Matthew Lawrence Lyons

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Minimum Two Year Clinical Outcomes

Objectives: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. The goal of this study is to compare the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral tenodesis. Our null hypothesis is that both methods yield satisfactory results with regards to shoulder and biceps function, postoperative shoulder scores, pain relief and complications. Methods: Retrospective cohort study. Patients who underwent either arthroscopic suprapectoral or open subpectoral biceps tenodesis for superior labral or long head biceps pathology with a minimum follow-up of 2 years were included in the study. Patients were excluded if they underwent significant additional shoulder procedures, including rotator cuff repair or procedures to address glenohumeral instability, if there was significant pre-operative range of motion deficits due to frozen shoulder or glenohumeral arthritis, or if they had significant contralateral shoulder pathology or surgery. Subjects were evaluated with several clinical outcome measures and physical examination including range of motion and strength. Range of motion and strength measurements were normalized to the asymptomatic contralateral limb. Power analysis indicated that a minimum of 17 subjects were required in each group (34 total) to determine a clinically meaningful difference in the outcome measures. Results: Between 2007 and 2011, 79 patients met all inclusion and exclusion criteria, which included 30 arthroscopic suprapectoral tenodesis (ASPBT) patients and 49 open subpectoral biceps tenodesis (OSPBT) patients. 23 of 30 (76.7%) ASPBT and 28 of 49 (57.1%) OSPBT patients completed clinical follow-up at an average of 3.1 year postoperative (range 2.2 - 4.3 years). The cohorts were similar in terms of age, gender, BMI, smoking and workers compensation status. Overall outcomes for both procedures were satisfactory. No significant differences were noted in post-operative Constant Murley (ASPBT: 89, OSPBT: 92, p = 0.567), ASES (ASPBT: 89, OSPBT: 88, p = 0.845), SANE (ASPBT: 86, OSPBT: 86, p = 0.982), SST (ASPBT: 10, OSPBT: 10, p = 0.597), LHB Score (ASPBT: 91, OSPBT: 94, p = 0.329), or VR-36 (ASPBT: 80, OSPBT: 79, p = 0.833). No significant range of motion or strength differences (expressed as percent of asymptomatic contralateral limb) were noted between procedures. (Table I). Conclusion: Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology. No significant differences in clinical outcomes as determined by several validated outcomes measures were found between the two tenodesis methods, nor were any range of motion or strength deficits noted at minimum two-years post-operatively.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Restoration of Length-Tension and Mechanical Strength Between Techniques

