Michael A. Terry

Hip Arthroscopic Surgery Patient Evaluation, Current Indications, and Outcomes

Arthroscopic surgery in the hip joint has historically lagged behind its counterparts in the shoulder and knee. However, the management of hip injuries in the athletic population has rapidly evolved over the past decade with our improved understanding of mechanical hip pathology as well as the marked improvement in imaging modalities and arthroscopic techniques. Current indications for hip arthroscopic surgery may include symptomatic labral tears, femoroacetabular impingement (FAI), hip capsular laxity/instability, chondral lesions, disorders of the peritrochanteric or deep gluteal space, septic joint, loose bodies, and ligamentum teres injuries. Furthermore, hip arthroscopic surgery is developing an increasingly important role as an adjunct diagnostic and therapeutic tool in conjunction with open femoral and/or periacetabular osteotomy for complex hip deformities. Arthroscopic techniques have evolved to allow for effective and comprehensive treatment of various hip deformities. Techniques for extensile arthroscopic capsulotomies have allowed for improved central and peripheral compartment exposure and access for labral takedown, refixation, treatment of chondral injury, and osteochondroplasty of the femoral head-neck junction and acetabular rim. While favorable short-term and midterm clinical outcomes have been reported after arthroscopic treatment of prearthritic hip lesions, greater long-term follow-up is necessary to assess the efficacy of hip arthroscopic surgery in altering the natural history and progressive degenerative changes associated with FAI.

Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment.

Autologous platelet-rich plasma (PRP) therapies have seen a dramatic increase in breadth and frequency of use for orthopaedic conditions in the past 5 years. Rich in many growth factors that have important implications in healing, PRP can potentially regenerate tissue via multiple mechanisms. Proposed clinical and surgical applications include spinal fusion, chondropathy, knee osteoarthritis, tendinopathy, acute and chronic soft-tissue injuries, enhancement of healing after ligament reconstruction, and muscle strains. However, for many conditions, there is limited reliable clinical evidence to guide the use of PRP. Furthermore, classification systems and identification of differences among products are needed to understand the implications of variability.

Measurement variance in limb length discrepancy: clinical and radiographic assessment of interobserver and intraobserver variability.

The purpose of this study was to assess interobserver and intraobserver variability in the assessment of clinical and radiographic measurement of lower limb length discrepancy. Clinical measurements included direct measurement with a tape measure from anterior superior iliac spine (ASIS) to lateral malleolus and ASIS to medial malleolus as well as block measurement. Slit scanogram radiographic measurement was also evaluated. All three clinical measurements had excellent reliability, but the relatively large mean differences and the large 95% confidence intervals for clinical measurements limit the usefulness of these techniques. Slit scanogram measurement was the most reliable measurement technique. The intraobserver variance of direct slit scanogram measurement included intraclass correlation coefficient of 0.99, mean difference of 0.1 cm, and 95% confidence interval of 0.4 cm. Results were not influenced by patient age or body mass index. Slit scanogram measurement is the preferred method for assessment of limb length discrepancy. The direct slit scanogram measurement described in the text follows the mechanical axis line of the leg in the “at ease” standing position described by Paley. Direct measurement using a measuring tape on a full-length slit scanogram is more reliable than indirect measurement using horizontal lines drawn to a radiolucent ruler that is positioned by a technician, since direct measurement avoids errors due to nonparallel positioning of the limb relative to the ruler, and direct measurement also avoids errors due to non-horizontal lines drawn from standard bony landmarks to the ruler. The ideal radiographic measurement technique would have high reliability and accuracy and would minimize or eliminate radiation.

All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii

Objectives: Pathology of the long head of the biceps tendon is a recognized source of shoulder pain in adults that can be treated with tenotomy or tenodesis when non-operative measures are not effective. It is not clear whether arthroscopic or open biceps tenodesis has a clinical advantage. To date, we are not aware of any studies that directly compare clinical outcomes between an arthroscopic and an open technique for tenodesis of the long head of the biceps brachii. The purpose of this study was to determine whether a difference in outcomes and complications exists between matched cohorts after biceps tenodesis utilizing an open subpectoral versus an all-arthroscopic suprapectoral technique. Methods: A prospective database was reviewed for patients undergoing an all-arthroscopic suprapectoral or open subpectoral biceps tenodesis. Adult patients with a minimum 18-month follow-up were included. Patients undergoing a concomitant rotator cuff or labral repair were excluded. The groups were matched to age within 3 years, sex, and time to follow-up within 3 months. Pain improvement, development of a popeye deformity, muscle cramping, post-operative ASES scores, satisfaction scores, and complications were evaluated. Results: Forty-six patients (23 all-arthroscopic, 23 open) patients with an average age of 57.2 years (range, 45-70) were evaluated at a mean 28.7 months (range, 18-42) follow-up. No patients in either group developed a popeye deformity or complained of arm cramping. There was no significant difference in mean ASES scores between the open and all-arthroscopic groups (92.7 vs. 88.9, P = 0.42, Table 1). Similarly, there was no significant difference between patient satisfaction scores (8.9 vs. 9.1, P = 0.73). Eighteen patients (78.3%) in the arthroscopic cohort and sixteen patients (69.6%) in the open cohort fully returned to athletic activity (P = 0.50). There were no complications in the all-arthroscopic group. There were two complications in the open group (superficial incisional erythema, and brachial plexopathy) that resolved by final follow-up. Conclusion: Biceps tenodesis is a reliable treatment option for pathology of the long head of the biceps that may avoid arm cramping and a cosmetic “popeye” deformity that can occur following tenotomy. Open subpectoral and all-arthroscopic suprapectoral are two commonly used techniques to reattach the biceps tendon distal to the bicipital groove. In this study, patients undergoing an all-arthroscopic tenodesis experienced similar pain relief, shoulder function, and return to athletic activity as patients undergoing an open tenodesis. An open subpectoral technique may increase the risk of complications secondary to a larger incision and increased surgical dissection. Larger studies with longer follow-up would help delineate the long-term effects and potential differences between an all-arthroscopic suprapectoral and open subpectoral biceps tenodesis.

