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Rezansoff A, Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PCM, Peterson D, Bardana D, Getgood AMJ. Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate. Arthroscopy 2024; 40:384-396.e1. [PMID: 37270112 DOI: 10.1016/j.arthro.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/02/2023] [Accepted: 05/17/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports. METHODS This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively. RESULTS We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001). CONCLUSIONS At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Alex Rezansoff
- University of Calgary Sport Medicine Centre, Calgary, Canada
| | - Andrew D Firth
- Health and Rehabilitation Sciences, Faculty of Health Sciences, Western University, London, Canada
| | - Dianne M Bryant
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada; School of Physical Therapy, Western University, London, Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada
| | - Robert G McCormack
- Department of Orthopedics, University of British Columbia, Vancouver, Canada; New West Orthopaedic & Sports Medicine Centre, New Westminster, Canada
| | - Mark Heard
- Department of Surgery, University of Calgary, Calgary, Canada; Banff Sport Medicine, Banff, Canada
| | - Peter B MacDonald
- Department of Surgery, University of Manitoba, Winnipeg, Canada; Pan Am Clinic, Winnipeg, Canada
| | - Tim Spalding
- University Hospitals Coventry and Warwickshire National Health Service Trust, Coventry, England
| | - Peter C M Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, Ghent, Belgium; Antwerp Orthopedic Center, Antwerp, Belgium
| | - Devin Peterson
- Department of Surgery, Queen's University, Kingston, Canada
| | - Davide Bardana
- Department of Surgery, McMaster University, Hamilton, Canada; Department of Surgery, Queen's University, Kingston, Canada
| | - Alan M J Getgood
- Fowler Kennedy Sport Medicine Clinic, London, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Canada.
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Heard M, Marmura H, Bryant D, Litchfield R, McCormack R, MacDonald P, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Getgood A. Corrigendum to 'No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction - Results from the stability randomized trial' [Journal of ISAKOS 8 (2023) 246-254]. J ISAKOS 2023; 8:513. [PMID: 37845163 DOI: 10.1016/j.jisako.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Affiliation(s)
- M Heard
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; Banff Sport Medicine, T1W 0L5, Canada
| | - H Marmura
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - D Bryant
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - R Litchfield
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada
| | - R McCormack
- Department of Orthopaedics, University of British Columbia, V5Z 1M9, Canada; New West Orthopaedic & Sports Medicine Centre, V3L 5P5, Canada
| | - P MacDonald
- Department of Surgery, University of Manitoba, R3A 1R9, Canada; Pan Am Clinic, R3M 3E4, Canada
| | - T Spalding
- University Hospital Coventry and Warwickshire NHS Trust, CV2 2DX, UK
| | - P Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, 9000, Belgium; Antwerp Orthopedic Center, 2018, Belgium
| | - D Peterson
- Department of Surgery, McMaster University, L8S 4K1, Canada
| | - D Bardana
- Department of Surgery, Queen's University, K7L 2V7, Canada
| | - A Rezansoff
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; University of Calgary Sport Medicine Centre, T2N 1N4, Canada
| | - A Getgood
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada.
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McNeill K, Marmura H, Werstine M, Alcock G, Birmingham T, Willits K, Getgood A, LeBel ME, Litchfield R, Bryant D, Giffin JR. The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction. J Sport Rehabil 2023; 32:884-893. [PMID: 37699588 DOI: 10.1123/jsr.2022-0343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 09/14/2023]
Abstract
CONTEXT The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. METHODS One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. RESULTS There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval, 1.3 to 10.4; P = .01). CONCLUSION A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.