Objectives: The approach to biceps tenodesis remains controversial, as the procedure can be performed open or arthroscopically. Little data exists directly comparing the arthroscopic suprapectoral and open subpectoral techniques, particularly in terms of location, restoration of the long head biceps length-tension relationship, and the mechanical strength of the tenodesis. The purpose of this study was to (1) determine the in-vivo tenodesis location using arthroscopic suprapectoral (ASPBT) and open subpectoral techniques (OSPBT) for long head biceps tenodesis and compare this to the location achieved in a separate clinical cohort, (2) evaluate the in-vivo restoration of the long head biceps length-tension relationship for both ASPBT and OSPBT techniques and (3) assess how location in the proximal humerus (suprapectoral or subpectoral) and method of fixation affects pull-out strength for biceps tenodesis using an interference screw implant. Our null hypothesis was that no difference existed between ASPBT and OSPBT with regards to location, restoration of the length-tension relationship, and pull-out strength. Methods: 18 matched cadaveric shoulder specimens were randomized to either open subpectoral or arthroscopic suprapectoral tenodesis groups (9 open, 9 arthroscopic.) Tenodesis was performed by two sports fellowship-trained surgeons using identical clinical techniques. Prior to surgery, a metallic bead was sutured in place, 1 cm distal to the musculotendinous junction of the long head of the biceps, and a pre-operative fluoroscopic image was obtained. Post-operatively, an additional fluoroscopic image was obtained to evaluate the location of the tenodesis and the metallic bead, which was compared to the pre-operative image to determine tensioning (Fig 1). Biomechanical testing was then performed using a MTS machine with 2.5kN load cell. Constructs were cycled for 100 cycles, then load to failure testing was performed. Results: The average tenodesis location in the ASPBT group of cadaveric specimens was 4.68 cm ± 0.97 cm distal to the top of the humerus, compared with 7.46 cm ± 1.7 cm (p < 0.0001) in the OSPBT group. This was very similar to the location observed in a separate clinical cohort. The ASPBT technique resulted in an average of 2.15 ± 0.62 cm of biceps over-tensioning compared with 0.78 ± 0.35 cm (p < 0.001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared to 197 ± 38.6 N (p = 0.002) in the OSPBT group. Implant pullout was significantly more frequent in the ASPBT (7/9) compared to the OSPBT (1/9) group. Conclusion: This study revealed several notable differences between the arthroscopic suprapectoral and open subpectoral biceps tenodesis techniques. The described ASPBT technique using an interference screw implant results in a more proximal tenodesis location, has the tendency to over-tension the biceps and has a significantly decreased ultimate load to failure compared with an open subpectoral technique in matched cadaver specimens. Modification of currently published arthroscopic suprapectoral techniques is necessary to improve restoration of the physiologic length-tension relationship of the biceps. Improved implants are likely necessary to achieve equivalent construct strength to the open subpectoral technique, although the clinical ramifications of this strength discrepancy have not been established.

Accelerated return to sport after osteochondral autograft plug transfer

Background: Previous studies have reported varying return-to-sport protocols after knee cartilage restoration procedures. Purpose: To (1) evaluate the time for return to sport in athletes with an isolated chondral injury who underwent an accelerated return-to-sport protocol after osteochondral autograft plug transfer (OAT) and (2) evaluate clinical outcomes to assess for any consequences from the accelerated return to sport. Study Design: Case series; Level of evidence, 4. Methods: An institutional cohort of 152 OAT procedures was reviewed, of which 20 competitive athletes met inclusion and exclusion criteria. All patients underwent a physician-directed accelerated rehabilitation program after their procedure. Return to sport was determined for all athletes. Clinical outcomes were assessed using International Knee Documentation Committee (IKDC) and Tegner scores as well as assessment of level of participation on return to sport. Results: Return-to-sport data were available for all 20 athletes; 13 of 20 athletes (65%) were available for clinical evaluation at a mean 4.4-year follow-up. The mean time for return to sport for all 20 athletes was 82.9 ± 25 days (range, 38-134 days). All athletes were able to return to sport at their previous level and reported that they were satisfied or very satisfied with their surgical outcome and ability to return to sport. The mean postoperative IKDC score was 84.5 ± 9.5. The mean Tegner score prior to injury was 8.9 ± 1.7; it was 7.7 ± 1.9 at final follow-up. Conclusion: Competitive athletes with traumatic chondral defects treated with OAT managed using this protocol had reduced time to preinjury activity levels compared with what is currently reported, with excellent clinical outcomes and no serious long-term sequelae.

Accelerated Return to Play Following Osteochondral Autograft Plug Transfer (OATS)

