Symptomatic flexion instability in posterior stabilized primary total knee arthroplasty.

Flexion instability in posterior-stabilized total knee arthroplasty is a relatively uncommon but distinct problem that is often underdiagnosed and may require surgical management. This retrospective study evaluated the authors' management strategy and assessed the results of revision surgery. The authors identified 19 knees that underwent revision for isolated flexion instability after primary posterior-stabilized total knee arthroplasty. All patients had typical symptoms and signs of flexion instability, which include diffuse pain, especially when negotiating stairs, a sense of instability without giving way, recurrent joint effusions, and diffuse periarticular tenderness. Knee Society scores were used to assess pain and function. Complete revision was performed in 11 knees, femoral revision with a thicker insert was performed in 1 knee, and isolated tibial polyethylene insert exchange was performed in 7 knees. Postoperatively, all patients reported improvement in instability symptoms and signs associated with improvement in mean Knee Society scores. Revision surgery with careful gap balancing is successful in the management of isolated flexion instability in posterior-stabilized total knee arthroplasty. Isolated tibial polyethylene insert exchange may have a role in selected patients where component malalignment and malrotation is ruled out and a thicker and/or semiconstrained insert can be used, while limiting the resultant flexion contracture to less than 5°.

Clinical and Biomechanical Evaluation of an All-Arthroscopic Suprapectoral Biceps Tenodesis.

BACKGROUND: Pathology of the long head of the biceps (LHB) is a well-recognized cause of shoulder pain in the adult population and can be managed surgically with tenotomy or tenodesis. PURPOSE: To compare the biomechanical strength of an all-arthroscopic biceps tenodesis technique that places the LHB distal to the bicipital groove in the suprapectoral region with a more traditional mini-open subpectoral tenodesis. This study also evaluates the clinical outcomes of patients who underwent biceps tenodesis using the all-arthroscopic technique. STUDY DESIGN: Controlled laboratory study and case series; Level of evidence, 4. METHODS: For the biomechanical evaluation of the all-arthroscopic biceps tenodesis technique, in which the biceps tendon is secured to the suprapectoral region distal to the bicipital groove with an interference screw, 14 fresh-frozen human cadaveric shoulders (7 matched pairs) were used to compare load to failure and displacement at peak load with a traditional open subpectoral location. For the clinical evaluation, 49 consecutive patients (51 shoulders) with a mean follow-up of 2.4 years who underwent an all-arthroscopic biceps tenodesis were evaluated using the American Shoulder and Elbow Surgeons (ASES) score preoperatively and at last follow-up, as well as the University of California, Los Angeles (UCLA) Shoulder Score at last follow-up. RESULTS: On biomechanical evaluation, there was no significant difference in peak failure load, displacement at peak load, or displacement after cyclic testing between the arthroscopic suprapectoral and mini-open subpectoral groups. In the clinical evaluation, the mean preoperative ASES score was 65.4, compared with 87.1 at last follow-up. The mean UCLA score at last follow-up was 30.2. Forty-eight (94.1%) patients reported satisfaction with the surgery. In subgroup analysis comparing patients who had a rotator cuff repair or labral repair at time of tenodesis with patients who did not have either of these procedures, there were no significant differences in UCLA or ASES scores. CONCLUSION: The excellent biomechanical strength as well as the high rate of satisfaction after surgery and high ASES and UCLA postoperative scores make this technique a novel option for treatment of biceps tendon pathology.

Time and Cost of Diagnosis for Symptomatic Femoroacetabular Impingement.

BACKGROUND: Femoroacetabular impingement (FAI) and labral tears are common causes of hip pain that are often not promptly or properly diagnosed. To our knowledge, no reports have defined the time and cost of diagnosis of labral tears associated with FAI. HYPOTHESIS: Patients with labral tears associated with FAI undergo extraneous diagnostic testing and pain and incur a significant amount of health care costs before they receive appropriate surgical management for their pathology. STUDY DESIGN: Economic and decision analysis; Level of evidence, 4. METHODS: A total of 78 patients diagnosed with symptomatic FAI were surveyed. A standardized questionnaire asked patients about time to diagnosis, symptoms, health care providers visited, imaging tests, and treatments prior to diagnosis. Costs were calculated based on 2012 national Medicare data. RESULTS: Patients in the cohort saw an average of 4.0 health care providers, had an average of 3.4 diagnostic imaging tests, and tried an average of 3.1 treatments prior to diagnosis. The average total amount spent per patient prior to diagnosis was US$2456.97. The calculated minimum cost of diagnosis, including a visit to an orthopaedic surgeon as well as an anteroposterior pelvis and lateral hip radiograph and 1 magnetic resonance arthrogram, was US$690.62. The average duration between onset of symptoms and diagnosis of labral tear was 32.0 months. CONCLUSION: The average amount of health care dollars spent per patient prior to receiving a diagnosis of acetabular labral tear was US$1766.35 higher than the calculated minimum cost. This figure is based on Medicare payment amounts, which may significantly underestimate the actual charges at many hospitals, thereby increasing the total cost of diagnosis. CLINICAL RELEVANCE: The costs and pain associated with this time, along with the potential long-term degradation of the hip joint, make it important for all health care professionals to recognize and appropriately manage or refer the patient.

Does the direct anterior approach in THA offer faster rehabilitation and comparable safety to the posterior approach?

BACKGROUND: Newer surgical approaches to THA, such as the direct anterior approach, may influence a patient's time to recovery, but it is important to make sure that these approaches do not compromise reconstructive safety or accuracy. QUESTIONS/PURPOSES: We compared the direct anterior approach and conventional posterior approach in terms of (1) recovery of hip function after primary THA, (2) general health outcomes, (3) operative time and surgical complications, and (4) accuracy of component placement. METHODS: In this prospective, comparative, nonrandomized study of 120 patients (60 direct anterior THA, 60 posterior THAs), we assessed functional recovery using the VAS pain score, timed up and go (TUG) test, motor component of the Functional Independence Measure™ (M-FIM™), UCLA activity score, Harris hip score, and patient-maintained subjective milestone diary and general health outcome using SF-12 scores. Operative time, complications, and component placement were also compared. RESULTS: Functional recovery was faster in patients with the direct anterior approach on the basis of TUG and M-FIM™ up to 2 weeks; no differences were found in terms of the other metrics we used, and no differences were observed between groups beyond 6 weeks. General health outcomes, operative time, and complications were similar between groups. No clinically important differences were observed in terms of implant alignment. CONCLUSIONS: We observed very modest functional advantages early in recovery after direct anterior THA compared to posterior-approach THA. Randomized trials are needed to validate these findings, and these findings may not generalize well to lower-volume practice settings or to surgeons earlier in the learning curve of direct anterior THA.

All-arthroscopic iliotibial band autograft harvesting and labral reconstruction technique.

The labrum is essential for stability, movement, and prevention of arthritis in the hip. In cases of labral damage where repair of a labral tear is not possible, reconstruction can be a useful alternative. Several different autografts have been used, including the iliotibial band (ITB), the ligamentum teres capitis, and the gracilis tendon. Authors have reported both open and arthroscopic techniques for reconstruction with good preliminary results. However, an all-arthroscopic labral reconstruction technique including the graft harvest and reconstruction portions of a labral reconstruction procedure using an ITB autograft has not been previously described. We describe a technique for an all-arthroscopic labral reconstruction performed using a novel method for arthroscopic harvest of the ITB. The decreased invasiveness of our described technique for labral reconstruction may potentially minimize scarring, bodily disfigurement, infection, and postoperative pain associated with the graft harvesting incision.