Publications by authors named "Erik Hohmann"

106 Publications

Editorial Commentary: Delphi Expert Consensus Clarifies Evidence-Based Medicine for Shoulder Instability and Bone Loss.

Authors:
Erik Hohmann

Arthroscopy 2021 Jun;37(6):1729-1730

Anterior glenohumeral instability with glenoid bone loss is a difficult problem and often requires open procedures with bone block augmentation. The current evidence suggests glenoid bone loss of 20% or more as a cutoff value indicating augmentation. Expert consensus-based techniques, such as the Delphi, clarify evidence-based medicine and allow pooling of expert opinion in a scientific fashion. These methods suggest that 3-dimensional computed tomography should be used to evaluate bone loss, previous dislocations, or failed soft-tissue surgery; Hill-Sachs lesions are poorly quantified by standard imaging; and, in cases with a bone deficit of >20%, glenoid bone graft should be considered. No consensus was reached regarding glenoid track evaluation, magnetic resonance imaging for evaluation of bone loss, safety of arthroscopic Latarjet, remplissage use for Hill-Sachs lesions of less than 30%, indications for a shoulder sling for 4 to 6 weeks after surgery, or postoperative rehabilitation timing and range-of-motion protocols.
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http://dx.doi.org/10.1016/j.arthro.2021.01.055DOI Listing
June 2021

Increased Posterior Slope of the Medial and Lateral Meniscus Posterior Horn Is Associated with Anterior Cruciate Ligament Injuries.

Arthroscopy 2021 May 6. Epub 2021 May 6.

Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa; Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates.

Purpose: To measure the slope of the medial and lateral posterior horn of the meniscus and its contribution to the overall resulting posterior tibial slope (bone and meniscus combined slope) in anterior cruciate ligament-intact (ACLI) and -deficient (ACLD) knees.

Methods: Magnetic resonance images of intact menisci in patients 16 to 60 years old were included. Posterior tibial bone slope (PTS) and meniscus slope (MS) were measured 25%, 50%, and 75% from the medial and lateral borders of the tibial plateau. Analysis of variance was used to determine differences in posterior tibial slopes between ACLD and ACLI knees and between sexes for ACLD and ACLI knees.

Results: 192 ACLI patients (age 35.2 ± 9.6 years, mean ± standard deviation) and 159 ACLD patients (age 34.2 ± 10.3 years) were included. Medial and lateral PTS in ACLD was significantly (P = .00001) higher at 25%, 50%, and 75%. Medial and lateral MS in ACLD was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences for medial or lateral MS in ACLD or ACLI patients (P = .51). The resultant combined medial and lateral slope in ACLD patients was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences in PTS (P = .68), MS (P = .51), or resultant slope (P = .79) CONCLUSIONS: The results of this study strongly suggest that lower meniscal slopes of both the medial and lateral posterior horns are associated with ACL injuries in both males and females. Although the posterior horns reversed the bone PTS to an anterior inclined slope in both ACLD and ACLI patients, both the meniscus slope and the combined resultant slope were significantly lower and more positive at all 6 measured locations in ACLD knees.

Level Of Evidence: III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.arthro.2021.04.066DOI Listing
May 2021

Editorial Commentary: If the Massive Rotator Cuff Tear is Irreparable, Just Fix the Rotator Cable.

Authors:
Erik Hohmann

Arthroscopy 2021 05;37(5):1411-1413

Large and massive rotator cuff tears are not always reparable and present a difficult clinical problem. If surgery is warranted surgical options range from arthroscopic debridement, partial repairs, degradable spacers, tendon transfers, and more superior capsular reconstruction. The rotator cable is formed by the deep layer of the coracohumeral ligament and the crescent structure running from the anterior insertion site of the supraspinatus to the inferior border of the infraspinatus. The role of the rotator cable is not clear but seems to play a role in reducing tendon stress and influence glenohumeral kinematics. In this laboratory-based cadaver study the anterior cable was reconstructed with semitendinosus allograft treating large "irreparable" rotator cuff defects. Reconstruction resulted in reduced superior migration and subacromial contact forces without inhibiting range of motion.
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http://dx.doi.org/10.1016/j.arthro.2021.01.016DOI Listing
May 2021

Nearly One-Third of Published Systematic Reviews and Meta-Analyses Yield Inconclusive Conclusions: A Systematic Review.

Arthroscopy 2021 Apr 20. Epub 2021 Apr 20.

Heartland Orthopedic Specialists, Alexandria, Minnesota, U.S.A.

Purpose: To perform a systematic review that determines the percentage of published orthopedic surgery and sports medicine systematic reviews and meta-analyses that have a conclusive conclusion.

