Struan H. Coleman

Arthroscopic labral repair versus selective labral debridement in female patients with femoroacetabular impingement: a prospective randomized study.

PURPOSE The purpose of this prospective randomized study was to compare the outcomes of arthroscopic labral repair and selective labral debridement in female patients undergoing arthroscopy for the treatment of pincer-type or combined pincer- and cam-type femoroacetabular impingement. METHODS Between June 2007 and June 2009, 36 female patients undergoing arthroscopic hip treatment for pincer- or combined-type femoroacetabular impingement were randomized to 2 treatment groups at the time of surgery: labral repair or labral debridement. The repair group comprised 18 patients with a mean age of 38; the debridement group comprised 18 patients with a mean age of 39. All patients underwent the same rehabilitation protocol postoperatively. At a minimum of 1 year, all patients were assessed using a validated Hip Outcome Score (HOS) to determine hip function, and also completed a simple subjective outcome measure. RESULTS All 36 patients were available for follow-up at an average time of 32 months (range, 12 to 48). In both groups, HOSs for activities of daily living (ADL) and sports improved significantly from before surgery to the final follow-up (P < .05). The postoperative ADL HOS was significantly better in the repair group (91.2; range, 73 to 100) compared with the debridement group (80.9; range, 42.6 to 100; P < .05). Similarly, the postoperative sports HOS was significantly greater in the repair group (88.7; range, 28.6 to 100) than in the debridement group (76.3; range, 28.6 to 100; P < .05). Additionally, patient subjective outcome was significantly better in the labral repair group (P = .046). CONCLUSIONS Arthroscopic treatment of femoroacetabular impingement with labral repair in female patients resulted in superior improvement in hip functional outcomes compared with labral debridement. In addition, a greater number of patients in the repair group subjectively rated their hip function as normal or nearly normal after surgery compared with the labral debridement group. LEVEL OF EVIDENCE Level I, prospective randomized study.

Arthroscopic Intratendinous Repair of the Delaminated Partial-Thickness Rotator Cuff Tear in Overhead Athletes

A distinct type of partial-thickness rotator cuff tear has been observed in overhead athletes, characterized by partial failure of the undersurface of the posterior supraspinatus and anterior infraspinatus tendons with intratendinous delamination. We present a technique of percutaneous intratendinous repair using nonabsorbable mattress sutures designed for the management of articular-side delaminated partial-thickness tears. After tear evaluation and preparation, the torn rotator cuff undersurface is held in a reduced position with a grasper through an anterolateral rotator interval portal while viewing intra-articularly. Two spinal needles are then placed percutaneously through the full thickness of the torn and intact rotator cuff. A polydioxanone suture is passed through each needle, retrieved out the anterior portal, and used to shuttle a single nonabsorbable No. 2 suture through the tissue, creating a mattress suture. Multiple mattress sutures can be placed as dictated by tear size and morphology, with suture retrieval and knot securing then proceeding in the subacromial space. We have adopted this approach with the goals of anatomically re-establishing the rotator cuff insertion and sealing the area of intratendinous delamination while preventing significant alteration to the anatomy of the rotator cuff insertion, which could lead to motion deficits, internal impingement, and potential tear recurrence.

Biomechanical Analysis of an Ovine Rotator Cuff Repair via Porous Patch Augmentation in a Chronic Rupture Model

Background Rotator cuff repair is a commonly performed procedure, but many of these repairs fail in the postoperative term. Despite advances in surgical methods to optimize the repair, failure rates still persist clinically, thereby suggesting the need for novel mechanical or biological augmentation strategies. Nonresorbable implants provide an appealing approach because patch materials may confer acute mechanical stability and act as a conductive scaffold for tissue ingrowth at the site of the tendon insertion. Hypothesis The polyurethane scaffold mesh will confer greater biomechanical function relative to a nonaugmented repair after 12 weeks in vivo using a chronic ovine model of rotator cuff repair. Study Design Controlled laboratory study. Methods After development of the chronic rupture model, the tensile failure properties of the nonresorbable mesh-augmented repair (n, 9) were compared with those of a surgical control in an ovine model (n, 8). Results Rotator cuff repair with the scaffold mesh in the chronic model resulted in a significant 74.2% increase in force at failure relative to the nonaugmented surgical control (P = .021). Apparent increases in stiffness (55.4%) and global displacement at failure (21.4%) in the mesh-augmented group relative to nonaugmented controls were not significant (P = .126 and P = .123, respectively). At the study endpoint, the augmented shoulders recovered 37.8% and 40.7% of the force at failure and stiffness, respectively, of intact, nonoperated controls. Conclusion Using the previously described chronic rupture model, this study demonstrated that repair of a chronic tendon tear with the polyurethane scaffold mesh provides greater mechanical strength in the critical healing period than that of traditional suture anchor repair. Clinical Relevance This device could be used to enhance the surgical repair of the rotator cuff and consequently improve long-term clinical outcome.

