Robin R. Leger

The development of an objective model to assess arthroscopic performance.

BACKGROUND Many residency and fellowship programs have cadaver laboratories to teach and practice arthroscopic skills. However, there is currently no validated method of evaluating arthroscopic skill in this setting. The purpose of the present study was to develop and validate an objective model for evaluating basic arthroscopic proficiency on a cadaver knee in a bioskills laboratory. METHODS Two measures from the educational literature were adapted for use specifically for arthroscopy: a task-specific checklist and a global rating scale were combined to create the Basic Arthroscopic Knee Skill Scoring System. Fifty-nine residents, three sports medicine fellows, and six sports medicine fellowship-trained attending surgeons were recruited. After completing a demographic survey, including the postgraduate year and number of knee and shoulder arthroscopies performed, each subject performed a diagnostic knee arthroscopy and a partial meniscectomy on a cadaver knee while being assessed by a single evaluator using the Basic Arthroscopic Knee Skill Scoring System. RESULTS There was a strong positive correlation between global rating scale scores and both the postgraduate year (r = 0.93, p < 0.01) and the ranked number of knee arthroscopies performed (r = 0.88, p < 0.01). These scores detected significant differences between postgraduate years 1 and 2, and years 4 and 5 at the p <or= 0.01 level and between years 2 and 3 at the p <or= 0.05 level. Task-specific checklist scores were moderately correlated with both postgraduate year (r = 0.73, p < 0.01) and ranked number of knee arthroscopies performed (r = 0.64, p < 0.01). These scores detected significant differences only between postgraduate year-1 and year-2 residents at the p <or= 0.01 level, indicating that these skills are acquired early in training. CONCLUSION The Basic Arthroscopic Knee Skill Scoring System can capture and differentiate levels of arthroscopic skill and was validated to objectively evaluate basic arthroscopic proficiency in a bioskills laboratory. This model will allow benchmarks of surgical skill to be created for each level of residency training and individual progress to be monitored over time.

Inter-Rater Agreement of the Goutallier, Patte, and Warner Classification Scores Using Preoperative Magnetic Resonance Imaging in Patients With Rotator Cuff Tears

PURPOSE The purpose of this study was to determine the interobserver reliability of 3 commonly used classification systems in describing preoperative magnetic resonance imaging (MRI) studies of patients undergoing surgery for full-thickness rotator cuff tears. METHODS Thirty-one patients who underwent arthroscopic rotator cuff repair and had preoperative MRI studies available were selected over a 2-year period. Three board-certified shoulder surgeons independently reviewed these images. Each was instructed in the published method for determining the Patte score on the T2 coronal images, supraspinatus and infraspinatus atrophy on the T1 sagittal images as described by Warner et al., and the Goutallier score of fatty infiltration of the supraspinatus on the T1 coronal/sagittal images. Statistical analysis was then performed to determine the interobserver agreement using the κ statistic, with the level of significance set a priori at P < .01. RESULTS None of the classification systems studied yielded excellent or high interobserver reliability. The strongest agreement was found with the Patte classification assessing tendon retraction in the frontal plane (κ = 0.58). The Goutallier classification, which grades fatty infiltration of the supraspinatus, showed moderate interobserver agreement (κ = 0.53) when dichotomized into none to mild (grades 0, 1, and 2) and moderate to severe (grades 3 and 4). Muscle atrophy of both the supraspinatus and infraspinatus yielded the worst interobserver reliability, with only 28% agreement. CONCLUSIONS The Goutallier, Patte, and Warner MRI classification systems for describing rotator cuff tears did not have high interobserver reliability among 3 experienced orthopaedic surgeons. Fatty infiltration of the supraspinatus and tendon retraction in the frontal planes showed only moderate reliability and moderate to high reliability, respectively. These findings have potential implications in the evaluation of the literature regarding the preoperative classification of rotator cuff tears and subsequent treatment algorithms. LEVEL OF EVIDENCE Level III, diagnostic agreement study with nonconsecutive patients.

