William A. Zuke

Establishing Maximal Medical Improvement After Arthroscopic Rotator Cuff Repair

Background: As health care transitions from a pay-for-service to a pay-for-performance infrastructure, the value of orthopaedic care must be defined accurately. Significant efforts have been made in defining quality and cost in arthroplasty; however, there remains a lag in ambulatory orthopaedic care. Purpose: Two-year follow-up has been a general requirement for reporting outcomes after rotator cuff repair. However, this time requirement has not been established scientifically and is of increasing importance in the era of value-based health care. Given that arthroscopic rotator cuff repair is a common ambulatory orthopaedic procedure, the purpose of this study was to establish a time frame for maximal medical improvement (the state when improvement has stabilized) after arthroscopic rotator cuff repair. Study Design: Systematic review. Methods: A systematic review of the literature was conducted, identifying studies reporting sequential patient-reported outcomes up to a minimum of 2 years after arthroscopic rotator cuff repair. The primary clinical outcome was patient-reported outcomes at 3-month, 6-month, 1-year, and 2-year follow-up. Secondary clinical outcomes included range of motion, strength, retears, and complications. Clinically significant improvement was determined between various time intervals by use of the minimal clinically important difference. Results: The review included 19 studies including 1370 patients who underwent rotator cuff repair. Clinically significant improvement in patient-reported outcomes was seen up to 1 year after rotator cuff repair, but no clinical significance was noted from 1 year to 2 years. The majority of improvement in strength and range of motion was seen up to 6 months, but no clinically meaningful improvement was seen thereafter. All reported complications and the majority of retears occurred within 6 months after rotator cuff repair. Conclusion: After rotator cuff repair, a clinically significant improvement in patient-reported outcomes, range of motion, and strength was seen up to 1 year after surgery, but not beyond this. This information is important not only to establish appropriate patient expectations but also to determine a time frame for outcome collection after surgery to better define value in orthopaedic care.

A Critical Review: Management and Surgical Options for Articular Defects in the Hip

Patients with articular cartilage lesions of the hip may present with pain and symptoms that may be vague in nature and onset. Therefore, a thorough history and physical examination should be performed for every patient presenting with hip pain and/or disability. The management may be operative or nonoperative. Nonoperative management includes a trial of rest and/or activity modification, along with anti-inflammatory medications, physical therapy, and biologic injections. Operative treatment in the form of arthroscopic techniques continues to decrease morbidity and offer innovative solutions and new applications for microfracture, ACT, and AMIC.

Imaging Diagnosis of Injury to the Anterolateral Ligament in Patients With Anterior Cruciate Ligaments: Association of Anterolateral Ligament Injury With Other Types of Knee Pathology and Grade of Pivot-Shift Examination: A Systematic Review

PURPOSE The purpose of this study is to systematically review the literature to evaluate the reliability, or the ability of a repeated measurement to yield consistent results, and validity of ultrasound (US) and magnetic resonance imaging (MRI) at evaluating anatomy and pathology of the anterolateral ligament of the knee (ALL) in the setting of anterior cruciate ligament (ACL) injuries. Furthermore, the incidence and association of ALL injury with the pivot-shift examination, and other structural injuries, will be reviewed for additional clinical relevance. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 2 reviewers independently searched the Medline, Embase, Cochrane, EBSCOhost, OVID, and Web of Science databases for all studies related to imaging of the ALL. All eligible articles and their references were screened by both reviewers. Studies discussing diagnostic imaging of the ALL with regard to identification of injury to the structure in patients with suspected ACL injury were included. No restrictions regarding date of publication, type of publication, or language in the included article were applied. The exclusion criteria included commentaries, case reports, and studies that did not attempt to identify the ALL as a discrete structure. Quality assessment and data extraction was performed for each included study before final analysis was performed. RESULTS A total of 13 articles were included for final analysis. In the included studies, at least 1 portion of the ALL could be visualized on MRI in 76% to 100% of knees, and injury to the ALL was identified in 10.8% to 62.5% of patients. Inter- and intraobserver reliabilities ranged from moderate to almost perfect. There was a consensus among studies that ALL injuries were significantly associated with injuries to the lateral collateral ligament, popliteus tendon, iliotibial band, and bony contusions to the lateral tibia and femur. Most of the included studies found a significant association of injuries to the ALL and a high-grade pivot-shift examination. Only 2 studies used US to evaluate for injury to the ALL, and both studies had almost perfect interobserver reliability. Only 1 study confirmed initial diagnoses at the time of the ACL reconstruction surgery. CONCLUSIONS In patients with ACL injuries, concomitant ALL injuries can be identified on MRI or US with high levels of inter- and intraobserver reliability, and are often associated with a high-grade pivot-shift examination, lateral collateral ligament injury, and lateral femoral condyle and tibial plateau bone bruises. LEVEL OF EVIDENCE Level IV, systematic review of level II-IV studies.

