Recommendations for standardization and phenotype definitions in genetic studies of osteoarthritis: the TREAT-OA consortium

OBJECTIVE

To address the need for standardization of osteoarthritis (OA) phenotypes by examining the effect of heterogeneity among symptomatic (SOA) and radiographic osteoarthritis (ROA) phenotypes.

METHODS

Descriptions of OA phenotypes of the 28 studies involved in the TREAT-OA consortium were collected. We investigated whether different OA definitions result in different association results by creating various hip OA definitions in one large population based cohort (the Rotterdam Study I (RSI)) and testing those for association with gender, age and body mass index using one-way ANOVA. For ROA, we standardized the hip-, knee- and hand ROA definitions and calculated prevalence's of ROA before and after standardization in nine cohort studies. This procedure could only be performed in cohort studies and standardization of SOA definitions was not feasible at this moment.

RESULTS

In this consortium, all studies with SOA phenotypes (knee, hip and hand) used a different definition and/or assessment of OA status. For knee-, hip- and hand ROA five, four and seven different definitions were used, respectively. Different hip ROA definitions do lead to different association results. For example, we showed in the RSI that hip OA defined as "at least definite joint space narrowing (JSN) and one definite osteophyte" was not associated with gender (P =0.22), but defined as "at least one definite osteophyte" was significantly associated with gender (P=3×10(-9)). Therefore, a standardization process was undertaken for ROA definitions. Before standardization a wide range of ROA prevalence's was observed in the nine cohorts studied. After standardization the range in prevalence of knee- and hip ROA was small.

CONCLUSION

Phenotype definitions influence the prevalence of OA and association with clinical variables. ROA phenotypes within the TREAT-OA consortium were standardized to reduce heterogeneity and improve power in future genetics studies.

Vascularized fibula transfer for lower limb reconstruction

Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.

The catabolic role of toll-like receptor 2 (TLR-2) mediated by the NF-κB pathway in septic arthritis

Toll-like receptors (TLRs) are involved in mediating cell activation on stimulation with microbial components. Our objective was to investigate the role of TLR-2 mediated by the NF-κB pathway in septic arthritic chondrocytes. TLR-1, -2, and -6 mRNA expression levels were investigated in septic and normal chondrocytes using real-time reverse transcription-PCR. TLR-2 and MMP-13 mRNA and protein levels were measured using real-time PCR and Western blot analysis, respectively. Blocking TLR-2 mRNA expression was performed using small interfering RNA (siRNA) against TLR-2 and subsequently MMP-3, MMP-13, IL-1β, and IL-6 mRNA levels, as well as p65 NF-κB, IkBα, and MMP-13 protein levels were evaluated using real-time PCR and Western blot analysis. IL-6 protein levels were measured using ELISA assay. We observed that TLR-1, -2, and -6 mRNA expression levels were significantly higher in septic compared to normal chondrocytes. MMP-13 mRNA and protein expressions were also significantly upregulated in septic arthritic cartilage. Blocking TLR-2 mRNA expression in septic chondrocytes resulted in significant increase of inactivated nonphosphorylated p65 NF-κB and IkBα protein levels and reduction in MMP-13, IL-1β, and IL-6 expression. Our findings suggest the pro-inflammatory and catabolic role of TLR-2 mediated by the NF-κB pathway in septic arthritis. Modulation of TLR-mediated signaling may be a potential therapeutic strategy for the prevention of postinfectious cartilage degradation in articular joints.

Delayed fracture of a zirconium head after total hip arthroplasty

We present a case of fracture of a zirconium head after a cemented total hip arthroplasty. The fracture occurred 81 months after the index operation without any history of trauma. The patient was thin, not participating in sports, and the zirconium head had 0-mm neck length. Preoperative radiographs demonstrated aseptic loosening of both components and significant polyethylene wear. Fracture pattern was unusual as the major fragment was half of the head. A revision was performed to a cementless arthroplasty. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.

