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Williams J, Albuquerque Ii JBD, Nuelle CW, Stannard JP, Cook JL. Impacts of Knee Arthroplasty on Activity Level and Knee Function in Young Patients: A Systematic Review. J Knee Surg 2024; 37:452-459. [PMID: 37714214 DOI: 10.1055/a-2176-4688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The annual demand for knee arthroplasty has been steadily rising, particularly in younger patients. The primary objective of this systematic review was to determine the impact of knee arthroplasties on knee function and activity levels in young (≤55 years) patients. A PubMed search from inception (1977) to March 2022 to identify eligible studies produced 640 peer-reviewed studies for consideration. A total of 18 studies including 4,186 knee arthroplasties in 3,200 patients (mean patient age at the time of surgery: 47.4 years, range: 18-55 years) were ultimately included for analysis. Mean final follow-up (FFU) duration was 5.8 years (range: 2-25.1 years). Mean FFU improvement in Knee Society Clinical Score was 48.0 (1,625 knees, range: 20.9-69.0), Knee Society Function Score was 37.4 (1,284 knees, range: 20-65). Mean FFU for the Tegner and Lysholm activity scale was 2.8 (4 studies, 548 knees, range: 0.7-4.2); University of California Los Angeles Physical Activity Questionnaire score was 2.8 (3 studies, 387 knees, range: 1.2-5); lower extremity activity scale was 1.84 (529 knees). The available evidence suggest that young patients typically realize sustained improvements in knee function compared to preoperative levels; however, these improvements do not typically translate into a return to desired activity levels or quality of life, and this patient population should expect a higher and earlier risk for revision than their older counterparts. Further research, including robust registry data, is needed to establish evidence-based indications, expectations, and prognoses for outcomes after knee arthroplasty in young and active patients.
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Affiliation(s)
- Jonathan Williams
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - João B de Albuquerque Ii
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Smith MD, Nuelle CW, Hartzler RU. Subacromial Surgery for Irreparable Posterosuperior Rotator Cuff Tears. Arthroscopy 2024; 40:1394-1396. [PMID: 38705639 DOI: 10.1016/j.arthro.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/06/2024] [Indexed: 05/07/2024]
Abstract
The irreparable posterosuperior rotator cuff tear describes a tear of the supraspinatus and/or infraspinatus tendon that is massive, contracted, and immobile in both the anterior-posterior and medial-lateral directions. Patients with an intact subscapularis and preserved forward elevation are challenging to treat because there is not a consensus treatment algorithm. For low-demand, elderly patients, several subacromial surgical options are available that can provide pain relief without the risks or burden of rehabilitation posed by reverse total shoulder arthroplasty or a complex soft-tissue reconstruction (e.g., superior capsular reconstruction, tendon transfer, bridging grafts). Debridement, more specifically the "smooth-and-move" procedure, offers a reliable outcome with documented improvements in pain and function at long-term follow-up. Similarly, the biodegradable subacromial balloon spacer (InSpace; Stryker, Kalamazoo, MI) has been shown to significantly improve pain and function in patients who are not responsive to nonoperative treatment. Disease progression with these options is possible, with a small percentage of patients progressing to rotator cuff arthropathy. Biologic tuberoplasty and bursal acromial reconstruction are conceptually similar to the balloon spacer but instead use biologic grafts to prevent bone-to-bone contact between the humeral head and the acromion. Although there is no single gold standard treatment, the variety of surgical techniques allows patients and surgeons to effectively manage these challenging situations.
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Affiliation(s)
- Matthew D Smith
- Department of Orthopaedic Surgery, University of Texas Health Science Center Houston, Houston, Texas, U.S.A..
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Robert U Hartzler
- Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A.; TSAOG Orthopaedics, San Antonio, Texas, San Antonio, Texas, U.S.A
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DeFoor MT, Cognetti DJ, Bedi A, Carmack DB, Arner JW, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ. Patient Resilience Does Not Conclusively Affect Clinical Outcomes Associated With Arthroscopic Surgery but Substantial Limitations of the Literature Exist. Arthrosc Sports Med Rehabil 2024; 6:100812. [PMID: 38379604 PMCID: PMC10877194 DOI: 10.1016/j.asmr.2023.100812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/13/2023] [Indexed: 02/22/2024] Open
Abstract
Purpose To determine whether low resilience is predictive of worse patient-reported outcomes (PROs) or diminished improvements in clinical outcomes after joint preserving and arthroscopic surgery. Methods A comprehensive search of PubMed, Medline, Embase, and Science Direct was performed on September 28, 2022, for studies investigating the relationship between resilience and PROs after arthroscopic surgery in accordance with the Preferred Reported Items for Systematic Reviews and Meta-analyses guidelines. Results Nine articles (level II-IV studies) were included in the final analysis. A total of 887 patients (54% male, average age 45 years) underwent arthroscopic surgery, including general knee (n = 3 studies), ACLR-only knee (n = 1 study), rotator cuff repair (n = 4 studies), and hip (n = 1 study). The Brief Resilience Scale was the most common instrument measuring resilience in 7 of 9 studies (78%). Five of 9 studies (56%) stratified patients based on high, normal, or low resilience cohorts, and these stratification threshold values differed between studies. Only 4 of 9 studies (44%) measured PROs both before and after surgery. Three of 9 studies (33%) reported rates of return to activity, with 2 studies (22%) noting high resilience to be associated with a higher likelihood of return to sport/duty, specifically after knee arthroscopy. However, significant associations between resilience and functional outcomes were not consistently observed, nor was resilience consistently observed to be predictive of subjects' capacity to return to a preinjury level of function. Conclusions Patient resilience is inconsistently demonstrated to affect clinical outcomes associated with joint preserving and arthroscopic surgery. However, substantial limitations in the existing literature including underpowered sample sizes, lack of standardization in stratifying patients based on pretreatment resilience, and inconsistent collection of PROs throughout the continuum of care, diminish the strength of most conclusions that have been drawn. Level of Evidence Level IV, systematic review of level II-IV studies.
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Affiliation(s)
| | | | - Asheesh Bedi
- NorthShore University Health System, Skokie, Illinois
| | | | - Justin W. Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Nuelle CW, Gelber PE, Waterman BR. Osteochondral Allograft Transplantation in the Knee. Arthroscopy 2024; 40:663-665. [PMID: 38388104 DOI: 10.1016/j.arthro.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/05/2024] [Indexed: 02/24/2024]
Abstract
Osteochondral injuries of the knee can be a frequent source of debilitating pain and dysfunction. Significant chondral (>1.5-2 cm2) lesions of the femoral condyles can be especially difficult to manage with nonsurgical measures. Fresh osteochondral allograft (OCA) transplantation has been shown to be a reliable surgical procedure to manage a wide array of high-grade focal chondral lesions, with or without subchondral bone involvement. OCA transplantation affords the transfer of a size-matched allograft of mature hyaline cartilage with its associated subchondral bony scaffold. Indications include primary or secondary management of large, high-grade chondral or osteochondral defects secondary to trauma, developmental malformation, osteonecrosis, or other focal degenerative disease. Contraindications include end-stage osteoarthritis, uncorrected malalignment, ligament or meniscus deficiency, and inflammatory joint disease. Improvements in surgical technique, allograft storage, and tissue availability have created more reproducible clinical results and increased chondrocyte viability. Long-term (>10 year) graft survival rates have been shown to be between 70% and 91%, and the procedure has been shown to be cost-effective based on cost per quality-adjusted life year. Finally, OCA transplantation has been shown to provide excellent return to play rate for athletes with medium-to-large cartilage lesions. OCA transplantation is therefore an important option in the treatment algorithm of articular cartilage injuries.
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Affiliation(s)
| | - Pablo E Gelber
- ReSport Clinic, Hospital de la Santa Creu, i Sant Pau, Barcelona, Spain
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Nuelle CW, Rucinski K, Stannard JP, Ma R, Kfuri M, Cook JL. Comparison of Outcomes After Primary Versus Salvage Osteochondral Allograft Transplantation for Femoral Condyle Osteochondritis Dissecans Lesions. Orthop J Sports Med 2024; 12:23259671241232431. [PMID: 38465259 PMCID: PMC10921854 DOI: 10.1177/23259671241232431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/06/2023] [Indexed: 03/12/2024] Open
Abstract
Background Osteochondral allograft transplantation (OCAT) allows the restoration of femoral condyle osteochondritis dissecans (OCD) lesions using an osteochondral unit. When OCD lesions are irreparable, or treatments have failed, OCAT is an appropriate approach for revision or salvage surgery. Based on its relative availability, cost-effectiveness, lack of donor site morbidity, and advances in preservation methods, OCAT is also an attractive option for primary surgical treatment for femoral condyle OCD. Hypothesis OCAT for large femoral condyle OCD lesions would be highly successful (>90%) based on significant improvements in knee pain and function, with no significant differences between primary and salvage procedure outcomes. Study Design Cohort study; Level of evidence, 3. Methods Patients were enrolled into a registry for assessing outcomes after OCAT. Those patients who underwent OCAT for femoral condyle OCD and had a minimum of 2-year follow-up were included. Reoperations, treatment failures, and patient-reported outcomes were compared between primary and salvage OCAT cohorts. Results A total of 22 consecutive patients were included for analysis, with none lost to the 2-year follow-up (mean, 40.3 months; range, 24-82 months). OCD lesions of the medial femoral condyle (n = 17), lateral femoral condyle (n = 4), or both condyles (n = 1) were analyzed. The mean patient age was 25.3 years (range, 12-50 years), and the mean body mass index was 25.2 kg/m2 (range, 17-42 kg/m2). No statistically significant differences were observed between the primary (n = 11) and salvage (n = 11) OCAT cohorts in patient and surgical characteristics. Also, 91% of patients had successful outcomes at a mean of >3 years after OCAT with 1 revision in the primary OCAT cohort and 1 conversion to total knee arthroplasty in the salvage OCAT cohort. For both primary and salvage OCATs, patient-reported measures of pain and function significantly improved at the 1-year and final follow-up, and >90% of patients reported that they were satisfied and would choose OCAT again for treatment. Conclusion Based on the low treatment failure rates in conjunction with statistically significant and clinically meaningful improvements in patient-reported outcomes, OCAT can be considered an appropriate option for both primary and salvage surgical treatment in patients with irreparable OCD lesions of the femoral condyles.
