Subacromial pain pump use is safe after arthroscopic rotator cuff repair.

BACKGROUND: Intra-articular pain pumps with local anesthetics have been implicated as a potential cause of post-arthroscopic glenohumeral chondrolysis (PAGCL) of the shoulder. In short-term studies, subacromial pain pump use is effective and safe without association with PAGCL. Patients with full thickness rotator cuff tears may be at high risk of PAGCL given disruption of the tendinous integrity which may allow intra-articular infusion of local anesthetics. We hypothesized that subacromial pain pump use after arthroscopic rotator cuff repair would not result in PAGCL. METHODS: We analyzed a consecutive series of 34 patients treated with subacromial pain pump placement after arthroscopic rotator cuff repair and subacromial decompression for full thickness rotator cuff tears. Thirty patients met inclusion criteria of greater than 12-month follow-up with an average age of 51 (28-68). All patients had the subacromial pain pumps placed under arthroscopic visualization and infused 0.25% bupivacaine without epinephrine at 2 cc/h for 48 h. All patients had clinical examinations and radiographic studies performed more than 1 year after surgery. RESULTS: Patients had an average rotator cuff size of 1.6 cm and fixation was performed with bioabsorbable suture anchors. All patients had at least 150° of abduction and forward flexion at latest follow-up without palpable crepitus and no patients had any evidence of joint space narrowing on post-operative radiographs. CONCLUSION: Subacromial pain pump use after arthroscopic rotator cuff repair is safe. Despite probable lack of a water-tight seal from repair, there were no cases of PAGCL. LEVEL OF EVIDENCE: IV.

The effect of local anaesthetics on synoviocytes: a possible indirect mechanism of chondrolysis.

PURPOSE: While the effect of local anaesthetics on chondrocyte viability is widely documented, the effect of these medications on synoviocytes is largely unknown. The purpose of this study was to understand the effect of 0.5 % bupivacaine and 0.5 % bupivacaine with epinephrine on synoviocyte viability, cytokine and growth factor release, and breakdown product formation. METHODS: Rabbit fibroblast-like synoviocyte (Type B) cultures were perfused with 0.5 % bupivacaine or 0.5 % bupivacaine with epinephrine (1:200,000) for 24 h. Cell viability was evaluated using a two-colour fluorescence assay. The supernatant was analysed using multiplex inflammatory and matrix metalloproteinase assays. RESULTS: Synoviocytes treated for 24 h with 0.5 % bupivacaine with epinephrine demonstrated a significant decrease in viability (31.3 ± 19.4 % cell death) when compared with synoviocytes cultured in control media (3.8 ± 1.3 % cell death, p = 0.000) and those cultured in 0.5 % bupivacaine alone (12.6 ± 11.1 % cell death, p = 0.003). No significant decrease in cell viability was observed in synoviocytes treated with 0.5 % bupivacaine compared to those in control media (12.6 ± 11.1 % vs 3.8 ± 1.3 % cell death, p = 0.194). Significantly greater amounts of MMP-1 (47.0 ± 9.2 pg/ml) and MMP-3 (250.0 ± 68.8 pg/ml) were observed in 0.5 % bupivacaine cultures compared with controls (14.3 ± 14.3, p = 0.023 and 72.0 ± 84.9, p = 0.045, respectively). CONCLUSIONS: 0.5 % bupivacaine with epinephrine caused a significant increase in cell death of the synoviocytes, while 0.5 % bupivacaine alone produced cell injury and a significant release of matrix metalloproteinases, which may also lead to indirect injury of the surrounding chondrocytes. These results may help explain the onset of chondrolysis observed in patients who have been treated with intra-articular local anaesthetics.

Glenohumeral joint sepsis after magnetic resonance imaging arthrogram.

A 65-year-old patient presented with right shoulder pain that had increased in severity over the preceding 2 days. The pain began after the patient had a gadolinium arthrogram for magnetic resonance imaging for rotator cuff evaluation. Examination and laboratory test findings were consistent with a septic glenohumeral joint and emergent arthroscopic irrigation and debridement were performed. Streptococcus sanguinis was isolated from the intraoperative culture, and the infection resolved after a course of antibiotics.

