Joint chondrolysis

One to Two Days of Rest Is Recommended Before Returning to Sport After Intra-Articular Corticosteroid Injection in the High-Level Athlete

Return to sport following a corticosteroid injection is a complex decision. Multiple considerations should be taken into account, including steroid dose and formulation, involvement of the affected joint in the activity, and intensity of the activity. Research investigating the adverse effects of corticosteroid injections with early initiation of high-intensity activity is limited and has produced mixed results. Rest following injections has typically been recommended to minimize both chondrotoxic effects and systemic absorption. Based on the current research and extensive experience treating professional athletes, we recommend 1 to 2 days of rest of the affected joint or region with a progressive increase of activity following a corticosteroid injection with possible benefits including maximizing the beneficial effects of the injection and a reduced systemic effect.

LEVEL OF EVIDENCE

Level V, expert opinion.

Dumontier group 2 radiocarpal fracture-dislocation: The results of open reduction and fixation without volar ligament repair

INTRODUCTION

The radiocarpal fracture-dislocations are a spectrum of severe injury involving both the bony and ligamentous structures that stabilise the wrist joint. The aim of this study was to analyse the outcome of open reduction and fixation without volar ligament repair for Dumontier group 2 radiocarpal fracture-dislocation and to evaluate the incidence and clinical relevance of ulnar translation and advanced osteoarthritis.

PATIENTS AND METHODS

We retrospectively reviewed 22 patients with Dumontier group 2 radiocarpal fracture-dislocation treated in our institute. Clinical and radiological outcomes were recorded. Postoperative visual analogue scale (VAS) score for pain, Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH), and Mayo modified wrist scores (MMWS) were collected. Furthermore, extension‒flexion and supination‒pronation arcs were collected by reviewing chart, either. We divided the patients into two groups according to the presence or absence of advanced osteoarthritis, and presented the differences in the pain, disability, wrist performance, and range of motion between the two groups. We performed the same comparison between the patients with and those without the ulnar translation of the carpus.

RESULTS

There were sixteen men and six women with a median age of 23 years (range, 20‒48 years). The median follow-up period was 33 months (range, 12-149 months). The median VAS, DASH and MMWS were 0 (range 0-2), 9.1 (range, 0-65.9) and 80 (range, 45-90), respectively. The median flexion‒extension and pronation‒supination arcs were 142.5° (range, 20°‒170°) and 147.5° (range, 70°‒175°), respectively. Ulnar translation was recognised in four patients and the development of advanced osteoarthritis was noted in 13 patients during the follow-up period. However, neither was highly correlated with functional outcomes.

CONCLUSION

The current study postulated that ulnar translation might occur following treatment for Dumontier group 2 lesions, whereas injury was predominantly caused by rotational force. Therefore, radiocarpal instability should be recognized during the operation. However, the clinical relevance of ulnar translation and wrist osteoarthritis needs to be assessed in further comparison studies.

Review article: Ankle intra-articular haematoma block for reduction of unstable ankle fractures in the emergency department: An integrative review

A review was conducted to assess the efficacy and safety of the intra-articular haematoma block (IAHB) for manipulation of ankle fractures in ED. Any study investigating the success of IAHB for ankle fracture reduction published in English was sought. Seven databases were searched. The Cochrane Risk of Bias tool was used to quality assess the included studies. Three studies met the inclusion criteria (n = 436 patients). Just one study was a randomised controlled trial (n = 42). The two non-randomised studies that included the majority of patients were assessed as at high overall risk of bias. The studies reported no significant difference in the overall rate of successful reduction or patient-reported pain scores between IAHB and procedural sedation groups. A subgroup analysis in one study suggested timelier reduction by 51.4 min (P = 0.01) for fractures involving subluxation when using IAHB, but that more patients with dislocation were reduced on first attempt when using procedural sedation compared to IAHB (74.0% vs 54.8%, P < 0.01). No adverse events were reported from using IAHB, although no study measured events such as joint sepsis or chondrolysis. Findings suggest that IAHB might be safe and effective but the evidence is very limited. High-quality research is required before IAHB can be considered a routine alternative. However, IAHB could be considered in situations where the risk of procedural sedation outweighs the likely very low risk of chondrolysis.

