James S. Shaha

Redefining “Critical” Bone Loss in Shoulder Instability: Functional Outcomes Worsen With “Subcritical” Bone Loss

Background: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the “critical” cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, “subcritical” amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability. Purpose: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability. Study Design: Cohort study; Level of evidence, 3. Methods: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable. Results: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile’s increasing bone loss predictive of a worse functional outcome. Conclusion: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that “critical” bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.

Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction A Prospective, Randomized Clinical Study With a Minimum 10-Year Follow-up

Background: The use of allografts for anterior cruciate ligament (ACL) reconstruction in young athletes is controversial. No long-term results have been published comparing tibialis posterior allografts to hamstring autografts. Purpose: To evaluate the long-term results of primary ACL reconstruction using either an allograft or autograft. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: From June 2002 to August 2003, patients with a symptomatic ACL-deficient knee were randomized to receive either a hamstring autograft or tibialis posterior allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same postoperative rehabilitation protocol, which was blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephone and Internet-based questionnaire to ascertain the functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability, and functional status. Results: There were 99 patients (100 knees); 86 were men, and 95% were active-duty military. Both groups were similar in demographics and preoperative activity level. The mean and median ages of both groups were identical at 29 and 26 years, respectively. Concomitant meniscal and chondral pathologic abnormalities, microfracture, and meniscal repair performed at the time of reconstruction were similar in both groups. At a minimum of 10 years (range, 120-132 months) from surgery, 96 patients (97 knees) were contacted (2 patients were deceased, and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean Single Assessment Numeric Evaluation, Tegner, or International Knee Documentation Committee scores. Conclusion: At a minimum of 10 years after ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft failed at a rate over 3 times higher than those with an autograft.

Clavicular Bone Tunnel Malposition Leads to Early Failures in Coracoclavicular Ligament Reconstructions

Background: Modern techniques for the treatment of acromioclavicular (AC) joint dislocations have largely centered on free tendon graft reconstructions. Recent biomechanical studies have demonstrated that an anatomic reconstruction with 2 clavicular bone tunnels more closely matches the properties of native coracoclavicular (CC) ligaments than more traditional techniques. No study has analyzed tunnel position in regard to risk of early failure. Purpose: To evaluate the effect of clavicular tunnel position in CC ligament reconstruction as a risk of early failure. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was performed of a consecutive series of CC ligament reconstructions performed with 2 clavicular bone tunnels and a free tendon graft. The population was largely a young, active-duty military group of patients. Radiographs were analyzed for the maintenance of reduction and location of clavicular bone tunnels using a picture archiving and communication system. The distance from the lateral border of the clavicle to the center of each bone tunnel was divided by the total clavicular length to establish a ratio. Medical records were reviewed for operative details and functional outcome. Failure was defined as loss of intraoperative reduction. Results: The overall failure rate was 28.6% (8/28) at an average of 7.4 weeks postoperatively. Comparison of bone tunnel position showed that medialized bone tunnels were a significant predictor for early loss of reduction for the conoid (a ratio of 0.292 vs 0.248; P = .012) and trapezoid bone tunnels (a ratio of 0.171 vs 0.128; P = .004); this correlated to an average of 7 to 9 mm more medial in the reconstructions that failed. Reconstructions performed with a conoid ratio of ≥0.30 were significantly more likely to fail (5/5, 100%) than were those performed lateral to a ratio of 0.30 (3/23, 13.0%) (P < .01). There were no failures when the conoid ratio was <0.25 (0/10, 0%). Conoid tunnel placement was also statistically significant for predicting return to duty in our active-duty population. Conclusion: Medial tunnel placement is a significant factor in risk for early failures when performing anatomic CC ligament reconstructions. Preoperative templating is recommended to evaluate optimal placement of the clavicular bone tunnels. Placement of the conoid tunnel at 25% of the clavicular length from the lateral border of the clavicle is associated with a lower rate of lost reduction and a higher rate of return to military duty.

