Krych, Aaron J.

Purpose The purpose of this study was to determine failure rates, functional outcomes, and risk factors for failure after revision anterior shoulder stabilization surgery in high‐risk adolescent athletes. Methods Adolescent athletes who underwent primary anterior shoulder stabilization were reviewed. Patients undergoing subsequent revision stabilization surgery were identified and analyzed. Failure rates after revision surgery were assessed by Kaplan‐Meier analysis. Failure was defined as recurrent instability requiring reoperation. Functional outcomes included the Marx activity score; American Shoulder and Elbow Surgeons score; and University of California, Los Angeles score. The characteristics of patients who required reoperation for recurrent instability after revision surgery were compared with those of patients who required only a single revision to identify potential risk factors for failure. Results Of 90 patients who underwent primary anterior stabilization surgery, 15 (17%) had failure and underwent revision surgery (mean age, 16.6 years; age range, 14 to 18 years). The mean follow‐up period was 5.5 years (range, 2 to 12 years). Of the 15 revision patients, 5 (33%) had recurrent dislocations and required repeat revision stabilization surgery at a mean of 50 months (range, 22 to 102 months) after initial revision. No risk factors for failure were identified. The Kaplan‐Meier reoperation‐free estimates were 86% (95% confidence interval, 67% to 100%) at 24 months and 78% (95% confidence interval, 56% to 100%) at 48 months after revision surgery. The mean final Marx activity score was 14.8 (range, 5 to 20); American Shoulder and Elbow Surgeons score, 82.1 (range, 33 to 100); and University of California, Los Angeles score, 30.8 (range, 16 to 35). Conclusions At 5.5 years' follow‐up, adolescent athletes had a high failure rate of revision stabilization surgery and modest functional outcomes. We were unable to convincingly identify specific risk factors for failure of revision surgery. Level of Evidence Level IV, retrospective therapeutic case series.

AbstractPurposeAssessment of hip internal rotation (IR) is a critical element in the evaluation of a painful hip, yet there currently exists no consistent method of determining this measurement. The purpose of this study is to report the intra‐rater and inter‐rater reliability of active and passive hip IR measurement using a digital inclinometer.MethodsTwenty‐five subjects (8 men, 17 women) with asymptomatic hip joints, and no known pathology between the ages of 22 and 42 participated. Two examiners measured hip IR for each subject using a digital inclinometer while visually monitoring pelvic motion. Measurements included passive IR, active IR, and active IR while internally rotating both legs simultaneously. Statistical analysis was performed including intra‐rater and inter‐rater reliability.ResultsThere was no significant difference in measured IR values. Mean range of motion values for all techniques and both examiners ranged from 30.7° to 32.8°. Intra‐rater reliability for examiner 1 ranged from 0.84 to 0.92. Inter‐rater reliability ranged from 0.89 to 0.93. Of the methods utilized, active IR of a single leg was the most responsive technique with a minimal detectable change value of 5.4°.ConclusionsClinical assessment of hip IR range of motion can be performed efficiently and reliably with a digital inclinometer along with visual monitoring of the pelvis for unwanted motion. Findings from this study support unilateral active hip IR in a seated position as a reliable and responsive technique for obtaining hip IR measurements.Level of evidenceIII.

AbstractImproving the effectiveness of adipose‐tissue derived human mesenchymal stromal/stem cells (AMSCs) for skeletal therapies requires a detailed characterization of mechanisms supporting cell proliferation and multi‐potency. We investigated the molecular phenotype of AMSCs that were either actively proliferating in platelet lysate or in a basal non‐proliferative state. Flow cytometry combined with high‐throughput RNA sequencing (RNASeq) and RT‐qPCR analyses validate that AMSCs express classic mesenchymal cell surface markers (e.g., CD44, CD73/NT5E, CD90/THY1, and CD105/ENG). Expression of CD90 is selectively elevated at confluence. Self‐renewing AMSCs express a standard cell cycle program that successively mediates DNA replication, chromatin packaging, cyto‐architectural enlargement, and mitotic division. Confluent AMSCs preferentially express genes involved in extracellular matrix (ECM) formation and cellular communication. For example, cell cycle‐related biomarkers (e.g., cyclins E2 and B2, transcription factor E2F1) and histone‐related genes (e.g., H4, HINFP, NPAT) are elevated in proliferating AMSCs, while ECM genes are strongly upregulated (>10‐fold) in quiescent AMSCs. AMSCs also express pluripotency genes (e.g., POU5F1, NANOG, KLF4) and early mesenchymal markers (e.g., NES, ACTA2) consistent with their multipotent phenotype. Strikingly, AMSCs modulate expression of WNT signaling components and switch production of WNT ligands (from WNT5A/WNT5B/WNT7B to WNT2/WNT2B), while upregulating WNT‐related genes (WISP2, SFRP2, and SFRP4). Furthermore, post‐proliferative AMSCs spontaneously express fibroblastic, osteogenic, chondrogenic, and adipogenic biomarkers when maintained in confluent cultures. Our findings validate the biological properties of self‐renewing and multi‐potent AMSCs by providing high‐resolution quality control data that support their clinical versatility. J. Cell. Biochem. 115: 1816–1828, 2014. © 2014 Wiley Periodicals, Inc.

