Publications by authors named "Craig R Bottoni"

32 Publications

Arthroscopic Versus Open Anterior Shoulder Stabilization: A Prospective Randomized Clinical Trial With 15-Year Follow-up With an Assessment of the Glenoid Being "On-Track" and "Off-Track" as a Predictor of Failure.

Am J Sports Med 2021 Jun 8:3635465211018212. Epub 2021 Jun 8.

Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: Recent studies have demonstrated equivalent short-term results when comparing arthroscopic versus open anterior shoulder stabilization. However, none have evaluated the long-term clinical outcomes of patients after arthroscopic or open anterior shoulder stabilization, with inclusion of an assessment of preoperative glenoid tracking.

Purpose: To compare long-term clinical outcomes of patients with recurrent anterior shoulder instability randomized to open and arthroscopic stabilization groups. Additionally, preoperative magnetic resonance imaging (MRI) studies were used to assess whether the shoulders were "on-track" or "off-track" to ascertain a prediction of increased failure risk.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Follow-up assessments were performed at minimum 15-year follow-up using established postoperative evaluations. Clinical failure was defined as any recurrent dislocation postoperatively or subjective instability. Preoperative MRI scans were obtained to calculate the glenoid track and designate shoulders as on-track or off-track. These results were then correlated with the patients' clinical results at their latest follow-up.

Results: Of 64 patients, 60 (28 arthroscopic and 32 open) were contacted or examined for follow-up (range, 15-17 years). The mean age at the time of surgery was 25 years (range, 19-42 years), while the mean age at the time of this assessment was 40 years (range, 34-57 years). The rates of arthroscopic and open long-term failure were 14.3% (4/28) and 12.5% (4/32), respectively. There were no differences in subjective shoulder outcome scores between the treatment groups. Of the 56 shoulders, with available MRI studies, 8 (14.3%) were determined to be off-track. Of these 8 shoulders, there were 2 surgical failures (25.0%; 1 treated arthroscopically, 1 treated open). In the on-track group, 6 of 48 had failed surgery (12.5%; 3 open, 3 arthroscopic [ = .280]).

Conclusion: Long-term clinical outcomes were comparable at 15 years postoperatively between the arthroscopic and open stabilization groups. The presence of an off-track lesion may be associated with a higher rate of recurrent instability in both cohorts at long-term follow-up; however, this study was underpowered to verify this situation.
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http://dx.doi.org/10.1177/03635465211018212DOI Listing
June 2021

Anterior Cruciate Ligament Repair: Historical Perspective, Indications, Techniques, and Outcomes.

J Am Acad Orthop Surg 2020 Dec;28(23):963-971

From the Department of Orthopaedics, Tripler Army Medical Center, Honolulu, Hawaii.

Anterior cruciate ligament (ACL) repair was first reported in 1895 by Sir Arthur Mayo-Robson. Open primary ACL repair was performed throughout the 1970s and 1980s; however, rerupture rates were as high as 50% at mid-term follow-up. Throughout the 1980s and 1990s, synthetic graft materials received consideration; however, the outcomes were abysmal. Recently, with a better understanding of ACL healing and improvement in technique, there has been renewed interest in ACL repair. The potential advantages of ACL repair include improvements in knee kinematics and proprioception, avoiding graft harvest, and preserving bone stock. Although recent data on short-term outcomes suggest potential in properly indicated patients, medium- and long-term outcomes are largely unknown. ACL repair has the greatest potential in cases of proximal ACL rupture (modified Sherman type I and II proximal tears). Repair of midsubstance tears (modified Sherman type III tears) should be avoided. Caution is advised in athletes and younger patients because of higher failure rates. Today, ACL repair remains controversial and should be performed with caution because of limited medium- and long-term outcomes.
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http://dx.doi.org/10.5435/JAAOS-D-20-00077DOI Listing
December 2020

Tenosynovial Giant-Cell Tumor Presenting as Septic Arthritis of the Knee.

J Am Acad Orthop Surg Glob Res Rev 2021 Apr 6;5(4). Epub 2021 Apr 6.

From the Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI (Dr. Lausé, Dr. Krul, Dr. Bottoni), and the Department of Orthopaedics, Walter Reed National Military Medical Center, Bethesda, MD (Dr. Baird).

Tenosynovial giant-cell tumor (TGCT) is an intraarticular giant-cell tumor of the synovial tissue and tendon sheaths which often mimics multiple conditions on presentation. This case report describes a previously asymptomatic 67-year-old man with preliminary clinical and laboratory evaluation suggestive of septic arthritis; however, arthroscopy revealed diffuse synovitis, and biopsy confirmed TGCT. To our knowledge, this is the first report of TGCT presenting as septic arthritis in an adult patient. This diagnosis should be considered in evaluation of acute, atraumatic knee pain with associated inflammatory marker elevation.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-20-00089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032351PMC
April 2021

Tibial Tubercle-Sparing Anterior Closing Wedge Osteotomy With Cross-Screw Fixation to Correct Pathologic Posterior Tibial Slope.

Arthrosc Tech 2021 Mar 22;10(3):e897-e902. Epub 2021 Feb 22.

Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu Hawaii, U.S.A.

Anterior cruciate ligament reconstruction failure remains a commonly seen outcome despite advances in technique and graft options. Recent studies have shown that the declination of the tibial plateau slope in the sagittal plane affects the in situ stress on the anterior cruciate ligament. The native posterior tibial slope has been described to range from 7° to 10°. However, several authors have suggested that a posterior tibial slope >12° should be considered pathologic. Given the recent evidence, our institution has begun performing a tibial tubercle-sparing anterior closing wedge proximal tibial osteotomy with cross screw fixation to decrease sagittal plane tibial slope.
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http://dx.doi.org/10.1016/j.eats.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953358PMC
March 2021

Comparing Bone-Tendon Autograft With Bone-Tendon-Bone Autograft for ACL Reconstruction: A Matched-Cohort Analysis.

Orthop J Sports Med 2020 Dec 4;8(12):2325967120970224. Epub 2020 Dec 4.

Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) using bone-tendon-bone (BTB) autograft is associated with increased postoperative anterior knee pain and pain with kneeling and has the risk of intra- and postoperative patellar fracture. Additionally, graft-tunnel mismatch is problematic, often leading to inadequate osseous fixation. Given the disadvantages of BTB, an alternative is a bone-tendon autograft (BTA) procedure that has been developed at our institution. BTA is a patellar tendon autograft with the single bone plug taken from the tibia.

Purpose/hypothesis: The purpose of this study was to evaluate the short-term outcomes of BTA ACLR. We hypothesized that this procedure will provide noninferior failure rates and clinical outcomes when compared with a BTB autograft, as well as a lower incidence of anterior knee pain, pain with kneeling, and patellar fracture.

Methods: A consecutive series of 52 patients treated with BTA ACLR were retrospectively identified and compared with 50 age-matched patients who underwent BTB ACLR. The primary outcome was ACL graft failure, while secondary outcomes included subjective instability, anterior knee pain, kneeling pain, and functional outcome scores (Single Assessment Numeric Evaluation, Lysholm, and International Knee Documentation Committee subjective knee form).

Results: At a mean follow-up of 29.3 months after surgery, there were 2 reruptures in the BTA cohort (4.0%) and 2 in the BTB cohort (4.0%). In the BTA group, 18% of patients reported anterior knee pain versus 36% of the BTB group ( = .04). A total of 22% of patients noted pain or pressure with kneeling in the BTA cohort, as opposed to 48% in the BTB cohort ( = .006). There were no differences in functional scores. In the BTA group, 94.2% of patients reported that their knees subjectively felt stable, as compared with 86% in the BTB group ( = .18).

Conclusion: This study demonstrated that the BTA ACLR leads to similarly low rates of ACL graft failure requiring revision surgery, with significantly decreased anterior knee pain and kneeling pain when compared with a BTB. Additionally, the potential complications of graft-tunnel mismatch and patellar fracture are eliminated with the BTA ACLR technique.
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http://dx.doi.org/10.1177/2325967120970224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7720344PMC
December 2020

Bone-Tendon-Autograft Anterior Cruciate Ligament Reconstruction: A New Anterior Cruciate Ligament Graft Option.

Arthrosc Tech 2020 Oct 7;9(10):e1525-e1530. Epub 2020 Oct 7.

Tripler Army Medical Center, Department of Orthopaedic Surgery, Honolulu Hawaii, U.S.A.

The bone-tendon-bone (BTB) autograft is widely used for anterior cruciate ligament (ACL) reconstruction. However, the primary disadvantages of this technique include postoperative kneeling pain, the risk of perioperative patellar fracture, and graft-tunnel mismatch. Therefore, a single bone plug technique for ACL reconstructions was developed to mitigate the disadvantages of the BTB technique. To differentiate this graft, we have coined the term BTA, for bone-tendon-autograft. The middle third of the patellar tendon is used with a typical width of 10 to 11 mm. A standard tibial tubercle bone plug is harvested. The length of the patellar tendon and graft construct is then measured. If the tendon is >45 mm and the construct at least 70 mm, then we proceed with the BTA technique. At the inferior pole of the patella, electrocautery is used to harvest the tendon from the patella. The advantages of this technique include faster graft harvest and preparation. Obviating the patellar bone plug harvest should eliminate the risk of perioperative patellar fracture and theoretically will mitigate donor site morbidity and kneeling pain, 2 of the most commonly cited complications of the use of BTB autografts for ACL reconstruction. In conclusion, the BTA technique is a reliable technique for ACL reconstruction.
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http://dx.doi.org/10.1016/j.eats.2020.06.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7587499PMC
October 2020

Anatomic Double Bundle Posterior Cruciate Ligament Reconstruction Using an Internal Splint.

Arthrosc Tech 2020 Jun 15;9(6):e729-e736. Epub 2020 Jun 15.

Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI, U.S.A.

Techniques for reconstruction of posterior cruciate ligament (PCL) tears are rapidly evolving. One problem with current techniques is that laxity may develop early in the postoperative period, leading to relapsed posterior translation of the tibia. Therefore, maintaining tibial reduction during graft incorporation is a target for improvement. We describe using an internal splint to optimize the 4-tunnel, double-bundle allograft PCL reconstruction.
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http://dx.doi.org/10.1016/j.eats.2020.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301276PMC
June 2020

Prospective Evaluation of Range of Motion in Acute ACL Reconstruction Using Patellar Tendon Autograft.

Orthop J Sports Med 2019 Oct 9;7(10):2325967119875415. Epub 2019 Oct 9.

Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: Optimal timing of anterior cruciate ligament (ACL) reconstruction has been a topic of controversy. Reconstruction has historically been delayed for at least 3 weeks, given previous studies reporting a high risk of postoperative arthrofibrosis and suboptimal clinical results.

Purpose: To prospectively evaluate postoperative range of motion following acutely reconstructed ACLs with patellar tendon autograft.

Study Design: Case series; Level of evidence, 4.

Methods: Patients (age >18 years) who had ACL reconstruction as soon as possible after injury, regardless of the condition or preoperative range of motion of the injured knee, underwent reconstruction with patellar tendon autograft. An identical standard surgical technique and postoperative rehabilitation were employed for all patients. Postoperative assessment included active range of motion measurements with a goniometer. Subjective outcomes were assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS).

Results: A total of 25 consecutive patients who met the inclusion criteria were enrolled. The mean age was 27.9 years (range, 20-48 years), and 19 were men. The time from injury to surgery was a mean 4.5 days (range, 1-9 days). The mean objective follow-up was 10.9 months (range, 3 days-19.4 months), and range of motion was regained at a mean 4.4 months (range, 1-9 months). Three meniscal repairs and 3 microfractures were performed concomitantly. There was 1 graft failure at 3 years postoperatively, noted at 50 months of subjective follow-up. There was no loss of extension >3° as compared with the contralateral knee in any patient. There was no loss of flexion >5° as compared with the contralateral knee in any patient who completed objective follow-up. The mean KOOS at final subjective follow-up was 82.8 (range, 57.7-98.8) at a mean 56.6 months postoperative (n = 14/24; range, 48-58 months).

Conclusion: Excellent clinical results can be achieved following ACL reconstruction performed ≤9 days after injury with patellar tendon autograft. The authors found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.
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http://dx.doi.org/10.1177/2325967119875415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785920PMC
October 2019

Meniscal and Chondral Pathology Associated With Anterior Cruciate Ligament Injuries.