Objectives: Chondral lesions about the knee are a challenging clinical entity particularly among high performance athletes whose return to play is dependant on the quality and durability of chondral repair. At our institution, we favor osteochondral autograft plug transfer (OATs) when lesion size and location allow, as we believe it results in the most durable cartilage repair currently available due to the transfer of autogenous hyaline cartilage into the area of injury. We further postulate that OATs may allow a more rapid return to play in the athlete population, as the release to full activity is predicated only on adequate time for bony healing and appropriate clinical progress. We investigated the time for return to play in a cohort of competitive athletes who had undergone OATs followed by an accelerated return to play protocol and compared this to previously published timelines for chondral repair procedures. Methods: This was a retrospective chart review of an overall institutional cohort of 152 osteochondral autograft transfer surgeries performed by 4 fellowship trained orthopaedic surgeons over the past 12 years. We identified 20 competitive athletes (average age of 21.6 years) who had undergone isolated OATs procedures of the knee, followed by a physician-directed accelerated progression and return to sports. Athletes were evaluated for clinical outcomes, and time until full return to their prior level of athletic competition. Results: In this cohort, osteochondral autograft transfer was carried out to address femoral condylar lesions in all 20 patients. The donor site was either the superolateral portion of the lateral condyle or the intercondylar notch. The average lesion size was 134mm2 (36-280mm2). The average number of plugs per lesion was 2.15, with a maximum of 4 plugs and 6 patients receiving more than 2. Our bias is to use fewer, larger plugs when possible. All patients were kept partial weight bearing initially, and released to normal ambulation as early as 2 weeks for single plugs and by week 6 for multiple plugs and then advanced as tolerated. The average time until release to play in this cohort was 88.4 days (39-185), with successful resumption of sports in all patients. There were no clinical failures in this cohort and no patient required a revision surgery. Four patients did develop a joint effusion at one point along their recovery course and required aspiration and intra-articular injection. Conclusion: Based on our findings, we assert that an accelerated return to play protocol following osteochondral autograft transfer will allow for a predictable and more rapid return to sports. This has resulted in a substantially reduced time to pre-injury activity levels in our elite athlete population when compared to the currently available literature. The majority of our patients in this cohort (80%) were cleared to resume athletics by 3 months post OATs procedure. When compared to the current literature on return to play after chondral surgery of the knee1, this represents a greater than 50% more rapid return to full activities in these patients.

Biceps Tenodesis: How Low Do You Go? A Comparison of Location Between Arthroscopic Suprapectoral and Open Subpectoral Techniques

Objectives: Long head biceps (LHB) tenodesis can be performed open or arthroscopically and can be positioned in a suprapectoral or subpectoral position. Suprapectoral tenodesis is easier to accomplish arthroscopically, whereas the subpectoral tenodesis is performed as an open procedure with a longitudinal skin incision at the lower border of the pectoralis major muscle. Numerous studies have investigated these tenodesis techniques, comparing them to tenotomy, and comparing fixation methods between techniques, however, no study has compared the actual postoperative clinical location of suprapectoral and subpectoral LHB tenodesis. The goal of this study is to compare the radiographic location of clinically-performed arthroscopic suprapectoral and open subpectoral biceps tenodesis. Methods: Study Design: Retrospective study. The charts of all patients who underwent arthroscopic or open biceps tenodesis in the past 5 years were reviewed. We routinely obtained post-operative x-rays in these patients and those with available x-rays and complete preoperative information were included in the study. Analysis: The location of all tenodesis sites were measured on x-rays as the distance from the top of the humeral head. Means and standard deviations were calculated and compared using Student’s t-test. Outliers were identified as patients with tenodesis locations greater than one standard deviation from the mean. Preoperative clinical characteristics of these patients were compared to the remaining tenodesis patients using Student’s t test for continuous variables and chi square tests for categorical variables. Results: We identified 158 patients who met inclusion criteria, which included 66 open subpectoral tenodeses and 92 arthroscopic tenodeses. Power analysis determined that 47 patients in each group (94 total) was the minimum number necessary to determine an 8 mm difference between groups. The average distance from the top of the humerus (TDH) in the arthroscopic suprapectoral group was 4.89 ± 0.8 cm, and in the open subpectoral group, 7.52 ± 1.2 cm. (Fig 1) This difference is statistically significant (p<0.0001). 12 (18%) distal outliers (more than one standard deviation distal) were found in the open subpectoral group. 11 (12%) proximal outliers were found in the arthroscopic suprapectoral group. Analysis determined that increased BMI and male gender were significant predictors for distal placement of an open tenodesis. No significant predictors of proximal arthroscopic tenodesis were found. Published cadaveric data localizes the proximal edge of the pectoralis major tendon to be 5.6 cm distal to the top of the humerus. Our data indicates that arthroscopic suprapectoral tenodesis results in a tenodesis location very near (within 0.7 cm on average) the proximal edge of pectoralis major tendon. Open subpectoral technique results in a truly subpectoral location, 1.9 cm distal to the proximal edge of the tendon, likely representing the clinical height of the pectoralis major tendon at the bicipital groove. Conclusion: Arthroscopic suprapectoral and open subpectoral techniques result in significantly different locations of biceps tenodesis. Surgeons experienced in these techniques can expect, on average, to localize their tenodesis just proximal to the pectoralis major tendon using an arthroscopic technique and just distal to the tendon using an open subpectoral technique. The clinical significance of these findings is currently being studied.