Abstract A recent randomized trial from the Finnish Degenerative Meniscal Lesion Study Group was published in the New England Journal of Medicine and attempted to determine the efficacy of partial meniscectomy without osteoarthritis. Patients were randomized to either arthroscopic partial meniscectomy or sham surgery. The authors concluded that the clinical outcomes after arthroscopic partial meniscectomy were no better than those after the sham surgical procedure. However, there are several important limitations of this trial that make it difficult to generalize to the 700,000 arthroscopic partial meniscectomies performed in the United States each year. In this small sample of 146 patients, patients with traumatic meniscal tears and locking symptoms—those most likely to benefit from a partial meniscectomy—were excluded. In addition, although patients with radiographic arthritis were excluded, most of the patients in the study had degenerative changes at the time of arthroscopy. Therefore it is difficult to determine whether the patients were symptomatic from their chondral degeneration or their degenerative meniscal tear. In our opinion this study does not change the role of surgery in current clinical practice. The primary indication for arthroscopic partial meniscectomy remains symptoms of well‐localized joint line pain with acute onset and mechanical symptoms such as catching or locking that have failed comprehensive nonoperative management.

AbstractPurposeTo identify patient concomitant injury and surgical characteristics associated with 6‐month excellent functional and isokinetic testing results following anterior cruciate ligament (ACL) reconstruction.MethodsPatients that underwent ACL reconstruction by a single surgeon had isokinetic and functional testing performed with excellent 6‐month outcome defined as greater than 85 % in isokinetic strength and 90 % in functional tests (excellent 6‐month group vs. delayed 6‐month group). Patient concomitant injury and surgical factors were then analysed in univariate and multivariate statistical models to assess which characteristics predicted the excellent 6‐month group.ResultsThe 224 patients included 93 males and 131 females, with median age of 22 (range 12–59) years, body mass index (BMI) of 25.4 (range 17–44), and median Tegner activity score of 6 (range 2–10). Fifty‐two patients (23 %) were included in the excellent 6‐month group, while 172 patients (77 %) were in the delayed 6‐month group. In univariate analysis, favourable factors with the excellent 6‐month outcome group were younger age (24 vs. 27; p = 0.01), lower BMI (24.5 vs. 26.2; p = 0.03), and minimal articular cartilage damage (71 vs. 56 %; p = 0.048). In multivariate analysis, a negative effect was observed for patients older than 30 years that had ACL reconstruction with autograft (p = 0.0004).ConclusionFactors significantly associated with excellent 6‐month functional and isokinetic test results following ACL reconstruction included younger age, lower BMI, and minimal cartilage degeneration. The use of allograft was associated with improved functional and strength testing after ACL reconstruction in patients over 30 years of age.Level of evidencePrognostic/therapeutic study, Level III.