Methods: A systematic review was performed using PRISMA guidelines. Six high-quality orthopedics journals were chosen for analysis over a 10-year eligibility period. Systematic reviews and meta-analyses published in these journals were included in the investigation. Narrative, scoping, and umbrella reviews were excluded. A systematic review or meta-analysis was defined as having an inconclusive conclusion if the conclusion in the manuscript body or abstract was stated directly as inconclusive, indeterminate, unknown, or having a lack of evidence (or no evidence). A conclusive conclusion stated a direct answer to the study's primary and/or accessory outcomes. Due to the categorical nature of the data, comparisons were made using χ test and logistic regression.

Results: There were 1,108 systematic reviews/meta-analyses analyzed (30.9 ± 70.3 studies analyzed per review). More reviews (69.9%) were published with conclusive conclusions rather than without (30.1%). More reviews were surgical (73%) rather than nonsurgical. The United States and North America published the most reviews by country and continent, respectively. There were statistically significant differences between countries (highest proportion with China) and continents (highest proportion with Asia) based on the number of conclusive conclusions in published reviews, respectively. There were no significant differences in the proportion of conclusive conclusion reviews between the 6 analyzed journals. Australia published the largest proportion on nonsurgical reviews. The British Journal of Sports Medicine published a significantly higher proportion of nonsurgical reviews than the other 5 journals. There was no temporal relationship with the proportion of conclusive conclusion reviews.

Conclusions: This systematic review observed that only 70% of orthopedic systematic reviews and meta-analyses published in 6 high-quality orthopedic journals over a 10-year eligibility period had conclusive conclusions.

Level Of Evidence: Level IV, systematic review and/or meta-analysis of studies with Levels I to IV.
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http://dx.doi.org/10.1016/j.arthro.2021.03.073DOI Listing
April 2021

Editorial Commentary: Stem Cells. They Are in the Fat Tissue, Bone Marrow, and Even in the Synovial Fluid of the Knee Joint.

Authors:
Erik Hohmann

Arthroscopy 2021 03;37(3):901-902

Adult stem cells have been isolated in bone marrow and adipose tissue. These mesenchymal stromal cells (MSCs) have the ability to differentiate into osteogenic, chondrogenic, and adipogenic cell lines. The study by Branch et al. has identified MSCs in the synovial fluid of the knee in patients after anterior cruciate ligament injury and in patients with osteoarthritis of the knee. When mixing synovial fluid with whole blood and using a commercially available platelet-rich plasma-processing system, the total number of MSCs doubled in both groups when compared with the cell count in synovial fluid only. However, it is not clear whether the MSCs in the processed synovium-whole blood mix include synovial MSCs versus MSCs from only the blood. In addition, cell counts were substantially lower when compared with the typical concentrations of MSCs in bone marrow aspirate. The clinical application is yet to be defined.
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http://dx.doi.org/10.1016/j.arthro.2020.12.216DOI Listing
March 2021

Defining the popliteal fossa by bony landmarks and mapping of the courses of the neurovascular structures for application in popliteal fossa surgery.

Anat Cell Biol 2021 Mar;54(1):10-17

Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa.

Surgical access to the posterior knee poses a high-risk for neurovascular damage. The study aimed to define the popliteal fossa by reliable bony landmarks and comprehensively mapping the neurovascular structures for application in posterior knee surgery. Forty-five (20 male, 25 female) embalmed adult cadaveric knees were included. The position of the small saphenous vein (SSV), medial cutaneous sural nerve (MCSN) and lateral cutaneous sural nerv (LCSN), tibial nerve (TN) and common fibular nerve (CFN) nerves, and popliteal vein (PV) and popliteal artery (PA) were determined in relation to either medial (MFE) or lateral (LFE) femoral epicondyles, medial (MTC) and lateral (LTC) tibial condyles and the midpoint between the MFE and MTC and LFEF and LTC. The distance between the MFE and the PA, PV, TN, MCSN, and SSV was 38.4±12.1 mm, 38.4±12.9 mm, 39.4±10.2 mm, 39.2±14.0 mm and 37.6±12.5 mm respectively for males and 34.6±4.9 mm, 32.8±5.6 mm and 38.0±8.1 mm 38.8±10.1 mm and 37.9±8.2 mm respectively for females. The distance between LFE and the CFN and LCSN was 13.4±8.2 mm and 24.9±7.3 mm respectively for males and 8.4±9.1 mm and 18.4±10.4 mm respectively in females. This study defined the popliteal fossa by reliable bony landmarks and provided a comprehensive map of the neurovascular structures and will help to avoid injuries to the important neurovascular structures.
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http://dx.doi.org/10.5115/acb.20.179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8017454PMC
March 2021

The posterior horn of the medial and lateral meniscus both reduce the effective posterior tibial slope: a radiographic MRI study.