An anatomical update on the morphologic variations of S1 and S2

Although percutaneous fixation with iliosacral screws has been shown to be a safe and reproducible method for sacroiliac dislocation and sacral fractures, it is a technically demanding technique, and one of its contraindications is sacral anatomical variations and dysmorphism. The incidence and pattern of S1 and S2 anatomical variations were evaluated in 61 patients (35 women and 26 men) using magnetic resonance imaging of the sacrum in an attempt to explore the possible existence of groups of individuals in whom percutaneous sacroiliac fixation is difficult due to local anatomy. S1 and S2 dimensions in both the transverse and coronal planes were recorded and evaluated. In each individual, S1 and S2 dimensions both in the coronal and transverse planes were proportional, with S2 dimensions being 80% of those of S1 on average. Patients were separated into 4 groups based on the S1 and S2 body size and the asymmetry of dimensions in the transverse and coronal planes. In 48 patients (78.6%), dimensions in both planes were symmetrical despite the varying size of the S1 and S2 body. In 2 patients (3.3%) there was a combination of large transverse plane and small coronal plane dimensions, with large S1 and S2 body size. In 9 patients (14.8%), coronal plane dimensions were disproportionately smaller compared to those of the transverse plane, with a varying size of S1 and S2 body making effective sacroiliac screw insertion a difficult task. Thus, a preoperative imaging study, preferably computed tomography scan, of S1 and S2 body size and coronal plane dimensions and an intraoperative fluoroscopic control of S1 and S2 dimensions on the coronal plane are suggested for safe sacroiliac screw fixation.

Vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand

Vascularized bone grafts have been successfully applied for the reconstruction of bone defects at the forearm, distal radius, carpus, and hand. Vascularized bone grafts are most commonly used in revision cases in which other approaches have failed. Vascularized bone grafts can be obtained from a variety of donor sites, including the fibula, the iliac crest, the distal radius (corticocancellous segments and vascularized periosteum), the metacarpals and metatarsals, and the medial femoral condyle (corticoperiosteal flaps). Their vascularity is preserved as either pedicled autografts or free flaps to carry the optimum biological potential to enhance union. The grafts can also be transferred as composite tissue flaps to reconstruct compound tissue defects. Selection of the most appropriate donor flap site is multifactorial. Considerations include size matching between donor and defect, the structural characteristics of the graft, the mechanical demands of the defect, proximity to the donor area, the need for an anastomosis, the duration of the procedure, and the donor site morbidity. This article focuses on defects of the distal radius, the wrist, and the hand.

Impaired expression of genes regulating cholesterol efflux in human osteoarthritic chondrocytes

Altered lipid metabolism has been implicated as a critical player in osteoarthritis (OA). Our study aimed to investigate the expression of genes regulating cholesterol efflux in human chondrocytes and to study the effect of an LXR agonist on cholesterol efflux and lipid accumulation in osteoarthritic chondrocytes. ATP-binding-cassette transporter A1 (ABCA1), apolipoprotein A1 (ApoA1), and liver X receptors (LXRalpha and LXRbeta) mRNA expression levels were evaluated using real-time polymerase chain reaction (PCR) and ApoA1 protein levels by Western blot analysis in normal and osteoarthritic articular cartilage samples. Cholesterol efflux was evaluated in osteoarthritic chondrocytes radiolabeled with [1,2(n)-(3)H] cholesterol after LXR treatment, while intracellular lipid accumulation was studied after Oil-red-O staining. Cholesterol efflux gene expressions were significantly lower in osteoarthritic cartilage compared to normal. Treatment of osteoarthritic chondrocytes with the LXR agonist TO-901317 significantly increased ApoA1 and ABCA1 expression levels, as well as cholesterol efflux. Additionally, osteoarthritic chondrocytes presented intracellular lipids deposits, while no deposits were found after treatment with TO-901317. Our findings suggest that impaired expression of genes regulating cholesterol efflux may be a critical player in osteoarthritis, while the ability of the LXR agonist to facilitate cholesterol efflux suggests that it may be a target for therapeutic intervention in osteoarthritis.

Repair of an anteroinferior glenoid defect by the latarjet procedure: quantitative assessment of the repair by computed tomography

PURPOSE

The purpose of this study was to determine quantitatively whether the Latarjet procedure (coracoid transfer to the glenoid) is sufficient to restore a significant defect area of the glenoid.

METHODS

Fourteen cadaveric shoulders were used (mean age, 76 years; range, 72 to 87 years). An anteroinferior glenoid defect was created and then the coracoid osteotomized to its angle and transferred to the defect. A 3-dimensional computed tomography scan was used to calculate the surface area of (1) the intact glenoid, (2) the osteotomized glenoid, and (3) the reconstructed glenoid.

