Kevin B. Freedman

Arthroscopic Anterior Cruciate Ligament Reconstruction A Metaanalysis Comparing Patellar Tendon and Hamstring Tendon Autografts

Background The best choice of graft tissue for use in anterior cruciate ligament reconstruction has been the subject of debate. Hypothesis: Anterior cruciate ligament reconstruction with patellar tendon autograft leads to greater knee stability than reconstruction with hamstring tendon autograft. Study Design Metaanalysis. Methods A Medline search identified articles published from January 1966 to May 2000 describing arthroscopic anterior cruciate ligament reconstruction with either patellar tendon or hamstring tendon autograft and with a minimum patient follow-up of 24 months. Results There were 1348 patients in the patellar tendon group (21 studies) and 628 patients in the hamstring tendon group (13 studies). The rate of graft failure in the patellar tendon group was significantly lower (1.9% versus 4.9%) and a significantly higher proportion of patients in the patellar tendon group had a side-to-side difference of less than 3 mm on KT-1000 arthrometer testing than in the hamstring tendon group (79% versus 73.8%). There was a higher rate of manipulation under anesthesia or lysis of adhesions (6.3% versus 3.3%) and of anterior knee pain in the patellar tendon group (17.4% versus 11.5%) and a higher incidence of hardware removal in the hamstring tendon group (5.5% versus 3.1%). Conclusions Patellar tendon autografts had a significantly lower rate of graft failure and resulted in better static knee stability and increased patient satisfaction compared with hamstring tendon autografts. However, patellar tendon autograft reconstructions resulted in an increased rate of anterior knee pain.

Treatment of osteoporosis: are physicians missing an opportunity?

Background: Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius. Methods: A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture. Results: A search of the database identified 1162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001). Conclusions: Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

Anterior Cruciate Ligament Reconstruction Autograft Choice: Bone-Tendon-Bone Versus Hamstring Does It Really Matter? A Systematic Review

Anterior cruciate ligament graft choice is controversial, with no evidence-based consensus available to guide decision making. The study design was evidence-based medicine systematic review of randomized controlled trials evaluating patellar tendon versus hamstring tendon autografts. A literature review identified 9 randomized controlled trials comparing patellar tendon and hamstring tendon autografts. An evidence-based systematic review was performed. Objective and subjective outcomes of interest included surgical technique, rehabilitation, instrumented laxity, isokinetic strength, patellofemoral pain, return to preinjury activity, and Tegner, Lysholm, Cincinnati, and International Knee Documentation Committee–1991 scores. Additional surgery, graft failure, and complications were reviewed. Slight increased laxity on arthrometer testing was seen in the hamstring population in 3 of 7 studies. Pain with kneeling was greater for the patellar tendon population in 4 of 4 studies. Only 1 of 9 studies showed increased anterior knee pain in the patellar tendon group. Frequency of additional surgery seemed to be related to the fixation method and not graft type. No study reported a significant difference in graft failure between patellar tendon and hamstring tendon autografts. Objective differences (range of motion, isokinetic strength, arthrometer testing) were not detected between groups in the majority of studies, suggesting that their sensitivity to detect clinical outcomes may be limited. Increased kneeling pain in the patellar tendon group was seen consistently in the studies evaluated. Subjective differences in anterior knee pain or return-to-activity level were not consistently observed in these studies. With numbers available, failure rates were not significantly different between groups. These findings suggest that graft type may not be the primary determinant for successful outcomes after anterior cruciate ligament surgery.

Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder : a meta-analysis

Background In published comparative studies, it remains unknown if arthroscopic techniques for performing Bankart repair for anterior shoulder instability equal the success of open repair. Hypothesis The current literature supports a lower rate of recurrent instability after open Bankart repair compared to arthro-scopic repair with bioabsorbable tacks or transglenoid sutures. Study Design Meta-analysis. Methods A Medline search identified all randomized controlled trials or cohort studies that directly compared open repair to arthroscopic techniques of Bankart repair for traumatic, unilateral, recurrent anterior instability. Data collected from each study included patient demographics, surgical technique, rehabilitation, outcome, and complications. Results Six studies met all inclusion criteria. There were 172 patients in the arthroscopic group (90 patients with transglenoid sutures, 77 patients with arthroscopic tacks, and 5 patients with suture anchors) and 156 patients in the open group. The groups were similar in demographic characteristics. When comparing the arthroscopic to the open group, there was a significantly higher rate of recurrent dislocation (12.6% vs 3.4%; P = .01) and total recurrence (recurrent dislocation or subluxation) (20.3% vs 10.3%; P = .01). In addition, there was a higher proportion of patients with an excellent or good postoperative Rowe score in the open group (88%) than in the arthroscopic group (71%) (P = .01). Conclusions Arthroscopic Bankart repair using transglenoid sutures or bioabsorbable tacks results in a higher rate of recurrence of instability compared to open techniques. Studies comparing open repair to newer arthroscopic techniques using suture anchor fixation and capsular plication are necessary.

