Total Shoulder Arthroplasty After Previous Arthroscopic Surgery for Glenohumeral Osteoarthritis: A Case-Control Matched Cohort Study

BACKGROUND

When comprehensive arthroscopic management (CAM) for glenohumeral osteoarthritis fails, total shoulder arthroplasty (TSA) may be needed, and it remains unknown whether previous CAM adversely affects outcomes after subsequent TSA.

PURPOSE

To compare the outcomes of patients with glenohumeral osteoarthritis who underwent TSA as a primary procedure with those who underwent TSA after CAM (CAM-TSA).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients younger than 70 years who underwent primary TSA or CAM-TSA and were at least 2 years postoperative were included. A total of 21 patients who underwent CAM-TSA were matched to 42 patients who underwent primary TSA by age, sex, and grade of osteoarthritis. Intraoperative blood loss and surgical time were assessed. Patient-reported outcome (PRO) scores were collected preoperatively and at final follow-up including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH), 12-Item Short Form Health Survey Physical Component Summary (SF-12 PCS), visual analog scale, and patient satisfaction. Revision arthroplasty was defined as failure.

RESULTS

Of 63 patients, 56 of them (19 CAM-TSA and 37 primary TSA; 88.9%) were available for follow-up. There were 16 female (28.6%) and 40 male (71.4%) patients with a mean age of 57.8 years (range, 38.8-66.7 years). There were no significant differences in intraoperative blood loss (P > .999) or surgical time (P = .127) between the groups. There were 4 patients (7.1%) who had failure, and failure rates did not differ significantly between the CAM-TSA (5.3%; n = 1) and primary TSA (8.1%; n = 3) groups (P > .999). Additionally, 2 patients underwent revision arthroplasty because of trauma. A total of 50 patients who did not experience failure (17 CAM-TSA and 33 primary TSA) completed PRO measures at a mean follow-up of 4.8 years (range, 2.0-11.5 years), with no significant difference between the CAM-TSA (4.4 years [range, 2.1-10.5 years]) and primary TSA (5.0 years [range, 2.0-11.5 years]) groups (P = .164). Both groups improved significantly from preoperatively to postoperatively in all PRO scores (P < .05). No significant differences in any median PRO scores between the CAM-TSA and primary TSA groups, respectively, were seen at final follow-up: ASES: 89.9 (interquartile range [IQR], 74.9-96.6) versus 94.1 (IQR, 74.9-98.3) (P = .545); SANE: 84.0 (IQR, 74.0-94.0) versus 91.5 (IQR, 75.3-99.0) (P = .246); QuickDASH: 9.0 (IQR, 3.4-27.3) versus 9.0 (IQR, 5.1-18.1) (P = .921); SF-12 PCS: 53.8 (IQR, 50.1-57.1) versus 49.3 (IQR, 41.2-56.5) (P = .065); and patient satisfaction: 9.5 (IQR, 7.3-10.0) versus 9.0 (IQR, 5.3-10.0) (P = .308).

CONCLUSION

Patients with severe glenohumeral osteoarthritis who failed previous CAM benefited similarly from TSA compared with patients who opted directly for TSA.

Open Implantation of Autologous Chondrocytes Cultured on Porcine Collagen Membrane for the Treatment of a Full-Thickness Patellar Cartilage Lesion

Large cartilage defects in the knee are debilitating for patients and challenging for surgeons to treat. Autologous chondrocyte implantation (ACI) has gained popularity over the past 20 years and has become the treatment of choice for large cartilage defects for some surgeons. Termed matrix-applied ACI (MACI), use of autologous chondrocytes cultured on porcine collagen membrane has recently been approved by the U.S. Food and Drug Administration for the treatment of symptomatic full-thickness cartilage defects in the knee. This new technique for cartilage repair is the third generation of chondrocyte implantation technology and the first to involve the use of a scaffolding to grow chondrocytes¹. MACI is a simpler technique than previous generations and has more reliable chondrocyte seeding. Research has shown that patients do well postoperatively, with improvements in patient-reported outcome out to 5 years postoperatively³. These improvements are statistically greater for patients who underwent MACI when compared to those who underwent microfracture². (1) Preoperative evaluation: patients are indicated for a cartilage procedure after magnetic resonance imaging (MRI) and clinical examination. (2) Stage 1: a diagnostic arthroscopy is performed, and chondrocytes are harvested and cultured. (3) Approach: a short vertical incision is made, followed by a medial parapatellar arthrotomy. (4) Debridement: the lesion is identified and debrided back to stable cartilage. (5): Hemostasis: hemostasis is obtained with an epinephrine-soaked sponge. (6) Template creation: foil is used to create a template of the lesion. (7) Cells cutting: with use of the foil, the membrane of cells is cut to the appropriate size and shape. (8) Implantation: the cut membrane is placed on the lesion and secured with fibrin glue. (9) Testing: the knee is taken through a range of motion and the stability of the membrane is confirmed. (10) Closure: standard closure in layers is performed.