RESULTS

The mean area of the intact inferior glenoid was 734 +/- 89 mm(2). After creation of the defect, the surface area of the glenoid was reduced significantly to 523 +/- 55 mm(2) (P = .011). The mean defect area was 28.7% +/- 6% of the intact glenoid. After coracoid transfer, the mean surface area of the reconstructed glenoid was 708 +/- 71 mm(2) but it was not significantly smaller than that of the intact glenoid (P = .274). The mean surface area of the coracoid that was used to repair the defect was 198 +/- 34 mm(2), or 27% +/- 5% of the intact glenoid.

CONCLUSIONS

In our cadaveric model, a mean 29% defect size of the inferior glenoid was restored to normal after coracoid transfer by use of the Latarjet procedure.

CLINICAL RELEVANCE

In the clinical scenario, the existence of a glenoid bone defect of more than 25% to 30% is very rare in patients with anterior shoulder instability. Therefore, when clinically indicated, large bony defects of the anterior glenoid can be adequately treated by the Latarjet procedure.

Evaluation of the bone bridge between the bone tunnels after anatomic double-bundle anterior cruciate ligament reconstruction: a multidetector computed tomography study

BACKGROUND

Double-bundle anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure; it requires drilling 2 tibial and 2 femoral tunnels. Tunnel communication, whether intraoperative or postoperative, is a serious complication: It jeopardizes knee stability and graft function.

HYPOTHESIS

During double-bundle ACL reconstruction, special aimers would be helpful to avoid intraoperative bone bridge fracture. The bone bridge between the bone tunnels would maintain its structural integrity, and no tunnel communication would be observed postoperatively because of tunnel widening.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This prospective study included 32 patients undergoing double-bundle ACL reconstruction. A multidetector computed tomography study was performed at a mean of 17 months postoperatively. The thickness of the bone bridge between the bone tunnels was measured in the femoral and tibial sides on an axial and sagittal plane, respectively, at 3 locations: the level of the joint line, the midportion of the bone bridge, and the base of the bone bridge. The bone density of the bone bridge was measured in Hounsfield units in the same locations. Bone density of the anterior tibial cortex and lateral femoral condyle was measured for comparisons.

RESULTS

Tunnel communication occurred intraoperatively in 1 patient on the tibial side at the level of the joint line. In the rest of the patients, a well-defined triangular bone bridge was present between the 2 tunnels in the femoral and tibial sides. The thickness at the apex of the bone bridge was 2.0 and 2.2 mm for the femur and tibia, respectively. In addition, the density of the bone bridge at its apex was similar to that of cortical bone.

CONCLUSION

This study demonstrated that double-bundle ACL reconstruction, as used with anatomic aimers, produces a low rate of tunnel convergence. The bone bridge remains intact postoperatively, although it is thin at the level of the joint line.

Clinical outcome study and radiological findings of Zweymuller metal on metal total hip arthroplasty. a follow-up of 6 to 15 years

We report the clinical and radiological outcome of 99 Zweymuller metal on metal total hip arthroplasties in 84 patients followed up prospectively for a mean period of 9.5 (range, 6-15) years. There were 29 (34.5%) male and 55 (65.5%) female patients with a mean age of 62.85 years (range, 50-70 years) at the time of surgery. All patients had osteoarthritis. One acetabular component and one stem were revised due to aseptic loosening. One femoral stem was revised due to a periprosthetic fracture. HHS score improved from a preoperative mean of 62.56 points (SD 8.87) to a final postoperative follow-up mean of 93.48 (SD 7.7). Cumulative success rate for both implants at 13 years, with aseptic loosening as the end point, was 97.05%, while for both implants at 13 years, with revision for any reason as the end point, it was 91.17%. Satisfactory results were observed with the use of this prosthesis.

New sequence variants in HLA class II/III region associated with susceptibility to knee osteoarthritis identified by genome-wide association study

Osteoarthritis (OA) is a common disease that has a definite genetic component. Only a few OA susceptibility genes that have definite functional evidence and replication of association have been reported, however. Through a genome-wide association study and a replication using a total of approximately 4,800 Japanese subjects, we identified two single nucleotide polymorphisms (SNPs) (rs7775228 and rs10947262) associated with susceptibility to knee OA. The two SNPs were in a region containing HLA class II/III genes and their association reached genome-wide significance (combined P = 2.43x10(-8) for rs7775228 and 6.73x10(-8) for rs10947262). Our results suggest that immunologic mechanism is implicated in the etiology of OA.