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Affiliation(s)
- Kestrel McNeill
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
| | - Hana Marmura
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Bone and Joint Institute, Western University, London, ON,Canada
| | - Melanie Werstine
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
| | - Greg Alcock
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
| | - Trevor Birmingham
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Bone and Joint Institute, Western University, London, ON,Canada
- Wolf Orthopedic Biomechanics Lab, Western University, London, ON,Canada
| | - Kevin Willits
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Marie-Eve LeBel
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - Dianne Bryant
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON,Canada
- School of Physical Therapy, Faculty of Health Sciences, Western University, London, ON,Canada
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
| | - J Robert Giffin
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON,Canada
- Wolf Orthopedic Biomechanics Lab, Western University, London, ON,Canada
- Division of Orthopedics, Department of Surgery, The Schulich School of Medicine and Dentistry, Western University, London, ON,Canada
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Heard M, Marmura H, Bryant D, Litchfield R, McCormack R, MacDonald P, Spalding T, Verdonk P, Peterson D, Bardana D, Rezansoff A, Getgood A. No increase in adverse events with lateral extra-articular tenodesis augmentation of anterior cruciate ligament reconstruction - Results from the stability randomized trial. J ISAKOS 2023; 8:246-254. [PMID: 36646169 DOI: 10.1016/j.jisako.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Results from the Stability Study suggest that adding a lateral extra-articular tenodesis (LET) to a hamstring tendon autograft reduces the rate of anterior cruciate ligament reconstruction (ACLR) failure in high-risk patients. The purpose of this study is to report adverse events over the 2-year follow-up period and compare groups (ACLR alone vs. ACLR + LET). METHODS Stability is a randomized clinical trial comparing hamstring tendon ACLR with and without LET. Patients aged 14-25 years with an ACL deficient knee were included. Patients were followed and adverse events documented (type, actions taken, resolution) with visits at 3, 6, 12, and 24 months postoperatively. Adverse events were categorized as none, minor medical, minor surgical, contralateral ACL rupture, or graft rupture. Patient reported outcome measures (PROMs) collected at each visit included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score (IKDC), and ACL Quality of Life Questionnaire (ACL-QOL). RESULTS In total, 618 patients were randomized (mean age 18.9 years, 302 (49%) male). Forty-five patients (7%) suffered graft rupture; 34 (11%) in the ACLR group compared to 11 (4%) in the ACLR + LET group (RRR = 0.67, 95% CI 0.36 to 0.83, p < 0.001). There were no differences in effusion or infection rates between groups. The ACLR + LET group experienced an increased number of hardware removals (10 vs. 4). Overall, the rate of minor medical events (11%), minor surgical events (7%), and ipsilateral or contralateral ACL tears (10%) were low considering the high-risk patient profile. Increasing severity of adverse events was associated with lower PROMs at 24 months post-operative. Patients in the ACLR + LET group reported greater degree of pain at 3 months only. There were no clinically significant differences in range of motion between groups. CONCLUSIONS The addition of LET to hamstring tendon autograft ACLR in young patients at high risk of re-injury resulted in a statistically significant reduction in graft rupture. While the addition of LET may increase rates of hardware irritation, there was no significant increase in overall rates of minor medical adverse events, minor surgical events, or overall re-operation rates. The concerns regarding complications associated with a LET did not materialize in this study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- M Heard
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; Banff Sport Medicine, T1W 0L5, Canada
| | - H Marmura
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - D Bryant
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; School of Physical Therapy, Western University, N6A 3K7, Canada
| | - R Litchfield
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada
| | - R McCormack
- Department of Orthopaedics, University of British Columbia, V5Z 1M9, Canada; New West Orthopaedic & Sports Medicine Centre, V3L 5P5, Canada
| | - P MacDonald
- Department of Surgery, University of Manitoba, R3A 1R9, Canada; Pan Am Clinic, R3M 3E4, Canada
| | - T Spalding
- University Hospital Coventry and Warwickshire NHS Trust, CV2 2DX, UK
| | - P Verdonk
- Department of Physical Medicine and Orthopedics, Ghent University, 9000, Belgium; Antwerp Orthopedic Center, 2018, Belgium
| | - D Peterson
- Department of Surgery, McMaster University, L8S 4K1, Canada
| | - D Bardana
- Department of Surgery, Queen's University, K7L 2V7, Canada
| | - A Rezansoff
- Deparment of Surgery, University of Calgary, T2N 1N4, Canada; University of Calgary Sport Medicine Centre, T2N 1N4, Canada
| | - A Getgood
- Fowler Kennedy Sport Medicine Clinic, N6A 3K7, Canada; Department of Surgery, Schulich School of Medicine and Dentistry, Western University, N6A 5C1, Canada.
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Getgood AMJ, Litchfield R, Amendola N. In Memoriam: A Life Well Lived: Remembering Dr Peter Fowler, MD, FRCSC (1938-2022). Am J Sports Med 2023; 51:850-853. [PMID: 37737098 DOI: 10.1177/03635465231156369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
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Alfaraidy M, Alraiyes T, Moatshe G, Litchfield R, LeBel ME. Low rates of serious complications after open Latarjet procedure at short-term follow-up. J Shoulder Elbow Surg 2023; 32:41-49. [PMID: 35872172 DOI: 10.1016/j.jse.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/27/2022] [Accepted: 06/05/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE To report on intraoperative and short-term postoperative adverse events after open Latarjet procedure in patients with recurrent anterior shoulder instability. These complications were classified into different grades of severity based on the treatment required and the learning curve of the procedure. METHODS Ninety-six patients (102 shoulders) underwent open Latarjet procedure for recurrent post-traumatic anterior glenohumeral instability between 2012 and 2020. The minimum duration of patients' follow-up was 6 months. Adverse events were classified into 3 classes based on the severity and subsequent treatment. The complications in the first 50% of all cases were compared with the latter 50% to evaluate the role of learning curve on the complication rates. RESULTS The mean follow-up was 7.2 ± 2.8 months. The patients' mean age was 26.7 ± 8.9 years and consisted of 83 (86.4%) male and 13 (13.6%) female patients. The total adverse events rate was 18.6%. Adverse events requiring no additional treatment (class 1) occurred in 6 cases (5.8%) including fibrous union (3.9%) and asymptomatic resorption of the graft (1.9%). Adverse events requiring additional or extended nonoperative management (class 2) occurred in 8 cases (7.8%), including coracoid fracture (2.9%), musculocutaneous nerve palsy (1.9%), axillary nerve palsy (0.9%), suprascapular nerve palsy (0.9%), and stiffness (0.9%). All the nerve palsies recovered without long-term sequelae. Adverse events requiring secondary operative procedures (class 3) occurred in 5 cases (4.9%), including symptomatic hardware (1.9%), medial healing of the graft (0.9%), screw loosening (0.9%), and deep infection (0.9%). The rate of adverse events in revision cases was higher than primary cases in 11.7% and 6.8%, respectively (P = .119). The complication rate was significantly higher in the first half of the surgeons' practice (14.7%) than in the second half (3.9%) (P ≤ .05). CONCLUSIONS The overall complication rate reported in this open Latarjet series is 18.6%; however, the rate of class 3 adverse events that required additional surgery or long-term medical treatment was only 4.9%. Revision cases had a higher rate of complications than primary cases, and the learning curve has had a significant impact on the rate of adverse events.