Surg Radiol Anat 2021 Feb 9. Epub 2021 Feb 9.

Faculty of Health Sciences, Department of Anatomy, School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: The purpose of this study was to quantify the posterior horn meniscal slope and determine its contribution to the reduction in posterior tibial slope.

Methods: Patients aged between 16 and 60 years and had intact menisci with no evidence of previous injury or surgery were included. Patients with radiological evidence of osteoarthritis Grade II-IV, any acute or chronic meniscus injuries, fractures, and ligamentous injuries were excluded. The posterior bony slope (PTS) and the meniscus slope (MS) of the posterior horns were measured at 25, 50, and 75% from the medial and lateral borders of the tibial plateau.

Results: 325 MR images (mean age 37.1 ± 10.9 years) were included. There were 194 males and 131 females, with 162 left and 163 right knees. The PTS in the medial compartment ranged from (-) 2.8° to 3.7° and from (-) 1.3° to 1.9° in the lateral compartment (p = 0.0001). The MS in the medial compartment ranged from 27.4° to 28.2°, and from 27.8° to 28.7° in the lateral compartment (p > 0.05). The differences between the medial and lateral knee compartment were statistically significant. At the 25% interval the p level was 0.037, at 50% p = 0.00001, and at 75% p = 0.0001. There were no significant between gender differences.

Conclusions: The results of this study demonstrated a significant reduction in posterior tibial bone slope by the posterior horns of both the medial and lateral meniscus, from a mean of (-) 1° to 2° to a more horizontal anterior slope. The posterior bone slope was larger in the medial compartment by 1°, resulting in a smaller slope reduction in the lateral compartment.
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http://dx.doi.org/10.1007/s00276-021-02696-8DOI Listing
February 2021

The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions.

Arch Orthop Trauma Surg 2021 Mar 3;141(3):437-445. Epub 2021 Jan 3.

Department of Anatomy, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed.

Methods: In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1-M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher's exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages.

Results: The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8-33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4-24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4-37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively.

Conclusion: The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit.

Clinical Relevance: Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.
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http://dx.doi.org/10.1007/s00402-020-03708-9DOI Listing
March 2021

The determination of safe zones for arthroscopic portal placement into the posterior knee by mapping the courses of neurovascular structures in relation to bony landmarks.

Eur J Orthop Surg Traumatol 2021 Jan 3. Epub 2021 Jan 3.

Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.

Purpose: Minimally invasive surgery in the posterior knee is high risk for iatrogenic injury to popliteal neurovascular neurovasculature structures. This study aimed to use reliable landmarks to define safe zones for arthroscopic portal placement into the posterior knee.

Methods: Distances were measured between bony landmarks and neurovascular structures within the popliteal fossa using 45 formalin-embalmed cadavers: small saphenous vein (SSV), medial (MCSN) and lateral (LCSN) cutaneous sural nerves, tibial nerve (TN), common fibular nerve (CFN), popliteal vein (PV) and artery (PA). The structures were measured in relation to medial (MEF) and lateral (LEF) femoral epicondyle, medial (MCT) and lateral (LCT) tibial condyle and the midpoint between the landmarks.

Results: The mean distance (mm) between MEF and structures was, male and female, respectively: SSV 37.6 + 12.5, 37.9 + 8.2; MCSN 39.2 + 14, 38.8 + 10.1; TN 39.4 + 10.2, 38.0 + 8.1; PV 38.4 + 12.9, 32.8 + 5.6; PA 38.4 + 12.1, 34.6 + 4.9. At midpoint and MCT all structures medialized between 5 and 28%. The mean distance between LEF and structures was, male and female, respectively: CFN 13.4 + 8.2, 8.4 + 9.1; LCSN 24.9 + 7.3, 18.4 + 10.4. At midpoint and LCT the CFN lateralized by 37-42% and the LCSN medialized by 8-9%.

Conclusions: Results suggest posteromedial portal placement can be safely established < 20 mm from the medial femoral epicondyle, tibial condyle or the midpoint between the two landmarks. Posterolateral portal placement is of higher risk, and entry point is 18 mm from the lateral femoral epicondyle, tibial condyle or the midpoint between the two landmarks in males and 12 mm in females. These landmarks will allow safe portal placement in 99% of cases.
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http://dx.doi.org/10.1007/s00590-020-02847-4DOI Listing
January 2021

Author Reply to "Is Criticism About Inherent Biases in Rigorous Orthopaedic Trials Prone to Biases?"

