Daniel B. Whelan

Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults

BACKGROUNDnReconstruction of the anterior cruciate ligament (ACL) commonly involves patellar tendon (PT) or hamstring tendon(s) (HT) autografts. There is no consensus with respect to the choice between these two grafts in ACL surgery.nnnOBJECTIVESnThis review compared the outcomes of ACL reconstruction using PT versus HT autografts in ACL deficient patients.nnnSEARCH STRATEGYnWe searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (2008, Issue 2), MEDLINE (1966 to April 10 2008), EMBASE (1980 to April 10 2008), conference proceedings and reference lists. No language restrictions were applied.nnnSELECTION CRITERIAnRandomized and quasi-randomized controlled trials comparing outcomes (minimum two year follow-up) following ACL reconstruction using either PT or HT autografts in skeletally mature adults, irrespective of the number of bundles, fixation method or incision technique.nnnDATA COLLECTION AND ANALYSISnAfter independent study selection, the four authors independently assessed trial quality and risk of bias, and extracted data using pre-developed forms. Trial authors were contacted for additional data and information. Risk ratios with 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals for continuous outcomes.nnnMAIN RESULTSnNineteen trials providing outcome data for 1597 young to middle-aged adults were included. Many trials were at high risk of bias reflecting inadequate methods of randomization, lack of blinding and incomplete assessment of outcome.Pooled data for primary outcomes, reported in a minority of trials, showed no statistically significant differences between the two graft choices for functional assessment (single leg hop test), return to activity, Tegner and Lysholm scores, and subjective measures of outcome. There were also no differences found between the two interventions for re-rupture or International Knee Documentation Committee scores. There were inadequate long-term results, such as to assess the development of osteoarthritis.All tests (instrumental, Lachman, pivot shift) for static stability consistently showed that PT reconstruction resulted in a more statically stable knee compared with HT reconstruction. Conversely, patients experienced more anterior knee problems, especially with kneeling, after PT reconstruction. PT reconstructions resulted in a statistically significant loss of extension range of motion and a trend towards loss of knee extension strength. HT reconstructions demonstrated a trend towards loss of flexion range of motion and a statistically significant loss of knee flexion strength. The clinical importance of the above range of motion losses is unclear.nnnAUTHORS CONCLUSIONSnThere is insufficient evidence to draw conclusions on differences between the two grafts for long-term functional outcome. While PT reconstructions are more likely to result in statically stable knees, they are also associated with more anterior knee problems.

Interobserver and intraobserver variation in the assessment of the healing of tibial fractures after intramedullary fixation.

The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by intramedullary fixation. The radiographs were selected from a database to represent fractures at various stages of healing. For each radiograph, the surgeon scored the degree of union, quantified the number of cortices bridged by callus or with a visible fracture line, described the extent and quality of the callus, and provided an overall rating of healing. The interobserver chance-corrected agreement using a quadratically weighted kappa (kappa) statistic in which values of 0.61 to 0.80 represented substantial agreement were as follows: radiological union scale (kappa= 0.60); number of cortices bridged by callus (kappa = 0.75); number of cortices with a visible fracture line (kappa= 0.70); the extent of the callus (kappa = 0.57); and general impression of fracture healing (kappa = 0.67). The intraobserver agreement of the overall impression of healing (kappa = 0.89) and the number of cortices bridged by callus (kappa = 0.82) or with a visible fracture line (kappa = 0.83) was almost perfect. There are no validated scales which allow surgeons to grade fracture healing radiologically. Among those examined, the number of cortices bridged by bone appears to be a reliable, and easily measured radiological variable to assess the healing of fractures after intramedullary fixation.

The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis

PURPOSEnDespite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP.nnnMETHODSnWe searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals.nnnRESULTSnFive studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score.nnnCONCLUSIONSnPRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings.nnnLEVEL OF EVIDENCEnLevel III, systematic review of Level I, II, and III studies.

