Shane J. Nho

Complications and Reoperations During and After Hip Arthroscopy: A Systematic Review of 92 Studies and More Than 6,000 Patients

PURPOSE To determine the prevalence of complications and reoperations during and after hip arthroscopy. METHODS A systematic review of multiple medical databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All clinical outcome studies that reported the presence or absence of complications and/or reoperations were eligible for inclusion. Length of follow-up was not an exclusion criterion. Complication and reoperation rates were extracted from each study. Duplicate patient populations within separate distinct publications were analyzed and reported only once. RESULTS Ninety-two studies (6,134 participants) were included. Most were Level IV evidence studies (88%) with short-term follow-up (mean 2.0 years). Labral tears and femoroacetabular impingement (FAI) were the 2 most common diagnoses treated, and labral treatment and acetabuloplasty/femoral osteochondroplasty were the 2 most common surgical techniques reported. Overall, major and minor complication rates were 0.58% and 7.5%, respectively. Iatrogenic chondrolabral injury and temporary neuropraxia were the 2 most common minor complications. The overall reoperation rate was 6.3%, occurring at a mean of 16 months. Total hip arthroplasty (THA) was the most common reoperation. The conversion rate to THA was 2.9%. CONCLUSIONS The rate of major complications was 0.58% after hip arthroscopy. The reoperation rate was 6.3%, and the most common reason for reoperation was conversion to THA. Minor complications and the reoperation rate are directly related to the learning curve of hip arthroscopy. As surgical indications evolve, patient selection should limit the number of cases that would have been converted to THA. Similarly, the number of minor complications is directly related to technical aspects of the procedure and therefore will decrease with surgeon experience and improvement in instrumentation. LEVEL OF EVIDENCE Level IV, a systematic review of Level I to IV studies.

Outcomes after the Arthroscopic Treatment of Femoroacetabular Impingement in a Mixed Group of High-Level Athletes:

Background Femoroacetabular impingement has become more widely recognized in the athletic patient population. The purpose of the present study was to review the clinical outcome after arthroscopic treatment of femoroacetabular impingement in a mixed population of high-level athletes. Hypothesis Arthroscopic treatment of femoroacetabular impingement results in significant improvement in clinical outcome and a high rate of return to play. Study Design Case series; Level of evidence, 4. Methods High-level athletes who underwent arthroscopic treatment of femoroacetabular impingement (rim trimming, labral refixation or debridement, femoral osteochondroplasty) with a minimum of 1-year follow-up were retrospectively identified. All patients completed hip-specific outcome scores (Modified Harris Hip Score [MHHS] and Hip Outcome Score [HOS]) at baseline and most recent follow-up. Results Forty-seven patients with an average age of 22.8 ± 6.2 years met the study criteria with a mean follow-up of 27.0 ± 5.5 months. Thirty-three patients (70.2%) were available for follow-up. The level of competition was 27.7% varsity high school, 53.2% college, and 19.1% professional athletes. There were statistically significant improvements in the mean MHHS score (preoperative, 68.6 ± 12.8; postoperative, 88.5 ± 17.7; P = .002) as well as the HOS score (preoperative, 78.8 ± 11.3; postoperative, 91.4 ± 14.0; P = .03). There was a significant improvement in the alpha angle, with 76.4° ± 14.5° preoperatively and 51.4° ± 11.7° postoperatively (P = .0003). Seventy-nine percent of patients were able to return to play after hip arthroscopy at a mean of 9.4 ± 4.7 months (range, 4-26 months); of those patients, 92.3% were able to return to the same level of competition. At 2-year follow-up, 73% of patients were able to return to play. Conclusion Arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes may result in a significant improvement in hip functional outcome: 78% of athletes were able to return to play at 1 year and 73% of athletes were able to play at 2-year follow-up.

Prospective analysis of arthroscopic rotator cuff repair: Prognostic factors affecting clinical and ultrasound outcome

The purpose of this study was to identify potential predictors of function and tendon healing after arthroscopic rotator cuff repair that will enable the orthopaedic surgeon to determine which patients can expect a successful outcome. Between 2003 and 2005, the Arthroscopic Rotator Cuff Registry was established to collect demographic, intraoperative, functional outcome, and ultrasound data prospectively on all patients who underwent primary arthroscopic rotator cuff repair. At total of 193 patients met the study criteria, and 127 (65.8%) completed the 2-year follow-up. The most significant independent factors affecting ultrasound outcome were age (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.02-1.14; P = .006) and tear size (OR, 2.29; 95% CI, 1.55-3.38; P < .001). After adjustment for age and tear size, the intraoperative factors found to be significantly associated with a tendon defect were concomitant biceps procedures (OR, 11.39; 95% CI, 2.90-44.69; P < .001) and acromioclavicular joint procedures (OR, 3.85; 95% CI, 1.46-10.12; P = .006). In contrast to the ultrasound data, the functional outcome variables, such as satisfaction (OR, 3.92; 95% CI, 2.00-7.68; P < .001) and strength (OR, 10.05; 95% CI, 1.61-62.77; P = .01), had a greater role in predicting an American Shoulder and Elbow Surgeons score greater than 90. The progression from a single-tendon rotator cuff tear to a multiple-tendon tear with associated pathology increased the likelihood of tendon defect by at least 9 times, and therefore, earlier surgical intervention for isolated, single-tendon rotator cuff tears could optimize the likelihood of ultrasound healing and an excellent functional outcome.

