To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA).Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale.The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA.The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings.Level II, randomized controlled trial.
Objectives: Most clinical studies pertaining to shoulder dislocation use age cutoffs of 16 years, and at present, only small case series of patients aged 10-16 years guide our management. Using a general population cohort aged 10 to 16 years, we sought to: 1) determine the overall and demographic-specific incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR), and 2) determine the rate of and risk factors for repeat shoulder CR. Methods: Using administrative databases, we identified all patients who underwent CR of a primary anterior shoulder dislocation by a physician in Ontario between April 2002 and September 2010 (the index event). Exclusion criteria included age (16 years), posterior dislocation, and prior shoulder dislocation or surgery. The IDR was calculated for the entire cohort and compared by age and sex subgroups. The main outcome, repeat shoulder CR, was sought until September 2012. A time-to-event analysis (cumulative incidence function) was used to determine the incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years for the entire cohort and subgroups based on age (10-12, 13, 14, 15, and 16 years). A competing risk model identified risk factors for repeat shoulder CR, which were reported using hazard ratios (HR) with 95% confidence intervals (CI). Results: We identified 2,066 patients aged 10-16 years who underwent CR following a primary anterior shoulder dislocation, of which, 1,937 met the exclusion criteria. The median age was 15.0 years and 79.7% were male. The IDR was 20.1 per 100,000 person-years, and was highest among 16 year-old males (164.4 per 100,000 person-years). In contrast, primary anterior shoulder dislocation was rare among patients aged 10-12 years [5.9% (N=115) of all primary dislocations]. Repeat shoulder CR was observed in 740 patients (38.2%) after a median of 0.8 years. The overall cumulative incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years was 13.0%, 21.3%, 29.2%, and 36.2%, respectively; however, the cumulative incidence by age (Figure 1) revealed the rate of repeat shoulder CR to be highest among 14-16 year-olds (37.2-42.3%), and considerably less among patients aged 10-13 years (0-25.0%). Male sex (HR 1.2, p=0.04; interpreted as a 20% increased risk for males as compared to females) and patient age (HR 1.2, p<0.001; interpreted as a 20% increased risk for each year over age 10) significantly influenced the risk of a repeat shoulder CR. Overall, 31.2% (N=604) of patients underwent shoulder stabilization, of which, half underwent surgery following the index shoulder CR (49.9%, N=369). Conclusion: Primary anterior shoulder dislocations are common among 14-16 year olds, and the rate of recurrence in this age group following non-operative management mirrors that of 17-20 year olds in previously published data. In contrast, both the incidence of primary anterior dislocation and rate of recurrence are considerably lower for patients aged 10-13 years. Going forward, clinicians should treat and counsel patients aged 14-16 years, particularly males, as they do older adolescents (17-20 years); however, patients 13 years of age or younger should be counselled regarding their low risk for recurrence.
We thank Drs. Vecchione and Boretsky for their comments[1][1] on our recent manuscript discussing the suitability of regional anesthesia (RA) for common orthopedic injuries and procedures that may be associated with acute compartment syndrome (ACS).[2][2] Although our manuscript did not
Many anesthesiologists are unfamiliar with the rate of surgical neurological complications of the shoulder and elbow procedures for which they provide local anesthetic–based anesthesia and/or analgesia. Part 1 of this narrative review series on neurological complications of elective orthopedic surgery describes the mechanisms and likelihood of peripheral nerve injury associated with some of the most common shoulder and elbow procedures, including open and arthroscopic shoulder procedures, elbow arthroscopy, and total shoulder and elbow replacement. Despite the many articles available, the overall number of studied patients is relatively low. Large prospective trials are required to establish the true incidence of neurological complications following elective shoulder and elbow surgery.
What's New
As the popularity of regional anesthesia increases with the development of ultrasound guidance, anesthesiologists should have a thoughtful understanding of the nerves at risk of surgical injury during elective shoulder and elbow procedures.
