-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND:The management of irreparable massive or full-thickness 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis remains a difficult challenge for the treating surgeon. Many different treatment options, with varied success, have been proposed. HYPOTHESES:(1) Patients undergoing reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft would demonstrate improvements in pain, range of motion, strength, and subjective functional outcomes. (2) Postoperative ultrasonography would demonstrate intact repairs at a minimum 2-year follow-up. STUDY DESIGN:Case series; Level of evidence, 4. METHODS:Twenty-six patients (27 shoulders) underwent reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft. Pain level (scale 0-10, 10 = severe pain), active range of motion, and supraspinatus and external rotation strength were assessed. Subjective outcome measures included American Shoulder and Elbow Score (ASES) and Short Form-12 (SF-12) score. Clinical and radiographic analyses were performed at an average 32-month follow-up period (minimum 2-year follow-up). Ultrasound imaging (static and dynamic) of the operative shoulder was performed at final follow-up to assess the integrity of the construct. RESULTS:Mean patient age was 60 years. Mean pain level decreased from 5.1 to 0.4 (P = .002). Mean active forward flexion and abduction improved from 138.8° to 167.3° (P = .024) and 117.9° to 149.3° (P = .001), respectively. Supraspinatus and external rotation strength improved from 7.2 to 9.4 (P = .001) and 7.4 to 9.5 (P = .001), respectively. Mean ASES improved from 62.7 to 91.8 (P = .0007), and mean SF-12 scores improved from 48.4 to 56.6 (P = .044). Twenty-one patients (22 shoulders) returned for a dynamic and static ultrasound of the operative shoulder at a minimum 2-year follow-up. Sixteen patients (73%) demonstrated a fully intact tendon-graft reconstruction, 5 patients (22%) had a partially intact reconstruction, and 1(5%) had a complete tear at the graft-bone interface caused by suture anchor pullout as a result of a fall. There were no cases of infection or tissue rejection. CONCLUSION:Active patients with massive or 2-tendon rotator cuff tears with minimal glenohumeral arthritis continue to be a subset of the population for whom there is no current standard of care. Results suggest that the use of porcine xenograft may be an effective means by which to treat these patients.
The American journal of sports medicine 02/2013; · 3.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Massive irreparable rotator cuff tears in patients without advanced glenohumeral arthritis can pose a challenge to surgeons. Numerous management strategies have been utilized, and studies have shown varied results with regard to shoulder pain, range of motion, strength, and overall function.
Patients undergoing repair of massive irreparable rotator cuff tears through a mini-open approach with the use of human dermal tissue matrix allograft would demonstrate an improvement in pain, range of motion, strength, and subjective functional outcomes.
Case series; Level of evidence, 4.
We performed a prospective observational study of 24 patients who underwent interposition repair of massive rotator cuff tears using human dermal allograft. All patients were evaluated preoperatively and postoperatively by the treating surgeon. Data were collected preoperatively and postoperatively for an average 3-year follow-up period (range, 29-40 months). Active range of motion as well as supraspinatus and infraspinatus strength was assessed. Subjective outcome measures included pain level (visual analog scale of 0-10, with 10 = severe pain), American Shoulder and Elbow Score (ASES), and Short-Form 12 (SF-12) score. Imaging evaluation to assess for repair integrity was performed using static and dynamic ultrasonography at final follow-up.
Mean pain level decreased from 5.4 to 0.9 (P = .0002). Mean active forward flexion and external rotation motion improved from 111.7° to 157.3° (P = .0002) and from 46.2° to 65.1° (P = .001), respectively. Mean shoulder abduction improved from 105.0° to 151.7° (P = .0001). Supraspinatus and infraspinatus strength improved from 7.2 to 9.4 (P = .0003) and from 7.8 to 9.3 (P = .002), respectively. Mean ASES improved from 66.6 to 88.7 (P = .0003). Mean SF-12 scores improved from 48.8 to 56.8 (P = .03). One partial graft retear occurred because of patient noncompliance during postoperative rehabilitation. However, this patient still demonstrated improvement in pain, motion, and subjective outcomes at final follow-up. Ultrasonography demonstrated "fully intact" repairs in 76% of patients. All remaining patients had "partially intact" repairs. There were no complete tears.
In our series of carefully selected candidates, all patients demonstrated a significant improvement in pain, range of motion, and strength. Subjective outcome measures, including mean ASES and SF-12 scores, also demonstrated significant improvement at an average 3-year follow-up.
