Patients With Intact Shoulder Superior Capsular Reconstruction Grafts on Ultrasound Show Significant Improvement in Functional Outcomes at Minimum 2-Year Follow-up.

Purpose: To assess the utility of using dynamic ultrasound for postoperative evaluation after superior capsular reconstruction (SCR) by evaluating graft integrity and its correlation with clinical outcomes at a minimum 2-year follow-up. Methods: A retrospective chart review was conducted to identify patients who underwent SCR between July 2015 and July 2020 with a minimum 2-year clinical and ultrasound follow-up. Clinical outcome measures included Simple Shoulder (SS) and American Shoulder and Elbow Surgeon (ASES) scores. Integrity of the SCR graft was evaluated by dynamic ultrasound. Results: We evaluated 22 shoulders in 21 patients with a mean follow-up of 44.8 months (range, 24-71 months). The graft was found to be intact by ultrasound evaluation in 82% (18/22). Patients with intact grafts had higher mean SS (11.6 vs 7.8, P = .00079) and ASES (91.2 vs 64.1, P = .0296) scores at latest follow-up compared to those with failed grafts. Those with intact grafts also had significant improvement in SS (3.7 vs 11.6, P < .00001) and ASES (23.2 vs 91.2, P < .00001) scores at latest follow-up compared to their preoperative scores. In contrast, patients with graft failure had no significant improvement in SS (6.3 vs 9.0, P = .123) and ASES (40.4 vs 58.3, P = .05469) scores at latest follow-up compared to their preoperative scores. There was no difference between clinical outcomes at 6 to 12 months vs latest follow-up for both SS (P = .11, P = .5) and ASES (P = .27, P = .21) scores. Conclusions: SCR grafts were found by ultrasound to be intact in 82% of cases. Patients with intact grafts on ultrasound had significant improvement in functional outcome scores while those with graft failure did not. Functional outcome scores suggest that maximal recovery from this procedure occurs by 6 to 12 months. Level of Evidence: Level IV, therapeutic case series.

Using Spinal Anesthesia and a Fracture Table for Closed Reduction of an Obturator Foramen Hip Dislocation: A Case Report.

CASE: A 37-year-old man with a right obturator foramen hip dislocation underwent closed reduction under spinal anesthesia with the use of a fracture traction table. CONCLUSION: This novel technique provides surgeons and anesthesiologists an alternative method of treating obturator foramen hip dislocations that provides a more controlled reduction and less need for assistants.

Well-Leg Compartment Syndrome Due to Hemilithotomy Positioning after Arthroscopic Reconstruction of the PCL.

Introduction: Acute compartment syndrome (ACS) occurs due to decreased perfusion of an osseofascial space due to increased compartmental pressure. Due to its potentially devastating sequelae, emphasis is placed on its prompt diagnosis. While fractures continue to be the most common cause of ACS, mechanisms such as crush injuries and even surgical positioning are described etiologies of compartment syndrome. ACS of the well-leg from hemilithotomy positioning has been previously depicted in medical literature; however, there have been no illustrations of this complication after elective arthroscopic-assisted posterior cruciate ligament (PCL) reconstruction. Case Report: This report discusses a patient undergoing PCL reconstruction who developed an ACS in the non-operative extremity that was positioned in hemilithotomy in a leg positioner. Conclusion: ACS is an uncommon but serious complication that can occur from hemilithotomy positioning. Surgeons should be mindful of risk factors that can place a patient at higher risk, including length of the case, body habitus, height of elevation of the leg, and method of leg support. The prompt recognition and surgical management of ACS can prevent the devastating long-term complications.