Performance outcomes of anterior cruciate ligament reconstruction in the National Basketball Association.

PURPOSE: The purpose of this study was to determine the rate of return to play and to quantify the effect on the basketball player's performance after surgical reconstruction of the anterior cruciate ligament (ACL). METHODS: Surgical injuries involving the ACL were queried for a 10-year period (1993-1994 season through 2004-2005 season) from the database maintained by the National Basketball Association (NBA). Standard statistical categories and player efficiency rating (PER), a measure that accounts for positive and negative playing statistics, were calculated to determine the impact of the injury on player performance relative to a matched comparison group. Over the study period, 31 NBA players had 32 ACL reconstructions. Two patients were excluded because of multiple ACL injuries, one was excluded because he never participated in league play, and another was the result of nonathletic activity. RESULTS: Of the 27 players in the study group, 6 (22%) did not return to NBA competition. Of the 21 players (78%) who did return to play, 4 (15%) had an increase in the preinjury PER, 5 (19%) remained within 1 point of the preinjury PER, and the PER decreased by more than 1 point after return to play in 12 (44%). Although decreases occurred in most of the statistical categories for players returning from ACL surgery, the number of games played, field goal percentage, and number of turnovers per game were the only categories with a statistically significant decrease. Players in the comparison group had a statistically significant increase in the PER over their careers, whereas the study group had a marked, though not statistically significant, increase in the PER in the season after reconstruction. CONCLUSIONS: After ACL reconstruction in 27 basketball players, 22% did not return to a sanctioned NBA game. For those returning to play, performance decreased by more than 1 PER point in 44% of the patients, although the changes were not statistically significant relative to the comparison group. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Distal clavicle fracture as a complication of arthroscopic distal clavicle resection.

Arthroscopic resection of the distal clavicle has been advocated as a surgical treatment option for acromioclavicular (AC) joint pathology. To our knowledge, iatrogenic fracture of the distal clavicle during distal clavicle resection has never been reported. This report describes distal clavicle fracture as a complication of misidentification of the AC joint and subsequent aggressive burring of the distal clavicle during shoulder arthroscopy. This case is further complicated by the development of symptomatic delayed union and adhesive capsulitis. Ultimately, a revision distal clavicle resection was performed, underscoring the fact that special care must be taken to properly identify the AC joint and rule out pre-existing distal clavicle stress fracture or osteolysis before performing the arthroscopic Mumford procedure.

The supraspinatus distension sign: an indicator of supraspinatus integrity.

PURPOSE: To determine if direct contact between the biceps tendon and supraspinatus in patients undergoing shoulder arthroscopy performed in the lateral decubitus position has predictive value in evaluating full-thickness and articular-sided, partial-thickness rotator cuff tears. METHODS: Five hundred sixty-three consecutive shoulder arthroscopies in the lateral decubitus position were performed by a single surgeon between September 2005 and September 2007. The presence or absence of distance between the biceps tendon and supraspinatus was evaluated upon entering the joint. A diagnostic arthroscopy of the glenohumeral and subacromial spaces then ensued to determine the presence and extent of rotator cuff tear. RESULTS: The biceps-supraspinatus interval was preserved in 211 of 232 (90.9%) of the articular-sided, partial-thickness tears. The biceps-supraspinatus space was absent in 76 of 77 (98.7%) of the full-thickness tears. After excluding cases of concomitant adhesive capsulitis, all 211 articular-sided, partial-thickness rotator cuff tears and only 1 of 75 (1.3%) full-thickness rotator cuff tears was associated with a preserved biceps-supraspinatus interval (false negative). CONCLUSIONS: Our study further validates the high sensitivity and specificity of using the loss of supraspinatus distension for predicting full-thickness rotator cuff tears. We also report the reliable preservation of supraspinatus distension with articular-sided, partial-thickness rotator cuff tears. These articular-sided partial-thickness tears typically do not lead to sufficient egress of arthroscopic fluid from the glenohumeral joint to cause a loss of supraspinatus distension. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis.