Despite most patients reporting optimal knee function after anterior cruciate ligament reconstruction (ACLR), not all return to their pre-injury level of sport, often due to psychological factors. The ACL-Return to Sport after Injury Scale (ACL-RSI) was developed to measure the emotions, confidence in performance, and risk appraisal among athletes returning to sport. The purpose of this study was to determine the Patient Acceptable Symptom State (PASS) threshold for the ACL-RSI in patients undergoing ACLR.
This study reports the clinical outcome of reconstruction of deficient abductor muscles following revision total hip arthroplasty (THA), using a fresh-frozen allograft of the extensor mechanism of the knee. A retrospective analysis was conducted of 11 consecutive patients with a severe limp because of abductor deficiency which was confirmed on MRI scans. The mean age of the patients (three men and eight women) was 66.7 years (52 to 84), with a mean follow-up of 33 months (24 to 41). Following surgery, two patients had no limp, seven had a mild limp, and two had a persistent severe limp (p = 0.004). The mean power of the abductors improved on the Medical Research Council scale from 2.15 to 3.8 (p < 0.001). Pre-operatively, all patients required a stick or walking frame; post-operatively, four patients were able to walk without an aid. Overall, nine patients had severe or moderate pain pre-operatively; ten patients had no or mild pain post-operatively. At final review, the Harris hip score was good in five patients, fair in two and poor in four. We conclude that using an extensor mechanism allograft is relatively effective in the treatment of chronic abductor deficiency of the hip after THA when techniques such as local tissue transfer are not possible. Longer-term follow-up is necessary before the technique can be broadly applied.
Anatomic techniques of ankle ligament repair have the advantage of restoring the anatomy and kinematics of the joint. This study presents a technique for anatomic reconstruction of the lateral ligament complex by way of lateral ligament advancement using suture anchors associated with immediate protected full weightbearing; 2- to 5-year clinical outcomes are reported.This technique of providing an anatomic reconstruction with a secure fixation will enable early rehabilitation with immediate, protected weightbearing, with favorable outcomes.Case series; Level of evidence, 4.Fifty-five patients with chronic lateral ankle instability who failed nonoperative management underwent modified Broström repair (lateral ligament fibular advancement) between 2005 and 2008. The anterior talofibular ligament and calcaneofibular ligament were released from the fibula and advanced using 2 double-loaded metallic suture anchors (3.5 mm). Full weightbearing in a walking boot was allowed from the first postoperative day. Patients were assessed preoperatively and at a minimum 2-year follow-up using the Foot and Ankle Outcome Score. Complication, failure (recurrent instability), and return-to-sport rates were also recorded.Six patients (11%) were lost to follow-up, leaving a study group of 49 patients (23 men, 26 women). The mean age at the time of surgery was 25 years (range, 18-37 years), with a mean duration of symptoms of 1.8 years (range, 6 months to 5 years). The mean follow-up time was 42 months (range, 24-60 months). Significant improvement was seen in the Foot and Ankle Outcome Score from preoperatively to postoperatively (from 36 to 75.4, P < .001): the pain subscale improved from 35 to 75 (P < .001), the symptom subscale from 29 to 77 (P = .01), the function subscale from 45 to 77 (P < .001), the function in sports and recreation subscale from 38 to 70 (P < .001), and the foot and ankle-related quality of life subscale from 35 to 78 (P < .001). No significant difference in range of motion with the contralateral side was seen (P = .34). The failure rate was 6%, with 3 patients reporting residual instability after a traumatic retear. Two cases of superficial wound infection were seen. One case of temporary neurapraxia of the superficial peroneal nerve was observed. The return-to-sport rate was 94%.This study demonstrates that anterior talofibular ligament and calcaneofibular ligament advancement using suture anchor fixation is an effective procedure for the treatment of chronic lateral ankle instability and allows immediate weightbearing.
