Lateral Epicondylitis Debridement and Repair Using Knotless Suture Anchor.

Lateral epicondylitis, or tennis elbow, involves degeneration of the extensor carpi radialis brevis tendon and is often self-limiting, with surgery reserved for recalcitrant cases. Surgical management of tennis elbow consists primarily of either debridement alone or debridement with repair. Surgical repair is often performed using either a suture or a suture anchor. Good outcomes have been reported using standard repair methods; however, complications exist. Complications include potential loss of grip strength with debridement alone, as well as soft-tissue irritation caused by a prominent suture or knot stack after suture repair and suture anchor techniques. We describe a technique for debridement and repair of the extensor carpi radialis brevis tendon to the lateral epicondyle of the humerus using a knotless suture anchor, allowing for a watertight anatomic repair, maximum preservation of grip strength, and absence of a knot stack and resultant suture prominence.

Heterotopic bone formation about the hip undergoes endochondral ossification: a rabbit model.

BACKGROUND: Heterotopic ossification (HO) occurs most commonly after trauma and surgery about the hip and may compromise subsequent function. Currently available animal models describing the cellular progression of HO are based on exogenous osteogenic induction agents and may not reflect the processes following trauma. QUESTIONS/PURPOSES: We therefore sought to characterize the histologic progression of heterotopic bone formation in an animal model that recapitulates the human condition without the addition of exogenous osteogenic material. METHODS: We used a rabbit model that included intramedullary instrumentation of the upper femur and ischemic crush injury of the gluteal muscle. Bilateral surgical induction procedures were performed on 30 animals with the intention of inciting the process of HO; no supplemental osteogenic stimulants were used. Three animals were sacrificed at each of 10 predetermined times between 1 day and 26 weeks postoperatively and the progression of tissue maturation was graded histologically using a five-item scale. RESULTS: Heterotopic bone reliably formed de novo and consistently followed a pathway of endochondral ossification. Chondroid elements were found in juxtaposition with immature woven bone in all sections that contained mature osseous elements. CONCLUSIONS: These results establish that HO occurs in an animal model mimicking the human condition following surgical trauma about the hip; it is predictable in its histologic progression and follows a pathway of endochondral bone formation. CLINICAL RELEVANCE: By showing a consistent pathway of endochondral ossification leading to ectopic bone formation, this study provides a basis for understanding the mechanisms by which HO might be mitigated by interventions.

Time from ACL injury to reconstruction and the prevalence of additional intra-articular pathology: is patient age an important factor?

PURPOSE: Meniscus and cartilage lesions have been reported to be prevalent during delayed reconstruction of anterior cruciate ligament (ACL) injuries. Relatively, little work has been done exploring the influence of patient age on this relationship. The purpose of this study is to determine whether the effect of time from ACL injury to reconstruction on the prevalence of associated meniscal and chondral injury is influenced by patient age. It was hypothesized that patients in whom the time from ACL injury to reconstruction exceeds 12 weeks will exhibit an increased prevalence of medial compartment pathology relative to those reconstructed within 12 weeks of injury in patients of all ages. METHODS: Data detailing time from ACL injury to reconstruction and the prevalence of intra-articular findings were obtained in 311 of 489 consecutive patients undergoing primary isolated ACL reconstruction. Patients were divided into two groups based on whether the time from ACL injury to reconstruction was <12 weeks or at least 12 weeks. The prevalence of associated intra-articular injury was then compared between the two groups. Patients were then stratified based on age (22 years and under vs. over the age of 22), and the analysis was repeated on both groups. RESULTS: Analysis of all patients together revealed a significantly higher prevalence of medial meniscus injury (p = 0.013) and medial compartment chondral injury (p < 0.0005) in patients in whom the time from ACL injury to reconstruction exceeded 12 weeks. The prevalence of lateral meniscal injury did not increase with increasing time ACL injury to surgery. Among patients aged 22 years and under, there was no increase in the prevalence of intra-articular pathology in any compartment in the late reconstruction group. In contrast, among patients over the age of 22, there was a significant increase in the prevalence of medial chondral injury (p = 0.042) in the late reconstruction group. CONCLUSION: The prevalence of injuries to the meniscus and articular cartilage in the medial compartment of the knee is increased with increasing time from ACL injury to reconstruction. This relationship may vary depending on patient age. Patients over the age of 22 exhibit a higher prevalence of intra-articular injury with delayed reconstruction, while no such differences are noted among younger patients. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

Arthroscopic suture anchor capsulorrhaphy versus labral-based suture capsulorrhaphy in a cadaveric model.

