anatomical Reconstruction for Chronic Lateral Ankle Instability in the High-Demand Athlete Functional Outcomes After the Modified Broström Repair Using Suture Anchors

Background Modification of the Bröstrom repair with suture anchors has been used to address chronic lateral ankle instability. However, there are few studies in the literature reporting the functional outcomes after this particular procedure in the high-demand athlete. Hypothesis Anatomical reconstruction of the lateral ankle ligaments for chronic instability will return the high-demand athlete functionally to his or her previous level of activity. Study Design Case series; Level of evidence, 4. Methods Sixty-two patients who had grade III ankle sprain that failed at least a 6-month course of supervised conservative management with a preinjury Tegner score of ≥ 6 underwent a variant of the Gould-modified Broström procedure with suture anchors for lateral ankle instability. Each patient was given the Tegner and Karlsson questionnaire at the 6-month, 1-year, and 2-year time points. Range of motion of the operative ankle was also assessed. The mean age was 19.6 years (range, 16-26 years), and 10 patients were lost to follow-up. Results The mean follow-up was 29 months (minimum, 24 months) in the remaining 52 patients (84%). Mean Tegner scores at the 1- and 2-year time points were 8.2 (range, 5-9) and 8.6 (range, 5-9), respectively. The mean Karlsson scores were 92 ± 5.2 and 95 ± 3.1 at the 1- and 2-year time points, respectively. Range of motion was equal to the contralateral ankle in all but 3 patients at the 2-year follow up. A 6% major complication rate included 3 reruptures. Conclusion Anatomical ligament reconstruction for chronic lateral ankle instability using a variant of the Gould-modified Broström procedure with suture anchors was effective in returning high-demand athletes to their preinjury functional level.

Arthroscopic Treatment of Concomitant Superior Labral Anterior Posterior (SLAP) Lesions and Rotator Cuff Tears in Patients over the Age of 45 Years

Background Rotator cuff tears commonly occur in combination with other shoulder injuries such as superior labral anterior posterior (SLAP) lesions. The incidence of these associated lesions increases with age; however, the management of concomitant SLAP and rotator cuff tears has yet to be convincingly addressed in the literature. Hypothesis Patients over the age of 45 years who have concomitant arthroscopic rotator cuff repair and debridement of their type II SLAP lesions will have improved patient satisfaction and functional outcome compared with those who undergo simultaneous rotator cuff and type II SLAP repair. Study Design Cohort study; Level of evidence, 2. Methods We recruited 48 patients (mean age, 51.9 years; range, 45-60 years) who had concomitant rotator cuff and type II SLAP tears. All underwent arthroscopic rotator cuff repair with subacromial decompression. Patients were randomized intraoperatively into 2 groups: repair versus debridement of their type II SLAP lesions. Ten patients were lost at final follow-up (4 in debridement and 6 in repair group). The outcome was assessed by the Tegner score and University of California at Los Angeles (UCLA) score and clinically to evaluate range of motion (forward elevation/internal rotation/external rotation). Results At 2 years postoperatively, both the debridement and repair groups showed significant improvement in Tegner score, UCLA score, and range of motion. Patients who underwent rotator cuff repair in combination with debridement of their SLAP tears had significantly better overall UCLA scores (34 vs 31; P < .001) and improved function (5.5 vs 3.8; P < .005) and pain relief (9.6 vs 7.7; P < .001) compared with those who underwent simultaneous rotator cuff and SLAP repair. Range of motion in both internal and external rotation was also significantly better in those patients who had SLAP debridement as compared to SLAP repair. Conclusion In patients over the age of 45 years with a minimally retracted rotator cuff tear and associated SLAP lesion, arthroscopic repair of the rotator cuff with combined debridement of the type II SLAP lesion may provide greater patient satisfaction and functional outcome in terms of pain relief and motion.

Athletic pubalgia (sports hernia)

Athletic pubalgia or sports hernia is a syndrome of chronic lower abdomen and groin pain that may occur in athletes and nonathletes. Because the differential diagnosis of chronic lower abdomen and groin pain is so broad, only a small number of patients with chronic lower abdomen and groin pain fulfill the diagnostic criteria of athletic pubalgia (sports hernia). The literature published to date regarding the cause, pathogenesis, diagnosis, and treatment of sports hernias is confusing. This article summarizes the current information and our present approach to this chronic lower abdomen and groin pain syndrome.

