Brian K. Downie

When Do Rotator Cuff Repairs Fail? Serial Ultrasound Examination After Arthroscopic Repair of Large and Massive Rotator Cuff Tears

Background: Despite advances in arthroscopic repair of rotator cuff tears, recurrent tears after repair of large and massive tears remain a significant clinical problem. The primary objective of this study was to define the timing of structural failure of surgically repaired large and massive rotator cuff tears by serial imaging with ultrasound. The secondary objective of this study was to investigate the association between recurrent tears and clinical outcome after rotator cuff repair. Hypothesis: Recurrent tear after arthroscopic repair of large rotator cuff tears is more likely to occur late (>3 months) in the postoperative period and will be associated with inferior clinical outcome scores. Study Design: Cohort study; Level of evidence, 3. Methods: Twenty-two consecutive patients with large (>3 cm) rotator cuff tears underwent arthroscopic repair with a standardized technique. Serial ultrasound examinations were performed at 2 days, 2 weeks, 6 weeks, 3 months, 6 months, 12 months, and 24 months after surgery. Western Ontario Rotator Cuff (WORC) Index scores were also collected at these time points. Results: Nine (41%) of the 22 arthroscopically repaired rotator cuff tears demonstrated recurrent tears. Seven of the 9 retears occurred within 3 months of surgery, and the other 2 occurred between 3 and 6 months. No retears occurred after 6 months. At 24-month follow-up, WORC scores favoring intact rotator cuffs over retears approached statistical significance (mean WORC intact 123.9 vs retear 659.8; P = .07). Conclusion: Recurrent rotator cuff tears are not uncommon after arthroscopic repair of large and massive tears. These recurrent tears appear to occur more frequently in the early postoperative period (within the first 3 months) and are associated with inferior clinical outcomes.

Complications after medial opening wedge high tibial osteotomy.

PURPOSE The purpose of this study was to investigate complications of the medial opening wedge high tibial osteotomy (HTO) procedure at our institution. METHODS All cases of medial opening wedge HTO performed between 2001 and 2004 at our institution were identified. Medical records, operative reports, and radiographs were retrospectively reviewed for all patients who experienced a complication within 12 months postsurgery. All complications were identified for analysis. RESULTS Forty-six patients were included in this study; 17 (36.9%) patients had a documented complication. There were 7 patients (15.2%) with loss of correction, 2 (4.3%) with intraoperative lateral cortex fractures, 2 (4.3%) with postoperative lateral cortex fractures, 2 (4.3%) with deep venous thrombosis, 2 (4.3%) with delayed unions, and 2 (4.3%) with symptomatic hardware. Patients with a loss of angular correction had a greater body mass index (BMI) than those without a loss of correction (mean BMI, 32.5 v 28.8; P = .0416). Of the 7 patients with loss of angular correction, 6 had a first-generation fixation device and 1 had a second-generation device. There was no apparent association between delayed union and graft type (allograft v autograft). CONCLUSIONS The medial opening wedge HTO is associated with a moderate frequency of complications. The frequency and type of complications seem to be similar to those reported for the lateral closing technique. Although there are technical advantages offered by the medial opening wedge HTO, their influence on the frequency and type of complications experienced by patients in our series was not apparent. LEVEL OF EVIDENCE Level IV, case series.

