Thomas M. DeBerardino

A Prospective, Randomized Evaluation of Arthroscopic Stabilization Versus Nonoperative Treatment in Patients with Acute, Traumatic, First-Time Shoulder Dislocations

Background Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. Hypothesis Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. Study Design Prospective, randomized clinical trial. Methods Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. Results Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. Conclusions Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

A Prospective Study of Autologous Chondrocyte Implantation in Patients With Failed Prior Treatment for Articular Cartilage Defect of the Knee: Results of the Study of the Treatment of Articular Repair (STAR) Clinical Trial

Background This is a prospective clinical study to assess the effectiveness of autologous chondrocyte implantation in patients who failed prior treatments for articular cartilage defects of the knee. Hypothesis Autologous chondrocyte implantation provides clinical benefit in patients with failed articular cartilage treatments. Study Design Cohort study; Level of evidence, 2. Methods One hundred fifty-four patients with failed treatment for articular cartilage defects of the knee received autologous chondrocyte implantation in a multicenter, prospective study. Follow-up was 48 months. Outcomes included change from baseline in knee function, knee pain, quality of life, and overall health. Duration of benefit after autologous chondrocyte implantation was compared with the failed prior non—autologous chondrocyte implantation procedure. Safety information was recorded. Additional analyses were performed on the 2 major cohorts of prior procedures entered into the study, marrow-stimulation technique or debridement alone, to assess if there were any significant differences in baseline characteristics, outcomes, or prognosis between the 2 groups. Results One hundred twenty-six patients (82%) completed the protocol. Seventy-six percent of patients were treatment successes at study end, while 24% were deemed treatment failures. Preoperative mean knee pain score was 3.0 (SD, 1.8; 0 = severe, 10 = normal). Mean improvements were observed from baseline to all time points (P < .001) for all outcome measures. Preoperative to 48-month values, respectively, were as follows: On the Knee injury and Osteoarthritis Outcome Score subscales of pain: 48.7 to 72.2; other symptoms: 51.8 to 70.8; sports/recreation: 25.8 to 55.8; knee quality of life: 20.9 to 52.2; and activities of daily living: 58.6 to 81.0; on the Modified Cincinnati Overall Knee score: 3.3 to 6.3; on the visual analog scale: 28.8 to 69.9; and on the SF-36 Overall Physical Health 33.0 to 44.4. Results did not differ between patients whose primary surgery had been a marrow-stimulating procedure and those whose primary procedure had been a debridement alone. The median difference in duration of benefit between autologous chondrocyte implantation and the failed non—autologous chondrocyte implantation prior procedure was at least 31 months (P < .001). Seventy-six patients (49%) had subsequent surgical procedure(s), predominantly arthroscopic. Need for a subsequent surgical procedure was not predictive of failure. Conclusion Patients with moderate to large chondral lesions with failed prior cartilage treatments can expect sustained and clinically meaningful improvement in pain and function after autologous chondrocyte implantation. The subsequent surgical procedure rate observed in this study (49% overall; 40% related to autologous chondrocyte implantation) appears higher than generally reported after autologous chondrocyte implantation.

The Incidence and Characteristics of Shoulder Instability at the United States Military Academy

Background The literature provides little information detailing the incidence of traumatic shoulder instability in young, healthy athletes. Hypothesis Shoulder instability is common in young athletes. Study Design Descriptive epidemiologic study. Methods We prospectively captured all traumatic shoulder instability events at the United States Military Academy between September 1, 2004, and May 31, 2005. Throughout this period, all new traumatic shoulder instability events were evaluated with physical examination, plain radiographs, and magnetic resonance imaging. Instability events were classified according to direction, chronicity, and type (subluxation or dislocation). Subject demographics, mechanism of injury, and sport were evaluated. Results Among 4141 students, 117 experienced new traumatic shoulder instability events during the study period; 11 experienced multiple events. The mean age of these 117 subjects was 20.0 years; 101 students were men (86.3%), and 16 were women (13.7%). The 1-year incidence proportion was 2.8%. The male incidence proportion was 2.9% and the female incidence proportion was 2.5%. Eighteen events were dislocations (15.4%), and 99 were subluxations (84.6%). Of the 99 subluxations, 45 (45.5%) were primary events, while 54 (54.5%) were recurrent. Of the 18 dislocations, 12 (66.7%) were primary events, while 6 (33.3%) were recurrent. The majority of the 117 events were anterior in nature (80.3%), while 12 (10.3%) were posterior, and 11 (9.4%) were multidirectional. Forty-four percent (43.6%) of the instability events experienced were as a result of contact injuries, while 41.0% were a result of noncontact injuries, including 9 subluxations caused by missed punches during boxing; information was unavailable for the remaining 15%. Conclusion Glenohumeral instability is a common injury in this population, with subluxations comprising 85% of instability events.