Results 25 Years After Hemiarthroplasty for Chondrolysis of the Shoulder. A Report of Two Cases

Two patients (age, 34 and 52 years) underwent an open repair of concealed rotator cuff tear with the aid of color arthrography using gentian violet. Postoperatively, they developed chondrolysis of the shoulder, which was treated with hemiarthroplasty. Twenty-five years after hemiarthroplasty, both patients showed good shoulder function without significant glenoid erosion on radiographs. Satisfactory long-term results are most probably due to maintenance of humeral head centering and glenohumeral conformity. These are the longest follow-up cases of arthroplasty for chondrolysis of the shoulder in the literature. We conclude that hemiarthroplasty can be a reasonable option for patients with this unfortunate disorder.

Imaging appearance of post-arthroscopic radiocarpal chondrolysis: comparison with osteoarthritis associated with scapholunate dissociation

BACKGROUND

Since the diagnosis of post-arthroscopic chondrolysis is very difficult, it can be underdiagnosed and confused with other diseases in clinical practice.

PURPOSE

To propose imaging features of post-arthroscopic radiocarpal chondrolysis (PRCC) and to compare these with osteoarthritis associated with scapholunate dissociation which are the most common misdiagnoses of PRCC.

MATERIAL AND METHODS

To identify missed diagnoses of PRCC, 994 magnetic resonance imaging scans performed in 910 patients were retrospectively reviewed. After the identification of 73 patients who exhibited significant radiocarpal cartilage loss, 11 were diagnosed with PRCC. Since scapholunate advanced collapse was the most common incorrect diagnosis of PRCC (4/11), the imaging findings were compared among the 11 patients with PRCC and 14 patients with osteoarthritis caused by scapholunate dissociation who were diagnosed in the same period. The following imaging features were evaluated: scapholunate dissociation; the center of disease and grade of radiocarpal joint destruction; characteristics of bone marrow edema; the presence of radial styloid and distal scaphoid osteophytes; and the extent of joint effusion and synovitis.

RESULTS

The imaging diagnosis of PRCC was significantly differentiated from osteoarthritis associated with scapholunate dissociation based on occurrence at a younger age, bone marrow edema crossing the joint, center of disease in the proximal radioscaphoid joint, and absence of radial styloid and scaphoid osteophytes (P < 0.05). PRCC occasionally presented with arch-shape bone marrow edema based on the proximal carpal row.

CONCLUSION

The diagnosis of PRCC can be aided if its characteristic imaging findings are differentiated from other disease entities in patients with a history of arthroscopy.

Risk Factors for Rapid Chondrolysis After Partial Lateral Meniscectomy: A Scoping Review of the Literature

Background

The occurrence of rapid chondrolysis after partial lateral meniscectomy is rare. The pathophysiology, risk factors, and outcomes of treatment have not been established.

Purpose

The primary aim of this study was to perform a scoping review of the literature to determine the potential risk factors and pathogenesis of rapid chondrolysis. The secondary objective was to report outcomes of treatment.

Study Design

Systematic (scoping) review.

Methods

A scoping review of the literature was conducted in accordance with the framework of Arksey and O'Malley. A search strategy based on the terms "chondrolysis" AND "knee," "chondrolysis" AND "meniscus," and "chondral damage" AND "lateral meniscus" was applied to the PubMed database on March 31, 2020. All relevant studies were included. Patient demographics and clinical data were extracted from these studies and analyzed in order to investigate the potential risk factors, pathogenesis, and outcomes of treatment for rapid chondrolysis.

Results

Five articles (22 cases) featuring rapid chondrolysis in the lateral compartment after partial lateral meniscectomy were identified and included. The condition occurred most frequently in patients who were young (mean age, 25.6 years), male (20/22 cases; 91%), and participating in high-intensity sports (19/22 cases; 86.4%) within 1 year of the index procedure. Half of the included study population underwent surgery for a radial tear. All professional athletes (13/13) returned to the preinjury level of sport. All authors of included studies suggested that the main causal risk factor was mechanical focal cartilage overload in the lateral compartment of the knee.