Causes and Risk Factors for Revision Hip Preservation Surgery

Background: Identifying causes and risk factors for failure of hip preservation surgery is critical to properly address residual pathological abnormalities in the revision setting and improve outcomes in this subset of patients. Purpose: To identify the structural causes of failure in both open and arthroscopic hip preservation procedures and to identify demographic and radiographic risk factors that correlate with the need for revision surgery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A single-center hip preservation registry was reviewed (N = 1898 procedures in 1600 patients) to identify 147 patients (n = 152 procedures) who had undergone previous pelvic surgery. Exclusion criteria included residual deformity from pediatric hip disease (n = 5 patients). Preoperative demographics, intraoperative findings, radiographic data, and clinical outcome scores were compared between cohorts with and without revision surgery in the registry. Postoperative, short-term patient-reported outcome scores for the revision cohort were described. Results: The most common reason for revision was residual intra-articular femoroacetabular impingement (74.8%), followed by extra-articular impingement (9.5%). The majority of revision cases (78.9%) could be addressed with arthroscopic surgery, with the exception of extra-articular impingement or residual acetabular dysplasia, which necessitated open approaches. Patients who underwent revision were more likely to be female, were younger in age, and had worse preoperative outcome scores than did those in the primary cohort. Abnormal femoral version and the presence of acetabular dysplasia were not significantly different between the revision and primary cohorts. Short-term improvements in patient-reported outcome scores were found in the revision cohort at a mean of 15.0 months from the last revision surgery. Conclusion: Residual intra- and extra-articular impingement were the most common reasons for revision in this cohort. Patients who underwent revision tended to be younger in age, were female, and had worse preoperative hip functional outcomes than did those in the primary cohort. Abnormal femoral version or acetabular coverage was not increased in our revision cohort.

Intraneural Ganglion Cyst of the Peroneal Nerve Accompanied by Complete Foot Drop A Case Report

Ganglion cysts occurring within sheaths of peripheral nerves have been documented, but are relatively rare entities. In the upper extremity, the most common site of involvement is the ulnar nerve as it passes through the cubital tunnel posterior to the elbow joint. Other common sites include the deep motor branch of the ulnar nerve at the wrist and the median nerve at the elbow. In the lower extremity, the peroneal nerve at the level of the knee and proximal tibiofibular joints is most commonly involved. These lesions are usually seen as tender masses that may cause numbness and tingling in the distribution of the involved nerve. Despite the fact that intraneural ganglions are a well-recognized entity, there are no reports in the literature describing muscle weakness as the primary clinical manifestation of these lesions. We present the case of a recreational athlete who developed a progressive foot drop as a result of compression of the deep peroneal nerve by an intraneural ganglion cyst.

Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial.

BACKGROUND:Hip arthroscopy causes moderate to severe postoperative pain. We hypothesized that performance of a lumbar plexus block (LPB) would reduce postoperative pain in the postanesthesia care unit (PACU) for patients discharged home on the day of surgery. METHODS:Patients received a combined spinal epidural with IV sedation, ondansetron, and ketorolac. Half of the patients (n = 42) also underwent a single-injection bupivacaine LPB. Postoperative analgesia (PACU and after discharge) was provided with oral hydrocodone/acetaminophen (5/500 mg) and an oral nonsteroidal antiinflammatory drug. IV hydromorphone was given as needed in the PACU. RESULTS:The LPB reduced pain at rest in the PACU (GEE: &bgr; estimate of the mean on a 0 to 10 scale = −0.9; 95% confidence interval = −1.7 to −0.1; P = 0.037). Mean PACU pain scores at rest were reduced by the LPB from 4.2 to 3.3 (P = 0.048, 95% confidence interval for difference = 0.007–1.8; uncorrected for multiple values per patient, using independent samples t test for preliminary evaluation comparing pain between the groups). There were no statistically significant differences in PACU analgesic usage, PACU pain with movement, and patient satisfaction. No permanent adverse events occurred, but 2 LPB patients fell in the PACU bathroom, without injury. Three unplanned admissions occurred; one LPB patient was admitted for epidural spread and urinary retention. Two control patients were admitted, one for oxygen desaturation and one for pain and nausea. CONCLUSION:LPB resulted in statistically significant reductions in PACU resting pain after hip arthroscopy, but the absence of improvement in most secondary outcomes suggests that assessment of risks and benefits of LPB should be individualized.

