Christian Veillette

Survivorship Analysis and Radiographic Outcome Following Tantalum Rod Insertion for Osteonecrosis of the Femoral Head

BACKGROUND For early stages of osteonecrosis, preservation of the femoral head is the primary objective; however, there has not been a consensus on how best to achieve this goal. Core decompression alone is associated with a lack of structural support with inconsistent outcomes, whereas vascularized fibular grafting requires an extensive surgical procedure with high donor-site morbidity and prolonged rehabilitation. The adjunctive use of a porous tantalum implant offers the advantages of core decompression, structural support, minimally invasive surgery, and no donor-site morbidity. The purpose of this study was to assess the survivorship and to evaluate the clinical results and radiographic outcomes of hips in which osteonecrosis of the femoral head was treated with core decompression and a porous tantalum implant. METHODS We evaluated fifty-four patients (sixty consecutive hips) in whom osteonecrosis of the femoral head was treated with core decompression and insertion of a porous tantalum implant. Fifty-two patients (fifty-eight hips) were available for follow-up at a mean of twenty-four months. All patients were sixty-five years of age or younger (mean age, thirty-five years). According to the classification system of Steinberg et al., one hip (2%) had stage-I disease, forty-nine hips (84%) had stage-II disease, and eight hips (14%) had stage-III disease. Outcome measures that were used included a limb-specific score (Harris hip score), radiographic outcome measures, and survivorship analysis with revision to total hip arthroplasty as the end point. RESULTS Overall, nine hips (15.5%) were converted to total hip arthroplasty, including six with stage-II disease and three with stage-III disease. The overall survival rates were 91.8% (95% confidence interval, 87.8% to 95.8%) at twelve months, 81.7% (95% confidence interval, 75.8% to 87.6%) at twenty-four months, and 68.1% (95% confidence interval, 54.7% to 81.5%) at forty-eight months. The absence of chronic systemic diseases resulted in a survival rate of 92% at forty-eight months (95% confidence interval, 87.4% to 96.4%). CONCLUSIONS Treatment of early stage osteonecrosis of the femoral head with core decompression and a porous tantalum implant can be accomplished with a minimally invasive technique and no donor-site morbidity. The early clinical results show encouraging survival rates in patients who do not have chronic systemic disease, especially in association with early stage disease. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Epidemiology of Primary Anterior Shoulder Dislocation Requiring Closed Reduction in Ontario, Canada

Background: There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation. Purpose: To (1) calculate the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; “index event”) in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age <16 and >70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model. Results: There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio [HR], 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001). Conclusion: Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.

Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada.

BACKGROUND Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort. METHODS Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes. RESULTS We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients. CONCLUSIONS Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic proficiency: methods in evaluating competency

BackgroundThe current paradigm of arthroscopic training lacks objective evaluation oftechnical ability and its adequacy is concerning given the acceleratingcomplexity of the field. To combat insufficiencies, emphasis is shiftingtowards skill acquisition outside the operating room and sophisticatedassessment tools. We reviewed (1) the validity of cadaver and surgicalsimulation in arthroscopic training, (2) the role of psychomotor analysisand arthroscopic technical ability, (3) what validated assessment tools areavailable to evaluate technical competency, and (4) the quantification ofarthroscopic proficiency.MethodsThe Medline and Embase databases were searched for published articles in theEnglish literature pertaining to arthroscopic competence, arthroscopicassessment and evaluation and objective measures of arthroscopic technicalskill. Abstracts were independently evaluated and exclusion criteriaincluded articles outside the scope of knee and shoulder arthroscopy as wellas original articles about specific therapies, outcomes and diagnosesleaving 52 articles citied in this review.ResultsSimulated arthroscopic environments exhibit high levels of internal validityand consistency for simple arthroscopic tasks, however the ability totransfer complex skills to the operating room has not yet been established.Instrument and force trajectory data can discriminate between technicalability for basic arthroscopic parameters and may serve as useful adjunctsto more comprehensive techniques. There is a need for arthroscopicassessment tools for standardized evaluation and objective feedback oftechnical skills, yet few comprehensive instruments exist, especially forthe shoulder. Opinion on the required arthroscopic experience to obtainproficiency remains guarded and few governing bodies specify absolutequantities.ConclusionsFurther validation is required to demonstrate the transfer of complexarthroscopic skills from simulated environments to the operating room andprovide objective parameters to base evaluation. There is a deficiency ofvalidated assessment tools for technical competencies and little consensusof what constitutes a sufficient case volume within the arthroscopycommunity.

