Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes.

BACKGROUND: Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair. PURPOSE: To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft. RESULTS: Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001). CONCLUSION: A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

The relationship between high-signal intensity changes in the glenohumeral joint capsule on MRI and clinical shoulder symptoms.

BACKGROUND/OBJECTIVE: High-signal intensity changes in the glenohumeral joint capsule on T2-and proton density-weighted magnetic resonance imaging are known as characteristic finding that is often observed in patients with frozen shoulder. We investigated the associations between high-signal intensity changes in the joint capsule on magnetic resonance imaging and the presence of rotator cuff tears and shoulder symptoms in patients with shoulder pain. METHODS: The medical records of 230 patients with shoulder pain who underwent magnetic resonance imaging at our hospital were reviewed. Patients were divided into three groups according to the presence and/or degree of rotator cuff tears (none, partial, or complete). The frequency of high-signal intensity changes in the joint capsule and its relationship with shoulder symptoms and the severity of rotator cuff tears were assessed. By quantitatively evaluating the intensity on MRI, the ratio between the joint capsule and the long head of the biceps (HSIC ratio) was calculated and compared with 15 healthy subjects. RESULTS: High-signal intensity changes were diagnosed in 165 (72%) patients, and it was significantly associated with night pain and range of motion limitation (p < 0.01). High-signal intensity changes were present in 66 patients (70%) with no rotator cuff tears, in 69 (71%) with partial rotator cuff tears, and in 36 (80%) with complete rotator cuff tears, without differences in their occurrence (p = 0.60), but were significantly associated with night pain in all the groups (p < 0.01) without differences in tear severity (p = 0.63). The ratio in the high-signal intensity changes (HSIC) positive group was approximately six times higher than that in the HSIC-negative and control groups (P < 0.01). Multivariate logistic regression analysis revealed that night pain is significantly associated with high-signal intensity changes (p < 0.01). CONCLUSION: Shoulder pain is a common and reliable clinical finding in patients with high-signal intensity changes, regardless of the presence and/or degree of rotator cuff tears, Such changes may indicate night pain and range of motion limitation in patients.

Tibial Stress Fractures in Athletes.

Tibial stress fractures are common in the athlete. There are various causes of these fractures, the most common being a sudden increase in training intensity. Most of these injuries are treated conservatively; however, some may require operative intervention. Intervention is mostly dictated by location of the fracture and failure of conservative treatment. There are several surgical options available to the treating surgeon, each with advantages and disadvantages. The physician must understand the nature of the fracture and the likelihood for it to heal in a timely manner in order to best treat these fractures in this patient subset.

Combined Arthroscopic Bankart Repair and Coracoid Process Transfer to Anterior Glenoid for Shoulder Dislocation in Rugby Players: Evaluation Based on Ability to Perform Sport-Specific Movements Effectively.

PURPOSE: To evaluate the outcomes of a combination of an arthroscopic Bankart repair and an open Bristow procedure in relation to the subjective quality of performance in movements that are typical in rugby. METHODS: Forty shoulders in 38 players who underwent surgery for traumatic anterior instability of the shoulder were reviewed. In all cases, arthroscopic Bankart repair was followed by a Bristow procedure, with preservation of the repaired capsular ligaments, during the same operation. The mean age at the time of surgery was 21 years. Patients were asked to describe common rugby maneuvers (tackle, hand-off, jackal, and saving) preoperatively and postoperatively as "no problem," "insufficient," or "impossible." RESULTS: There were no recurrent dislocations at a mean follow-up of 30.5 months. The mean Rowe score improved significantly from 65.0 (range, 55 to 75) to 97.5 (range, 95 to 100) (P < .001) after surgery. Preoperatively, regarding the tackling motion, none of the patients reported having no problem, whereas the ability was described as insufficient for 23 shoulders and impossible for 17 shoulders. Postoperatively, no problem with tackling was reported for 36 shoulders, whereas insufficiency was reported for 4. The results for the hand-off, jackal, and saving maneuvers were similar (P < .001). No patient rated any of the motions as impossible postoperatively. CONCLUSIONS: This combined surgical procedure clearly is effective in preventing recurrent dislocation in rugby players; however, some players complained of insufficiency in the quality of their play when they were tackling or performing other rugby-specific movements. LEVEL OF EVIDENCE: Level IV, case series.

Ethical review of projects involving non-human primates funded under the European Union's 7th Research Framework Programme.