Shoulder arthroscopy has become a routine outpatient surgery. Pain control is a limiting factor for patient discharge after surgery, and several modalities are used to provide continued analgesia postoperatively. Regional anesthetic blocks and shoulder pain pumps are common methods to provide short-term pain control. Shoulder pain pumps can be used either in the subacromial space or within the glenohumeral joint. Several clinical studies suggested--which was confirmed by a bovine and rabbit cartilage study--that there is significant chondrotoxicity from bupivacaine, a local anesthetic commonly used in pain pumps. Postarthroscopic glenohumeral chondrolysis is a noninfectious entity associated with factors including use of radiofrequency thermal instruments and intra-articular pain pumps that administer bupivacaine, but there have been no cases reported with subacromial pain pump placement. Treatment options are difficult in a young patient with postarthroscopic glenohumeral chondrolysis, and understanding the literature with regard to risk factors is paramount to counseling patients and preventing this devastating complication.

Obturator internus strain in the hip of an adolescent athlete.

A male 13-year-old presented with acute onset of right hip pain as he prepared to kick a soccer ball. A case of acute strain of the obturator internus is reported. The strain resolved completely after a period of activity modification and physical therapy.

Subacromial pain pump use with arthroscopic shoulder surgery: a short-term prospective study of complications in 583 patients.

Pain pumps containing local anesthetics, with or without opioids, can be used for perioperative analgesia after arthroscopic shoulder surgery to reduce pain. Although several smaller studies have demonstrated the analgesic properties, no large series to date has reported the short-term complication rate of subacromial pain pumps. We prospectively studied (2005 to 2007) 583 patients who underwent arthroscopic shoulder surgery at a single outpatient surgery center and had intraoperative placement of a pain pump catheter into the subacromial space. Patients had at least 1 month of follow-up. No patient received perioperative brachial plexus regional anesthesia. There were no cases of infection, internal catheter breakage, pump failure, or hospital admission for pain control. The only complication was external catheter breakage that occurred when a patient attempted to remove the pump without removing the tape fastening the catheter at the skin. Subacromial pain pumps used for arthroscopic shoulder procedures are safe in the short-term.

A biomechanical comparison of 2 technical variations of double-row rotator cuff fixation: the importance of medial row knots.

BACKGROUND: Previous studies have shown comparable biomechanical properties of double-row fixation versus double-row fixation with a knotless lateral row. SutureBridge is a construct that secures the cuff with medial row mattress suture anchors and knotless lateral row fixation of the medial suture ends. Recent completely knotless constructs may lead to lesser clinical outcomes if the construct properties are compromised from lack of suture knots. HYPOTHESIS: A completely knotless construct without medial row knots will compromise the biomechanical properties in both cyclic and failure-testing parameters. STUDY DESIGN: Controlled laboratory study. METHODS: Six matched pairs of cadaveric shoulders were randomized to 2 groups of double row fixation with SutureBridge: group 1 with medial row knots, and group 2 without medial row knots. The specimens were placed in a materials test system at 30 degrees of abduction. Cyclic testing to 180 N at 1 mm/sec for 30 cycles was performed, followed by tensile testing to failure at 1 mm/sec. RESULTS: Data included cyclic and failure data from the materials test system and gap data using a video digitizing system. All data from paired specimens were compared using paired Student t tests. Group 1 had a statistically significant difference (P < .05) for gap formation for the 1st (3.47 vs 5.05 mm) and 30th cycle (4.22 vs 8.10 mm) and at yield load (5.2 vs 9.1 mm). In addition, there was a greater energy absorbed (2805 vs 1648 N-mm), yield load (233 vs 183.1 N), and ultimate load (352.9 vs 253.9 N) for group 1. The mode of failure for the majority (4/6) of group 2 was lateral row failure, whereas all group 1 specimens failed at the clamp. CONCLUSION: Although lateral row knotless fixation has been shown not to sacrifice structural integrity of this construct, the addition of a knotless medial row compromises the construct leading to greater gapping and failure at lower loads. CLINICAL RELEVANCE: This may raise concerns regarding recently marketed completely knotless double row constructs.

