Zachary T. Sharfman

Pathological findings in patients with low anterior inferior iliac spine impingement

PurposeFemoroacetabular impingement (FAI) has been well described in recent years as one of the major causes of hip pain potentially leading to acetabular labral tears and cartilage damage, which may in turn lead to the development of early degenerative changes. More recently, extra-articular patterns of impingement such as the anterior inferior iliac spine (AIIS)/subspine hip impingement have gained focus as a cause of hip pain and limitation in terminal hip flexion and internal rotation. The purpose of this study was to evaluate the prevalence of low AIIS in patients undergoing hip arthroscopy and to characterize the concomitant intra-articular lesions.MethodsBetween November 2011 and April 2013, 100 consecutive patients underwent hip arthroscopy for various diagnoses by a single surgeon. After intra-operative diagnosis of low AIIS was made, a comprehensive review of the patients’ records, preoperative radiographs, and intra-operative findings was conducted to document the existence and location of labral and chondral lesions.ResultsTwenty-one (21xa0%) patients had low AIIS. There were 13 males (mean age 38.4xa0years) and eight females (mean age 35.5xa0years). Eight patients had pre-operative radiographic evidence of low AIIS. All patients had a labral tear anteriorly, at the level of the AIIS; 17 had chondrolabral disruption and 17 had chondral lesions in zone two (antero-superior); and four patients had lesion in zones two and three.ConclusionsLow AIIS is a common intra-operative finding in hip arthroscopy patients. Characteristic labral and chondral lesions are routinely found in a predictable location that effaces the low AIIS.Level of Evidence—Level IV, Case Series

Dynamic locking plate vs. simple cannulated screws for nondisplaced intracapsular hip fracture: A comparative study

INTRODUCTIONnIntracapsular hip fractures (ICHF) are a common cause of morbidity and mortality and pose a great economic burden on the health care systems. Appropriate surgical treatment requires balancing optimal outcomes with the cost of treatment to the health care system. While in elderly patients with displaced ICHF arthroplasty became the standard of care, the internal fixation method for conserving the femoral head in younger patients or in nondisplaced ICHF is still in debate. We compared a dynamic locking plate with the standard cancellous cannulated screws (CCS) for treatment of nondisplaced ICHF.nnnMETHODSnAll patients treated with internal fixation for nondisplaced ICHF between July 2009 and December 2012 at our level one trauma center were included in this study. Patients treated with Targon FN (Aesculap) implants and CCS (Synthes) were compared. Charts were reviewed for demographics, intraoperative data and peri/post operative complications retrospectively. Radiographical analysis, pain (VAS), quality of life (SF12) and function (MHHS) data were prospectively gathered.nnnRESULTSnOne hundred and fifteen non-displaced ICHFs were treated with internal fixation, 81 with CCS and 34 with Targon FN implant; the mean follow-up was 19 and 28 months, respectively. Group fracture characteristics (Garden/Powel classification), and demographics, excluding age, were not significantly different. Post-operative revision rates of the Targon FN and CCS groups, perioperative complications were not statistically different (p>0.05). Quality of life (SF-12), function (Modified Harris Hip Score) and Visual Analogue Scale (VAS) pain scores were not statistical different.nnnCONCLUSIONSnComplication rates and clinical outcomes for the treatment of nondisplaced ICHF with Targon FN and SCC showed no significant differences. Based on this evidence in consideration of the substantial cost differential between the Targon FN and SCC we suggest SCC for treatment of nondisplaced ICHF.nnnLEVEL OF EVIDENCEnIII.

Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine

PURPOSEnTo evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy.nnnMETHODSnForty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20xa0mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20xa0mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20xa0mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2xa0weeks after surgery.nnnRESULTSnTwenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30xa0minutes postoperatively and 18xa0hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; Pxa0<xa0.045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption.nnnCONCLUSIONSnPeriacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30xa0minutes and 18xa0hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.nnnLEVEL OF EVIDENCEnLevel I, randomized controlled trial.

Hip Arthroscopy for Femoral-Acetabular Impingement: Do Active Claims Affect Outcomes?