Conclusion

Rapid chondrolysis after partial lateral meniscectomy is a rare condition that typically occurs within 12 months of the index procedure. Younger age, male sex, high-intensity sports participation, and some meniscal tear patterns (eg, radial tear) are potentially important risk factors. Return-to-sport rates at short-term follow up are high, but no long-term studies were identified. The pathogenesis of rapid chondrolysis seems to relate to mechanical focal cartilage overload.

Local Hematoma Block as Postoperative Analgesia in Pediatric Supracondylar Humerus Fractures

Purpose

Supracondylar humerus fracture (SHF) is the most common type of fracture in children. The aim of this study was to evaluate the efficacy of local hematoma block with 0.25% bupivacaine as postoperative pain control in patients with pediatric SHF who underwent closed reduction pin fixation.

Methods

We performed an institutional review board–approved, prospective cohort study of 65 patients with SHF treated with closed reduction percutaneous pin fixation. For 6 months, all patients were randomly divided into 2 groups. The treatment group (35 patients) received an intraoperative local hematoma block using 0.25% bupivacaine whereas the control group (30 patients) did not receive a local hematoma block as postoperative pain management adjuvant. After surgery, all patients were prescribed opioid pain medication. To evaluate the efficacy of the hematoma block, postoperative morphine equivalent consumption and the Faces Pain Scale–Revised (FPS-R) survey were blindly recorded during postoperative day 1. Demographic data, surgical details, clinical neurovascular examination during the hospital stay, and complications were also evaluated.

Results

Comparison of the control group with the treatment group showed similar morphine equivalent consumption and Face Pain Scale–Revised Survey results. No hematoma block-associated complications were reported.

Conclusions

The result of this study do not favor the use of local hematoma block to improve pain control and decrease the need for opioid use on postoperative day 1 in pediatric SHF after patients undergo closed reduction percutaneous pin fixation. These results can lay the foundation for future studies while suggesting new, novel opioid-free pain control strategies in patients with SHF.

Type of study/level of evidence

Therapeutic II.

Long-term Results of Combined Epiphysiodesis and Imhauser Intertrochanteric Osteotomy in SCFE: A Retrospective Study on 53 Hips

BACKGROUND

The management of moderate and severe slipped capital femoral epiphysis is still an issue. The main concern is represented by the choice of an intra-articular or an extra-articular osteotomy to correct the deformity. Theoretically, the intra-articular osteotomy allows the best correction, but it is technically demanding and involves a higher risk of avascular necrosis (AVN); conversely, an extra-articular intertrochanteric osteotomy (ITO) is easier and involves a lower risk of early complications, but may lead to femoroacetabular impingement, resulting in early osteoarthritis and the need for total hip replacement (THR).The aim of this study was to analyze the long-term survivorship free from THR after combined epiphysiodesis and Imhauser ITO.

METHODS

From 1975 to 2000, 45 patients (53 hips) underwent a combined epiphysiodesis and Imhauser ITO. There were 27 male and 18 female patients with an average age of 12.8±1.9 years. All cases showed a posterior sloping angle >40 degrees (mean, 69±16 degrees). The cumulative survivorship was determined according to Kaplan and Meier, with the end point defined as conversion to THR.

RESULTS

A total of 6 patients (6 hips; 11%) had a follow-up <2 years. Among them, no postoperative complications occurred. For the remaining 39 patients (47 hips, 89%), the mean follow-up was 21±11 years. Four early postoperative complications were reported (2 AVN, 2 chondrolysis). The cumulative 39 years' survivorship free from THR was 68.5% (95% confidence interval, 42.4%-84.7%). The age at surgery (hazard ratio=1.849 per year older, P=0.017) and the postoperative onset of AVN or chondrolysis (hazard ratio=10.146, P=0.010) affected the long-term prognosis significantly.

CONCLUSIONS

The combined epiphysiodesis and Imhauser ITO is a valid surgical option in moderate to severe slipped capital femoral epiphysis, preserving the natural hip for at least 39 years in the majority of the patients. Care must be taken to avoid AVN or chondrolysis. The age at surgery affects the prognosis negatively.

LEVEL OF EVIDENCE

Level III-a retrospective study.