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Affiliation(s)
- Moaad Alfaraidy
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada; Medical Cities, General Directorate of Medical Services, Ministry of Interior, Riyadh, Saudi Arabia
| | - Thamer Alraiyes
- Roth
- McFarlane Hand and Upper Limb Centre, Western University, London, ON, Canada; Department of Orthopaedics, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Gilbert Moatshe
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada; OSTRC, Norwegian School of Sports Sciences, Oslo, Norway; Orthopaedic Division, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, Western University, London, ON, Canada
| | - Marie-Eve LeBel
- Roth
- McFarlane Hand and Upper Limb Centre, Western University, London, ON, Canada.
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Lodhia P, Nazari G, Bryant D, Getgood A, McCormack R, Getgood AM, Bryant DM, Litchfield R, Willits K, Birmingham T, Hewison C, Firth AD, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, McCormack RG, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Payne K, Heard M, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, MacDonald PB, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Rezansoff A, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Peterson D, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Bardana D, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Verdonk PC, Declerq G, Vuylsteke K, Van Haver M. Performance of 5-Strand Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the STABILITY Study: A Subgroup Analysis. Am J Sports Med 2022; 50:3502-3509. [PMID: 36260487 PMCID: PMC9630854 DOI: 10.1177/03635465221128581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters <8mm have been shown to have higher revision rates. The 5-strand (5S) hamstring autograft configuration is a proposed option to increase graft diameter. PURPOSE To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)-namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. RESULTS Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors-namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman (P = .46) and pivot-shift (P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL (P = .67) and IKDC (P = .83) scores between the 2 subgroups. CONCLUSION At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.
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Affiliation(s)
- Parth Lodhia
- Parth Lodhia, MD, University of British Columbia, 403-233
Nelson’s Crescent, New Westminster, V3L 0E4, Canada (
)
| | - Goris Nazari
- Canadian Institutes of Health Research, Ottawa,
Ontario, Canada
| | - Dianne Bryant
- The University of Western Ontario, London,
Ontario, Canada
| | - Alan Getgood
- Western Ontario University, London, Ontario,
Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western
University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | | | | | - Kyrsten Payne
- Fraser Orthopaedic Institute, New Westminster,
Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary,
Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent,
Belgium,Investigation performed at University of
British Columbia, Vancouver, BC, Canada
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Marmura H, Firth A, Batty L, Bryant DM, Getgood AMJ, Bryant D, Litchfield R, Willits K, Birmingham T, Hewison C, Wanlin S, Firth A, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, McCormack B, Zomar M, Moon K, Moon R, Fan B, Mohan B, Heard M, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, MacDonald P, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Rezansoff A, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Peterson D, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Bardana D, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Millan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Verdonk P, Declerq G, Vuylsteke K, Van Haver M. Meniscal repair at the time of primary ACLR does not negatively influence short term knee stability, graft rupture rates, or patient-reported outcome measures: the STABILITY experience. Knee Surg Sports Traumatol Arthrosc 2022; 30:3689-3699. [PMID: 35451638 DOI: 10.1007/s00167-022-06962-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess how meniscal repair and excision impact short term patient-reported outcome measures (PROMs), knee stability, and early graft rupture rates following primary hamstring anterior cruciate ligament reconstruction (ACLR) with or without lateral extra-articular tenodesis (LET) in a group of young active patients where meniscal repair is commonly advocated. METHODS Six hundred and eighteen patients under 25 years of age at high-risk of graft failure following ACLR were recruited to the Stability 1 study. Multivariable regression models were developed to identify statistically and clinically significant surgical and demographic predictors of Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Subjective Knee Form (IKDC), ACL Quality