Arthroscopic treatment of type II superior labral anterior to posterior (SLAP) lesions in a younger population: minimum 2-year outcomes are similar between SLAP repair and biceps tenodesis.

PURPOSE: Compared to a relatively older population over 30-40 years of age, the efficacy of biceps tenodesis for type II SLAP lesions in a younger population is not well studied. The purpose of this study was to compare outcomes between biceps tenodesis and labral repair for type II SLAP lesions in a young active population. METHODS: Patients aged 15-40 who underwent primary arthroscopic biceps tenodesis or SLAP repair for type II SLAP tears between 2009 and 2016 were included. Shoulders with intraarticular chondral damage, full thickness rotator cuff tear, rotator cuff repair, labral repair outside of the superior labrum, bony subacromial decompression, and acromioclavicular joint resection were excluded. Patient-reported outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand Sports/Performing Arts Module (DASH-sport), visual analog scale (VAS) for pain, and satisfaction. Return to sport rates were also recorded. RESULTS: Fifty-three patients (20 tenodesis, 33 repair) were available for minimum 2-year follow-up. Postoperatively, there were no significant differences in mean ASES, DASH-sport, VAS, and satisfaction between groups [ASES: tenodesis 86.3 vs. repair 86.4 (n.s.); DASH-sport: 11.0 vs. 22.5 (n.s.); VAS: 1.85 vs. 1.64 (n.s.); satisfaction: 8.50 vs. 8.00 (n.s.)]. Rate of return to pre-injury level of performance/competition in sport/physical activity was also similar between groups [tenodesis 63% vs. repair 50% (n.s.)]. CONCLUSIONS: In a young active population, primary arthroscopic biceps tenodesis is a viable surgical alternative to labral repair for type II SLAP lesions. The results of this study suggest that indications for arthroscopic tenodesis can safely be expanded to a younger patient group than has previously been demonstrated in the literature. LEVEL OF EVIDENCE: III.

Efficacy of Celecoxib for Early Postoperative Pain Management in Hip Arthroscopy: A Prospective Randomized Placebo-Controlled Study.

PURPOSE: To determine whether 400 mg of celecoxib administered 1 hour before hip arthroscopy surgery would reduce pain, provide reduction in overall narcotic consumption, and lead to more rapid discharge from recovery rooms. METHODS: Ninety-eight patients were randomized to either the celecoxib group (n = 50) or the placebo group (n = 48). An a priori power analysis was done set to detect a difference of 0.50 on the visual analog scale (VAS), based on the senior author's preference. The number of patients planned for recruitment was rounded up to 100 to allow for flexibility in the study. Inclusion criteria were any patient at least 18 years old who underwent hip arthroscopy surgery performed by the senior author. All patients had less than Tönnis grade 2 arthritis. Exclusion criteria were allergy to sulfa-based drugs, prior adverse reaction to celecoxib, or patients who were on chronic narcotics for whom alternative pain management regimens were arranged before surgery. Randomization was performed on a 1:1 basis in blocks of 10 using sealed envelopes stating celecoxib or placebo. One hour before surgery, all patients received either 400 mg celecoxib or placebo. Patients were evaluated using a VAS preoperatively, immediately postoperatively, and at 1 and 2 hours postoperatively. Time from the operating room to "ready for discharge" and number of morphine equivalents of narcotic medication required in the postanesthesia care unit were recorded. RESULTS: Age and preoperative VAS were similar between the celecoxib and placebo control group, with average ages of 34.2 ± 11.9 and 35.8 ± 11.6 (P = .27) and preoperative VAS of 2.1 ± 2.06 and 2.3 ± 1.98 (P = .29), respectively. The celecoxib group had 26 females and 24 males, whereas the placebo group had 29 females and 19 males (P = .42). The most common surgical procedures were labral repair (31 patients in the celecoxib group and 29 patients in the placebo group), and labral repair with acetabular osteoplasty (13 patients in the celecoxib group and 11 patients in the placebo group). There were no significant differences in procedures performed between the 2 groups (P > .05). At 1 hour postoperatively, patients who received celecoxib had a lower pain score that was statistically significant compared with the placebo group (4.6 vs 5.4, P = .03). There was a significant difference in discharge time between patients who received celecoxib and the control group (152.9 minutes vs 172.9 minutes, P = .04). There was no significant difference found in morphine equivalents consumed in the postanesthesia care unit between the 2 groups (15.3 vs 15.4, P = .48). CONCLUSIONS: A preoperative dose of 400 mg of celecoxib led to statistically significantly reduced patient-reported pain on the VAS in the acute postoperative period after hip arthroscopy surgery, though the difference is not likely clinically significant. There was a significantly shorter time to discharge in patients who received celecoxib versus placebo. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

Shoulder Arthroplasty Outcomes in Patients With Multiple Reported Drug Allergies: Does Number of Drug Allergies Have an Effect on Outcome?