The Incidence of Heterotopic Ossification After Hip Arthroscopy

Background: Minimally invasive techniques to treat femoroacetabular impingement (FAI), snapping hip syndrome, and peritrochanteric space disorder (PSD) were developed to reduce complications and recovery time. Although a multitude of studies have reported on the incidence of heterotopic ossification (HO) after open procedures of the hip, there is little known about the rate of HO after hip arthroscopy. Hypotheses: The incidence of HO after hip arthroscopy is comparable with that after open surgical dislocation of the hip and can be reduced with the addition of indomethacin to an existing nonsteroidal anti-inflammatory medication prophylaxis protocol. Study Design: Cohort study; Level of evidence, 3. Methods: Between July 2008 and July 2010, 616 primary hip arthroscopies were performed to treat FAI and PSD. In July 2009, indomethacin was added in the acute postoperative period to an existing HO prophylactic protocol of naproxen administered for 30 days postoperatively. Postoperative radiographs were reviewed to detect the presence and classify the size and location of HO. Odds ratios and logistic regression explored predictor variables and their relationships with HO, with P < .05 defined as significant. Results: Twenty-nine (21 male, 8 female) of 616 (4.7%) hip procedures developed HO postoperatively. Brooker classification of HO was 18 grade I, 4 grade II, 6 grade III, and 1 grade IV. Mean follow-up was 13.2 months (range, 2.9-26.5 months). Rate of HO for cases with and without indomethacin for prophylaxis was 1.8% (6/339) and 8.3% (23/277), respectively. This difference was statistically significant (P < .05), and patients who underwent protocol 1 were 4.36 times more likely to develop HO postoperatively than those who had protocol 2. The majority of cases of HO (72.4%) occurred in male patients, and all cases occurred in the setting of osteoplasty performed for symptomatic FAI. We were not able to demonstrate statistically significant clinical risk factors that were predictive for the development of postoperative HO. However, the data clearly demonstrate that the performance of arthroscopic osteoplasty with a capsular cut in male patients represented the majority of cases, who are likely the group at highest risk. Seven cases (~1%) required revision procedures to excise HO. There were no cases of recurrence of HO after excision, whether it was performed open or arthroscopically. Conclusion: The addition of indomethacin is effective in reducing the incidence of HO after hip arthroscopy and should be especially considered in male patients who undergo osteoplasty for correction of symptomatic FAI.

Pain and Effusion and Quadriceps Activation and Strength

CONTEXT Quadriceps dysfunction is a common consequence of knee joint injury and disease, yet its causes remain elusive. OBJECTIVE To determine the effects of pain on quadriceps strength and activation and to learn if simultaneous pain and knee joint effusion affect the magnitude of quadriceps dysfunction. DESIGN Crossover study. SETTING University research laboratory. PATIENTS OR OTHER PARTICIPANTS Fourteen (8 men, 6 women; age = 23.6 ± 4.8 years, height = 170.3 ± 9.16 cm, mass = 72.9 ± 11.84 kg) healthy volunteers. INTERVENTION(S) All participants were tested under 4 randomized conditions: normal knee, effused knee, painful knee, and effused and painful knee. MAIN OUTCOME MEASURE(S) Quadriceps strength (Nm/kg) and activation (central activation ratio) were assessed after each condition was induced. RESULTS Quadriceps strength and activation were highest under the normal knee condition and differed from the 3 experimental knee conditions (P < .05). No differences were noted among the 3 experimental knee conditions for either variable (P > .05). CONCLUSIONS Both pain and effusion led to quadriceps dysfunction, but the interaction of the 2 stimuli did not increase the magnitude of the strength or activation deficits. Therefore, pain and effusion can be considered equally potent in eliciting quadriceps inhibition. Given that pain and effusion accompany numerous knee conditions, the prevalence of quadriceps dysfunction is likely high.

Clinical Outcomes following the Microfracture Procedure for Chondral Defects of the Knee: A Longitudinal Data Analysis

The purpose of this study was to evaluate long-term outcome, following microfracture of the knee in a large patient group, using a random-effect model for longitudinal data analysis. There were 350 subjects (males, 55%; females, 65%) who underwent knee microfracture by a single surgeon between 1992 and 2002. Mean age was 48 years (range, 12-76 years). Subjective questionnaires were collected from patients at 1 year postsurgery and each consecutive year thereafter. Of treated chondral lesions, 53% were traumatic lesions, and 47% were degenerative. Average initial follow-up was 4 years (range, 1-12 years). Outcome variables included Lysholm score and Tegner activity scale. Analysis showed that Lysholm score improved during the first 2 years following microfracture. After 2 years, the score remained steady with a slight decline but remained above preoperative level through the study period. There was no significant difference in the improvement of outcome over time between men and women (P > 0.05). There was no significant difference in improvement of outcome over time between degenerative and traumatic chondral lesions (P > 0.05). Subjects with traumatic lesions demonstrated a significant difference in trajectory of Lysholm scores over time by age (≤45 years, >45 years) (P = 0.04). This study showed that there was no difference in improvement in outcome following microfracture between men and women or between degenerative and traumatic chondral lesions. However, there were age-dependent differences in the improvement in outcome over time.

