Fotios P. Tjoumakaris

Arthroscopic and open Bankart repairs provide similar outcomes.

Recurrent instability after arthroscopic Bankart repair has decreased, largely because of improvements in surgical technique. We wanted to know whether there were differences in functional outcomes (using a validated outcomes measure) in patients who had arthroscopic Bankart repair or open Bankart repair for recurrent anterior glenohumeral instability. We retrospectively reviewed 106 patients who had a Bankart repair for recurrent anterior glenohumeral instability from 1998-2001. Of the 93 patients included, 69 patients had arthroscopic Bankart repair and 24 patients had open Bankart repair. The indications for surgery in the two groups were similar. The average age of the patients was 29.9 years (arthroscopic Bankart repair, 31 years; open Bankart repair, 28 years). The followup ranged from 24-77 months. The average modified American Shoulder and Elbow Surgeons score (PENN score) for pain, satisfaction, and function were 26.3, 8.5, and 55.1, respectively, in the arthroscopic Bankart repair group and 26.6, 8.8, and 54.2, respectively, in the open Bankart repair group. The total score was 90 in the arthroscopic Bankart repair group and 89.5 in the open Bankart repair group. Recurrent instability occurred in one patient in each group. We found no difference in outcomes between the arthroscopic and open Bankart repair groups using patient-assessed outcomes.Level of Evidence: Therapeutic Study, Level III (retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.

Chondroprotection and the Prevention of Osteoarthritis Progression of the Knee A Systematic Review of Treatment Agents

Background: Structure-modifying medications or nutraceuticals may be an effective treatment for osteoarthritis. This study identified 12 treatments that may possess chondroprotective properties: oral glucosamine; chondroitin; nonsteroidal anti-inflammatory drugs (NSAIDs); polyunsaturated fatty acids; S-adenosylmethionine; avocado and soybean unsaponifiable fractions; methylsulfonylmethane; vitamins C, D, and E; intra-articular injections of hyaluronic acid; and platelet-rich plasma (PRP). Purpose: To perform a systematic review of randomized controlled trials for the effectiveness of each agent in preserving articular cartilage of the knee and delaying the progression of osteoarthritis. Study Design: Systematic review; Level of evidence, 2. Methods: A literature search was performed using PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. Searches were performed using “treatment,” “osteoarthritis,” and “knee” as keywords. Selection criteria included randomized controlled trials of ≥12 months, with a placebo control, measuring radiographic changes in joint space width, cartilage volume, or radiographic progression of osteoarthritis. The primary outcome was changes in joint integrity measures. Results: A total of 3514 studies were identified from the initial search, 13 of which met inclusion criteria. Treatment with chondroitin sulfate showed a significant reduction in cartilage loss in 3 of 4 studies identified compared with placebo. Two of 3 trials identified for glucosamine also reported significant structural effects relative to placebo. Intra-articular hyaluronic acid was effective in lowering the rate of cartilage loss in only 1 of 3 studies identified versus placebo. Of the 6 studies identified for NSAIDs, vitamin E, and vitamin D, none showed any structural effect compared with placebo. No studies were found that met the inclusion criteria for polyunsaturated fatty acids, S-adenosylmethionine, avocado and soybean unsaponifiable fractions, methylsulfonylmethane, vitamin C, or PRP. Conclusion: For patients with or at risk for osteoarthritis, the use of glucosamine and chondroitin sulfate may serve as a nonoperative means to protect joint cartilage and delay osteoarthritis progression. Hyaluronic acid injections showed variable efficacy, while NSAIDs and vitamins E and D showed no effect on osteoarthritis progression. The other agents evaluated had no evidence in the literature to support or refute their use for chondroprotection.

Elbow arthroscopy: basic setup and portal placement.

Since the first reports of elbow arthroscopy in the American literature,1,2 advances in arthroscopic technique and equipment have made elbow arthroscopy an effective and safe method for the diagnosis and treatment of a variety of elbow ailments.3 With elbow arthroscopy becoming more common, precise knowledge of the neurovascular anatomy, preferred arthroscopic portals, and considered indications for definitive arthroscopic procedures is required to maximize the success rate and improve the clinical outcome.

Neuralgic amyotrophy (Parsonage-Turner syndrome).