The Professional Athlete Spine Initiative: outcomes after lumbar disc herniation in 342 elite professional athletes.

BACKGROUND CONTEXT Although clinical outcomes after lumbar disc herniations (LDHs) in the general population have been well studied, those in elite professional athletes have not. Because these athletes have different measures of success, studies on long-term outcomes in this patient population are necessary. PURPOSE This study seeks to define the outcomes after an LDH in a large cohort of professional athletes of American football, baseball, hockey, and basketball. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 342 professional athletes from four major North American sports from 1972 to 2008 diagnosed with an LDH were identified via a previously published protocol. Two hundred twenty-six players underwent lumbar discectomy, and 116 athletes were treated nonoperatively. Only those players who had at least 2 years of follow-up were included. OUTCOME MEASURES Functional outcome measures as defined by successful return-to-play (RTP), career games, and years played for each player cohort were recorded both before and after treatment. Conversion factors based on games/regular season and expected career length (based on individual sport) were used to standardize the outcomes across each sport. METHODS Using Statistical Analysis Software v. 9.1, outcome measures were compared in each cohort both before and after treatment using linear and mixed regression analyses and Cox proportional hazards models. A Kaplan-Meier survivorship curve was calculated for career length after injury. Statistical significance was defined as p<.05. RESULTS After the diagnosis of an LDH, professional athletes successfully returned to sport 82% of the time, with an average career length of 3.4 years. Of the 226 patients who underwent surgical treatment, 184 successfully returned to play (81%), on average, for 3.3 years after surgery. Survivorship analysis demonstrated that 62.3% of players were expected to remain active 2 years after diagnosis. There were no statistically significant differences in outcome in the surgical and nonoperative cohorts. Age at diagnosis was a negative predictor of career length after injury, whereas games played before injury had a positive effect on outcome after injury. Major League Baseball (MLB) players demonstrated a significantly higher RTP rate than those of other sports, and conversely, National Football League (NFL) athletes had a lower RTP rate than players of other sports (p<.05). However, the greatest positive treatment effect from surgery for LDH was seen in NFL players, whereas for MLB athletes, a lumbar discectomy led to a shorter career compared with the nonoperative cohort (p<.05). CONCLUSIONS Professional athletes diagnosed with an LDH successfully returned to play at a high rate with productive careers after injury. Whereas older athletes have a shorter career length after diagnosis of LDH, experienced players (high number of games played) demonstrate more games played after treatment than inexperienced athletes. Notably, surgical treatment in baseball players led to significantly shorter careers, whereas for NFL athletes, posttreatment careers were longer than those of the corresponding nonoperative cohort. The explanation for this is likely multifactorial, including the age at diagnosis, respective contractual obligations, and different physical demands imposed by each individual professional sport.

Biologic and pharmacologic augmentation of rotator cuff repairs.

As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. Histologic studies have shown that restoration of the rotator cuff footprint during repair can help reestablish the enthesis. In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.