Early failures with single clavicular transosseous coracoclavicular ligament reconstruction

INTRODUCTION Coracoclavicular (CC) ligament reconstruction remains a challenging procedure. The ideal reconstruction is biomechanically strong, allows direct visualization of passage around the coracoid, and is minimally invasive. Few published reports have evaluated arthroscopic techniques with a single clavicular tunnel and transcoracoid reconstruction. One such report noted early excellent results, but without specific outcome measures. This study reports the clinical and radiographic results of a minimally invasive, arthroscopically assisted technique of CC ligament reconstruction using a transcoracoid and single clavicular tunnel technique. MATERIALS AND METHODS A retrospective review was performed of 10 consecutive repairs in 9 active duty patients who underwent CC ligament reconstruction with the GraftRope (Arthrex, Naples FL, USA). All reconstructions were performed according to the manufacturers technique by a single, fellowship-trained surgeon. Medical records and radiographs were evaluated for demographics, operative details, loss of reduction, and return to duty. RESULTS In 8 of 10 repairs (80%) intraoperative reduction was lost at an average of 7.0 weeks (range, 3-12 weeks). Four patients (40%) required revision. Subjective patient outcomes included 5 excellent/good results, 1 fair result, and 4 poor results. Tunnel widening was universally noted, and the failure mode in most patients appeared to be at the holding suture. CONCLUSION This transcoracoid, single clavicular tunnel technique was not a reliable approach to CC ligament reconstruction. We noted a high percentage of radiographic redisplacement and clinical failure. This technique, in its current form, cannot be recommended to treat AC joint injuries in our population.

Return to an Athletic Lifestyle After Osteochondral Allograft Transplantation of the Knee

Background: Osteochondral allograft transplantation (OATS) is a treatment option that provides the ability to restore large areas of hyaline cartilage anatomy and structure without donor site morbidity and promising results have been reported in returning patients to some previous activities. However, no study has reported on the durability of return to activity in a setting where it is an occupational requirement. Hypothesis: Osteochondral allograft transplantation is less successful in returning patients to activity in a population in which physical fitness is a job requirement as opposed to a recreational goal. Study Design: Case series; Level of evidence, 4. Methods: A retrospective review was conducted of 38 consecutive OATS procedures performed at a single military institution by 1 of 4 sports medicine fellowship–trained orthopaedic surgeons. All patients were on active duty at the time of the index procedure, and data were collected on demographics, return to duty, Knee Injury and Osteoarthritis Outcome Score (KOOS), and ultimate effect on military duty. Success was defined as the ability to return to the preinjury military occupational specialty (MOS) with no duty-limiting restrictions. Results: The mean lesion size treated was 487.0 ± 178.7 mm2. The overall rate of return to full duty was 28.9% (11/38). An additional 28.9% (11/38) were able to return to limited activity with permanent duty modifications. An alarming 42.1% (16/38) were unable to return to military activity because of their operative knee. When analyzed for return to sport, only 5.3% (2/38) of patients were able to return to their preinjury level. Eleven patients underwent concomitant procedures. Statistical power was maintained by analyzing data in aggregate for cases with versus without concomitant procedures. When the 11 undergoing concomitant procedures were removed from the data set, the rate of return to full activity was 33.3% (9/27), with 22.3% (6/27) returning to limited activity and 44.4% (12/27) unable to return to activity. In this subset, 7.4% (2/27) were able to return to a preinjury level of sport. The KOOS values were significantly higher in the full activity group when compared with the limited and no activity groups (P < .01). Branch of service was a significant predictor of outcome, with Marine Corps and Navy service members more likely to return to full activity compared with Army and Air Force members. A MOS of combat arms was a significant predictor of a poor outcome. All patients demonstrated postoperative healing of their grafts as documented in their medical chart, and no patient in the series required revision for problems with graft incorporation. Conclusion: Osteochondral allograft transplantation for the treatment of large chondral defects in the knee met with disappointing results in an active-duty population and was even less reliable in returning this population to preinjury sport levels. Branch of service and occupational type predicted the return to duty, but other traditional predictors of outcome such as rank and years of service did not. The presence of concomitant procedures did not have an effect on outcome with respect to activity or sport level with the numbers available for analysis.