Defects in Tendon, Ligament, and Enthesis in Response to Genetic Alterations in Key Proteoglycans and Glycoproteins: A Review

This review summarizes the genetic alterations and knockdown approaches published in the literature to assess the role of key proteoglycans and glycoproteins in the structural development, function, and repair of tendon, ligament, and enthesis. The information was collected from (i) genetically altered mice, (ii) in vitro knockdown studies, (iii) genetic variants predisposition to injury, and (iv) human genetic diseases. The genes reviewed are for small leucine-rich proteoglycans (lumican, fibromodulin, biglycan, decorin, and asporin); dermatan sulfate epimerase (Dse) that alters structure of glycosaminoglycan and hence the function of small leucine-rich proteoglycans by converting glucuronic to iduronic acid; matricellular proteins (thrombospondin 2, secreted phosphoprotein 1 (Spp1), secreted protein acidic and rich in cysteine (Sparc), periostin, and tenascin X) including human tenascin C variants; and others, such as tenomodulin, leukocyte cell derived chemotaxin 1 (chondromodulin-I, ChM-I), CD44 antigen (Cd44), lubricin (Prg4), and aggrecan degrading gene, a disintegrin-like and metallopeptidase (reprolysin type) with thrombospondin type 1 motif, 5 (Adamts5). Understanding these genes represents drug targets for disrupting pathological mechanisms that lead to tendinopathy, ligamentopathy, enthesopathy, enthesitis and tendon/ligament injury, that is, osteoarthritis and ankylosing spondylitis.

Predictors of Dislocation and Revision After Shoulder Stabilization in Ontario, Canada, From 2003 to 2008

Background: Factors contributing to recurrent dislocation, revision stabilization, and complications requiring reoperation after an initial shoulder stabilization procedure for instability have not been evaluated on a population level. Purpose: (1) To define the rate of ipsilateral revision stabilization, contralateral primary stabilization, postoperative dislocation, and complications after primary shoulder stabilization in a population cohort. (2) To understand which risk factors among patient, surgical, and provider factors influence these outcomes. Study Design: Cohort study; Level of evidence, 3. Methods: All residents of Ontario, Canada, aged 16 to 60 years undergoing primary shoulder stabilization between July 2003 and December 2008 were identified from billing and hospital databases. Separate Cox proportional hazards survivorship models were built for the outcomes revision stabilization and postoperative physician-documented shoulder relocation (minimum 2-year follow-up). Model covariates included patient demographics (age, sex, preoperative dislocations), provider characteristics (surgeon volume, hospital academic status), and type of surgery (open, arthroscopic). The frequency and risk factors for contralateral stabilization were identified. Results: A total of 5904 patients (80.6% male; median age, 29 years) were identified. Arthroscopic stabilization was used in ~60% of cases in 2003, increasing to ~80% in 2008. The rates of postoperative dislocation were 6.9%, revision stabilization 4%, and contralateral primary stabilization 3.9%. Patients aged younger than 20 years had a 7.7% revision rate (hazard ratio [HR], 2.7; 95% confidence interval [CI], 1.7-4.2; P < .0001) and a 12.6% rate of postoperative physician-documented dislocation (HR, 2.4; 95% CI, 1.8-3.4; P < .0001), compared with 2.8% and 5.5%, respectively, in patients 29 years old (median cohort age). Patients with 3 or more preoperative dislocations in Ontario had an increased risk of revision (HR, 2.1; 95% CI, 1.5-3.0; P < .0001) and postoperative dislocation (HR, 10.6; 95% CI, 8.1-14.0; P < .0001). Revision was more common after arthroscopic (4.3%) compared with open (3.5%) stabilization (HR, 1.4; 95% CI, 1.02-1.98; P = .04). No provider factor was predictive, including surgeon volume. Reoperation rate for complications not related to recurrent instability was 0.23% (infection, 0.07%; manipulation under anesthesia, 0.15%). Conclusion: The risks of revision stabilization and postoperative (either shoulder) dislocation were most influenced by young age (<20 years) and having had 3 or more preoperative dislocations. Complications requiring surgery are rare.