Spin in the Abstracts of Meta-analyses and Systematic Reviews: Quadriceps Tendon Graft for Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Spin is a reporting bias that misrepresents research. Ultimately it can affect surgeon decision making and patient care. Anterior cruciate ligament (ACL) reconstruction is common, but debate continues over optimal treatment modalities. PURPOSE: To identify the prevalence of spin in meta-analysis and systematic review abstracts regarding the treatment of ACL injuries with quadriceps tendon graft. STUDY DESIGN: Cross-sectional study. METHODS: Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were searched for meta-analyses and systematic reviews regarding the treatment of ACL tears with quadriceps tendon graft. The 9 most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Two reviewers each performed a blinded assessment of each article for spin. A third reviewer helped after review was done to address any discrepancies between the original reviewers. Further evaluation included year of publication, number of citations, journal impact factor, and A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) score. RESULTS: The electronic database search resulted in 986 articles, of which 13 met our inclusion criteria. After review, we found that 53.8% (7/13) of the included articles contained 1 of the 9 most severe forms of spin. Of the 13 articles, 15.4% (n = 2) contained 2 types of spin, and 38.5% (n = 5) contained 1 type of spin. No studies contained ≥3 types of spin. Of the types of spin evaluated, the most prevalent (n = 4; 30.8%) was type 3 ("selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention"). All studies, regardless of the presence of spin, were found to be low or critically low quality according to the AMSTAR-2 assessment. CONCLUSION: This study demonstrated the presence of spin in 53.8% of meta-analysis and systematic review abstracts pertaining to quadriceps tendon graft for ACL reconstruction. Orthopaedic surgeons should learn to recognize spin as they review articles when deciding the treatment course for ACL injuries. Additionally, strict criteria should be considered to reduce the prevalence of spin in orthopaedic literature.

Rupture of the Proximal Long Head of Biceps Tendon Presenting as a Pectoralis Major Tear: A Case Report.

CASE: We report a case of a 56-year-old man who sustained a ruptured long head of biceps tendon (LHBT) that presented with symptoms typical of a pectoralis major rupture. Magnetic resonance imaging revealed an isolated LHBT tear. Intraoperatively, the biceps tendon had an unusually thick distal segment entrapped under the insertion of the pectoralis major. Surgery led to an excellent outcome. CONCLUSION: A ruptured LHBT with an associated large distal segment producing a mass effect on the pectoralis major can mimic a pectoralis major rupture and may ultimately require surgery to alleviate symptoms.

Arthroscopic Vastus Elevation (AVE) for Arthrofibrosis of the Knee: Surgical Technique and Literature Review.

Arthrofibrosis of the knee continues to challenge Orthopaedic surgeons. With a wide etiology, lack of knee motion can be debilitating. Its surgical management has several complications. The purpose of this study is to describe a modification of previously described techniques to aid in the management of knee arthrofibrosis. Arthroscopic vastus elevation in conjunction with adjuvant hemostatic agents allows for a controlled quadriceps elevation in the setting of arthrofibrosis. In addition to a thorough intra-articular lysis of adhesions, this appears to improve motion, while minimizing postoperative complications. Minimized postoperative complications include extensor lag, skin necrosis, and bleeding complications. (Journal of Surgical Orthopaedic Advances 29(2):117-120, 2020).

Chondrotoxicity of Local Anesthetics: Liposomal Bupivacaine Is Less Chondrotoxic than Standard Bupivacaine.

OBJECTIVE: The purpose of this study is to determine whether (1) liposomal bupivacaine is chondrotoxic; (2) the chondrotoxicity of liposomal bupivacaine differs from standard bupivacaine; and (3) chondrotoxic effects are time dependent. MATERIALS AND METHODS: We obtained 72 10 mm articular cartilage plugs from 12 fresh bovine distal femoral knee joints and exposed them to either saline, 0.5% bupivacaine, or liposomal bupivacaine for either 30 or 90 minutes. Twenty-four hours after treatment, chondrocyte viability was measured with the use of a fluorescent live/dead assay. An ANOVA test of variance was performed followed by a Holm-Sidak test to make pairwise comparisons across conditions. Student's t-test was used to compare means. RESULTS: Percent viability of cells exposed to liposomal bupivacaine for 30 minutes was less versus saline control (53.9% ± 21.5% vs. 73.7 ± 18.4%, p=0.035), and this remained significant at 90 minutes (49.1% ± 20.3% vs. 67.2% ± 25.6%, p < 0.001). Liposomal bupivacaine had less chondrotoxic effects when compared with bupivacaine after 90 minutes, with greater viability (49.1% ± 20.3% vs. 21.4% ± 14.0%, p=0.003). Chondrotoxicity was found to be time dependent within the bupivacaine group (percent viability at 30 min: 45.5 ± 18.2%, 90 min: 21.4 ± 14.0%, p=0.001); however, liposomal bupivacaine did not demonstrate a significant time-dependent chondrotoxic relationship (p=0.583). CONCLUSIONS: Bupivacaine and liposomal bupivacaine are both toxic to chondrocytes. Liposomal bupivacaine is less chondrotoxic than standard bupivacaine and does not demonstrate a time-dependent toxicity.