J Am Acad Orthop Surg 2019 Feb;27(3):75-84

From the Department of Orthopaedic Surgery, Division of Sports Medicine, Tripler Army Medical Center, Honolulu, HI.

Anterior cruciate ligament (ACL) ruptures are commonly associated with meniscal and articular cartilage injuries, and the presence of these defects influences both short- and long-term outcomes. Multiple variables are predictive of this pathology including time from injury, age, and sex. Revision ACL reconstructions demonstrate higher rates of chondral injury than primary reconstructions. Menisci are important secondary stabilizers of the knee in the setting of ACL deficiency, and specific tear types are more consistently associated with ACL injury. Successful outcomes with multiple treatment options for meniscal tears in conjunction with ACL reconstruction have been reported. Maintaining meniscal integrity may be protective of both joint surfaces and graft stability in the long term; however, clear treatment recommendations for tear subtypes remain ill defined. High-grade chondral defects have the most consistent and potentially largest negative effect on long-term patient-reported outcomes; however, optimal treatment is also controversial with successful results demonstrated with several modalities including benign neglect.
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http://dx.doi.org/10.5435/JAAOS-D-17-00670DOI Listing
February 2019

Editorial Commentary: Every Cloud Has a Silver Lining…but Silver May Not Be the Currency of Choice: The Bioelectric Silver-Zinc Dressing Requires Additional Investigation.

Authors:
Craig R Bottoni

Arthroscopy 2018 10;34(10):2892-2893

F. E. Edward Hébert School of Medicine.

The use of silver in various forms has been advocated for its antibacterial properties for centuries, because its toxicity to human cells is considerably lower than its toxicity to bacteria. The Greek historian Herodotus recounted how the king of Persia, before going to war, among his provisions included boiled water stored in flagons of silver, ostensibly to mitigate the risk of foodborne infections in his troops. Additionally, recent studies support the use of silver to generate an electrical stimulation for promotion of wound healing. These concepts have been combined in a proprietary postoperative dressing that is promoted to mitigate the risk of postoperative infections.
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http://dx.doi.org/10.1016/j.arthro.2018.07.039DOI Listing
October 2018

Glenoid Bone Loss in Posterior Shoulder Instability: Prevalence and Outcomes in Arthroscopic Treatment.

Am J Sports Med 2018 04 29;46(5):1053-1057. Epub 2018 Jan 29.

Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, South Carolina, USA.

Background: Glenoid bone loss is a well-accepted risk factor for failure after arthroscopic stabilization of anterior glenohumeral instability. Glenoid bone loss in posterior instability has been noted relative to its existence in posterior instability surgery. Its effect on outcomes after arthroscopic stabilization has not been specifically evaluated and reported.

Purpose: The purpose was to evaluate the presence of posterior glenoid bone loss in a series of patients who had undergone arthroscopic isolated stabilization of the posterior labrum. Bone loss was then correlated to return-to-duty rates, complications, and validated patient-reported outcomes.

Study Design: Case-control study; Level of evidence, 3.

Methods: A retrospective review was conducted at a single military treatment facility over a 4-year period (2010-2013). Patients with primary posterior instability who underwent arthroscopic isolated posterior labral repair were included. Preoperative magnetic resonance imaging was used to calculate posterior glenoid bone loss using a standardized "perfect circle" technique. Demographics, return to duty, complications, and reoperations, as well as outcomes scores including the Single Assessment Numeric Evaluation and the Western Ontario Shoulder Instability Index (WOSI) scores, were obtained. Outcomes were analyzed across all patients based on percentage of posterior glenoid bone loss. Bone loss was then categorized as below or above the subcritical threshold of 13.5% to determine if bone loss effected outcomes similar to what has been shown in anterior instability.

Results: There were 43 consecutive patients with primary, isolated posterior instability, and 32 (74.4%) completed WOSI scoring. Mean follow-up was 53.7 months (range, 25-82 months) The mean posterior glenoid bone loss was 7.3% (0%-21.5%). Ten of 32 patients (31%) had no appreciable bone loss. Bone loss exceeded 13.5% in 7 of 32 patients (22%), and 2 patients (6%) exceeded 20% bone loss. Return to full duty or activity was nearly 90% overall. However, those with >13.5%, subcritical glenoid bone loss, were statistically less likely to return to full duty (relative risk = 1.8), but outcomes scores, complications, and revision rates were otherwise not different in those with no or minimal bone loss versus those with more significant amounts.

Conclusion: Posterior glenoid bone loss has not previously been evaluated independently relative to patients with shoulder instability repairs. Sixty-nine percent of our patients had measurable bone loss, and 22% had greater than 13.5%, or above subcritical bone loss. While these patients were statistically less likely to return to full duty, the reoperation rate, complications, and patient-reported outcomes between groups were not different.
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http://dx.doi.org/10.1177/0363546517750628DOI Listing
April 2018

Implementing an Electronic Patient-Based Orthopaedic Outcomes System: Factors Affecting Patient Participation Compliance.

Mil Med 2017 01;182(1):e1626-e1630

Department of Surgery, Orthopaedic Service, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859.

Introduction: Few studies have reported on the optimization of patient compliance within outcome registries and no studies exist on orthopaedic outcome registries in the military to date. Our aim is to report on the compliance rate of an electronic, web-based, patient-reported outcomes program, with particular emphasis on the effect of variables in data acquisition on survey compliance at a single military installation.

Methods: 1,814 patients were entered into the database allowing patients to complete subjective preoperative validated scores. Patient compliance and completeness was calculated. Furthermore, we compared compliance rates for paper vs. electronic platforms and length of survey.

Results: 40% complied without staff intervention. This increased to 73% with staff intervention. The electronic platform had a higher compliance rate (67%) and lower incompletion rate (3%) than paper (59%, p = 0.044). Short form compliance was 89% compared to standard form of 70% (p = 0.006).

