Jonathan M. Frank

Utility of Modern Arthroscopic Simulator Training Models

PURPOSE The purpose of this study was to review the published literature on modern arthroscopic simulator training models to (1) determine the ability to transfer skills learned on the model to the operating room and (2) determine the learning curve required to translate such skills. METHODS A systematic review of all studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed. Two independent reviewers then analyzed studies deemed appropriate for inclusion. Study data collected included participant demographic characteristics, simulator model, type and number of tasks, method of analysis, and results of training, when available. Given the different methods used in each study, descriptive analysis was performed. RESULTS Nineteen studies met the inclusion criteria (9 shoulder, 9 knee, and 1 hip). A total of 465 participants with a mean age of 30 years were evaluated. Twelve studies (63%) compared task performance among participants of different experience levels, with 100% reporting a positive correlation between experience level and simulator performance. Eight studies (42%) evaluated task performance before and after simulator training, with 6 studies showing improvement after training; 1 study noted no difference in performance after 1 hour of training. One study commented on improved operating room performance after simulator training. No studies commented on the number of training sessions needed to translate skills learned on the models to the operating room. CONCLUSIONS This review suggests that practice on arthroscopic simulators improves performance on arthroscopic simulators. We cannot, however, definitively comment on whether simulator training correlates to an improved skill set in the operating room. Further work is needed to determine the type and number of training sessions needed to translate arthroscopic skills learned on the models to the operating room. LEVEL OF EVIDENCE Level IV, systematic review of studies with Level I through IV evidence.

Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: A systematic review

We conducted a systematic review of studies reporting clinical outcomes after proximal row carpectomy or to four-corner arthrodesis for scaphoid non-union advanced collapse or scapholunate advanced collapse arthritis. Seven studies (Levels I–III; 240 patients, 242 wrists) were evaluated. Significantly different post-operative values were as follows for four-corner arthrodesis versus proximal row carpectomy groups: wrist extension, 39 (SD 11º) versus 43 (SD 11º); wrist flexion, 32 (SD 10º) versus 36 (SD 11º); flexion-extension arc, 62 (SD 14º) versus 75 (SD 10º); radial deviation, 14 (SD 5º) versus 10 (SD 5º); hand grip strength as a percentage of contralateral side, 74% (SD 13) versus 67% (SD 16); overall complication rate, 29% versus 14%. The most common post-operative complications were non-union (grouped incidence, 7%) after four-corner arthrodesis and synovitis and clinically significant oedema (3.1%) after proximal row carpectomy. Radial deviation and post-operative hand grip strength (as a percentage of the contralateral side) were significantly better after four-corner arthrodesis. Four-corner arthrodesis gave significantly greater post-operative radial deviation and grip strength as a percentage of the opposite side. Wrist flexion, extension, and the flexion-extension arc were better after proximal row carpectomy, which also had a lower overall complication rate. Level of evidence: Level III (Level I-III studies), Systematic Review. Therapeutic.

Return to Sport Following Shoulder Surgery in the Elite Pitcher: A Systematic Review

Context: The ability to return to elite pitching, performance, and clinical outcomes of shoulder surgery in elite baseball pitchers are not definitively established. Objective: To determine (1) the rate of return to sport (RTS) in elite pitchers following shoulder surgery, (2) postoperative clinical outcomes upon RTS, and (3) performance upon RTS and to compare RTS rates in different types of shoulder surgery. Data Sources: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched. Study Selection: Levels I-IV evidence were eligible for inclusion if performance-based (eg, RTS) and/or clinical outcome–based reporting of outcomes were reported following surgical treatment of shoulder pathology in elite pitchers (major or minor league or collegiate). Data Extraction: Subject, shoulder, and pre- and postoperative performance-based variables of interest were extracted. All shoulder surgery types were potentially inclusive (eg, open, arthroscopic, rotator cuff, labrum, biceps, acromioclavicular joint, fracture). Study methodological quality was analyzed using the Modified Coleman Methodology Score (MCMS). Results: Six studies were analyzed (287 elite male pitchers [mean age, 27 years] who underwent shoulder surgery, with 99% on the dominant, throwing shoulder). MCMS was 38 (poor). Most pitchers were professional, with a mean career length of 6.58 years and postoperative clinical follow-up of 3.62 years. In 5 of 6 studies, multiple diagnoses were addressed concomitantly at surgery. Rate of RTS was 68% at mean 12 months following surgery. Twenty-two percent of Major League Baseball (MLB) pitchers never RTS in MLB. Overall performance did improve following surgery; however, this did not improve to pre-injury levels. Conclusion: In this systematic review, the rate of return to elite baseball pitching following surgery was established. Performance tended to decrease prior to surgery and gradually improve postoperatively, though not reaching pre-injury levels of pitching. Level of Evidence: IV (systematic review of studies level I-IV evidence), therapeutic.

