Timothy Leroux

Epidemiology of Primary Anterior Shoulder Dislocation Requiring Closed Reduction in Ontario, Canada

Background: There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation. Purpose: To (1) calculate the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; “index event”) in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age <16 and >70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model. Results: There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio [HR], 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001). Conclusion: Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.

Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada.

BACKGROUND Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort. METHODS Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes. RESULTS We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients. CONCLUSIONS Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses.

PURPOSE Shoulder instability frequently recurs in young patients without operative treatment. Both open and arthroscopic approaches to shoulder stabilization with labral repair and capsulorrhaphy have been described and are routinely used. Multiple trials have been conducted to compare these approaches, with multiple meta-analyses performed to synthesize these trials; however, the results remain controversial. The purpose of this study was to critically evaluate the current meta-analyses to identify the current state of the art. METHODS In this study we evaluate available scientific support for the ability of both arthroscopic and open soft-tissue stabilization techniques to restore stability of the shoulder by performing a systematic review of the literature for previous meta-analyses. Data were extracted for rates of recurrence and patient outcomes. Study quality was measured with the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied independently by 4 authors to determine which meta-analysis provided the highest level of available evidence. RESULTS After application of the inclusion and exclusion criteria, 8 meta-analyses were included. Both studies published prior to 2007 concluded that open stabilization provided lower recurrence rates than arthroscopic stabilization, the 3 studies published in 2007 are discordant, and all 3 studies published after 2008 concluded that open and arthroscopic stabilization provided equivalent results. Two meta-analyses had low Oxman-Guyatt scores (<3) signifying major flaws. Four authors independently selected the same meta-analysis as providing the highest quality of evidence using the Jadad algorithm, and this meta-analysis found no difference in recurrence rates between open and arthroscopic stabilization. CONCLUSIONS This systematic review of overlapping meta-analyses comparing arthroscopic and open shoulder stabilization suggests that according to current best available evidence, there are no significant differences in failure rates. LEVEL OF EVIDENCE Level IV, systematic review of Level I through IV studies.

The risk of knee arthroplasty following cruciate ligament reconstruction: a population-based matched cohort study.

BACKGROUND Evidence regarding the risk of end-stage osteoarthritis following cruciate ligament reconstruction is based upon small sample sizes and radiographic, rather than clinical, criteria. The goals of this study were to determine the risk of knee arthroplasty, a surrogate for end-stage osteoarthritis, following cruciate ligament reconstruction, and to identify patient, provider, and surgical factors that influence knee arthroplasty risk. METHODS Using administrative databases, we identified all patients who were sixteen to sixty years of age and had undergone cruciate ligament reconstruction in Ontario from July 1993 to March 2008. Case patients were matched by demographic variables to five individuals without knee injury from the general population of Ontario, Canada, who had not undergone previous knee surgery, including cruciate ligament reconstruction. The main outcome was knee arthroplasty. Kaplan-Meier survival curves were generated for both cohorts. A Cox proportional hazards model determined those factors that influenced knee arthroplasty risk. RESULTS We identified 30,301 eligible patients who had undergone cruciate ligament reconstruction; of these patients, 30,277 were matched to 151,362 individuals from the general population; the median patient age was twenty-eight years and 65% of the patients were male. Primary anterior cruciate ligament reconstruction accounted for >98% of index cases. During the follow-up period, there was a significant difference (p < 0.001) between matched case and control cohorts with respect to the number of patients who underwent knee arthroplasty during the study period; in the matched case cohort, 209 patients underwent knee arthroplasty (event rate, 0.68 of 1000 person-years), and in the control cohort, 125 patients underwent knee arthroplasty (event rate, 0.10 of 1000 person-years). Moreover, fifteen years after cruciate ligament reconstruction (case cohort) or study enrollment (control cohort), there was a significant difference (p < 0.001) in the cumulative incidence of knee arthroplasty between the case cohort (1.4%) and the control cohort (0.2%). Age of fifty years or more (hazard ratio, 37.28; p < 0.001), female sex (hazard ratio, 1.58; p = 0.001), comorbidity score of ≥5 points (hazard ratio, 5.91; p = 0.002), surgeon annual volume of cruciate ligament reconstruction of twelve or fewer cases per year (hazard ratio, 2.53; p < 0.001), and cruciate ligament reconstruction undertaken in university-affiliated hospitals (hazard ratio, 1.51, p = 0.008) increased the odds of knee arthroplasty; however, male sex (hazard ratio, 0.63; p = 0.001) and patient age of less than twenty years (hazard ratio, 0.07; p = 0.009) were protective. Concurrent meniscal repair or debridement did not increase arthroscopy risk. CONCLUSIONS After fifteen years, the cumulative incidence of knee arthroplasty following cruciate ligament reconstruction was low (1.4%); however, it was seven times greater than the cumulative incidence of knee arthroplasty among matched control patients from the general population (0.2%). Older age, female sex, higher comorbidity, low surgeon annual volume of cruciate ligament reconstruction, and cruciate ligament reconstruction performed in a university-affiliated hospital were factors that increased knee arthroplasty risk.