Osteoarticular and total elbow allograft reconstruction with severe bone loss.

UNLABELLED: Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2-12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Acromioclavicular joint reoperation after arthroscopic subacromial decompression with and without concomitant acromioclavicular surgery.

PURPOSE: The purpose of this study was to examine the reoperation rate on the acromioclavicular (AC) joint after arthroscopic subacromial decompression (ASAD) with and without concomitant AC joint surgery and to identify factors related to continued AC joint symptoms. METHODS: We conducted a retrospective review of 1,482 cases without concomitant shoulder pathology that were followed up by physical examination, phone interview, questionnaire, or chart review. Group A, patients who underwent ASAD alone, consisted of 1,091 cases. Group B, patients who underwent ASAD with concomitant AC joint surgery consisting of either co-planing or arthroscopic distal clavicle resection (ADCR), consisted of 391 cases. RESULTS: A total of 22 patients underwent reoperation on the AC joint. The overall reoperation rate was 1.5%, or 22 of 1,482 patients. The index procedure failed in 16 patients from the ASAD group (group A), yielding a reoperation rate of 1.5%. The index procedure failed in 6 patients from the group undergoing ASAD with concomitant AC joint surgery (group B), for a reoperation rate of 1.5%. Reoperation occurred at a mean of 22 months and 8 months for group A and group B, respectively. Overall, 17 of 22 patients (77%) who required AC joint reoperation were either Workers' Compensation (WC) or litigation cases. The reoperation rate was 2.4% for WC patients and 0.8% for non-WC patients. WC status was found to be a statistically significant factor in the rate of reoperation for AC joint symptoms (P < .05). Of the 22 patients, 10 continued to have pain at a mean of 25.9 months (range, 9 to 53 months) after reoperation. Given the similar rates of reoperation, routine AC joint violation by co-planing or ADCR is not recommended during ASAD. Reoperation for continued AC joint symptoms was associated with a nearly 50% rate of continued symptoms. CONCLUSIONS: The results of the study show that the incidence of reoperation on the AC joint after ASAD with or without concomitant AC joint surgery is small for both groups with a 1.5% rate of reoperation for each group. The incidence of reoperation is lower, at 0.8%, for non-WC cases. In addition, there was a high rate of continued symptoms, with 45% of patients having continued pain after reoperation. Violation of the AC joint during the initial surgery by co-planing or ADCR did not alter the reoperation rate for AC joint symptoms. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Sterile pretibial abscess after anterior cruciate reconstruction from bioabsorbable interference screws: a report of 2 cases.

We report 2 cases of extra-articular pretibial sterile abscesses with minimal osteolysis after anterior cruciate ligament reconstruction with poly-L-lactic acid bioabsorbable interference screw fixation. No joint involvement was evident in either case. Both patients underwent surgical exploration for incision, drainage, and excision with debridement of the biodegradable screw debris from the tibial bone tunnel. The cystic area in case 1 contained 8 mL of chalky white fluid with fragments of particulate matter. Microscopic evaluation revealed birefringent foreign material in a benign histiocyte-lined cyst. We encountered 20 mL of chalky white material during surgical debridement in case 2. Intraoperative cultures and Gram's stain were negative. Both patients had an uneventful recovery after surgical debridement and were able to return to their athletic activities. To our knowledge, this is the first case report of a local reaction to poly-L-lactic acid bioabsorbable interference screws after anterior cruciate ligament reconstruction.

Whole patellar allograft for total knee arthroplasty after previous patellectomy.