Return to Duty After Elective Fasciotomy for Chronic Exertional Compartment Syndrome

Background: Civilian literature has reported excellent outcomes after elective fasciotomy for chronic exertional compartment syndrome (CECS). Our study’s purpose was to objectively investigate the functional outcome of fasciotomies performed for CECS in a high demand military population. Methods: A retrospective review of all fasciotomies performed for CECS at a single tertiary military medical center was performed. The primary outcome measure was the ability to return to full active duty. Diagnosis, operative technique, and number of compartments addressed were collected and analyzed. Patients were contacted and the visual analog scale (VAS) pain score, functional single assessment numeric evaluation (SANE) score, as well as overall satisfaction were reported. Return to duty status was collected on 70 of 70 (100%) consecutive operative extremities in 46 patients with an average follow-up of 26 months. Results: Only 19 patients (41.3%) were able to return to full active duty. Ten patients (21.7%) underwent a medical separation from the military and 17 patients (37%) remained in the military but were on restricted duty secondary to persistent leg pain. Thirty-five of 46 (76%) of the patients were contacted and provided subjective feedback. The average SANE score was 72.3, and there was a mean improvement of 4.4 points in VAS score postoperatively. Overall, 71% of patients were satisfied and would undergo the procedure again. Outcomes were correlated to operative technique, patient rank, and branch of military service. Conclusion: Our study showed a return to full military duty in 41% of patients who underwent elective fasciotomy for CECS. Overall 78% of patients remained in the military, which is consistent with previous military literature. Subjective satisfaction rate was 71%. Both the return to activity and subjective outcomes in our study population were substantially lower than reported results in civilian populations. Level of Evidence: Level IV, case series.

Predictive Value and Clinical Validation of the “On-Track” vs. “Off-Track” Concept in Bipolar Bone Loss in Anterior Glenohumeral Instability

Objectives: Bone loss is a well-described risk factor for failure with arthroscopic stabilization. The isolated importance of bone loss on both the glenoid and humeral side has been increasingly studied. A more recent evolution considers how both the glenoid and humeral bone loss interact to determine whether their combination results in an “on-track” or “off-track” lesion, which may be more predictive of recurrent instability than looking at either side individually. While the biomechanics of this concept have been elucidated, no study has tested this theory in a clinical population. The purpose of this study is to compare a series of arthroscopic Bankart reconstructions stratified by whether they are “on-track” or “off-track” with regard to bipolar bone loss and to compare their rates of recurrence and functional outcome scores. Methods: Over a two year period, all isolated, primary Bankart reconstructions performed at a single facility by one of three fellowship trained Orthopaedic Sports Surgeons were included in this study. All patients had preoperative advanced imaging and had postoperative outcome measures including SANE and WOSI scores, as well as data return to work status. Glenoid bone loss, Hill-Sachs lesion size and location, as well as a radiographic measurement of the glenoid track were measured. Patients were stratified according to whether they sustained a subsequent recurrence of their instability, and these groups were analyzed according to their bone loss status, specifically whether they were “on-track” or “off-track”. Results: 57 shoulders met inclusion criteria. The average age was 25.5 years (range 20-42) at the time of surgery. Average follow up was 28.4 mos. There were 10 recurrences (18%). Patients in the recurrent group had WOSI and SANE scores that were roughly half as good as the group that did not recur (p=0.003 and p=0.002 respectively). Of the 49 on-track patients, 4 (8.2%) failed. Conversely, of the 8 off-track patients, 6 (75%) failed (p=0.0001). Six of the 10 (60%) of the patients who sustained a recurrence of their instability after arthroscopic stabilization were off-track at the time of their surgery. In contrast, in the 47 patients who remained stable at latest follow-up, only 2 (4.3%) were off-track (p=0.0001). Eight of 47 patients (17%) in the non-recurrent group had glenoid bone loss greater than 20%; two of 47 stable patients (4%) were off-track. The positive predictive value (PPV) of the off-track measurement was 75% which was significantly higher than the predictive value of glenoid bone loss >20% (PPV=43%, p=0.02). Conclusion: This is the first study to apply the on-track vs. off-track assessment of bipolar bone loss to a clinical population. In this study, being off-track was a significant predictor of recurrent instability after isolated Bankart reconstruction, correctly predicting failure in 75% of cases. This was superior to the predictive value of glenoid bone loss >20% alone, which correctly predicted failure 43% of the time. Recurrence correlated with worse functional outcomes scores. Bipolar bone loss as measured by the track method is quite accurate in predicting success and failure after arthroscopic Bankart reconstruction in a clinical population. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.