The epidemiology of primary anterior shoulder dislocations in patients aged 10 to 16 years.

Background: Clinical studies of shoulder dislocations typically include adult patients (>16 years of age). Only small case series of patients aged 10 to 16 years are available to guide management. Purpose: Using a cohort of patients aged 10 to 16 years, this study sought to determine (1) the incidence density rate (IDR) of primary anterior shoulder dislocations requiring closed reduction (CR) and (2) the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: With use of administrative databases, patients aged 10 to 16 years who underwent CR of a primary anterior shoulder dislocation in Ontario, Canada, between April 2002 and September 2010 were gathered. IDRs for the entire cohort and demographic subgroups were calculated. The main outcome, repeat shoulder CR, was sought until September 2012. The cumulative incidence of repeat CR was calculated at multiple time points for the entire cohort and age subgroups. A competing risk model identified risk factors for repeat CR (reported as hazard ratios [HRs] with 95% CIs). Results: There were 1937 patients aged 10 to 16 years who underwent primary CR (median age, 15.0 years; 79.7% male). The incidence of primary CR was highest among male patients aged 16 years (164.4 per 100,000 person-years), but primary dislocations were rare in 10- to 12-year-old children (n = 115; 5.9% of all dislocations). Repeat CR was observed in 740 patients (38.2%) after a median of 0.8 years; however, the rate of repeat CR was age dependent: it was highest among 14- to 16-year-old patients (37.2%-42.3%) and considerably lower among 10- to 13-year-old patients (0%-25.0%). Male sex (HR, 1.2 [95% CI, 1.0-1.5]; P = .04) and older patient age (HR, 1.2 [95% CI, 1.1-1.3]; P < .001) significantly increased the odds of repeat CR. Conclusion: Among 14- to 16-year-old patients, the rate of primary and recurrent shoulder CR mirrors that of high-risk adults (17-20 years of age) from previously published data; however, the rate of shoulder CR (primary or recurrent) is considerably lower among 10- to 13-year-olds. In addition to older patient age, male sex increased the odds of repeat shoulder CR. Going forward, clinicians should counsel male patients and those aged 14 to 16 years regarding their increased risk of recurrence after the nonoperative management of a primary anterior shoulder dislocation.

Combined Arthroscopic Bankart Repair and Remplissage for Recurrent Shoulder Instability

PURPOSE The objective of our study was to summarize the available clinical evidence pertaining to the combined arthroscopic Bankart repair and remplissage procedure (BRR) for the management of recurrent anterior glenohumeral instability. METHODS We searched Medline (1946 to the third week of November, 2012), the Cochrane Central Register of Controlled Trials, Embase (1947 to the 50th week of 2012), and PubMed for studies that reported clinical outcome data at a minimum of 1 year after BRR. Two independent reviewers selected studies for inclusion, assessed methodological quality, and extracted relevant data. Clinical outcome data were pooled and summarized. RESULTS Seven clinical studies with a total of 220 patients met the inclusion criteria. Mean patient age was 29 years and mean follow-up was 26 months. Among all studies, the pooled rate of recurrent dislocation after BRR was 3.4%. Compared with preoperative range of motion (ROM) and ROM after Bankart repair (BR) for similar pathologic conditions, there were no clinically significant losses in glenohumeral motion after BRR. Moreover, BRR resulted in favorable functional outcome scores and high patient satisfaction. Four studies reported on postoperative imaging and found high rates of healing and tissue fill-in at the site of infraspinatus tenodesis. CONCLUSIONS After BRR, the rate of recurrent dislocation is low and there are no clinically significant losses in glenohumeral ROM. Moreover, functional outcome scores are good and there is a high rate of patient satisfaction. Going forward, there is a need for high-level clinical studies to support the findings of this systematic review and to develop an evidence-based approach to the management of patients with recurrent glenohumeral instability in the setting of a Hill-Sachs defect (HSD).