PURPOSE: The purpose of this study was to establish whether suture anchor capsulorrhaphy (SAC) is biomechanically superior to suture capsulorrhaphy (SC) in the management of recurrent anterior shoulder instability without a labral avulsion. METHODS: Twelve matched pairs of shoulders were randomized to either SC or SAC. Specimens were mounted in 60° of abduction and 90° of external rotation. Testing was conducted on an MTS servohydraulic load testing device (MTS, Eden Prairie, MN). A compressive load of 22 N was applied, followed by a 2-N anterior and posterior force to establish a 0 point. Translation with 10-N anterior and posterior loads was recorded for baseline laxity measurement. Arthroscopic capsulorrhaphy was performed with either 3 solitary sutures or 3 suture anchors. Specimens were remounted and returned to the 0 point. Translation was measured with 10-N anterior and posterior loads to determine reduction in translation. Specimens were then loaded to failure to the 0 point at a rate of 0.1 mm/s. RESULTS: Load to failure was significantly greater (P = .02) in the SC group (13.6 ± 1.0 N) versus the SAC group (20.5 ± 2.8 N). No differences were found between SC (2.7 ± 0.7 mm) and SAC (2.3 ± 0.6 mm) when we compared reduction of anterior translation with a 10-N load. The percent reduction of anterior displacement with a 10-N load was similar for the SC (49.9%) and SAC (49.6%) groups. The dominant mode of failure in the study was suture pull-through of the capsular tissue. CONCLUSIONS: Our study indicates that labral-based SC and SAC similarly reduce anterior glenohumeral translation at low loading conditions. Load-to-failure studies indicate that SAC exhibits significantly greater resistance to translation at higher loading conditions. Our study suggests that the use of a suture anchor when one is performing a capsulorrhaphy may provide biomechanical advantage at high loading conditions. CLINICAL RELEVANCE: Our study suggests that when one is performing capsulorrhaphy, the use of a suture anchor may provide biomechanical advantages at high loading conditions.

Treatment of chronic glenoid defects in the setting of recurrent anterior shoulder instability: a systematic review.

OBJECTIVE: The purpose is to systematically evaluate the literature regarding treatment of chronic glenoid bone defects in the setting of recurrent anterior shoulder instability to determine if, from an evidence-based outcomes approach, one technique may be recommended over the other. METHODS: PubMed 1966-2009, Embase 1980-2009, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials databases were searched for human studies in English. Keywords were osseous glenoid defects, glenoid bone grafting, Latarjet procedure, iliac crest and glenoid defects, and glenoid rim fractures. Inclusion criteria were all articles evaluating chronic glenoid deficiency in the setting of recurrent anterior glenohumeral instability. Exclusion criteria were surgical techniques not reporting follow-up, glenoid rim fractures treated by open reduction internal fixation, and investigations not quantifying glenoid deficiency assessments. RESULTS: Six articles met all inclusion and exclusion criteria. All articles were level IV (case series), most (5/6) were retrospective. Multiple techniques involving coracoid transfer and allograft or autograft reconstruction have been described for management of chronic glenoid deficiency. Lack of high level evidence in the form of prospective randomized trials limits our ability to recommend one technique over another. The 6 techniques reviewed here were all effective at preventing recurrent instability. CONCLUSIONS: Chronic glenoid deficiency in the setting of recurrent anterior instability is an extremely challenging problem. There remains a lack of strong evidence guiding the surgeon in the decision-making process. Additional research is needed to optimize the preoperative glenoid defect assessment, further evaluate the reconstruction techniques, and follow the long-term effects of reconstruction on the development of glenohumeral arthrosis.

The Mark Coventry Award: Prevention of readmission for venous thromboembolism after total knee arthroplasty.

Venous thromboembolism is the most common reason for readmission after total knee arthroplasty. Prospective contrast venography was conducted from 1984 to 2003 in 1321 patients undergoing total knee arthroplasty. Patients with deep venous thrombosis or pulmonary embolism were treated with warfarin; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993 patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venography was completed in 810 patients; 343 (42.3%) had deep venous thrombosis. Readmission for venous thromboembolism occurred in 0.6% of patients after total knee compared with 1.62% after total hip arthroplasty. Following total knee arthroplasty, patients discharged on warfarin (target INR 2.0) had a 0.21% readmission rate compared with 1.05% for patients with negative venograms discharged without further anticoagulation. One patient suffered a fatal pulmonary embolism after negative venography and no outpatient prophylaxis. Secondary prophylaxis with extended warfarin therapy reduced venous thromboembolism-related readmission. Surveillance venograms were a poor predictor of ultimate thromboembolism risk and need for extended anticoagulation therapy. We therefore recommend extended warfarin prophylaxis for all patients after hospital discharge following total knee arthroplasty.

The John Charnley Award: prevention of readmission for venous thromboembolic disease after total hip arthroplasty.

UNLABELLED: Venous thromboembolic disease remains the most common reason for readmission after total hip arthroplasty. Prospective analysis of screening contrast venography was done from 1984 to 2003 in 1972 patients having elective total hip arthroplasty. Patients with deep venous thrombosis or pulmonary embolism received warfarin therapy; those with negative venograms received no further anticoagulation. From 1984 to 1992, patients not completing venography were discharged without warfarin; since 1993, patients without venography received warfarin for 6 weeks. Readmission for deep venous thrombosis, pulmonary embolism, or bleeding was tracked for 6 months. Venograms were completed in 1032 patients; 175 (16.9%) had deep venous thrombosis. Deep venous thrombosis was reduced by a clinical pathway that included continuous epidural anesthesia (14.2% versus 22.5%). The overall readmission rate for venous thromboembolic disease was 1.62%, including 14 pulmonary emboli (three fatal) and 18 femoral deep venous thrombosis. Readmission occurred in 0.27% (1 of 360) patients on continued warfarin, compared with 2.2% (19 of 880) with negative venograms discharged without further anticoagulation. Three patients (0.15%) suffered fatal pulmonary emboli; all had negative venograms and received no outpatient prophylaxis. Extended outpatient warfarin therapy provided effective protection against venous thromboembolic disease readmission. Surveillance venography was a poor predictor of need for continued prophylaxis; all patients should have extended anticoagulation after total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic study, Level I-1 (high-quality randomized trial with statistically significant difference or no statistically significant difference but narrow confidence intervals). See the Guidelines for Authors for a complete description of levels of evidence.