Arthroscopy 2021 01;37(1):9-11

Department of Orthopaedic Sports Medicine, School of Medicine and Sports Science, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany.

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http://dx.doi.org/10.1016/j.arthro.2020.11.002DOI Listing
January 2021

Editorial Commentary: Discovery: Progenitor Cells and Endothelial Cells Are Found in the White-White Zone of the Meniscus, But This Does Not Mean That These Tears Heal or Should Be Repaired.

Authors:
Erik Hohmann

Arthroscopy 2021 01;37(1):266-267

More than 35 years ago, the concept of vascular zones of the meniscus was introduced. It has been shown that blood supply is limited to the peripheral 25% of the lateral and 30% of the medial meniscus. This obviously has repercussions with regard to the healing potential of meniscus tears, whether repaired or not. In general, tears that extend into the white-white zone, such as flaps, cleavage tears, and radial tears, are deemed irreparable. However, several recent reports have suggested that radial tears in the white-white zone, when repaired, heal and have good clinical outcomes. Now progenitor mesenchymal cells have been identified in the white-white zones, confirming the potential of the meniscus to heal. However, blood supply was demonstrated only by indirect signs such as the presence of endothelial cells and the presence of endothelial surface markers.
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http://dx.doi.org/10.1016/j.arthro.2020.11.007DOI Listing
January 2021

Editorial Commentary: Another Take on the Anterolateral Ligament: High-Grade Are Worse Than Low-Grade Injuries, But the Categorization Is Problematic.

Authors:
Erik Hohmann

Arthroscopy 2021 01;37(1):231-233

The anatomy, function, and existence of the anterolateral ligament (ALL) is still hotly debated and a controversial topic. Currently both basic biomechanical and clinical studies are not providing sufficient and strong evidence to either support or refute that the ALL plays an important role for knee stability. One could argue that stability is provided by the anterolateral complex, including the iliotibial band, Kaplan fibers, and the anterolateral capsule, which may contain a structure called the ALL. Magnetic resonance imaging (MRI) is routinely performed in patients with anterior cruciate ligament (ACL) injury, but unfortunately ALL injuries cannot be reliably diagnosed in patients with concomitant ACL tears. When dividing ALL injuries into high and low grade using preoperative MRI and investigating clinical outcomes after double-bundle ACL reconstruction, patients with high-grade injuries have inferior outcomes and a significantly greater revision rates. However, the limitations of this research reduce the validity of these conclusions: high rate of loss to follow-up above accepted standard, unequal size of their study groups, fragility index of zero, the inaccuracy of diagnosing ALL injuries in the presence of ACL tears on MRI, and the dilemma with randomly classifying high- and low-grade ALL injury based on MRI.
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http://dx.doi.org/10.1016/j.arthro.2020.10.022DOI Listing
January 2021

Editorial Commentary: Platelet-Rich Plasma and Hyaluronic Acid Injection for Knee Osteoarthritis Are Both Cost Effective.

Authors:
Erik Hohmann

Arthroscopy 2020 12;36(12):3079-3080

Knee osteoarthritis is associated with an annual cost to society exceeding US$27 billion. Value-based treatment is an important consideration, and cost-benefit analyses are crucial to determine the benefits to both patients and society. The quality-adjusted life year (QALY) is a generic measure of burden including both quality and quantity. Recent studies have suggested that intra-articular injection of platelet-rich plasma (PRP) is effective treatment for knee osteoarthritis and comparable to hyaluronic acid (HA). Although the costs (dollars) per QALY were higher for PRP ($8,635) than for HA ($5,331), PRP was more cost effective at 1 year and was associated with an incremental cost-effectiveness ratio (ICER) of $12,628 QALY. Similarly, the utility value (proportion of QALY compared with perfect health) of PRP was higher by 0.11 QALY: 0.69 versus 0.58.
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http://dx.doi.org/10.1016/j.arthro.2020.09.039DOI Listing
December 2020

Editorial Commentary: Posterior Shoulder Instability and Anatomic Capsular-Labral Reconstruction: Repair the Posterior Inferior Glenohumeral Ligament to the Glenoid Neck at the 7 O'Clock Position.