The Effect of Monophasic Pulsed Current with Stretching Exercise on the Heel Pain and Plantar Fascia Thickness in Plantar Fasciitis: A Randomized Controlled Trial.

Plantar fasciitis (PF) is one of the most common causes of heel and foot pain. Monophasic pulsed current (MPC) is an electrical stimulation used to accelerate the healing processes. The purpose of this study was to determine the effect of MPC and MPC combined with plantar fascia stretching exercises (SE) on heel pain and plantar fascia thickness in treatment of PF and see if there is any relationship between heel pain and plantar fascia thickness after intervention. Forty-four participants diagnosed with PF were randomly assigned to two group; MPC group or MPC combined with plantar fascia SE. Plantar fascia thickness was measured with musculoskeletal ultrasound. Although no statistical differences between the two groups were found, heel pain and the plantar fascia thickness significantly decreased in both groups after the intervention (p < 0.001). No significant correlation was found between changes in heel pain and plantar fascia thickness after 4 weeks of treatment. Our results indicated that MPC can reduce heel pain and plantar fascia thickness caused by PF. However, MPC combined with plantar fascia SE is not superior to MCP only in terms of reduction in heel pain and plantar fascia thickening.

Effect of Ulnar-Based Orthotics and Strengthening Exercises on Subjects With Ulnar Wrist Pain.

CONTEXT: In comparison with the published research on the surgical management of ulnar wrist pain, fewer studies that discuss the nonsurgical management of ulnar wrist pain exist. OBJECTIVE: The purpose of this pilot study was to investigate the effect of ulnar-based wrist orthotics and strengthening exercises on subjects with ulnar wrist pain. STUDY DESIGN: Prospective randomized controlled pilot study. SETTING: Research laboratory. PARTICIPANTS: Thirty subjects with acute and subacute ulnar wrist pain and age ranging from 18 to 53. INTERVENTIONS: Participants were randomized to receive either ulnar-based orthotics, ulnar-based orthotics plus strengthening exercises, or placebo intervention. MAIN OUTCOME MEASURES: The authors measured pain and function using the Patient-Rated Wrist Evaluation questionnaire, and grip strength using the JAMAR dynamometer, at baseline and at 2- and 4-week postrandomization. A mixed analysis of variance modeling was used to investigate the effect of the intervention over time. RESULTS: There were statistically significant differences between the 2 intervention groups and the control group regarding improvement in pain, function, and strength, whereas there were no statistically significant differences between the 2 intervention groups over the 3 measurement occasions regarding the outcome measures. CONCLUSION: Based on the results, orthotics intervention is as effective as orthotics plus strengthening exercises in improving pain, function, and grip strength in subjects with ulnar wrist pain. LEVEL OF EVIDENCE: Therapy, level 2b individual Randomized Controlled Trial.

Linking physical therapy outcome measures to the Brief International Classification of Functioning Core Set for Hand Conditions in subjects with ulnar wrist pain.