of Life Questionnaire (ACL-QOL) and Marx Activity Rating Scale (MARS) scores. Chi-Square tests of independence were used to explore the association between meniscal status (torn, not torn), meniscal treatment (excision or repair), graft rupture, and rotatory knee laxity. RESULTS Medial meniscus repair was associated with worse outcomes on the KOOS (β = -1.32, 95% CI: -1.57 to -1.10, p = 0.003), IKDC (β = -1.66, 95% CI: -1.53 to -1.02, p = 0.031) and ACL-QOL (β = -1.25, 95% CI: -1.61 to 1.02, p = n.s.). However, these associations indicated small, clinically insignificant changes based on reported measures of clinical relevance. Other important predictors of post-operative PROMs included age, sex, and baseline scores. Medial meniscus excision and lateral meniscus treatment (repair or excision) did not have an important influence on PROMs. There was no significant association between meniscal treatment and graft rupture or rotatory knee laxity. CONCLUSION While repairing the medial meniscus may result in a small reduction in PROM scores at two-year follow-up, these differences are not likely to be important to patients or clinicians. Any surgical morbidity associated with meniscal repair appears negligible in terms of PROMs. Meniscal repair does not affect rotatory laxity or graft failure rates in the short term. Therefore, meniscal repair should likely be maintained as the standard of care for concomitant meniscal tears with ACLR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hana Marmura
- Faculty of Health Sciences, Western University, London, Canada.,Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6K 4P3, Canada.,Bone and Joint Institute, Western University, London, Canada.,Lawson Research, London Health Sciences Centre, London, Canada
| | - Andrew Firth
- Faculty of Health Sciences, Western University, London, Canada.,Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6K 4P3, Canada.,Bone and Joint Institute, Western University, London, Canada.,Lawson Research, London Health Sciences Centre, London, Canada
| | - Lachlan Batty
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6K 4P3, Canada.,OrthoSport Victoria Research Unit, Richmond, Australia.,St. Vincent's Hospital, Melbourne, Australia
| | - Dianne M Bryant
- Faculty of Health Sciences, Western University, London, Canada.,Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6K 4P3, Canada.,Bone and Joint Institute, Western University, London, Canada.,Lawson Research, London Health Sciences Centre, London, Canada.,Schulich School of Medicine and Dentistry, Western University, London, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Alan M J Getgood
- Faculty of Health Sciences, Western University, London, Canada. .,Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, 3M Centre, London, ON, N6K 4P3, Canada. .,Bone and Joint Institute, Western University, London, Canada. .,Lawson Research, London Health Sciences Centre, London, Canada. .,Schulich School of Medicine and Dentistry, Western University, London, Canada.
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9
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Marsh JD, Degen R, Birmingham TB, Giffin JR, Getgood A, Litchfield R, Willits K, McClure JA, Welk B. The rate of unnecessary interventions for the management of knee osteoarthritis: a population-based cohort study. Can J Surg 2022; 65:E114-E120. [PMID: 35181579 PMCID: PMC8863184 DOI: 10.1503/cjs.002221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Several commonly used procedures for knee osteoarthritis (OA) are not supported by evidence-based guidelines. The objective of this study was to identify the proportion of patients who underwent knee arthroscopy or magnetic resonance imaging (MRI) and the timing of these procedures before total knee arthroplasty (TKA). METHODS We conducted a retrospective cohort study using administrative data sets from Ontario, Canada. We identified the proportion of patients who underwent knee arthroscopy in the previous 10 years or an MRI in the 3 years before their primary TKA. We also evaluated the rate of arthroscopies by diagnosis. We report the timing of each outcome in relation to the TKA, rates by geographical area, and differences in rates over time. RESULTS We included 142 275 patients, of whom 36 379 (25.57%) underwent knee arthroscopy (median time 2.8 [interquartile range (IQR) 1.1-6.0] years); 22% of those were within 1 year of TKA and 52% were within 3 years. The rates of arthroscopies for a diagnosis of osteoarthritis (OA) steadily decreased, while those for meniscal-related diagnoses increased over the study period (p < 0.0001). There was significant variation by region. Of the cohort, 23.2% (n = 32 989) had an MRI before their TKA, with rates significantly increasing over time (p < 0.0001). CONCLUSION A substantial proportion of patients with knee OA received diagnostic and therapeutic interventions before TKA that are contrary to clinical practice guidelines.