PURPOSEnTo compare outcomes of 3 patient groups undergoing hip arthroscopy.nnnMETHODSnThis study included 138 consecutive hip arthroscopies (106 analyzed) for femoral-acetabular impingement (FAI) with or without labral tear in patients with a minimum 1-year follow-up. Inclusion criteria included patients older than 18 with clinical or radiologic manifestation of FAI with or without labral tear. Exclusion criteria included previous hip surgery and various hip pathologies. Patients were classified into 3 study groups. Group 1 included work-related injuries with active claims ACs (n = 33); mean age, 32 (range, 19 to 63); group 2 included sports injuries with no ACs (n = 35); mean age, 32 (range, 18 to 69); and group 3 included non-sports-related injuries without pending ACs (NAS; n = 38); mean age, 45 (range, 20 to 68). Outcomes were assessed using modified Harris hip scores (mHHS) and hip outcome scores (HOS) preoperatively and during the final evaluation.nnnRESULTSnBaseline score for all groups did not significantly differ (P = .210 for mHHS, P = .176 for HOS). All groups significantly improved from preoperative to final evaluation (group 1: mHHS P = .42, HOS P = .001; group 2: mHHS P < .001, HOS P < .001; group 3 NAS: mHHS P = .001, HOS P = .007). AC patients had the lowest final evaluation scores, while the sports group had the highest. The NAS group did not differ from either group at final evaluation. Preoperative and final evaluation scores inversely correlated with age (r range, -24 to -28; P < .05).nnnCONCLUSIONSnThis study has shown that patients may benefit from arthroscopic repair of FAI and labral tears regardless of ACs. The level of improvement, however, is not constant across patients with different characteristics. Moreover, it appears that age may impact perceived improvement after hip arthroscopy. Hip arthroscopy as an intervention in patients with ACs provided positive outcomes, corroborating that an AC is not a contraindication for this procedure.nnnLEVEL OF EVIDENCEnLevel III, retrospective comparative study.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes

Purpose and hypothesisThe aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair.MethodsBetween 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS).ResultsTwenty-two patients with follow-up of more than 2xa0years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22–68xa0years old). The median follow-up time was 36.2xa0months with a range from 24 to 72xa0months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7–100) (pxa0<xa00.0001).ConclusionAcetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission.Level of evidenceIV.

Effect of preemptive intra-articular morphine and ketamine on pain after arthroscopic rotator cuff repair: a prospective, double-blind, randomized controlled study

BackgroundRotator cuff tear is a leading etiology of shoulder pain and disability. Surgical treatment is indicated in patients with persistent pain who fail a trial of non-surgical treatment. Pain reduction following rotator cuff repair, particularly within the first 24–48xa0h, is a major concern to both doctors and patients. This study aimed to compare the postoperative antinociceptive additive effects of pre-incisional intra-articular (IA) ketamine when combined with morphine with two times the dose of morphine or saline.MethodsIn this prospective, randomized, double blind, controlled trial patients undergoing arthroscopic rotator cuff tear repair (ARCR) under general anesthesia were enrolled. Patients were randomly assigned to one of the three intervention groups. Twenty minutes prior to incision, morphine (20xa0mg/10xa0ml), ketamine (50xa0mgxa0+xa0morphine 10xa0mg/10xa0ml), or saline (0.9xa0% 10xa0ml) (nxa0=xa015/group), were administered to all patients. First 24xa0h postoperative analgesia consisted of intravenous patient controlled analgesia (IV-PCA) morphine and oral rescue paracetamol 1000xa0mg or oxycodone 5xa0mg. 24-h, 2-week and 3-month patient rated pain numeric rating scale (NRS) and analgesics consumption were documented.ResultsPatients’ demographic and perioperative data were similar among all groups. The 24-h and the 2-week NRSs were significantly (pxa0<xa00.05) lower in both treatment groups compared to placebo, but were not significantly different between the two intervention groups. PCA-morphine and oral analgesics were consumed similarly among the groups throughout the study phases.ConclusionsPre-incisional intra-articular morphine reduced pain in the first 2xa0weeks after arthroscopic rotator cuff repair. Further research is warranted to elucidate the optimal timing and dosing of IA ketamine and morphine for postoperative analgesic effects.

Subspinal impingement: clinical outcomes of arthroscopic decompression with one year minimum follow up

PurposeThis study was designed to (1) evaluate the clinical outcomes after arthroscopic subspinal decompression in patients with hip impingement symptoms and low AIIS, and to (2) assess the presence of low anterior inferior iliac spine on the pre-operative radiographs of patients with established subspinal impingement diagnosed intra-operatively.MethodsRetrospective analysis of patients who underwent arthroscopic subspinal decompression has been performed. The indications for surgery were femoroacetabular impingement (FAI), or subspinal impingement. Pre-operative radiographs were assessed for anterior inferior iliac spine type. Intra-operative diagnosis of low anterior inferior iliac spine was based on the level of anterior inferior iliac spine extension relative to the acetabulum and the presence of reciprocal labral and chondral lesions. In patients where low anterior inferior iliac spine was not diagnosed on pre-operative radiographs, the pre-operative radiographs were re-read retrospectively to assess missed signs of low anterior inferior iliac spine.ResultsThirty-four patients underwent arthroscopic subspinal decompression between 2012 and 2015. The patients were followed for a median of 25xa0months (13–37xa0months). Intra-operatively, grade 2 anterior inferior iliac spine was found in 27 patients and grade 3 anterior inferior iliac spine was found in 7 patients. MHHS, HOS, and HOSS scores increased from median (range) pre-operative scores of 55 (11–90), 48 (20–91) and 20 (0–80) to 95 (27–100), 94 (30–100) and 91 (5–100), respectively (pu2009<u20090.0001, pu2009=u20090.001, pu2009<u20090.0001, respectively). Pre-operative diagnosis of low AIIS was made in 6/34 patients via AP radiographs. On retrospective analysis of pre-operative radiographs, signs of low AIIS were still not observed in 21/34 (61.8%) patients.ConclusionsArthroscopic subspinal decompression of low AIIS yielded significantly improved outcome measures and high patient satisfaction at a minimum of 13xa0months follow-up. Low AIIS is often under-diagnosed on AP pelvis and lateral frog radiographs and if left untreated, may result in unresolved symptoms and failed procedure.Level of evidenceIV.