Management of proximal humeral fractures based on current literature

Proximal humeral fractures are the second most common upper-extremity fracture and the third most common fracture, after hip fractures and distal radial fractures, in patients who are older than sixty-five years of age1. Although the overwhelming majority of proximal humeral fractures are either nondisplaced or minimally displaced and can be treated with sling immobilization and physical therapy, approximately 20% of displaced proximal humeral fractures may benefit from operative treatment. Many surgical techniques have been described, but no single approach is considered to be the standard of care. Surgeons who treat proximal humeral fractures should be able to identify the fracture pattern and select an appropriate treatment on the basis of this pattern and the underlying quality of the bone. Orthopaedic surgeons should have experience with a broad range of techniques, including transosseous suture fixation, closed reduction and percutaneous fixation, open reduction and internal fixation with conventional and locked-plate fixation, and hemiarthroplasty. In the future, locked-plate technology and the use of osteobiologics may play an increasingly important role in the treatment of displaced proximal humeral fractures, facilitating preservation of the humeral head in appropriately selected patients. The goals of this article are to enable the reader to: (1) become familiar with the recent literature on the classification of and treatment options for proximal humeral fractures, and (2) better identify fracture characteristics and devise an appropriate treatment plan. ### Transosseous Suture Fixation #### Surgical Technique Park et al.2 described different operative approaches for each fracture pattern described by Neer 3. For two-part greater tuberosity fractures, an anterosuperior approach along the Langer lines extending from the lateral aspect of the acromion toward the lateral tip of the coracoid is used. The split occurs in the anterolateral raphe and allows exposure of the displaced greater tuberosity fracture. When a surgical neck fracture exists, Park et al.2 …

Prospective Evaluation of Allograft Meniscus Transplantation A Minimum 2-Year Follow-up

Background Clinical and biomechanical studies have demonstrated the increase in contact pressure and progressive deterioration of the tibiofemoral compartments that occur after partial or complete meniscectomy. Meniscus transplantation has been indicated for the symptomatic postmeniscectomy patient to alleviate symptoms and potentially prevent the progression of articular degeneration. Purpose To report the early-term results after allograft meniscus transplantations from a single institution performed by a single surgeon. Study Design Case series; Level of evidence, 4. Methods Forty-four meniscus transplants in 39 patients were evaluated at minimum 2-year follow-up using the Lysholm, Tegner, International Knee Documentation Committee, Knee Injury and Osteoarthritis Outcome Score, Noyes symptom rating and sports activity, and SF-12 scoring systems; visual analog pain scales; patient satisfaction; and physical examination. Four transplants failed early, leaving 40 transplants in 36 patients for review. Patients were grouped into medial and lateral transplant groups as well as those with isolated and combined procedures. Twenty-one menisci were transplanted in isolation (52.5%), and 19 were combined with other procedures (47.5%) to address concomitant articular cartilage injury. Results Patients demonstrated statistically significant improvements in standardized outcomes surveys and visual analog pain and satisfaction scales. In 7 patients, treatment had failed at final follow-up. Overall, 77.5% of patients reported they were completely or mostly satisfied with the procedure, and 90% of patients were classified as normal or nearly normal using the International Knee Documentation Committee knee examination score at final follow-up. There were no significant differences in the medial and lateral subgroups, although the lateral subgroup did demonstrate a trend toward greater improvement. No significant differences were noted in the isolated and combined subgroups. Conclusion Meniscus transplantation alone or in combination with other reconstructive procedures results in reliable improvements in knee pain and function at minimum 2-year follow-up. Longer term studies are necessary to determine if transplantation can prevent the articular degeneration associated with meniscectomy.

Does the Literature Confirm Superior Clinical Results in Radiographically Healed Rotator Cuffs After Rotator Cuff Repair