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Affiliation(s)
- Jacquelyn D Marsh
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Ryan Degen
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Trevor B Birmingham
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - J Robert Giffin
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Alan Getgood
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Robert Litchfield
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Kevin Willits
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - J Andrew McClure
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
| | - Blayne Welk
- From the Faculty of Health Sciences, Western University, London, Ont. (Marsh, Birmingham); the Bone and Joint Institute, Western University, London, Ont. (Marsh, Birmingham); the Fowler Kennedy Sport Medicine Clinic, London, Ont. (Degen, Giffin, Getgood, Litchfield, Willits); the Schulich School of Medicine and Dentistry, Department of Surgery, Division of Orthopaedics, Western University, London, Ont. Giffin, Getgood, Litchfield, Willits); the Institute of Clinical Evaluative Sciences (ICES) Western, London, Ont. (McClure, Welk); and the Schulich School of Medicine and Dentistry, Department of Surgery (Urology) Western University, London, Ont. (Welk)
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10
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Firth AD, Bryant DM, Litchfield R, McCormack RG, Heard M, MacDonald PB, Spalding T, Verdonk PC, Peterson D, Bardana D, Rezansoff A, Getgood AM, Willits K, Birmingham T, Hewison C, Wanlin S, Pinto R, Martindale A, O’Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Moon R, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Milan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declerq G, Vuylsteke K, Van Haver M. Predictors of Graft Failure in Young Active Patients Undergoing Hamstring Autograft Anterior Cruciate Ligament Reconstruction With or Without a Lateral Extra-articular Tenodesis: The Stability Experience. Am J Sports Med 2022; 50:384-395. [PMID: 35050817 PMCID: PMC8829733 DOI: 10.1177/03635465211061150] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. PURPOSE/HYPOTHESIS The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. RESULTS Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. CONCLUSION The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.
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Affiliation(s)
| | | | - Robert Litchfield
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | - Tim Spalding
- University Hospitals Coventry Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alex Rezansoff
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | - Alan M.J. Getgood
- Alan M.J. Getgood, MD, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, London, ON N6A 3K7, Canada () (Twitter: FKSMC_Getgood)
| | | | | | | | | | | | | | | | | | - Michal Daniluk
- London Health Sciences Centre, Western University, Fowler Kennedy Sport Medicine Clinic, London, Canada
| | | | | | | | | | | | - Bindu Mohan
- Fraser Orthopaedic Institute, New Westminster, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michelle Mayer
- Sport Medicine Centre, University of Calgary, Calgary, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mieke Van Haver
- Antwerp Orthopaedic Center, Ghent, Belgium,Investigation performed at the Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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11
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Sidhu R, Moatshe G, Firth A, Litchfield R, Getgood A. Low rates of serious complications but high rates of hardware removal after high tibial osteotomy with Tomofix locking plate. Knee Surg Sports Traumatol Arthrosc 2021; 29:3361-3367. [PMID: 32789527 DOI: 10.1007/s00167-020-06199-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to analyse adverse events encountered in medial opening wedge high tibial osteotomy (MOWHTO) utilizing contemporary surgical techniques with the Tomofix locking plate (DePuy Synthes, Raynham, MA, USA) and categorize them by their severity and need for further medical/surgical management. It was hypothesized that there would be low rates of serious complications after medial opening wedge high tibial osteotomy utilizing an internal locking plate fixator. METHODS This study included 169 consecutive patients (200 knees) who underwent MOWHTO with a Tomofix locking plate at a single center, completing a minimum 2-year follow-up. Types of intra- and post-operative adverse events were retrospectively identified by an independent observer and categorized by their severity and further need of management. Additional surgery due to elective hardware removal was not included in the adverse event classification. RESULTS There were in total 58 (29%) adverse events, the majority (13.5%) of which required no additional treatment (class 1). Class 1 events included lateral cortex hinge fractures that were observed in 8.5% (17 knees) and delayed wound healing 2% (4/200). Adverse events requiring additional or extended nonoperative management (class 2) were 9%. These included post-operative stiffness in 1% (2/200), low grade infection in 1.5% (3/200), delayed union in 5.4% (11/200), deep vein thrombosis 0.5% (1/200). One hundred and four knees (52%) underwent elective hardware removal. Serious adverse events requiring unplanned additional or revision surgery and/or long-term medical care (class 3) were the least reported (6.5%). Aseptic non-union was reported in 2.5%, deep infection requiring revision in 2% and limited hardware failure 1%. CONCLUSION A low rate of serious complications (6.5%) requiring unplanned additional surgery (class 3) was found. The overall rate of complications following MOWHTO with Tomofix locking plate was 29% and the majority (13.5%) required no additional treatment (class 1). Lateral hinge fractures were the most common complication (8.5%) and these were associated with corrections over 12 mm. However, 52% knees required a further operation for elective hardware removal. LEVEL OF EVIDENCE Level IV, prospective study without control group.
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Affiliation(s)
- Rajeshwar Sidhu
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Gilbert Moatshe
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada.,OSTRC, Norwegian School of Sports Sciences, Oslo, Norway
| | - Andrew Firth
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Robert Litchfield
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada
| | - Alan Getgood
- Fowler Kennedy Sports Medicine Clinic, University of Western Ontario, London, Canada.