OBJECTIVE: The purpose of this study was to apply the Brief International Classification of Functioning (ICF) Core Set for Hand Conditions to the physical therapy outcome measures, and to evaluate the contribution of these measures to overall health in subjects with ulnar wrist pain. METHODS: Thirty-five subjects with ulnar wrist pain received a 4-week home-based treatment program including orthotics and strengthening exercises. Investigators measured pain, function, grip strength, and overall health four weeks post-intervention. Regression analysis was used to investigate the effect of these variables on overall health represented by the Short Form (SF-36) questionnaire. RESULTS: Fifty-three percent of the variability in SF-36 physical health summary scores was explained by the studied variables with grip strength predicting 31% of the variability. CONCLUSIONS: The Brief ICF Core Set for Hand Conditions can be a useful abridged list of categories relevant to functioning and health in subjects with ulnar wrist pain.

A Novel Treatment for a Rare Injury: Pediatric Massive Intrasubstance Rotator Cuff and Periscapular Muscle Tears Treated with a Custom Brace: A Case Report.

CASE: A 9-year-old boy sustained intrasubstance tears of the rotator cuff and periscapular muscles due to a fall, resulting in scapular winging and severely decreased shoulder range of motion. Treatment consisted of a modified thoracolumbosacral orthosis (TLSO) with a shoulder immobilizer attachment (to reduce the scapula to the thoracic wall and hold the arm in 10° of abduction). The brace was worn for 8 weeks. The patient recovered full, pain-free shoulder function and range of motion, and returned to high-level athletics. CONCLUSION: Pediatric massive intrasubstance rotator cuff and periscapular muscle tears can be treated nonoperatively with use of a modified TLSO.

Arthroscopic Repair of an Isolated Teres Minor Tear: A Case Report.

CASE: Isolated avulsion of the teres minor tendon is exceedingly uncommon and, to our knowledge, the presentation and arthroscopic repair of this type of injury have not been described. Known musculotendinous avulsions about the shoulder frequently involve the supraspinatus, long head of the biceps, and pectoralis major. CONCLUSION: We present the case of a patient with an isolated teres minor avulsion and an otherwise intact rotator cuff. The patient underwent successful arthroscopic repair and rehabilitation, allowing for a return to the pre-injury level of function.

Two Helpful MRI Signs for Evaluation of Posterolateral Bundle Tears of the Anterior Cruciate Ligament: A Pilot Study.

BACKGROUND: Diagnosis of partial anterior cruciate ligament (ACL) tears is difficult on magnetic resonance imaging (MRI), particularly the isolated tears of the posterolateral bundle. PURPOSE: To describe 2 MRI signs of partial ACL tear involving the posterolateral bundle on conventional knee MRI sequences, specifically, the "gap" and "footprint" signs. STUDY DESIGN: Case-control study. METHODS: We retrospectively reviewed the MRI appearance of the ACL in 11 patients with arthroscopically proven partial ACL tears isolated to the posterolateral bundle, as well as in 10 patients with arthroscopically proven intact ACLs, and evaluated for the presence of gap and/or footprint signs. RESULTS: There was high degree of sensitivity and specificity associated with the MRI findings of "gap" and "footprint" signs with arthroscopically proven isolated posterolateral bundle tears. CONCLUSION: Gap and footprint signs are suggestive of posterolateral bundle tear of the ACL, and the presence of 1 or both of these imaging findings should alert the radiologist to the possibility of a posterolateral bundle tear.

Effect of monophasic pulsed current on heel pain and functional activities caused by plantar fasciitis.