BACKGROUND: The presence of multiple allergies has been correlated with worse outcomes for patients undergoing hip and knee arthroplasty, but the effect of allergies has not yet been elucidated with respect to shoulder arthroplasty. PURPOSE/HYPOTHESIS: The purpose of this study is to identify any discrepancies in shoulder arthroplasty outcomes with respect to reported drug allergies. We hypothesized that patients with multiple drug allergies would have inferior outcomes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included in the analysis were a single surgeon's cases between 2009 and 2014 of primary total shoulder arthroplasty with a minimum of 180 days of follow-up. Cases with fracture as the indication were excluded. Preoperative and postoperative metrics included visual analog scale (VAS) for pain, forward flexion range of motion, and Simple Shoulder Test (SST) results, and postoperative patient satisfaction scores were also collected. Chi-square and 1-way analysis of variance with Tukey post hoc analyses were performed when appropriate. RESULTS: A total of 98 patients were included (no allergies, n = 51; single allergy, n = 21; multiple allergies, n = 26). The proportion of females was greater with increasing number of allergies (no allergies, 31%; single allergies, 47%; multiple allergies, 88%; Pearson χ2 = 22.5; P < .0001). Both preoperatively and postoperatively, no difference was found between cohorts with respect to SST score, VAS score, or forward flexion. There was also no difference in postoperative satisfaction between cohorts. No difference between cohorts was identified when comparing the pre- to postoperative change in SST scores, VAS scores, or forward flexion. CONCLUSION: The presence of single or multiple allergies is not correlated with worse outcomes after primary anatomic total shoulder arthroplasty.

Assessment of Intraoperative Intra-articular Morphine and Clonidine Injection in the Acute Postoperative Period After Hip Arthroscopy.

BACKGROUND: Previous authors have suggested that intra-articular morphine and clonidine injections after knee arthroscopy have demonstrated equivocal analgesic effect in comparison with bupivacaine while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine after hip arthroscopy. PURPOSE: To evaluate the efficacy of intra-articular morphine in combination with clonidine on postoperative pain and narcotic consumption after hip arthroscopy surgery for femoroacetabular impingement. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective chart review was performed on 43 patients that underwent hip arthroscopy for femoroacetabular impingement at a single institution between September 2014 and May 2015. All patients received preoperative celecoxib and acetaminophen, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 µg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the 2 groups. RESULTS: Patients who received intra-articular morphine and clonidine used significantly less opioid analgesic (mEq) in the postanesthesia recovery (median difference, 17 mEq [95% CI, -32 to -2 mEq]; P = .02) compared with the control group. There were no differences in time spent in recovery before hospital discharge or in visual analog pain scores recorded immediately postoperatively and at 1 hour after surgery. CONCLUSION: Intraoperative intra-articular injection of morphine and clonidine significantly reduced the narcotic requirement during the postsurgical recovery period after hip arthroscopy. The reduction in postsurgical opioids may decrease adverse effects, improve overall pain management, and lead to better quality of recovery and improved patient satisfaction.

Patterns of strain and the determination of the safe arc of motion after subscapularis repair--A biomechanical study.

This study characterizes the strain patterns and safe arcs for passive range of motion (ROM) in the superior and inferior subscapularis tendon in seven cadaveric shoulders, mounted for controlled ROM, after deltopectoral approach to the glenohumeral joint, including tenotomy of the subscapularis tendon 1 cm medial to its insertion on the lesser tuberosity. The tenotomy was repaired with end-to-end suture in neutral rotation. Strain patterns were measured during passive ROM in external rotation (ER), ER with 30° abduction (ER+30), abduction, and forward flexion in the scapular plane (SP) before and after surgery. Percentages were calculated from 35 trials corresponding to five trials of each motion across seven specimens. With ER of 0-30°, 89% of trials of superior subscapularis tendon and 100% of trials of inferior subscapularis tendon achieved strains >3%, with very similar patterns noted in ER+30. In abduction of 0-90°, 5.8% of trials of superior and 85.3% of trials of inferior tendon achieved >3% strain. With passive ROM in SP, 26.5% of trials reached 3% strain in superior tendon compared to 100% in inferior tendon. Strain patterns in abduction and SP differed significantly (p < 0.001). Selective tenotomy and repair of the superior subscapularis tendon with open reparative or reconstructive shoulder procedures, when feasible, may be favorable for protected early passive ROM and rehabilitation postoperatively.