Shoulder range of motion: Validation of an innovative measurement method using a smartphone

Objectives: An accurate and consistent measurement of shoulder range of motion (ROM) is of vital importance in the examination and functional evaluation of the shoulder. Classically, shoulder ROM is measured using a goniometer for research purposes, although clinically, visual estimation is typically utilized given its efficiency and providers’ lack of access to a goniometer.While visual estimation is likely sufficient for a single provider to follow a patient over time, it has been demonstrated to have very low interobserver reliability, especially for patients with pain or shoulder pathology. Current medical practice has led most orthopaedic surgeons to rely heavily on residents and physician assistants, especially in the clinic setting. Despite the importance of accurate and consistent measurement of shoulder ROM, a reliable and reproducible method of measurement for all levels of care providers does not exist. A widely-available and low-cost alternative for measurement of shoulder ROM is the Clinometer application (Plaincode Software Solutions) available inexpensively to all iPhone and smartphone users. Such a readily-available and accurate device could provide practicioners with a much simpler method for measuring shoulder ROM, as well as allowing physician extenders, primary care physicians and other non-orthopaedic trained physicians to easily obtain reproducible shoulder ROM measurements. The goal of this study is to establish the validity and reliability of shoulder ROM measurements amongst varying types of healthcare providers using the Clinometer application in healthy adult patients and compare these results to goniometry. Methods: Examiners: One sports fellowship-trained orthopaedic surgeon, one current orthopaedic sports fellow, one orthopaedic resident physician, one orthopaedic physician assistant and one medical student. Subjects: Bilateral shoulders of twenty three healthy adult volunteer subjects, yielding 46 shoulders. Procedures: Each examiner first measured each subject using the iPhone clinometer, and then later repeated measurements using a standard goniometer. Abduction and forward flexion were measured with the patient standing. External rotation with the arm at the patient’s side, external rotation with the arm abducted at 90 degrees and internal rotation with the arm abducted at 90 degrees were measured with the patient supine. (Fig 1A-1E) Analysis: ICC(3,1) comparing iPhone measurements with goniometer measurements were calculated for each examiner. ICC(3,1) were also calculated comparing iPhone measurements with goniometer measurements across examiners for each measurement. Results: ICC results are reported in Table IA-B. On average, examiners demonstrated good correlation (average ICC = 0.650) between their goniometer and iPhone measurements. Even better correlation was noted between examiners for each individual measure (average ICC = 0.721). Conclusion: Smartphones have good correlation with the “gold standard” goniometer for measuring shoulder range of motion. Additionally, there is good correlation amongst different levels of providers with measurements obtained using the smartphone. Given their wide availability and the low cost of measurement applications, smartphones are a good resource for shoulder range of motion measurement. Additional studies are underway to validate their use in post-operative and symptomatic patients.