Descriptive epidemiology of the Multicenter ACL Revision Study (MARS) cohort.

Background Revision anterior cruciate ligament (ACL) reconstruction has worse outcomes than primary reconstructions. Predictors for these worse outcomes are not known. The Multicenter ACL Revision Study (MARS) Group was developed to perform a multisurgeon, multicenter prospective longitudinal study to obtain sufficient subjects to allow multivariable analysis to determine predictors of clinical outcome. Purpose To describe the formation of MARS and provide descriptive analysis of patient demographics and clinical features for the initial 460 enrolled patients to date in this prospective cohort. Study Design Cross-sectional study; Level of evidence, 2. Methods After training and institutional review board approval, surgeons began enrolling patients undergoing revision ACL reconstruction, recording patient demographics, previous ACL reconstruction methods, intra-articular injuries, and current revision techniques. Enrolled subjects completed a questionnaire consisting of validated patient-based outcome measures. Results As of April 1, 2009, 87 surgeons have enrolled a total of 460 patients (57% men; median age, 26 years). For 89%, the reconstruction was the first revision. Mode of failure as deemed by the revising surgeon was traumatic (32%), technical (24%), biologic (7%), combination (37%), infection (<1%), and no response (<1%). Previous graft present at the time of injury was 70% autograft, 27% allograft, 2% combination, and 1% unknown. Sixty-two percent were more than 2 years removed from their last reconstruction. Graft choice for revision ACL reconstruction was 45% autograft, 54% allograft, and more than 1% both allograft and autograft. Meniscus and/or chondral damage was found in 90% of patients. Conclusion The MARS Group has been able to quickly accumulate the largest revision ACL reconstruction cohort reported to date. Traumatic reinjury is deemed by surgeons to be the most common single mode of failure, but a combination of factors represents the most common mode of failure. Allograft graft choice is more common in the revision setting than autograft. Concomitant knee injury is extremely common in this population.

Prospective Evaluation of Arthroscopic Stabilization of Acute, Initial Anterior Shoulder Dislocations in Young Athletes Two- to Five-Year Follow-up

From March 1992 to November 1998, 57 patients sustained 58 acute, initial, traumatic anterior shoulder dislocations at the United States Military Academy. Six patients selected nonoperative treatment. Three patients underwent primary open repair after diagnostic arthroscopy revealed no Bankart lesion amenable to repair with the bioabsorbable tissue tack. The remaining 48 patients with 49 anterior dislocations were treated with arthroscopic primary repair. There were 45 men and 3 women with an average age of 20 years (range, 17 to 23) and an average follow-up of 37 months (range, 24 to 60). The average Rowe score was 92 (range, 30 to 100). The average single assessment numeric evaluation patient rating was 95.5% (range, 50% to 100%). The average Short Form-36 score (physical function) for the stable shoulders was 99 (range, 95 to 100). Forty-three shoulders remained stable (88%). There were six failures (12%). Factors associated with failure included a history of bilateral shoulder instability, a 2+ sulcus sign, and poor capsulolabral tissue at the time of repair. All patients with stable shoulders returned to their preinjury levels of athletic activity. With follow-up of 5 years, we have observed significantly better results compared with nonoperative treatment in young, active adults at the United States Military Academy.

Epidemiology of Ankle Sprain at the United States Military Academy

Background Ankle sprain is a common injury in athletic populations that results in significant time lost to injury. Hypothesis The incidence rates (IRs) of ankle ligament sprains are influenced by gender, height, weight, body mass index (BMI), physical conditioning, level of competition, type of sport, and athlete exposure to sport. Study Design Cohort study; Level of evidence, 2. Methods A longitudinal cohort study was performed to determine the effect of risk factors for ankle sprain at the United States Military Academy between 2005 and 2007. Results A total 614 cadets sustained new ankle sprains during 10 511 person-years at risk, resulting in an overall IR of 58.4 per 1000 person-years. Women (96.4), compared with men (52.7), had a significantly increased rate ratio (IRR) for ankle sprain of 1.83 (95% confidence interval [CI], 1.52-2.20). Men with ankle sprains had higher mean height, weight, and BMI than uninjured men (P < .001). Men with ankle sprains had higher average scores in push-ups, sit-ups, and run time than uninjured men (P < .001). Ankle sprain occurred most commonly during athletics (64.1%). Ankle sprain IR did not significantly differ between intercollegiate and intramural athletic competition after controlling for athlete-exposure (IRR, 1.05; 95% CI, 0.81-1.37). The ankle sprain IRR of female compared with male intercollegiate athletes was 0.93 (95% CI, 0.67-1.32) per 1000 person-years and 1.04 (95% CI, 0.74-1.47) per 1000 athlete-exposures. The intercollegiate sports of mens rugby, womens cheerleading, and mens/womens basketball, soccer, and lacrosse had the highest ankle sprain IR. Conclusion Higher mean height and weight in men, increased BMI in men, greater physical conditioning in men, and athlete exposure to selected sports were all risk factors for ankle sprain.