&NA; Neuralgic amyotrophy (Parsonage‐Turner syndrome or brachial plexus neuritis) is an uncommon syndrome whose cause is unknown. The suprascapular and axillary nerves and corresponding muscles are affected most frequently. The disorder exhibits a broad range of clinical manifestations, and patients frequently present to physicians of different subspecialties. Accurate diagnosis can be challenging and requires a thorough history and physical examination. Nerve conduction velocity and imaging studies assist in the evaluation. Treatment consists of symptomatic management. Symptoms can persist for more than than a year, but most patients note resolution of symptoms over time.

The Evaluation of Arthroscopic Remplissage by High-Resolution Magnetic Resonance Imaging

Background: Arthroscopic remplissage is a novel procedure recently advocated for the treatment of large Hill-Sachs lesions with recurrent anterior glenohumeral instability. We have shown previously that infraspinatus tenodesis and Bankart repair reduce the risk of recurrent instability in high-risk patients. The ability to perform this procedure arthroscopically and without the need for bone grafting or an open approach makes this an appealing alternative to more traditional techniques. Purpose: To evaluate and characterize the postoperative appearance of the remplissage procedure on high-resolution magnetic resonance imaging (MRI) and to correlate these findings to clinical outcome (Western Ontario Shoulder Instability [WOSI] score, range of motion). Study Design: Case series; Level of evidence, 4. Methods: In patients who had undergone arthroscopic remplissage for recurrent glenohumeral instability with large Hill-Sachs defects, images were acquired with a 3-T protocol (and reviewed by 2 musculoskeletal radiologists) with the shoulder in the abduction-external rotation (ABER) and neutral positions at the time of the latest clinical examination. Measured parameters included signal intensity of tissue within the prior defect, signal intensity of the residual infraspinatus, degree of fatty infiltrate and muscle atrophy as a percentage of fat signal versus muscle signal (Goutallier grade), presence of marrow edema, and number of anchors in the defect. Functional scores were obtained with the WOSI questionnaire, and comprehensive range of motion data were recorded with a goniometer. Results: In 11 patients with an average clinical follow-up of 18.0 months (range, 8.8-27.2 months), the average size of the Hill-Sachs deformity was 334.3 mm3 (range, 93.6-825.1 mm3). The percentage of the deformity filled in with tendon was 75% to 100%, and the degree of atrophy was 0% to 25% for all patients studied. No defects were left unfilled. Two patients had granulation tissue filling the lesion, and 3 patients had fibrous tissue, while the rest of the patients had the MRI appearance of both granulation and fibrous tissue. Four of 9 patients had tendinopathy or partial tears of the residual infraspinatus tendon insertion, and 1 patient demonstrated residual bone marrow edema. The average number of anchors used was 1.4 (range, 1-3). The average WOSI score was 74.3% (range, 41.6%-99.2%), with an average external rotation loss of 5.8° (range, 0°-22°). One patient had recurrence of instability. Conclusion: Our data suggest that there is evidence of tendon incorporation and fill into the Hill-Sachs defect following arthroscopic remplissage at 8 months and beyond. Although MRI findings did not correlate with the clinical findings, patients were satisfied with the procedure and demonstrated minimal loss of external rotation (average, 5.8°) at early follow-up.

Combined Glenoid and Humeral Head Allograft Reconstruction for Recurrent Anterior Glenohumeral Instability

Recurrent glenohumeral instability can be a challenging therapeutic problem to orthopedic surgeons. Oftentimes, recurrent anterior glenohumeral instability is associated with a host of capsular, labral, and occasionally, osseous deficiencies. Current treatment strategies for significant bony deficiency within the shoulder are aimed at nonanatomic restoration of glenohumeral anatomy with resultant limitation in range of motion parameters. While these techniques may prevent recurrence of instability, the resulting loss of motion and decreased function may not be suitable for young, active individuals. This case report presents a patient with recurrent anterior glenohumeral instability from a combined, large glenoid and humeral head bone deficiency. A novel surgical technique of restoring both humeral and glenoid bone is introduced as a way to prevent decreased motion after surgery while still maintaining stability. This reconstruction offers a more anatomic restoration of bone deficiency with the desired effect of achieving a more complete postoperative range of motion, while still conferring stability. The patient has returned to activities of daily living.