The incidence and clinical outcomes of peroneal nerve injuries associated with posterolateral corner injuries of the knee

PURPOSE

The purpose of the study was to investigate the incidence of complete and partial peroneal nerve injuries in patients with posterolateral corner (PLC) knee injuries; additionally, to compare patient-reported outcomes among patients with and without peroneal nerve injury and to examine the factors that predict the recovery of nerve function.

METHODS

A retrospective chart review was performed to identify patients who underwent PLC reconstruction or repair from 2000 to 2012 with a minimum 6-month clinical follow-up. Peroneal nerve injuries were identified, and treatments and outcomes were analyzed. IKDC and KOOS outcome scores at the final follow-up were reported.

RESULTS

There were 61 PLC injuries in 60 patients. Sixteen of the 61 knees (26.2%) had a peroneal nerve injury at initial presentation; there were 13 complete and 3 partial nerve injuries. The median age was 31 years (15 men and 1 woman) and 31 years (33 men and 12 women) in the nerve and non-nerve injury cohorts, respectively. The median follow-up in the nerve injury group was 26 months (interquartile range (IQR): 12-48), and in the non-nerve injury cohort (n.s.) 61 months (IQR 22-85). All 13 complete injuries were treated with neurolysis: 3 were complete transections and 10 were stretch injuries. Of the ten stretch injuries, five (50%) spontaneously recovered full nerve function at the final follow-up. The remaining six patients chose definitive treatment with ankle-foot orthoses. Two of the three transected nerve patients underwent successful posterior tibialis transfer, and one chose ankle-foot orthoses. All three partial nerve injuries underwent neurolysis and had complete nerve recovery at the final follow-up. The median IKDC scores in the nerve injury group and the non-nerve injury group were 64.4 (IQR 47.8-73.3) and 72.8 (IQR 59.3-87.9) (n.s.), respectively, and the median Lysholm scores were 85 (IQR 83-92) and 86.5 (IQR 79-90) (n.s.), respectively. There were no significant differences in the rates of complications, secondary surgeries, mechanism of injury, KDIII injuries, or other injuries.

CONCLUSION

This study demonstrated comparable rates of peroneal nerve injuries in PLC injuries (26.2%) to that in the literature. The rates of nerve recovery for complete disrupted injury, complete stretched injury, and partial injury were 0, 50, and 100% with an overall rate of recovery of 50%. The outcome scores were similar between patients with and without nerve injuries; however, a small cohort size led to limitations in statistical analysis. Thus, a prolonged trial of non-operative treatment is recommended for peroneal nerve injuries to allow for assessment of nerve recovery and patient outcome before entertaining surgical treatments.

LEVEL OF EVIDENCE

Level IV.

Age Differences in the Prevalence of Isolated Medial and Lateral Meniscal Tears in Surgically Treated Patients

PURPOSE

To compare the prevalence of isolated lateral and medial meniscal tears in different aged populations.

METHODS

A five-year retrospective review for meniscal procedures performed on a total of 782 patients. Each chart was reviewed to document the prevalence of medial or lateral meniscal injuries. Inclusion criteria were patients found to have documented evidence of meniscal tear, either lateral or medial, without any concomitant injuries and/or any other procedures performed. Patients excluded from the study were those with concomitant pathologies, such as chondromalacia, malalignment or ligamentous injuries. Patients were classified by age into three groups: < 20 years, 20-30 years and > 30 years old.