Ankle and foot osteomyelitis: treatment protocol and clinical results

INTRODUCTION

A management protocol for ankle and foot osteomyelitis and the outcome in 84 patients treated in a unit with special interest in musculoskeletal infection, is presented.

PATIENTS AND METHODS

Patients' mean age was 50.7+/-16.5 years and mean follow-up 31.5+/-18.2 months. Systemic antibiotics were administered initially empirically, and later according to cultures. Surgical treatment included surgical debridement and bead-pouch technique, minor amputation (ray or toe), below knee amputation, and joint fusion. "Second-look" procedures were performed after 48-7h. Vascularised grafts or Ilizarov's technique were used for bone defect reconstruction. Soft tissues were managed according the 'reconstructive ladder' concept.

RESULTS

Host-type (Cierny's classification) was A in 25, B in 53 and C in 6 patients. Seventy-six infections were chronic. Causes were: open trauma without fracture (45/84), open fractures (9/84), ORIF of closed fractures (25/84) and elective surgery (5/84). Patients underwent 3.0+/-1.5 (range 1-10) operative procedures and spent 14.8+/-12.2 (range 3-60) days in hospital. Two (host-C) patients died. Complications requiring reoperations occurred in 20/84 (2/25 host-A, 16/53 host-B, 2/6 host-C; significant difference between host-A versus host-B and -C patients, p<0.001). Infection recurrence occurred in 12 (none host-A; significant difference between host-A versus host-B and -C patients, p<0.001). Multiple organisms were isolated in 39/84. Ankle arthrodesis using external fixation was performed in 9 (fusion rate 8/9). The free vascularised fibula graft was used in 2 and distraction osteogenesis in 8 patients with a mean bone defect of 5.4 cm (range 3-13). Below knee amputations were performed in 5/84 (3/53 host-B, 2/6 host-C) and foot ray amputations in 8/84 (6/53 host-B, 2/6 host-C). Soft tissue coverage required: free muscle flap transfer in 6/84, reverse soleus flap in 1/84, local fasciocutaneous flaps in 7/84, split thickness skin grafts in 5/84, and vacuum assisted closure in 5/84 patients. Eighty-two surviving patients, including amputees, were able to mobilise independently and were satisfied with the result of treatment.

CONCLUSIONS

Host-B and -C patients had more complications and infection recurrences and occasionally required amputations. Reconstructive procedures were performed for limb salvage in patients with soft tissue and bone defects and restoration of a functional limb was achieved.

Low-density lipoprotein receptor-related protein 5 (LRP5) expression in human osteoarthritic chondrocytes

The aim of this study was to investigate the activation of the Wnt/beta-catenin pathway in osteoarthritis and the role of low-density lipoprotein receptor-related protein 5 (LRP5) in human osteoarthritic chondrocytes. The influence of 1,25(OH)2D3 on the expression of the LRP5 gene in human chondrocytes was also assessed. Human cartilage was obtained from 11 patients with primary osteoarthritis (OA) undergoing total knee replacement surgery. Normal cartilage was obtained from five healthy individuals. Beta-catenin and LRP5 mRNA levels were investigated using real-time PCR and LRP5 protein expression using Western blot analysis. Furthermore, we evaluated the effect of 1,25(OH)2D3 on LRP5 mRNA expression levels in osteoarthritic chondrocytes. Blocking LRP5 expression was performed using small interfering RNA (siRNA) against LRP5, and subsequent MMP-13 mRNA and protein levels were evaluated by real-time PCR and Western blot analysis, respectively. We confirmed the activation of the Wnt/beta-catenin pathway in OA, as we observed significant up-regulation of beta-catenin mRNA expression in osteoarthritic chondrocytes. We also observed that LRP5 mRNA and protein expression were significantly up-regulated in osteoarthritic cartilage compared to normal cartilage, and LRP5 mRNA expression was further increased by vitamin D. Also, blocking LRP5 expression using siRNA against LRP5 resulted in a significant decrease in MMP-13 mRNA and protein expressions. Our findings suggest the catabolic role of LRP5 is mediated by the Wnt/beta-catenin pathway in human osteoarthritis.