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Affiliation(s)
- Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Kylee Rucinski
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Medicine, University of Missouri, Columbia, Missouri, USA
| | - James P. Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Medicine, University of Missouri, Columbia, Missouri, USA
| | - Richard Ma
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, USA
- Thompson Laboratory for Regenerative Medicine, University of Missouri, Columbia, Missouri, USA
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Sheean AJ, DeFoor MT, Spindler KP, Arner JW, Athiviraham A, Bedi A, DeFroda S, Ernat JJ, Frangiamore SJ, Nuelle CW, Sheean AJ, Spindler KP, Bedi A. The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions. Sports Health 2024:19417381241226896. [PMID: 38374636 DOI: 10.1177/19417381241226896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024] Open
Abstract
CONTEXT Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed. EVIDENCE ACQUISITION Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR. CONCLUSION The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes. STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT) B.
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Affiliation(s)
| | | | | | - Justin W Arner
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Asheesh Bedi
- NorthShore University Health System, Skokie, Illinois
| | | | | | | | | | | | | | - Asheesh Bedi
- NorthShore University Health System, Skokie, Illinois
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Hurley ET, Sherman SL, Chahla J, Gursoy S, Alaia MJ, Tanaka MJ, Pace JL, Jazrawi LM, Hughes AJ, Arendt EA, Ayeni OR, Bassett AJ, Bonner KF, Camp CL, Campbell KA, Carter CW, Ciccotti MG, Cosgarea AJ, Dejour D, Edgar CM, Erickson BJ, Espregueira-Mendes J, Farr J, Farrow LD, Frank RM, Freedman KB, Fulkerson JP, Getgood A, Gomoll AH, Grant JA, Gwathmey FW, Haddad FS, Hiemstra LA, Hinckel BB, Savage-Elliott I, Koh JL, Krych AJ, LaPrade RF, Li ZI, Logan CA, Gonzalez-Lomas G, Mannino BJ, Lind M, Matache BA, Matzkin E, Mandelbaum B, McCarthy TF, Mulcahey M, Musahl V, Neyret P, Nuelle CW, Oussedik S, Verdonk P, Rodeo SA, Rowan FE, Salzler MJ, Schottel PC, Shannon FJ, Sheean AJ, Strickland SM, Waterman BR, Wittstein JR, Zacchilli M, Zaffagnini S. A modified Delphi consensus statement on patellar instability: part II. Bone Joint J 2023; 105-B:1265-1270. [PMID: 38035602 DOI: 10.1302/0301-620x.105b12.bjj-2023-0110.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The aim of this study was to establish consensus statements on medial patellofemoral ligament (MPFL) reconstruction, anteromedialization tibial tubercle osteotomy, trochleoplasty, and rehabilitation and return to sporting activity in patients with patellar instability, using the modified Delphi process. Methods This was the second part of a study dealing with these aspects of management in these patients. As in part I, a total of 60 surgeons from 11 countries contributed to the development of consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered unanimous. Results Of 41 questions and statements on patellar instability, none achieved unanimous consensus, 19 achieved strong consensus, 15 achieved consensus, and seven did not achieve consensus. Conclusion Most statements reached some degree of consensus, without any achieving unanimous consensus. There was no consensus on the use of anchors in MPFL reconstruction, and the order of fixation of the graft (patella first versus femur first). There was also no consensus on the indications for trochleoplasty or its effect on the viability of the cartilage after elevation of the osteochondral flap. There was also no consensus on postoperative immobilization or weightbearing, or whether paediatric patients should avoid an early return to sport.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | - Jorge Chahla
- Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Safa Gursoy
- Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Michael J Alaia
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
| | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J L Pace
- Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | | | - Christopher L Camp
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - David Dejour
- Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Cory M Edgar
- Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | | | - João Espregueira-Mendes
- Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal
| | - Jack Farr
- OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA
| | - Lutul D Farrow
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Andreas H Gomoll
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - John A Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - F W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jason L Koh
- NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Catherine A Logan
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Brian J Mannino
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Martin Lind
- Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Bogdan A Matache
- Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bert Mandelbaum
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | | | - Mary Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Tulane University, New Orleans, Louisiana, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Sam Oussedik
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium
| | - Scott A Rodeo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Fiachra E Rowan
- Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland
| | - Matthew J Salzler
- Department of Orthopedics, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Patrick C Schottel
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Fintan J Shannon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | | | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Jocelyn R Wittstein
- Department of Orthopaedic Surgery, Duke University Hospital, Durham, North Carolina, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Hurley ET, Hughes AJ, Savage-Elliott I, Dejour D, Campbell KA, Mulcahey MK, Wittstein JR, Jazrawi LM, Alaia MJ, Arendt EA, Ayeni OR, Bassett AJ, Bonner KF, Camp CL, Carter CW, Chahla J, Ciccotti MG, Cosgarea AJ, Edgar CM, Erickson BJ, Espregueira-Mendes J, Farr J, Farrow LD, Frank RM, Freedman KB, Fulkerson JP, Getgood A, Gomoll AH, Grant JA, Gursoy S, Gwathmey FW, Haddad FS, Hiemstra LA, Hinckel BB, Koh JL, Krych AJ, LaPrade RF, Li ZI, Logan CA, Gonzalez-Lomas G, Mannino BJ, Lind M, Matache BA, Matzkin E, McCarthy TF, Mandelbaum B, Musahl V, Neyret P, Nuelle CW, Oussedik S, Pace JL, Verdonk P, Rodeo SA, Rowan FE, Salzler MJ, Schottel PC, Shannon FJ, Sheean AJ, Sherman SL, Strickland SM, Tanaka MJ, Waterman BR, Zacchilli M, Zaffagnini S. A modified Delphi consensus statement on patellar instability: part I. Bone Joint J 2023; 105-B:1259-1264. [PMID: 38037678 DOI: 10.1302/0301-620x.105b12.bjj-2023-0109.r1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. Methods A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous. Results Of 27 questions and statements on patellar instability, three achieved unanimous consensus, 14 achieved strong consensus, five achieved consensus, and five did not achieve consensus. Conclusion The statements that reached unanimous consensus were that an assessment of physeal status is critical for paediatric patients with patellar instability. There was also unanimous consensus on early mobilization and resistance training following nonoperative management once there is no apprehension. The statements that did not achieve consensus were on the importance of immobilization of the knee, the use of orthobiologics in nonoperative management, the indications for MPFC repair, and whether a vastus medialis oblique advancement should be performed.