Authors:
Erik Hohmann

Arthroscopy 2020 11;36(11):2820-2821

Posteroinferior glenohumeral instability occurs in 10% of all instability cases but is observed increasingly more often. Arthroscopic posterior capsulolabral repair is the current standard for surgical management if nonoperative treatment fails. In contrast to the anterior inferior glenohumeral ligament (IGHL), the posterior IGHL inserts onto the glenoid surface rather than onto the labrum. This implies that suture anchors should be placed on the glenoid rim when repairing these defects. However, clinical studies demonstrate excellent clinical outcomes irrespective of the location of the suture anchor.
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http://dx.doi.org/10.1016/j.arthro.2020.08.022DOI Listing
November 2020

What is the optimal timing for bone grafting during staged management of infected non-unions of the tibia? A systematic review and best evidence synthesis.

Injury 2020 Dec 10;51(12):2793-2803. Epub 2020 Oct 10.

Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Queensland University of Technology, Australia; Orthopaedic Research Centre of Australia, Australia. Electronic address:

Purpose: To summarize the best available evidence with regards to timing of staged bone grafting for infected tibial non-union, and to extract evidence-based criteria indicating when bone grafting can be safely performed.

Methods: Medline, Embase, Scopus, and Google Scholar were searched, and publications of evidence Level I-IV from 2000 to 2020 were included. Risk of bias was assessed with the Cochrane Collaboration's Risk of Bias Tool and ROBINS-I tool. Study quality was assessed with the GRADE system, Coleman methodology score, and Methodological Index for Non-Randomized Studies (MINORS). Heterogeneity was assessed with the I statistic. A forest plot was used to pool the timing of bone grafting for all included studies. For data synthesis and analysis, a best evidence synthesis was used.

Results: A total of 15 studies were included (353 cases). Risk of bias was high in 8 studies and the quality for 14 studies was assessed as very low, with a mean Coleman score of 33.5 and a mean MINORS score of 7.9. The mean time from the index surgery to bone grafting was 7.03 weeks ranging from 2 to 15 weeks (lower limit 6 weeks, upper limit 8.07 weeks). Best evidence analysis demonstrated that 8 of the 15 studies (53%) with 237 cases (67%) performed staged bone grafting inside this window. Union was achieved in 92%.

Conclusion: The results of this best evidence systematic review suggest that, for most infected tibial non-unions, secondary bone grafting can be successfully performed between 6-8 weeks with expected union rates over 90%.
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http://dx.doi.org/10.1016/j.injury.2020.10.043DOI Listing
December 2020

Editorial Commentary: Medial Meniscal Root Repair May Not Be Required During Knee Medial-Compartment Unloading High Tibial Osteotomy.

Authors:
Erik Hohmann

Arthroscopy 2020 09;36(9):2476-2477

Medial meniscal root tears are biomechanically similar to a total meniscectomy. Repair is clinically indicated and supported by evidence. Increased contact pressures can result in cartilage degeneration and early onset of osteoarthritis. Once diffuse grade 3 or 4 osteoarthritis has settled in, repair may not be indicated anymore. Combining medial meniscal root repair with a high tibial osteotomy for grade 3 or 4 medial-compartment osteoarthritis is not beneficial, and osteotomy alone provides very similar clinical outcomes at 2 years. Meniscal healing was observed in only 18% of patients, and the rate of "cartilage recovery" during second-look arthroscopy was between 8% and 24%. The low sample size, short follow-up, and historical control group limit the validity and generalizability of these conclusions.
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http://dx.doi.org/10.1016/j.arthro.2020.06.026DOI Listing
September 2020

Surgical Translational Research May Be Forward or Reverse.

Arthroscopy 2020 09;36(9):2345-2346

The classic concept of translational research can be described as a bench-to-bedside approach. Reverse translational research, bedside-to-benchtop, also may have a place. Under some circumstances, innovative clinicians may develop new techniques in advance of basic science research. A recent example of the success of reverse translational research is shoulder superior capsular reconstruction. Theoretically, new surgical techniques are ideally first tested ex vivo, but this does not guarantee clinical success, and in some cases, experienced, specialized surgeon-scientists can modify existing techniques and perform novel interventions with little risk to patients. Benefits of reverse translational research include a shorter time from innovation to application, and real, not theoretical, determination of clinical outcome. If a reverse approach is warranted, strict adherence to bioethical principles is required, including cooperation with ethics committees, institutional review boards, trial registration, and informed consent. Translational research can be bidirectional.
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http://dx.doi.org/10.1016/j.arthro.2020.07.001DOI Listing
September 2020

Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 04 21;49(5):1381-1393. Epub 2020 Aug 21.

Orthopaedic Research Centre of Australia, Brisbane, Australia.

Background: Plantar fasciitis is a common cause of heel pain. Corticosteroid injections are commonly used and proven to be effective, and lately platelet-rich plasma (PRP) has been used with mixed results.