The Use of Intra-articular Hylan G-F 20 in the Treatment of Symptomatic Osteoarthritis of the Shoulder A Preliminary Study

Background While hylan G-F 20 is an approved therapy for the treatment of knee osteoarthritis, there are few reports of its use in shoulder osteoarthritis. Hypothesis Hylan G-F 20 can reduce pain and improve function in patients with glenohumeral osteoarthritis. Study Design Case series; Level of evidence, 4. Methods Thirty consecutive patients with idiopathic glenohumeral osteoarthritis who failed to respond to standard conservative measures were enrolled. Patients received 3 weekly intra-articular hylan G-F 20 injections in their affected shoulder and completed a visual analog scale for pain, the UCLA score, and the Simple Shoulder Test at baseline and at 1, 3, and 6 months after the third injection. Results Of the 30 patients, 3 withdrew during the washout period before treatment; the remaining patients (17 men and 10 women) had an average age of 62 years. The mean baseline visual analog scale score was 54, UCLA score was 15.7, and Simple Shoulder Test score was 5.7 (of 12 possible “yes” responses). At the 6-month follow-up, hylan G-F 20 significantly improved visual analog scale (mean 30, P < .001), UCLA (mean 24, P < .001), and Simple Shoulder Test (7.6 “yes” responses, P < .001) scores. More patients slept comfortably after treatment (56%) versus before treatment (15%). Nine patients had a visual analog scale improvement >40 points after 6 months. No device-related adverse events were observed. Conclusion Hylan G-F 20 may have a beneficial therapeutic effect on some symptomatic patients with glenohumeral osteoarthritis.

Posterolateral Corner Reconstruction of the Knee: Evaluation of a Technique With Clinical Outcomes and Stress Radiography

Background: Injuries to the posterolateral corner of the knee remain a challenging problem and have been cited frequently as a reason for failure of anterior and posterior cruciate ligament reconstructions. Although several reconstructive techniques currently exist, there are relatively few clinical outcomes data after reconstruction of the posterolateral corner. Purpose: The study was undertaken to examine the clinical outcomes and provide objective data using arthrometry and stress radiography of a posterolateral corner reconstruction technique. Study Design: Case series; Level of evidence, 4. Methods: A retrospective cohort study of a consecutive series of patients who underwent posterolateral corner reconstruction of the knee was evaluated. The surgery featured dual femoral tunnels, a transfibular tunnel, and a free graft to reconstruct the posterolateral corner of the knee. All patients had concomitant reconstruction of one or both cruciate ligaments. Outcomes were assessed using the Short Form–12, Lysholm, and Tegner knee scores. A clinical examination, KT-2000 arthrometry measurements, single-legged hop quotient, and varus and posterior Telos stress radiographs were obtained and compared with results for the contralateral, uninjured knees. Results: Twenty-four (83%) of 29 consecutive patients were evaluated at a mean 39 months postoperatively (range, 24-81 months). The mean Lysholm and Tegner knee scores were 83 and 6, respectively. The mean difference (± standard deviation) in total anterior-posterior side-to-side KT arthrometry measurements was 1.4 ± 1.3 mm. The varus stress radiographic mean side-to-side difference measured at 20° of flexion was 0.2 ± 1.9 mm. The mean radiographic posterior tibial displacement with a 15-kg stress at 90° of flexion was 3.2 ± 4.5 mm in patients undergoing posterior cruciate ligament reconstruction. Conclusion: This reconstruction of the posterolateral corner of the knee with concomitant cruciate ligament reconstruction restores varus and rotational stability at a minimum of 2 years postoperatively.

Relationship of serum relaxin to generalized and trapezial-metacarpal joint laxity.

PURPOSE The reproductive hormone relaxin acts to loosen pelvic ligaments in preparation for childbirth and is thought to be a mediator of joint laxity. The purpose of this study was to evaluate the correlation of serum relaxin with radiographic laxity at the trapezial-metacarpal joint and with generalized joint laxity. METHODS We enrolled 289 healthy subjects prospectively. Participants completed a demographic questionnaire and were examined for generalized joint hypermobility using the Beighton-Horan scale. Stress radiographs of the trapezial-metacarpal joint were obtained in 163 subjects (56%). Blood samples were collected, and serum relaxin was measured for 287 subjects using enzyme-linked immunosorbent assay for human relaxin-2. RESULTS The mean serum relaxin level among all subjects was 1.84 pg/mL (range, 0-45.25 pg/mL). Relaxin was not detectable in 166 of 287 samples, whereas the mean serum relaxin level among the 121 subjects with a detectable relaxin level (of 287 total relaxin samples) was 4.37 pg/mL (range, 0.46-45.25 pg/mL). Mean trapezial-metacarpal subluxation ratio scores were higher among those with a detectable relaxin level compared to those without a detectable relaxin level (0.34 vs 0.30 pg/mL). The average Beighton-Horan laxity score was 1.8 (range, 0-9). There was no correlation between generalized joint laxity measures and serum relaxin levels. CONCLUSIONS In a large volunteer population, we demonstrated a relationship between circulating relaxin and trapezial-metacarpal joint laxity. However, we were unable to show a direct link between serum relaxin and generalized joint laxity. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Duration of postoperative dressing after mini-open carpal tunnel release: a prospective, randomized trial.