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Affiliation(s)
- Eoghan T Hurley
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Andrew J Hughes
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Ian Savage-Elliott
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - David Dejour
- Orthopaedic Department, Lyon-Ortho-Clinic, Clinique de La Sauvegarde, Lyon, France
| | - Kirk A Campbell
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, School of Medicine, Loyola University, Chicago, Illinois, USA
| | - Jocelyn R Wittstein
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Laith M Jazrawi
- Department of Orthopedic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Elizabeth A Arendt
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Canada
| | - Ashley J Bassett
- The Orthopedic Institute of New Jersey, Morristown, New Jersey, USA
| | | | - Christopher L Camp
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Cordelia W Carter
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Jorge Chahla
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - Michael G Ciccotti
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - Andrew J Cosgarea
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Cory M Edgar
- Department of Orthopedics, University of Connecticut Health Center, Farmington, Connecticut, USA
| | | | - João Espregueira-Mendes
- Dom Research Center, Clinica Espregueira Mendes, FIFA Medical Centre of Excellence, Porto, Portugal
| | - Jack Farr
- OrthoIndy Knee Preservation and Cartilage Restoration Center, Indianapolis, Indiana, USA
| | - Lutul D Farrow
- Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA
| | - Rachel M Frank
- Department of Orthopaedic Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute at Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
| | - John P Fulkerson
- Department of Orthopaedic Surgery and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, Western University, London, Canada
| | - Andreas H Gomoll
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - John A Grant
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Safa Gursoy
- Division of Sports Medicine, Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, USA
| | - F W Gwathmey
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London, UK
| | | | - Betina B Hinckel
- Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA
| | - Jason L Koh
- NorthShore Orthopaedic Institute, NorthShore University Health System, Evanston, Illinois, USA
| | - Aaron J Krych
- Department of Orthopaedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Zachary I Li
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Catherine A Logan
- Center for Regenerative Sports Medicine, Steadman Philippon Research Institute, Vail, Colorado, USA
| | | | - Brian J Mannino
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
| | - Martin Lind
- Department of Sports Traumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Bogdan A Matache
- Division of Orthopaedic Surgery, Department of Surgery, Laval University, Quebec, Canada
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Bert Mandelbaum
- Cedars-Sinai Kerlan-Jobe Institute, Los Angeles, California, USA
| | - Volker Musahl
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Philippe Neyret
- Department of Orthopaedic Surgery, Centre Albert-Trillat, Hôpital de La Croix-Rousse, Lyon, France
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri, USA
| | - Sam Oussedik
- University College London Hospitals NHS Foundation Trust, London, UK
| | - J L Pace
- Children's Health Andrews Institute for Orthopaedics and Sports Medicine, Plano, Texas, USA
| | - Peter Verdonk
- Antwerp Orthopaedic Center, AZ Monica Hospitals, Antwerp, Belgium
| | - Scott A Rodeo
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, USA
| | - Fiachra E Rowan
- Department of Trauma & Orthopaedic Surgery, University Hospital Waterford, Waterford, Ireland
| | - Matthew J Salzler
- Department of Orthopedics, Tufts University School of Medicine, Boston, USA
| | - Patrick C Schottel
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, Burlington, Vermont, USA
| | - Fintan J Shannon
- Department of Trauma and Orthopaedics, Galway University Hospitals, Galway, Ireland
| | - Andrew J Sheean
- San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, Stanford University, Stanford, California, USA
| | | | - Miho J Tanaka
- Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian R Waterman
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | | | - Stefano Zaffagnini
- IIa Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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9
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Kelly SR, Stannard JT, Reddy J, Cook JL, Stannard JP, Nuelle CW. Meniscus Allograft Transplantation With Bone Plugs Using Knotless All-Suture Anchors and Cortical Button Suspensory Fixation. Arthrosc Tech 2023; 12:e1707-e1714. [PMID: 37942117 PMCID: PMC10627850 DOI: 10.1016/j.eats.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 11/10/2023] Open
Abstract
Meniscus allograft transplantation can be successful for treatment of meniscal deficiency using a number of transplant techniques. In this Technical Note, we describe a double bone plug medial meniscus allograft transplantation technique that uses knotless all-suture anchors with cortical-button suspensory fixation. This technique maintains the reported advantages for bone-plug fixation while mitigating the risk for meniscal root damage, facilitating easier bone plug insertion and seating, expanding tensioning capabilities, and preventing soft-tissue irritation from suture knot stacks.
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Affiliation(s)
- Shayne R. Kelly
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - James T. Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Jahnu Reddy
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - James L. Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - James P. Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
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10
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Kelly SR, Mustafa L, Al-Kharabsheh Y, DeFroda SF, Nuelle CW. All-Arthroscopic Bone Grafting and Primary Fixation of a Medial Femoral Condyle Osteochondritis Dissecans Lesion. Arthrosc Tech 2023; 12:e1721-e1725. [PMID: 37942112 PMCID: PMC10627890 DOI: 10.1016/j.eats.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/28/2023] [Indexed: 11/10/2023] Open
Abstract
Treatment of osteochondritis dissecans (OCD) lesions poses a significant challenge for orthopaedic surgeons and can cause debilitating limitations on the activity of patients. Timing of intervention, surgical technique, and selection of graft when needed are all key elements of treatment that need to be considered carefully and discussed with patients. Primary fixation of an OCD fragment with intact subchondral bone has been shown to be beneficial in some cases. There is limited literature, however, on how to approach large chondral lesions in young patients without a large subchondral base attached to the fragment. Treatment of large OCD lesions of the knee with an all-arthroscopic approach provides several benefits, including limited dissection for exposure, improved ability to assess the stability of the OCD lesion during articulation after fixation, and an expedited recovery compared to an open approach. The purpose of this technical note is to detail a technique of performing an all-arthroscopic bone grafting and primary fixation of a medial femoral condyle OCD lesion.
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Affiliation(s)
- Shayne R. Kelly
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Luai Mustafa
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | | | - Steven F. DeFroda
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
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11
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Oladeji LO, Reynolds G, Nuelle CW, DeFroda SF. Securing the Root: Meniscus Root Repair with Rip Stop and Cannulated Drilling. Arthrosc Tech 2023; 12:e1665-e1672. [PMID: 37942109 PMCID: PMC10627872 DOI: 10.1016/j.eats.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/27/2023] [Indexed: 11/10/2023] Open
Abstract
Meniscal root pathology has garnered increased attention over the past decade. Meniscal root tears are considered to essentially represent a meniscus-deficient state, which has led to a rise in the surgical fixation of this pathology. Meniscus root tears are classified as either radial tears within 1 cm of the root insertion, or a direct avulsion of meniscal root. These injuries are important to recognize because they contribute to impaired joint mechanics and rapid articular cartilage degeneration. Given this, there remains significant interest in identifying novel surgical techniques that may facilitate better surgical repair and enhance patient outcomes. The purpose of this technical note is to describe a surgical technique for a medial meniscus root ripstop repair with cannulated drilling. This technique is simple and reproducible, while also allowing for the augmentation of potentially poor tissue quality.
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Affiliation(s)
- Lasun O. Oladeji
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri, USA
| | - Grace Reynolds
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri, USA
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri, USA
| | - Steven F. DeFroda
- Department of Orthopaedic Surgery, University of Missouri Columbia, Columbia, Missouri, USA
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12
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Kelly S, DeFroda S, Nuelle CW. Arthroscopic Assisted Anterior Cruciate Ligament Tibial Spine Avulsion Reduction and Cortical Button Fixation. Arthrosc Tech 2023; 12:e1033-e1038. [PMID: 37533906 PMCID: PMC10390881 DOI: 10.1016/j.eats.2023.02.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/19/2023] [Indexed: 08/04/2023] Open
Abstract
Tibial spine avulsion fractures, or tibial eminence fractures, are intra-articular knee injuries that affect the bony attachment of the anterior cruciate ligament (ACL). It is commonly seen in children and adolescents aged 8 to 15 years old and can be caused by noncontact pivot shift injuries or by traumatic hyperextension knee injuries, as seen in adult ACL patients. A thorough history and physical exam is important in these patients alongside proper imaging that will confirm the diagnosis of a tibial spine avulsion. Proper imaging may also demonstrate other associated conditions or injuries to the cartilage, meniscus, or ligamentous structures. Following diagnosis, treatment can be both nonoperative versus operative, depending upon the degree of displacement and reducibility of the fragment, as well as other concomitant injuries. For nondisplaced or minimally displaced, and reducible injuries, the patient can be immobilized in full extension for several weeks. For displaced fragments that are unable to be reduced by closed methods, open reduction internal fixation or arthroscopic fixation is recommended. In this Technical Note, we describe an arthroscopy-assisted reduction and internal fixation with suture tape through 2 transtibial tunnels with a cortical suture button fixation technique.
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Affiliation(s)
| | | | - Clayton W. Nuelle
- Address correspondence to Clayton W. Nuelle, M.D., Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, 1100 Virginia Ave., Columbia, MO 65212, U.S.A.
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13
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Nuelle CW, Shubert D, Leary E, Pringle LC. Two-Dimensional Magnetic Resonance Imaging in Preparation for Autograft Anterior Cruciate Ligament Reconstruction Demonstrates Quadriceps Tendon Is Thicker Than Patellar Tendon. Arthrosc Sports Med Rehabil 2023; 5:e783-e791. [PMID: 37388871 PMCID: PMC10300585 DOI: 10.1016/j.asmr.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/13/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose The purpose of this study was to assess patellar tendon (PT) and quadriceps tendon (QT) thickness on preoperative magnetic resonance imaging (MRI), in both the sagittal and axial planes, at multiple points along each tendon, and to correlate these findings to anthropometric patient data before anterior cruciate ligament (ACL) surgery. Methods Patients who underwent PT or QT autograft ACL reconstruction between 2020 and 2022 and who had preoperative MRIs with adequate visualization of the proximal QT and distal PT were retrospectively identified. Patient demographics were recorded (age, height, weight, sex, injury side). Preoperative MRI measurements were performed by 3 independent examiners using standardized protocol. Preoperative MRI measurements were the QT anterior-posterior (AP) thickness at 1, 2, and 4 cm from the proximal patella on axial and sagittal MRI images at the central aspect of the tendon, as well as PT AP thickness at 1, 2, and 4 cm from the distal patella on axial and sagittal MRI images at the central aspect of the tendon. Results Forty-one patients (21 females, 20 males) were evaluated, with a mean age of 33.4 years. The quadriceps tendon was significantly thicker than the patellar tendon at all measured locations (P < .0001) with average QT versus PT thickness (in mm) at each level sagittal 1 cm (7.13 vs 4.35), sagittal 2 cm (7.41 vs 4.44), sagittal 4 cm (7.26 vs 4.81), axial 1 cm (7.35 vs 4.50), axial 2 cm (7.63 vs 4.47), axial 4 cm (7.46 vs 4.62), respectively. There were no significant correlations between tendon size and patient body mass index. Conclusions The quadriceps tendon is significantly thicker than the patellar tendon at 1, 2, and 4 cm from the patella in both males and females based on preoperative MRI before ACL surgery. Clinical relevance Investigating the thickness of the tendons available for autograft harvest before surgery will give us a better understanding of tendon anatomy in the setting of ACL reconstruction.