BACKGROUND: Plantar fasciitis (PF) is a soft tissue disorder considered to be one of the most common causes of inferior heel pain. The aim of this study was to investigate the effect of monophasic pulsed current (MPC) and MPC coupled with plantar fascia-specific stretching exercises (SE) on the treatment of PF. MATERIAL AND METHODS: Forty-four participants (22 women and 22 men, with a mean age of 49 years) diagnosed with PF were randomly assigned to receive MPC (n=22) or MPC coupled with plantar fascia-specific SE (n=22). Prior to and after 4 weeks of treatment, participants underwent baseline evaluation; heel pain was evaluated using a visual analogue scale (VAS), heel tenderness threshold was quantified using a handheld pressure algometer (PA), and functional activities level was assessed using the Activities of Daily Living subscale of the Foot and Ankle Ability Measure (ADL/FAAM). RESULTS: Heel pain scores showed a significant reduction in both groups compared to baseline VAS scores (P<0.001). Heel tenderness improved significantly in both groups compared with baseline PA scores (P<0.001). Functional activity level improved significantly in both groups compared with baseline (ADL/FAAM) scores (P<0.001). However, no significant differences existed between the 2 treatment groups in all post-intervention outcome measures. CONCLUSIONS: This trial showed that MPC is useful in treating inferior heel symptoms caused by PF.

Arthroscopic acetabular recession with chondrolabral preservation.

Cam and pincer lesions found in femoral acetabular impingement (FAI) serve as bony substrates for the development of labral tears and can lead to osteoarthritis. Prior acetabuloplasty techniques have described surgical detachment of the labrum at the chondrolabral junction to facilitate osteoplasty. Histologically, the healing at the chondrolabral junction may be limited and surgical labral detachment may compromise the vascular supply to the labrum. We present a technique of maintaining the chondrolabral junction during acetabuloplasty. The labrum/chondral complex is subperiosteally elevated off the acetabular rim and the acetabular shelf is contoured with fluoroscopic guidance. Intermittent traction is used to minimize total traction time. Vertical mattress stitches are used to repair the labrum. The main advantage of this technique is that it allows contouring of the underlying pincer deformity commonly found in FAI without compromising the contiguous transition zone between the articular surface of the acetabulum and labrum.

Bupivacaine and triamcinolone may be toxic to human chondrocytes: a pilot study.

BACKGROUND: Intraarticular injections of corticosteroids combined with local anesthetics are commonly used for management of chronic pain symptoms associated with degenerative joint diseases and after arthroscopic procedures. Several studies suggest chondrotoxicity of local anesthetics whereas others report chondroprotective and cytotoxic effects of corticosteroids on cartilage. Given the frequency of use of these agents, it is important to know whether they are in fact toxic. QUESTIONS/PURPOSES: We asked whether (1) bupivacaine and triamcinolone acetonide, alone and combined, were chondrotoxic to chondrocytes in culture; (2) buffering of the reagents diminished toxicity of the bupivacaine and triamcinolone; and (3) the presence of the superficial layer of articular cartilage protects against toxicity. MATERIALS AND METHODS: We obtained cartilage from three patients undergoing arthroplasty. To address triamcinolone acetonide, bupivacaine, and combinatorial toxicity to human chondrocytes, we set up monolayer chondrocyte cultures (n = 8 wells per condition). The question of buffering was addressed by performing the same assays as above, but the reagents were buffered. An MTT assay was used to assess chondrocyte survival in the monolayer. We harvested 21 articular plugs from each of three patients (total 63 plugs) and exposed them to the same reagents as above, including the buffered reagents. A Live/Dead assay was used to determine chondrocyte survival. RESULTS: Triamcinolone acetonide, bupivacaine, and their combination were toxic to human chondrocytes in the monolayer comparisons. The addition of buffering did not mitigate chondrocyte death. With the intact superficial layer in the plug group, bupivacaine was not toxic as compared with for the control group; all the other reagents (triamcinolone, combination bupivacaine/triamcinolone, buffered bupivacaine, buffered triamcinolone, and buffered combination) produced chondrotoxicity. CONCLUSIONS: Triamcinolone induced chondrotoxicity in the articular plug and monolayer culture, whereas bupivacaine induced chondrotoxicity only in monolayer culture. The combined used of triamcinolone and bupivacaine did not show additive chondrocyte death in any arm. Buffering of bupivacaine increased its chondrotoxicity. CLINICAL RELEVANCE: Although not necessarily reflecting in vivo conditions, our data suggest physicians should be cognizant of the potential in vitro chondrotoxicity of bupivacaine and triamcinolone when contemplating intraarticular administration.