Single-Bundle Augmentation for a Partial Tear of the Anterior Cruciate Ligament

Given the prevalence of anterior cruciate ligament (ACL) tears in young athletes, it is essential to elucidate and illustrate surgical interventions that return the most favorable outcomes. Although most ACL injuries are full-thickness tears, occasionally either the anteromedial (AM) or posterolateral (PL) bundle is torn in isolation, allowing consideration of an ACL reconstruction or augmentation. Because the ACL-deficient knee has been shown to exhibit less proprioceptive feedback, the preservation of the intact bundle may offer an inherent component of stability. After arthroscopy has confirmed a partial ACL tear, the decision to augment the intact bundle can be made. The technique is adapted from principles of the double-bundle reconstruction such that the graft follows the path of either the native AM bundle or the native PL bundle, depending on the location of the partial tear. We present our surgical technique for ACL AM bundle augmentation with PL bundle reconstruction using a semitendinosus tendon autograft.

The lack of standardized outcome measures following lower extremity injury in elite soccer: a systematic review

PurposeSport-specific, performance-based outcomes are increasingly used to improve evaluation of treatment efficacy in elite athletes; however, its usage in elite soccer may be limited. The purpose of this investigation is to (1) assess current outcome reporting in elite soccer; (2) identify any variability in reporting of outcomes; and (3) determine how sport-specific performance-based outcomes are utilized to assess treatment efficacy in elite soccer.MethodsA systematic review of the Pubmed, MEDLINE, and Embase, Scopus, SportDiscus, CINAHL and HealthSource: Nursing databases was performed without limitation on publication year. Inclusion criteria were (1) reporting of outcomes after a (2) lower extremity injury in (3) elite soccer players. The study’s population, type of injury, return to play, as well as functional, objective, and sport-specific performance-based outcomes were extracted from each article. The methodological index for nonrandomized studies was used for quality assessment.ResultsTwenty-one studies were selected after application of the inclusion and exclusion criteria. Objective outcomes were reported by 6 (29%) studies, and 6 (29%) employed patient-reported outcomes. The visual analog scale, Lysholm, and Tegner scores were the most common patient-reported outcomes (PROs). Return to play was reported by 18 (86%) studies, and only 2 (10%) utilized sport-specific performance-based outcomes. Despite the majority of studies reporting return to play, variation was seen in the definitions, and 15 (71%) studies reported the activity level of the players at final follow-up.ConclusionAssessment of treatment efficacy is limited in elite athletes, and PROs lack the sensitivity to identify residual performance deficits after an injury. Although performance-based measures are available at the elite level, these outcomes were seldom used for evaluation of treatment efficacy.Clinical relevanceWhen treating elite soccer players, patient-reported outcome measures lack the sensitivity to detect changes in patient function, thus performance-based metrics may be more efficacious in assessing return from injury in these patients.Level of evidenceIV.

Safety and patient satisfaction of outpatient shoulder arthroplasty

Background There is increasing interest in outpatient shoulder arthroplasty (SA); however, the clinical evidence behind this practice is sparse. The purpose of this study was to assess the safety of outpatient SA performed in an ambulatory surgery center and to determine patient factors that are associated with increased risk for perioperative complications or dissatisfaction. Methods Patient demographics and operative variables were collected retrospectively for patients undergoing outpatient SA at 2 ambulatory surgery centers with a minimum follow-up of 90 days. Patients completed a postsurgery questionnaire about their experience, satisfaction, pain control, and health care use. Results Forty-one anatomic total SAs (n = 32) and reverse SAs (n = 9) with a mean follow-up of 60 weeks (16.4 weeks-3 years) were included. The mean age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiologists class were 60.6 ± 4.8 years, 31.8 ± 6.6, 2.9 ± 1.9, and 2.3 ± 0.6, respectively. Three (7.3%) minor complications occurred within 90 days of the SA, none before first follow-up. Two patients stayed in the ambulatory surgery center 23-hour observation unit. Thirty-five patients (85.4%) completed the questionnaire, of whom 97.0% (n = 32) were satisfied with the outpatient procedure. Two patients had difficulties with postoperative pain control and were taking chronic narcotic medication before surgery. Conclusion Outpatient SA in an ambulatory surgery center is safe with high patient satisfaction and low rates of perioperative complications. Although larger cohorts are required to adequately determine which patients will be appropriate candidates for an outpatient SA, our findings do suggest that patients with a history of preoperative narcotic use may have difficulties or dissatisfaction with outpatient SA.