Outcomes of Osteochondral Allograft Transplantation in the Knee

PURPOSEnThe objectives of this study were (1) to conduct a systematic review of clinical outcomes after osteochondral allograft transplantation in the knee and (2) to identify patient-, defect-, and graft-specific prognostic factors.nnnMETHODSnWexa0searched PubMed, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials. Studies that evaluated clinical outcomes in adult patients after osteochondral allograft transplantation for chondral defects in the knee were included. Pooled analyses for pertinent continuous and dichotomous variables were performed where appropriate.nnnRESULTSnThere were 19 eligible studies resulting in a total of 644 knees with a mean follow-up of 58 months (range, 19 to 120 months). The overall follow-up rate was 93% (595 of 644). The mean age was 37 years (range, 20 to 62 years), and 303 patients (63%) were men. The methods of procurement and storage time included fresh (61%), prolonged fresh (24%), and fresh frozen (15%). With regard to etiology, the most common indications for transplantation included post-traumatic (38%), osteochondritis dissecans (30%), osteonecrosis from all causes (12%), and idiopathic (11%). Forty-six percent of patients had concomitant procedures, and the mean defect size across studies was 6.3 cm(2). The overall satisfaction rate was 86%. Sixty-five percent of patients (72 of 110) showed little to no arthritis at final follow-up. The reported short-term complication rate was 2.4%, and the overall failure rate was 18%. Heterogeneity in functional outcome measures precluded a meta-analysis; a qualitative synthesis allowed for the identification of several positive and negative prognostic factors.nnnCONCLUSIONSnOsteochondral allograft transplantation for focal and diffuse (single-compartment) chondral defects results in predictably favorable outcomes and high satisfaction rates at intermediate follow-up. Patients with osteochondritis dissecans and traumatic and idiopathic etiologies have more favorable outcomes, as do younger patients with unipolar lesions and short symptom duration. Future studies should include comparative control groups and use established outcome instruments that will allow for pooling of data across studies.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level IV studies.

Return to Preinjury Activity Levels After Surgical Management of Femoroacetabular Impingement in Athletes

PURPOSEnA systematic review was conducted to identify, assess, and summarize the available evidence pertaining to surgical intervention for femoroacetabular impingement (FAI) in athletes. Summary estimates of treatment effect (proportion with 95% confidence interval [CI]) were calculated specifically for the rate of return to sport.nnnMETHODSnElectronic databases (Medline, Embase, and Cochrane Library) were searched from inception to November 2011. The references of included articles were reviewed for eligible studies. The inclusion criteria were clinical studies, studies involving humans, minimum 6 months follow-up, exclusive FAI treatment, and focus on athletes. Exclusion criteria were review articles, basic science investigations, radiologic studies, arthroplasty, and nonathlete clinical studies. A quality assessment of the included articles was conducted by 2 reviewers using a quality assessment tool developed by Yang et al. We used a random-effects model (DerSimonian-Laird method) to calculate weighted proportions. Percentages with 95% CIs are reported.nnnRESULTSnNine articles met the inclusion and exclusion criteria in this review. There was 72% agreement (95% CI, 0% to 94%) between the 2 independent reviewers for inclusion and quality assessment of the studies. A total of 418 athletes were surgically treated for FAI and were available for assessment. The rate of return to sport was 92% (95% CI, 87% to 96%), and the rate of return to the previous level of competition was 88% (95% CI, 80% to 94%).nnnCONCLUSIONSnDespite the limitations of our systematic review, the findings suggest that surgical treatment for FAI resulted in a high return to preinjury activity levels of sports.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level IV studies (case series).

Generalized ligamentous laxity as a predisposing factor for primary traumatic anterior shoulder dislocation

HYPOTHESISnThe purpose of this study was to determine whether generalized ligamentous laxity and increased shoulder external rotation represent predisposing factors for primary traumatic anterior shoulder dislocation in young, active patients. We hypothesized that generalized ligamentous laxity and increased shoulder external rotation would be more common in individuals with first-time traumatic shoulder dislocations compared with controls.nnnMATERIALS AND METHODSnThis retrospective case-control study examined hyperlaxity and shoulder external rotation >85° in 57 consecutive individuals (age <30 years) who sustained a primary traumatic anterior shoulder dislocation between 2003 and 2006. The Hospital Del Mar Criteria (battery of 10 clinical examination maneuvers) was used to measure generalized ligamentous laxity, which was determined to be present by overall scores exceeding 4/10 for men or 5/10 for women. The control group comprised 92 age-matched university students without a history of shoulder dislocation or anterior cruciate ligament injury.nnnRESULTSnGeneralized ligamentous laxity was present in 33.3% of the cases compared with 15.2% of controls (P = .014). Increased contralateral shoulder external rotation (>85°) was observed in 38.6% of the study group compared with 22.8% of controls (P = .043). Men who had dislocated their shoulder were 6.8 times more likely to demonstrate generalized ligamentous laxity and increased shoulder external rotation compared with age and sex matched controls (P = .003).nnnDISCUSSIONnIdentifying hyperlax individuals may allow for shoulder-specific proprioceptive training.nnnCONCLUSIONnGeneralized joint laxity and increased external rotation in the contralateral shoulder were more common in patients who had sustained a primary shoulder dislocation.