RESULTS

68.7% of patients had medial meniscal tears, (average age 37.6 years), 17.1% of these were isolated medial meniscus injuries (average 31.9 years). 31.3% had lateral meniscal injuries (average 27.7 years). Of these, 18.8 % had isolated lateral meniscal injuries (average 22.8 years). All remaining patients had additional diagnoses/procedures. Isolated medial meniscal injuries were more common in older patients as 48 of the 92 isolated medial tears (52.2%) were found in patients > 30 years of age (p <0.001). Isolated lateral meniscal injuries, on the other hand, were more common in younger patients. 29 of the 46 isolated lateral tears (63%) occurred in patients under 20 years (p = 0.002). Only seven (15.2%) isolated lateral tears were shown in patients older than 30 years.

CONCLUSION

Isolated lateral meniscal tears are more common in patients < 20 years, and decrease with age, while the prevalence of medial meniscal tears increase with age.

Surgical treatment of multiligament knee injuries

PURPOSE

To analyse one institution's experience with multiligament knee injuries.

METHODS

Over 10 years, 133 multiligament knee injuries including 130 patients were included in the study. Inclusion criteria included: (1) injury to two or more knee ligaments (2) multiligament knee repair/reconstructive surgery.

RESULTS

The average age at time of injury was 26 years old, and 76 % were male. Fifty-one (38 %) multiligament knee injuries had >2 ligaments injured. Peroneal injuries occurred in 26 patients (20 %), and four (3 %) had associated vascular injuries. A high energy mechanism of injury was noted in 39 %. Twenty-five per cent of patients had an additional orthopaedic injury and, 11.5 % suffered additional non-orthopaedic injuries. Definitive surgical intervention was performed acutely (<3 weeks) in 47 %. Ninety-one per cent of multiligament knee injuries underwent reconstruction with or without repair. Forty-three complications occurred in 37 patients. Patients who suffered >2 ligament injury or had surgery acutely were at an increased risk of knee stiffness requiring manipulation under anaesthesia (MUA) (p = 0.016 and p = 0.047, respectively). Knees with >2 ligaments injured were associated with higher post-operative complications (p = 0.007). Knee dislocation IV knees were at increased risk to undergo revision surgery (p = 0.041). Obese patients were more likely to have a post-operative infection (p = 0.038). Repair, reconstruction or type of graft used had no impact on need for revision surgery.

CONCLUSIONS

Multiligament knee injured patients undergoing surgical intervention are a highly complex patient population. This study outlines the patient population, treatment, and complications of one academic institution over 10 years. Overall complications were higher in patients with >2 ligaments injured. Knee stiffness requiring MUA was more common in patients who had >2 ligaments ruptured and those treated acutely. Knees with all four ligaments injured were more likely to undergo revision surgery.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Posterolateral Knee Reconstruction Versus Repair

BACKGROUND

Recent literature has shown that posterolateral corner injuries of the knee have poor results when treated with repair, when compared to reconstruction. Our study sought to compare outcomes of posterolateral knee injuries treated with repair versus reconstruction and report results from our institution, with the hypothesis that acute repairs have comparable results to reconstructions.

METHODS

We identified patients with posterolateral knee reconstruction or repair from January 1, 2000 to March 1, 2012. Patients returned for outcome measures, clinical exam and varus stress radiographs. Further, each patient underwent a chart review. Varus stress radiographs were obtained in 20 control knees, with no history of knee trauma, to our two cohort groups.

RESULTS

26 knees in 25 patients (17 reconstructions and 9 repairs) were evaluated in clinic at mean of 42 months postoperatively for repairs and 38 months postoperatively for reconstructions. Average IKDC scores for reconstruction and repair were 68 and 71, respectively. Average Lysholm scores for these groups were 83 for reconstructions and 83 for repairs. No statistically significant differences existed. Average varus gapping at zero degrees was 8.21 and 8.84 millimeters (mm) for reconstructions and repairs, respectively. Average varus gapping at 20 degrees knee flexion was 11.25 mm for reconstructions and 10.34 mm for repairs. No statistically significant differences were observed in varus gapping between the two groups. Each patient chart was reviewed for complications. There were 2 failures in the 44 patient reconstruction group (4.7%) and 2 failures in the 18 patient repair group (11.1%). We noted a high rate (10/19 patients) of primarily distally-based injuries in our repair group. All failures were treated with revision reconstructions.