The Epidemiology of Revision Anterior Cruciate Ligament Reconstruction in Ontario, Canada

Background: Knowledge of the rate of and risk factors for re-revision, reoperation, and readmission after revision anterior cruciate ligament reconstruction (ACLR) is limited. Purpose: To determine the rate of and risk factors for re-revision, reoperation, and readmission after revision ACLR. Study Design: Descriptive epidemiology study. Methods: All patients who underwent first revision ACLR in Ontario, Canada, from January 2004 to December 2010 were identified and followed until December 2012. Exclusions included age <16 years, previous osteotomy, or multiligament knee reconstruction. The main outcome was re-revision ACLR. Secondary outcomes included reoperation (irrigation and debridement [I&D], meniscectomy, manipulation under anesthesia, contralateral ACLR, and total knee arthroplasty) and readmission. Survival to re-revision was determined using the Kaplan-Meier approach. A Cox proportional hazards model or logistic regression were used to determine the influence of patient, surgical, and provider factors on outcomes. A post hoc analysis was performed to determine the influence of the aforementioned factors on postoperative infection risk. Results: Overall, 827 patients were included (median age, 30 years; 58.8% males). Single-stage revisions comprised 92.9% of cases, and a meniscal procedure (repair or debridement) was performed in 45.3% of cases. The re-revision rate at a mean follow-up of 4.8 ± 2.2 years was 4.4%, and the 5-year survival rate was 95.4%. The rates of I&D, meniscectomy, contralateral ACLR, and readmission were 0.8%, 3.1%, 3.4%, and 4.1%, respectively. Manipulation under anesthesia and total knee arthroplasty were rare. Young age significantly increased contralateral ACLR risk (risk decreased by 5.1% with each year of age >16 years; P = .02) but not re-revision ACLR risk. Low surgeon’s annual volume of revision ACLR (<4 revisions/year: odds ratio, 1.2; P = .02) and male sex (odds ratio, 13.3; P = .01) significantly increased overall infection risk; male sex also influenced I&D risk. Conclusion: Re-revision, reoperation, and readmission rates after revision ACLR were low, and the risk for I&D, infection, and contralateral ACLR were influenced by male sex, low surgeon volume, and young age, respectively. Clinical Relevance: This is the first study to determine morbidity rates and risk factors after revision ACLR, providing reference data from the general population.

The epidemiology of primary anterior shoulder dislocations in patients aged 10 to 16 years.