Protective effect of atorvastatin in cultured osteoarthritic chondrocytes

The aim of our study was to evaluate the in vitro effect of an HMG-CoA reductase inhibitor, atorvastatin, on the expression of significant anabolic and catabolic genes in human osteoarthritic chondrocytes and to explore the metabolic pathways involved in this process. Human articular osteoarthritic chondrocytes were cultured in the presence and absence of atorvastatin (10 and 50 micromol/L) for 24 h. Metalloproteinase 13 (MMP-13), collagen type II (COL2A1), and aggrecan (AGC) mRNA expression levels were evaluated by real-time PCR, and protein expression levels by Western blot analysis. IL-1beta levels in culture medium was analyzed with ELISA. The effect of the treatment with the mevalonate isoprenoid derivatives farnesol and geranylgeraniol, or the cholesterol precursor squalene, was evaluated in the atorvastatin osteoarthritic chondrocyte cultures. Incubation of osteoarthritic chondrocyte cultures with atorvastatin produced a significant dose-dependent reduction in IL-1beta production. Atorvastatin supplementation in cultures produced a decrease in MMP-13 mRNA and protein expression levels, which was reversed by the addition of farnesol. Regarding AGC and COL2A1 mRNA expression, a significant increase was observed only in chondrocytes cultures treated with 50 micromol/L atorvastatin. Our findings suggest that atorvastatin may have potential chondroprotective effects mostly by reducing cartilage degradation.

A mid-term clinical outcome study of the Advance Medial Pivot knee arthroplasty

The Advance Medial Pivot Total Knee Arthroplasty (Wright Medical Technology, Arlington, Tennessee, USA) has been designed to reproduce modern ideas of knee kinematics. We report a prospective clinical outcome study of 284 arthroplasties in 225 consecutive patients with a mean follow-up of 6.7 years (range 4 to 9 years). For evaluation, both objective and subjective clinical rating systems and serial radiographs were used. At final follow-up, 10 (4.4%) patients (10 knees) only were lost from follow-up and four (1.8%) patients (five knees) had died for reasons unrelated to the surgery with their knees performing well. There was an 82% compliance in the intervals of follow-up evaluation. All patients showed a statistically significant improvement (p=0.01) in the Knee Society clinical rating system, WOMAC questionnaire, SF-12 questionnaire, and Oxford knee score. The majority of patients (92%) were able to perform age-appropriate activities with a mean knee flexion of 117 degrees (range 85 degrees to 135 degrees) at final follow-up. Survival analysis showed a cumulative success rate of 99.1% at 5 years. Two (0.7%) arthoplasties, in which patient selection and surgical errors were identified, were revised due to aseptic loosening, one due to infection and one due to a traumatic dislocation. This study demonstrates satisfactory mid-term clinical results for this knee design.

Donor sites for pedicled skeletal grafts of the hand, wrist, and forearm

Pedicled bone and periosteal grafts provide successful reconstruction of skeletal problems of the distal radius, wrist, and hand. The purpose of this study was to evaluate the available alternatives and to propose the most suitable skeletal grafts for the reconstruction of the distal radius, and the carpal and hand bones. The alternative donor sites (dorsal and palmar distal radius, and metacarpals), their pedicles, and the potential coverage area in relation to specific wrist and hand pathology were determined in the cadaveric dissections. In the clinical setting, 75 pedicled grafts were used for the treatment of scaphoid nonunions (62 cases), lunate necrosis (8 cases), reconstruction of the metacarpal defects (2 cases), and wrist fusions (3 cases). All alternatives have the advantage of a single approach that may be performed under tourniquet control, from the same team. Among the available alternatives, surgeon's familiarity plays the most important role for the final selection of the graft.

Association of biofilm formation and methicillin-resistance with accessory gene regulator (agr) loci in Greek Staphylococcus aureus clones

Pathogenicity of Staphylococcus aureus is coordinated by the accessory gene regulator (agr) system. Previous studies suggested that agr Group II methicillin-resistant S. aureus (MRSA), a polymorphism that has been associated with moderate response to vancomycin, may also be related with overproduction of biofilm. In a hospital environment with endemic occurrence of MRSA, the distribution of agr groups and their association with biofilm formation was investigated. Forty-two MRSA and 32 methicillin-susceptible S. aureus (MSSA) isolates were tested and had derived from 10 genotypes and 8 clonal complexes. agr Groups I, II and IV were evenly distributed among MRSAs and MSSAs but agr Group III was not detected. agr Group II MRSAs showed significantly higher levels of biofilm production in comparison with MRSAs of the remaining agr groups as well as with all three agr groups of MSSAs. These findings suggest that agr Group II is simultaneously associated with methicillin-resistance and biofilm overproduction in a region with endemic MRSA.