AbstractPurposeCurrently, there is a paucity of literature regarding outcomes after isolated labral debridement. The purpose of this study was to (1) report the reoperation rate following isolated labral debridement, (2) report clinical and functional outcomes after labral debridement with a minimum 2‐year follow‐up and (3) identify risk factors for worse clinical and functional outcomes. It was hypothesized that inferior outcomes are associated with an increasing Tönnis grade and those with untreated femoral acetabular impingement (FAI).MethodsThe records of patients undergoing hip arthroscopy between 1998 and 2005 were reviewed. Patients with labral tears who underwent isolated arthroscopic labral debridement were identified. Kaplan–Meier estimate of failure (defined as subsequent surgery) was performed for all patients. Patients with minimum 2‐year follow‐up were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate analysis was then performed to assess which factors were associated with worse clinical and functional outcomes.ResultsFifty‐nine hips in 57 patients met our inclusion criteria (39 females, 18 males) with a mean age of 46 ± 14 years and mean follow‐up of 5 (range 2–14) years. Overall, 45 % of the hips failed for repeat surgery (20 %) or rating for hip function as abnormal or severely abnormal (25 %). Twelve hips (20 %) required subsequent surgical intervention at a mean 23 (range 6–60) months (7 total hip arthroplasties, 2 open revisions, 3 arthroscopic revisions). Of the remaining hips, mean MHHS was 83.4 ± 19.7, mean HOS ADL score was 83.8 ± 21.3 and mean HOS sport score was 70.6 ± 32.9, with 33 of 41 (75 %) reporting normal or nearly normal current level of function. Univariate analysis revealed that hips with untreated bony impingement (p = 0.01) or requiring concomitant chondroplasty (p = 0.03) had inferior clinical outcome scores.ConclusionsIsolated arthroscopic labral debridement for hip labral tears had 45 % combined poor results when strictly defining failure as repeat surgery or abnormal hip rating. Untreated FAI and concomitant chondroplasty were risk factors for inferior outcome. We recommend concomitant treatment for bony impingement lesions and preservation of the labrum whenever possible.Level of evidenceRetrospective case series, Level IV.

Abstract Purpose Intra‐articular (IA) hip cortisone injection is commonly performed as a therapeutic modality in patients with femoral acetabular impingement (FAI). To our knowledge, there is no published data evaluating the clinical benefit of these injections. The purpose of this study was to assess the efficacy of therapeutic IA cortisone injection in these patients. Methods At our institution, patients with FAI and labral tear prospectively recorded their numerical rating scale (NRS) pain scores pre‐injection, during post‐injection anaesthetic phase, and at 14 days post‐injection. From this cohort, all patients treated with guided IA cortisone injection, no radiographic evidence of arthritis (Tönnis grade 0 or 1) and pain relief during the anaesthetic phase of the IA injection were included. An absolute change of two points on the NRS score was considered the minimal amount of clinically significant pain relief. Pain scores were compared between the different types of steroid injected. Results Fifty‐four patients (35 females, 19 males) with a mean age of 32 ± 12 years were included. Average median pre‐injection NRS score was 7.0 (range 2.5–10.0), post‐injection anaesthetic phase was 1.0 (range 0.0–5.0), and 14 day post‐injection was 5.0 (range 0.0–10.0). As a group, NRS scores significantly diminished from post‐injection anaesthetic phase to 14 days post‐injection ( p < 0.001). At 14 days post‐injection, only 20 patients (37 %) and at 6 weeks, only 3 patients (6 %) reported a clinically significant decrease in pain. Average duration of pain relief was 9.8 days. There was no difference in pain reduction between steroid preparations. Conclusion In patients with symptomatic FAI and labral tear, intra‐articular cortisone injection has limited clinical benefit as a therapeutic modality. However, anaesthetic‐only IA injections for patients who may be candidates for hip arthroscopy can be a useful diagnostic tool. Level of evidence Therapeutic case series, Level IV.

Abstract We present our technique for isolated arthroscopic rotator interval closure in the treatment of mild symptomatic glenohumeral instability in the absence of a labral tear. A careful history, physical examination, and imaging help to identify a select subset of atraumatic instability patients who may benefit from this procedure, and diagnostic arthroscopy can provide further evidence. By use of a posterior viewing portal with anterior and anterolateral working portals, the anterior capsuloligamentous complex is mobilized, and the rotator interval is closed with carefully placed sutures to advance the capsule superiorly and provide tension through decreased capsular volume. Technique Video video See video under supplementary data.

Abstract Femoral neck osteoplasty is an integral component for successful treatment of femoroacetabular impingement. Current techniques allow this to be performed arthroscopically, and results are equivalent to those of open procedures when typical anterior and anterosuperior lesions are considered. The arthroscopic procedure is dependent on obtaining adequate visualization through capsular management and proper leg positioning, and it requires fluoroscopy to guide and verify an adequate resection. We present our preferred technique for arthroscopic femoral neck osteoplasty. Technique Video video See video under supplementary data.