Conclusions: This is the first report of an orthopaedic registry in a U.S. military population. Self-prompted compliance occurred in 40% of patients and can be increased to over 70% with staff intervention. Electronic platforms are logistically simpler, and result in higher patient compliance, as do shorter survey lengths. Further study on longer term compliance is warranted.
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http://dx.doi.org/10.7205/MILMED-D-15-00499DOI Listing
January 2017

Clinical Validation of the Glenoid Track Concept in Anterior Glenohumeral Instability.

J Bone Joint Surg Am 2016 Nov;98(22):1918-1923

Department of Orthopaedic Surgery, Steadman Hawkins Clinic of the Carolinas, Greenville, South Carolina.

Background: Glenoid and humeral bone loss are well-described risk factors for failure of arthroscopic shoulder stabilization. Recently, consideration of the interactions of these types of bone loss (bipolar bone loss) has been used to determine if a lesion is "on-track" or "off-track." The purpose of this study was to study the relationship of the glenoid track to the outcomes of arthroscopic Bankart reconstructions.

Methods: Over a 2-year period, 57 shoulders that were treated with an isolated, primary arthroscopic Bankart reconstruction performed at a single facility were included in this study. The mean patient age was 25.5 years (range, 20 to 42 years) at the time of the surgical procedure, and the mean follow-up was 48.3 months (range, 23 to 58 months). Preoperative magnetic resonance imaging was used to determine glenoid bone loss and Hill-Sachs lesion size and location and to measure the glenoid track to classify the shoulders as on-track or off-track. Outcomes were assessed according to shoulder stability on examination and subjective outcome.

Results: There were 10 recurrences (18%). Of the 49 on-track patients, 4 (8%) had treatment that failed compared with 6 (75%) of 8 off-track patients (p = 0.0001). Six (60%) of 10 patients with recurrence of instability were off-track compared with 2 (4%) of 47 patients in the stable group (p = 0.0001). The positive predictive value of an off-track measurement was 75% compared with 44% for the predictive value of glenoid bone loss of >20%.

Conclusions: The application of the glenoid track concept to our cohort was superior to using glenoid bone loss alone with regard to predicting postoperative stability. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.15.01099DOI Listing
November 2016

Successful Nonoperative Management of HAGL (Humeral Avulsion of Glenohumeral Ligament) Lesion With Concurrent Axillary Nerve Injury in an Active-Duty US Navy SEAL.

Am J Orthop (Belle Mead NJ) 2016 Jul-Aug;45(5):E236-9

Department of Orthopedic Surgery, Tripler Army Medical Center, Honolulu, HI.

Humeral avulsion of the glenohumeral ligament (HAGL) is a lesion that has been recognized as a cause of recurrent shoulder instability. To our knowledge there are no reports of successful return to full function in young, competitive athletes or return to manual labor following nonoperative management of a HAGL lesion. A 26-year-old Navy SEAL was diagnosed with a HAGL injury, and associated traction injury of the axillary nerve as well as a partial tear of the rotator cuff. Operative intervention was recommended; however, due to issues with training and with inability to properly rehab with the axillary nerve injury, surgical plans were delayed. Interestingly, the patient demonstrated both clinical and radiographic magnetic resonance imaging healing of his lesion over an 18-month period. At 18 months the patient had returned to full active duty without pain or instability as a Navy SEAL.
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February 2017

Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Clinical Study With a Minimum 10-Year Follow-up.

Am J Sports Med 2015 Oct 26;43(10):2501-9. Epub 2015 Aug 26.

Sports Medicine Section, Orthopaedic Surgery Service, Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: The use of allografts for anterior cruciate ligament (ACL) reconstruction in young athletes is controversial. No long-term results have been published comparing tibialis posterior allografts to hamstring autografts.

Purpose: To evaluate the long-term results of primary ACL reconstruction using either an allograft or autograft.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: From June 2002 to August 2003, patients with a symptomatic ACL-deficient knee were randomized to receive either a hamstring autograft or tibialis posterior allograft. All allografts were from a single tissue bank, aseptically processed, and fresh-frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same postoperative rehabilitation protocol, which was blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephone and Internet-based questionnaire to ascertain the functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability, and functional status.

Results: There were 99 patients (100 knees); 86 were men, and 95% were active-duty military. Both groups were similar in demographics and preoperative activity level. The mean and median ages of both groups were identical at 29 and 26 years, respectively. Concomitant meniscal and chondral pathologic abnormalities, microfracture, and meniscal repair performed at the time of reconstruction were similar in both groups. At a minimum of 10 years (range, 120-132 months) from surgery, 96 patients (97 knees) were contacted (2 patients were deceased, and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures that required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean Single Assessment Numeric Evaluation, Tegner, or International Knee Documentation Committee scores.

Conclusion: At a minimum of 10 years after ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft failed at a rate over 3 times higher than those with an autograft.
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http://dx.doi.org/10.1177/0363546515596406DOI Listing
October 2015

Utility of computed tomography arthrograms in evaluating osteochondral allograft transplants of the distal femur.

J Surg Orthop Adv 2015 ;24(2):111-4

Tripler Army Medical Center, Honolulu, Hawaii.

Postsurgical evaluation of osteochondral allograft transplant surgery (OATS) of the distal femur most commonly utilizes radiographs or magnetic resonance imaging. This article proposes the utilization of computed tomography (CT) arthrography as an additional option, which allows clear assessment of articular congruity and osseous integration. A retrospective review was performed of 18 patients who underwent an OATS for distal femoral chondral lesions and obtained CT arthrograms postoperatively. CT arthrograms were evaluated for osseous integration and articular congruity. The average age and follow-up were 30.9 years and 4.3 years, respectively. Only 60% of patients were able to remain in the military postoperatively. The articular cartilage was smooth in eight (44.4%); complete bony integration was noted in eight (44.4%) patients. Neither articular congruity nor bony integration was associated with duty status at final follow-up. Although it allows excellent evaluation, similar to other modalities, CT arthrogram does not appear predictive of functional outcome.
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August 2015

Redefining "Critical" Bone Loss in Shoulder Instability: Functional Outcomes Worsen With "Subcritical" Bone Loss.

Am J Sports Med 2015 Jul 16;43(7):1719-25. Epub 2015 Apr 16.

Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: Glenoid bone loss is a common finding in association with anterior shoulder instability. This loss has been identified as a predictor of failure after operative stabilization procedures. Historically, 20% to 25% has been accepted as the "critical" cutoff where glenoid bone loss should be addressed in a primary procedure. Few data are available, however, on lesser, "subcritical" amounts of bone loss (below the 20%-25% range) on functional outcomes and failure rates after primary arthroscopic stabilization for shoulder instability.

Purpose: To evaluate the effect of glenoid bone loss, especially in subcritical bone loss (below the 20%-25% range), on outcomes assessments and redislocation rates after an isolated arthroscopic Bankart repair for anterior shoulder instability.

Study Design: Cohort study; Level of evidence, 3.

Methods: Subjects were 72 consecutive anterior instability patients (73 shoulders) who underwent isolated anterior arthroscopic labral repair at a single military institution by 1 of 3 sports medicine fellowship-trained orthopaedic surgeons. Data were collected on demographics, the Western Ontario Shoulder Instability (WOSI) score, Single Assessment Numeric Evaluation (SANE) score, and failure rates. Failure was defined as recurrent dislocation. Glenoid bone loss was calculated via a standardized technique on preoperative imaging. The average bone loss across the group was calculated, and patients were divided into quartiles based on the percentage of glenoid bone loss. Outcomes were analyzed for the entire cohort, between the quartiles, and within each quartile. Outcomes were then further stratified between those sustaining a recurrence versus those who remained stable.

Results: The mean age at surgery was 26.3 years (range, 20-42 years), and the mean follow-up was 48.3 months (range, 23-58 months). The cohort was divided into quartiles based on bone loss. Quartile 1 (n = 18) had a mean bone loss of 2.8% (range, 0%-7.1%), quartile 2 (n = 19) had 10.4% (range, 7.3%-13.5%), quartile 3 (n = 18) had 16.1% (range, 13.5%-19.8%), and quartile 4 (n = 18) had 24.5% (range, 20.0%-35.5%). The overall mean WOSI score was 756.8 (range, 0-2097). The mean WOSI score correlated with SANE scores and worsened as bone loss increased in each quartile. There were significant differences (P < .05) between quartile 1 (mean WOSI/SANE, 383.3/62.1) and quartile 2 (mean, 594.0/65.2), between quartile 2 and quartile 3 (mean, 839.5/52.0), and between quartile 3 and quartile 4 (mean, 1187.6/46.1). Additionally, between quartiles 2 and 3 (bone loss, 13.5%), the WOSI score increased to rates consistent with a poor clinical outcome. There was an overall failure rate of 12.3%. The percentage of glenoid bone loss was significantly higher among those repairs that failed versus those that remained stable (24.7% vs 12.8%, P < .01). There was no significant difference in failure rate between quartiles 1, 2, and 3, but there was a significant increase in failure (P < .05) between quartiles 1, 2, and 3 (7.3%) when compared with quartile 4 (27.8%). Notably, even when only those patients who did not sustain a recurrent dislocation were compared, bone loss was predictive of outcome as assessed by the WOSI score, with each quartile's increasing bone loss predictive of a worse functional outcome.

Conclusion: While critical bone loss has yet to be defined for arthroscopic Bankart reconstruction, our data indicate that "critical" bone loss should be lower than the 20% to 25% threshold often cited. In our population with a high level of mandatory activity, bone loss above 13.5% led to a clinically significant decrease in WOSI scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrence of their instability.
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http://dx.doi.org/10.1177/0363546515578250DOI Listing
July 2015

High frequency of posterior and combined shoulder instability in young active patients.

J Shoulder Elbow Surg 2015 Feb 11;24(2):186-90. Epub 2014 Sep 11.

Orthopedic Surgery Service, Tripler Army Medical Center, Honolulu, HI, USA; Steadman Hawkins clinic of the Carolinas, Greenville, SC, USA.

Objective: The purpose of this study was to describe the epidemiology and demographics of surgically treated shoulder instability stratified by direction. We hypothesized that there would be an increased frequency of posterior and combined shoulder instability in our population compared with published literature. Secondarily, we assessed preoperative magnetic resonance imaging (MRI) reports to determine how accurately they detected the pathology addressed at surgery.

Materials And Methods: A retrospective review was conducted at a single facility during a 46-month period. The study included all patients who underwent an operative intervention for shoulder instability. The instability in each case was characterized as isolated anterior, isolated posterior, or combined, according to pathologic findings confirmed at arthroscopy. The findings were retrospectively compared with official MRI reports to determine the accuracy of MRI in characterizing the clinically and operatively confirmed diagnosis.

Results: A consecutive series of 231 patients (221 men, 10 women) underwent stabilization for shoulder instability over 46 months. Patients were a mean age of 26.0 years. There were 132 patients (57.1%) with isolated anterior instability, 56 (24.2%) with isolated posterior instability, and 43 (18.6%) with combined instability. Overall, MRI findings completely characterized the clinical diagnosis and arthroscopic pathology in 149 of 219 patients (68.0%).

Conclusion: The rate of posterior and combined instability in an active population is more common than has been previously reported, making up more than 40% of operatively treated instability, including a previously unreported incidence of 19% for combined instabilities. In addition, MRI was often incomplete or inaccurate in detecting the pathology eventually treated at surgery.
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http://dx.doi.org/10.1016/j.jse.2014.06.053DOI Listing
February 2015

Glenoid bare area: arthroscopic characterization and its implications on measurement of bone loss.

Arthroscopy 2013 Oct 29;29(10):1671-5. Epub 2013 Aug 29.

Tripler Army Medical Center, Honolulu, Hawaii, U.S.A.. Electronic address:

Purpose: The purpose of this study was to characterize arthroscopically the frequency and location of the glenoid bare area.

Methods: Three fellowship-trained orthopaedic sports surgeons evaluated and characterized the bare area of the glenoid in 52 consecutive patients undergoing arthroscopic surgery of the shoulder without a diagnosis of instability. Among the patients with a visible bare area, the position was measured, and when eccentrically located, an apparent bone loss or gain was calculated.

Results: The bare area of the glenoid was observed in only 48% of patients undergoing arthroscopic surgery, and when observed, it was at the center only 37% of the time. Of the glenoids with visible bare areas, 8% were located anteriorly enough to result in an apparent bone loss calculation of greater than 20%. An additional 25% of visible bare areas were posteriorly located, resulting in an apparent bone gain.