Purpose: To perform a systematic review and meta-analysis comparing intralesional injections of PRP and steroid infiltration.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar including all level 1 and 2 studies from 2010 to 2019 was perfomed. American Orthopaedic Foot and Ankle Society and visual analog scale for pain scores were used as outcome variables. Publication bias and risk of bias was assessed with the Cochrane Collaboration tools. The Grading of Recommendations, Assessment, Development and Evaluations system was used to assess the quality of the body of evidence. Heterogeneity was assessed with χ and statistics.

Results: Fifteen studies were included in the analysis. Nine studies had a high risk of bias. There was 1 study with high quality, 9 with moderate, 2 studies with low, and 3 with very low quality. The pooled estimate for the American Orthopaedic Foot and Ankle Society score demonstrated nonsignificant differences at 1 month ( = .4) and 3 months ( = .076). At 6 months ( = .009) and 12 months ( = .009), it indicated significant differences in favor of PRP. The pooled estimate for visual analog scale demonstrated nonsignificant differences at 1 month ( = .653). At 3 months ( = .0001), 6 months ( = .002), and 12 months ( = .019), it yielded significant differences in favor of PRP.

Conclusion: The results of this systematic review and meta-analysis suggest that PRP is superior to corticosteroid injections for pain control at 3 months and lasts up to 1 year. In the short term, there is no advantage of corticosteroid infiltration. However, the low study quality, high risk of bias, and different protocols for PRP preparation reduce the internal and external validity of these findings, and these results must be viewed with caution.
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http://dx.doi.org/10.1177/0363546520937293DOI Listing
April 2021

Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex.

Strategies Trauma Limb Reconstr 2019 Sep-Dec;14(3):142-147

Medical School, University of Pretoria, Pretoria, Gauteng, South Africa.

Aim: The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators.

Material And Methods: This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months' follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student's tests.

Results: In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF ( = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) ( = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) ( = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) ( = 0.34 and 0.69).

Conclusion: The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients.

Level Of Evidence: Therapeutic level III.

How To Cite This Article: Naude J, Manjra M, Birkholtz FF, Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. Strategies Trauma Limb Reconstr 2019;14(3):142-147.
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http://dx.doi.org/10.5005/jp-journals-10080-1443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368362PMC
August 2020

Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification.

J Orthop Trauma 2021 02;35(2):71-76

Orthopaedic Research Centre of Australia, Brisbane, QLD, Australia.

Objectives: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability.

Design: Retrospective classification.

Setting: Tertiary referral trauma center.

Patients/participants: Twenty open fractures with bone loss.

Intervention: Assignment of a bone defect classification grade.

Main Outcome Measurements: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests.

Results: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001.

Conclusions: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.
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http://dx.doi.org/10.1097/BOT.0000000000001896DOI Listing
February 2021

Author Reply: Arthroscopic Subacromial Decompression. What Are the Indications? A Level V Evidence Clinical Guideline.

Arthroscopy 2020 06;36(6):1493-1495

Department of Orthopaedic Sports Medicine, School of Medicine and Sports Science, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany.

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http://dx.doi.org/10.1016/j.arthro.2020.03.023DOI Listing
June 2020

Editorial Commentary: Femoral Nerve Block: Don't Kill the Motor Branch.

Authors:
Erik Hohmann

Arthroscopy 2020 07 23;36(7):1981-1982. Epub 2020 May 23.

Femoral nerve block is commonly used for pain control after knee surgery and helps to reduce the need for opioids in the early postoperative period. The potential disadvantage is blockage of the motor branch of the femoral nerve, resulting in quadriceps weakness and reduced strength by up to 50%. Adductor canal nerve block is a possible alternative resulting in less muscle weakness. The rationale behind adductor canal nerve block is blockage of the saphenous nerve and part of the obturator nerve, providing reliable and adequate pain relief.
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http://dx.doi.org/10.1016/j.arthro.2020.05.020DOI Listing
July 2020

Editorial Commentary: Coracoclavicular Ligament Reconstruction. Double Up It Is?

Authors:
Erik Hohmann

Arthroscopy 2020 05;36(5):1271-1272

More than 100 surgical techniques have been described for the reconstruction of the coracoclavicular ligament complex. None of the techniques appears superior, but double-button fixation for acute high-grade acromioclavicular dislocations has become an attractive option. The clinical outcomes are good to excellent, and the return to physical activity and sport is above 90%. However, complications such as loss of reduction and tunnel widening have been described and can reach up to 80%. The load to failure of the native coracoclavicular complex is more than 600 N, and any surgical technique must surpass this figure. Single-button and loop techniques do not always sufficiently stabilize the acromioclavicular joint. Even double- and triple-button techniques may not restore vertical and horizontal stability of the acromioclavicular joint to its native normal state. Double-button technique restores both scapula and clavicular rotation closest to the native state, but still has lower stiffness and results in higher superior-inferior translation, which could cause ongoing vertical instability.
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http://dx.doi.org/10.1016/j.arthro.2020.03.015DOI Listing
May 2020

The Association Between Anterior Cruciate Ligament Length and Femoral Epicondylar Width Measured on Preoperative Magnetic Resonance Imaging or Radiograph.

