Leslie J. Bisson

Which Method of Rotator Cuff Repair Leads to the Highest Rate of Structural Healing? A Systematic Review

Background The purpose of rotator cuff repair is to diminish pain and restore function, and this most predictably occurs when the tendon is demonstrated to heal. Recent improvements in repair methods have led to improved biomechanical performance, but this has not yet been demonstrated to result in higher healing rates. The purpose of our study was to determine whether different repair methods resulted in different rates of recurrent tearing after surgery. Hypotheses We hypothesized that (1) the rotator cuff repair method will not affect retear rate, and (2) the surgical approach will not affect the retear rate for a given repair method. Study Design Systematic review of the literature. Methods The literature was systematically searched to find articles reporting imaging study assessment of structural healing rates after rotator cuff repair, with data stratified according to tear size. Retear rates were compared for transosseous (TO), single-row suture anchor (SA), double-row suture anchor (DA), and suture bridge (SB) repair methods, as well as for open (O), miniopen (MO), and arthroscopic (A) approaches. Results Retear rates were available for 1252 repairs collected from 23 studies. Retear rates were significantly lower for double-row repairs when compared with TO or SA for all tears greater than 1 cm and ranged from 7% for tears less than 1 cm to 41% for tears greater than 5 cm, in comparison with retear rates for single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than 5 cm, respectively. There was no significant difference in retear rates between TO and SA repair methods or between arthroscopic and nonarthroscopic approaches for any tear size. Conclusion Double-row repair methods lead to significantly lower retear rates when compared with single-row methods for tears greater than 1 cm. Surgical approach has no significant effect on retear rate.

Operative Versus Nonoperative Management of Acute Achilles Tendon Ruptures A Quantitative Systematic Review of Randomized Controlled Trials

Background: Despite several randomized controlled trials comparing operative to nonoperative management of Achilles tendon ruptures, the optimal management of this condition remains the subject of significant debate. Rerupture is a known complication, but most level I studies have not shown a significant difference in the incidence of reruptures when comparing operative to nonoperative management. Purpose: The goal of this systematic review was to identify all randomized controlled trials comparing operative and nonoperative management of Achilles tendon ruptures and to meta-analyze the data with reruptures being the primary outcome. Secondary outcomes including strength, time to return to work, and other complications were analyzed as well. Study Design: Meta-analysis. Methods: We searched multiple online databases to identify English-language, prospective randomized controlled trials comparing open surgical repair of acute Achilles tendon ruptures to nonoperative management. Rerupture was our primary outcome. Secondary outcomes included strength, time to return to work, deep infections, sural nerve sensory disturbances, noncosmetic scar complaints, and deep venous thrombosis. Coleman methodology scores were calculated for each included study. Data were extracted from all qualifying articles and, when appropriate, pooled and meta-analyzed. Results: Seven level I trials involving 677 patients met inclusion criteria. Coleman scores were 95, 95, 95, 89, 78, 97, and 92. Open repair was associated with a significantly lower rerupture rate compared with nonoperative treatment (3.6% vs 8.8%; odds ratio, 0.425; 95% confidence interval, 0.222-0.815). The incidence of deep infections was significantly higher for patients treated with surgery (P = .0113). The incidences of noncosmetic scar complaints and sural nerve sensory disturbances were also significantly higher in patients treated with surgery (P < .001 for each). Strength measurements were not standardized and therefore could not be meta-analyzed. Conclusion: Open surgical repair of acute Achilles tendon ruptures significantly reduces the risk of reruptures when compared with nonoperative management. Several other complications, which are clearly avoided with nonoperative treatment, occur with a significantly higher incidence when surgical repair is performed. The available literature makes it difficult to compare the return of strength in the involved lower extremity after operative or nonoperative management. Future studies may focus on testing strength in a more functional and reproducible manner than isokinetic testing.