Internet searches were performed on projects involving non-human primates ('primates') funded under the European Union (EU) 7th Research Framework Programme (FP7), to determine how project proposals are assessed from an ethical point of view. Due to the incompleteness of the information publicly available, the types and severity of the experiments could not be determined with certainty, although in some projects the level of harm was considered to be 'severe'. Information was scarce regarding the numbers of primates, their sourcing, housing, care and fate, or the application of the Three Rs within projects. Project grant holders and the relevant Commission officer were consulted about their experiences with the FP7 ethics review process. Overall, it was seen as meaningful and beneficial, but some concerns were also noted. Ethical follow-up during project performance and upon completion was recognised as a valuable tool in ensuring that animal welfare requirements were adequately addressed. Based upon the outcome of the survey, recommendations are presented on how to strengthen the ethical review process under the upcoming Framework Programme 'Horizon 2020', while adequately taking into account the specific requirements of Directive 2010/63/EU, with the aim of limiting the harms inflicted on the animals and the numbers used, and ultimately, replacing the use of primates altogether.

Ultra-low-velocity knee dislocations.

BACKGROUND: Reports of low-velocity knee dislocations have focused primarily on dislocations occurring during athletic competition. The authors identified a subset of patients with low-velocity knee dislocations that occurred during activities of daily living, such as stepping off a curb, stepping off a stair, or simply falling while walking (ultra-low-velocity dislocations). HYPOTHESIS: Ultra-low-velocity knee dislocations are common in obese individuals and are associated with more complications than high-velocity knee dislocations. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A review of records identified 17 patients with knee dislocations that occurred during daily activities. All 17 were clinically obese, with an average body mass index (BMI) of 48 (BMI <25 is normal; ≥40 is severe obesity). Ligament injuries occurred in all 17 patients, neurologic injuries in 7, and popliteal artery injuries in 7. Thirteen (76.4%) of the 17 dislocations were anterior, 2 (11.8%) were posterior, and 2 (11.8%) were lateral. All dislocations were reduced closed and stabilized with splints, crossed pins, or external fixation; ligament reconstructions were done in 8 patients and popliteal artery repairs in 7. Above-knee amputations were required in 2 patients with vascular repairs because of tissue ischemia; 1 patient died from cardiac arrest 7 days after injury; and 3 were lost to follow-up. Of the 11 remaining patients, 6 had ligament reconstructions and 5 did not. RESULTS: Four standardized knee scoring systems (International Knee Documentation Committee [IKDC], Hospital for Special Surgery [HSS], Lysholm, Tegner) were used to evaluate outcome at an average follow-up of 28.5 months. Although scores were low in all patients, those with ligamentous reconstruction had better outcomes ("fair": 74 ± 22) than those without reconstruction ("poor": 21 ± 8.5), with a statistically significant (P = .013) difference in HSS scores. Lysholm scores also were higher in those with reconstruction (average 67) than in those without (average 53), but the difference was not statistically significant (P = .45). CONCLUSION: These results indicate that (1) neurovascular injuries are frequent with these ultra-low-velocity dislocations in severely obese patients, (2) the likelihood of combined neurovascular injury tends to increase as BMI increases, and (3) surgical ligament reconstruction with emphasis on posterolateral corner repair appears to improve outcomes.

Home Office licence abstracts--an assessment.

Since late in 2004, brief abstracts of projects licensed under the Animals (Scientific Procedures) Act 1986 have been published on the Home Office website. These are produced by the Project Licence Holders, and their publication is seen by the Home Office as contributing to greater openness and to greater public understanding of the use of animals in science, and how it is regulated. Here, we assess the value of the database for this purpose, based on an examination of the 1400 abstracts published up to January 2008. The abstracts are generally strong on justification, but often very poor at describing the likely effects on the animals used. In many cases, they lack basic information on the procedures applied, and the numbers, and even the species, of animals involved. A significant number of projects lack abstracts altogether. In order to ensure that the database gives a complete and balanced picture of animal use in research, we consider that it should be mandatory to submit an abstract, which should include at least the species and numbers of animals used, the adverse effects they are likely to experience, and the severity limits assigned to the procedures applied to them. The value of the database would also be improved greatly, if it were more readily searchable, at least by species, level of severity, and broad area of research.

Opportunities to replace the use of animals in sepsis research. The report and recommendations of a Focus on Alternatives workshop.

Sepsis and multiple organ failure are common causes of death in patients admitted to intensive care units. The incidence of sepsis and associated mortalities has been steadily increasing over the past 20 years. Sepsis is a complex inflammatory condition, the precise causes of which are still poorly understood. Animal models of sepsis have the potential to cause substantial suffering, and many of them have been poorly representative of the human syndrome. However, a number of non-animal approaches, including in vitro, in silico and clinical studies, show promise for addressing this situation. This report is based on discussions held at an expert workshop convened by Focus on Alternatives and held in 2004 at the Wellcome Trust, London. It provides an overview of some non-animal approaches to sepsis research, including their strengths and weaknesses, and argues that they should be prioritised for further development.