Autograft vs Allograft ACL Reconstructions: A Prospective, Randomized Clinical Study with Minimum 10 Year Follow-up

Objectives: To evaluate the long-term results of primary Anterior Cruciate Ligament (ACL) reconstructions using either allograft or autograft. Methods: From June 2002 to August 2003, patients with a symptomatic ACL deficient knee were randomized to either hamstring autograft (AUTO) or tibialis posterior allograft (ALLO). All allografts were from a single tissue bank, aseptically processed and fresh frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same post-operative rehabilitation protocol, blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephonic and internet-based questionnaire to ascertain functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability and functional status. Results: There were 99 patients (100 knees); 87 were male and 95 active duty military. Both groups were similar in demographics and preoperative activity level. The mean and median age of both groups was identical at 29 and 26, respectively. Concomitant meniscal and chondral pathology, microfracture and meniscal repairs performed at the time of reconstruction were similar in both groups. At a minimum 10 years (range: 120-134 mos) from surgery, 96 pts (97 knees) were contacted (2 patients were deceased and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures which required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean SANE, Tegner, or IKDC scores. Conclusion: At a minimum of 10 years following ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft, failed at a rate over three times higher than those reconstructed with a autograft.

Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Outcomes in Arthroscopic Treatment.

Background: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported. Purpose: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized “perfect circle” technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability. Results: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts. Conclusion: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different.

Arthroscopic Repair of Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions Does Not Have an Increased Failure Rate Compared to Arthroscopic Bankart Repair

Objectives: Anterior labroligamentous periosteal sleeve avulsion lesions (ALPSA) have been identified as a potential risk factor for failure of an arthroscopic labral repair. The objective of this study was to compare the failure rates and clinical outcomes of arthroscopic ALPSA repair to arthroscopic Bankart repair. Additionally, the role of glenoid bone loss on failure rates was analyzed within each group. Methods: This was a retrospective review of 72 consecutive patients with anterior shoulder instability (73 shoulders) who underwent an anterior arthroscopic labral repair at a single military institution by one of three Sports medicine fellowship trained orthopaedic surgeons. At the time of surgery, a diagnostic arthroscopy identified 13 (17.8%) ALPSA lesions and 60 (82.2%) isolated Bankart lesions. All lesions were repaired and placed on standard post-operative protocol. Data was collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, SANE score, and recurrence rates. Failure was defined as recurrent dislocation. Additionally, glenoid bone loss in all patients was calculated using a standardized technique on preoperative images. Outcomes were analyzed by type of initial lesion. The effect of bone loss on failure rate was analyzed between and within groups. Results: The average age at surgery was 26.3 years (range, 20-42) with an average follow-up of 53.3 months (range, 28-63). There were 13 distinct ALPSA lesions and 60 Bankart lesions identified on diagnostic arthroscopy. There were no significant differences between groups with respect to any demographic data. There was 1 failure (7.7%) in the ALSPA group and 8 failures (13.3%) in the Bankart group (p=0.10). There was no significant difference between groups for WOSI or SANE scores. There was no significant difference in glenoid bone loss between groups. The ALPSA group had 13.1% glenoid bone loss compared to 13.5% in the Bankart group (p=0.88). Conclusion: Contrary to previously published data, we did not find patients with ALPSA lesions to be at an increased risk for failure of an arthroscopic repair compared to an isolated Bankart repair, nor was there a difference in functional outcomes between groups. Finally, the presence of an ALPSA lesion was not predictive on increased glenoid bone loss in this population.