Conclusions: The glenoid bare area is a variably visible and eccentric landmark on the glenoid and thus should not be used as the sole reference point to measure glenoid bone loss.
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http://dx.doi.org/10.1016/j.arthro.2013.06.019DOI Listing
October 2013

Return to an athletic lifestyle after osteochondral allograft transplantation of the knee.

Am J Sports Med 2013 Sep 10;41(9):2083-9. Epub 2013 Jul 10.

Department of Orthopaedic Surgery, Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859, USA.

Background: Osteochondral allograft transplantation (OATS) is a treatment option that provides the ability to restore large areas of hyaline cartilage anatomy and structure without donor site morbidity and promising results have been reported in returning patients to some previous activities. However, no study has reported on the durability of return to activity in a setting where it is an occupational requirement.

Hypothesis: Osteochondral allograft transplantation is less successful in returning patients to activity in a population in which physical fitness is a job requirement as opposed to a recreational goal.

Study Design: Case series; Level of evidence, 4.

Methods: A retrospective review was conducted of 38 consecutive OATS procedures performed at a single military institution by 1 of 4 sports medicine fellowship-trained orthopaedic surgeons. All patients were on active duty at the time of the index procedure, and data were collected on demographics, return to duty, Knee Injury and Osteoarthritis Outcome Score (KOOS), and ultimate effect on military duty. Success was defined as the ability to return to the preinjury military occupational specialty (MOS) with no duty-limiting restrictions.

Results: The mean lesion size treated was 487.0 ± 178.7 mm(2). The overall rate of return to full duty was 28.9% (11/38). An additional 28.9% (11/38) were able to return to limited activity with permanent duty modifications. An alarming 42.1% (16/38) were unable to return to military activity because of their operative knee. When analyzed for return to sport, only 5.3% (2/38) of patients were able to return to their preinjury level. Eleven patients underwent concomitant procedures. Statistical power was maintained by analyzing data in aggregate for cases with versus without concomitant procedures. When the 11 undergoing concomitant procedures were removed from the data set, the rate of return to full activity was 33.3% (9/27), with 22.3% (6/27) returning to limited activity and 44.4% (12/27) unable to return to activity. In this subset, 7.4% (2/27) were able to return to a preinjury level of sport. The KOOS values were significantly higher in the full activity group when compared with the limited and no activity groups (P < .01). Branch of service was a significant predictor of outcome, with Marine Corps and Navy service members more likely to return to full activity compared with Army and Air Force members. A MOS of combat arms was a significant predictor of a poor outcome. All patients demonstrated postoperative healing of their grafts as documented in their medical chart, and no patient in the series required revision for problems with graft incorporation.

Conclusion: Osteochondral allograft transplantation for the treatment of large chondral defects in the knee met with disappointing results in an active-duty population and was even less reliable in returning this population to preinjury sport levels. Branch of service and occupational type predicted the return to duty, but other traditional predictors of outcome such as rank and years of service did not. The presence of concomitant procedures did not have an effect on outcome with respect to activity or sport level with the numbers available for analysis.
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http://dx.doi.org/10.1177/0363546513494355DOI Listing
September 2013

Clavicular bone tunnel malposition leads to early failures in coracoclavicular ligament reconstructions.

Am J Sports Med 2013 Jan 8;41(1):142-8. Epub 2012 Nov 8.

Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI 96734, USA.

Background: Modern techniques for the treatment of acromioclavicular (AC) joint dislocations have largely centered on free tendon graft reconstructions. Recent biomechanical studies have demonstrated that an anatomic reconstruction with 2 clavicular bone tunnels more closely matches the properties of native coracoclavicular (CC) ligaments than more traditional techniques. No study has analyzed tunnel position in regard to risk of early failure.

Purpose: To evaluate the effect of clavicular tunnel position in CC ligament reconstruction as a risk of early failure.

Study Design: Case series; Level of evidence, 4.

Methods: A retrospective review was performed of a consecutive series of CC ligament reconstructions performed with 2 clavicular bone tunnels and a free tendon graft. The population was largely a young, active-duty military group of patients. Radiographs were analyzed for the maintenance of reduction and location of clavicular bone tunnels using a picture archiving and communication system. The distance from the lateral border of the clavicle to the center of each bone tunnel was divided by the total clavicular length to establish a ratio. Medical records were reviewed for operative details and functional outcome. Failure was defined as loss of intraoperative reduction.

Results: The overall failure rate was 28.6% (8/28) at an average of 7.4 weeks postoperatively. Comparison of bone tunnel position showed that medialized bone tunnels were a significant predictor for early loss of reduction for the conoid (a ratio of 0.292 vs 0.248; P = .012) and trapezoid bone tunnels (a ratio of 0.171 vs 0.128; P = .004); this correlated to an average of 7 to 9 mm more medial in the reconstructions that failed. Reconstructions performed with a conoid ratio of ≥0.30 were significantly more likely to fail (5/5, 100%) than were those performed lateral to a ratio of 0.30 (3/23, 13.0%) (P < .01). There were no failures when the conoid ratio was <0.25 (0/10, 0%). Conoid tunnel placement was also statistically significant for predicting return to duty in our active-duty population.

Conclusion: Medial tunnel placement is a significant factor in risk for early failures when performing anatomic CC ligament reconstructions. Preoperative templating is recommended to evaluate optimal placement of the clavicular bone tunnels. Placement of the conoid tunnel at 25% of the clavicular length from the lateral border of the clavicle is associated with a lower rate of lost reduction and a higher rate of return to military duty.
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http://dx.doi.org/10.1177/0363546512465591DOI Listing
January 2013

Early failures with single clavicular transosseous coracoclavicular ligament reconstruction.

J Shoulder Elbow Surg 2012 Dec 21;21(12):1746-52. Epub 2012 Apr 21.

Orthopaedic Surgery, Tripler Army Medical Center, HI 96859, USA.

Introduction: Coracoclavicular (CC) ligament reconstruction remains a challenging procedure. The ideal reconstruction is biomechanically strong, allows direct visualization of passage around the coracoid, and is minimally invasive. Few published reports have evaluated arthroscopic techniques with a single clavicular tunnel and transcoracoid reconstruction. One such report noted early excellent results, but without specific outcome measures. This study reports the clinical and radiographic results of a minimally invasive, arthroscopically assisted technique of CC ligament reconstruction using a transcoracoid and single clavicular tunnel technique.