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Affiliation(s)
- Clayton W. Nuelle
- University of Missouri Hospitals, Columbia, Missouri
- Mizzou Joint Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
| | | | - Emily Leary
- University of Missouri Hospitals, Columbia, Missouri
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14
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Temperato J, Ewing M, Nuelle CW. Lateral Extra-articular Tenodesis with Iliotibial Band Using Knotless All-Suture Anchor Femoral Fixation. Arthrosc Tech 2023; 12:e677-e682. [PMID: 37323783 PMCID: PMC10265525 DOI: 10.1016/j.eats.2023.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/18/2023] [Indexed: 06/17/2023] Open
Abstract
Common injuries, such as anterior cruciate ligament (ACL) tears, can result in both anterior and rotational instability of the knee. An arthroscopic anterior cruciate ligament reconstruction (ACLR) method has been shown to be effective in restoring anterior translational stability, but this could be followed by persistent rotational instability by means of residual pivot shifts or repeat instability episodes. Alternative techniques, such as a lateral extraarticular tenodesis (LET), has been proposed as a technique for preventing persistent rotational instability following ACLR. This article presents a case of a LET using an autologous central slip of iliotibial (IT) band with fixation to the femur using a 1.8-mm knotless all-suture anchor.
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Affiliation(s)
- Joseph Temperato
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Michael Ewing
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
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15
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Nuelle CW, Ohnoutka CJ, Oladeji LO, Ewing MA, Nuelle JA, Pringle LK. Primary Repair of Peroneus Longus Myofascial Herniation With Symptomatic Superficial Peroneal Nerve Compression. Arthrosc Tech 2023; 12:e459-e463. [PMID: 37138688 PMCID: PMC10149782 DOI: 10.1016/j.eats.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/10/2022] [Indexed: 05/05/2023] Open
Abstract
Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect.
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Affiliation(s)
- Clayton W. Nuelle
- Departments of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri
- Address correspondence to Robert Clayton Nuelle, M.D., Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics University of Missouri, 1100 Virginia Ave., Columbia, MO 65212.
| | - Cole J. Ohnoutka
- Department of Orthopaedic Surgery, University of Nebraska Medica Center, Omaha, Nebraska, U.S.A
| | - Lasun O. Oladeji
- Departments of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri
| | - Michael A. Ewing
- Departments of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri
| | - Julia A.V. Nuelle
- Departments of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri
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16
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Abstract
Anterior cruciate ligament (ACL) reconstruction is one of the most commonly performed knee operations. An "all-inside" technique creates bone sockets for ACL graft passage, as opposed to more traditional full bone tunnels, and typically incorporates suspensory fixation instead of screw fixation to secure the graft. This technique may be indicated for any ACL reconstruction surgery, where adequate bone stock exists to drill sockets and to use cortical fixation. The technique may be used with all soft tissue, as well as bone plug ACL grafts and autograft hamstring or quadriceps tendon; most allograft tendon options may be performed with an all-inside technique. Advantages include anatomic tunnel/socket placement, decreased postoperative pain and swelling, minimal hardware, appropriate graft tensioning and retensioning, and circumferential graft to bone healing. Tips for successful all-inside surgery include matching graft diameter to socket diameter, drilling appropriate length sockets based on individual graft length, so as not to "bottom out" the graft and confirming cortical button fixation intraoperatively. Potential complications include graft-socket mismatch, full-tunnel reaming, and loss of cortical fixation. Multiple studies have shown the all-inside technique to have similar or superior biomechanical properties and clinical outcomes compared to the more traditional full-tunnel ACL reconstruction techniques.
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Affiliation(s)
| | | | - Harris S Slone
- Medical University of South Carolina, Charleston, South Carolina, U.S.A
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17
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Shubert D, DeFroda S, Nuelle CW. Concurrent Needle and Standard Arthroscopy for Posterior Cruciate Ligament Reconstruction. Arthrosc Tech 2022; 11:e1335-e1340. [PMID: 35936863 PMCID: PMC9353534 DOI: 10.1016/j.eats.2022.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/10/2022] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic posterior cruciate ligament (PCL) reconstruction is a technically demanding procedure, particularly with respect to tibial footprint debridement and tibial tunnel placement, where iatrogenic damage to anatomic structures is a well reported complication and incorrect tunnel placement can have functional implications. Preparation of the tibial component often involves switching between 30° and 70° arthroscopes and frequent portal swapping and reorientation, which can be inefficient and time-consuming. As the technology and picture resolution of needle arthroscopy has improved, its clinical application has widened. This manuscript describes the use of needle arthroscopy-assisted arthroscopic PCL reconstruction for optimal visualization of the PCL tibial footprint using an accessory posterolateral portal, while obviating the need of both 30° and 70° arthroscopes.
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Affiliation(s)
- Daniel Shubert
- Department of Orthopaedic Surgery, Columbia, Missouri, U.S.A
| | - Steven DeFroda
- Department of Orthopaedic Surgery, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, Columbia, Missouri, U.S.A
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
- Address correspondence to Clayton Nuelle, M.D., Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, 1100 Virginia Ave., Columbia, MO 65212.
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18
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Temperato J, Nuelle CW. Tibial Tubercle Osteotomy With Anteriorization and Distalization for Treatment of Patellar Instability With Patella Alta. Arthrosc Tech 2022; 11:e1045-e1051. [PMID: 35782840 PMCID: PMC9244642 DOI: 10.1016/j.eats.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/06/2022] [Indexed: 02/03/2023] Open
Abstract
Patellofemoral instability is a common cause of knee pain that can lead to long-standing pain, chondral injury, recurrent dislocations, and degenerative changes if not treated appropriately. Tibial tubercle osteotomy is indicated when there is anatomy predisposing to patellar maltracking and instability, namely abnormal patellar height or tibial tubercle location. In this Technical Note, we describe a technique for tibial tubercle anteriorization and distalization as part of the overall treatment algorithm for patellar instability with associated patella alta. This method of tibial tubercle osteotomy reliably produces anterior and distal translation of the patella to correct patellar height and decrease contact pressure across the patellofemoral joint.
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Affiliation(s)
- Joseph Temperato
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A.,Address correspondence to Clayton W.Nuelle, M.D., Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, 1100 Virginia Ave, Columbia, MO 65212, U.S.A.
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19
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Phillips R, Choo S, Nuelle CW. Bracing for the Patellofemoral Joint. J Knee Surg 2022; 35:232-241. [PMID: 35088399 DOI: 10.1055/s-0041-1741429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellofemoral disorders are common causes of knee pain that result in frequent visitations to musculoskeletal care clinics. Patellar tendinopathy, patellar instability and patellar maltracking, and pain are some of the most common pathologies resulting in patellofemoral dysfunction. For each of these diagnoses, there are unique orthoses and braces available, some of which are uniquely designed to address the pathology involved. While the spectrum of patellofemoral disorders is wide ranging and can often be challenging to treat, bracing frequently plays a large role in the overall treatment algorithm. In this article, we summarized the current literature and treatment recommendations related to the most common types of patellar braces. We performed a thorough review of randomized controlled trials and up to date literature to reach well-informed conclusions on current best practice regarding the uses of patellar braces for patellofemoral disorders.
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Affiliation(s)
- Rachel Phillips
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Stephanie Choo
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
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20
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Blecha K, Nuelle CW, Smith PA, Stannard JP, Ma R. Efficacy of Prophylactic Knee Bracing in Sports. J Knee Surg 2022; 35:242-248. [PMID: 34952553 DOI: 10.1055/s-0041-1740930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are common knee injuries, which can result from contact and noncontact during sports, recreation, or work-related activities. Prophylactic knee braces (PKBs) have been designed to protect the knee and decrease risk of recurrence of these injuries. Despite their success, PKBs have not been proven to be consistently effective and cost of the device must be evaluated to optimize its use in sports, particularly American football. Biomechanical studies have suggested that increased hip and knee flexion angles may reduce frontal plane loading with bracing which can protect the knee joint. This is essential with knee loading and rotational moments because they are associated with jumping, landing, and pivoting movements. The clinical efficacy of wearing PKBs can have an impact on athletic performance with respect to speed, power, motion, and agility, and these limitations are evident in athletes who are unaccustomed to wearing a PKB. Despite these concerns, use of PKBs increases in patients who have sustained an MCL injury or recovering from an ACL reconstruction surgery. As the evidence continues to evolve in sports medicine, there is limited definitive data to determine their beneficial or detrimental effects on overall injury risk of athletes, therefore leading those recommendations and decisions for their usage in the hands of the athletic trainers and team physicians' experience to determine the specific brace design, brand, fit, and situations for use.
