Revision Shoulder Instability Surgery After Failed Latarjet: Glenoid Reconstruction Using Distal Tibial Allograft and Humeral Head Reconstruction Using Osteochondral Allograft.

Revision surgery for a failed Latarjet procedure is rare and technically demanding with few viable options. Similarly, massive defects to the articular humeral head require thoughtful techniques to recreate a congruent joint. Revision options for failed Latarjet have been studied, but there is yet to be a consensus on graft options. Distal tibial allograft has shown favorable outcomes in midterm data. Humeral head osteochondral allograft has also shown favorable outcomes for very large humeral head defects. However, there is a paucity of literature to demonstrate efficacy of combining the 2 aforementioned techniques. Revision shoulder instability surgery with glenoid reconstruction using distal tibial allograft and humeral head reconstruction using osteochondral allograft restores the glenohumeral articulation while preserving the remaining native bone stock.

Anterior Cable Reconstruction of the Superior Capsule Using Semitendinosus Allograft for Large Rotator Cuff Defects Limits Superior Migration and Subacromial Contact Without Inhibiting Range of Motion: A Biomechanical Analysis.

PURPOSE: To biomechanically assess translation, contact pressures, and range of motion for anterior cable reconstruction (ACR) using hamstring allograft for large to massive rotator cuff tears. METHODS: Eight cadaveric shoulders (mean age, 68 years) were tested with a custom testing system. Range of motion (ROM), superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation (ER) with 0°, 20°, and 40° of glenohumeral abduction. Three conditions were tested: intact, stage III tear (supraspinatus + anterior half of infraspinatus), and stage III tear + allograft ACR (involving 2 supraglenoid anchors for semitendinosus tendon allograft fixation. Allograft ACR included loop-around fixation using 3 side-to-side sutures and an anchor at the articular margin to restore capsular anatomy along the anterior edge of the cuff defect. RESULTS: ACR with allograft for stage III tears showed significantly higher total ROM compared with intact at all angles (P ≤ .028). Augmentation significantly decreased superior translation for stage III tears at 0°, 30°, and 60° ER for both 0° and 20° abduction, and at 0° and 30° ER for 40° abduction (P ≤ .043). Augmentation for stage III tears significantly reduced overall subacromial contact pressure at 30° ER with 0° and 40° abduction, and at 60° ER with 0° and 20° abduction (P ≤ .016). CONCLUSION: Anterior cable reconstruction using cord-like allograft semitendinosus tendon can biomechanically improve superior migration and subacromial contact pressure (primarily in the lower combined abduction and rotation positions), without limiting range of motion for large rotator cuff tendon defects or tears. CLINICAL RELEVANCE: In patients with superior glenohumeral instability, using hamstring allograft for ACR may improve rotator cuff tendon defect longevity by providing basic static ligamentous support to the dynamic tendon while helping to limit superior migration, without restricting glenohumeral kinematics.

Medial Elbow Pain During the Return-to-Throwing Period After Ulnar Collateral Ligament Reconstruction in Pitchers.

BACKGROUND: Ulnar collateral ligament reconstruction (UCLR) is common in the sport of baseball, particularly among pitchers. Postoperative return-to-sport protocols have many players beginning to throw at 4 to 5 months and returning to full competition between 12 and 16 months after surgery. Medial elbow pain during the return-to-throwing period often occurs and can be difficult to manage. PURPOSE: To evaluate the incidence of medial elbow pain and associations with outcomes and revision surgery during the return-to-throwing period after UCLR. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Between the years of 2002 and 2014, all pitchers who underwent UCLR at a single institution were identified. Charts were reviewed for incidence of medial elbow pain during return to throwing, return to sport, and subsequent operative interventions, including revision ulnar collateral ligament surgery. RESULTS: Of a total of 616 pitchers who underwent UCLR during the study period, 317 were included in this study. Medial elbow pain was experienced by 45.1% (143 of 317), with a mean time of complaint of 9.75 months after surgery. The groups with and without pain did not differ statistically with regard to age (pain, 20.6 years; no pain, 20.9 years) or level of competition. Of those who experienced medial elbow pain, 10.5% did not return to sport; 5.6% underwent revision UCLR; and 19.6% underwent other operative procedures at the elbow. Among those who did not experience medial elbow pain when returning to throw, 8.7% did not return to sport, with only 1.7% undergoing revision UCLR and 6.9% undergoing other operative elbow procedures. CONCLUSION: Of the pitchers evaluated in the study, approximately half reported pain during the return-to-throwing phase after UCLR. Those who experienced medial elbow pain had a higher rate of subsequent surgical intervention.