Background: Clinical studies of shoulder dislocations typically include adult patients (>16 years of age). Only small case series of patients aged 10 to 16 years are available to guide management. Purpose: Using a cohort of patients aged 10 to 16 years, this study sought to determine (1) the incidence density rate (IDR) of primary anterior shoulder dislocations requiring closed reduction (CR) and (2) the rate of and risk factors for repeat shoulder CR. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: With use of administrative databases, patients aged 10 to 16 years who underwent CR of a primary anterior shoulder dislocation in Ontario, Canada, between April 2002 and September 2010 were gathered. IDRs for the entire cohort and demographic subgroups were calculated. The main outcome, repeat shoulder CR, was sought until September 2012. The cumulative incidence of repeat CR was calculated at multiple time points for the entire cohort and age subgroups. A competing risk model identified risk factors for repeat CR (reported as hazard ratios [HRs] with 95% CIs). Results: There were 1937 patients aged 10 to 16 years who underwent primary CR (median age, 15.0 years; 79.7% male). The incidence of primary CR was highest among male patients aged 16 years (164.4 per 100,000 person-years), but primary dislocations were rare in 10- to 12-year-old children (n = 115; 5.9% of all dislocations). Repeat CR was observed in 740 patients (38.2%) after a median of 0.8 years; however, the rate of repeat CR was age dependent: it was highest among 14- to 16-year-old patients (37.2%-42.3%) and considerably lower among 10- to 13-year-old patients (0%-25.0%). Male sex (HR, 1.2 [95% CI, 1.0-1.5]; P = .04) and older patient age (HR, 1.2 [95% CI, 1.1-1.3]; P < .001) significantly increased the odds of repeat CR. Conclusion: Among 14- to 16-year-old patients, the rate of primary and recurrent shoulder CR mirrors that of high-risk adults (17-20 years of age) from previously published data; however, the rate of shoulder CR (primary or recurrent) is considerably lower among 10- to 13-year-olds. In addition to older patient age, male sex increased the odds of repeat shoulder CR. Going forward, clinicians should counsel male patients and those aged 14 to 16 years regarding their increased risk of recurrence after the nonoperative management of a primary anterior shoulder dislocation.

A Systematic Review and Meta-analysis Comparing Clinical Outcomes After Concurrent Rotator Cuff Repair and Long Head Biceps Tenodesis or Tenotomy.

Context: A comparison of clinical outcomes after long head of biceps (LHB) tenotomy or tenodesis performed concurrently with rotator cuff repair (RCR) is of interest to physicians and patients. Objective: A systematic review of clinical outcome studies examining LHB tenotomy or tenodesis performed concurrently with RCR. Secondarily, perform a meta-analysis of data from comparative studies. Data Sources: MEDLINE (1946 to week 30 of 2013) and EMBASE (1980 to week 30 of 2013). Study Selection: Levels 1 through 4 studies reporting clinical outcomes of concurrent RCR and LHB tenotomy or tenodesis with minimum 1-year follow-up. Study Design: Systematic review and meta-analysis. Level of Evidence: Level 4. Data Extraction: Two independent reviewers identified eligible studies and applied the exclusion criteria. Clinical outcome data, including functional outcome score(s), biceps deformity and cramping, and patient satisfaction, were extracted. Clinical outcome data from included studies were pooled (weighted according to study size) and reported. A meta-analysis was performed only on outcomes extracted from comparative studies (α = 0.05). Results: Twelve studies (N = 565 patients; mean age, 61.3 years; 46.3% men) were included. Of these, 6 (N = 263) included RCR and LHB tenotomy and 9 (N = 302) included RCR and LHB tenodesis. A meta-analysis was performed on 3 comparative studies (levels 1 and 2), demonstrating that the postoperative Constant score at a mean follow-up of 25.5 months was significantly greater after tenodesis (92.8 [tenodesis] vs 90.6 [tenotomy], P < 0.01); however, this difference was less than the reported minimal clinically important difference of 10.4 points. Similarly, the rate of biceps deformity was significantly less after tenodesis (15.5% [tenotomy] vs 3.9% [tenodesis], P < 0.01); however, most patients were not bothered by it. There were no significant differences in the rate of biceps cramping or patient satisfaction. Conclusion: Although the postoperative Constant score and rate of biceps deformity favor LHB tenodesis statistically, the clinical significance appears negligible.

Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty

BACKGROUND The rate of total shoulder arthroplasty (TSA) is rising, which has an impact on health care expenditure. One avenue to mitigate cost is outpatient TSA. There are currently no published reports of this practice. In this study, we determine the 30-day adverse event and readmission rates after outpatient TSA and compare these rates with inpatient TSA. METHODS A retrospective cohort study using a population database in the United States was undertaken. Patients who underwent primary TSA between 2005 and 2014 were identified and divided into 2 cohorts based on length of stay (LOS): outpatient TSA (LOS 0 days) and inpatient TSA (LOS >0 days). Patient and procedure characteristics were collected. The 30-day adverse event and readmission rates were calculated for each cohort. A multivariate logistic regression determined if the odds of an adverse event or readmission were significantly different between the inpatient and outpatient TSA cohorts. RESULTS Overall, 7197 patients in this database underwent TSA between 2005 and 2014, of which 173 patients (2.4%) underwent outpatient TSA. The 30-day adverse event rate in the outpatient and inpatient TSA cohorts was 2.31% and 7.89%, respectively. The 30-day readmission rate in the outpatient and inpatient TSA cohorts was 1.74% and 2.93%, respectively. In the multivariate logistic regression, the odds of an adverse event or readmission were not significantly different (odds ratio of 0.4 [P = .077] and odds ratio of 0.7 [P = .623], respectively). CONCLUSION There are no significant differences in the 30-day adverse event and readmission rates between outpatient and inpatient TSA. In the appropriately selected patient, outpatient TSA is safe and cost-effective.

Evaluation of a ski and snowboard injury prevention program

The objective was to study the effectiveness of a brochure and video at improving skiing and snowboarding knowledge. Sixty-nine Grade 7 students were randomised to an educational intervention (n = 35) or control (n = 34) group. The intervention group viewed an injury prevention video aimed at improving skiers and snowboarders knowledge, attitudes and behaviours about ski and snowboard safety and received a brochure. The control group participated in a teaching session and had a simple question and answer session about snow sports. Pre- and post-tests were administered and injuries during four trips were documented. Pre-test scores were similar between the two groups. Compared with the control group, there was a significantly greater improvement in post-test scores among the intervention group (WMD: 2.1; 95% CI: 0.19–4.01). There was no significant difference in injury rates (RR: 0.49; 95% CI: 0.04, 3.39). All injuries were minor and did not require medical attention. The intervention aimed at youth skiers and snowboarders appears to be effective at improving knowledge, attitudes and behaviours of skiing and snowboarding safety.

The Influence of Evidence-Based Surgical Indications and Techniques on Failure Rates After Arthroscopic Shoulder Stabilization in the Contact or Collision Athlete With Anterior Shoulder Instability.

Background: It has been reported that arthroscopic shoulder stabilization yields higher rates of failure in contact or collision athletes as compared with open shoulder stabilization; however, this is largely based upon studies that do not employ modern, evidence-based surgical indications and techniques for arthroscopic shoulder stabilization. Purpose: To (1) determine the pooled failure rate across all studies reporting failure after primary arthroscopic shoulder stabilization for anterior shoulder instability in contact or collision athletes and (2) stratify failure rates according to studies that use evidence-based surgical indications and techniques. Study Design: Systematic review. Methods: A review of PubMed, Medline, and Embase was performed to identify all clinical studies with a minimum of 1-year follow-up that reported failure rates after arthroscopic shoulder stabilization for anterior shoulder instability in contact or collision athletes. Data pertaining to patient demographics, clinical and radiographic preoperative assessment, surgical indications, surgical technique, rehabilitation, and outcome were collected from each included study. An overall failure rate was determined across all included studies. After this, a secondary literature review was performed to identify factors related to patient selection and surgical technique that significantly influence failure after primary arthroscopic shoulder stabilization. Failure rates were then determined among included studies that used these evidence-based indications and techniques. Results: Overall, 26 studies reporting on 779 contact or collision athletes met the inclusion criteria. The mean patient age was 19.9 years, 90.3% were male, and the most common sport was rugby. There was considerable variability in the reporting of patient demographics, preoperative assessment, surgical indications, surgical technique, and patient outcomes. Across all included studies, the pooled failure rate after arthroscopic shoulder stabilization in the contact or collision athlete was 17.8%; however, among studies that excluded patients with significant bone loss, used a minimum of 3 suture anchors, and performed the stabilization in the lateral decubitus position, the failure rate was 7.9%. Conclusion: The rate of failure after arthroscopic shoulder stabilization in contact or collision athletes decreases from 17.8% to 7.9% after the use of evidence-based surgical indications and techniques.