The Rationale for an Arthroscopic Approach to Shoulder Stabilization

The gold standard of treatment for glenohumeral instability has traditionally been viewed as open shoulder stabilization. With the increased awareness of complex instability patterns and the ability to preoperatively detect concomitant pathology with advanced imaging modalities, an evidence-based shift to an all-arthroscopic approach to shoulder stabilization surgery is occurring. Current data suggest that patients who meet eligibility criteria for arthroscopic stabilization (those without significant bony lesions or significant deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity. Modern arthroscopic techniques using suture anchors and capsular plication have resulted in a significant improvement over previous reports in the orthopaedic literature. An argument is put forth on the benefits of an all-arthroscopic approach to shoulder stabilization in athletes and nonathletes alike based on a review of the current orthopaedic literature comparing the evolved arthroscopic technique with more traditional open methods.

Complications In Brief: Anterior Cruciate Ligament Reconstruction

When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.

Comparison of arthroscopic osteochondral substitute grafting and remplissage for engaging Hill-Sachs lesions.

The optimum management for recurrent glenohumeral instability with significant humeral head defects remains controversial. The purpose of this study was to compare outcomes and recurrence rates between patients who underwent osteochondral substitute grafting and patients who underwent remplissage to treat recurrent shoulder instability from an engaging Hill-Sachs defect with a Bankart lesion. Twenty consecutive patients who underwent remplissage and 19 consecutive patients who underwent osteochondral substitute grafting with Bankart repair were studied. Mean follow-up was 29.6 months for the remplissage group and 32.1 months for the osteochondral substitute grafting group. All patients had an engaging Hill-Sachs lesion, and indications for surgery were identical between groups. Three postoperative recurrences occurred in the remplissage group and 6 occurred in the osteochondral substitute grafting group (P=.18). Nineteen patients in the remplissage group and 7 patients in the osteochondral substitute grafting group had a large humeral head defect. Patients in the remplissage group had better Western Ontario Shoulder Instability Index [WOSI] scores than those in the osteochondral substitute grafting group for large lesions (74.7 vs 50.4, respectively), although they were not statistically significant (P=.077). After controlling for age, sex, lesion size, and follow-up differences, the remplissage group reported significantly better WOSI scores (P=.016). This study demonstrated a potential advantage of remplissage compared with osteochondral synthetic grafting in patients who experienced recurrent anterior shoulder instability, particularly in shoulders with a large humeral head defect.

Levels of Evidence in the Clinical Sports Medicine Literature: Are We Getting Better Over Time?

Background: There has been an increased emphasis on improving the level of evidence used as the basis for clinical treatment decisions. Several journals now require a statement of the level of evidence as a basic gauge of the study’s strength. Purpose: To review the levels of evidence in published articles in the clinical sports medicine literature and to determine if there has been an improvement in the levels of evidence published over the past 15 years. Study Design: Systematic review. Methods: All articles from the years 1995, 2000, 2005, and 2010 in The American Journal of Sports Medicine (AJSM), Arthroscopy, and sports medicine–related articles from The Journal of Bone and Joint Surgery–American (JBJS-A) were analyzed. Articles were categorized by type and ranked for level of evidence according to guidelines from the Centre for Evidence-Based Medicine. Excluded were animal, cadaveric, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence. Statistical analysis was performed with chi-square. Results: A total of 1580 articles over the 4 periods met the inclusion criteria. The percentage of level 1 and 2 studies increased from 6.8% to 12.6%, 22.9%, and 23.5%, respectively (P < .0001), while level 4 and 5 studies decreased from 78.9% to 72.4%, 63.9%, and 53.0% (P < .0001). JBJS-A had a significant increase in level 1 and 2 studies (4.1%, 5.1%, 28.2%, 27.8%; P < .0001), as did AJSM (9.4%, 17.1%, 36.1%, 30.1%; P < .0001). Arthroscopy showed no significant change over time. Diagnostic, therapeutic, and prognostic studies all showed significant increases in level 1 and 2 studies over time (P < .05). Conclusion: There has been a statistically significant increase in the percentage of level 1 and 2 studies published in the sports medicine literature over the past 15 years, particularly in JBJS-A and AJSM. The largest increase was seen in diagnostic studies, while therapeutic and prognostic studies demonstrated modest improvement. The emphasis on increasing levels of evidence to guide treatment decisions for sports medicine patients may be taking effect.