Fenestrated cannulae with outflow reduces fluid gain in shoulder arthroscopy.

UNLABELLED: Soft tissue fluid retention is a common problem after arthroscopy, with as much as 2% of patients having complications develop. A fenestrated outflow cannula has been introduced to reduce interstitial swelling. We tested the ability of this outflow cannula design to reduce fluid weight gain. We enrolled 28 patients undergoing shoulder arthroscopy and randomized them into two groups using fenestrated outflow versus conventional cannulae. The conventional group had greater weight gain as a function of the procedure duration than the fenestrated outflow group (slope = 0.542 +/- 1.160 kg/hour versus 0.0144 +/- 0.932 kg/hour). The conventional group also had greater weight gain as a function of fluid volume than the fenestrated outflow group (slope = 0.022 +/- 0.038 kg/L versus 0.002 +/- 0.341 kg/L). Compared with conventional nonoutflow cannulae, fenestrated outflow cannulae with negative pressure reduced weight gain associated with longer arthroscopic surgeries and increased arthroscopic fluid volume. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Early versus late repair of orbital blowout fractures.

BACKGROUND AND OBJECTIVE: To compare early and late surgical repair of orbital blowout floor fractures. PATIENTS AND METHODS: A retrospective, comparative interventional case series reviewed medical records of 50 consecutive patients who underwent unilateral orbital floor fracture repair in a 4-year period. Comparative analysis was performed between patients operated on within 2 weeks of injury and those operated on at a later stage. RESULTS: Assault, motor vehicle accidents, and sports injuries were the most common causes of injury. Surgery was performed due to inferior rectus muscle entrapment and limitations in up gaze in 20 (40%) patients or to prevent enophthalmos in cases with significant bony orbital expansion in 30 (60%) patients. After surgery, enophthalmos improved an average of 0.8 mm. Limitation in ocular motility improved after surgery but was statistically significant only in up gaze. Patients who underwent early repair (within 2 weeks) achieved less improvement in enophthalmos versus patients who underwent late repair (delta enophthalmos of 0.2 +/- 1.1 vs 1.3 +/- 1.9 mm, respectively; P = .02). CONCLUSION: In these patients, postoperative vertical ductions and postoperative enophthalmos improved after fracture repair. Surgery was associated with a low rate of postoperative complications. No apparent difference in surgical outcome was seen between early (within 2 weeks) and late surgical repair.

Clinical manifestations and treatment outcome of optic neuropathy in thyroid-related orbitopathy.

BACKGROUND AND OBJECTIVE: To investigate the incidence and outcome of optic neuropathy associated with thyroid-related orbitopathy. PATIENTS AND METHODS: All patients diagnosed as having optic neuropathy associated with thyroid-related orbitopathy who underwent treatment for optic neuropathy between January 1, 1999, and March 1, 2003, were reviewed. Demographic and clinical data were extracted from the oculoplastic registry (electronic medical record). RESULTS: Optic neuropathy occurred in 20 of 595 patients with thyroid-related orbitopathy (3.4%). All patients received systemic steroids, 7 patients received orbital steroid injections, and 2 patients were treated with orbital radiotherapy. Orbital decompression was performed in all 26 orbits. Visual acuity improved from a mean of 20/150 to 20/30 (P < .001). Color vision improved from a mean of 5.2/14 to 11/14 (P = .001). The afferent pupillary defect disappeared shortly after treatment for all but 1 case, and improved in all cases. Exophthalmos decreased from 26.4 +/- 2.5 to 21.5 +/- 2.1 mm (P< .001; 95% confidence interval, 3.8 to 5.7). CONCLUSIONS: Optic neuropathy manifests rarely in patients with thyroid-related orbitopathy. Monitoring visual acuity or afferent pupillary response may be a reliable way of assessing and monitoring optic neuropathy. In this study, patients had improved visual acuity and optic nerve function after a combination of medical and surgical treatment.