Materials And Methods: A retrospective review was performed of 10 consecutive repairs in 9 active duty patients who underwent CC ligament reconstruction with the GraftRope (Arthrex, Naples FL, USA). All reconstructions were performed according to the manufacturer's technique by a single, fellowship-trained surgeon. Medical records and radiographs were evaluated for demographics, operative details, loss of reduction, and return to duty.

Results: In 8 of 10 repairs (80%) intraoperative reduction was lost at an average of 7.0 weeks (range, 3-12 weeks). Four patients (40%) required revision. Subjective patient outcomes included 5 excellent/good results, 1 fair result, and 4 poor results. Tunnel widening was universally noted, and the failure mode in most patients appeared to be at the holding suture.

Conclusion: This transcoracoid, single clavicular tunnel technique was not a reliable approach to CC ligament reconstruction. We noted a high percentage of radiographic redisplacement and clinical failure. This technique, in its current form, cannot be recommended to treat AC joint injuries in our population.
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http://dx.doi.org/10.1016/j.jse.2012.01.018DOI Listing
December 2012

Operative treatment of a complete rupture of the origination of the rectus femoris.

Sports Health 2009 Nov;1(6):478-80

Aspetar Orthopaedic and Sports Medicine Hospital, DOHA, Qatar.

A 23-year-old male athlete reported both feeling and hearing a pop in his anterior thigh while sprinting. This was followed by immediate pain and an inability to walk. He had swelling and tenderness in his inguinal region. Radiographs were normal. An magnetic resonance imaging revealed a complete avulsion of the rectus femoris from its origin on the anterior inferior iliac spine. Following discussions of his treatment options, the patient chose to undergo operative management of the injury. A surgical repair was performed of the tendon of the direct head to the anterior inferior iliac spine through bone tunnels. He had a full recovery over the next 6 months and subsequently returned to unrestricted active military duty.
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http://dx.doi.org/10.1177/1941738109337777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445143PMC
November 2009

Acute operative stabilization versus nonoperative management of clavicle fractures.

Am J Orthop (Belle Mead NJ) 2009 Jul;38(7):341-5

Tripler Army Medical Center, Honolulu, HI 96859, USA.

We conducted a prospective, randomized study to determine if patients with midshaft clavicle fractures would benefit from immediate operative stabilization with a modified Hagie pin in comparison with a matched group treated with nonoperative therapy. At a level II trauma center, patients with closed midshaft clavicle fractures were prospectively randomized to receive either operative or nonoperative treatment. Fifty-seven (29 operative, 28 nonoperative) patients were enrolled in the study. Operative patients underwent open reduction and internal fixation of the clavicle using a modified Hagie pin; nonoperative patients were treated with a sling for comfort. All patients were followed at regular intervals for 1 year. They were evaluated for radiographic healing and complications and were scored with the Single Assessment Numeric Evaluation and L'Insalata instruments. Injury severities and radiographs were not statistically significantly different between the 2 groups. Functional scores in the operative group were slightly higher at 3 weeks, and the nonoperative group had slightly higher scores at 6 months and 1 year. The only statistically significant difference between the groups was at 3 weeks. Percentage follow-up at 1 year was 93% for the operative group and 82% for the nonoperative group. One patient in each group developed a nonunion, and 1 patient in each group had a refracture. Complications were higher in the operative group, and most were related to pin prominence at the posterior shoulder. Results of this study suggest that, though patients with midshaft clavicle fractures had higher functional scores at short-term follow-up after internal fixation, functional scores were similar at 6 months and 1 year. In addition, internal fixation with a modified Hagie pin was associated with a higher complication rate.
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July 2009

A comparison of bioabsorbable and metallic suture anchors in a dynamically loaded, intra-articular caprine model.

Orthopedics 2008 Nov;31(11):1106

Aspetar Orthopaedic and Sports Medicine Hospital, PO Box 29222, Doha, Qatar.

Little is known about the in vivo behavior of bioabsorbable suture anchors. A goat model was used to biomechanically and histologically test bioabsorbable and metallic suture anchors in an intra-articular environment at 0, 6, and 12 weeks. Significantly greater force was required to break the bioabsorbable construct than the metallic construct at 0 and 6 weeks. Failure of the metallic anchor constructs occurred at the eyelet. Histological analysis of both bone-anchor interfaces demonstrated equally good osteointegration without evidence of osteolysis. The bioabsorbable suture anchor tested is safe for use in clinical practice without concerns for the strength of the construct or bony reaction to the material.
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November 2008

Postoperative range of motion following anterior cruciate ligament reconstruction using autograft hamstrings: a prospective, randomized clinical trial of early versus delayed reconstructions.

Am J Sports Med 2008 Apr 22;36(4):656-62. Epub 2008 Jan 22.

Aspetar Orthopaedic & Sports Medicine Hospital, Doha, Qatar.

Background: There is a common belief that surgical reconstruction of an acutely torn anterior cruciate ligament (ACL) should be delayed for at least 3 weeks because of the increased incidence of postoperative motion loss (arthrofibrosis) and suboptimal clinical results.

Hypothesis: There is no difference in postoperative range of motion or stability after ACL reconstructions performed either acutely or delayed.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Patients with an acute ACL tear were prospectively randomized to either early (within 21 days) or delayed (beyond 6 weeks) reconstruction using autograft hamstring tendon. Previous knee surgery on the index extremity and a multiligamentous injury were exclusionary criteria. Surgical technique and postoperative rehabilitation were identical for all patients. Postoperative assessments included range of motion and KT-1000 arthrometer measurements compared with the contralateral knee. Standardized outcome measures were used including single assessment numeric evaluation (SANE), Lysholm, and Tegner Activity Score.

