Jacob M. Kirsch

Does Hip Arthroscopy Have a Role in the Treatment of Developmental Hip Dysplasia

BACKGROUND Indications for hip arthroscopy in mildly dysplastic patients with a symptomatic hip remain controversial. METHODS This article provides a concise review of the available literature evaluating the role of hip arthroscopy in treating symptomatic dysplasia. Potential indications for hip arthroscopy in isolation are reviewed. Emerging evidence on the role of hip arthroscopy based on patient-specific pathomorphology is highlighted. RESULTS Hip arthroscopy in isolation may be helpful for select dysplastic patients with dynamic impingement or microinstability. Isolated arthroscopic treatment of intra-articular pathology resulting from static overload is unlikely to be successful in the long term and may be detrimental. CONCLUSION Arthroscopic procedures for individuals with mild dysplasia in the absence of frank instability may be effective; however, great caution should be exercised when approaching dysplastic patients with symptomatic hips.

Common Injuries in Professional Football Quarterbacks

Purpose of ReviewProfessional football quarterbacks are at particular risk for upper extremity injuries due to the physical demands of their position coupled with the inherent risks associated with professional football. This review sought to evaluate current clinical literature to better characterize the injury profile unique to this athletic population.Recent FindingsShoulder injuries are the most prevented upper extremity injury among professional football quarterbacks. The quarterback position is disproportionately impacted by shoulder injuries when compared to professional athletes at other positions. Moreover, contrary to other professional throwing athletes, the majority of upper extremity injuries in the professional quarterback result from direct contact as opposed to the throwing motion.SummaryThe injury profile among professional quarterbacks is unique compared to other positions and other overhead professional throwing athletes. Overall, a paucity of high quality clinical evidence exists to support the management of injuries in this elite population.

Tranexamic acid in shoulder arthroplasty a systematic review and meta-analysis

Background: The role of tranexamic acid (TXA) in reducing blood loss following primary shoulder arthroplasty has been demonstrated in small retrospective and controlled clinical trials. This study comprehensively evaluates current literature on the efficacy of TXA to reduce perioperative blood loss and transfusion requirements following shoulder arthroplasty. Methods: PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through October 27, 2016, for all articles evaluating TXA in shoulder arthroplasty. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of the risk of bias and strength of evidence. The primary outcome was change in hemoglobin and the secondary outcomes were drain output, transfusion requirements, and complications. Pooled outcomes assessing changes in hemoglobin, drain output, and transfusion requirements were determined. Results: Five articles (n = 629 patients), including 3 Level-I and 2 Level-III studies, were included. Pooled analysis demonstrated a significant reduction in hemoglobin change (mean difference [MD], −0.64 g/dL; 95% confidence interval [CI], −0.84 to −0.44 g/dL; p < 0.00001) and drain output (MD, −116.80 mL; 95% CI, −139.20 to −94.40 mL; p < 0.00001) with TXA compared with controls. TXA was associated with a point estimate of the treatment effect suggesting lower transfusion requirements (55% lower risk); however, the wide CI rendered this effect statistically nonsignificant (risk ratio, 0.45; 95% CI, 0.18 to 1.09; p = 0.08). Findings were robust with sensitivity analysis of pooled outcomes from only Level-I studies. Conclusions: Moderate-strength evidence supports use of TXA for decreasing blood loss in primary shoulder arthroplasty. Further research is necessary to evaluate the efficacy of TXA in revision shoulder arthroplasty and to identify the optimal dosing and route of administration of TXA in shoulder arthroplasty. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Significant demographic and geographic differences exist in the reporting of superior labrum from anterior to posterior tear literature: a systematic review

Importance Superior labrum from anterior to posterior (SLAP) pathology can result in significant pain and functional limitation for a wide variety of patients. Although many different options have been described for the diagnosis and treatment of SLAP pathology, there is little high-quality evidence to support a given diagnosis/treatment method. Objective The aim of this study was to review the global demographics and trends of SLAP literature, diagnosis, management and consistency of reported outcomes Evidence review We performed a systematic search for studies addressing SLAP pathology published over the last 10 years. Extracted data included sample size, study location, intervention, outcome measures reported, sex distribution and level of evidence. Management was compared between geographic areas. Findings We identified 363 studies reporting on SLAP management over the past decade that met our inclusion and exclusion criteria. The majority of studies originated from North America (50.4%), followed by Asia (22.3%) and Europe (20.9%) with most studies describing results of operative intervention originating from the USA (58.5%). We found the majority of literature related to SLAP pathology was case series level data (44.0%) consisting of sample sizes of less than 40 patients (50.1%). The majority of studies presented clinical outcome scores with the ASES score being the most commonly reported (28.3%). The most common complications reported were pain (32.6%) and stiffness (30.4%) following surgical intervention. Conclusions Current literature related to the management of SLAP pathology demonstrates a predominance of North American studies with low levels of evidence consisting of small sample sizes and variably reported clinical outcome scores. Future research should focus on multicentre, randomised studies to clarify current controversies in the surgical versus non-operative management of SLAP pathology. Relevance Significant demographic and geographic differences exist in the diagnosis and treatment of SLAP. Level of evidence Level IV, systematic review of level I–IV studies.