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12
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MacDermid JC, Bryant D, Holtby R, Razmjou H, Faber K, Balyk R, Boorman R, Sheps D, McCormack R, Athwal G, Hollinshead R, Lo I, Bicknell R, Mohtadi N, Bouliane M, Glasgow D, Lebel ME, Lalani A, Moola FO, Litchfield R, Moro J, MacDonald P, Bergman JW, Bury J, Drosdowech D. Arthroscopic Versus Mini-open Rotator Cuff Repair: A Randomized Trial and Meta-analysis. Am J Sports Med 2021; 49:3184-3195. [PMID: 34524031 DOI: 10.1177/03635465211038233] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. PURPOSE This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. RESULTS From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]). CONCLUSION Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. TRIAL REGISTRATION NCT00128076.
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Affiliation(s)
- Joy C MacDermid
- Departments of Surgery and Physical Therapy, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Dianne Bryant
- Departments of Surgery and Physical Therapy, University of Western Ontario, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Richard Holtby
- Department of Orthopaedic Surgery, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Helen Razmjou
- Department of Rehabilitation, Holland Orthopaedic & Arthritis Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Kenneth Faber
- Department of Surgery, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
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- Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Robert Balyk
- Department of Surgery and Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Richard Boorman
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - David Sheps
- Department of Surgery and Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Robert McCormack
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - George Athwal
- Department of Surgery, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Robert Hollinshead
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Ian Lo
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Ryan Bicknell
- Department of Surgery, Queen's University, Kingston, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Nicholas Mohtadi
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Martin Bouliane
- Department of Surgery and Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Donald Glasgow
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Marie-Eve Lebel
- Department of Surgery, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Aleem Lalani
- Department of Surgery and Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Farhad O Moola
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, University of Western Ontario, London, Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Jaydeep Moro
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Peter MacDonald
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - J W Bergman
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Jeff Bury
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
| | - Darren Drosdowech
- Department of Surgery, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Investigation performed at the University of Western Ontario, London, Ontario, Canada
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13
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Getgood A, Hewison C, Bryant D, Litchfield R, Heard M, Buchko G, Hiemstra LA, Willits KR, Firth A, MacDonald P. No Difference in Functional Outcomes When Lateral Extra-Articular Tenodesis Is Added to Anterior Cruciate Ligament Reconstruction in Young Active Patients: The Stability Study. Arthroscopy 2020; 36:1690-1701. [PMID: 32147485 DOI: 10.1016/j.arthro.2020.02.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the functional outcomes of patients included in the Stability Study randomized controlled trial comparing anterior cruciate ligament reconstruction (ACLR) alone with ACLR with lateral extra-articular tenodesis (LET) at 6, 12, and 24 months postoperatively. METHODS Six hundred eighteen patients undergoing ACLR, all under the age of 25 years either returning to contact pivoting sport or displaying signs of high-grade rotatory laxity or generalized ligamentous laxity, were randomly assigned to receive ACLR alone or ACLR plus LET. A total of 356 of these patients were randomized at centers participating in the functional assessments. Our primary outcome was Limb Symmetry Index, calculated using a series of 4-hop tests at 6, 12, and 24 months postoperatively. Secondary outcome measures included pain, patient-reported function, and isokinetic strength testing. RESULTS We found no statistically significant difference in the proportion of patients either unwilling or unfit to complete the hop testing in the ACLR alone or ACLR with LET group at 6 months (40 vs 40 respectively; P = 1.00), 12 months (25 vs 27; P = .76), and 24 months (21 vs 23; P = .87). Of those who completed hop testing, there were no statistically significant differences between groups in Limb Symmetry Index at 6, 12, or 24 months. Self-reported function (Lower Extremity Functional Score) significantly favored the ACLR alone group at 3 (P = .01) and 6 months (P = .02) postoperative but was similar by 12 months postoperative. Pain scores (P4) also showed a statistically significant difference in favor of the ACL alone group, but this also resolved by 6 months. Quadriceps peak torque (P = .03) and average power (P = .01) were also significantly different in favor of the ACLR alone group at 6 months postoperative; however, these were similar between groups by 12 months postoperative (P = .11 and P = .32, respectively). CONCLUSIONS The addition of a LET to ACLR results in slightly increased pain, a mild reduction in quadriceps strength, and reduced subjective functional recovery up to 6 months postoperatively. However, these differences do not have any impact on objective function as measured by hop test limb symmetry index. LEVEL OF EVIDENCE I, Randomized Controlled Trial.
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Affiliation(s)
- Alan Getgood
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada.