A Cadaveric Study of the Mean Distance of the Radial Artery During the Approach to the First Carpometacarpal Joint

Multiple surgical procedures have been described to treat first carpometacarpal (CMC) arthritis. Although the superiority of one procedure over the others continues to be a controversial topic, they all approach the trapezium and require careful attention to the surrounding structures. One potential complication is injury to the radial artery, which lies in close proximity to the trapezium and is often encountered during surgical approach. Using cadaveric specimens, the authors dissected to identify and isolate the radial artery as it travels in the forearm, wrist, and hand while being careful not to disturb its native course. The authors then measured the shortest distance interval from the radial artery to the first CMC joint and from the radial artery to the scaphotrapeziotrapezoidal joint. Descriptive statistics were calculated from these measurements and averaged over the various specimens. The mean distance of the radial artery to the closest segment of the volar CMC joint was 11.6±2.5 mm. The mean distance of the radial artery to the closest segment of the volar scaphotrapeziotrapezoidal joint was 1.6±1.8 mm. A precise understanding of nearby anatomy is paramount to a successful surgical treatment for first CMC arthritis and to avoid iatrogenic complications. The authors describe the mean distance from the radial artery to 2 major landmarks used during surgical treatment and provide insight to surgeons who perform these CMC reconstruction procedures to decrease the risk of intraoperative radial artery injury. [Orthopedics. 2018; 41(4):e541-e544.].

Nonunions of the Wrist and Hand

Nonunions of the wrist and hand present a challenging problem with continually evolving treatment modalities. Appropriate evaluation of the nonunited wrist or hand fracture, identification of the causal factors leading to nonunion, and subsequent choice of intervention are critical to providing a functional and painless extremity. This chapter will discuss nonunions of the wrist and hand, their sequelae, and treatment options ranging from reconstructions to salvage procedures.

Return to Play and Long-Term Clinical Outcomes after Suture Anchor Repair of Thumb Ulnar Collateral Ligament Injuries in Collegiate Football Athletes

Objectives: Thumb ulnar collateral ligament injuries (UCL, gamekeeper’s thumb), their surgical treatment and the potential need for prolonged immobilization can significantly damage the careers of collegiate football athletes. Suture anchor fixation may allow quicker return to play with good clinical outcomes but has not been previously studied in this population. The goal of this study is to evaluate return to play and minimum two-year clinical outcomes in collegiate football athletes treated for thumb UCL injuries with suture anchor repair. Methods: Retrospective study. Inclusion criteria were 1) complete rupture of the thumb MCP joint UCL 2) suture anchor repair of UCL 3) collegiate football athlete 4) minimum 2 years postoperative. Data collection included chart review, return to play, and QuickDASH (including work and sport module) outcomes.Skill position players were scheduled for surgery immediately, while non-skilled position players were typically casted until the end of the season and then underwent repair. A single surgeon performed all procedures. Surgical technique was the same for all patients, which included absorbable suture anchor repair of the UCL to the thumb proximal phalanx utilizing two suture anchors. Patients were then immobilized in a thumb spica. Non-skilled position players were cleared for return to play in a cast after sutures were removed. Skilled position players were not cleared until after the cast was removed. Results: A cohort of 18 collegiate football athletes treated with suture anchor thumb UCL repair at minimum 2 years post-procedure was identified. All 18 patients (100%) were available for evaluation at average 6.0 years follow-up (range, 2.5-9.5 yrs). Nine players were skill position players (WR, TE, RB) while the remaining 9 were non-skill positions (OL, DL, LB.) Average age was 19.7 yrs (range, 18-22 yrs). Average time from injury until surgery was 27 days (range 2-105 days). Average return to play for the entire cohort was 5.4 weeks postoperatively (range, 1.5-12.0 weeks). All players returned to at least the same level of play as preoperatively (collegiate). Seven players eventually continued to play professional football. The average QuickDASH score for the entire cohort was 1.2/100 (95% CI 0.40-2.26). Average QuickDASH Work Score was 0.0/100 (95% CI 0.0-0.0) and average QuickDASH Sport Score was 0.7/100 (95% CI 0.0-1.85). Average time to surgery for skill position (n=9) players was 12 days (range 2-26 days) compared to 43 days (range 10-105) in non-skilled (n=9) position players (p = 0.025). Average return to play for skill position players was 7.0 weeks postoperatively (range 4-12 weeks) compared to 3.8 weeks (range 1.5-8.0 weeks) postoperatively in the non-skilled cohort (p = 0.027). There was no difference in average QuickDASH overall score, work score or sport score between the cohorts (Table I). Conclusion: Collegiate football athletes treated for thumb UCL injuries with dual suture anchor repair have quick return to play, reliable return to the same level of play and excellent long-term clinical outcomes. Using the described treatment protocol, skill position players have surgery earlier after injury and return to play later than non-skill position players, without any differences in final level of play or clinical outcomes. Thus, thumb ulnar collateral ligament injuries can be safely and effectively managed by football position demands.