Results: Seventy consecutive patients were enrolled, and 1 patient was dropped after a postoperative infection. Sixty-nine patients (34 acute, 35 delayed) with an average age of 27 years composed the study cohort. The mean time from injury to surgery was 9 days (range, 2-17 days) for patients in the early group and 85 days (range, 42-192) for those in the delayed group. The average follow-up from surgery was 366 days (range, 185-869). Articular cartilage and meniscal injuries were comparable between the 2 groups. There were no significant differences between the 2 treatment groups in degrees of extension or flexion lost relative to the nonoperative side, operative time, KT-1000 arthrometer differences, or subjective knee evaluations.

Conclusion: Excellent clinical results can be achieved after ACL reconstructions performed soon after injury using autograft hamstrings. Although the authors do not advocate that all reconstructions should be performed acutely, they found that early ACL reconstructions do not result in loss of motion or suboptimal clinical results as long as a rehabilitation protocol emphasizing extension and early range of motion is employed.
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http://dx.doi.org/10.1177/0363546507312164DOI Listing
April 2008

Prophylactic bracing versus taping for the prevention of ankle sprains in high school athletes: a prospective, randomized trial.

J Foot Ankle Surg 2006 Nov-Dec;45(6):360-5

Orthopaedic Surgery, National Naval Medical Center, Rockville Pike, Bethesda, MD, USA.

Prophylactic ankle taping has been considered the mainstay of ankle injury prevention and has been used at all levels of competitive football. An alternative to taping is a semirigid ankle orthosis. This study prospectively compared the incidence of ankle sprains in high school football players during a single season, after randomization to either prophylactic bracing or taping of both ankles. Of 83 athletes followed up for an entire season, 6 ankle sprains occurred, 3 in each treatment group; and there was no statistically significant difference in the incidence of ankle sprains between the 2 groups. The time required to tape an athlete averaged 67 seconds per ankle, resulting in a total of 97 minutes per ankle during an entire season, and the average cost to tape each ankle during an entire season was greater than the cost of the commercially available brace. The projected cost savings for an athletic program using prophylactic bracing could be substantial when compared with the use of prophylactic taping of the ankle.
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http://dx.doi.org/10.1053/j.jfas.2006.09.005DOI Listing
April 2007

Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial.

Am J Sports Med 2006 Nov 30;34(11):1730-7. Epub 2006 May 30.

Orthopaedic Surgery Service, Tripler Army Medical Center, Honolulu, Hawaii, USA.

Background: Arthroscopic stabilization for anterior shoulder instability has been reported to result in a higher rate of recurrent instability compared to traditional open techniques.

Purpose: To test the null hypothesis that there is no difference in the clinical outcomes in patients with recurrent anterior shoulder instability treated with open or arthroscopic stabilization.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Magnetic resonance arthrogram studies were obtained preoperatively. These findings were compared to arthroscopic findings. Postoperative evaluations included range of motion, stability, and subjective assessments including Single Assessment Numeric Evaluation, Simple Shoulder Test, Western Ontario Instability Index, and University of California, Los Angeles evaluation. Failure was defined as a second dislocation, recurrent subluxation, or symptoms precluding return to previous work or unrestricted active military duty.

Results: Sixty-one patients, 29 who received open stabilization and 32 who received arthroscopic stabilization, were evaluated at a mean of 32 months postoperatively (range, 24-48 months). Patient demographics were equivalent. Preoperative magnetic resonance arthrogram findings were confirmed at arthroscopic examination. The mean operative time was significantly shorter for the arthroscopic repairs (59 vs 149 minutes; P < .001). There were 3 clinical failures (2 open stabilizations, 1 arthroscopic stabilization) by the established criteria. There was a statistically significant improvement from preoperative to postoperative Single Assessment Numeric Evaluation scores in both groups (P < .001). The mean loss of motion (compared to the contralateral shoulder) was greater in the open shoulders. Subjective evaluations were equal in both groups.

Conclusion: Clinical outcomes after arthroscopic and open stabilization were comparable. Preoperative magnetic resonance arthrograms in shoulders with anterior instability allow an accurate diagnosis of intra-articular abnormality that correlates well with operative findings. Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization.
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http://dx.doi.org/10.1177/0363546506288239DOI Listing
November 2006

Physiological changes in venous hemodynamics associated with elective fasciotomy.

Ann Vasc Surg 2006 May 13;20(3):301-5. Epub 2006 Apr 13.

Department of Vascular Surgery, Washington Hospital Center, Washington, DC 20010, USA.

It has been postulated that lower extremity fasciotomy may disrupt the calf musculovenous pump and predisposes to development of chronic venous insufficiency (CVI). However, studies based on trauma patients who undergo emergent fasciotomy are confounded by the possibility of concomitant vascular and soft tissue injury and use historical controls. This is a prospective study that evaluates venous hemodynamics in young patients undergoing elective fasciotomy for chronic exertional compartment syndrome (CECS), eliminating the problems associated with retrospective study of trauma patients. CECS was diagnosed by history and, when indicated, measurement of compartment pressures. Prior to elective two- or four-compartment fasciotomy, each patient underwent lower extremity air plethysmography (APG) and colorflow duplex ultrasonography. These studies were repeated a minimum of 6 weeks postoperatively. Fifteen patients who had fasciotomies for CECS were studied; two of these patients had bilateral fasciotomies for a total of 17 limbs. There were 13 male and two female patients (average age 31.2 years). APG and colorflow duplex were performed an average of 12 weeks after fasciotomy. Outflow fraction, venous volume, and ejection volume showed no significant changes postoperatively. However, the venous filling index (VFI) increased (0.9 +/- 0.1 vs. 1.1 +/- 0.1 mL/sec; p < 0.05, paired t-test), the ejection fraction tended to decrease (59 +/- 4% vs. 52 +/- 2%; p < 0.08, paired t-test), and the residual volume fraction (RVF) increased (26 +/- 3% vs. 36 +/- 5%; p < 0.05, paired t-test). There were no patients with evidence of deep venous reflux. Two extremities with preoperative greater saphenous vein (GSV) reflux did not worsen, and three extremities developed new GSV reflux following fasciotomy, although VFI remained normal in each extremity. Elective fasciotomy for CECS does not lead to significant venous reflux but likely does diminish calf muscle pump function and increases RVF moderately in young adult patients. With longer follow-up this diminished calf muscle pump function may increase the risk of CVI.
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http://dx.doi.org/10.1007/s10016-006-9041-zDOI Listing
May 2006