Effect of tibial tunnel dilation on pullout strength of semitendinosus-gracilis graft in anterior cruciate ligament reconstruction.

This biomechanical cadaver study evaluated the effect of tibial tunnel dilation on the pullout strength of semitendinosus and gracilis tendon grafts in anterior cruciate ligament reconstruction. Fourteen grafts were harvested, and the anterior cruciate ligament was reconstructed in the tibial and femoral tunnels. All femoral tunnels were reamed to the diameter of the graft. In seven knees, the tibial tunnels were reamed to the diameter of the graft. In the remaining seven knees, the tibial tunnels were reamed 2 mm smaller than the diameter of the graft and then serially dilated to the graft size using cannulated smooth dilators. Mechanical testing to graft failure was conducted. All grafts failed by graft pullout from the tibial tunnel. However, mean peak load was significantly higher for the dilated tibial specimens (616 +/- 263 N) than for the reamed specimens (453 +/- 197 N) (P = .0025).

Optimising the design of preliminary toxicity studies for pharmaceutical safety testing in the dog.

A working party, comprising two animal welfare organisations and some 12 pharmaceutical companies in Europe, was established to minimise the use of the dog in safety testing. As first step, the participants defined the major objectives of preliminary dose-range finding/MTD toxicity studies in non-rodents, defined the principles and requirements for this study type and agreed on a proposal for an optimised study design, based on collective experience of conducting such studies in industry, involving an evaluation of 100 individual study data sets. The suggested study design is explained and described, and reflects current best practice in the pharmaceutical industry in Europe. The implementation of such an optimised design is believed to result in a reduction in the overall numbers of animals used for this purpose, without jeopardising the scientific rationale and usefulness of the studies for informing the conduct of later regulatory studies.

Correlation of interference screw insertion torque with depth of placement in the tibial tunnel using a quadrupled semitendinosus-gracilis graft in anterior cruciate ligament reconstruction.

PURPOSE: To evaluate the insertion torque of a soft-tissue interference screw in relation to depth of insertion into the tibial tunnel when used for fixation of a quadrupled semitendinosus-gracilis autograft in anterior cruciate ligament reconstruction. TYPE OF STUDY: Biomechanical cadaver study. METHODS: Ten quadrupled semitendinosus-gracilis grafts were harvested from fresh-frozen cadaver knees and fixed in donor proximal tibias using 10-mm bioabsorbable interference screws (Arthrex, Naples, FL). A cannulated torque screwdriver was used to measure screw insertion torque at 3 depths in the tibial tunnel: the outer cortex (distal third), the articular surface (proximal third), and between these 2 points (middle third). RESULTS: The mean insertion torques for the distal third, middle third, and proximal third were 8.7, 4.7, and 4.3 in/lb, respectively. The insertion torque was significantly higher at the outer cortex (distal third) than the middle third and proximal third (joint line of the tibial tunnel) ( P < .05). CONCLUSIONS: Our results indicate a correlation between insertion torque and depth of placement of bioabsorbable interference screws used for fixation of a semitendinosus-gracilis graft. Lower insertion torque at the articular surface, resulting in lower peak load or pullout strength, may outweigh the proposed benefits of joint-line fixation of a semitendinosus-gracilis graft used for anterior cruciate ligament reconstruction. CLINICAL RELEVANCE: Studies have suggested that anatomic proximal fixation of ACL grafts in the tibial tunnel produces stability similar to intact knees. The results of our study indicate that lower insertion torque at the articular surface results in lower peak load and pullout strength of the graft, which may outweigh the proposed benefits of joint-line fixation.

An approach to minimise dog use in regulatory toxicology: production of a best practice guide to study design.

The primary non-rodent species used in toxicology is the dog. It is generally agreed that, for ethical reasons, dog use should be reduced to the minimum consistent with maintaining the scientific quality of toxicology studies and ensuring human safety. Dog use in toxicology has been discussed widely, both from a scientific and ethical viewpoint, and there appears to be real potential for achieving significant reductions in the number of dogs used in pharmaceutical safety testing. An industry animal welfare initiative commenced in 2000, with the aim of evaluating and, where possible, putting into practice, scientifically valid approaches to minimise dog use in regulatory toxicology without increasing the use of other non-rodent species, such as non-human primates or minipigs. The study's Steering Group categorised potential reduction approaches into three distinct areas, one of which is the production of a best practice guide on aspects of study design, including: group sizes, use of control animals, single sex studies and design of maximum tolerated dose (MTD) studies. Information on current practice and experience within the pharmaceutical industry is now being analysed, and additional input is invited.