Radial collateral ligament of the elbow: sonographic characterization with cadaveric dissection correlation and magnetic resonance arthrography.

An abnormality of the radial collateral ligament (RCL) in the setting of lateral epicondylitis can indicate a poor clinical outcome; therefore, accurate assessment is important. The purpose of this study was to characterize the proximal RCL attachment, or footprint, as seen on sonography using cadaveric dissection correlation and magnetic resonance arthrography.

Time to Return to Play After High Ankle Sprains in Collegiate Football Players: A Prediction Model

Background: Determining the severity of high ankle sprains in athletes and predicting the time that an athlete can return to unrestricted sport activities following this injury remain significant challenges. Purpose: The objectives of this study were (1) to determine if objective measurements of injury severity after high ankle sprains could predict the time to return to play in Division I football players and (2) to determine whether physical examination or diagnostic musculoskeletal ultrasound was more predictive of return to play. The hypothesis was that objective measures of injury severity of a high ankle sprain can be predictive of time to return to athletic participation in collegiate football players. Study Design: Prospective case series. Methods: Twenty consecutive Division I collegiate football players with a diagnosis of a grade I high ankle sprain (syndesmosis sprain without diastasis) were studied. Two clinical measurements of injury severity were determined: the height of the zone of injury on physical examination and the height of the zone of injury as defined by diagnostic musculoskeletal ultrasound examination. All athletes followed a standardized treatment program and return-to-play criteria. A regression model and Cox proportional hazards model were developed to determine time to return to unrestricted play as a function of injury severity and player position. Results: Physical examination but not ultrasound was significantly correlated with time to return to play. Regression and Cox analyses revealed that injury severity on physical examination and player position were significant predictors of time to return to unrestricted play following high ankle sprain. Conclusions: Injury severity on physical examination and player position are associated with the time to return to unrestricted athletic activity after injury. A model based on the data can be applied to help predict the time to return to unrestricted play in Division I collegiate football players following high ankle sprain.

Impact of pain on shoulder elevation velocity in patients with rotator cuff tears

Pain is routinely implicated as a factor when considering impaired movement in injured populations. Movement velocity is often considered during the rehabilitation process; unfortunately our understanding of pains impact on shoulder movement velocity in rotator cuff tear patients is less understood. Therefore, the purpose of this study was to test the hypothesis that there would be an increase in peak and mean shoulder elevation velocities following the decrease of shoulder pain in rotator cuff tear patients, regardless of tear size. Fifteen subjects with full-thickness rotator cuff tears (RCT) performed humeral elevation and lowering in three planes before and after receiving a lidocaine injection to relieve pain. Pain was assessed using a visual analog scale. Humeral elevation velocity data were collected using an electromagnetic tracking system. A significant reduction in pain (pre-injection 3.53 ± 1.99; post-injection 1.23 ± 1.43) resulted in significant increases in maximum and mean humeral elevation velocities. Mean shoulder elevation and lowering velocities increased 15.10 ± 2.45% while maximum shoulder movement velocities increased 12.77 ± 3.93%. Furthermore, no significant relationships were noted between tear size and movement velocity. These significant increases in movement velocity provide evidence to further support the notion that human motion can be inhibited by injury-associated pain, and that by reducing that pain through clinical interventions, human movement can be impacted in a positive fashion.

Sonography of cat scratch disease

To characterize the sonographic features of cat scratch disease and to identify features that allow differentiation from other causes of medial epitrochlear masses.