Volar Dislocation of the Metacarpophalangeal Joint of the Ring Finger Complicated with Chondrolysis: A Case Report and Review of the Literature

Volar dislocation of the metacarpophalangeal joint is rare injury. In the literature consulted only seven cases of isolated volar dislocation of the metacarpophalangeal joint of the ring finger have been published. Chondrolysis associated with the metacarpophalangeal joint dislocation has not been reported in the English literature. In this paper, an unusual case of volar dislocation of the metacarpophalangeal joint is presented and a review of the literature is described.

Adult-onset idiopathic chondrolysis of the hip

We report the case of a 23-year-old man diagnosed with adult-onset idiopathic chondrolysis of the hip. Chondrolysis of the hip is a disorder most frequently seen in children who have suffered with slipped capital femoral epiphyses. Idiopathic chondrolysis of the hip is extremely rare and to our knowledge, its onset has never been documented in adults aged over 20. With reference to the available medical literature, we summarise the current clinical management of this unusual but important cause of young adult hip pain.

In Vivo Arthroscopic Temperatures: A Comparison Between 2 Types of Radiofrequency Ablation Systems in Arthroscopic Anterior Cruciate Ligament Reconstruction-A Randomized Controlled Trial

PURPOSE

To compare a plasma ablation device with a standard ablation device in anterior cruciate ligament (ACL) reconstruction to determine which system is superior in terms of intra-articular heat generation and diathermy efficiency.

METHODS

This was a prospective, randomized controlled trial. The inclusion criteria were adult patients undergoing primary ACL reconstruction. Patients were randomized preoperatively to the standard ablation group or the plasma ablation group. A thermometer was inserted into the inferior suprapatellar pouch, and the temperature, time, and duration of radiofrequency ablation were measured continually.

RESULTS

No significant differences were found between the standard ablation system and the plasma ablation system for maximum temperature (29.77°C and 29.34°C, respectively; P = .95), mean temperature (26.16°C and 26.99°C, respectively; P = .44), minimum temperature (22.66°C and 23.94°C, respectively; P = .54), and baseline temperature (26.80°C and 27.93°C, respectively; P = .35). Similarly, no significant differences were found for operative time (82.90 minutes and 80.50 minutes, respectively; P = .72) and mean diathermy activation times (2.6 minutes for both systems; P = .90). The between-system coefficient of variation for the measured parameters ranged from 0.12% to 3.69%. No intra-articular readings above the temperature likely to damage chondrocytes were recorded. The mean irrigation fluid temperature had a significant correlation with the maximum temperature reached during the procedure (Spearman rank correlation, r = 0.87; P < .01).

CONCLUSIONS

No difference in temperature was observed between the standard ablation and plasma ablation probes during ACL reconstruction. Temperatures did not exceed critical temperatures associated with chondrocyte death.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Normal radiological unossified hip joint space and femoral head size development during growth in 675 children and adolescents

Evaluation of hip joint space width during child growth is important to aid in the early diagnosis of hip pathology in children. We established reference values for hip joint space and femoral head size for each age. Hip joint space development during growth was retrospectively investigated medial and cranial in 1350 hip joints of children using standard anteroposterior supine plain pelvic radiographs. Maximum capital femoral epiphysis diameter and femoral radii were further more investigated. Hip joint space values show a slow decline during growth. Joint space was statistically significantly (p < 0.006) larger in boys than girls. Our hip joint space measurements on supine subjects seem slightly larger than those reported by Hughes on standing subjects. Evaluation of the femoral head diameter and the radii showed a size curve quite parallel to the known body growth charts. Radii medial and perpendicular to the physis are not statistically significantly different. We recommend to compare measurements of hip joint space at two locations to age dependent charts using the same imaging technique. During growth, a divergence in femoral head size from the expected values or loss of the spherical shape should raise the question of hip disorder. Clin. Anat. 30:267-275, 2017. © 2016 Wiley Periodicals, Inc.

Shoulder arthroplasty for chondrolysis

BACKGROUND

Chondrolysis is a rare complication after shoulder arthroscopy leading to early joint destruction. Shoulder arthroplasty may be considered for end-stage chondrolysis, but concerns exist about implant survivorship, given the younger age of this population. This study aimed to assess pain relief, function, and survivorship of shoulder arthroplasty for chondrolysis and to assess risk factors for failure.

