Return to Sports Following Meniscal Allograft Transplantation Is Possible but Remains Questionable: A Systematic Review.

OBJECTIVE: To evaluate the return to sports rate and time following meniscal allograft transplantation (MAT). METHODS: PubMed, Web of Science, and Embase were searched in December 2020. Eligibility criteria included clinical studies reporting the return to sport rate following MAT with ≥12-month follow-up. RESULTS: A total of 14 case series were included with 670 patients. The bone bridge technique was used for all transplantations in 5 studies, and suture fixations with bone tunnels were used for all transplantations in 5 studies. In 2 studies, bone plugs were used for medial menisci and bone bridge for lateral menisci. In 1 study, suture fixation was used for medial menisci, and bone bridge for lateral menisci. The return to sports rate ranged from 20% to 91.7%, with 2 studies reporting low return to sport rates. The return to sport time ranged between 7.6 and 16.9 months. The return to preinjury level had a rate of 7% to 100%. Return to a higher level of sports was reported in only 2 studies (28.5% to 86%). Return to a lower level of sports was reported in low proportions in most studies. In terms of patient-reported outcomes, the Lysholm knee and subjective International Knee Documentation Committee (IKDC) scores and Knee Osteoarthritis Outcome Score (KOOS) had significant improvements after MAT. The KOOS quality of life subscore did not change significantly in 1 study. The total reoperation rate after MAT ranged between 3.1% and 80%, whereas the total failure ranged between 1.1% and 30.1%. CONCLUSION: Despite that most studies reporting high return to sports rates, the current level of evidence is low, with all studies being case series. There is significant variability in the reported return to sports rate, time, and level. Therefore, high-quality comparative studies are mandated to elucidate whether MAT is associated with higher return to sports rates and levels. LEVEL OF EVIDENCE: IV, systematic review.

Prosthetic Bearing Surfaces in Anatomic and Reverse Total Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA) and reverse TSA have provided an effective treatment for glenohumeral osteoarthritis; however, longevity of the procedure may be limited by osteolysis and polyethylene wear. In TSA, glenoid component failure occurs through several mechanisms, the most common being aseptic loosening and polyethylene wear. Newer bearing surfaces such as highly cross-linked ultra-high-molecular-weight polyethylene, vitamin E processing, ceramic heads, and pyrolytic carbon surfaces have shown improved wear characteristics in biomechanical and some early clinical studies. The purpose of this review is to provide a historical perspective and current state of the art of bearing surface technology in anatomic and reverse TSA.

Arthroscopic Repair of a Coronoid Process Fracture: A Case Report.

CASE: A 68-year-old woman sustained an isolated type III left coronoid fracture after mechanical ground-level fall. The patient underwent left elbow arthroscopy with minimally invasive arthroscopic reduction and internal fixation of the coronoid fracture using Arthrex Mini TightRope. The patient achieved successful elbow stabilization with a postoperative Mayo Elbow Score of 100. CONCLUSION: We present a case report of a novel technique in coronoid fracture management with stable fixation, minimal soft-tissue violation, and restoration of highly functional elbow range of motion. Minimal soft-tissue violation with use of arthroscopy and suture button was the key element in successful surgical treatment and outcome.

Surgical anatomy of the axillary artery: clinical implications for open shoulder surgery.

BACKGROUND: Axillary artery injury is a devastating complication related to anterior shoulder surgery and can result in significant morbidity and/or mortality. The purpose of our study was to evaluate the course of the axillary artery in relation to bony landmarks of the shoulder and identify variations in artery position with humeral external rotation. MATERIALS AND METHODS: Dissection of 18 shoulders (9 fresh whole-body cadavers) with simulated vessel perfusion using radiopaque dye was performed. The axillary artery position was measured from multiple points including 2 points on the coracoid base (C1 and C2), 3 points on the coracoid tip (C3-C5), 4 points on the glenoid: superior, middle, and inferior glenoid (D1-D4), and 2 points on the lesser tuberosity (L1 and L2). Fluoroscopic measurements were taken and compared at 0° and 90° of external rotation (F1 vs. F1' and F2 vs. F2'). Manual and fluoroscopic measurements were compared with one another using Kendall's τb correlation. RESULTS: There were 6 male and 3 female cadavers with an average age of 67.2 ± 9.3 years (range: 49-77 years). The mean distance from the axillary artery to the coracoid base (C1 and C2) measured 21.1 ± 7.3 and 22.3 ± 7.4 mm, respectively, whereas the mean distance to the coracoid tip (C3, C4, and C5) measured 30.7 ± 9.3, 52.1 ± 20.2, and 46.5 ± 14.3 mm, respectively. Measurements relative to the glenoid face (D1, D2, and D3) showed a progressive decrease in mean distance from superior to inferior, measuring 31.6 ± 10.3, 16.5 ± 7.5, and 10.3 ± 7.3 mm, respectively, whereas D4 (inferior glenoid to axillary artery) measured 17.8 ± 10.7 mm. The minimum distance from the axillary artery to any point on the glenoid was as close as 4.1 mm (D3). There was a statistically significant difference in F1 (0° external rotation) vs. F1' (90° external rotation) (18.5 vs. 13.4 mm, P = .03). Kendall's τb correlation showed a strong, positive correlation between manual and fluoroscopic measurements (D4: 16.0 ± 12.5 mm vs. F1: 18.5 ± 10.7 mm) (τb = 0.556, P = .037). CONCLUSION: The axillary artery travels an average of 1-1.8 cm from the inferior glenoid margin, which puts the artery at significant risk. In addition, the artery is significantly closer to the inferior glenoid with humeral external rotation. Surgeons performing anterior shoulder surgery should have a thorough understanding of the axillary artery course and understand changes in the position of the artery with external rotation of the humerus.

Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most?

OBJECTIVES: Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN: Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS: Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING: This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS: The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS: A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS: Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. METHODS: We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. RESULTS: 107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. CONCLUSIONS: We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures.

BACKGROUND: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS: This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.