Combined Flexor-Pronator Mass and Ulnar Collateral Ligament Injuries in the Elbows of Older Baseball Players

Background Ulnar collateral ligament reconstruction techniques have afforded baseball players up to a reported 90% return to prior or higher level of play. A subpopulation exists with less impressive clinical outcomes potentially related to the presence of a concomitant flexor-pronator mass injury. Hypothesis/Purpose Combined flexor-pronator and ulnar collateral ligament injuries occur in older players, and results in this group are inferior to those reported for isolated ulnar collateral ligament reconstructions. Study Design Case Series; Level of evidence, 4. Methods All baseball players who had ulnar collateral ligament reconstructions by 1 surgeon over a 6-year period were identified, and the authors studied those treated for a combined flexor-pronator and ulnar collateral ligament injury. The ulnar collateral ligament reconstruction was accomplished using the docking technique, and the flexor-pronator injury was treated with debridement if tendinotic or reattachment if torn. A 2-sample t test was conducted to evaluate the likelihood of developing the combined flexor-pronator/ulnar collateral ligament compared with ulnar collateral ligament injury based on age, while a Pearson χ 2 test was used to evaluate the likelihood of a patient being ≥30 years of age in the combined flexor-pronator/ulnar collateral ligament versus ulnar collateral ligament groups. Outcome was assessed using a modified Conway classification. Results A total of 187 male baseball players between 14 and 42 years of age (mean, 20.7 years) had an ulnar collateral ligament reconstruction by 1 surgeon. Eight (4%) of 187 baseball players were treated for the combined flexor-pronator/ulnar collateral ligament injury. There was a statistically significant difference in age between the ulnar collateral ligament group (20.1 years) and the flexor-pronator/ulnar collateral ligament group (33.4 years) (P < .001). Age ≥30 years was a statistically significant age limit to predict the presence of a combined flexor-pronator/ulnar collateral ligament injury (88%) compared with an isolated ulnar collateral ligament injury (1%) (P < .001). Outcomes were 1 excellent (12.5%), 2 fair (25%), and 5 poor (62.5%). Conclusion Combined fflexor-pronator and ulnar collateral ligament injuries in baseball players may portend a worse prognosis, with a 12.5% return to prior level of play. Older age (≥30 years) is a risk factor in the development of this combined injury. When combined flexor-pronator/ulnar collateral ligament injury is suspected preoperatively, patients should be counseled on expected outcomes appropriately.

Return-to-play rates following arthroscopic treatment of femoroacetabular impingement in competitive baseball players.

ABSTRACT Objective: Femoroacetabular impingement (FAI) has been increasingly recognized in cutting sports including soccer, hockey and football. More recently, the prevalence among overhead athletes has also been recognized. The purpose of this study was to review impingement patterns, return-to-play rates and clinical outcome following arthroscopic treatment of FAI among high-level baseball players. Methods: Between 2010 and 2014, 70 competitive baseball players (86 hips; age 22.4 ± 4.5 years) were identified. Demographics and return-to-play rates were recorded. Patient-reported outcome scores, including the Modified Harris Hip Score (mHHS), the Hip Outcome Score-Activity of Daily Living (HOS-ADL), the Sport-specific Subscale (HOS-SSS), and the International Hip Outcome Tool (iHOT-33), were collected pre-operatively at 6 months and 1year (n = 34, 49% of cohort). Results: The cohort included professional (27.1%), college (57.1%), high-school (8.6%) and club-team athletes (7.1%). Infielder (37.5%), pitcher (22.9%) and catcher (16.7%) were the most common positions. Average follow-up was 16.8 months (range 12.1–34.2). There was no relationship between playing position and impingement pattern (p ≥ 0.459), or between symptom laterality and handedness, batting position or playing position (p ≥ 0.179). One patient required revision surgery (infection). Return to sport rate was 88%, at a mean of 8.6 ± 4.2 months, with 97.7% returning at/above their pre-injury level of play. There was significant improvement in all outcome measures: mHHS (60.1 ± 11.9 to 93 ± 9.5), HOS-ADL (71.3 ± 16.7 to 96.3 ± 3.6), HOS-SSS (51.3 ± 24.8 to 92.3 ± 8.2) and iHOT-33 (40.7 ± 19.9 to 85.9 ± 14) (p < 0.001). Conclusion: Arthroscopic treatment of FAI in competitive baseball players resulted in high return-to-play rates at short-term follow-up, with significant improvements in clinical outcome scores.

