Evaluation of the Trends, Concomitant Procedures, and Complications With Open and Arthroscopic Rotator Cuff Repairs in the Medicare Population.

BACKGROUND: Medicare insures the largest population of patients at risk for rotator cuff tears in the United States. PURPOSE: To evaluate the trends in incidence, concomitant procedures, and complications with open and arthroscopic rotator cuff repairs in Medicare patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All Medicare patients who had undergone open or arthroscopic rotator cuff repair from 2005 through 2011 were identified with a claims database. Annual incidence, concomitant procedures, and postoperative complications were compared between these 2 groups. RESULTS: In total, 372,109 rotator cuff repairs were analyzed. The incidence of open repairs decreased (from 6.0 to 4.3 per 10,000 patients, P < .001) while the incidence of arthroscopic repairs increased (from 4.5 to 7.8 per 10,000 patients, P < .001) during the study period. Patients in the arthroscopic group were more likely to have undergone concomitant subacromial decompression than those in the open group (87% vs 35%, P < .001), and the annual incidence of concomitant biceps tenodesis increased for both groups (from 3.8% to 11% for open and 2.2% to 16% for arthroscopic, P < .001). While postoperative complications were infrequent, patients in the open group were more likely to be diagnosed with infection within 6 months (0.86% vs 0.37%, P < .001) but no more likely to undergo operative debridement (0.43% vs 0.26%, P = .08). Additionally, patients in the open group were more likely to undergo intervention for shoulder stiffness within 1 year (1.4% vs 1.1%, P = .01). CONCLUSION: In the Medicare population, arthroscopic rotator cuff repairs have increased in incidence and now represent the majority of rotator cuff repair surgery. Among concomitant procedures, subacromial decompression was most commonly performed despite evidence suggesting a lack of efficacy. Infections and stiffness were rare complications that were slightly but significantly more frequent in open rotator cuff repairs.

Arthroscopic double-bundle anterior cruciate ligament reconstruction: an anatomic approach.

The anterior cruciate ligament consists of 2 functional bundles, the anteromedial and the posterolateral bundle. Anterior cruciate ligament reconstruction has traditionally focused on recreating the anteromedial bundle, while the reconstruction of the posteromedial bundle has not routinely been addressed. The authors, from 2 academic centers, present a technique of arthroscopic anterior cruciate ligament reconstruction that restores both the anteromedial and the posterolateral bundle using either semitendinosus and gracilis autografts or tibialis anterior allografts. This technique represents a novel approach to restore the anteromedial and the posterolateral bundle at their anatomic insertion sites on both the tibia and the femur through separate bone tunnels. We believe that our double-bundle anatomic anterior cruciate ligament reconstruction closely reapproximates the native insertion sites of the anterior cruciate ligament on the tibia and the femur while more closely recreating the biomechanical function of the native ligament.

Surgical management of knee dislocations. Surgical technique.

BACKGROUND: The evaluation and management of knee dislocations remain variable and controversial. The purpose of this study was to describe our method of surgical treatment of knee dislocations with use of a standardized protocol and to report the clinical results. METHODS: Forty-seven consecutive patients presented with an occult (reduced) or grossly dislocated knee. Fourteen of these patients were not included in this series because of confounding variables: four had an open knee dislocation, five had vascular injury requiring repair, three were treated with external fixation, and two had associated injury. The remaining thirty-three patients underwent surgical treatment for the knee dislocation with our standard approach. Anatomical repair and/or replacement was performed with fresh-frozen allograft tissue. Thirty-one of the thirty-three patients returned for subjective and objective evaluation with use of four different knee-rating scales at a minimum of twenty-four months after the operation. RESULTS: Nineteen of the thirty-one patients were treated acutely (less than three weeks after the injury) and twelve, chronically. The mean Lysholm score was 91 points for the acutely reconstructed knees and 80 points for the chronically reconstructed knees. The Knee Outcome Survey Activities of Daily Living scores averaged 91 points for the acutely reconstructed knees and 84 points for the chronically reconstructed knees. The Knee Outcome Survey Sports Activity scores averaged 89 points for the acutely reconstructed knees and 69 points for the chronically reconstructed knees. According to the Meyers ratings, twenty-three patients had an excellent or good score and eight had a fair or poor score. Sixteen of the nineteen acutely reconstructed knees and seven of the twelve chronically reconstructed knees were given an excellent or good Meyers score. The average loss of extension was 1 degrees , and the average loss of flexion was 12 degrees . There was no difference in the range of motion between the acutely and chronically treated patients. Four acutely reconstructed knees required manipulation because of loss of flexion. Laxity tests demonstrated consistently improved stability in all patients, with more predictable results in the acutely treated patients. CONCLUSIONS: Surgical treatment of the knee dislocations in our series provided satisfactory subjective and objective outcomes at two to six years postoperatively. The patients who were treated acutely had higher subjective scores and better objective restoration of knee stability than did patients treated three weeks or more after the injury. Nearly all patients were able to perform daily activities with few problems. However, the ability of patients to return to high-demand sports and strenuous manual labor was less predictable.

The acutely dislocated knee: evaluation and management.

Acute knee dislocations are uncommon orthopaedic injuries. Because they often spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee, resulting in multidirectional instability. Associated meniscal, osteochondral, and neurovascular injuries are often present and can complicate management. The substantial risk of associated vascular injury mandates that vascular integrity be confirmed by angiography in all suspected knee dislocations. Evaluation and initial management must be performed expeditiously to prevent limb-threatening complications. Definitive management of acute knee dislocation remains a matter of debate; however, surgical reconstruction or repair of all ligamentous injuries likely can help in achieving the return of adequate knee function. Important considerations in surgical management include surgical timing, graft selection, surgical technique, and postoperative rehabilitation.