CONCLUSION

We found low failure rates in both groups. All knees in the repair group were operated within three weeks of injury. Our repair knees had a high rate of distally based avulsion and, were felt to have acceptable tissue that could be successfully repaired. We recommend posterolateral knee repair in cases with distally based avulsions that can be operatively treated within 3 weeks of injury, and have good tissue quality at the time of surgery.

LEVEL OF EVIDENCE

IV.

Effect of body mass index on patients with multiligamentous knee injuries

PURPOSE

Our goal was to evaluate the impact of body mass index (BMI) on complications and associated injuries in patients undergoing surgical treatment for multiligamentous knee injuries (MLKIs).

METHODS

Over a period of 10 years, 126 MLKIs (123 patients) were included in the study. The inclusion criteria were (1) injury to 2 or more knee ligaments, (2) multiligament repair and/or reconstruction performed by 1 of 3 sports medicine orthopaedic surgeons at our institution, and (3) minimum of 1 year of follow-up. A chart review was performed to collect demographic data, mechanism of injury, ligaments involved, complications, and associated neurovascular injuries. Lastly, patients were divided by BMI into non-obese (<30 kg/m(2)) and obese (≥30 kg/m(2)) groups.

RESULTS

Of the 126 MLKIs, 87 occurred in non-obese patients and 39 occurred in obese patients. Surgical complication rates for non-obese and obese patients were 8.05% and 15.4%, respectively (P = .21). Revisions were needed in 8.05% and 5.1% of patients in these groups, respectively (P = .72). Three wound complications were found in the obese group only. Vascular injuries were found in 2.3% and 7.7% of patients in the non-obese and obese groups, respectively (P = .17). The rates of nerve injuries were 11.49% and 20.51%, respectively (P = .18). Patients in the obese group were most likely to have an MLKI from low-energy mechanisms, disregarding sports-related injuries (51.28%, P = .02). Using a logistic model and BMI as a continuous variable, we found that a 1-unit increase in BMI increased the odds ratio of complications by 9.2%, with statistical significance (P = .0174). In addition, post hoc power analysis using previous literature showed that this study could produce satisfactory power.

CONCLUSIONS

Our results indicate that (1) obese individuals are significantly more likely to have an MLKI caused by low-energy mechanisms and (2) complication rates increase by 9.2% for every 1-unit increase in BMI.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Femoral tunnel placement in medial patellofemoral ligament reconstruction

INTRODUCTION

Medial Patellofemoral Ligament (MPFL) reconstruction is an accepted treatment for recurrent patellofemoral instability when patients have normal alignment and deficient proximal medial restraints. There are several reports of malpositioned femoral tunnels leading to poor outcomes. The purpose of this study was to analyze femoral tunnel placement after MPFL reconstruction and correlate this with outcomes.

METHODS

We performed a retrospective review of MPFL reconstructions done at our institution from 2006-2010. We then evaluated lateral radiographs and measured the distance between the radiographic femoral MPFL isometric point and the center of the femoral tunnel. We also evaluated post-operative KOOS scores.

RESULTS

The average distance from the femoral tunnel to the MPFL isometric point was 13.25 mm. Sixty-four percent of tunnels were placed greater than nine millimeters from our isometric point and deemed to be malpositioned. There was no statistically significant difference in outcomes scores in patients with anatomically placed MPFL tunnels when compared to those placed non-anatomically.

CONCLUSION

Sixty-four percent of MPFL reconstruction femoral tunnels were placed non-anatomically, but this did not correlate with a worse outcome. Graft tension, trochlear groove anatomy, patellar height, and dynamic restraints all play important roles in outcomes after MPFL reconstruction. Even though non-anatomic tunnel placement does not guarantee a poor result, we believe an anatomic tunnel placement will give the best chance to maximize graft function and outcome.