The Role of Acromioplasty for Rotator Cuff Problems

Acromioplasty is a well-described technique used throughout the wide spectrum of treatment options for shoulder impingement and rotator cuff pathology. Several randomized prospective studies have described clinical outcomes that are statistically similar when comparing patients undergoing rotator cuff repair either with or without concomitant acromioplasty. This article reviews the current evidence for use of acromioplasty in patients with subacromial impingement syndrome and during arthroscopic rotator cuff repair. Despite recently published studies, more long-term data, especially with regard to failure rates and return-to-surgery rates over time, are needed to better determine the role of acromioplasty.

Genome-wide analysis identifies differential promoter methylation of Leprel2, Foxf1, Mmp25, Igfbp6, and Peg12 in murine tendinopathy

We have used a murine Achilles tendinopathy model to investigate whether tissue changes (such as collagen disorganization, chondroid metaplasia, and loss of tensile properties) which are broadly characteristic of human tendinopathies, are accompanied by changes in the expression of chromatin‐modifying enzymes and the methylation status of promoter regions of tendon cell DNA. Tendinopathy was induced by two intra‐tendinous TGF‐β1 injections followed by cage activity or treadmill running for up to 28 days. Activation of DNA methyltransferases occurred at 3 days after the TGF‐β1 injections and also at 14 days, but only with treadmill activity. Genome‐wide Methyl Mini‐Seq™ analysis identified 19 genes with differentially methylated promoters, five of which perform functions with an apparent direct relevance to tendinopathy (Leprel2, Foxf1, Mmp25, Igfbp6, and Peg12). The functions of the genes identified included collagen fiber assembly and pericellular interactions, therefore their perturbation could play a role in the characteristic disorganization of fibers in affected tendons. We postulate that a study of the functional genomics of these genes in animal and human tendon could further delineate the pathogenesis of this multi‐factorial complex disease.

Treatment of Osteonecrosis of the Talus

More than 60% of the talar surface area consists of articular cartilage, thereby limiting the possible locations for vascular infiltration and leaving the talus vulnerable to osteonecrosis.Treatment strategies for talar osteonecrosis can be grouped into four categories: nonsurgical, surgical-joint sparing, surgical-salvage, and joint-sacrificing treatments. Nonoperative and joint-sparing treatments include restricted weight-bearing, patellar tendon-bearing braces, bone-grafting, extracorporeal shock wave therapy, internal implantation of a bone stimulator, core decompression, and vascularized or non-vascularized autograft, whereas joint-sacrificing or salvage procedures include talar replacement (partial or total) and arthrodesis.In patients with a Ficat and Arlet grade-I through III osteonecrosis, evidence in favor of a specific treatment is poor, although tibiotalar or tibiotalocalcaneal arthrodesis may represent a suitable salvage operation.

Two cases of avascular necrosis after prophylactic pinning of the asymptomatic, contralateral femoral head for slipped capital femoral epiphysis: case report and review of the literature.

Background: In a child with a unilateral slipped capital femoral epiphysis (SCFE), the treatment of the radiographically normal, asymptomatic contralateral hip remains controversial. The risks of a subsequent slip have to be measured against the risks involved with an additional surgical procedure. Proponents of prophylactic pinning believe that fixation with a single cannulated screw is a safe method to prevent secondary arthrosis from a missed minor slip. Others argue that in most cases it is an unnecessary procedure and with careful follow-up, any issues with the asymptomatic, normal hip can be identified early and addressed. Methods: We retrospectively look at 2 cases where avascular necrosis (AVN) developed in the prophylactically pinned asymptomatic and radiographically normal hip in the setting of an identified SCFE on the contralateral hip. Results: Two cases of AVN developed in the prophylactically pinned hips within 8 months of the initial pinning procedure. Conclusions: This case report demonstrates that prophylactic pinning of an asymptomatic, radiographically normal hip in the setting of a SCFE on the contralateral side is not a benign procedure and is one that has potential for significant complications. The risk of AVN in the prophylactically pinned hip needs to be taken into careful consideration as this risk can have devastating consequences to the patient. Level of Evidence: Level IV.