Arthroscopic Suprapectoral Biceps Tenodesis With Tenodesis Screw

There are many methods for long head of the biceps tendon (LHBT) tenodesis, but a consensus on a superior method has yet to be met. In this article, we introduce a method for arthroscopic suprapectoral biceps tenodesis using a tenodesis screw in the bicipital tunnel. The intra-articular portion of the biceps tendon is transected. The subdeltoid space is then viewed via a lateral portal, and the tendon is mobilized from the bicipital tunnel. The tendon is retrieved through the anterior portal, and 5 whipstitch passes and a second distal stitch are placed. Three of the suture tails are passed through the tenodesis screwdriver, and the tendon is maneuvered to the previously reamed bone socket located 1.5 cm superior to the pec tendon, just inferior to the bicipital groove. Once the tenodesis screw is fixated in sufficient bone stock, 5 alternating half hitches reinforce the construct by creating a closed loop through the screw. This described technique allows full visualization of the LHBT dissection and tenodesis throughout the procedure. Additionally, this technique provides a method to incorporate whipstitching with an arthroscopic tenodesis screw to provide additional strength to tendon fixation.

Lateral Augmentation Procedures in Anterior Cruciate Ligament Reconstruction: Anatomic, Biomechanical, Imaging, and Clinical Evidence

Background: There has been an increasing interest in lateral-based soft tissue reconstructive techniques as augments to anterior cruciate ligament reconstruction (ACLR). The objective of these procedures is to minimize anterolateral rotational instability of the knee after surgery. Despite the relatively rapid increase in surgical application of these techniques, many clinical questions remain. Purpose: To provide a comprehensive update on the current state of these lateral-based augmentation procedures by reviewing the origins of the surgical techniques, the biomechanical data to support their use, and the clinical results to date. Study Design: Systematic review. Methods: A systematic search of the literature was conducted via the Medline, EMBASE, Scopus, SportDiscus, and CINAHL databases. The search was designed to encompass the literature on lateral extra-articular tenodesis (LET) procedures and the anterolateral ligament (ALL) reconstruction. Titles and abstracts were reviewed for relevance and sorted into the following categories: anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes. Results: The search identified 4016 articles. After review for relevance, 31, 53, 27, 35, 45, and 78 articles described the anatomy, biomechanics, imaging/diagnostics, surgical techniques, and clinical outcomes of either LET procedures or the ALL reconstruction, respectively. A multitude of investigations were available, revealing controversy in addition to consensus in several categories. The level of evidence obtained from this search was not adequate for systematic review or meta-analysis; thus, a current concepts review of the anatomy, biomechanics, imaging, surgical techniques, and clinical outcomes was performed. Conclusion: Histologically, the ALL appears to be a distinct structure that can be identified with advanced imaging techniques. Biomechanical evidence suggests that the anterolateral structures of the knee, including the ALL, contribute to minimizing anterolateral rotational instability. Cadaveric studies of combined ACLR-LET procedures demonstrated overconstraint of the knee; however, these findings have yet to be reproduced in the clinical literature. The current indications for LET augmentation in the setting of ACLR and the effect on knee kinematic and joint preservation should be the subject of future research.

Quadriceps Tendon Rupture in an Adolescent Athlete

Quadriceps tendon rupture is an uncommon injury that usually occurs in middle-aged and elderly men with a history of chronic illnesses. We report the case of a 17-year-old healthy adolescent male baseball player who sustained this injury as a result of sudden deceleration in his left knee. He initially reported to the emergency department and then presented to our practice, where he was diagnosed with a quadriceps tendon tear. Preoperatively, he was unable to perform a single straight-leg raise. During surgical repair, the free edge of the quadriceps tendon was mobilized and anchored into the superior pole of the patella, followed by sutures to ensure reinforcement of the quadriceps footprint. His postoperative course progressed normally, demonstrating full range of motion at 3 months and return to team training at 5 months. Unlike previously reported quadriceps tendon ruptures in adolescents, to our knowledge, this is the first report of a patient who sustained such an injury without previous trauma to his knee or quadriceps mechanism. It is possible that weakened tendon integrity from repeated microtrauma during training combined with the sudden weight change distribution may have resulted in the injury. As urgent surgical intervention is necessary to ensure efficient recovery and return to sport, the sports medicine practitioner must remain educated and vigilant on caring for these patients.

Arthroscopic Saucerization and All-Inside Repair of a Delaminated Discoid Lateral Meniscus

Preservation of the meniscus has been shown to influence the progression of degenerative changes of the knee. As more meniscus is preserved, the propensity for development of osteoarthritis is lessened. Surgical treatment of a torn discoid meniscus has typically been a subtotal meniscectomy or partial meniscectomy. Similar to tears of a normal meniscus, partial meniscectomy compared with subtotal meniscectomy of the discoid meniscus confers better long-term results. With the abnormal morphology predisposing the discoid meniscus to tearing, several characteristic tear patterns can be observed—the horizontal tear being commonly encountered. We present a technique that not only creates a more normal morphology of a discoid meniscus but also preserves the tissue by using an all-inside, intrameniscal repair technique. This technique restores the central rim of the meniscus in the setting of a horizontal cleavage plane, thus restoring a more normal meniscus morphology.