The Future of Orthopaedic Information Management

Not long ago, if you were reading an article of this type, it was safe to assume that you were holding a printed journal. Today, while some readers might have a document in hand, many are sitting in front of a computer monitor, and still others are reading on a smartphone, tablet, or other wireless device. Accordingly, as paper is replaced by pixels, readers around the world can readily access their reading material at the point of need. Yet this foray into the digital domain does not represent unalloyed progress: the Internet has provided everyone with a printing press, allowing experts, quacks, and all those in between the ability to publish medical material with at least a veneer of authority. Thus, the challenge for the consumer is not so much to find some medical information, but to find valid, trusted, and pertinent medical information1. This challenge is especially daunting, given the size of the World Wide Web. For example, a keyword search of “carpal tunnel syndrome” in PubMed returns less than 8000 entries (as of October 2011), whereas the same search in Google finds more than 12.3 million results. Beredjiklian et al.2 evaluated the quality of information regarding carpal tunnel syndrome on the Internet and found that 23% of web sites offered unconventional or misleading information, and the mean informational value of the web sites was 28.4 of a possible 100 points. Likewise, Labovitch et al.3 examined Internet sources regarding minimally invasive hip arthroplasty and found information that was often “misleading and of poor quality.” In response, new models for obtaining information have been created. Web sites of well-respected organizations such as the American Academy of Orthopaedic Surgeons (AAOS) aggregate material and post commentaries. Web 2.0 technologies4, including forums, blogs, and social networks, allow …

The frequency and risk factors for subsequent surgery after a simple elbow dislocation

INTRODUCTION Simple elbow dislocations treated by closed reduction are thought to result in a satisfactory return of function in most patients. Little, however, is known about how many patients ultimately proceed to subsequent surgical treatment due to the low patient numbers and significant loss to follow-up in the current literature. The purpose of this study was to establish the rate of and risk factors for subsequent surgical treatment after closed reduction of a simple elbow dislocation at a population level. PATIENTS AND METHODS All patients aged 16 years or older who underwent closed reduction of a simple elbow dislocation between 1994 and 2010 were identified using a population database. Subsequent procedures performed for joint contractures, instability or arthritis were recorded. Outcomes were modelled as a function of age, sex, income quintile, co-morbidity, urban/rural status, physician speciality performing the initial reduction and whether orthopaedic consultation and/or post-reduction radiograph was performed within 28 days of the injury, in a time-to-event analysis. RESULTS We identified 4878 elbow dislocations with a minimum 2-year follow-up: stabilisation surgery was performed in 112 (2.3%) at a median time of 1 month, contracture release in 59 (1.2%) at median 9 months and arthroplasty in seven (0.1%) at median 25 months. Admission to hospital for the initial reduction was associated with an increased risk of undergoing stabilisation (hazard ratio (HR), 2.50; 95% confidence interval (CI), 1.67-3.74) and contracture release (HR, 1.93; CI, 1.08-3.44). Multiple reduction attempts increased the risk of requiring contracture release (HR, 3.71; CI, 1.22-11.29). Survival analysis demonstrated that all subsequent procedures had taken place by 4-5 years. CONCLUSION Few patients with simple elbow dislocations develop complications requiring surgery, but those that do most commonly undergo soft-tissue stabilisation or contracture release within 4 years of the injury. Contrary to current thinking, surgery for instability is performed more often than joint contracture release, albeit with slightly different time patterns.