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Affiliation(s)
- Kyle Blecha
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri
| | - Patrick A Smith
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Columbia Orthopedic Group, Columbia, Missouri
| | - James P Stannard
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri.,Department of Orthopedic Surgery, Thompson Laboratory of Orthopedic Institute, University of Missouri, Columbia, Missouri
| | - Richard Ma
- Department of Orthopedic Surgery, University of Missouri, Columbia, Missouri
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21
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Worley JR, Brimmo O, Nuelle CW, Zitsch BP, Leary EV, Cook JL, Stannard JP. Revision Anterior Cruciate Ligament Reconstruction after Surgical Management of Multiligament Knee Injury. J Knee Surg 2022; 35:72-77. [PMID: 32544974 DOI: 10.1055/s-0040-1712969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study is to determine factors associated with the need for revision anterior cruciate ligament reconstruction (ACLR) after multiligament knee injury (MLKI) and to report outcomes for patients undergoing revision ACLR after MLKI. This involves a retrospective review of 231 MLKIs in 225 patients treated over a 12-year period, with institutional review board approval. Patients with two or more injured knee ligaments requiring surgical reconstruction, including the ACL, were included for analyses. Overall, 231 knees with MLKIs underwent ACLR, with 10% (n = 24) requiring revision ACLR. There were no significant differences in age, sex, tobacco use, diabetes, or body mass index between cohorts requiring or not requiring revision ACLR. However, patients requiring revision ACLR had significantly longer follow-up duration (55.1 vs. 37.4 months, p = 0.004), more ligament reconstructions/repairs (mean 3.0 vs. 1.7, p < 0.001), more nonligament surgeries (mean 2.2 vs. 0.7, p = 0.002), more total surgeries (mean 5.3 vs. 2.4, p < 0.001), and more graft reconstructions (mean 4.7 vs. 2.7, p < 0.001). Patients in both groups had similar return to work (p = 0.12) and activity (p = 0.91) levels at final follow-up. Patients who had revision ACLR took significantly longer to return to work at their highest level (18 vs. 12 months, p = 0.036), but similar time to return to their highest level of activity (p = 0.33). Range of motion (134 vs. 127 degrees, p = 0.14), pain severity (2.2 vs. 1.7, p = 0.24), and Lysholm's scores (86.3 vs. 90.0, p = 0.24) at final follow-up were similar between groups. Patients requiring revision ACLR in the setting of a MLKI had more overall concurrent surgeries and other ligament reconstructions, but had similar final outcome scores to those who did not require revision surgery. Revision ligament surgery can be associated with increased pain, stiffness, and decrease patient outcomes. Revision surgery is often necessary after multiligament knee reconstructions, but patients requiring ACLR in the setting of a MLKI have good overall outcomes, with patients requiring revision ACLR at a rate of 10%.
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Affiliation(s)
- John R Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Olubusola Brimmo
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopaedics, TSAOG Orthopaedics, San Antonio, Texas.,Department of Orthopaedics, Burkhart Research Institute for Orthopaedics, San Antonio, Texas
| | | | - Emily V Leary
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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22
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Goldenberg NB, Nuelle CW. Knotless Suture Anchor Fixation of a Traumatic Osteochondral Lesion of the Lateral Femoral Condyle. Arthrosc Tech 2021; 10:e2547-e2551. [PMID: 34868860 PMCID: PMC8626706 DOI: 10.1016/j.eats.2021.07.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/27/2021] [Indexed: 02/03/2023] Open
Abstract
Osteochondral injuries commonly occur after lateral patellar instability events. Recognition and early intervention of displaced fragments is key to maintaining the viability of the fragment and congruency of the articular surface. Multiple fixation techniques exist for achieving stable fixation of displaced osteochondral lesions, including metal or bioabsorbable screws and all suture techniques. In this Technical Note, we describe a technique for internal fixation of a displaced osteochondral fragment of the lateral femoral condyle using knotless suture anchors. This technique affords minimally invasive restoration of the native anatomy with excellent stability of the fracture fragment, allowing early range of motion and ambulation.
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Affiliation(s)
- Neal B. Goldenberg
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
- Address correspondence to Neal B. Goldenberg, M.D., Department of Orthopedic Surgery, Cheshire Medical Center/ Dartmouth-Hitchcock Keene, 580 Court Street, Keene, NH 03431, U.S.A.
| | - Clayton W. Nuelle
- San Antonio Orthopedic Group (TSAOG) and Burkhart Research Institute for Orthopedics, San Antonio, Texas, U.S.A
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23
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Abstract
Posterior cruciate ligament (PCL) injuries are often encountered in the setting of other knee pathology and sometimes in isolation. A thorough understanding of the native PCL anatomy is crucial in the successful treatment of these injuries. The PCL consists of two independent bundles that function in a codominant relationship to perform the primary role of resisting posterior tibial translation relative to the femur. A secondary role of the PCL is to provide rotatory stability. The anterolateral (AL) bundle has a more vertical orientation when compared with the posteromedial (PM) bundle. The AL bundle has a more anterior origin than the PM bundle on the lateral wall of the medial femoral condyle. The tibial insertion of AL bundle on the PCL facet is medial and anterior to the PM bundle. The AL and PM bundles are 12-mm apart at the center of the femoral origins, while the tibial insertions are more tightly grouped. The different spatial orientation of the two bundles and large distance between the femoral centers is responsible for the codominance of the PCL bundles. The AL bundle is the dominant restraint to posterior tibial translation throughout midrange flexion, while the PM bundle is the primary restraint in extension and deep flexion. Biomechanical testing has shown independent reconstruction of the two bundles that better reproduces native knee biomechanics, while significant differences in clinical outcomes remain to be seen. Stress X-rays may play an important role in clinical decision-making process for operative versus nonoperative management of isolated PCL injuries. Strong understanding of PCL anatomy and biomechanics can aid surgical management.
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Affiliation(s)
- Thomas B Lynch
- San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Jorge Chahla
- Rush University Medical Center Midwest Orthopaedics at Rush, Chicago, Illinois
| | - Clayton W Nuelle
- Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
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24
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Patel SP, Nuelle CW, Hartzler RU. Arthroscopic Reduction and Internal Fixation of Proximal Humerus Greater Tuberosity Fracture. Arthrosc Tech 2020; 9:e1363-e1367. [PMID: 33024678 PMCID: PMC7528626 DOI: 10.1016/j.eats.2020.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/25/2020] [Indexed: 02/03/2023] Open
Abstract
Proximal humerus fractures are common fractures that may occur after ground level falls or other traumatic events resulting in a direct injury to the shoulder. Depending on the fracture morphology and the age of the patient, anatomic reduction can vastly improve outcomes, especially in fracture patterns that involve the greater tuberosity. In this case example, we performed a minimally invasive, arthroscopic reduction and fixation of a proximal humerus fracture that involved significant displacement of the greater tuberosity. The technique employed is reproducible and avoids the morbidity of a large open incision while simultaneously providing compression of the fracture fragment for excellent healing potential.
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Affiliation(s)
- Shiv P. Patel
- Baylor College of Medicine-Burkhart Research Institute for Orthopaedics, San Antonio, Texas, U.S.A.,Address correspondence to Dr. Shiv P. Patel, M.D., Baylor College of Medicine-Burkhart Research Institute for Orthopaedics, 1207 Agora Springs Dr., San Antonio, TX 78258.
| | - Clayton W. Nuelle
- Orthopaedic Sports Medicine, Joint Replacement, The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.,Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A
| | - Robert U. Hartzler
- Orthopaedic Sports Medicine, Joint Replacement, The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.,Shoulder & Elbow, The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A.,Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A
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25
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Abstract
Subpectoral biceps tenodesis of the shoulder may be a useful tool that can address a wide range of disorders in the setting of pathology of the long head of the biceps tendon. Primary indications include (1) zone 2 or zone 3 tendon pathology and (2) failed previous proximal tendon tenodesis. Secondary indications include (1) an overhead athlete or thrower, (2) chronic tendinopathy, and (3) surgeon preference. A subpectoral technique allows tendon fixation directly posterior (deep) to the pectoralis tendon high in the bicipital fossa or in the mid fossa or fixation low in the fossa inferior to the pectoralis tendon (infrapectoral). Fixation technique options include an onlay suture anchor, onlay unicortical button, inlay bicortical button, or inlay interference screw. Potential surgical complications include humeral fracture, loss of fixation, tendon pullout or rupture, and neurovascular injury. Regardless of the specific location or technique used, subpectoral tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology.
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Affiliation(s)
| | - Andrew Sheean
- San Antonio Military Medical Center, San Antonio, Texas, U.S.A
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26
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Balldin BC, Nuelle CW, DeBerardino TM. Is Intraoperative Fluoroscopy Necessary to Confirm Device Position for Femoral-Sided Cortical Suspensory Fixation during Anterior Cruciate Ligament Reconstruction? J Knee Surg 2020; 33:265-269. [PMID: 30736051 DOI: 10.1055/s-0039-1678523] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Increased laxity within the graft construct system can lead to graft failure after anterior cruciate ligament (ACL) reconstruction. Suboptimal cortical device positioning could lead to increased laxity within the system, which could influence the mechanics and function of the graft reconstruction. This study evaluates the benefit of intraoperative fluoroscopy to confirm device position on the femur during ACL reconstruction using cortical suspensory fixation. One hundred consecutive patients who underwent soft tissue ACL reconstruction using a suspensory cortical device for femoral fixation were retrospectively evaluated. Patients were split into two groups: Group A utilized anteromedial portal visualization and had intraoperative fluoroscopic imaging performed at the time of ACL graft fixation to confirm femoral device placement on the lateral femoral metaphyseal cortex. Group B utilized anteromedial portal visualization alone. Both groups had radiographic X-rays performed at the first postoperative visit to evaluate device location and all images were independently evaluated by three fellowship trained orthopaedic surgeons. Device position was classified as optimal if there was complete apposition of the entire device against the femoral cortex and suboptimal if it was > 2 mm off the cortex. Fisher's exact test, analysis of variance, and 95% confidence intervals were calculated to compare the groups for statistical significance. The results showed 0/60 (0%) patients in group A had suboptimal device position at postoperative follow-up, while 4/40 (10%) patients in group B had suboptimal device position (p = 0.013). There were no graft failures in group A and one graft failure in group B. There was a significant difference in cortical device position in patients who had intraoperative fluoroscopic imaging versus patients who had no intraoperative imaging. The use of confirmatory intraoperative imaging may be beneficial to confirm appropriate device location when using a femoral cortical suspensory fixation technique for ACL reconstruction.