Articular shear injuries of the capitellum in adolescents

BACKGROUND Fractures of the capitellum are rare and are commonly classified into 4 types. Type II variants involve a shear injury with a mostly articular cartilage component and little subchondral bone. Symptoms upon presentation after these injuries are variable, and the diagnosis can be difficult to make in the immature skeleton. METHODS We retrospectively reviewed 3 cases of type II capitellar fractures in adolescent athletes who presented for evaluation with the senior author. RESULTS All patients were initially treated conservatively, without identification or treatment of the capitellar shear component of their injury. Unfortunately, radiocapitellar arthrosis rapidly developed in all 3 and required surgical intervention at our institution. At an average postoperative follow-up of 49 months from the index procedure, patients ultimately had positive outcomes despite advanced degenerative changes on imaging. One patient required 2 subsequent operations for mechanical symptoms and pain. DISCUSSION The 3 reported cases represent adolescent, athletic patients with missed shear injuries to the capitellum. These patients exhibited low Disabilities of Arm, Shoulder and Hand scores and high Mayo Elbow Performance Scores at final follow-up, but each patient demonstrated advanced degenerative changes on imaging, and 1 patient required 2 subsequent operations for mechanical symptoms and pain. A high index of suspicion is necessary to identify this injury pattern, and proper plain radiographic imaging with a low threshold for advanced imaging is necessary. Although the overall long-term prognosis is unknown for these patients, early recognition likely would have changed the initial conservative management decision in each and, theoretically, might have altered the outcome for these patients.

Synovial Chondromatosis of the Elbow With Asymptomatic Ulnar Nerve Compression

Primary synovial chondromatosis is a rare, benign, proliferative disease of hyaline cartilaginous bodies within the synovium of joints. We report a rare case of primary synovial chondromatosis diffusely affecting the ulnohumeral joint causing pain and motion limitations with extrusion into the cubital tunnel and compressing the ulnar nerve but without any preoperative signs or symptoms of ulnar nerve compression. The patient was successfully treated with an open synovectomy to limit disease progression and improve motion. This case highlights that synovial conditions of the elbow may involve the ulnar nerve even when a patient is asymptomatic. Preoperative use of magnetic resonance imaging of the elbow should be considered in patients undergoing either an open or arthroscopic synovectomy.

Acute Postoperative Renal Failure Following Insertion of an Antibiotic-Impregnated Cement Spacer in Revision Total Joint Arthroplasty

Chronic periprosthetic infection is one of the most feared and difficult to treat complications of total joint arthroplasty1-3. Although treatment is controversial, a two-stage revision with interim placement of an antibiotic-impregnated polymethylmethacrylate (PMMA) spacer is considered the so-called “gold standard4-6.” Vancomycin and tobramycin are two of the most common antibiotics admixed with PMMA. Spacers with this combination of antibiotics have been demonstrated to elute bactericidal concentrations of antibiotics locally7-10. While systemic concentrations of antibiotic used in this technique are generally low8,9,11-13, several factors can lead to high serum concentrations, including the amount of antibiotic implanted14, combining vancomycin and an aminoglycoside10,15, and manual mixing, which causes variation in elution pharmacodynamics15. Both vancomycin and tobramycin have been associated with renal failure when used systemically in 13.5% (thirty-nine of 289) and 12.9% (275 of 2130) of cases, respectively16,17; there is a synergistic effect when both are used concurrently18,19. To the best of our knowledge, although previous series have not demonstrated nephrotoxicity when these antibiotics were used in PMMA spacers8,13-15,20, previous case reports have21-24. In this report, we present two cases of nephrotoxicity and elevated serum tobramycin levels that developed after the implantation of a PMMA spacer with high doses of vancomycin and tobramycin. Improvement in renal function occurred following removal of the spacers. Both patients were informed that data concerning their cases would be submitted for publication, and they provided consent. Case 1. A seventy-seven-year-old woman with a history of hypertension, gout, a seizure disorder, and a right total knee arthroplasty presented to our …