Ulnar Collateral Ligament Repair With Suture Bridge Augmentation.

The gold standard for management of elbow ulnar collateral ligament (UCL) injuries in elite athletes is reconstruction of the UCL with a tendon graft. Over the past several years, UCL repair for acute tears, as well as partial tears, in young athletes has gained increasing popularity, with studies reporting good outcomes and high rates of return to sports. Additionally, there is increased interest in ligament augmentation using the InternalBrace concept. A recent technique paper describes a direct repair of the UCL augmented with a spanning suture bridge. Although clinical outcomes for this method are promising, one possible concern when using this technique is bone loss at the ulnar origin of the UCL should revision reconstruction be required. We propose an alternative augmentation method that allows for stress shielding of the healing native ligament while minimizing bone compromise in the face of UCL reconstruction at a later time point.

Medicaid Health Insurance Status Limits Patient Accessibility to Rehabilitation Services Following ACL Reconstruction Surgery.

BACKGROUND: In the senior author's (X.L.) orthopaedic sports medicine clinic in the United States (US), patients appear to have difficulty finding physical therapy (PT) practices that accept Medicaid insurance for postoperative rehabilitation. PURPOSE: To determine access to PT services for privately insured patients versus those with Medicaid who underwent anterior cruciate ligament (ACL) reconstruction in the largest metropolitan area in the state of Massachusetts, which underwent Medicaid expansion as part of the Affordable Care Act. STUDY DESIGN: Cross-sectional study. METHODS: Locations offering PT services were identified through Google, Yelp, and Yellow Pages internet searches. Each practice was contacted and queried about health insurance type accepted (Medicaid [public] vs Blue Cross Blue Shield [private]) for postoperative ACL reconstruction rehabilitation. Additional data collection points included time to first appointment, reason for not accepting insurance, and ability to refer to a location accepting insurance type. Median income and percentage of households living in poverty were also noted through US Census data for the town in which the practice was located. RESULTS: Of the 157 PT locations identified, contact was made with 139 to achieve a response rate of 88.5%. Overall, 96.4% of practices took private insurance, while 51.8% accepted Medicaid. Among those locations that did not accept Medicaid, only 29% were able to refer to a clinic that would accept it. "No contract" was the most common reason why Medicaid was not accepted (39.4%). Average time to first appointment was 5.8 days for privately insured patients versus 8.4 days for Medicaid patients (P = .0001). There was no significant difference between clinic location (town median income or poverty level) and insurance type accepted. CONCLUSION: The study results reveal that 43% fewer PT clinics accept Medicaid as compared with private insurance for postoperative ACL reconstruction rehabilitation in a large metropolitan area. Furthermore, Medicaid patients must wait significantly longer for an initial appointment. Access to PT care is still limited despite the expansion of Medicaid insurance coverage to all patients in the state.

Corrigendum to "Fatal Vertebral Artery Injury in Penetrating Cervical Spine Trauma".

[This corrects the article DOI: 10.1155/2015/571656.].

BMPR1A antagonist differentially affects cartilage and bone formation during fracture healing.