Repair of the Ruptured Distal Biceps Tendon A Systematic Review

Background Reinsertion of the acutely ruptured distal biceps is the preferred method of treatment for most patients and is designed to restore flexion and supination strength. It is not clear which, if any, method of fixation is superior or whether a 2-incision or single-incision approach is associated with fewer complications or better outcomes. Hypotheses (1) There is no difference in biomechanical performance between currently used fixation methods, (2) there is no difference in incidence of complications between the 2-incision and single-incision approach, and (3) there is no difference in clinical outcomes between the 2-incision and single-incision approach. Study Design Systematic review; Level of evidence, 4. Methods The authors performed a systematic review of the literature studying treatment of the ruptured distal biceps tendon to determine optimal fixation method as well as surgical approach with lowest incidence of complications and highest proportion of satisfactory results. Results The review identified 8 articles that had relevant biomechanical data, 23 with relevant complication data, and 19 with relevant clinical results data. EndoButton fixation performed best in comparative biomechanical studies. There was no difference in overall incidence of complications between 2-incision approaches (16%) and single-incision approaches (18%), but there were significantly more instances of significant loss of forearm rotation with the 2-incision approach. There were significantly more unsatisfactory clinical results in the 2-incision repair group (31 % vs 6%; odds ratio, 7.6; 95% confidence interval, 3.2-17.7), with the majority of unsatisfactory results in the 2-incision group due to loss of forearm rotation or rotational strength. Conclusion EndoButton fixation has the highest load and stiffness of currently available fixation methods. Two-incision repairs have a significantly greater proportion of unsatisfactory results than do single-incision repairs.

ACL Reconstruction in Children With Open Physes

Nine male patients with wide open physes who underwent intra-articular anterior cruciate ligament (ACL) reconstruction using semitendinosus and gracilis tendon grafts passed through the tibial physis and over the top of the femoral condyles were retrospectively reviewed at an average follow-up of 39 months (range: 24 to 72 months). Five patients underwent reconstruction < 6 weeks following injury (range: 11 days to 41 days); the other four underwent reconstruction 2, 3, 5, and 24 months following injury. Seven patients had excellent results and fully returned to their sport. Mean Lysholm score in these patients was 99 (range: 95 to 100), and the mean maximum KT-1000 difference (available for six patients) was 2.8 mm (range: 0 to 5.5 mm). Four of six intact grafts had a mean maximum KT-1000 difference < or = 3.5 mm. Two grafts ruptured and were considered failures (one complete rupture at 10 months and one partial rupture at 3 years). Postoperative height increase averaged 10.7 cm (range: 4 to 22.9 cm). No patient had a clinically significant leg-length discrepancy, angular deformity, or radiographic evidence of physeal injury.

Improving Injection Accuracy of the Elbow, Knee, and Shoulder Does Injection Site and Imaging Make a Difference? A Systematic Review

Background: Joint injections and aspirations are used to reduce joint pain and decrease inflammation. The efficacy of these injections is diminished when they are placed inadvertently in the wrong location or compartment. The purpose of this study was to determine whether the use of varying sites or imaging techniques affects the rate of accurate needle placement in aspiration and injection in the shoulder, elbow, and knee. Hypotheses: (1) Accuracy rates of different joint injection sites will demonstrate variability. (2) Injection accuracy rates will be improved when performed with concomitant imaging. Study Design: Systematic review of the literature. Methods: Studies reporting injection accuracy based on image verification were identified through a systematic search of the English literature. Accuracy rates were compared for currently accepted injection sites in the shoulder, elbow, and knee. In addition, accuracy rates with and without imaging of these joints were compared. Results: In the glenohumeral joint, there is a statistically higher accuracy rate with the posterior approach when compared with the anterior approach (85% vs 45%). Injection site selection did not affect accuracy for the subacromial space, acromioclavicular joint, elbow, or knee. The use of imaging improved injection accuracy in the glenohumeral joint (95% vs 79%), subacromial space (100% vs 63%), acromioclavicular joint (100% vs 45%), and knee (99% vs 79%). Conclusion: Injection accuracy rates are significantly higher for the posterior approach compared with the anterior approach for the glenohumeral joint. Similarly, the accuracy rates are also higher when imaging is used in conjunction with injection of the glenohumeral joint, subacromial space, acromioclavicular joint, and knee.

Reliability of a graded exercise test for assessing recovery from concussion.