PURPOSE In this prospective, randomized, controlled study, we hypothesized that there would be no difference in short-term functional, subjective, and blinded wound outcome measures between patients treated after mini-open carpal tunnel release (CTR) with a postoperative bulky dressing for 2 weeks and those with dressing removal and placement of an adhesive strip after 48 to 72 hours. METHODS A total of 94 consecutive patients underwent mini-open CTR and placement of a bulky dressing and were randomized to either bandage removal at 48 to 72 hours with placement of an adhesive strip or continuation of the postoperative dressing until initial follow-up at approximately 2 weeks. We evaluated patient demographics, Levine-Katz scores, range of motion, strength, and a blinded assessment of wound healing at approximately 2 weeks and between 6 and 12 weeks. We conducted paired and independent sample t-tests to evaluate for statistical significance. RESULTS There was no significant difference in Levine-Katz scores between groups at either the first follow-up or final visit. One patient with a longer dressing duration had evidence of a wound dehiscence. CONCLUSIONS Removal of a bulky dressing after mini-open CTR and replacement with an adhesive strip at 48 to 72 hours causes no wound complications and results in equal short-term clinical and subjective outcome measures compared with using a bulky dressing for 2 weeks. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

Short-term effects of thoracic spinal manipulations and message conveyed by clinicians to patients with musculoskeletal shoulder symptoms: a randomized clinical trial

Abstract Study design: Randomized clinical trial. Objectives: To evaluate the effects of high-velocity, low-amplitude thrust manipulations (HVLATMs) and various messages on patients with musculoskeletal shoulder symptoms. Background: Previous studies indicated that HVLATM directed at the thoracic spine and ribs resulted in improvements of shoulder range of motion, pain, and disability in patients with musculoskeletal shoulder symptoms. These studies did not explore if the outcome was dependent on thrust location, clinician communication with the patient, or if there were any lasting effects. Methods: A consecutive sample of 100 patients with shoulder pain was randomized into four groups. Patients received one intervention session including: six thoracic HVLATM (spine versus scapula), a message about HVLATM (neutral versus positive), and standardized home exercises. Outcome measures included shoulder Numeric Pain Rating Scale (NPRS), NPRS with impingement testing, and Shoulder Pain and Disability Index (SPADI). Measurements were recorded prior to intervention, immediately following intervention, and at short-term follow-up. Kruskal–Wallis statistics were used for between-group comparisons and Wilcoxon signed ranks for within-group comparisons. Results: Eighty-eight patients (22 per group) completed the study. Statistically significant differences were found for within-group comparisons for most time points assessed. No statistical differences were found for between-group comparisons. Conclusion: Patients improved following the interventions. Neither the type of HVLATM nor the message conveyed to the patients had a significant effect on the patients’ improvements. Level of evidence: 1b

Total Hip Arthroplasty Surveillance: When Do We See Our Patients Postoperatively?

Despite the high volume of total hip arthroplasties (THAs) performed in North America, there is no consensus regarding postoperative implant surveillance. Therefore, an Internet survey of Hip Society members was performed to determine the timing of follow-up visits after THA. The surgeons were queried with respect to the time until the first and second postoperative visits and the interval of follow-up for the first and second decades. The average time until the first follow-up visit is 4.9 weeks, and 63% of patients are seen by 6 weeks after surgery. Ninety percent of respondents saw patients at 1 year after THA. Follow-up visits after year 1 were more variable. Guidelines for follow-up should be established to enhance patient outcomes over time.

Severity of illness, functional status, and health-related quality of life in youth with spina bifida

Background As youth with spina bifida age out of pediatrics, they have difficulty transferring care to adult providers. Care is fragmented with a loss of follow-up. Clinicians in adult health care are untrained in historically, pediatric conditions. Understanding health status, functional status, and health-related quality of life [1]in spina bifida is important in a life-span approach to care.