Most elite athletes return to competition following operative management of meniscal tears: a systematic review

Importance Meniscal injuries are common among athletes. When operative management is indicated, the decision between meniscal repair and meniscectomy is not always clear, particularly in elite athletes. Objective The aim of this systematic review was to (1) compare outcomes for partial meniscectomy and repair for the management of meniscus tears in elite athletes and (2) describe return-to-play (RTP) rates and complications for each operation. Evidence review MEDLINE, Embase and PubMed were searched from inception through to 5 March 2017. All studies were screened in duplicate for eligibility. Data extracted included demographics, surgical technique and RTP rate and timeline. Findings Ten studies (725 athletes) were included involving 355 elite athletes undergoing meniscal repair (111 patients) or partial/total meniscectomy (244). The majority of athletes were men (82.8%) and had a mean age of 25.0 years (14–38). Athletes were followed for a mean of 5.3 years (range=3 months to 18.4 years). American football was the most common sport (153 athletes), followed by soccer (69) and basketball (67). Athletes undergoing meniscal repair demonstrated a pooled mean RTP time of 7.6 months in comparison to 4.3 months for those undergoing partial meniscectomy (P<0.0001). Of athletes undergoing meniscal repair, 86.5% RTP at their preoperative level, compared with 80.4% of athletes undergoing partial meniscectomy (P=0.24). Following meniscectomy, athletes who were taller, drafted in higher rounds and had played or started more games preoperatively were less likely to suffer negative career impacts postoperatively. Satisfaction rates (92% vs 76%) and clinical scores (8.8 vs 6.9, P=0.05) were higher among recreational than elite athletes. Conclusion Athletes undergoing partial meniscectomy RTP sooner than those undergoing meniscal repair. Both operations are safe and the majority of athletes RTP at their preoperative level of competition following either operation. Further research is required to identify when each option is preferable in this population. Relevance Based on the currently available evidence, meniscectomy and meniscal repair are both viable options for elite athletes with meniscal injuries. Each method has small advantages and disadvantages compared with the other, and thus a shared decision should be made with the athlete. Level of evidence Level IV, systematic review of level III and IV studies.

Platform shoulder arthroplasty: a systematic review

BACKGROUND Platform shoulder arthroplasty systems may allow conversion to a reverse total shoulder arthroplasty (RTSA) without removing a well-fixed, well-positioned humeral stem. We sought to evaluate the complications associated with humeral stem exchange versus retention in patients undergoing conversion shoulder arthroplasty with a platform shoulder arthroplasty system. METHODS PubMed, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase were searched from database inception through October 9, 2016, for all articles comparing humeral stem retention versus exchange during conversion RTSA or that pertained to conversion RTSA with stem retention alone. All studies were screened in duplicate for eligibility. A methodologic quality assessment was completed for included studies. Pooled outcomes assessing complications, operative time, blood loss, and reoperations were determined. RESULTS We included 7 studies (236 shoulders), including 1 level III and 6 level IV studies. Pooled analysis demonstrated significantly higher overall complications (odds ratio, 6.89; 95% confidence interval [CI], 2.48-19.13; P = .0002), fractures (odds ratio, 4.62; 95% CI, 1.14-18.67; P = .03), operative time (mean difference, 62.09 minutes; 95% CI, 51.17-73.01 minutes; P < .00001), and blood loss (mean difference, 260.06 mL; 95% CI, 165.30-354.83 mL; P < .00001) with humeral stem exchange. Stem exchange was also associated with increased risk of reoperation (P = .0437). CONCLUSION Conversion arthroplasty with retention of the humeral stem is associated with lower overall complications, blood loss, operative time, and reoperations in comparison with stem exchange.

Current Concepts Osteochondritis Dissecans of the Capitellum and the Role of Osteochondral Autograft Transplantation

Background: Osteochondritis dissecans (OCD) of the capitellum is a painful condition, which often affects young throwing athletes. Our current understanding regarding the etiology, risks factors, diagnosis, and efficacy of the available treatment options has expanded over recent years, however remains suboptimal. Recent data on patient-reported outcomes following osteochondral autograft transplantation (OAT) for the treatment of large osteochondral lesions of the capitellum have been promising but limited. This review seeks to critically analyze and summarize the available literature on the etiology, diagnosis, and reported outcomes associated with OCD of the capitellum and the use of OAT for its treatment. Methods: A comprehensive literature search was conducted. Unique and customized search strategies were formulated in PubMed, Embase, Scopus, Web of Science, and CENTRAL. Combinations of keywords and controlled vocabulary terms were utilized in order to cast a broad net. Relevant clinical, biomechanical, anatomic and imaging studies were reviewed along with recent review articles, and case series. Results: Forty-three articles from our initial literature search were found to be relevant for this review. The majority of these articles were either review articles, clinical studies, anatomic or imaging studies or biomechanical studies. Conclusions: Current evidence suggests that OAT may lead to better and more consistent outcomes than previously described methods for treating large OCD lesions of the capitellum.

Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma.

Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results.