PURPOSE Because recurrent or persistent defects in the rotator cuff after repair are common, we sought to clarify the correlation between structural integrity of the rotator cuff and clinical outcomes through a systematic review of relevant studies. METHODS Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials were searched for all literature published from January 1966 to December 2008 that used the key words shoulder, rotator cuff, rotator cuff tear, rotator cuff repair, arthroscopic, integrity, healed, magnetic resonance imaging (MRI), computed tomography arthrography (CTA), and ultrasound. The inclusion criteria were studies (Levels I to IV) that reported outcomes after arthroscopic rotator cuff repair in healed and nonhealed repairs based on ultrasound, CTA, and/or MRI. Exclusionary criteria were studies that included open repair or subscapularis repair and studies that did not define outcomes based on healed versus nonhealed but rather used another variable (i.e., repair technique). Data were abstracted from the studies including patient demographics, tear characteristics, surgical procedure, rehabilitation, strength, range of motion, clinical scoring systems, and imaging studies. RESULTS Thirteen studies were included in the final analysis: 5 used ultrasound, 4 used MRI, 2 used CTA, and 2 used combined CTA/MRI for diagnosis of a recurrent tear. Statistical improvement in patients who had an intact cuff at follow-up was seen in Constant scores in 6 of 9 studies; in University of California, Los Angeles scores in 1 of 2 studies; in American Shoulder and Elbow Surgeons scores in 0 of 3 studies; and in Simple Shoulder Test scores in 0 of 2 studies. Increased range of motion in forward elevation was seen in 2 of 5 studies and increased strength in forward elevation in 5 of 8 studies. CONCLUSIONS The results suggest that some important differences in clinical outcomes likely exist between patients with healed and nonhealed rotator cuff repairs. Further study is needed to conclusively define this difference and identify other important prognostic factors related to clinical outcomes. LEVEL OF EVIDENCE Level IV, systematic review.

Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery

BACKGROUND Tenodesis of the long head of the biceps tendon is a common procedure used to alleviate pain caused by instability or inflammation of the tendon. The purpose of this study is to report on the incidence and types of complications following an open subpectoral biceps tenodesis (OBT) procedure. HYPOTHESIS Our hypothesis was that the rate of adverse events after OBT was low. METHODS From January 2005 to December 2007, all patients that underwent an OBT with bioabsorbable interference screw fixation performed by 1 of the 2 senior authors for biceps tendonitis were reviewed, excluding tenotomy, revision cases, or fixation methods other than interference screw fixation. RESULTS Over a 3-year period, 7 of 353 patients had complications with OBT with an incidence of 2.0%. The mean age of patients with complications was 44.67 years, with 57.1% males and 42.9% females. There were 2 patients (0.57%) with persistent bicipital pain. Two patients (0.57%) had failure of fixation resulting in a Popeye deformity. One patient (0.28%) presented with a deep postoperative wound infections that necessitated irrigation and debridement with intravenous antibiotics. Another patient (0.28%) developed a musculotaneous neuropathy. Another patient (0.28%) developed reflex sympathetic dystrophy necessitating pain management and stellate ganglion block. CONCLUSION The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2.0%.

Long Head of the Biceps Tendinopathy: Diagnosis and Management

&NA; Tendinopathy of the long head of the biceps brachii encompasses a spectrum of pathology ranging from inflammatory tendinitis to degenerative tendinosis. Disorders of the long head of the biceps often occur in conjunction with other shoulder pathology. A thorough patient history, physical examination, and radiographic evaluation are necessary for diagnosis. Nonsurgical management, including rest, nonsteroidal anti‐inflammatory drugs, physical therapy, and injections, is attempted first in patients with mild disease. Surgical management is indicated for refractory or severe disease. In addition to simple biceps tenotomy, a variety of tenodesis techniques has been described. Open biceps tenodesis has been used historically. However, promising results have recently been reported with arthroscopic tenodesis.

Thermal chondroplasty of chondromalacic human cartilage. An ex vivo comparison of bipolar and monopolar radiofrequency devices.

We compared the effects of treatment with bipolar and monopolar radiofrequency energy on 30 osteochondral sections harvested from 22 patients with spontaneously occurring chondromalacia who were undergoing knee arthroplasty. Specimens with chondromalacia grades 2 or 3 were randomly assigned to one of two bipolar or one monopolar treatment groups. All samples were marked and mounted on a jig to allow simulation of an arthroscopic surgical procedure with a flow rate of 100 ml/min of a balanced electrolyte solution at 22°C. Under arthroscopic visualization, the designated area was treated until smooth, and the total treatment time was recorded. There was no difference in patients’ ages, chondromalacia grade, or cartilage thickness among groups. Significant chondrocyte death, as determined by cell viability staining with confocal laser microscopy, was observed with each group. The bipolar devices produced significantly greater depths of chondrocyte death (2228 ± 1003 μm and 2810 ± 517 μm) than did the monopolar device (737 ± 391 μm). The bipolar devices caused cell death to subchondral bone significantly more often (13 of 20 specimens) than did the monopolar device (0 of 10 specimens). Caution should be used in treating fibrillated cartilage with radiofrequency energy, particularly with the bipolar devices tested.

Rotator Cuff Degeneration: Etiology and Pathogenesis

By virtue of its anatomy and function, the rotator cuff is vulnerable to considerable morbidity, often necessitating surgical intervention. How we intervene is governed by our understanding of the pathological mechanisms in cuff disease. These factors can be divided into those extrinsic to the rotator cuff (impingement, demographic factors) and those intrinsic to the cuff (age-related degeneration, hypovascularity, inflammation, and oxidative stress, among others). In an era where biologic interventions are increasingly being investigated, our understanding of these mechanisms is likely to become more important in designing effective new interventions. Here we present a literature review summarizing our current understanding of the pathophysiological mechanisms underlying rotator cuff degeneration.