Objective:To evaluate a graded treadmill test for retest reliability (RTR) and interrater reliability (IRR) in the evaluation of the physiologic effects of symptom exacerbation from concussion. Design:Prospective case series (RTR) and blinded rater assessment of 10 actors portraying patients with and without symptom exacerbation (IRR). Setting:University Sports Medicine Concussion Clinic. Participants:For RTR, 21 refractory concussed patients (11 athletes and 10 nonathletes) and 10 healthy subjects; for IRR, 32 raters representing a variety of health care disciplines. Intervention:For RTR, a Balke protocol treadmill test to symptom exacerbation before and after 2 to 3 weeks. For IRR, video recordings of actors during the treadmill test viewed by raters blinded to condition. Main Outcome Measures:For RTR, agreement of the tests for maximal heart rate (HR), systolic blood pressure, diastolic blood pressure, and rating of perceived exertion. For IRR, presence or absence of symptom exacerbation and the symptom exacerbation HR. Results:Raters achieved a sensitivity of 99% for identifying actors with symptom exacerbation and a specificity of 89% for ruling out concussion symptoms and agreed on 304 of 320 observations (accuracy of 95%). The intraclass correlation coefficient for the symptom exacerbation HR was large at 0.90 (95% confidence interval, 0.78-0.98). The treadmill test had good RTR for maximum HR (intraclass correlation coefficient, 0.79) but not for systolic blood pressure, diastolic blood pressure, or rating of perceived exertion. Conclusions:The Balke exercise treadmill protocol has very good IRR and sufficient RTR for identifying patients with symptom exacerbation from concussion.

The use of systemic hypothermia for the treatment of an acute cervical spinal cord injury in a professional football player.

Study Design. Case Report. Objective. We will describe the injury and clinical course of an NFL Football player who sustained a complete spinal cord injury and was treated with conventional care in addition to modest systemic hypothermia. Summary of Background Data. Systemically induced moderate hypothermia is a potentially neuroprotective intervention in acute spinal cord injury. However, case descriptions of human patients receiving systemic hypothermia after spinal cord injuries are lacking in the literature. Methods. Here, we present the case of a National Football League player who sustained a complete (ASIA A) spinal cord injury from a C3/4 fracture dislocation. Moderate systemic hypothermia was instituted immediately after his injury, in addition to standard medical/surgical treatment, including, surgical decompression and intravenous methylprednisolone. Results. The patient experienced significant and rapid neurologic improvement, and within weeks of his injury was walking with harness assistance. Since that time, the patient has continued to make significant progress in his rehabilitation (now ASIA D). Conclusion. The extent to which this hypothermia contributed to his neurologic recovery is difficult to determine. It is hoped that this case will draw attention to the need for further preclinical and clinical studies to elucidate the role of hypothermia in acute spinal cord injury. Until these studies are completed, it is impossible to advocate for systemic hypothermia as a standard of care.

Minimum 10-Year Follow-up of Arthroscopic Intra-articular Bankart Repair Using Bioabsorbable Tacks

Background: There are few long-term studies evaluating functional outcomes and rates of arthrosis after arthroscopic Bankart repair with bioabsorbable tacks. Purpose: We evaluated the clinical and radiographic results of arthroscopic Bankart repair using intra-articular bioabsorbable tacks at a minimum of 10 years’ follow-up. Study Design: Case series; Level of evidence, 4. Methods: Thirty-two consecutive patients were retrospectively identified. Twenty patients (63%) were evaluated at a mean follow-up of 13.5 years (range, 10.75-17.5 years) and average age of 43 years (range, 28-73 years). The surgical shoulder (SS) was compared with a healthy control shoulder (CS) in 15 of 20 patients. Outcome tools included the Western Ontario Shoulder Instability Index (WOSI) and Disabilities of the Shoulder, Arm, and Hand (DASH). Blinded, independent evaluators performed physical examinations and reviewed radiographs. Results: Thirteen patients (65%) had stable shoulders, 5 of 7 (25%) failed by dislocation, and 2 of 7 (10%) failed by signs of anterior instability on examination. Three patients underwent revision stabilization surgery. Average time to failure was 4.2 years (range, 0.25-14.7 years). Average WOSI and DASH scores were 80% and 7.3, respectively. The CS faired better than SS in WOSI scores (97% vs 83%, respectively; P = .008), main DASH scores (0.39 vs 6.79, respectively; P = .024), and the DASH sports module (0.00 vs 10.94, respectively; P = .043). Patients lost 5.9° of passive forward flexion (P = .031) and 4.3° of passive external rotation (P = .001). Forty percent returned to their preoperative sports level. Higher grades of arthrosis were seen in the SS (20% absent, 40% mild, 25% moderate, and 15% severe) versus CS (P = .002). Conclusion: At long-term follow-up, 65% of patients treated with an arthroscopic Bankart repair using bioabsorbable tacks had a well-functioning, stable shoulder. Disability scores were greatest with sports; however, the majority of patients had well-preserved ranges of motion and good functional WOSI scores. Despite this, 40% had evidence of moderate to severe glenohumeral arthrosis.