Cyclic Testing of 3 All-Inside Meniscal Repair Devices A Biomechanical Analysis

Background Despite the growing popularity of all-inside meniscal repair devices, concerns remain about their fixation strength. It is also unclear which of these devices have the most ideal biomechanical properties. Purpose To compare the biomechanical properties of 3 all-inside meniscal repair devices: the Meniscal Cinch, Ultra FAST-FIX, and MaxFire. Study Design Controlled laboratory study. Methods Twenty-seven human cadaveric menisci (3 groups of 9) were repaired using 3 different meniscal repair devices. The repaired menisci were then subjected to cyclic loading and load-to-failure testing. Gap formation and ultimate load to failure were measured. Results Six of the devices failed during cyclic testing, 4 in the MaxFire group (44%), 1 in the Ultra FAST-FIX group (11%), and 1 in the Meniscal Cinch group (11%). After 1 cycle, there was a trend toward larger gap formation in the MaxFire group (3.65 mm) compared with the Meniscal Cinch group (2.12 mm, P = .05). After 100 cycles, group differences were found in gap formation (P = .03), with the MaxFire group exhibiting greater displacement (6.70 mm) than the Ultra FAST-FIX group (3.59 mm). After 500 cycles, group differences in gap formation (Meniscal Cinch, 5.94; Ultra FAST-FIX, 4.74 mm; Max Fire, 7.19 mm) did not reach statistical significance (P = .20). A trend was found toward higher ultimate load to failure in the Ultra FAST-FIX (86.1 N) and Meniscal Cinch (85.3 N) groups compared with the MaxFire group (64.5 N, P = .06). Stiffness was also higher in the Ultra FAST-FIX (25.2 N/mm) and Meniscal Cinch (25.5 N/mm) groups than the MaxFire group (16.3 N/mm, P = .02). Conclusion The Meniscal Cinch and Ultra FAST-FIX devices have more desirable biomechanical properties than the MaxFire as demonstrated by higher stiffness and a lower failure rate during cyclic testing. Clinical Relevance The Meniscal Cinch and Ultra FAST-FIX devices may be more desirable implants for use during all-inside meniscal repair as they have superior biomechanical properties when compared with the MaxFire device.

Performance-Based Outcomes After Nonoperative Treatment, Discectomy, and/or Fusion for a Lumbar Disc Herniation in National Hockey League Athletes

Background: Ice hockey players have a high incidence of lumbar spine disorders; however, there is no evidence in the literature to guide the treatment of an ice hockey player with a herniated lumbar disc. Purpose: To determine the performance-based outcomes in professional National Hockey League (NHL) athletes with a lumbar disc herniation after either nonsurgical or surgical treatment. Study Design: Descriptive epidemiological study. Methods: Athletes in the NHL with a lumbar disc herniation were identified through team injury reports and archives on public record. The return-to-play rate, games played per season, points per game, and performance score for each player were determined before and after the diagnosis of a lumbar disc herniation. Statistical analysis was used to compare preinjury and postinjury performance measures for players treated with either nonsurgical or surgical treatment. Results: A total of 87 NHL players met the inclusion criteria; 31 underwent nonoperative care, 48 underwent a discectomy, and 8 underwent a single-level fusion. The return-to-play rate for all players was 85%. There was a significant decrease in performance in all players after a lumbar disc herniation in games played per season, points scored per game, and performance score. A comparison of the posttreatment results for the nonsurgical and surgical patient groups revealed no significant difference in performance measures. Notably, the lumbar fusion group did not show a decrease in games played per season or performance score after surgery, likely secondary to a small sample size. Conclusion: National Hockey League players with a lumbar disc herniation have a high return-to-play rate regardless of the type of treatment; however, performance-based outcomes may decrease compared with preinjury levels. The study data suggest that a lumbar fusion is compatible with a return to play in the NHL, which is in contrast to other professional sports.

Oxidative Cell Membrane Alteration: Evidence for Surfactant-Mediated Sealinga

ABSTRACT: Exposure to very intense ionizing irradiation produces acute tissue sequelae including inflammation, pain, and swelling that often results in tissue fibrosis and/or necrosis. Acute tissue necrosis occurs in hours when sufficiently rapid damage to membrane lipids and proteins leads to altered membrane structure, disrupting the vital electrochemical diffusion barrier necessary for cell survival. 1,2 This damage mechanism is thought to underlie the interphase death of lethally irradiated postmitotic cells such as neurons, but it has also been implicated in the rapid cell death of lymphocytes and acute vascular changes due to capillary epithelium dysfunction. 3,4 It is not known whether sealing of radiation‐permeabilized cell membranes will prolong survival of lethally irradiated cells or perhaps lead to repair of damaged nucleic acids. The purpose of this study is to begin to address the first question.

Solitary Osteochondroma of the Proximal Femur and Femoral Acetabular Impingement

Although osteochondromas can be present within the context of multiple hereditary exostosis, these tumors are overwhelmingly found as isolated lesions. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Despite these observations, the relationship of more common isolated exostoses near the proximal femur and their role in femoral acetabular impingement has never been depicted. Although solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, they have not previously been associated with femoral acetabular impingement. This article presents a novel case of a proximal femoral osteochondroma of the greater trochanter leading to the development and associated symptoms and radiographic findings consistent with hip impingement. A 24-year-old man presented with groin and lower extremity pain thought to be due to an exostosis of the proximal femur. Following surgical excision and persistence of anterior groin pain, the patient was found to display a presentation and radiographic findings consistent with femoral acetabular impingement. He successfully underwent a hip arthroscopy, femoroacetabular osteochondroplasty, and labral repair. Postoperatively, his symptoms improved significantly, and he returned to normal activity. The presence of a proximal femoral exostosis can be associated with the development of femoral acetabular impingement. Awareness of this relationship may lead to a better understanding of patient symptoms and expectations associated with treatment.