A soluble form of BMP receptor type 1A (mBMPR1A-mFC) acts as an antagonist to endogenous BMPR1A and has been shown to increase bone mass in mice. The goal of this study was to examine the effects of mBMPR1A-mFC on secondary fracture healing. Treatment consisted of 10 mg/kg intraperitoneal injections of mBMPR1A-mFC twice weekly in male C57BL/6 mice. Treatment beginning at 1, 14, and 21 days post-fracture assessed receptor function during endochondral bone formation, at the onset of secondary bone formation, and during coupled remodeling, respectively. Control animals received saline injections. mBMPR1A-mFC treatment initiated on day 1 delayed cartilage maturation in the callus and resulted in large regions of fibrous tissue. Treatment initiated on day 1 also increased the amount of mineralized tissue and up-regulated many bone-associated genes (p = 0.002) but retarded periosteal bony bridging and impaired strength and toughness at day 35 (p < 0.035). Delaying the onset of treatment to day 14 or 21 partially mitigated these effects and produced evidence of accelerated coupled remodeling. These results indicate that inhibition of the BMPR1A-mediated signaling has negative effects on secondary fracture healing that are differentially manifested at different stages of healing and within different cell populations. These effects are most pronounced during the endochondral period and appear to be mediated by selective inhibition of BMPRIA signaling within the periosteum. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2096-2105, 2016.

Fatal Vertebral Artery Injury in Penetrating Cervical Spine Trauma.

Study Design. This case illustrates complications to a vertebral artery injury (VAI) resulting from penetrating cervical spine trauma. Objectives. To discuss the management of both VAI and cervical spine trauma after penetrating gunshot wound to the neck. Summary of Background Data. Vertebral artery injury following cervical spine trauma is infrequent, and a unilateral VAI often occurs without neurologic sequela. Nevertheless, devastating complications of stroke and death do occur. Methods. A gunshot wound to the neck resulted in a C6 vertebral body fracture and C5-C7 transverse foramina fractures. Neck CT angiogram identified a left vertebral artery occlusion. A cerebral angiography confirmed occlusion of the left extracranial vertebral artery and patency of the remaining cerebrovascular system. Following anterior cervical corpectomy and stabilization, brainstem infarction occurred and resulted in death. Results. A fatal outcome resulted from vertebral artery thrombus propagation with occlusion of the basilar artery triggering basilar ischemia and subsequent brainstem and cerebellar infarction. Conclusions. Vertebral artery injury secondary to cervical spine trauma can lead to potentially devastating neurologic sequela. Early surgical stabilization, along with anticoagulation therapy, contributes towards managing the combination of injuries. Unfortunately, despite efforts, a poor outcome is sometimes inevitable when cervical spine trauma is coupled with a VAI.

Use of intravenous conivaptan in neurosurgical patients with hyponatremia from syndrome of inappropriate antidiuretic hormone secretion.

BACKGROUND: Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is the most common cause of hyponatremia in hospitalized patients and is frequently associated with neurologic disorders and neurosurgical procedures. Traditional therapies such as fluid restriction, sodium repletion, and diuretics can help correct hyponatremia but do not address the underlying pathophysiology of excess arginine vasopressin secretion. Conivaptan is an arginine vasopressin receptor antagonist that has been shown to be both safe and effective in the treatment of euvolemic and hypervolemic hyponatremia. OBJECTIVE: To analyze the use of conivaptan to treat SIADH in a mixed neurosurgical population. METHODS: We conducted a retrospective review of 13 patients with neurosurgical disorders with SIADH that were treated with intravenous conivaptan at our institution between 2007 and 2009. RESULTS: The mean pretreatment serum sodium concentration was 125.8 ± 3.5 mEq/L. Conivaptan administration resulted in a rise in serum sodium to 132.5 ± 5.6 mEq/L at 12 hours (P < .01) and 134.1 ± 4.7 mEq/L at 24 hours posttreatment (P < .01). The mean time to an increase in serum sodium ≥ 6 mEq/L was 17.8 hours. There were no instances of rapid overcorrection. There were 3 cases of asymptomatic hyperkalemia, 3 cases of asymptomatic hypotension, and 1 case of elevated creatinine associated with conivaptan administration. CONCLUSION: These data provide further support that conivaptan can be safely used for the treatment of SIADH-induced hyponatremia in the neurosurgical arena.