The epidemiology of single season musculoskeletal injuries in professional baseball

The aim of this descriptive epidemiology study was to evaluate the injury incidence, pattern and type as a function of position in one professional baseball organization for one complete season. The study was carried out in a major academic center. Participants were all major/minor league baseball players playing for one professional organization. The disabled/injury list of one single professional baseball organization (major and minor league players) was reviewed for all of the injuries and the number of total days missed secondary to each injury. All injuries were categorized into major anatomic zones that included: shoulder, elbow, wrist/hand, back, abdomen/groin, hip, knee, and ankle/foot. The data was further stratified based on the injury type and the number of days missed due to that particular injury and a statistical analysis was performed. In pitchers, elbow injuries (n=12) resulted in 466 days missed. In catchers, wrist injuries (n=4) resulted in 89 days missed. In position players, abdominal/groin injuries (n=16) resulted in 318 days missed and shoulder injuries (n=9) resulted in 527 days missed. Overall, 134 players were injured and a total of 3209 days were missed. Pitchers had 27 times and 34 times the rate of days missed due to elbow injuries compared to position players and all players, respectively. Abdominal and groin injuries caused the pitchers to have 5.6 times and 6.4 times the rate of days missed than the position and all players, respectively. Both elbow and abdominal/groin injuries are the most disabling injury pattern seen in pitchers. Among the position players, shoulder injuries resulted in the most days missed and knee injuries resulted in the highest rate of days missed in both pitchers and catchers.

Diagnosis of Intraabdominal Fluid Extravasation After Hip Arthroscopy With Point-of-Care Ultrasonography Can Identify Patients at an Increased Risk for Postoperative Pain.

BACKGROUND: Intraabdominal fluid extravasation (IAFE) after hip arthroscopy has historically been diagnosed in catastrophic circumstances with abdominal compartment syndrome requiring diuresis or surgical decompression. A previous retrospective study found the prevalence of symptomatic IAFE requiring diuresis or decompression to be 0.16%, with risk factors including surgical procedure and high pump pressures. IAFE can be diagnosed rapidly by using point-of-care ultrasound (POCUS) via the Focused Assessment With Sonography for Trauma (FAST) examination, which is a well-established means to detect free fluid with high specificity and sensitivity. In this study, we used POCUS to determine the incidence of IAFE in patients undergoing hip arthroscopy. We predicted a higher incidence and that patients with IAFE would have symptoms of peritoneal irritation such as pain and nausea. METHODS: One hundred patients undergoing ambulatory hip arthroscopy were prospectively enrolled. A FAST examination was performed after induction by a trained anesthesiologist to exclude the preoperative presence of intraperitoneal fluid. Postoperatively, the same anesthesiologist repeated the FAST examination, and patients with new fluid in the abdominal or pelvic peritoneum were diagnosed with IAFE. Patients were followed up in the postanesthesia care unit (PACU) for 6 hours assessing pain, antiemetic and opioid use, and length of stay. RESULTS: Sixteen of 100 patients were found to have IAFE (16.0%; 99% confidence interval [CI], 8.4–28.1). These patients had, on average, a greater increase in pain score from their baseline assessment throughout their entire PACU stay (adjusted difference in means [99% CI]: 2.1 points [0.4–3.9]; P = .002). Patients with IAFE used more opioids, but this difference did not meet statistical significance (adjusted difference in means [99% CI]: 7.8 mg oral morphine equivalents [−2.8 to 18.3]; P = .053). There were no differences in postoperative nausea interventions or length of stay. CONCLUSIONS: Our incidence of IAFE was 16%, showing that IAFE occurs quite commonly in hip arthroscopy. Patients with IAFE had a greater increase in pain scores from baseline throughout the PACU stay. None of our patients required interventions. These findings suggest that even a small amount of new fluid in the peritoneum may be associated with a worse postoperative experience. This study brings awareness to a common yet potentially life-threatening complication of hip arthroscopy and highlights a unique and meaningful way that anesthesiologists in the perioperative setting can use POCUS to rapidly identify and guide management of these patients. Further studies with a larger sample size are needed to identify surgical and patient risk factors.