Triple nerve block at the knee for foot and ankle surgery performed by the surgeon: difficulties and efficiency

BACKGROUND

Combined nerve blocks at the knee can provide safe anesthesia below the knee avoiding the potential complications of general or spinal anesthesia while reducing the need for opioids in the postoperative period. This study presents the outcomes of a large series of patients that underwent foot and ankle surgery receiving a triple nerve block at the knee.

MATERIALS AND METHODS

Three hundred eighty patients underwent foot and ankle surgery receiving anesthesia with triple nerve block at the knee (tibial, common peroneal and saphenous nerve). Surgery included a variety of bone and soft tissue procedures. The nerve block was performed by an orthopaedic surgeon in the lateral decubitus position.

RESULTS

The successful nerve block rate was 91 percent. There was no need to convert to general or spinal anesthesia, although 34 patients (9%) needed additional analgesia intraoperatively. Complete anesthesia required 25 to 30 minutes from the time of performing the block. No complication occurred secondary to the use of the anesthetic agent (ropivacaine 7.5%). Postoperative analgesia lasted from 5 to 12 hours, reducing the need of additional analgesics. Hospitalization averaged 1.4 days (from 0 to 5) with the majority of patients discharged the day after the operation (248/380). A high satisfaction rate was reported by the patients with no adverse effects and complications.

CONCLUSION

We found triple nerve block at the knee to be a safe and reliable method of regional anesthesia providing low morbidity, high success rate, long acting analgesia, and fewer complications than general or spinal anesthesia. It is a simple method that can be performed by the orthopaedic surgeon.

Scaphoid reconstruction with vascularized bone grafts from the distal radius

The aim of the present technical report is to describe the alternative solutions for the reconstruction of scaphoid nonunions with pedicled vascularized bone grafts from the distal radius. The surgical technique for the reconstruction A. of proximal scaphoid nonunions with pedicled bone grafts (based on the 1,2 or on the 2,3 intercomparmtental arteries) or with capsular bone grafts from the dorsal distal radius and B. of waist nonunions of the scaphoid with grafts from the palmar distal radius, pedicled on the palmar carpal arch, is presented. Vascularized bone grafts from the adjacent radius are used for the treatment of scaphoid nonunions to enhance union and to revascularize a nonviable proximal pole. The most suitable graft is selected according to the location of the nonunion (at the waist or the proximal pole of the scaphoid) and to the previous procedures/scars at the wrist level.

Arthroscopic repair for chronic anterior shoulder instability: a comparative study between patients with Bankart lesions and patients with combined Bankart and superior labral anterior posterior lesions

BACKGROUND

Although labrum lesions in patients with chronic anterior shoulder instability may not only involve detachment of the anteroinferior labrum but a lesion of the superior glenoid labrum as well, no studies have compared the clinical outcome between patients with a lesion of the anteroinferior labrum and patients with a combined lesion of the anterior and superior labrum after arthroscopic shoulder stabilization.

HYPOTHESIS

Arthroscopic repair of a combined lesion of the anterior and superior labrum may have inferior clinical outcome to repair of an anterior lesion only in patients with anterior shoulder instability.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Sixty-three patients operated on for anterior shoulder instability between April 2002 and June 2006 were included in this study. Patients with bone deficiency were excluded. Fixation of the detached labrum was performed using suture anchors. Thirty-eight patients had a lesion of the anterior labrum (group A), and 25 had a combined lesion of the anterior and superior labrum (group B). Patients were evaluated after a 2-year minimum follow-up with Constant and Rowe scores. Failure was defined as a redislocation or a subluxation episode.

RESULTS

Patients in group B experienced a significantly higher number of dislocations preoperatively (P < .05). However, there was no difference between the 2 groups regarding the failure rate postoperatively. One patient from each group had a failed result. A mean loss of 5 degrees and 8 degrees of external rotation at 90 degrees of abduction was noted in patients in groups A and B, respectively (P = .113). The Constant score was 94 in group A and 93 in group B (P = .435). The Rowe score was 91 in group A and 90 in group B (P = .338).

CONCLUSION

There are no differences in shoulder stability and function in patients with anterior shoulder instability and a lesion of the anteroinferior labrum and patients with an extended lesion of the anterior and superior labrum after arthroscopic shoulder stabilization.

Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report

Introduction

Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery.

Case presentation

We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively.

Conclusion

A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.