New Developments in the Use of Biologics and Other Modalities in the Management of Lateral Epicondylitis.

Lateral epicondylitis is a common source of elbow pain. Though it is often a self-limited condition, refractory lateral epicondylitis can lead to problems with activities of daily living and sometimes requires sick leave from work. Therefore prompt treatment is essential. Histopathologic studies have suggested that lateral epicondylitis is a tendinopathy, associated with apoptosis and autophagy, rather than a tendonitis associated with inflammation. Although corticosteroids have been used for short-term treatment, recent studies have suggested that they are not helpful and may even be harmful and delay healing in the treatment of lateral epicondylitis. Researchers have recently begun to investigate the use of biologics as potential treatment options for lateral epicondylitis. Autologous blood preparations including platelet rich plasma (PRP) and autologous whole blood injections (ABIs) have been proposed in order to deliver growth factors and other nutrients to the diseased tendon. Stem cell therapies have also been suggested as a method of improving tendon healing. This review discusses the current evidence for the use of PRP, ABI, and stem cell therapies for treatment of lateral epicondylitis. We also review the evidence for nonbiologic treatments including corticosteroids, prolotherapy, botulinum toxin A, and nitric oxide.

All-Arthroscopic Suprapectoral Biceps Tenodesis.

Biceps tenodesis is a common treatment for pathology of the long head of the biceps tendon. Several authors have described various arthroscopic and open techniques for biceps tenodesis. Open techniques have been associated with complications such as wound infection and nerve injury. Previously described arthroscopic techniques have placed the tenodesis site within the bicipital groove, which may lead to persistent pain. We describe an all-arthroscopic suprapectoral biceps tenodesis technique that places the tenodesis site distal to the bicipital groove. This technique potentially avoids the complications associated with open tenodesis surgery while still removing the biceps tendon from the bicipital groove.

Conflict of interest in the assessment of hyaluronic acid injections for osteoarthritis of the knee: an updated systematic review.

The search results of a recent systematic review of prospective, randomized, placebo-controlled trials on hyaluronic acid injections for knee arthritis were updated and reviewed for funding source and qualitative conclusions. Forty-eight studies were identified; 30 (62.5%) were industry funded, and 3 (6.25%) were not. Fifteen (31.3%) studies did not identify a funding source. An association was observed between a reported potential financial conflict of interest of the author and the qualitative conclusion (P=0.018). None of the studies with a reported financial conflict of interest of at least one author had an unfavorable conclusion; 11 (35%) of the 31 studies with no industry-affiliated authors indicated that hyaluronic acid injection for knee osteoarthritis was no more effective than a placebo injection.

Osteochondral injury after acute patellar dislocation in children and adolescents.

BACKGROUND: Acute patellar dislocation (APD) is a common injury in the pediatric patient population and may be associated with a spectrum of soft tissue and osteochondral injuries. This study describes the incidence of osteochondral fracture and associated injury patterns in a pediatric population after first-time APD and assesses functional outcomes after treatment. METHODS: One hundred twenty-two patients, aged 11 to 18 years, who were evaluated after first-time APD over a 10-year period were identified, 46 of whom had confirmed osteochondral injury on magnetic resonance imaging (MRI). Demographic data, including knee affected, mechanism of injury, recurrent dislocation, operations performed, and condition at last follow-up, were retrieved from the medical record. Operative reports and MRI were used to characterize the location of osteochondral injury. The functional outcome of each patient with an osteochondral fracture was assessed using the Pedi-IKDC questionnaire. RESULTS: Forty-six patients, mean age 14.6 years (range, 11 to 18 y), were included. Osteochondral fracture occurred at the patella in 35 patients (76%), the lateral femoral condyle in 11 patients (24%), and at both locations in 3 patients (6.5%). In 21 patients (44%), MRI confirmed osteochondral injury despite the plain radiograph interpretation as negative for fracture. Twenty-six patients (68%) subsequently underwent surgery after injury. Injury to the medial patellofemoral ligament was identified on MRI in 97.8% of patients (45/46). Fifteen patients (32.6%) underwent a concomitant medial repair at the time of surgery. Osteochondral injury to the distal femur on average had a lower International Knee Documentation Committee score than patellar injuries (72.3±18 vs. 91.1±10.2, P<0.003). Femoral osteochondral injury involving the weight-bearing surface (75.27±18.19) scored lower than non-weight-bearing surface injuries (93.22±7.47; P<0.001). CONCLUSIONS: The incidence of osteochondral injury associated with APD is high. Osteochondral fractures may initially go unrecognized on plain radiographs. Patients with weight-bearing lateral femoral condyle injuries had lower short-term functional scores, suggesting that outcomes depend on location of injury. LEVEL OF EVIDENCE: Level IV, diagnostic and therapeutic study.