External Rotation Immobilization for Primary Shoulder Dislocation: A Randomized Controlled Trial

BackgroundThe traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation.Questions/purposesWe performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients.MethodsSixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1–7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12–43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%).ResultsWith the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance.ConclusionsDespite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device.Level of EvidenceLevel I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Peroneal Nerve Injury and Recovery in Knee Dislocation

BackgroundAcute knee dislocation is rare but has a high rate of associated neurovascular injuries and potentially limb-threatening complications. These include the substantial morbidity associated with peroneal nerve injury: neuropathic pain, decreased mobility, and considerably reduced function, which not only impairs patient function but complicates treatment.Questions/purposesWe therefore identified and quantified the risks associated with specific factors for peroneal nerve injury and recovery in patients with knee dislocations.Patients and Methods We retrospectively reviewed the charts of 26 patients, from among a cohort of all 91 knee dislocations, with a peroneal nerve palsy over a 5-year period. We then used univariable and multivariable statistics to identify risk factors predicting peroneal nerve injury and recovery.ResultsGender (odds ratio, 5.47), body mass index (odds ratio, 1.14), and fibular head fracture (odds ratio, 4.77) were associated with peroneal nerve injury. Only younger age was associated with peroneal nerve recovery.ConclusionsKnowledge of the risk factors for peroneal nerve injury and the predictors of recovery in knee dislocation allows the treating surgeon to have a better understanding of the nature of the neurologic injury and modify management based on the anticipated return of nerve function.Level of Evidence Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Microfracture for knee chondral defects: a survey of surgical practice among Canadian orthopedic surgeons

PurposeThe purpose of this study was to describe the practice of microfracture surgery for knee chondral defects among Canadian orthopedic surgeons.MethodsAll orthopedic surgeon members of the Canadian Orthopaedic Association were invited to participate in a survey, designed to explore the microfracture technique used by orthopedic surgeons in the treatment for knee chondral defects The primary outcome measure was an emailed 26-item questionnaire, which explored indications for microfracture surgery, surgical techniques, types of postoperative rehabilitation regimes used and assessment of outcome. In addition, responses were compared between orthopedic surgeons with a sports medicine practice to surgeons with a non-sports medicine practice.ResultsThe survey response rate was 24.6% (299/1,216), with 131 regularly performing microfracture. 41% of surgeons indicated that they had no upper limit for age at the time of surgery, and 87% indicated no upper limit for body mass index. The majority of respondents (97%) resected cartilage back to a stable margin, while 69% of respondents removed the calcified cartilage layer prior to creating holes. Only 11% of respondents used continuous passive motion (CPM) postoperatively, and 39% did not restrict weight bearing. Sports surgeons were more likely than non-sports surgeons to remove the calcified cartilage layer, use a 45° pick, use CPM and restrict weight bearing postoperatively (all P valuesxa0<xa00.05).ConclusionsThis survey on microfracture for knee chondral defects revealed widespread variation among surgeons regarding the indications for surgery, surgical technique, postoperative rehabilitation and assessment of outcome. Sports surgeons demonstrate better evidence-based practice than non-sports surgeons for a few important parameters.Level of evidenceCross-sectional survey, Level II.

Injury patterns to the posteromedial corner of the knee in high-grade multiligament knee injuries: a MRI study.

Injury patterns to the posteromedial corner of the knee have not been previously studied in the context of multiligament knee injuries. We performed a retrospective magnetic resonance imaging and clinical review of a consecutive series of 27 dislocatable knees presenting to a single level-one trauma center from 2005 to 2008. Post-injury magnetic resonance imaging studies were reviewed by two fellowship-trained musculoskeletal radiologists to assess injury patterns to the posteromedial corner. In our series, injury to at least one structure within the posteromedial corner was observed in 81% (22/27) of cases while injury to the superficial medial collateral ligament alone was seen in 63% (17/27) of cases. Furthermore, injuries to the posterior horn of the medial meniscus were associated with a tear of the meniscotibial ligaments in all cases and with a tear of the posterior oblique ligament in 67% of cases. All patients with grade III laxity (>10xa0mm medial opening) under an examination under anesthesia had a complete tear of the posterior oblique ligament and meniscotibial ligament in addition to a medial collateral ligament injury. Injury to the semimembranosus attachment alone was not associated with clinically significant laxity under an examination under anesthesia. Our findings demonstrate that injuries to the posteromedial corner are common in the setting of traumatic knee dislocations. Interestingly, high-grade medial instability during an examination under anesthesia and injury to the posterior horn of the medial meniscus may be important indicators for further posteromedial corner injury.