Long-term Follow-up of Acute Arthroscopic Bankart Repair for Initial Anterior Shoulder Dislocations in Young Athletes

Background Little is known of the long-term results of acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations. Hypothesis Acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations will provide good results at long-term follow-up. Study Design Case series; Level of evidence, 4. Methods The authors evaluated a cohort of young patients who sustained first-time anterior glenohumeral dislocations and were acutely treated with arthroscopic Bankart repair using bioabsorbable tacks. Subjective outcome measures were obtained at a mean follow-up of 11.7 years (range, 9.1-13.9 years). Results Thirty-nine patients (40 shoulders) were available of the original cohort of 49 shoulders (82%). Two of the 9 who were lost to follow-up had revision surgery before being lost and are carried forward in the calculations of recurrent instability and revision surgery but are not included in the calculation of the functional scores. The mean Single Assessment Numeric Evaluation was 91.7, the mean Western Ontario Shoulder Instability score was 371.7, the mean subjective Rowe score was 25.3, the mean Simple Shoulder Test was 11.1, the mean American Shoulder and Elbow Society score was 90.9, the mean Short Form-36 Physical Component score was 94.4, and the mean Tegner score was 6.5. Six patients sustained recurrent dislocations for a redislocation rate of 14.3%. Nine patients (21.4%) reported experiencing subluxation events. Six patients (14.3%) underwent revision stabilization surgery. Conclusion At long-term follow-up, acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics in young, active patients with an acceptable rate of recurrence and reoperation.

The Relationship Between Posterior Tibial Slope and Anterior Cruciate Ligament Injuries

Background Two previous studies have examined the association between an increased posterior tibial slope and anterior cruciate ligament (ACL) injuries as measured on plain radiographs. The study results were contradictory, with 1 reporting a statistical difference and the other showing no association. Purpose To determine if there is a difference in posterior tibial slope angle between patients with a history of noncontact ACL injury and a control group with no history of ACL injury. A secondary objective was to examine differences in tibial slope angle between male and female subjects within each group. Study Design Case-control study; Level of evidence, 3. Methods We identified all noncontact ACL injuries that were treated operatively at the United States Military Academy, West Point, New York, from 2004 to 2007. We digitally measured the posterior tibial slope from plain film radiographs of 140 noncontact ACL injuries, stratified them by sex, and compared them with a control cohort of 179 patients and radiographs. Results Subjects in the noncontact ACL group had significantly greater slope angles (9.39° ± 2.58°) than did control subjects (8.50° ± 2.67°) (P = .003). The trend toward greater tibial slope angles in the noncontact ACL group was also observed when each sex was examined independently; however, the difference was only statistically significant for the female subjects between the injury and control groups (9.8° ± 2.6° vs 8.20° ± 2.4°) (P = .002). Conclusion Despite the identification of an increased posterior tibial slope as a possible risk factor for women, more research that combines the multifactorial nature of an ACL injury must be performed.

NeoCart, an autologous cartilage tissue implant, compared with microfracture for treatment of distal femoral cartilage lesions: an FDA phase-II prospective, randomized clinical trial after two years.