Novel method for ensuring leg length in total hip arthroplasty.

Despite the overwhelming clinical success of total hip arthroplasty, complications such as leg-length discrepancy can be a significant cause of functional impairment and patient dissatisfaction. Multiple intraoperative techniques are available for measuring femoral limb length; however, many require additional invasive hardware and those that do not are less accurate at measuring limb length. This article introduces a novel, noninvasive intraoperative technique that quickly and accurately measures limb length and prevents postoperative leg-length discrepancy.The authors' method relies on the accurate reproduction of a line perpendicular to the femoral axis near the proximal aspect of the greater trochanter intraoperatively and during preoperative planning and requires minor modifications to the instrumentation used. A narrow slot for the placement of a guide plate was machined into a standard trial head 37° from the axis of the neck for use with a high offset 127° Secur-Fit PLUS stem and 42° from the axis of the neck for use with a standard offset 132° Secur-Fit stem (Stryker Orthopaedics, Kalamazoo, Michigan). Once a broach is securely seated, a trial neck, slotted trial head, and guide plate are assembled and the distance from the guide plate to the proximal tip of the greater trochanter is compared with the preoperative planning measurements to assess the stem position.A retrospective radiographic analysis of 31 consecutive primary total hip arthroplasty using this technique showed the mean postoperative leg-length discrepancy to be 2.18±6.08 mm. This method is an additional tool for the arthroplasty surgeon's armamentarium to ensure accurate leg-length restoration.

Diagnosis and management of superior labral anterior posterior tears in throwing athletes.

Injury to the superior glenoid labrum is increasingly recognized as a significant source of shoulder pain and dysfunction in the throwing athlete. Several theories have been proposed to explain the pathogenesis of superior labral anterior posterior (SLAP) tears. The clinical examination of the superior labrum-biceps tendon complex remains challenging because of a high association of other shoulder injuries in overhead athletes. Many physical examination findings have high sensitivity and low specificity. Advances in soft tissue imaging such as magnetic resonance arthrography allow for improved detection of labrum and biceps tendon lesions, although correlation with history and physical examination is critical to identify symptomatic lesions. Proper treatment of throwers with SLAP tears requires a thorough understanding of the altered biomechanics and the indications for nonoperative management and arthroscopic treatment of these lesions.

Inflammatory biomarker profiling in elderly patients with acute hip fracture treated with heparins.

Hip fracture is common in the elderly patients with associated high risk of venous thromboembolic complications. Pathogenic activation results in the generation of various surrogate markers in plasma. This study is designed to identify unique biomarkers in elderly patients with hip fracture using protein chip array enzyme-linked immunosorbent assay (ELISA) methods. Plasma from a randomized hip fracture study (PK-532; n = 341) treated with either enoxaparin (40 mg once daily) or unfractionated heparin (UFH; 5000 IU twice daily) were collected prior to and at 1, 3, 5, and 7 days. A total of 52 samples were analyzed using proteomic surface-enhanced laser desorption/ ionization-time of flight (SELDI-TOF) mass spectrometry to identify unique biomarkers in the molecular weight range of 0 to 150 kd. Twenty-nine healthy volunteer's and pooled plasma from total hip replacement/total knee replacement patients with a unique biomarker at 11.9 kd were used as quality controls. In the 29 healthy individuals, the biomarker profile did not reveal the presence of any unique peak in comparison to the reference normal human plasma (NHP). Plasma obtained prior to surgery exhibits unique biomarkers in 4 of 52 (7.6%) of the samples. On day 1 postoperatively, 41 of 51 (80.3%) showed a distinct peak at 11.9 kd. On day 3, 43 of 49 (87.8%) patients showed the presence of this biomarker most often at its strongest intensity. In all, 22 of 44 (50%) showed this biomarker on day 5 and 4 of 23 (17.9%) on day 7. C-reactive protein (CRP), tumor necrosis factor alpha (TNF-alpha), and serum amyloid A were also increased after surgery. Tissue factor pathway inhibitor (TFPI) antigen levels were increased due to the treatment modalities.