Intermediate Outcomes After Primary Traumatic Anterior Shoulder Dislocation in Skeletally Immature Patients Aged 10 to 13 Years

A paucity of literature exists regarding the outcome of skeletally immature patients who sustain a primary traumatic anterior shoulder dislocation. Most published results focus on adolescents and young adults, using recurrent dislocation/instability as a determinant of outcome, rather than a validated quality of life measurement tool. The purpose of this study is to assess the intermediate term functional outcome after anterior traumatic shoulder dislocation in the skeletally immature patient population. Fourteen patients (age range, 10.9-13.1 years; 14 shoulders) who sustained a primary anterior traumatic unidirectional shoulder dislocation were included. Each patient underwent successful documented closed reduction of the dislocated shoulder and was subsequently treated with initial nonsurgical intervention. All patients were monitored in the clinic routinely, until skeletal maturity was reached. The Western Ontario Shoulder Instability index (WOSI), range of motion, complications, and recurrent dislocations were recorded. The average WOSI score for all patients at the time of injury was 1635 (range, 1550-1690). At final follow-up (mean, 5.6 years), the average WOSI score for all patients was 39.6 (range, 0-195). Subgroup analysis revealed that those treated nonoperatively fared better than their operative counterparts (average final follow-up WOSI score, 9.1 vs 151.7, respectively). Three patients (21.4%) ultimately sustained a recurrent shoulder dislocation that necessitated surgical intervention. Based on the above data, in the pediatric skeletally immature patient who sustained a primary, traumatic, anterior shoulder dislocation, nonoperative treatment results in low shoulder instability recurrence risk and sound functional outcomes.

Assessing the Effectiveness of Neuromuscular Training Programs in Reducing the Incidence of Anterior Cruciate Ligament Injuries in Female Athletes A Systematic Review

Background: Anterior cruciate ligament (ACL) injuries are more common in female athletes because of anatomic and biomechanical factors. These injuries can have detrimental ramifications for the athlete and the health care system. Neuromuscular training programs have been designed to modify risk factors and prevent ACL injuries. Purpose: This systematic review evaluates studies that assess the effectiveness of neuromuscular training programs in reducing ACL injuries in female athletes and provides an update to 2 previously published reviews. Study Design: Systematic review. Methods: Medline, Cochrane, and CINAHL databases were searched for relevant journal articles published from 1995 to 2011. We performed a manual review of relevant articles, authors, and journals, including bibliographies from identified articles. Ten studies were included in this review. Results: Only 2 studies demonstrated a statistically significant decrease in ACL injuries with neuromuscular training programs. Two additional studies showed a statistically significant decrease in subgroup analyses only. Four studies did show a trend toward reduced ACL injuries with neuromuscular training programs but were unable to achieve statistical significance. Neuromuscular training programs utilizing plyometric exercises and a preseason component were the most beneficial. Two studies actually showed an increase in injuries with intervention programs. Conclusion: Neuromuscular training programs may be a useful adjunct to training, but current literature precludes our universal recommendation of them.

Soft Tissue Pathology Around the Hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Chronic, painful ankle instability in skeletally immature athletes : Ununited osteochondral fractures of the distal fibula

We report 10 cases of chronic, painful ankle instability in skeletally immature athletes associated with un united osteochondral fragments of the distal fibula. All the patients experienced multiple inversion injuries with recurrent pain and instability that failed to improve after a supervised exercise and rehabilitation program. Osteochondral fragments of the distal fibula were vis ible on all standard radiographs of the affected ankles. Treatment consisted of operative excision of the bony fragment and an anatomic nonaugmented repair of the lateral ligament complex and capsule. All 10 patients were available for long-term followup an average of 6.5 years (±2) after surgery; all ankles improved function ally, with no recurrences of instability.

Congenital instability of the shoulder joint: assessment and treatment options.

UNLABELLED Congenital instability of the shoulder is a form of multidirectional instability not caused by a traumatic event. It is believed that excess laxity may be responsible for an overly elastic capsule and, therefore, can contribute to multidirectional instability. Minor microtraumatic events can progressively lead to the development of pain and lead to instability. The current preferred treatment is largely nonoperative with extensive rehabilitation of the dynamic restraints of the shoulder complex. In recalcitrant cases, operative intervention to restore stability may be necessary. It is of paramount importance to notice the directions of instability and to address each of them. Surgical procedures include open capsular shift, as well as arthroscopic capsular plication. Because multidirectional instability can be difficult to diagnose, this article will attempt to provide the clinician with a better understanding of the pathophysiology involved in this condition, the necessary steps for diagnosis, and considerations for treatment. A comprehensive guide to both nonoperative and operative treatment is reviewed in this article, as well as the surgical techniques used to decrease the capsular volume. LEVEL OF EVIDENCE Level 5.