Jay J. Irrgang

Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study.

Background: Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift. Methods: Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery. Results: There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures. Conclusions: Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.

Treatment of osteoarthritis of the knee (nonarthroplasty).

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Interobserver reliability of the international society of arthroscopy, knee surgery and orthopaedic sports medicine (ISAKOS) classification of meniscal tears

Background: Consistency of arthroscopic evaluation and documentation in meniscal tears between investigators is essential to the validity of multicenter studies. A group of experts developed a classification of meniscal tears that may be used internationally. Hypothesis: The International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine (ISAKOS) classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears. Study Design: Cohort study (diagnosis); Level of evidence, 1. Methods: A pilot study was performed by having 8 members of the committee grade 10 arthroscopic videos for classification of tear depth, rim width, location, tear pattern, and quality of the tissue. The results of the pilot study were used to change the instruction sheet and evaluation form. International interobserver reliability was determined by having 8 orthopaedic surgeons who practice in different countries evaluate 37 arthroscopic videos selected to represent different meniscal tear characteristics. The Spearman ρ correlation coefficient was used to compare the area of the meniscus excised, as drawn on the diagram, with the numeric percentage of meniscus excised. Results: There was an 87% agreement for anterior-posterior location of the tear (κ = .65); 79% agreement for tear pattern (κ = .72); 88% agreement for tear depth (κ = .52); 68% agreement for anterior, middle, and posterior location of the tear (κ = .46); and 72% agreement for tissue quality (κ = .47). There was 54% agreement for the rim width (κ = .25) and 67% agreement if the tear was central to the popliteal hiatus (κ = .36). Based on the Landis and Koch criteria for κ coefficients, there was substantial agreement for anterior-posterior location of the tear and tear pattern; moderate agreement for tear depth, anterior, middle, and posterior location of the tear, and tissue quality; and fair agreement for rim width and if the tear was central to the popliteal tear. Interobserver reliability based on the intraclass correlation coefficient (ICC) was good for tear length (ICC = .83) and moderate for percentage of meniscus that was excised (ICC = .65). The mean ρ for all raters was .92 (95% confidence interval [CI], .89-.94) comparing the values for percentage of meniscus excised with the area on the diagrams. Conclusion: The ISAKOS classification of meniscal tears provides sufficient interobserver reliability for pooling of data from international clinical trials designed to evaluate the outcomes of treatment for meniscal tears.

ICRS Recommendation Document: Patient-Reported Outcome Instruments for Use in Patients with Articular Cartilage Defects.

Objective: The purpose of this article is to describe and recommend patient-reported outcome instruments for use in patients with articular cartilage lesions undergoing cartilage repair interventions. Methods: Nonsystematic literature search identifying measures addressing pain and function evaluated for validity and psychometric properties in patients with articular cartilage lesions. Results: The knee-specific instruments, titled the International Knee Documentation Committee Subjective Knee Form and the Knee injury and Osteoarthritis and Outcome Score, both fulfill the basic requirements for reliability, validity, and responsiveness in cartilage repair patients. A major difference between them is that the former results in a single score and the latter results in 5 subscores. A single score is preferred for simplicity’s sake, whereas subscores allow for evaluation of separate constructs at all levels according to the International Classification of Functioning. Conclusions: Because there is no obvious superiority of either instrument at this time, both outcome measures are recommended for use in cartilage repair. Rescaling of the Lysholm Scoring Scale has been suggested, and confirmatory longitudinal studies are needed prior to recommending this scale for use in cartilage repair. Inclusion of a generic measure is feasible in cartilage repair studies and allows analysis of health-related quality of life and health economic outcomes. The Marx or Tegner Activity Rating Scales are feasible and have been evaluated in patients with knee injuries. However, activity measures require age and sex adjustment, and data are lacking in people with cartilage repair.

Hamstring Injuries in Professional Football Players: Magnetic Resonance Imaging Correlation With Return to Play

Background: Magnetic resonance imaging (MRI) allows for detailed evaluation of hamstring injuries; however, there is no classification that allows prediction of return to play. Purpose: To correlate time for return to play in professional football players with MRI findings after acute hamstring strains and to create an MRI scoring scale predictive of return to sports. Study Design: Descriptive epidemiologic study. Methods: Thirty-eight professional football players (43 cases) sustained acute hamstring strains with MRI evaluation. Records were retrospectively reviewed, and MRIs were evaluated by 2 musculoskeletal radiologists, graded with a traditional radiologic grade, and scored with a new MRI score. Results were correlated with games missed. Results: Players missed 2.6 ± 3.1 games. Based on MRI, the hamstring injury involved the biceps femoris long head in 34 cases and the proximal and distal hamstrings in 25 and 22 cases, respectively. When < 50% of the muscle was involved, the average number of games missed was 1.8; if > 75%, then 3.2. Ten players had retraction, missing 5.5 games. By MRI, grade I injuries yielded an average of 1.1 missed games; grade II, 1.7; and grade III, 6.4. Players who missed 0 or 1 game had an MRI score of 8.2; 2 or 3 games, 11.1; and 4 or more games, 13.9. Conclusions: Rapid return to play (< 1 week) occurred with isolated long head of biceps femoris injures with < 50% of involvement and minimal perimuscular edema, correlating to grade I radiologic strain (MRI score < 10). Prolonged recovery (missing > 2 or 3 games) occurs with multiple muscle injury, injuries distal to musculotendinous junction, short head of biceps injury, > 75% involvement, retraction, circumferential edema, and grade III radiologic strain (MRI score > 15). Clinical Relevance: MRI grade and this new MRI score are useful in determining severity of injury and games missed—and, ideally, predicting time missed from sports.