Osteochondral Autograft Plug Transfer for Treatment of Osteochondritis Dissecans of the Capitellum in Adolescent Athletes

Objectives: Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive over-head sports and can profoundly affect both ability to return to play and long-term elbow function. Large, unstable defects, defined as those greater than 1 cm in size, have unproven or poor long term outcomes with surgical interventions such as fragment excision, microfracture or attempted fixation. Treatment of similarly sized OCD lesions in the knee with osteochondral autograft plug transfer has proven both effective and safe. While interest has developed for expansion of its use to the elbow, it has yet to be adequately studied. The goal of this study is to evaluate clinical outcomes and return to play in adolescent athletes treated with osteochondral autograft plug transfer from the knee for large, unstable OCD defects of the capitellum. Methods: Inclusion Criteria: 1) Inability to participate in competitive sports 2) OCD defect of the capitellum that was either unstable on MRI or in patients who had failed 6 months of conservative treatment 3) Defect measuring at least 1 cm in area on diagnostic arthroscopy 4)Reconstruction of capitellar OCD with osteochondral autograft plug transfer 5) Minimum of 6 months post-operative follow-up. Data collection included chart review, determination of return to play, elbow range of motion, and DASH outcomes. The surgical technique was the same for all patients. It included initial diagnostic elbow arthroscopy, including loose body removal, followed by posterolateral approach to the elbow with lateral collateral ligament takedown from lateral epicondyle and eventual suture anchor repair, preparation of the capitellar osteochondral defect and appropriate plug transfer from the lateral trochlear ridge of the ipsilateral knee through a lateral approach. All patients followed the same post operative protocol, consisting of splint immobilization for 2 weeks, conversion to a hinged elbow brace for 4 weeks with progressive range of motion, and resumption of throwing and strengthening exercises at 3 months. Results: A cohort of 11 patients with a minimum of 6 months post procedure was identified. All patients were available for evaluation at an average 22.7 months follow up (range 6-49 months). Average age at the time of surgery was 14.5 years (range 13-17 years). The group consisted of 10 males and 1 female, all of which were involved in competitive athletics. Average return to play was 4.4 months (range 3-7 months). All athletes returned to at least their same level of play as pre-operatively. 3 have received Division 1 college scholarships (gymnastics, lacrosse and baseball pitcher). Of the 5 pitchers, 4 returned to pitching. The average DASH score was 1.36 (95% CI 0.59-2.12) and the average Sport Specific DASH score was 1.7 (95% CI -1.78-5.17). There were statistically significant improvements in elbow flexion from 125.45 degrees to 141.36 degrees (p=0.009) and extension from 20.45 degrees to 4.55 degrees (p=0.006). There was one adverse event. This consisted of a superficial wound infection, which resolved with surgical debridement and antibiotics and did not adversely affect eventual return to play. There were no complications or donor site morbidity related to graft harvest. Conclusion: Treatment of large, unstable osteochondritis dissecans lesions of the capitellum in adolescent athletes allows reliable return to high level of sports, is safe and has excellent long-term clinical outcomes.