METHODS

Between January 2000 and January 2013, 26 consecutive shoulders with chondrolysis were treated at our institution with shoulder arthroplasty. All shoulders had a prior arthroscopic procedure that predated a phase of rapid joint destruction. Twenty-three shoulders were followed up for a minimum of 2 years or until reoperation (mean, 4.0 years; range, 0.7-8.6 years). The mean age of the patients was 40 years (range, 21-58 years). Outcome measures included pain, range of motion, postoperative modified Neer ratings, American Shoulder and Elbow Surgeons scores, complications, and reoperations.

RESULTS

At most recent follow-up, only 14 of 23 shoulders had no or mild pain. Overall pain scores improved from 4.7 to 2.6 points. Abduction and external rotation improved significantly. Five shoulders required reoperation, 2 for glenoid loosening and 1 each for infection, instability, and stiffness. Subjectively, 8 patients rated their shoulder as much better, 7 as better, 4 the same, and 4 worse. Most recent American Shoulder and Elbow Surgeons scores averaged 64 points (range, 20-95 points).

CONCLUSIONS

Shoulder arthroplasty for the treatment of chondrolysis improves pain and range of motion. However, patient satisfaction is variable. Early follow-up shows a higher than expected rate of reoperation (25%). Patients undergoing shoulder arthroplasty for chondrolysis should be counseled appropriately about expectations after surgery.

Idiopathic Chondrolysis of the Hip ( ICH): Report of three Cases

Idiopathic Chondrolysis of the Hip (ICH) is a rare condition, occurring mostly in black female adolescence. It is characterized by the rapidly progressive destruction of articular cartilage in the hip joint resulting in premature degeneration and subsequent joint arthrosis. We report three cases of ICH: a 13-year old boy presented with left knee pain, an 11-year old girl with right hip pain and a 12-year old girl with right thigh pain. All of them had the same characteristic radiographic findings. The initial treatment was started conservatively. Surgical treatment was performed in one patient in order to confirm diagnosis and correct deformity.

Current perspectives on the pediatric hip: selected topics in hip dysplasia, Perthes disease, and chondrolysis: synopsis of the hip subspecialty session at the POSNA Annual Meeting, May 1, 2013, Toronto

The following are proceedings from the Hip Breakout Session held at the 2013 annual meeting of the Pediatric Orthopaedic Society of North America in Toronto, Canada. The organizer's goal of the meeting was to gather experts with years of clinical experience to discuss topics based upon both experience and current clinical evidence. The topics that were selected represented the most commonly encountered pathology where there are wide variations of clinical practice. The invited speakers were asked to summarize both their clinical experience and the current scientific evidence and to summarize areas that require further scientific investigation.

Knee chondrolysis by infusion of bupivacaine with epinephrine through an intra-articular pain pump catheter after arthroscopic ACL reconstruction

BACKGROUND

Postoperative knee chondrolysis caused by continuous intra-articular pain pumps infusing bupivacaine with epinephrine is a rare but serious complication.

PURPOSE

To determine the association between postoperative intra-articular infusion of bupivacaine with epinephrine and the development of knee chondrolysis in patients who have undergone arthroscopic anterior cruciate ligament reconstruction (ACLR). The authors hypothesized that the development of knee chondrolysis after ACLR is associated with postoperative high-dose intra-articular bupivacaine with epinephrine infusion.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In this retrospective cohort study, the charts of all patients treated with arthroscopic ACLR by a single surgeon between January 1, 2004, and December 31, 2006, were reviewed. Patients with severe articular cartilage damage at the time of the index procedure, with known knee joint infection, inflammatory arthritis, multiligament knee injury, bilateral knee injury, or any previous knee surgery, were excluded. Patients were grouped into 2 cohorts: the exposure group (those who had postoperative infusion of bupivacaine with epinephrine via an intra-articular pain pump [IAPP]) and the nonexposure group (those without postoperative infusion).