Arthrosc Sports Med Rehabil 2020 Feb 18;2(1):e23-e31. Epub 2019 Dec 18.

School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: To determine whether femoral epicondylar width (FECW) obtained from either magnetic resonance imaging (MRI) or plain radiographs could be used to predict anterior cruciate ligament (ACL) length. A secondary purpose was to develop a formula to use maximum FECW on either MRI or plain radiographs to estimate ACL length preoperatively.

Methods: The MRIs and radiographs of 40 patients (mean age 41.0 years), with no apparent knee pathology, surgery, or trauma were included. The ACL length was measured on MRI followed by FECW on both MRI and radiograph of the same patient. This allowed the development of equations able to predict ACL length according to the FECW measured on either an MRI or radiograph.

Results: The mean ACL length was 40.6 ± 3.6 mm. FECW measured on both MRIs and radiographs was sufficient to predict ACL length. Pearson's correlations revealed a high positive relationship between ACL length and FECW on MRI (r = 0.89, < .0001) and ACL length and FECW on radiograph (r = 0.83, < .0001). The coefficient of determination (R) was calculated to be MRI: R = 0.78 and radiograph: R = 0.68 and confirmed that FECW measured on both MRI and radiograph were sufficient to predict ACL length. Based on these models, ACL length can be predicted by FECW using the following formulas: MRI: ACL length = 0.47 (FECW) + 1.93 and radiograph: ACL length = 0.31 (FECW) + 11.33.

Conclusions: This study demonstrated that FECW measured on either MRI or anteroposterior radiograph could reliably estimate ACL length on a sagittal MRI. There was a high positive relationship between ACL length and FECW on both MRI and radiographs, although MRIs do predict ACL length more reliably.

Clinical Relevance: Preoperative ACL length assessment, using FECW on MRI or radiograph, is useful in graft selection and in preventing inadequate graft harvesting for ACL reconstruction, especially if an individualized anatomical approach is pursued.
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http://dx.doi.org/10.1016/j.asmr.2019.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120849PMC
February 2020

Editorial Commentary: Meniscal Repair-Why Bother?

Authors:
Erik Hohmann

Arthroscopy 2020 04;36(4):1154-1155

Whether to repair or resect meniscal tears remains a matter of controversy. In theory, partial meniscectomy increases contact pressure, which may result in progressive and early cartilage degeneration and early osteoarthritis. Meniscal preservation is the preferred treatment option, but only a small percentage of meniscal tears are suitable for repair. Two recent registry studies challenge this approach and suggest that partial meniscectomy has similar clinical outcomes in the short term. Whether these findings can be maintained in the long term remains to be seen.
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http://dx.doi.org/10.1016/j.arthro.2020.01.010DOI Listing
April 2020

Editorial Commentary: Shoulder Superior Capsule Reconstruction: Should We Suture Leftover Dermal Allograft to the Inferior Acromion?

Authors:
Erik Hohmann

Arthroscopy 2020 03;36(3):687-688

Superior capsular reconstruction remains a controversial procedure, and long-term results still need to be established. Graft thickness seems crucial and fascia lata appears superior to dermal allograft. Using a subacromial spacer by suturing dermal allograft to the subacromial bone "increases graft thickness" and reduces superior humeral head migration but increases subacromial pressures in a static laboratory cadaver model. It remains to be seen whether clinical studies support this concept.
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http://dx.doi.org/10.1016/j.arthro.2019.12.010DOI Listing
March 2020

Is platelet-rich plasma effective for the treatment of knee osteoarthritis? A systematic review and meta-analysis of level 1 and 2 randomized controlled trials.

Eur J Orthop Surg Traumatol 2020 Aug 14;30(6):955-967. Epub 2020 Feb 14.

Orthopaedic Research Centre of Australia, Brisbane, Australia.