Functional outcomes after removal of hardware in patellar fracture: are we helping our patients?

PurposeFunctional outcomes after Open Reduction Internal Fixation (ORIF) of the patella are variable. Common complications of patella ORIF include persistent anterior knee pain, limited range of motion and symptomatic hardware. The purpose of this study was to evaluate if removal of hardware is beneficial to symptomatic patients after patellar fracture fixation.MethodsPatients who presented to our institution between December 2006 and November 2014 with patella fractures treated with ORIF were eligible for inclusion. Patella ORIF was performed using (1) K-wires (KW) with a tension band construct or (2) Cannulated Screws (CS) with a tension band construct. Radiological analyses included (1) AO classification and (2) measurements of prominent hardware length. Patient medical charts were reviewed for demographic and intraoperative data as well as peri/postoperative complications. All patients completed the SF-12 score, visual analog scale, Kujala score, Lysholm score and questionaries’ regarding return to previous activity levels.ResultsForty-seven patients met the inclusion criteria. The average time from fracture fixation to removal of hardware was 15.8 (SDu2009±u200914.9) months. The mean follow-up was 43.1 (SDu2009±u200927.1) months. Patella fixation was accomplished using tension band constructs with KW in 28 patients (59.5%) or with CS in 19 patients (40.5%). Patient reported quality of life and pain outcomes improved significantly after removal of hardware (pu2009=u20090.001, and pu2009=u20090.002 respectively). Functional outcome scores (Kujala and Lysholm) did not improve significantly after hardware removal in the KW or CS groups. Significantly more patients in the KW group returned to pre-injury activity (pu2009=u20090.005).ConclusionsHardware removal after patella ORIF significantly improves patient reported pain and quality of life outcomes but not functional outcomes. Patients should be counseled regarding the expected outcome of hardware removal following patella ORIF and diabetic patients should be given special consideration before undergoing this procedure.

Anatomy, Assesment, and Surgery of the Biceps Tendon

Pathology of the Long Head of the Biceps Tendon (LBHT) is common and often associated with marked disability. The pathologies causing functional disabilities exist in many forms and are frequently associated with additional shoulder pathologies. Although the anatomy and anatomic variation of the LHBT and superior labrum have been well documented, data regarding the function and biomechanical properties of the LHBT are not consistent. Clinical and diagnostic examinations can accurately diagnoses LHBT pathology however, arthroscopy is a valuable tool with which to identify and treat biceps pathology. Surgical interventions for biceps pathology include debridement, decompression, tenotomy, and tenodesis. Multiple factors must be weighed when considering these surgical interventions. Surgical approach and restoring native or functional anatomy must be considered in addition to evaluating patient age, activity level, functional demand, compliance, and patient expectations in order to achieve optimal outcomes. This chapter will outline the functional anatomy, clinical presentation, physical examination and imaging, in addition to common pathologies and surgical treatments for biceps injuries.

Effects of Modification of Pain Protocol on Incidence of Post Operative Nausea and Vomiting

Background: A Perioperative Surgical Home (PSH) care model applies a standardized multidisciplinary approach to patient care using evidence-based medicine to modify and improve protocols. Analysis of patient outcome measures, such as postoperative nausea and vomiting (PONV), allows for refinement of existing protocols to improve patient care. We aim to compare the incidence of PONV in patients who underwent primary total joint arthroplasty before and after modification of our PSH pain protocol. Methods: All total joint replacement PSH (TJR-PSH) patients who underwent primary THA (n=149) or TKA (n=212) in the study period were included. The modified protocol added a single dose of intravenous (IV) ketorolac given in the operating room and oxycodone immediate release orally instead of IV Hydromorphone in the Post Anesthesia Care Unit (PACU). The outcomes were (1) incidence of PONV and (2) average pain score in the PACU. We also examined the effect of primary anesthetic (spinal vs. GA) on these outcomes. The groups were compared using chi-square tests of proportions. Results: The incidence of post-operative nausea in the PACU decreased significantly with the modified protocol (27.4% vs. 38.1%, p=0.0442). There was no difference in PONV based on choice of anesthetic or procedure. Average PACU pain scores did not differ significantly between the two protocols. Conclusion: Simple modifications to TJR-PSH multimodal pain management protocol, with decrease in IV narcotic use, resulted in a lower incidence of postoperative nausea, without compromising average PACU pain scores. This report demonstrates the need for continuous monitoring of PSH pathways and implementation of revisions as needed.