RESULTS

A total of 105 patients met the inclusion and exclusion criteria. There were 57 male and 48 female patients with a mean age at surgery of 25.5 ± 8.6 years (range, 13-52 years). The exposure group consisted of 46 patients and the control group of 59 patients. Thirteen of 46 patients (28.3%) who received an IAPP developed chondrolysis. There were no cases of chondrolysis in the control group. Of those in the exposure group, 32 patients were exposed to 0.5% bupivacaine with epinephrine and 12 developed chondrolysis (37.5%), while 14 patients were exposed to 0.25% bupivacaine with epinephrine and 1 developed chondrolysis (7.1%). Patients exposed to 0.5% bupivacaine with epinephrine had a significantly higher incidence of chondrolysis compared with those exposed to 0.25% (P = .03). Patients with chondrolysis had severe pain and limitations in daily activity.

CONCLUSION

The development of knee chondrolysis was associated with the intra-articular infusion of bupivacaine with epinephrine postoperatively. Furthermore, the presented evidence suggests that this occurs in a dose-dependent manner. The risk of knee chondrolysis might be reduced by avoidance of intra-articular infusion of bupivacaine with epinephrine. We recommend against continuous intra-articular infusion of local anesthetic postoperatively.

Chondrolysis after hip arthroscopy

We report the case of a 58-year-old woman who presented with left hip pain and was diagnosed with femoroacetabular impingement. She underwent hip arthroscopy to repair a degenerative labral tear, as well as radiofrequency debridement and microfracture of the exposed chondral defect, and femoral osteoplasty. Two months after hip arthroscopy, hip pain and limping began. Hip radiography showed a concentric decrease of joint space and no signs of joint incongruity or osteophytosis. Revision surgery 4 months after hip arthroscopy showed that the cartilage of the femoral head was soft and separated from the subchondral bone.

Inhibition of chondrocyte and synovial cell death after exposure to commonly used anesthetics: chondrocyte apoptosis after anesthetics

BACKGROUND

An intra-articular injection of local anesthetics is a common procedure for diagnostic and therapeutic purposes. It has been shown that these agents are toxic to articular cartilage and synovial tissue in a dose- and time-dependent fashion, and in some cases, they may lead to postarthroscopic glenohumeral chondrolysis (PAGCL). However, the role of apoptosis in cell death is still unclear, and the potential role of apoptosis inhibition in minimizing chondrocyte and synovial cell death has not been reported.

PURPOSE

(1) To quantify the degree of apoptotic cell death in chondrocytes and synovial cells exposed to local anesthetics, and (2) to determine whether caspase inhibition could reduce cell death.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human chondrocytes and synovial cells were expanded in vitro and exposed to normal saline, 0.5% bupivacaine, 0.5% ropivacaine, 1% lidocaine, or 1:1000 epinephrine for 90 minutes. Apoptosis was then detected at 1, 3, 5, and 7 days after exposure using terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) and immunohistochemistry. Apoptosis was then inhibited using the pan-caspase inhibitor z-vad-fmk. Results were normalized to normal saline controls and analyzed by generalized regression models and pairwise confidence intervals.

RESULTS

Analysis of cumulative chondrocyte apoptosis relative to controls after anesthetic exposure demonstrated more than 60% cell death with 0.5% bupivacaine and 1:1000 epinephrine. The greatest chondroprotective effect of caspase inhibition occurred with 0.5% ropivacaine. Similarly, in synovial cells, epinephrine was also very cytotoxic; however, 1% lidocaine induced the most apoptosis. Synovial cells exposed to 0.5% ropivacaine were again most sensitive to protective caspase inhibition.

CONCLUSION

Local anesthetics induce chondrocyte and synovial cell apoptosis in a time-dependent fashion, with peak apoptosis occurring 5 days after exposure. Both chondrocytes and synovial cells are most sensitive to caspase inhibition after exposure to 0.5% ropivacaine.

CLINICAL RELEVANCE

Apoptosis inhibition may be an effective strategy in minimizing chondrocyte and synovial cell death after exposure to anesthetics. Further investigation is clinically warranted.

Revision posterior shoulder stabilization

BACKGROUND

Revision arthroscopic posterior glenohumeral stabilization requires a thorough understanding of the static and dynamic stabilizers of the glenohumeral joint. The evaluation of these patients is complex but critical given the variety of possible underlying lesions.