The Effect of Corticosteroid on Collagen Expression in Injured Rotator Cuff Tendon

BACKGROUND Subacromial corticosteroid injections are commonly used in the nonoperative management of rotator cuff disease. The effects of corticosteroid injection on injured rotator cuff tendons have not been studied. Our aims were to characterize the acute response of rotator cuff tendons to injury through the analysis of the type-III to type-I collagen expression ratio, a tendon injury marker, and to examine the effects of corticosteroid on this response. METHODS Sixty Sprague-Dawley rats were randomly assigned to four groups: control, tendon injury, steroid treatment, and tendon injury and steroid treatment. Six rats served as sham controls. Unilateral tendon injuries were created with full-thickness defects across 50% of the total width of the infraspinatus tendon, 5 mm from its humeral insertion. Steroid treatment with a single dose of methylprednisolone (0.6 mg/kg), equivalent to that given to humans, was injected into the subacromial space under direct visualization. Steroid treatment followed the creation of an injury in the rats in the injury and steroid treatment group. At one, three, and five weeks after the injury, the total RNA isolated from tendons was quantified with real-time polymerase chain reaction with use of primers for type-I and type-III collagen and ribosomal 18s RNA. RESULTS The type-III to type-I collagen expression ratio remained at baseline at all time-points in the control and sham groups. At one week, the type-III to type-I collagen expression ratio increased more than fourfold above the control level in the tendon injury group (p = 0.017) and the tendon injury and steroid treatment group (p = 0.003). The ratio remained greater than twofold above the control at three weeks in both groups (p = 0.003 and p = 0.037) and returned to baseline at five weeks. Interestingly, the group that had steroid treatment only showed an increase of >4.5-fold (p = 0.001) in the type-III to type-I collagen expression ratio, without structural injury to the tendon. This ratio returned to baseline levels by three weeks. CONCLUSIONS A single dose of corticosteroid does not alter the acute phase response of an injured rotator cuff tendon in the rat. However, the same steroid dose in uninjured tendons initiates a short-term response equivalent to that of structural injury.

Marrow stimulating technique to augment meniscus repair

Several techniques exist to increase the rate of healing of meniscal tears after repair. We describe a simple arthroscopic technique of microfracture to the intercondylar notch. This technique can provide marrow elements to the site of meniscus repair to aid in meniscal healing at the time of repair.

Comparison of a Novel FiberWire-Button Construct versus Metallic Screw Fixation in a Syndesmotic Injury Model

Background: There is minimal experience with less rigid syndesmotic fixation devices which may approximate the normal distal tibio-fibular mechanics during healing. This study evaluates the ability of a FiberWire-button implant (Arthrex, Naples, FL) to maintain syndesmotic reduction as compared with a metallic screw. Methods: Ten matched fresh-frozen cadaveric ankle pairs with intact ligaments were tested (12.5 Nm external rotation force) to establish physiologic syndesmotic diastasis. The same force was applied to the ankles after sectioning of the syndesmotic and deltoid ligaments. Within the pairs, each limb was randomized to receive a FiberWire-button implant or a metallic screw (Synthes, Paoli, PA); the ankles were tested for syndesmotic diastasis with progressive external rotation force, from 2.5 Nm to 25 Nm (or failure). Results: There was no significant difference in diastasis amongst pairs with intact or sectioned syndesmosis (p = 0.64 and p = 0.80, respectively). There was a significantly greater diastasis in the FiberWire-button group at all external rotation loads (p < 0.0001). Nine of the ten pairs failed (all through fracture of the distal fibula). There were no hardware failures. The metallic screw group failed at a lower load (mean 15 Nm) compared to the FiberWire-button group (mean 18 Nm, p = 0.0004). The metallic screw group maintained syndesmotic reduction up to 5 Nm of force. Conclusions: The FiberWire-button was unable to maintain syndesmotic reduction of the ankles at any of the forces applied. The ankles fixed with the FiberWire-button demonstrated significantly greater widening of the syndesmosis compared to the screw, at all loads. Clinical Relevance: The FiberWire-button implant may not maintain adequate ankle syndesmotic reduction in the immediate post-operative period relative to a metallic screw.

Autologous Chondrocyte Implantation in the Knee

Overview The purpose of this document is to describe the guidelines Neighborhood Health Plan (NHP) utilizes to determine the medical appropriateness for autologous chondrocyte implantation (ACI) for repairing cartilage defects of the knee. NHP may also consider FDA-approved matrix-induced chondrocyte implantation (e.g., MACI®, Vericel) as an acceptable alternative to autologous cultured chondrocytes (e.g., Carticel®) under the conditions listed in the coverage guidelines below. The treating specialist must request prior authorization for this procedure.

Cost Benefit Analysis of Sports Medicine Team Coverage: Is It Worth Our While?

Objectives: Coverage of high school athletic football by orthopaedic sports medicine specialists is considered standard of care in many localities. Taking time away from an orthopaedic practice to provide on field athletic care has potential advantages and disadvantages. Determining the economic viability of this endeavor has never been investigated. The purpose of the present investigation was to perform a cost/benefit risk analysis of local high school sports coverage by an orthopaedic sports medicine practice. Methods: From January 2010 to June 2012, a prospective injury report database was used to collect sports injuries from five high school athletic programs covered by a single orthopaedic sports medicine practice. Patients referred for orthopaedic care were then tracked to determine ultimate cost of care (potential revenue). Evaluation and management codes and current procedure terminology codes were obtained to determine the value of physician visits and surgical care rendered using standardized Medicare reimbursement rates. Total values were also analyzed in respect to visits and surgical treatments for the covering practice during this time period. Direct costs were estimated based on physician time required for team coverage and hourly reimbursement rates for orthopaedic surgeons, based on previously reported hourly reimbursement rates. Results: 19,165 athletic trainer evaluations resulted in 473 (2.5%) physician referrals. 185 (39%) of these referrals were to an orthopaedic surgeon. Of the physician referrals, 26 (5.4%) required orthopaedic surgical treatment. The covering team practice handled 89/185 (48%) of the orthopaedic referrals, and handled 17/26 (65%) of the patients that required surgical treatment. The total cost of orthopaedic care for the athletes requiring treatment was

The Adequacy of Medical School Education in Musculoskeletal Medicine

44,239.94 (total potential revenue). The total revenue collected by the covering team practice was