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Affiliation(s)
- B Christian Balldin
- Department of Orthopaedics, TSAOG Orthopaedics, San Antonio, Texas.,Department of Orthopaedics, Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas
| | - Clayton W Nuelle
- Department of Orthopaedics, TSAOG Orthopaedics, San Antonio, Texas.,Department of Orthopaedics, Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas
| | - Thomas M DeBerardino
- Department of Orthopaedics, TSAOG Orthopaedics, San Antonio, Texas.,Department of Orthopaedics, Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas
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27
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Nuelle CW, Nuelle JA, Balldin BC. Open Reduction Internal Fixation of a Traumatic Osteochondral Lesion of the Patella With Bioabsorbable Screw Fixation. Arthrosc Tech 2019; 8:e1361-e1365. [PMID: 31890508 PMCID: PMC6926324 DOI: 10.1016/j.eats.2019.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 07/17/2019] [Indexed: 02/03/2023] Open
Abstract
Osteochondral injuries of the patella occur often in the setting of traumatic patellar dislocations. Early fixation of the displaced fragment(s) is paramount to maintaining the viability of the articular cartilage and the congruency of the patella. Multiple fixation techniques have been described to ensure stable fixation, including wires, screws, and all-suture techniques with both absorbable and nonabsorbable materials. We performed an open reduction and internal fixation of a large traumatic patellar osteochondral lesion using 3 bioabsorbable compression screws. The technique is straightforward and provides compression across the fragments, affording excellent stability, which allows early range of motion and ambulation.
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Affiliation(s)
- Clayton W. Nuelle
- TSAOG Orthopaedics and the Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A.,Address correspondence to Clayton W. Nuelle, M.D., TSAOG Orthopaedics and the Burkhart Research Institute for Orthopaedics (BRIO), 400 Concord Plaza Dr., Suite 300, San Antonio, TX 78216, U.S.A.
| | | | - B. Christian Balldin
- TSAOG Orthopaedics and the Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A
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28
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Nuelle CW. Editorial Commentary: Biceps Tendon Tenderness… Is It Enough to Guide Surgical Management? Arthroscopy 2019; 35:2001-2002. [PMID: 31272620 DOI: 10.1016/j.arthro.2019.03.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 03/18/2019] [Indexed: 02/02/2023]
Abstract
Pathology of the long head of the biceps tendon is often encountered concurrently with rotator cuff tears. Although both preoperative and intraoperative evaluations may play a role in the decision-making process of when and how to treat the biceps, it can still be a conundrum. The more straightforward tests and reliable evaluation methods we have in our repertoire, the more likely the appropriate treatment choice to address the pathology will be made. The subpectoral biceps test is a helpful examination maneuver as part of the preoperative biceps evaluation.
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29
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Worley JR, Brimmo O, Nuelle CW, Cook JL, Stannard JP. Incidence of Concurrent Peroneal Nerve Injury in Multiligament Knee Injuries and Outcomes after Knee Reconstruction. J Knee Surg 2019; 32:560-564. [PMID: 29898474 DOI: 10.1055/s-0038-1660512] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to determine incidence of concurrent peroneal nerve injury and to compare outcomes in patients with and without peroneal nerve injury after surgical treatment for multiligament knee injuries (MLKIs). A retrospective study of 357 MLKIs was conducted. Patients with two or more knee ligaments requiring surgical reconstruction were included. Mean follow-up was 35 months (0-117). Incidence of concurrent peroneal nerve injury was noted and patients with and without nerve injury were evaluated for outcomes. Concurrent peroneal nerve injury occurred in 68 patients (19%). In patients with nerve injury, 45 (73%) returned to full duty at work; 193 (81%) patients without nerve injury returned to full duty (p = 0.06). In patients with nerve injury, 37 (60%) returned to their previous level of activity; 148 (62%) patients without nerve injury returned to their previous level of activity (p = 0.41). At final follow-up, there were no significant differences in level of pain (mean visual analog scale 1.6 vs. 2; p = 0.17), Lysholm score (mean 88.6 vs. 88.8; p = 0.94), or International Knee Documentation Committee score (mean 46.2 vs. 47.8; p = 0.67) for patients with or without peroneal nerve injury, respectively. Postoperative range of motion (ROM) (mean 121 degrees) was significantly lower (p = 0.02) for patients with nerve injury compared with patients without nerve injury (mean 127 degrees). Concurrent peroneal nerve injury occurred in 19% of patients in this large cohort suffering MLKIs. After knee reconstruction surgery, patients with concurrent peroneal nerve injuries had significantly lower knee ROM and trended toward a lower rate of return to work. However, outcomes with respect to activity level, pain, and function were not significantly different between the two groups. This study contributes to our understanding of patient outcomes in patients with concurrent MLKI and peroneal nerve injury, with a focus on the patient's ability to return to work and sporting activity.
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Affiliation(s)
- John R Worley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Olubusola Brimmo
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- TSAOG Orthopaedics, Burkhart Research Institute for Orthopaedics, San Antonio, Texas
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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30
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Nuelle CW. Author Reply to "Regarding 'Editorial Commentary: Thank You, Thank You, Thank You…for Demonstrating Histologic Evidence of Shoulder Bicipital Tunnel Disease in the Absence of Magnetic Resonance Imaging Findings'". Arthroscopy 2019; 35:9-10. [PMID: 30611373 DOI: 10.1016/j.arthro.2018.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 02/02/2023]
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31
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Nuelle CW. Editorial Commentary: The Search for the Perfect Fixation Method in Anterior Cruciate Ligament Reconstruction Continues. Arthroscopy 2018; 34:3071-3072. [PMID: 30392690 DOI: 10.1016/j.arthro.2018.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 02/02/2023]
Abstract
Anterior cruciate ligament reconstruction fixation methods have long been the subject of frequent debate. The ability to optimize tendon-to-bone or bone-to-bone healing with secure graft fixation in a manner that can be performed as minimally invasively as possible is the goal. As we continue to develop and understand various graft fixation methods, our ability to achieve this goal continues to improve.
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32
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Nuelle CW, Stokes DC, Kuroki K, Crim JR, Sherman SL. Radiologic and Histologic Evaluation of Proximal Bicep Pathology in Patients With Chronic Biceps Tendinopathy Undergoing Open Subpectoral Biceps Tenodesis. Arthroscopy 2018; 34:1790-1796. [PMID: 29573932 DOI: 10.1016/j.arthro.2018.01.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To correlate preoperative magnetic resonance imaging (MRI) and intraoperative anatomic findings within the proximal long head biceps tendon to histologic evaluation of 3 separate zones of the tendon in patients with chronic biceps tendinopathy. METHODS Sixteen patients with chronic biceps tendinopathy were treated with open subpectoral biceps tenodesis. Preoperative MRI tendon grading was as follows: normal tendon, increased signal, tendon splitting, incomplete/complete tear. The removed portion of the biceps tendon was split into 3 segments: zone 1, 0-3.5 cm from the labral insertion; zone 2, 3.5-6.5 cm; and zone 3, 6.5-9 cm, and was histologically evaluated using the Bonar score. Tenosynovium adjacent to the tendon was assessed histologically using the Osteoarthritis Research Society International score. CD31, CD3, and CD79a immunohistochemistries were conducted to determine vascularization, T-cell infiltrates, and B-cell infiltrates, respectively. Analysis of variance and Pearson correlations were performed for statistical analysis. RESULTS Preoperative MRI showed no significant differences in tendon appearance between zones 1-3. Intraoperative findings included nonspecific degenerative SLAP tears or mild/moderate biceps tenosynovitis in all cases. Significantly (P < .001) higher Bonar scores were noted for tendon in zones 1 (7.9 ± 1.8) and 2 (7.3 ± 1.5) compared with zone 3 (5.0 ± 1.1). Cell morphology scores in zone 1 (1.9 ± 0.4) and zone 2 (1.5 ± 0.6) were significantly higher than that in zone 3 (0.8 ± 0.3) (P < .05). Inflammatory tenosynovium showed weak correlation with tendon changes in zone 1 (r = 0.08), zone 2 (r = 0.03), or zone 3 (r = 0.1). CONCLUSIONS In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. Severity of tendon histopathology was more pronounced in the proximal and mid-portions of the tendon. CLINICAL RELEVANCE Proximal versus distal biceps tenodesis is a subject of frequent debate. This study contributes to the ongoing evaluation of the characteristics of the proximal biceps in this type of pathologic condition.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A..
| | - Derek C Stokes
- School of Medicine, University of Missouri, Columbia, Missouri, U.S.A
| | - Keiichi Kuroki
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri, U.S.A
| | - Julia R Crim
- Department of Radiology, University of Missouri, Columbia, Missouri, U.S.A
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
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33
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Abstract
Osteochondritis dissecans (OCD) lesions of the patellofemoral joint can be difficult to identify and treat. Asymptomatic or stable lesions in skeletally immature patients may be treated nonoperatively, but symptomatic lesions often require surgical intervention. Evidence of instability should be carefully evaluated with preoperative magnetic resonance imaging or computed tomography arthrogram. Careful preoperative planning is necessary to ensure the appropriate surgical approach and implants are selected for surgical management. Multiple techniques have been described, but internal fixation of both "classic" and cartilage-only OCD lesions has been shown to have strong outcomes in managing these difficult cases.