The American journal of sports medicine 01/2012; 40(1):141-7. · 3.61 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Postoperative inflammation and stiffness, as well as the struggle to achieve full range of motion (ROM), following knee surgery is a significant clinical challenge. Interleukin-1 is a crucial mediator of the inflammatory response and development of pathological conditions leading to chronic inflammation. We hypothesized that intra-articular injection of intra-articular anakinra, an IL-1 antagonist, would result in sustained improvements of chronic refractory arthrofibrosis and limited arthrofibrosis of the knee joint. We retrospectively reviewed 8 patients who underwent injection of intra-articular anakinra, 200 mg. Four patients (3 women, 1 man) had intra-articular anakinra for treatment of chronic refractory arthrofibrosis, and 4 patients (4 women) had intra-articular anakinra for limited arthrofibrosis. All 4 of the refractory arthrofibrosis patients had failed conservative treatment with intensive physical therapy, corticosteroid injections, and anti-inflammatory medication. Three of the 4 patients had failed a prior manipulation under anesthesia with lysis of adhesions. All 4 reported improvement in ROM (10°-45°) and swelling, with 75% reporting improvement in pain. Seventy-five percent of these patients returned to prior activity level. All 4 of the limited arthrofibrosis also failed similar attempts at conservative treatment, and 2 of the 4 had failed a prior manipulation under anesthesia with lysis of adhesions. After intra-articular anakinra, all 4 reported improvement in ROM (20°-45°) and swelling, with 80% reporting improvement in pain. Seventy-five percent of these patients were able to return to prior activity level. We found intra-articular anakinra to be effective in this small cohort of patients with refractory arthrofibrosis and limited arthrofibrosis.
Orthopedics 12/2010; 33(12):877. · 2.66 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Despite surgical and mechanical stabilization of an acutely injured joint through ligament reconstruction, meniscus repair, or labral repair, the risk of posttraumatic arthritis remains high. Joint injury triggers three phases of pathogenic events: the early (acute) phase involves joint swelling, hemarthrosis, expression of inflammatory cytokines (especially interleukin-1 [IL-1] and tumor necrosis factor-α [TNF-α]), and biomarkers of cartilage catabolism; an intermediate phase is characterized by reduction of joint inflammation, ongoing joint catabolism, but no evidence yet for typical features of radiographic osteoarthritis (OA); and a late phase characterized by radiographic OA.
We hypothesize that the early phase of acute knee injury represents a window of opportunity for providing biologic treatment to promote healing and to slow or prevent a subsequent cascade of destructive joint processes leading to OA. PROPOSED PROGRAM: We propose a phase II, randomized, placebo-controlled, double-blinded, clinical trial to treat acute knee injuries with intraarticular injection of an IL-1 inhibitor. Patient-centered outcomes will include pain reduction and improvement of knee function. MR imaging and measurement of biochemical markers will be monitored during the subsequent 2 years to determine if the structural response to injury can be reversed.
If this model is validated, modulation of the molecular pathways responsible for articular cartilage breakdown will augment current reconstructive procedures in the treatment of acute joint injuries and prevent the development of injury-related arthritis.
Clinical Orthopaedics and Related Research 12/2010; 469(12):3522-6. · 2.53 Impact Factor
-
Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 12/2008; 18(2):e1-5. · 1.93 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: There is little in the radiology literature regarding the MRI appearance of a torn posterior cruciate ligament (PCL). The purpose of this study was to describe the MRI appearance of surgically proven PCL tears and to emphasize previously unreported signs. CONCLUSION: The PCL is usually injured as the result of stretching deformation; on MRI, the ligament maintains continuity as a single structure with apparent thickening. On sagittal T2-weighted images, an anteroposterior diameter of 7 mm or more is highly suggestive of a torn PCL. Increased intrasubstance signal intensity in the PCL on proton-density images with lower signal intensity on T2-weighted images is another common feature.
American Journal of Roentgenology 11/2008; 191(4):1031. · 2.78 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this review of prospectively collected data, representing the largest series of its kind, we identified 25 stress injuries of the diaphyseal femur in 20 athletes at an NCAA (National Collegiate Athletic Association) Division I university. All 20 patients successfully completed rehabilitation and returned to activity without limitations. Seventeen of these patients (representing 22 injuries) were female, and all 5 patients who sustained 2 stress injuries were female. The higher proportion of injured females in this study, and the histories of menstrual irregularities and disordered eating, raised the concern that the female athlete triad may be a factor. It is important to consider the diagnosis of stress injuries of the diaphyseal femur when evaluating thigh pain in running athletes, especially females, as early diagnosis and treatment lead to excellent outcomes and full return to activity. Magnetic resonance imaging should be considered the gold standard in the diagnostic evaluation of these injuries. Further, as stress fractures may be the first presentation of the female athlete triad, it is also important for orthopedic surgeons to identify the presence of risk factors that may predispose athletes to recurrent stress injuries and other health problems.