BACKGROUND Despite introduction of autologous chondrocyte therapy for repair of hyaline articular cartilage injury in 1994, microfracture remains a primary standard of care. NeoCart, an autologous cartilage tissue implant, was compared with microfracture in a multisite prospective, randomized trial of a tissue-engineered bioimplant for treating articular cartilage injuries in the knee. METHODS Thirty patients were randomized at a ratio of two to one (two were treated with an autologous cartilage tissue implant [NeoCart] for each patient treated with microfracture) at the time of arthroscopic confirmation of an International Cartilage Repair Society (ICRS) grade-III lesion(s). Microfracture or cartilage biopsy was performed. NeoCart, produced by seeding a type-I collagen matrix scaffold with autogenous chondrocytes and bioreactor treatment, was implanted six weeks following arthroscopic cartilage biopsy. Standard evaluations were performed with validated clinical outcomes measures. RESULTS Three, six, twelve, and twenty-four-month data are reported. The mean duration of follow-up (and standard deviation) was 26 ± 2 months. There were twenty-one patients in the NeoCart group and nine in the microfracture group. The mean age (40 ± 9 years), body mass index (BMI) (28 ± 4 kg/m2), duration between the first symptoms and treatment (3 ± 5 years), and lesion size (287 ± 138 mm2 in the NeoCart group and 252 ± 135 mm2 in the microfracture group) were similar between the groups. Adverse event rates per procedure did not differ between the treatment arms. The scores on the Short Form-36 (SF-36), Knee Injury and Osteoarthritis Outcome Score (KOOS) activities of daily living (ADL) scale, and International Knee Documentation Committee (IKDC) form improved from baseline (p < 0.05) to two years postoperatively in both treatment groups. In the NeoCart group, improvement, compared with baseline, was significant (p < 0.05) for all measures at six, twelve, and twenty-four months. Improvement in the NeoCart group was significantly greater (p < 0.05) than that in the microfracture group for the KOOS pain score at six, twelve, and twenty-four months; the KOOS symptom score at six months; the IKDC, KOOS sports, and visual analog scale (VAS) pain scores at twelve and twenty-four months; and the KOOS quality of life (QOL) score at twenty-four months. Analysis of covariance (ANCOVA) at one year indicated that the change in the KOOS pain (p = 0.016) and IKDC (p = 0.028) scores from pretreatment levels favored the NeoCart group. Significantly more NeoCart-treated patients (p = 0.0125) had responded to therapy (were therapeutic responders) at six months (43% versus 25% in the microfracture group) and twelve months (76% versus 22% in the microfracture group). This trend continued, as the proportion of NeoCart-treated patients (fifteen of nineteen) who were therapeutic responders at twenty-four months was greater than the proportion of microfracture-treated participants (four of nine) who were therapeutic responders at that time. CONCLUSIONS This randomized study suggests that the safety of autologous cartilage tissue implantation, with use of the NeoCart technique, is similar to that of microfracture surgery and is associated with greater clinical efficacy at two years after treatment.

Operative stabilization of posterior shoulder instability.

Background Symptomatic, traumatic posterior shoulder instability is often the result of a posteriorly directed blow to an adducted, internally rotated, and forward-flexed upper extremity. Operative repair has been shown to provide favorable results. Current arthroscopic techniques with suture anchors and the ability to plicate the capsule using a nonabsorbable suture may provide favorable outcomes with reduced morbidity. Purpose To evaluate the results of operative shoulder stabilization in patients with traumatic posterior shoulder instability. Study Design Case series; Level of evidence, 4. Methods A consecutive series of patients who underwent arthroscopic or open posterior stabilization for traumatic posterior shoulder instability were evaluated using subjective assessments, physical examinations, the Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and the Western Ontario Shoulder Instability Index. Results Between May 1996 and February 2002, 31 shoulders (30 patients) underwent posterior stabilization (19 arthroscopically, 12 open). There were 29 men and 1 woman (mean age, 23 years). Preoperatively, all patients had a distinct traumatic cause for the instability. On physical examination, all patients had posterior apprehension and increased (2+, 3+) posterior load-shift testing. Preoperative radiographs and/or magnetic resonance imaging revealed posterior rim calcification or reverse Bankart lesions in 29 cases (94%). At arthroscopy, posterior labral injuries, reverse Bankart lesions, or humeral head defects were identified. Follow-up averaged 40 months, and the mean duration between injury and surgery was 21 months. The mean Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and Western Ontario Shoulder Instability Index scores, respectively, for the entire group were 89, 87, 11, and 346; for the open group, they were 81, 80, 10.5, and 594; for the arthroscopic group, they were 92, 92, 11.4, and 190. The Western Ontario Shoulder Instability Index (P <. 03) and Rowe score (P <. 04) outcomes scores for the arthroscopic group were statistically better than those of the open group. Twenty-nine of 31 shoulders were rated as excellent or good. Conclusion In the case of traumatic posterior shoulder subluxation, posterior lesions of the labrum (“reverse Bankart”), articular edge, and capsule are observed. Surgical treatment addressing these lesions led to satisfactory results for both the open and arthroscopic treated groups. In this study, an arthroscopic technique utilizing suture anchor repair with capsular placation provided the most favorable outcomes.