Bryant G. Marchant

Prevalence of Nonanatomical Graft Placement in a Series of Failed Anterior Cruciate Ligament Reconstructions

Background Anterior cruciate ligament reconstruction employing transtibial tunnel techniques may result in less than ideal femoral and tibial vertical graft placement, with a residual pivot shift and instability symptoms. Hypothesis Nonanatomical graft placement is highly prevalent among knees with failed primary and revision anterior cruciate ligament grafts. Study Design Case series; Level of evidence, 4. Methods A total of 122 consecutive patients presented to the authors’ center with a failed anterior cruciate ligament reconstruction. Radiographs, magnetic resonance imaging, and operative reports were used to define graft placement. Arthroscopic confirmation of graft placement was obtained in 92 knees during subsequent revision surgery. A nonanatomical graft placement was assigned when ≥50% of the graft was outside of the native tibial and femoral insertions. All patients prospectively completed Cincinnati Knee Rating System questionnaires. Results A nonanatomical graft placement occurred in 107 of 122 (88%) knees; 61% of the grafts were entirely on the intercondylar femoral roof, and 35% extended posterior to the anterior cruciate ligament tibial attachment. A transtibial technique had been used in 83%. The mean values for the coronal and sagittal graft placement showed a significantly increased vertical orientation in comparison with a control group (P < .01). Forty-two of the 107 nonanatomical grafts had undergone 1 or more revisions without correction of the misplaced graft tunnels, and these subsequently failed. Conclusion The occurrence of nonanatomical graft placement in primary and revision knees may represent an inadequacy of transtibial tunnel drilling techniques to obtain graft placement within the native femoral and tibial footprints. In revision cases, the prior graft location requires close scrutiny so the new graft tunnels are placed at the native anterior cruciate ligament attachments. Independent drilling of tibial and femoral tunnels is recommended using either 2-incision or anteromedial portal techniques.

A Simple Surgical Technique for Subpectoral Biceps Tenodesis Using a Double-Loaded Suture Anchor

Multiple different surgical techniques have previously been described to address long head of the biceps tendinopathy. Subpectoral biceps tenodesis has proven to be an effective procedure to relieve pain and maintain function. We describe a surgical technique for subpectoral biceps tenodesis using a single double-loaded suture anchor implant. Advantages of this procedure include the ease of implant placement and the freedom this technique affords to perform the anchor placement without direct visualization of the docking site.

Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up:

Background: Arthroscopic hip surgery has risen 18-fold in the past decade; however, there is a dearth of clinical trials comparing surgery with nonoperative management. Purpose: To determine the comparative effectiveness of surgery and physical therapy for femoroacetabular impingement syndrome. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Patients were recruited from a large military hospital after referral to the orthopaedic surgery clinic and were eligible for surgery. Of 104 eligible patients, 80 elected to participate, and the majority were active-duty service members (91.3%). No patients withdrew because of adverse events. The authors randomly selected patients to undergo either arthroscopic hip surgery (surgery group) or physical therapy (rehabilitation group). Patients in the rehabilitation group began a 12-session supervised clinic program within 3 weeks, and patients in the surgery group were scheduled for the next available surgery at a mean of 4 months after enrollment. Patient-reported outcomes of pain, disability, and perception of improvement over a 2-year period were collected. The primary outcome was the Hip Outcome Score (HOS; range, 0-100 [lower scores indicating greater disability]; 2 subscales: activities of daily living and sport). Secondary measures included the International Hip Outcome Tool (iHOT-33), Global Rating of Change (GRC), and return to work at 2 years. The primary analysis was on patients within their original randomization group. Results: Statistically significant improvements were seen in both groups on the HOS and iHOT-33, but the mean difference was not significant between the groups at 2 years (HOS activities of daily living, 3.8 [95% CI, –6.0 to 13.6]; HOS sport, 1.8 [95% CI, –11.2 to 14.7]; iHOT-33, 6.3 [95% CI, –6.1 to 18.7]). The median GRC across all patients was that they “felt about the same” (GRC = 0). Two patients assigned to the surgery group did not undergo surgery, and 28 patients in the rehabilitation group ended up undergoing surgery. A sensitivity analysis of “actual surgery” to “no surgery” did not change the outcome. Twenty (33.3%) patients who underwent surgery and 4 (33.3%) who did not undergo surgery were medically separated from military service at 2 years. Conclusion: There was no significant difference between the groups at 2 years. Most patients perceived little to no change in status at 2 years, and one-third of military patients were not medically fit for duty at 2 years. Limitations include a single hospital, a single surgeon, and a high rate of crossover. Registration: NCT01993615 (ClinicalTrials.gov identifier)

Accuracy of Ultrasound-Guided Intra-articular Hip Injections Performed in the Orthopedic Clinic.