American journal of orthopedics (Belle Mead, N.J.) 10/2008; 37(9):476-80.
-
[show abstract]
[hide abstract]
ABSTRACT: Treatment options are limited for young, meniscal-deficient patients with pain. This patient population is not age appropriate for total joint replacement, yet the loss of the meniscus leaves them at significant risk for the development of osteoarthritis. One increasingly popular option is the use of allograft meniscal transplantation. However, many questions, both clinical and biomechanical, still surround allograft meniscus transplantation. Clinical questions include risks of disease transmission, patient factors affecting ultimate outcome, optimal graft preservation methods, and surgical technique choice. Biomechanical questions include whether allograft meniscus transplantation can reproduce the functions of the meniscus, the effects of proper sizing and fixation methods on contact mechanics, and the effects of freezing on allograft strength. This article reviews these questions and more current concepts regarding allograft meniscus transplantation.
The journal of knee surgery 05/2008; 21(2):163-72.
-
[show abstract]
[hide abstract]
ABSTRACT: The results of treatment of femoral head osteonecrosis with free vascularized fibular grafting (FVFG) following failed core decompression (core decompression-FVFG [CD-FVFG] group: 32 hips) were reviewed and compared with those of a control group that underwent FVFG only (54 hips). Outcome was considered unsuccessful if total hip arthroplasty was subsequently performed. Total hip arthroplasty was performed in 15 and 20 hips of the CD-FVFG and control groups, respectively. When considering age, sex, and presence of bilateral disease, patients with previous core decompression did not have a significantly different failure rate from patients with FVFG only. However, patients with preoperative stage V osteonecrosis or corticosteroid use had worse outcomes after vascularized fibular grafting if they had a previous core decompression of the femoral head.
The Journal of Arthroplasty 09/2007; 22(5):679-88. · 2.38 Impact Factor
-
The Foot and Ankle Online Journal 05/2007; 28(4):506-10. · 1.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This article reviews medicolegal issues in sports medicine. Nonmusculoskeletal medical conditions discussed include cardiac abnormalities, heat illness, and concussion in the athlete. Musculoskeletal injuries with the greatest potential for litigation, knee dislocation, and cervical spine trauma, are also reviewed. We provide legal case examples and discuss evaluation and treatment strategies to assist the medical team in the care of athletes.
Clinical Orthopaedics and Related Research 05/2005; · 2.53 Impact Factor
-
The American Journal of Sports Medicine 07/2004; 32(4):1049-53. · 3.79 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The relationship between volume and outcome of total knee arthroplasties has never been evaluated in a nationally representative sample, to our knowledge. We hypothesized that surgeons and hospitals with higher patient volumes would have better outcomes, as defined by lower mortality rates, shorter hospital stays, and lower postoperative complication rates.
The 1997 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample, Release 6, provided discharge abstracts of patients undergoing total knee arthroplasty from a national stratified probability sample. Logistic and multiple regression models were used to estimate the adjusted association of surgeon or hospital volume with rates of in-hospital mortality, pulmonary thromboembolism, deep venous thrombosis in the lower extremity, and postoperative wound infection as well as length of hospital stay. Estimates were calculated for a target population of 277,550 patients. Models were adjusted for comorbidity, age, gender, race, household income, and procedure (primary or revision arthroplasty).
The patients were mostly white (70.2%) and female (62.7%), with a mean age of 68.9 years. The overall in-hospital mortality rate for the target population was 0.2%, and the average length of stay was 4.6 days for the primary total knee arthroplasties and 4.9 days for the revision procedures. Surgeon volumes of at least fifteen procedures per year and hospital volumes of at least eighty-five per year were significantly and linearly associated with lower mortality rates (odds ratio = 0.56 [0.24 to 1.31] for surgeon volume of > or = 60). No other association demonstrated a significant and directionally consistent linear trend for improved outcomes.
Patients treated by providers with lower caseload volumes had higher rates of mortality following total knee arthroplasty in 1997. Proposing volume standards could decrease patient mortality following this procedure.
The Journal of Bone and Joint Surgery 09/2003; 85-A(9):1775-83. · 3.27 Impact Factor