Introduction: The purpose of this study was to perform a systematic review and meta-analysis comparing intra-articular knee injection of PRP and hyaluronic acid and investigate clinical outcomes and pain at both 6 and 12 months.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar was performed in the English and German literature reporting on intra-articular knee injections for knee osteoarthritis. All level 1 and 2 studies with a minimum of 6-month follow-up in patients with knee osteoarthritis from 2010 to 2019 were included. Clinical outcome was assessed by WOMAC and IKDC scores and pain by VAS and WOMAC pain scores. Subgroup analysis for autologous platelet-rich plasma (ACP) was performed. Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. The GRADE system was used to assess the quality of the body of evidence. Heterogeneity was assessed using χ and I statistics.

Results: Twelve studies (1,248 cases; 636 PRP, 612 HA) met the eligibility criteria. The pooled estimate demonstrated non-significant differences between PRP and HA for clinical outcomes at 6 months (p = 0.069) and at 12 months (p = 0.188). However, the pooled estimate for pain did demonstrate significant differences in favour of PRP at 6 months (p = 0.001) and 12 months (p = 0.001). For the ACP subgroup (249 cases), the pooled estimate for these studies demonstrated significant differences in favour of PRP (p < 0.0001) at 6 months.

Conclusion: The results of this systematic review and meta-analysis suggest that PRP is superior to HA for symptomatic knee pain at 6 and 12 months. ACP appears to be clearly superior over HA for pain at both 6 and 12 months. There were no advantages of PRP over HA for clinical outcomes at both 6 and 12 months.

Level Of Evidence: Level 2; systematic review and meta-analysis.
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http://dx.doi.org/10.1007/s00590-020-02623-4DOI Listing
August 2020

Editorial Commentary: Fifty Is the New 30? Do Patients in Their 50s Deserve an Anterior Cruciate Ligament Reconstruction?

Authors:
Erik Hohmann

Arthroscopy 2020 02;36(2):563-565

Evidence suggests that anterior cruciate ligament reconstruction in patients older than 50 years of age has similar outcomes when compared with younger patients. However, poorer results are associated with advanced degenerative intra-articular chondral changes. The caveat here is that these conclusions are mainly based on retrospective level IV case series. The question is whether functionally unstable patients 50 years and older, whether active or not, benefit from surgical reconstruction and the answer is clearly yes. It provides restoration of function and should be considered in active older patients with subjective instability who have not responded to nonoperative treatment.
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http://dx.doi.org/10.1016/j.arthro.2019.10.038DOI Listing
February 2020

Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique.

Arthroscopy 2020 02 31;36(2):501-512. Epub 2019 Dec 31.

Orthopaedic Research Centre of Australia, Brisbane, Australia; Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia.

Purpose: The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears.

Methods: Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%.

Results: There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes.

Conclusions: This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes.

Level Of Evidence: Level V - expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2019.08.014DOI Listing
February 2020

An anatomical investigation into the blood supply of the proximal humerus: surgical considerations for rotator cuff repair.

JSES Open Access 2019 Dec 18;3(4):320-327. Epub 2019 Nov 18.

Department of Orthopaedic Surgery and Sports Medicine, Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.

Background: The purpose of this study was to investigate the blood supply of the humeral head (HH) originating from the anterior (ACHA) and posterior circumflex humeral arteries (PCHA).

Methods: Formalin preserved specimens were used to measure ACHA length, ACHA length in the bicipital groove (BG), the length of the ascending branch of the ACHA, the penetration point of the ascending branch of the ACHA at the greater tuberosity (GT), and the penetration point of the ascending branch PCHA at the GT. Fresh specimens were used to identify the intraosseous vascular network by both the ACHA and PCHA by injecting a contrast medium using a high-resolution microfocus computed tomography. Specimens were then dissected to expose where the branches of the ACHA and PCHA penetrate the bone, and a small section of the medial head was removed to visualize dye penetration of the cancellous bone.

Results: Seven variations for the course of the ACHA were observed. In 36%, the ACHA runs posterior to the BG and posterior to the long head of biceps tendon, and splits into the anterolateral ascending and descending branch. The ascending branch enters the medial wall of the GT. Microfocus computed tomography demonstrated that the intraosseous branch of the ascending branch of the ACHA runs within the GT in a medial direction from its penetration point just along the lateral edge of the BG. Intraosseous accumulation of contrast within the GT supply occurs more toward the inferior aspect of the HH, and the anterior-superior and superior-medial aspect of the HH is not perfused. This region is a high-risk zone for avascular necrosis.

Conclusion: The results of this study suggest that 7 variations for the course of the ACHA exist. These variations and the interruption of the intraosseous arterial network in the GT with surgery and suture anchor placement result in a high-risk zone in the superomedial aspect of the humeral head overlapping with the area where early aseptic necrosis is identified.
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http://dx.doi.org/10.1016/j.jses.2019.09.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928301PMC
December 2019