Factors Associated With Meniscal Tears and Chondral Lesions in Patients Undergoing Anterior Cruciate Ligament Reconstruction A Prospective Study

Background: Increased time from anterior cruciate ligament (ACL) injury to surgery is known to be associated with increased medial meniscal tears. Few studies have examined the predictors of meniscal tears and chondral lesions, including instability episodes. Purpose: To examine the predictors of meniscal tears and chondral injuries in patients undergoing ACL reconstruction. Study Design: Case-control study; Level of evidence, 3. Methods: Data were collected prospectively from 541 patients undergoing ACL reconstruction. Logistic regression was used to calculate adjusted odds ratios and 95% confidence intervals for predictors of meniscal tears, tear management, and chondral injuries. Predictors included age, sex, body mass index (25-29.99 and ≥30 vs ≤24.99 kg/m2), mechanism (contact vs noncontact) and type (high-impact sports [basketball, football, soccer, and skiing] and other sports vs not sports related) of injury, interval from injury to surgery (≤6 vs >6 weeks and ≤12 vs >12 weeks), and instability episodes (vs none). Results: A total of 211 lateral meniscal tears (35.3% untreated, 48.3% meniscectomized, 16.4% repaired), 197 medial meniscal tears (25% untreated, 52% meniscectomized, 23% repaired), and 82 chondral injuries occurred. Age predicted chondral injuries. Male sex predicted more lateral meniscal tears overall, untreated lateral tears, and lateral meniscectomies as well as predicting medial meniscal tears overall and medial meniscectomies. Obesity predicted more chondral injuries. Sports-related injuries predicted fewer medial meniscal tears overall and medial meniscectomies. Injuries ≤6 weeks from surgery predicted more lateral meniscal repairs but fewer medial meniscectomies. Injuries ≤12 weeks from surgery predicted more chondral injuries. More instability episodes predicted medial meniscal tears overall, untreated medial tears, medial meniscectomies, and medial repairs. Conclusion: Male sex predicted lateral meniscal tears and management. Male sex, sports, injuries ≤6 weeks from surgery, and preoperative episodes of instability predicted medial meniscal tears and management. Age predicted chondral injuries. This was one of the first studies to examine the number of instability episodes as a predictor of an intra-articular injury.

Axial and Sagittal Knee Geometry as a Risk Factor for Noncontact Anterior Cruciate Ligament Tear: A Case-Control Study

PURPOSE The purpose of this study was to compare the axial and sagittal geometry of the distal femur and proximal tibia in men and women with and without noncontact anterior cruciate ligament (ACL) tears to determine whether a difference existed in these groups. METHODS Twenty men and 20 women with noncontact ACL tears and preoperative magnetic resonance imaging scans of their knees were compared with 20 men and 20 women who had magnetic resonance imaging for meniscal pathology. Patients were not matched for age, weight, or height. We measured the anteroposterior dimensions of the femoral condyles, the medial-lateral width of the femur, and the angle of intersection between the transepicondylar axis and the long axis of the femoral condyles. We also measured the anteroposterior dimension of the tibial plateaus, as well as the width of the proximal tibia. Finally, the posterior tibial slope was measured for the medial and lateral tibial plateaus. All dimensional measurements were standardized and compared statistically. RESULTS When compared with normal men, normal women had proportionally deeper medial (3%, P = .049) and lateral (7%, P < .001) femoral condyles, as well as deeper medial tibial plateaus (5%, P = .025). There were no differences between normal women and women with ACL tears (P = .09 to .83). Men with ACL tears had deeper medial (5%, P = .04) and lateral (10%, P = .01) tibial plateaus, as well as an increased posterior slope of the lateral tibial plateau (12 degrees vs 8 degrees , P = .006), when compared with normal men. CONCLUSIONS We compared normal men and women with those with noncontact ACL tears and found that womens knees were characterized by proportionally deeper medial and lateral femoral condyles, as well as deeper medial tibial plateaus. When compared with normal men, men with ACL tears had deeper medial and lateral tibial plateaus, as well as an increased posterior slope of the lateral tibial plateau. LEVEL OF EVIDENCE Level III, case-control study.