| | | | - Dianne Bryant
- Lawson Health Research Institute, London, Ontario, Canada; Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Mark Heard
- Banff Sport Medicine, Banff, Alberta, Canada
| | - Greg Buchko
- Banff Sport Medicine, Banff, Alberta, Canada
| | | | - Kevin R Willits
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Andrew Firth
- Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada; Lawson Health Research Institute, London, Ontario, Canada
| | - Peter MacDonald
- Pan Am Clinic, University of Manitoba, Winnipeg, Manitoba, Canada
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Litchfield R. In Anterior Shoulder Instability with Glenoid Bone Loss, Iliac Crest Bone Graft Transfer and the Latarjet Procedure Did Not Differ for Instability Measures at 6, 12, and 24 Months. J Bone Joint Surg Am 2020; 102:340. [PMID: 31834105 DOI: 10.2106/jbjs.19.01329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Getgood AMJ, Bryant DM, Litchfield R, Heard M, McCormack RG, Rezansoff A, Peterson D, Bardana D, MacDonald PB, Verdonk PCM, Spalding T, Willits K, Birmingham T, Hewison C, Wanlin S, Firth A, Pinto R, Martindale A, O'Neill L, Jennings M, Daniluk M, Boyer D, Zomar M, Moon K, Pritchett R, Payne K, Fan B, Mohan B, Buchko GM, Hiemstra LA, Kerslake S, Tynedal J, Stranges G, Mcrae S, Gullett L, Brown H, Legary A, Longo A, Christian M, Ferguson C, Mohtadi N, Barber R, Chan D, Campbell C, Garven A, Pulsifer K, Mayer M, Simunovic N, Duong A, Robinson D, Levy D, Skelly M, Shanmugaraj A, Howells F, Tough M, Spalding T, Thompson P, Metcalfe A, Asplin L, Dube A, Clarkson L, Brown J, Bolsover A, Bradshaw C, Belgrove L, Millan F, Turner S, Verdugo S, Lowe J, Dunne D, McGowan K, Suddens CM, Declercq G, Vuylsteke K, Van Haver M. Lateral Extra-articular Tenodesis Reduces Failure of Hamstring Tendon Autograft Anterior Cruciate Ligament Reconstruction: 2-Year Outcomes From the STABILITY Study Randomized Clinical Trial. Am J Sports Med 2020; 48:285-297. [PMID: 31940222 DOI: 10.1177/0363546519896333] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. HYPOTHESIS We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. RESULTS A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 (P = .003) and KOOS (P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months (P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale (P = .11). CONCLUSION The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. REGISTRATION NCT02018354 ( ClinicalTrials.gov identifier).
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Affiliation(s)
- Alan M J Getgood
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dianne M Bryant
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert Litchfield
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mark Heard
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Robert G McCormack
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alex Rezansoff
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Devin Peterson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Davide Bardana
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter B MacDonald
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Peter C M Verdonk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kevin Willits
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Trevor Birmingham
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Chris Hewison
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Stacey Wanlin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Firth
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ryan Pinto
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ashley Martindale
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Lindsey O'Neill
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Morgan Jennings
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michal Daniluk
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Dory Boyer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mauri Zomar
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karyn Moon
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Raely Pritchett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Krystan Payne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Brenda Fan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Bindu Mohan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Gregory M Buchko
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laurie A Hiemstra
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Kerslake
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jeremy Tynedal
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Greg Stranges
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sheila Mcrae
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - LeeAnne Gullett
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Holly Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Legary
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Longo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mat Christian
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Celeste Ferguson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nick Mohtadi
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Rhamona Barber
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Denise Chan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Caitlin Campbell
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alexandra Garven
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Karen Pulsifer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Michelle Mayer
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Nicole Simunovic
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Duong
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Robinson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - David Levy
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Matt Skelly
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Ajaykumar Shanmugaraj
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Fiona Howells
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Murray Tough
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Tim Spalding
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Pete Thompson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Andrew Metcalfe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Laura Asplin
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alisen Dube
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Louise Clarkson
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Jaclyn Brown
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Alison Bolsover
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Carolyn Bradshaw
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Larissa Belgrove
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Francis Millan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sylvia Turner
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Sarah Verdugo
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Janet Lowe
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Debra Dunne
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kerri McGowan
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Charlie-Marie Suddens
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Geert Declercq
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Kristien Vuylsteke
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
| | - Mieke Van Haver
- Investigation performed at The Fowler Kennedy Sport Medicine Clinic, Western University, London, Ontario, Canada
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Johnston DF, Sondekoppam RV, Uppal V, Litchfield R, Giffin R, Ganapathy S. Effect of combining peri-hamstring injection or anterior obturator nerve block on the analgesic efficacy of adductor canal block for anterior cruciate ligament reconstruction: a randomised controlled trial. Br J Anaesth 2020; 124:299-307. [PMID: 31980156 DOI: 10.1016/j.bja.2019.11.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/21/2019] [Accepted: 11/02/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Pain after anterior cruciate ligament reconstruction (ACLR) with autologous hamstring graft can be attributed to both arthroscopic surgery and the graft donor site. This study investigated whether donor site pain control was superior with the addition of either peri-hamstring injection or anterior division obturator nerve block in comparison with adductor canal block (ACB) alone. METHODS Patients scheduled to undergo knee arthroscopy with ACLR using a graft from the ipsilateral hamstring were randomised to one of three groups. All patients received ACB and multimodal analgesia. Subjects in Group H received peri-hamstring local anaesthetic injection while subjects in Group O received an anterior division of the obturator nerve block, and subjects in Group C served as a control group (ACB alone). RESULTS In 105 subjects undergoing ACLR, there was no significant difference between groups H, O, and C for the primary outcome of pain on movement as assessed by numerical rating scale (NRS) on knee flexion at 2 h after operation (P=0.11). There was no difference in NRS at any time point in the first 48 h after operation, nor was there a difference in oxycodone consumption between the three groups at 24 h (P=0.2). Worst knee pain was initially at the graft donor site in all three groups, which transitioned to anterior knee pain after 12 h. CONCLUSIONS The addition of ultrasound-guided peri-hamstring injection or anterior division of obturator nerve block to ACB did not result in a significant reduction in pain or opioid consumption after ACLR with ipsilateral hamstring graft. CLINICAL TRIAL REGISTRATION NCT01868282.
