Matthew D. Pepe

Hemiarthroplasty Versus Reverse Total Shoulder Arthroplasty for Acute Proximal Humerus Fractures in Elderly Patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.

Short-/Intermediate-Term Outcomes after Medial Patellofemoral Ligament Reconstruction in the Treatment of Chronic Lateral Patellofemoral Instability

Abstract Purpose: Disruption of the medial patellofemoral ligament (MPFL) is now considered the essential lesion of recurrent lateral patellar dislocation in patients with normal lower extremity alignment. Reconstruction of the MPFL is a technique gaining significant success in the treatment of patients with this disabling condition. Hypothesis: Reconstruction of the MPFL in patients with chronic patellar instability and normal lower extremity alignment will improve knee function and symptoms, with a high percentage of patients achieving good to excellent results at early follow-up. Study Design: Case series; Level of evidence; 4. Methods: A consecutive series of patients with lateral patellofemoral instability who underwent MPFL reconstruction were reviewed. Reconstruction was performed with either soft tissue allograft (23 patients) or hamstring tendon autograft (12 patients). Outcomes were determined by patient scores from the Kujala Anterior Knee Pain Scale, recurrence of patellar instability, and patient function at a minimum of 12 months of postoperative follow-up. Results: Thirty-five patients were followed for a mean of 21.0 months (range, 12-45 months) after surgery. The Kujala subjective knee score improved significantly from 49.0 preoperatively to 89.5 postoperatively (P < 0.001). No statistical significance was found between postoperative Kujala scores and graft type, or time from initial injury to surgical reconstruction. A firm endpoint to lateral translation of the patella, and no feelings of apprehension were noted in all patients at most recent follow-up. The majority of patients noted that they were more active than before reconstructive surgery, with 86% participating in “strenuous” to “very strenuous” activities at the time of follow-up. No recurrent dislocations were reported. Conclusion: Reconstruction of the MPFL provides excellent stability and functional outcomes for patients with recurrent patellar instability.

Triceps Tendon Ruptures Requiring Surgical Repair in National Football League Players.

Background: Complete triceps tendon ruptures are relatively rare in the general population but slightly more prevalent in professional football. One prior study found 11 complete ruptures over a 6-season period. Hypothesis: Triceps ruptures occur more commonly in football linemen due to forced elbow flexion during an eccentric contraction and may occur more commonly with the increasing size and speed of professional players. Surgical repair allows full return to sports, but with a lengthy recovery time. Study Design: Case series; Level of evidence, 4. Methods: A search of the National Football League Injury Surveillance System (NFLISS) found a total of 37 triceps tendon ruptures requiring surgical repair from the years 2000 to 2009. Data were obtained for setting of injury, player position, activity causing injury, play type, time of game when injury occurred, height, weight, body mass index (BMI), and number of days lost from football. Results: There were 37 players requiring surgical repair for triceps tendon ruptures over the 10-season period. The average height, weight, and BMI of the players were 75 inches, 292 pounds, and 36.5 kg/m2, respectively. The majority of players were linemen (86%): 16 defensive, 15 offensive, and 1 tight end. The injury took place while blocking or being blocked in 29 players (78%) and while tackling or being tackled in 5 players (14%). Players missed an average of 165 days (range, 49-318 days) from football as a result of their injury and surgery. Conclusion: Triceps tendon tears requiring surgical repair are more common in professional football players than in the general population and are occurring more commonly than previously reported. Surgical repair allows return to play. Clinical Relevance: Our study identifies the rate of triceps tendon tears requiring repair in the NFL according to position, identifying which players may be most at risk for this injury.

Sleep Disturbance Associated With Rotator Cuff Tear Correction With Arthroscopic Rotator Cuff Repair

Background: Sleep disturbance is a common complaint of patients with a rotator cuff tear. Inadequate and restless sleep, along with pain, is often a driving symptom for patients to proceed with rotator cuff repair. To date, no studies have examined sleep disturbance in patients undergoing rotator cuff repair, and there is no evidence that surgery improves sleep disturbance. Hypothesis: Sleep disturbance is prevalent in patients with a symptomatic rotator cuff tear, and sleep disturbance improves after arthroscopic rotator cuff repair. Study Design: Case series; Level of evidence, 4. Methods: A total of 56 patients undergoing arthroscopic rotator cuff repair for full-thickness tears were enrolled in a prospective study. Patients were surveyed preoperatively and postoperatively at intervals of 2, 6, 12, 18, and 24 weeks. Patient outcomes were scored using the Pittsburgh Sleep Quality Index (PSQI), Simple Shoulder Test (SST), visual analog scale for pain (VAS), and single assessment numeric evaluation (SANE). Demographic and surgical factors were also collected for analysis. Results: Preoperative PSQI scores indicative of sleep disturbance were reported in 89% of patients. After surgery, a statistically significant improvement in PSQI was achieved at 3 months (P = .0012; 91% follow-up) and continued through 6 months (P = .0179; 93% follow-up). Six months after surgery, only 38% of patients continued to have sleep disturbance. Multivariable linear regression of all surgical and demographic factors versus PSQI was performed and demonstrated that preoperative and prolonged postoperative narcotic use negatively affected sleep. Conclusion: Sleep disturbance is common in patients undergoing rotator cuff repair. After surgery, sleep disturbance improves to levels comparable with those of the general public. Preoperative and prolonged postoperative use of narcotic pain medication negatively affects sleep.

Arthroscopic lysis of adhesions for the stiff total knee: results after failed manipulation.

Arthrofibrosis after total knee arthroplasty (TKA) is a potentially devastating complication, resulting in loss of motion and function and residual pain. For patients in whom aggressive physical therapy and manipulation under anesthesia fail, lysis of adhesions may be the only option to rescue the stiff TKA. The purpose of this study is to report the results of arthroscopic lysis of adhesions after failed manipulation for a stiff, cruciate-substituting TKA. This retrospective study evaluated patients who had undergone arthroscopic lysis of adhesions for arthrofibrosis after TKA between 2007 and 2011. Minimum follow-up was 12 months (average, 31 months). Average total range of motion of patients in this series was 62.3°. Average preoperative flexion contracture was 16° and average flexion was 78.6°. Statistical analysis was performed using Students t test. Pre- to postoperative increase in range of motion was significant (P<.001) (average, 62° preoperatively to 98° postoperatively). Average preoperative extension deficit was 16°, which was reduced to 4° at final follow-up. This value was also found to be statistically significant (P<.0001). With regard to ultimate flexion attained, average preoperative flexion was 79°, which was improved to 103° at final follow-up. This improvement in flexion was statistically significant (P<.0001). Patients can reliably expect an improvement after arthroscopic lysis of adhesions for a stiff TKA using a standardized arthroscopic approach; however, patients achieved approximately half of the improvement that was obtained at the time of surgery.

Accuracy of Athletic Trainer and Physician Diagnoses in Sports Medicine

It is standard practice in high school athletic programs for certified athletic trainers to evaluate and treat injured student athletes. In some cases, a trainer refers an athlete to a physician for definitive medical management. This study was conducted to determine the rate of agreement between athletic trainers and physicians regarding assessment of injuries in student athletes. All high school athletes who were injured between 2010 and 2012 at 5 regional high schools were included in a research database. All patients who were referred for physician evaluation and treatment were identified and included in this analysis. A total of 286 incidents met the inclusion criteria. A total of 263 (92%) of the athletic trainer assessments and physician diagnoses were in agreement. In the 23 cases of disagreement, fractures and sprains were the most common injuries. Kappa analysis showed the highest interrater agreement in injuries classified as dislocations and concussions and the lowest interrater agreement in meniscal/labral injuries and fractures. In the absence of a confirmed diagnosis, agreement among health care providers can be used to infer accuracy. According to this principle, as agreement between athletic trainers and physicians improves, there is a greater likelihood of arriving at the correct assessment and treatment plan. Athletic trainers are highly skilled professionals who are well trained in the evaluation of athletic injuries. The current study showed that additional training in identifying fractures may be beneficial to athletic trainers and the athletes they treat. [Orthopedics. 2016; 39(5):e944-e949.].

Clinical Differentiation of Upper Extremity Pain Etiologies.

Upper extremity pain can result from many overlapping etiologies. These can be categorized into anatomic regions and specific organ systems. Anatomically, pain etiologies are classified into four major groups: neurologic, musculoskeletal, vascular, and other (eg, tumor, infection). Knowledge of the characteristic clinical presentation and physical examination findings of each group can help distinguish the source of the patient’s complaints quickly so that an accurate clinical diagnosis can facilitate appropriate diagnostic measures and treatment. A focus on the neurologic causes of upper extremity pain (ie, cervical spine pathology, peripheral nerve compression, neuropathy) and musculoskeletal causes of shoulder and elbow pain (eg, adhesive capsulitis, calcific tendinitis, biceps tendinitis, synovitis) and the distinguishing characteristics (eg, periscapular pain, two-point discrimination, signal intensity on T2-weighted MRI) helps determine the appropriate diagnosis.

Long-term Correction in Sleep Disturbance Is Sustained After Arthroscopic Rotator Cuff Repair

Background: Sleep disturbance is a major complaint of patients with rotator cuff disease that often leads them to seek treatment. The authors previously reported a prospective analysis of patients who underwent rotator cuff repair and found that sleep disturbance significantly improved at 3 months after surgery. That improvement in sleep was maintained at 6 months. Hypothesis: In the current study, the authors sought to gain medium-term data on this same population at greater than 2 years. The hypotheses were that improvement in sleep disturbance after arthroscopic rotator cuff repair is maintained at 2-year follow-up and that the continued use of narcotic pain medication has a negative effect on sleep quality at 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: The original cohort of patients was contacted at a minimum of 24 months after their surgery. Thirty-seven of the 56 patients (66%) involved in the original study were available. Patient outcomes were scored using the Pittsburgh Sleep Quality Index (PSQI), Simple Shoulder Test (SST), visual analog scale (VAS) for pain, and Single Assessment Numeric Evaluation (SANE). The newly obtained scores were compared with prior scores, which ranged from preoperatively to 6 months postoperatively. Results: The statistically significant improvement of the PSQI score demonstrated in our prior analysis at 6 months postoperatively was maintained, with a mean PSQI score of 5.5 for the 37 patients followed beyond 24 months. Of those patients, 41% still had a PSQI score >5, indicative of sleep disturbance. However, even those patients in our study with a PSQI score >5, indicative of sleep disturbance, had an improved mean score of 9.3 at greater than 24 months compared with those patients with a PSQI score >5 at 6 months, who had a mean PSQI score of 11.5 (P = .13). Both the SST and VAS scores displayed continued improvement at greater than 24 months, with both displaying moderate strength correlation to the PSQI score (VAS: Spearman rho = 0.479, P < .001; SST: Spearman rho = −0.505, P < .001). Regression models again demonstrated the continued use of narcotic pain medication correlating with poor sleep as the difference in the mean PSQI score between users and nonusers increased as postoperative time increased. At greater than 24 months after surgery, patients using narcotics had a mean PSQI score that was 7.4 points higher than narcotic nonusers (standard error [SE] = 1.93; P = .00017). Conclusion: At greater than 24 months, 41% of patients still demonstrated sleep disturbance, with both SST and VAS scores showing improvement. The prolonged use of narcotic medication negatively affects sleep, with a greater effect seen over time.

Economic analysis of athletic team coverage by an orthopedic practice.

Abstract Objective: Coverage of high school football by orthopedic sports medicine specialists is considered standard of care in many localities. Determining the economic viability of this endeavor has never been investigated. The primary purpose of the present investigation was to perform an economic analysis of local high school sports coverage by an orthopedic 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, private orthopedic sports medicine practice. Patients referred for orthopedic care were then tracked to determine expected 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. Overhead costs were calculated based on historical rates within our practice and incorporated to determine estimated profit. Results: 19,165 athletic trainer contacts with athletes playing all sports, including both those ‘on-field’ and in the training room, resulted in 473 (2.5%) physician referrals. The covering orthopedic practice handled 89 (27.9%) of the orthopedic referrals. Of orthopedic physician referrals, 26 (5.4%) required orthopedic surgical treatment. The covering team practice handled 17/26 (65%) surgical cases. The total revenue collected by the covering team practice was

Arthroscopic Transosseous Rotator Cuff Repair: A Prospective Study on Cost Savings, Surgical Time, and Outcomes

26,226.14. The overhead cost of treatment was