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Affiliation(s)
| | - Jack Farr
- Cartilage Restoration Center, OrthoIndy, Greenwood, Indiana
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34
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Nuelle CW, Cook CR, Stoker AM, Cook JL, Sherman SL. In Vivo Toxicity of Local Anesthetics and Corticosteroids on Supraspinatus Tenocyte Cell Viability and Metabolism. Iowa Orthop J 2018; 38:107-112. [PMID: 30104932 PMCID: PMC6047373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND This study was conducted to evaluate the effects of commonly used injection medication combinations on supraspinatus tenocyte cell viability and tissue metabolism. METHODS Twenty adult dogs underwent ultrasound guided injection of the canine equivalent of the subacromial space, based on random assignment to one of four treatment groups (n=5/group): normal saline, 1.0% lidocaine/methylprednisolone, 1.0% lidocaine/triamcinolone or 0.0625% bupivacaine/triamcinolone. Full-thickness sections of supraspinatus tendon were harvested under aseptic conditions and evaluated on days 1 and 7 post-harvest for cell viability and tissue metabolism. Data were analyzed for significant differences among groups. RESULTS Tendons exposed to 1% lidocaine/ methylprednisolone had significantly lower cell viability at day 1 as compared to all other groups and control. All local anesthetic/ corticosteroid combination groups had decreased cell viability at day 7 when compared to the control group. CONCLUSIONS This study demonstrated significant in vivo supraspinatus tenotoxicity following a single injection of combination local anesthetic/ corticosteroid when compared to saline controls. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- The San Antonio Orthopaedic Group, San Antonio, TX
| | - Cristi R Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - Aaron M Stoker
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia
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35
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Nuelle CW, Milles JL, Pfeiffer FM, Stannard JP, Smith PA, Kfuri M, Cook JL. Biomechanical Comparison of Five Posterior Cruciate Ligament Reconstruction Techniques. J Knee Surg 2017; 30:523-531. [PMID: 27780285 DOI: 10.1055/s-0036-1593625] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
No surgical technique recreates native posterior cruciate ligament (PCL) biomechanics. We compared the biomechanics of five different PCL reconstruction techniques versus the native PCL. Cadaveric knees (n = 20) were randomly assigned to one of five reconstruction techniques: Single bundle all-inside arthroscopic inlay, single bundle all-inside suspensory fixation, single bundle arthroscopic-assisted open onlay (SB-ONL), double bundle arthroscopic-assisted open inlay (DB-INL), and double bundle all-inside suspensory fixation (DB-SUSP). Each specimen was potted and connected to a servo-hydraulic load frame for testing in three conditions: PCL intact, PCL deficient, and PCL reconstructed. Testing consisted of a posterior force up to 100 N at a rate of 1 N/s at four knee flexion angles: 10, 30, 60, and 90 degrees. Three material properties were measured under each condition: load to 5 mm displacement, maximal displacement, and stiffness. Data were normalized to the native PCL, compared across techniques, compared with all PCL-intact knees and to all PCL-deficient knees using one-way analysis of variance. For load to 5 mm displacement, intact knees required significantly (p < 0.03) more load at 30 degrees of flexion than all reconstructions except the DB-SUSP. At 60 degrees of flexion, intact required significantly (p < 0.01) more load than all others except the SB-ONL. At 90 degrees, intact, SB-ONL, DB-INL, and DB-SUSP required significantly more load (p < 0.05). Maximal displacement testing showed the intact to have significantly (p < 0.02) less laxity than all others except the DB-INL and DB-SUSP at 60 degrees. At 90 degrees the intact showed significantly (p < 0.01) less laxity than all others except the DB-SUSP. The intact was significantly stiffer than all others at 30 degrees (p < 0.03) and 60 degrees (p < 0.01). Finally, the intact was significantly (p < 0.05) stiffer than all others except the DB-SUSP at 90 degrees. No technique matched the exact properties of the native PCL, but the double bundle reconstructions more closely recreated the native biomechanics immediately after implantation, with the DB-SUSP coming closest to the native ligament. This study contributes new data for consideration in PCL reconstruction technique choice.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Jeffrey L Milles
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - Patrick A Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Columbia Orthopaedic Group, Columbia, Missouri
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, Missouri
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Milles JL, Nuelle CW, Pfeiffer F, Stannard JP, Smith P, Kfuri M, Cook JL. Erratum: Biomechanical Comparison: Single-Bundle versus Double-Bundle Posterior Cruciate Ligament Reconstruction Techniques. J Knee Surg 2017; 30:e1. [PMID: 27635940 DOI: 10.1055/s-0036-1592409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey L Milles
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ferris Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Patrick Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Milles JL, Nuelle CW, Pfeiffer F, Stannard JP, Smith P, Kfuri M, Cook JL. Biomechanical Comparison: Single-Bundle versus Double-Bundle Posterior Cruciate Ligament Reconstruction Techniques. J Knee Surg 2017; 30:347-351. [PMID: 27543681 DOI: 10.1055/s-0036-1588014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Controversy exists regarding double-bundle (DB) versus single-bundle (SB) posterior cruciate ligament (PCL) reconstruction, with differences in multiple variables affecting biomechanical and clinical results. Our objective was to compare immediate postimplantation biomechanics of SB versus DB reconstructions to determine the relative importance of restoring both PCL bundles versus total graft volume. Twenty knees were randomly assigned to five techniques (n = 4 knees/technique), performed by three surgeons experienced in their technique(s), three SB techniques (n = 12; all-inside arthroscopic inlay, all-inside suspensory fixation, and arthroscopic-assisted open onlay), and two DB techniques (n = 8; arthroscopic-assisted open inlay and all-inside suspensory fixation). Each knee was tested in three conditions: PCL-intact, PCL-deficient, and post-PCL reconstruction. Testing consisted of a posterior-directed force at four knee flexion angles, 10, 30, 60, and 90 degrees, to measure load to 5 mm of posterior displacement, maximum displacement (at 100 N load), and stiffness. Data for each knee were normalized, combined into two groups (SB and DB), and then compared using one-way analysis of variance. Graft volumes were calculated and analyzed to determine if differences significantly influenced the biomechanical results. Intact knees were stiffer than both groups at most angles (p < 0.02; p < 0.05). DB was stiffer than SB at all angles except 30 degrees (p < 0.05). Intact knees had less laxity than SB (p < 0.03) and DB (p < 0.05) at 60 and 90 degrees. DB had less laxity than SB at all angles except 60 degrees (p < 0.05). Intact knees required more load than SB at 30, 60, and 90 degrees (p < 0.01) and more than DB at 60 and 90 degrees (p < 0.05). DB required more load than SB at 30, 60, and 90 degrees (p < 0.01). Graft volumes did not have strong correlations (r = 0.13-0.37) to any measurements. Neither group of PCL reconstruction techniques was able to replicate native PCL biomechanics. DB reconstructions were biomechanically superior to SB reconstructions; they may be preferred for clinical use when immediate post-reconstruction graft strength and stability are critical. These results were not strongly influenced by graft size differences, further supporting the PCL codominance theory.
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Affiliation(s)
- Jeffrey L Milles
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Ferris Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Patrick Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Mauricio Kfuri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Abstract
Osteochondral autologous transplantation (OAT) is a treatment strategy for small and medium sized focal articular cartilage defects in the knee. This article reviews the indications, surgical techniques, outcomes, and limitations of OAT for the management of symptomatic chondral and osteochondral lesions in the knee joint.