UNLABELLED: We treated seven consecutive patients (nine knees) with previous total knee arthroplasties and patellectomies with whole patellar allograft reconstructions of the extensor mechanism. The patients' extensor mechanism soft tissue sleeve was intact, but the patella was not present. Deficient patellae were reconstructed using patellar ligament (whole patella) quadriceps tendon allograft. Six knees had previous patellectomies and underwent primary total knee arthroplasties. Three knees had previous patellectomies and underwent revision total knee arthroplasties. Two patients who had primary total knee arthroplasties had failed results; one from infection and one from aseptic allograft resorption and fragmentation. One patient in the revision total knee arthroplasty group had failed results from infection. After an average followup of 44 months (range, 39-48 months), the six intact knees had an increase in quadriceps strength of one grade. The average Knee Society knee and function scores increased from 59 and 63 points, respectively, to 85 and 67 points, respectfully. The average patellar thickness was 24 mm 6 weeks postoperatively, and 15 mm (38% decrease) at the most recent followup. Patellar allografting improved quadriceps function by restoring patellar height. However, a high risk of allograft complications can occur with this procedure. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series).

Extensor mechanism disruption after contralateral middle third patellar tendon harvest for anterior cruciate ligament revision reconstruction.

The contralateral central third patellar tendon autograft is a reliable graft choice for revision, and recently, for primary reconstruction of the anterior cruciate ligament (ACL). We report 2 complications including a lateral third tibial tuberosity fracture and a distal patellar tendon avulsion with contralateral patellar tendon autograft with disruption of the extensor mechanism of the donor knee. A patient sustained a lateral tibial tuberosity fracture of the donor knee and underwent open reduction and internal fixation. At 1-year follow-up, she had no extensor lag and full range of motion. Another patient sustained a distal patellar tendon avulsion of the donor knee and underwent primary repair. Three years postoperatively, she had a full range of motion and no extensor lag. Although contralateral middle third patellar tendon autograft for primary and revision ACL reconstruction is established in the literature, extensor mechanism complications can occur. Technical considerations are important to avoid weakening the remaining patellar tendon insertion. Postoperative nerve blocks or local anesthetics may alter pain feedback for regulation of weight bearing and contribute to overload of the donor knee.

Extended medial gastrocnemius rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and without total knee arthroplasty.

Nine patients with chronic extensor mechanism disruption were treated with an extended medial gastrocnemius rotational flap reconstruction of the extensor mechanism. Seven patients previously had total knee arthroplasty and two patients had chronic infection of nonreplaced, native knees. Four patients previously had failed Achilles' tendon allograft reconstruction after total knee arthroplasty and two were complicated by infection. Infected arthroplasty patients had a staged procedure with placement of an antibiotic spacer after debridement and extended medial gastrocnemius rotational flap, followed by total knee arthroplasty replant 8 weeks later. The four infected arthroplasty patients had medical comorbidities that included a patient with HIV and hemophilia, and two with diabetes mellitus. Another patient with rheumatoid arthritis was severely malnourished as a result of dumping syndrome. Of the four patients treated by this two-stage procedure, one died in the early postoperative period from chronic medical issues after the second stage and another patient elected to have above-knee amputation after the first stage because of severe reflex sympathetic dystrophy. The final group of seven patients was studied at a mean followup of 21 months (range, 7-31 months), the average extensor lag was 13.5 degrees (range, 0-50 degrees ), and the average range of motion was 2 degrees to 93 degrees . The two patients with nonreplaced, native knees had extensor lags of 30 degrees and 10 degrees . All patients were able to regain sufficient extensor mechanism strength to return to independent ambulation, and all infections resolved after treatment. Two patients were able to ascend stairs foot over foot without support. In addition to the patient who had amputation, the other complication involved a wound breakdown that required a free flap at 13 months in a patient who had a failed Achilles' tendon allograft reconstruction after takedown of a knee fusion. Medial gastrocnemius flap reconstruction can provide successful salvage of a failed extensor mechanism allograft or an alternative to allograft reconstruction in patients with poor soft tissue coverage, previous infection, or a compromised immune system.