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Affiliation(s)
- David F Johnston
- Department of Anaesthesia and Perioperative Medicine, Royal Victoria Hospital, Belfast Trust, Belfast, UK
| | | | - Vishal Uppal
- Department of Anesthesia, University of Dalhousie, Halifax, NS, Canada
| | - Robert Litchfield
- Department of Orthopedic Surgery, London Health Sciences Centre, Western University, London, ON, Canada
| | - Robert Giffin
- Department of Orthopedic Surgery, London Health Sciences Centre, Western University, London, ON, Canada
| | - Sugantha Ganapathy
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, Western University, London, ON, Canada
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McKee MD, Litchfield R, Hall JA, Wester T, Jones J, Harrison AJ. NASHA hyaluronic acid for the treatment of shoulder osteoarthritis: a prospective, single-arm clinical trial. Med Devices (Auckl) 2019; 12:227-234. [PMID: 31354368 PMCID: PMC6573776 DOI: 10.2147/mder.s189522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/14/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Osteoarthritis of the shoulder or glenohumeral joint is a painful condition that can be debilitating. Intra-articular injection with hyaluronic acid should be considered for patients not responding adequately to physical therapy or anti-inflammatory medication. Methods: This was a single-arm, open-label, prospective study of a single intra-articular injection of NASHA (non-animal hyaluronic acid) in patients with symptomatic glenohumeral osteoarthritis. Patients were followed up for 26 weeks post-treatment, during which time rescue medication with acetaminophen was permissible. The study objective was to demonstrate that a single injection of NASHA is well tolerated with an over-6-month 25% reduction in shoulder pain on movement, assessed using a 100-mm visual analog scale. Results: Forty-one patients were enrolled, all of whom received study treatment. The mean decrease in shoulder pain on movement score over the 6-month study period was −20.1 mm (95% CI: −25.2, −15.0 mm), corresponding to a mean reduction of 29.5% (22.0, 37.0%). Statistically significant improvements were also observed in shoulder pain at night and patient global assessment. There was no clear change over time in the percentage of patients using rescue medication and mean weekly doses were below 3500 mg. Seventeen patients (41.5%) experienced adverse events, all of which were mild or moderate. Two adverse events (both shoulder pain) were deemed related to study treatment. Conclusion: This study provides preliminary evidence that a single injection of NASHA may be efficacious over 6 months and well tolerated in patients with symptomatic glenohumeral osteoarthritis. Larger studies are needed for confirmation.
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Affiliation(s)
- Michael D McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Robert Litchfield
- Department of Surgery, Fowler Kennedy Sport Medicine Clinical, London, ON, Canada
| | - Jeremy A Hall
- Department of Surgery, St Michael's Hospital, Toronto, ON, Canada
| | - Tawana Wester
- Research and Development, Bioventus LLC, Durham, NC 27703, USA
| | - John Jones
- Research and Development, Bioventus LLC, Durham, NC 27703, USA
| | - Andrew J Harrison
- Research and Development, Bioventus Cooperatief UA, Hoofddorp, Netherlands
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Young J, Litchfield R. Eating Competence Among College Students. J Acad Nutr Diet 2018. [DOI: 10.1016/j.jand.2018.06.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Witjes S, Wanlin S, Litchfield R, van Geenen RCI, Kerkhoffs GMMJ, Getgood A. Realignment osteotomy of the knee allows for return to work and sport activities in the young athletic population. J ISAKOS 2018. [DOI: 10.1136/jisakos-2018-000212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wong I, Hiemstra L, Ayeni OR, Getgood A, Beavis C, Volesky M, Outerbridge R, Sheehan B, McCormack R, Litchfield R, Whelan D, Mohtadi N, Coady C, MacDonald PB. Position Statement of the Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint-September 2017. Orthop J Sports Med 2018; 6:2325967118756597. [PMID: 29511702 PMCID: PMC5833175 DOI: 10.1177/2325967118756597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
| | - Ivan Wong
- Ivan Wong, MD, MACM, FRCSC, DipSportMed, Dalhousie University, 2nd Floor, Room 2106, Camp Hill Veteran’s Memorial Building, 5955 Veteran’s Memorial Lane, Halifax, