Louis F. McIntyre

The arthroscopic treatment of posterior shoulder instability: two-year results of a multiple suture technique.

This study was undertaken to review the results of an arthroscopic posterior capsular shift procedure. Twenty consecutive shoulders in 19 patients were treated with an arthroscopic posterior capsular shift for symptomatic posterior shoulder instability. Patients underwent the procedure if they exhibited a posterior Bankart lesion or had complaints of posterior instability and evidence of increased posterior joint laxity on physical examination and examination under anesthesia. Twelve of the 20 patients were injured during athletic activity. All surgeries were performed in an outpatient setting. Twelve of the 20 patients had posterior Bankart lesions and 10 had anterior Hill-Sachs lesions. The procedure entails releasing the posterior labroligamentous structures from the posterior glenoid and freshening the glenoid neck with a bur. A suture punch is used to place multiple absorbable monofilament stitches in the ligament complex. The stitches are brought through a supraclavicular portal and tied over the clavicle or scapular spine. All 20 shoulders were evaluated at an average of 31 months postoperatively with a minimum follow-up of 24 months. Based on the outcome scale described by Tibone and Bradley, the average postoperative score was 83 out of a possible 100, with 15 excellent, 2 good, 1 fair, and 3 poor results. There were two recurrent dislocations and three subluxations for an overall recurrence rate of 25%. All the recurrences occurred in patients with posterior Bankart lesions and four of the five had a voluntary component to their instability. There were no neurovascular complications or infections. Arthroscopic evaluation facilitated the diagnosis of posterior instability with the visualization of intra-articular pathology that is difficult to identify during open procedures. Although the majority of patients were able to return to vigorous activities, a recurrence rate of 25% is disturbing and consistent with recurrence rates for open procedures.

The arthroscopic treatment of multidirectional shoulder instability: two-year results of a multiple suture technique

Nineteen consecutive shoulders in 19 patients were treated for multidirectional shoulder instability with an arthroscopic capsular shift. Indications for the procedure included complaints of pain, instability, or both that was unresponsive to a prescribed exercise program that stressed rotator cuff and scapular stabilizer strengthening. All patients had evidence of increased joint laxity on physical examination; 17 had a 2+ or greater sulcus test and 2 had 3+ laxity both anteriorly and posteriorly. Fourteen of the 19 patients were injured during athletic activity. All surgeries were performed in an outpatient setting. All the patients were evaluated at an average of 34 months postoperatively with a minimum follow-up of 25 months. Based on the outcome scale described by Tibone and Bradley, the average postoperative score was 91 out of a possible 100 with 13 excellent, 5 good, and 1 fair result. All but 1 of the athletes returned to their previous level of performance but none were elite throwers. One patient had recurrent anterior subluxations treated with a repeat arthroscopic capsular shift and was rated as good. The patient rated as fair had no improvement in her pain after surgery. One patient complained of a painful supraclavicular suture that resolved spontaneously. There were no neurovascular complications or infections. Visualization of intra-articular pathology was enhanced with the arthroscope and aided in the diagnosis of multidirectional instability. The described technique proved safe and effective in treating multidirectional instability and enabling athletes to return to their previous level of function.

Arthroscopic treatment of triplane fractures of the ankle

Failure to obtain and/or maintain adequate closed reduction of triplane ankle fractures is an indication for surgical reduction and internal fixation. Operative treatment requires anteromedial and/or anterolateral incisions for adequate visualization of fracture fragments. The added surgical trauma associated with operative treatment of these fractures can be minimized without loss of efficacy using minimally invasive techniques under arthroscopic control. Arthroscopic reduction and internal fixation (ARIF) of two-part triplane fractures provides the advantages of complete evacuation of fracture hemarthrosis, accurate and certain reduction of the articular surface, and secure fixation of fracture fragments. Two patients treated with ARIF demonstrated rapid and complete fracture healing without complication. Follow-up at 6-12 months showed no leg length discrepancy, angulation, swelling, persistent symptoms, or limitation of function. ARIF of triplane ankle fractures reduces surgical trauma, provides a method for accurate delineation of fracture fragment orientation, and ensures accurate reduction and joint congruity under direct visualization.

Safety and efficacy of US-approved viscosupplements for knee osteoarthritis: a systematic review and meta-analysis of randomized, saline-controlled trials

Background Intra-articular injection of hyaluronic acid is a common, yet controversial, therapeutic option for patients with knee osteoarthritis (OA). The purpose of this research was to determine the safety and efficacy of US-approved viscosupplements for symptomatic knee OA. Methods We searched MedLine and EMBase for randomized, sham-controlled trials evaluating safety and/or clinical efficacy of US-approved viscosupplements in patients with symptomatic knee OA. Knee pain severity and knee joint function were assessed at 4 to 13 weeks and 14 to 26 weeks. Safety outcomes included serious adverse events, treatment-related serious adverse events, patient withdrawal, and adverse event-related patient withdrawal occurring at any time during follow-up. Results A total of 29 studies representing 4,866 unique patients (active: 2,673, control: 2,193) were included. All sham-controlled trials used saline injections as a control. Viscosupplementation resulted in very large treatment effects between 4 and 26 weeks for knee pain and function compared to preinjection values, with standardized mean difference values ranging from 1.07 to 1.37 (all P<0.001). Compared to controls, standardized mean difference with viscosupplementation ranged from 0.38 to 0.43 for knee pain and 0.32 to 0.34 for knee function (all P<0.001). There were no statistically significant differences between viscosupplementation and controls for any safety outcome, with absolute risk differences of 0.7% (95% confidence interval [CI]: −0.2 to 1.5%) for serious adverse events, 0% (95% CI: −0.4 to 0.4%) for treatment-related serious adverse events, 0% (95% CI: −1.6 to 1.6%) for patient withdrawal, and 0.2% (95% CI: −0.4 to 0.8%) for adverse event-related patient withdrawal. Conclusion Intra-articular injection of US-approved viscosupplements is safe and efficacious through 26 weeks in patients with symptomatic knee OA.

Did the American Academy of Orthopaedic Surgeons Osteoarthritis Guidelines Miss the Mark

The American Academy of Orthopaedic Surgeons (AAOS) 2013 guidelines for knee osteoarthritis recommended against the use of viscosupplementation for failing to meet the criterion of minimum clinically important improvement (MCII). However, the AAOSs methodology contained numerous flaws in obtaining, displaying, and interpreting MCII-based results. The current state of research on MCII allows it to be used only as a supplementary instrument, not a basis for clinical decision making. The AAOS guidelines should reflect this consideration in their recommendations to avoid condemning potentially viable treatments in the context of limited available alternatives.

Evidence-Based Medicine, Appropriate-Use Criteria, and Sports Medicine: How Best to Develop Meaningful Treatment Guidelines

We propose using appropriate-use criteria (AUC) as the methodology of choice for formulating and disseminating evidence-based medicine guidelines in sports medicine and arthroscopy. AUC provide a structured process for integrating findings from the scientific literature with clinical judgment to produce explicit criteria for determining the appropriateness of specific treatments. The use of AUC will enable surgeons to treat patients in a more consistent manner based on expert clinical consensus and evidence-based medicine. This methodology also will ensure that guidelines represent all stakeholders and available evidence.

The Prevalence of Obesity and Elevated Blood Pressure in Adolescent Student Athletes From the State of Mississippi

Background: Over the past 30 years, there has been a dramatic increase in the prevalence of childhood obesity and hypertension in the United States. The prevalence of these diagnoses among individuals participating in school-sanctioned sports has not been clearly defined. Purpose: To identify the prevalence of obesity and elevated blood pressure (BP) among student athletes and investigate associations between race, sex, type and number of sports played, and the prevalence of these diseases. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pre–sports participation medical examinations (N = 7705) performed between 2009 and 2013 were reviewed to identify the prevalence of obesity and elevated BP and examine relationships between the type of sports played, participation in multiple sports versus a single sport, and the athlete’s body weight and body mass index (BMI). Results: The prevalence of obesity was 23.5%. There was a significant association (P < .001) between the number of sports played by the student and BMI. The risk of obesity among single-sport athletes was more than 2-fold the risk (relative risk [RR], 2.13) compared with ≥3-sport athletes and 1.42 times greater compared with 2-sport athletes (RR, 1.42). The prevalence of elevated BP was 21.2%. There was a significant association (P < .001) between the number of sports played by the student and elevated BP. The risk of elevated BP among single-sport athletes was 1.59 times greater (RR, 1.59) than ≥3-sport athletes and 1.30 times greater compared with 2-sport athletes (RR, 1.30). Finally, obese students were 2.40 times more likely to have elevated BP compared with nonobese students (P < .001). Conclusion: The result of this study confirms the progressive nature of the obesity epidemic and identifies the contribution of obesity to the worsening cardiometabolic profiles in student athletes. The study also identifies that participation in multiple sports and running sports decreases the individual’s risk for obesity and hypertension. Clinical Relevance: The present study emphasizes the importance of screening for obesity and elevated blood pressure during the athlete’s preparticipation physical examination.

Unraveling the confusion behind hyaluronic acid efficacy in the treatment of symptomatic knee osteoarthritis

Hyaluronic acid (HA) is a commonly prescribed treatment for knee pain resulting from osteoarthritis (OA). Although numerous HA products have been approved for use by the US Food and Drug Administration, the efficacy of HA injections for knee OA remains disputed with meta-analyses and societal clinical guidelines drawing disparate conclusions. The American Academy of Orthopaedic Surgeons (AAOS) recently published a best-evidence systematic review and concluded that available data did not support the routine use of HA for knee OA. The purpose of the current article is to highlight issues that confound interpretation of meta-analyses on HA for knee OA, to provide realistic estimates of the true efficacy of HA injections in knee OA, and to provide commentary on the methods and conclusions from the AAOS systematic review. In general, the clinical benefit of HA is underestimated using conventional meta-analytic techniques. When accounting for differential control group effects in HA studies, it can be reasonably concluded that HA injections may be beneficial to an appreciable number of patients with knee OA. In addition, the systematic review methodology used by AAOS was questionable due to exclusion of numerous relevant studies and inclusion of studies that used HAs not approved for use in the US, both of which underestimated the true efficacy of HA injections. Overall, the efficacy of HA injections for knee OA is likely better than previously reported. Future clinical trials and meta-analyses should account for differential control group effects in order to avoid the continued confusion surrounding HA injection efficacy.

Arthroscopic Lysis of Adhesions for Treatment of Post-traumatic Arthrofibrosis of the Knee Joint

Normal knee range of motion varies slightly between individuals and measures approximately 0° to −5° of extension to 140° of flexion. A full arc of motion is required for normal gait and knee function. Loss of normal joint range of motion may occur after a traumatic knee injury and may contribute to increased pain, lower functional outcome scores, and decreased patient satisfaction. Although multiple factors may contribute to the development of motion loss, the occurrence of intra-articular scar tissue adhesions, or post-traumatic arthrofibrosis, may limit the patients knee motion in the early postoperative period. Once motion loss has been identified, it can be a challenging complication to manage. Arthroscopic lysis of adhesions with manipulation under anesthesia is a reliable surgical technique that can improve range of motion in patients with knee stiffness due to post-traumatic arthrofibrosis.

The changing world of healthcare delivery.

Medicine is witnessing an unprecedented amount of change with respect to the delivery of health care services in the Unites States. This change had been occurring for the past 20 years, brought on by severe cost inflation as a result of the domination of third-party reimbursement in the delivery marketplace. This inflation led to efforts by both private and government payers to limit cost and the access to care. These trends initially slowed down cost inflation in the mid 1990s, but demographic changes, provider consolidations, vertical integrations, and malpractice premium increases mitigated the initial attempts of payers to limit medical inflation. The changes already in progress have recently accelerated because of a significant increase in the involvement of the federal government in managing the day-to-day affairs of medical practice through the HITECH (2009) and Affordable Care Acts (ACA 2010). HITECH mandated the use of electronic medical records (EMR) by 2015. The ACA vastly expands the government’s role by significantly increasing Medicaid enrollment, creating government controlled, defined, and subsidized health insurance–purchasing exchanges, and creating entirely new delivery entities, Accountable Care Organizations (ACO), to supposedly integrate and coordinate care. Physicians and other health care providers are being asked to define and document disease states and treatments better (EMR, ICD-10 Coding), coordinated care more efficiently (ACOs Bundled Payment methodologies), and report outcomes of care to demonstrate both efficacy and cost effectiveness. They are asked to do all these things in an environment of increasing business costs, unprecedented regulation and review (RACs and MACs), and decreasing reimbursements on a per-service basis. This is creating considerable anxiety and restlessness among providers, fueling an accelerating trend of physician employment and abandonment of the traditional private practice model of service delivery. These areas are all creating great interest in the socioeconomic issues surrounding the delivery of health care services, including sports medicine. This review is intended to be a primer on those issues affecting the practice of sports medicine and other areas of orthopedics. Surgeons will have to master these issues to have both clinical and financial success in the coming years.