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Affiliation(s)
- Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA; Missouri Orthopaedic Institute, 1100 Virginia Avenue, Columbia, MO 65212, USA.
| | - Emil Thyssen
- School of Medicine, University of Missouri, One Hospital Drive, MA204, Columbia, MO 65212, USA
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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Nuelle CW, Nuelle JAV, Cook JL, Stannard JP. Patient Factors, Donor Age, and Graft Storage Duration Affect Osteochondral Allograft Outcomes in Knees with or without Comorbidities. J Knee Surg 2017; 30:179-184. [PMID: 27228198 DOI: 10.1055/s-0036-1584183] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Limited data exists defining preoperative variables that affect outcomes after osteochondral allograft transplantation (OAT) in the knee. In this retrospective study, we examined 75 patients who underwent OAT for large (≥2 cm2) grade IV cartilage defects in the femoral condyle. Patient variables evaluated included the following: smoking, workers compensation, body mass index (BMI), pre-injury activity level, number, and the type of co-morbidities in the operated knee, lesion location and number of grafts placed. OCA donor age and graft storage duration from procurement were also evaluated. Preoperative and postoperative visual analogue scale (VAS) pain scores were the primary outcome measure. Overall, 53 patients (71%) had successful outcomes, with 81% of patients without co-morbidities having successful outcomes. Active patients were significantly (p = 0.023) more likely to have a successful outcome than low activity patients. Patients with BMI <35 were 4 times more likely to have a successful outcome (p = 0.01). There were no significant differences based on donor age. Patients with transplanted grafts stored >28 days were significantly (p = 0.048) and 2.6 times more likely to have an unsuccessful outcome. This study provides new evidence for preoperative patient factors and graft variables that may influence the overall outcome after osteochondral transplantation in the knee.
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Affiliation(s)
- Clayton W Nuelle
- Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Julia A V Nuelle
- Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - James L Cook
- Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
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Nuelle CW, Cook CR, Stoker AM, Cook JL, Sherman SL. In vitro toxicity of local anaesthetics and corticosteroids on supraspinatus tenocyte viability and metabolism. J Orthop Translat 2016; 8:20-24. [PMID: 30035090 PMCID: PMC5987053 DOI: 10.1016/j.jot.2016.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 07/12/2016] [Accepted: 08/15/2016] [Indexed: 02/07/2023] Open
Abstract
Background/Objective The purpose of this study was to evaluate supraspinatus tenocyte viability and metabolism in explants exposed to various local anaesthetics and corticosteroids. Our hypothesis was that the tendons exposed to these common injectates would have significantly decreased cell viability and metabolism compared with controls. Methods Supraspinatus tendon explants were obtained from dogs, placed in a culture media, and randomly assigned to one of the following groups: culture media only (control), 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupivacaine, 0.0625% bupivacaine, betamethasone acetate (5 mg), methylprednisolone acetate (40 mg), or triamcinolone acetonide (40 mg). Cell viability was determined on Days 1 and 7 after culture treatment using calcein AM (live cell) and Sytox Blue (dead cell) stains. Tissue metabolism was assessed on Days 1 and 7 using the resazurin blue metabolic assay. Significant differences were evaluated using a one-way analysis of variance with Tukey post hoc analysis. Results Compared with the controls, there were significant decreases in cell viability noted at Days 1 and 7 in tenocytes exposed to 1% lidocaine, betamethasone, and methylprednisolone. Significant decreases in cell metabolism were also noted at Days 1 and 7 in those groups. Treatment with 0.125% bupivacaine, 0.0625% bupivacaine, and triamcinolone demonstrated no decrease in cell viability or metabolism when compared with controls at any time point. Conclusion This data confirms that peritendinous injection of commonly used local anaesthetics and corticosteroids results in significant supraspinatus tenotoxicity in vitro. Further in vivo studies are required before making definitive clinical recommendations.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA
| | - Cristi R Cook
- Thompson Laboratory for Regenerative Orthopaedics, Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA
| | - Aaron M Stoker
- Thompson Laboratory for Regenerative Orthopaedics, Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA.,Thompson Laboratory for Regenerative Orthopaedics, Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA
| | - Seth L Sherman
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO, USA
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Nuelle CW, Cook JL, Gallizzi MA, Smith PA. Posterior single-incision semitendinosus harvest for a quadrupled anterior cruciate ligament graft construct: determination of graft length and diameter based on patient sex, height, weight, and body mass index. Arthroscopy 2015; 31:684-90. [PMID: 25522679 DOI: 10.1016/j.arthro.2014.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 10/10/2014] [Accepted: 10/24/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to determine final graft length and diameter for a quadrupled semitendinosus anterior cruciate ligament (ACL) construct harvested from a single-incision posterior approach with correlation to preoperative patient variables of sex, height, weight, and body mass index (BMI). METHODS This was a retrospective review of data collected prospectively on 60 patients undergoing all-inside quadrupled semitendinosus autograft ACL reconstruction. RESULTS The mean values of the final quadrupled constructs were a length of 70.3 mm and a diameter of 9.0 mm. Separated based on sex, female versus male final mean graft length was 68.1 mm versus 71.7 mm, and final mean graft diameter was 8.6 mm and 9.3 mm, respectively. In both sexes, patient height and weight were strongly correlated to final construct diameter (r = 0.60 and r = 0.56) and length (r = 0.47 and r = 0.44), respectively. CONCLUSIONS A single-incision posterior harvest approach allowed for retrieval of semitendinosis tendon autografts of sufficient dimension to allow for construction of quadrupled ACL grafts of a diameter of 8 mm or more in 95% of cases. In addition, desired graft length was achieved in all cases. Graft dimensions had moderately strong direct correlations to patient height and weight, with significant size differences noted between the sexes. We believe this to be helpful data for surgeons who might consider performing a quadrupled semitendinosus autograft ACL reconstruction. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
| | - Michael A Gallizzi
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri, U.S.A
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Abstract
BACKGROUND Our hypothesis was that patients treated with hinged external fixators as an adjunct to multiple-ligament reconstruction would have fewer reconstruction failures than patients treated without external fixation. METHODS In this prospective randomized study, patients with a knee dislocation either underwent ligament reconstruction with placement of an external hinged knee brace following surgery (Group A) or underwent ligament reconstruction with placement of a hinged external fixator (Compass Knee Hinge) for six weeks instead of the brace (Group B). The patients were followed clinically and were evaluated with physical examination, Lysholm and International Knee Documentation Committee knee scores, visual analog scale pain scores, and status regarding return to work and activities. RESULTS One hundred patients with 103 knee dislocations were enrolled. Seventy-seven patients with seventy-nine dislocations (thirty-two in Group A and forty-seven in Group B), with a minimum follow-up interval of twelve months, were available for evaluation. The mean duration of follow-up was thirty-nine months (range, twelve to eighty-six months). Nine patients (29%) in Group A had failed reconstructions compared with seven (15%) in Group B (p = 0.15). Group-A patients had twenty-two (21%) of 105 reconstructed individual ligaments fail compared with eleven (7%) of 157 reconstructed ligaments in Group B. The difference in ligament failure was significant (p < 0.001; power > 0.8), with more favorable results for the patients managed with the external fixation. CONCLUSIONS Hinged external fixation as a supplement to reconstruction following knee dislocation was associated with fewer failed ligament reconstructions compared with external bracing. Patients presenting with highly unstable knee dislocations should be considered for hinged external fixation to supplement initial reconstructive procedures.
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Affiliation(s)
- James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - Gerald McGwin
- University of Alabama at Birmingham, 510 South 20th Street, FOT 960, Birmingham, AL 35294-3409
| | - David A Volgas
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
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Nuelle CW, Stannard JP. Placement of a Compass Knee Hinge: Surgical Technique. JBJS Essent Surg Tech 2014; 4:e2. [PMID: 30775109 DOI: 10.2106/jbjs.st.m.00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The Compass Knee Hinge can be a useful part of the treatment regimen for highly unstable knee dislocations. Step 1 Initial Alignment of Wires Make sure to place the centering wire at the isometric point of the knee. Step 2 Placement of the Compass Knee Hinge Take the necessary steps to place the Compass Knee Hinge over the wire. Step 3 Application of the Compass Knee Hinge with Concurrent Procedures If repair or reconstruction of either the posteromedial or the posterolateral corner is part of the planned surgical procedure, place the centering wire prior to the repair or reconstruction of the injured corner. Step 4 Postoperative Protocol Postoperatively, use progressive protocols to enable the patient to regain knee motion following the application of the hinge. Results The above technique was used to treat fifty-five patients with a total of fifty-six knee dislocations who had various concurrent ligamentous reconstructions14.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Clayton W Nuelle
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, DC953.00, Columbia, MO 65212. E-mail address for J.P. Stannard:
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Smith PA, Nuelle CW, Bradley JP. Arthroscopic repair of a posterior bony humeral avulsion of the glenohumeral ligament with associated teres minor avulsion. Arthrosc Tech 2014; 3:e89-94. [PMID: 24749048 PMCID: PMC3986478 DOI: 10.1016/j.eats.2013.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/20/2013] [Indexed: 02/03/2023] Open
Abstract
Humeral avulsion of the inferior glenohumeral ligament (HAGL) has recently gained more recognition as a cause of shoulder instability. Posterior HAGL lesions, being much more infrequent than anterior disruptions, have only recently been documented as a notable cause of posterior instability. We detail the treatment of a previously unreported case of a posterior HAGL variant lesion consisting of a bony avulsion with involvement of the teres minor tendon. Arthroscopic fixation was facilitated by use of a "sheathless" arthroscopic approach with a 70° arthroscope and suture anchor.
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Affiliation(s)
- Patrick A. Smith
- Columbia Orthopaedic Group, Columbia, Missouri, U.S.A,Address correspondence to Patrick A. Smith, M.D., Columbia Orthopaedic Group, 1 S Keene St, Columbia, MO 65201, U.S.A.
| | - Clayton W. Nuelle
- Department of Orthopaedic Surgery, University of Missouri–Columbia, Columbia, Missouri, U.S.A
| | - James P. Bradley
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
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