Intra-articular hip injections have proven clinical value for both diagnostic and therapeutic purposes. Historically, these injections have been performed by radiologists using fluoroscopic guidance. This necessitates a radiology referral, delays the injection, and represents lost productivity for the orthopedist. Ultrasound-guided intra-articular hip injections have been described in the radiology literature with excellent accuracy. These injections were performed by radiologists. The purpose of this study was to determine the accuracy of ultrasound-guided hip injections performed in the orthopedic clinic by orthopedic surgeons and orthopedic physician assistants. Fifty ultrasound-guided hip injections were performed using a standard technique. Contrast was included, and an anteroposterior pelvis radiograph was obtained immediately following injection. Diagnosis, body mass index, procedure time, and visual analog scale scores were recorded. Radiographs were reviewed independently by a musculoskeletal radiologist and an orthopedic surgeon to determine intra-articular placement of the injection. A total of 50 hips were injected. There was no identifiable contrast in 2 patients, leaving 48 hips for analysis. Of these, contrast was injected intra-articularly in 46 hips for an accuracy of 96%. Average procedural time was 2.6 minutes, and the average visual analog scale score was 1.9 during the procedure. Revenue value units ranged from 1.72-2.55 for ultrasound-guided hip injections. These findings indicate ultrasound-guided intra-articular hip injections performed in the orthopedic clinic by surgeons or physician assistants are accurate, efficient, and patient-friendly. Additionally, they preserve patient continuity and maintain productivity within the orthopedic clinic. [Orthopedics. 2017; 40(2):96-100.].

Return to Duty Rates Following Meniscal Repair Surgery in an Active Duty Military Population

Meniscal injury is a common knee injury in a young athletic population. Maintaining the integrity of the meniscus is critical to reducing contact pressures on the tibiofemoral articulation. The purpose of this study is to analyze the outcomes of meniscal repair in a young military population. We conducted a retrospective review of all meniscal repairs performed on active duty Army personnel at a Military Medical Center from January 2002 to December 2012. One hundred seventy-eight active duty patients, mean age 28 (19-48) years underwent 178 meniscal repairs. Postoperatively, 33 (18.5%) patients were medically separated from the military at an average time of 29 months. Fifty (28%) patients required a permanent duty restricting profile. Ninety-five (53.5%) patients required no profile after meniscal repair at an average follow-up of 5 (1.5-12.3) years. Meniscal repair in this young military population allowed 81.5% of patients to return to duty; however, 34% of those required a permanent duty restricting profile. Approximately 20% of patients required medical separation from the military after meniscal repair. Older age was significantly associated with the ability to remain on active duty (p = 0.01).

Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions

Objectives We aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy. Methods Data from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery. Results 1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (p<0.001) proportionally for all comorbidities after surgery. Relative to baseline, cases of mental health disorders rose 84%, chronic pain diagnoses increased 166%, substance abuse disorders rose 57%, cardiovascular disorders rose by 71%, metabolic syndrome cases rose 85.9%, systemic arthropathy rose 132% and sleep disorders rose 111%. Conclusions Major (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery. Level of evidence Prognostic, level III.

Randomized Controlled Trial of Hip Arthroscopy Surgery vs Physical Therapy: Response:

Dear Editor: We read with great interest the recent article published in AJSM by Mansell et al titled ‘‘Arthroscopic Surgery or Physical Therapy for Patients With Femoroacetabular Impingement Syndrome: A Randomized Controlled Trial With 2-Year Follow-up.’’ This trial is one of several ongoing randomized controlled trials (RCTs) on this welldeserving topic. The authors should be congratulated for performing an RCT of this nature to attempt to answer this important question. However, we have a number of concerns regarding the authors’ methods, results, and conclusions, and the potential for readers to misinterpret the presented results. These major concerns include (1) a high rate of crossover, (2) a significantly underpowered ‘‘as treated’’ analysis, (3) very small improvements in patient-reported outcomes (PRO) after surgery (which is inconsistent with the previous peer-reviewed literature), and (4) inclusion of patients with less than 2 years of follow-up in the primary analysis. RCTs represent the highest level of evidence given their ability to limit the effect of bias. However, RCTs are not immune to the effect of bias. In fact, some RCTs of lesser quality or with less than 80% follow-up are better classified as level 2 evidence according to the Centre for EvidenceBased Medicine (CEBM) guidelines followed by AJSM. One major source of bias in RCTs is patient crossover, which has the potential to obscure the effect of an intervention. While some patient crossover is unavoidable, efforts to minimize crossover in an RCT are important. Intention-to-treat analyses are commonly used to counteract the effects of patient crossover but become invalid in the setting of excessive patient crossover. While no exact threshold of crossover percentage that invalidates a trial is known, with a 0% crossover being theoretically ideal and a 100% crossover rate completely invalidating a trial, the CEBM suggests a ‘‘rate of greater than 20% is a rough guide to the number that may invalidate the final results.’’ The 70% rate of crossover in the current study, with patients crossing over on average less than 3 months after their surgical counterparts, is concerning and should be interpreted as a ‘‘fatal flaw’’ of the study. The outcomes of the physical therapy (PT) group in this study are heavily dependent on the outcomes (at all time points) of the majority of patients ultimately having surgery. This results in a comparison of a group in which 95% had surgery to a group where 70% had surgery. This is an unfortunate result of the current study design and setting. Other similar studies have made efforts to limit early crossover in this setting. The crossover rate of this study alone confounds the data and limits the reader’s ability to draw any significant conclusions. As a comparison, the METEOR RCT comparing arthroscopic partial meniscectomy to PT was criticized for a high rate of crossover (27%). The authors and reviewers of the study concluded that the lack of difference between the 2 groups in the setting of this crossover ‘‘suggest that an initial course of rigorous PT . may not compromise surgical outcome.’’ This conclusion is perhaps better suited to the current study. Second, after crossover and loss to follow-up, only 11 patients remained in the PT group (compared to 63 for surgery). No data are provided to better understand if deterioration, no change, or another factor was the reason for crossover, which occurred on average less than 3 months after the surgical group, after the patients have evaluated their improvement after PT. The authors did perform an ‘‘as treated’’ or sensitivity analysis, in addition to the intention-to-treat analysis, and stated it ‘‘did not change the outcome’’ with no mention of the power of this comparison. However, in the ‘‘as treated’’ analysis, the advantages of the RCT are lost at this point, as shown in the significantly different characteristics of the patient groups (as seen in pain chronicity 62% vs 14%; no P value noted). In a trial comparing surgery and PT, the inclusion of patients from the surgery group (n = 2) who did not undergo surgery in the comparison group also doesn’t seem appropriate because they did not cross over to the structured PT group but rather had no intervention at all. With only 11 patients remaining in the actual PT group (35% of the number of patients needed based on power analysis), the study is at a high risk of type II error. Detailed assessment of the cohorts by established minimal clinically important difference (MCID) standards is not well reported in the current study; instead, the authors rely on the global rating of change (GRC) assessment tool. Most studies currently favor use of MCID change in PROs for assessing change due to the potential recall bias of GRC in remembering a health state several years prior. While ‘‘no statistically significant difference between the surgery and no surgery groups’’ was present, the surgery group demonstrated a significant increase in Hip Outcome Score (HOS) activities of daily living (ADLs), while a negative nonsignificant trend was present in the no surgery group. The results of this underpowered analysis are better described as ‘‘not finding a statistical difference’’ rather than ‘‘there being no difference’’ between the 2 groups. The external validity of RCTs is an additional important factor for the reader. In the current study, the single surgeon and military setting of the study should be considered. The military population has unique issues and challenges and is similar to a workers’ compensation population. The use of narcotic pain medication in both cohorts for an average of 16 months is concerning and not typical of most femoroacetabular impingement (FAI) patients. The PROs after surgery in this study are low compared with the multiple published reports on hip arthroscopy for FAI The American Journal of Sports Medicine 2018;46(8):NP35–NP39 2018 The Author(s)

Biomechanical Evaluation of Unicortical Stress Risers of the Proximal Humerus Associated With Pectoralis Major Repair

Proximal humerus fracture after pectoralis major tendon repair has been recently reported. Although this complication is rare, it may be possible to decrease such risk using newer techniques for myotenodesis. This study was designed to evaluate various unicortical stress risers created at the proximal humeral metadiaphysis during myotenodesis for repair of pectoralis major ruptures. A simulated pectoralis major myotenodesis was performed using fourth-generation Sawbones (N=30). Using previously described anatomic landmarks for the tendinous insertion, 3 repair techniques were compared: bone trough, tenodesis screws, and suture anchors (N=10 each). Combined compression and torsional load was sequentially increased until failure. Linear and rotational displacement data were collected. The average number of cycles before reaching terminal failure was 383 for the bone trough group, 658 for the tenodesis group, and 832 for the suture anchor group. Both the tenodesis and the suture anchor groups were significantly more resistant to fracture than the bone trough group (P<.001). The suture anchor group was significantly more resistant to fracture than the tenodesis group (P<.001). All test constructs failed in rotational stability, producing spiral fractures, which incorporated the unicortical defects in all cases. When tested under physiologic parameters of axial compression and torsion, failure occurred from rotational force, producing spiral fractures, which incorporated the unicortical stress risers in all cases. The intramedullary suture anchor configuration proved to be the most stable construct under combined axial and torsional loading. Using a bone trough technique for proximal humerus myotenodesis may increase postoperative fracture risk. [Orthopedics. 2017; 40(5):e801-e805.].