METHOD

We reviewed the literature surrounding recurrent and revision posterior instability biomechanics, etiology, evaluation, treatment, and outcomes. We also reviewed our own database of posterior instability cases and isolated revision procedures to review our own outcomes and to highlight overall concepts.

DISCUSSION/CONCLUSION

Although other authors have argued that performing a revision procedure indicates for an open procedure and osseous augmentation, our experience has been that revision posterior stabilization arthroscopic soft-tissue repair alone may be indicated in selected patients. After identification of posterior glenoid bone loss/effective retroversion and mechanical failure of prior repairs, the majority of the patients with recurrence of posterior instability likely have either recurrent or persistent labral pathology or patulous capsules with occult multi-directional instability primarily manifesting in the posterior direction. These patients are best served with capsular shift, reefing, and plication, often requiring 180-270° repair and 4 or greater suture anchors. Because of significant heterogeneity in the clinical outcomes reported to date further research will be necessary to define the clinical outcomes in revision posterior stabilization.

Glenohumeral chondrolysis: part I--clinical presentation and predictors of disease progression

PURPOSE

The objective of this 2-part study is to report on the etiology, clinical findings, and predictors of disease progression (part I) and the results of treatment (part II) in a group of patients with glenohumeral chondrolysis.

METHODS

Forty patients presented with glenohumeral chondrolysis after treatment elsewhere. Twenty patients have been followed up since their initial presentation before arthroplasty (group 1), and 20 patients were referred either for management of complications arising after prosthetic arthroplasty or for evaluation only (group 2).

RESULTS

Thirty-seven patients received an intra-articular pain pump (IAPP) delivering bupivacaine, and 3 patients had prominent suture anchors or tacks. Symptoms related to chondrolysis developed in patients at a mean of 9.8 months (range, 1 to 34 months) after the index procedure. Radiographs showed joint space obliteration in 30 of 40 patients at most recent follow-up or before arthroplasty. Of the patients receiving an IAPP delivering bupivacaine, the majority received 0.5% with epinephrine. Higher bupivacaine dose (P < .05) and female gender (P < .05) were associated with a longer interval to onset of symptoms. In addition, a shorter interval to onset of symptoms predicted the need for subsequent surgery (P < .05) and a shorter interval to second-look arthroscopy (P < .001).

CONCLUSIONS

Post-arthroscopic glenohumeral chondrolysis is a devastating and rapidly evolving condition that most often strikes young patients. The use of IAPPs delivering local anesthetics should be abandoned because nearly all cases of glenohumeral chondrolysis in this series were associated with their use.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Chondrolysis of the Ankle Joint following Ankle Arthroscopy and Microfracture of the Osteochondral Lesion of the Talar Dome

Chondrolysis of the ankle is a very rare condition. We report a case of chondrolysis of the ankle following ankle arthroscopy and microfracture of the osteochondral lesion of the talar dome. The patient's symptoms were relieved after articulated distraction arthroplasty.

Traumatic ulnar translocation of the carpus: early recognition and treatment

This study evaluated the clinical outcomes and radiographic features of surgically treated traumatic ulnocarpal translocation in nine patients (ten cases). All ligament and fracture repairs were completed within 2 months of injury. Seven cases were examined at a mean of 6.5 years, and information in three cases was obtained from medical records at a mean of 13 months after injury. At final evaluation, the mean disabilities of the arm, shoulder, and hand score was 6 (range, 0-16), and the mean Mayo modified wrist score was 76 (range, 40-100). Ulnocarpal translocation was evident in nine of the injured wrists, six of which showed arthritis, and in four of the uninjured wrists. Ulnar variance measured negative in nine cases and neutral in one case. Pre-existing medial alignment of the carpus and ulnar minus variance may predispose to traumatic ulnocarpal translocation. Early injury repair does not assure restoration of radiocarpal alignment or prevent joint deterioration; however, these changes do not always portend a suboptimal result.

The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial

BACKGROUND

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population.

METHODS

Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded.

RESULTS

The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables.

CONCLUSIONS

The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.