The Third FRAME Toxicity Committee: working toward greater implementation of alternatives in toxicity testing.

FRAME (the Fund for the Replacement of Animals in Medical Experiments; http://www. frame.org.uk) is a scientific charity, which has, for over 30 years, been advocating and conducting its own research on the application of the Three Rs (reduction, refinement and replacement) to animal experimentation. FRAME develops and validates scientifically based replacement alternative methods to facilitate their acceptance by scientists and regulators. As part of these activities, FRAME established a FRAME Toxicity Committee in 1979, and a report of its work was published in 1982, and discussed in the proceedings of a subsequent meeting, published in 1983. A Second Toxicity Committee formed in 1988, reported its work in 1990, which was discussed in the proceedings of a subsequent conference, published in 1991. The work of these committees was extremely successful and influential in laying the foundation for later activities in alternatives research. A Third FRAME Toxicity Committee was formed in 1999, since much progress had been achieved in the previous decade, especially with regard to the successful validation of several non-animal replacement methods and the start of their regulatory acceptance. Moreover, some new test methods are on the point of being validated, and many new techniques and discoveries are impacting on toxicity testing. Also, interest in reduction and refinement in toxicology has increased. However, there is considerable scope and need for the further implementation of the Three Rs in toxicity testing, especially due to recent plans for the large-scale testing of high-production volume, hormonally-active and existing chemicals, and the increasing use of transgenic animal models. The new committee comprises 18 experts from industry, academia, animal welfare, legislative and regulatory bodies, with one observer from the UK Government Home Office. The main objective is to review progress made in the application of the Three Rs in the development and safety evaluation of medicines, biologicals, cosmetics, agrochemicals and other products, as well as industrial chemicals, and to make recommendations as a basis for further sensible progress according to sound scientific and ethical criteria. The main committee is to be augmented by several working parties that will focus on specific scientific issues: 1) targeted risk assessment versus hazard identification; 2) data sharing; 3) endocrine disruption; and 4) carcinogenicity testing. The Committee is also to publish a status report on the current situation regarding alternatives in toxicity testing, based on the recommendations of the Second Toxicity Committee, and will organise a conference to discuss its overall conclusions and recommendations.

Preclinical safety evaluation using nonrodent species: an industry/welfare project to minimize dog use.

This review of the dog, the primary nonrodent species used in toxicology, and its use in the safety evaluation of pharmaceuticals, provides data on the number used in particular projects in an effort to establish a baseline from which some minimization can be measured. Opportunities for reduction and replacement, as identified by a European Industry/Welfare Steering Group, are discussed. The three distinct areas of potential approaches to minimize dog use are categorized as industrial cooperation/data sharing, achieving best practice in study design, and assessing the need for a particular study. The Steering Group prioritized the approaches based on the impact on the number of animals used, the impact on the welfare of the remaining animals, the potential for industry's acceptance of the scientific approach, the potential for regulators' acceptance of the validated approach, and the time/cost of evaluation or implementation. Examples of each category are presented, and the work needed to facilitate industry/regulatory change is discussed.

Effort thrombosis in the elite throwing athlete.

BACKGROUND: Upper extremity vascular injuries are uncommon in the elite throwing athlete. However, the extreme stresses that are placed on the upper extremity of elite baseball players, especially pitchers, puts them at risk for such injuries. One such injury is upper extremity venous thrombosis or "effort thrombosis." PURPOSE: We wanted to review the common initial clinical symptoms and physical examination findings of effort thrombosis in elite baseball players and to review the associated clinical conditions such as hypercoagulable states and pulmonary embolism. STUDY DESIGN: Retrospective review of a series of cases. METHODS: A retrospective review of the medical records of a Major League Baseball organization and a Division I college was performed for the period 1987 to 1997. RESULTS: We located four cases of effort thrombosis involving elite baseball players. Contrast venography was used to confirm the diagnosis in all cases. All patients were successfully treated with transluminal catheter-directed urokinase thrombolysis followed by first rib resection and systemic anticoagulant therapy for up to 3 months. All four players returned to play at or above their previous level of competition with no long-term chronic sequelae. CONCLUSIONS: Prompt clinical recognition, diagnosis, and treatment of effort thrombosis in the elite baseball player provides the player with an excellent prognosis for return to the previous level of play.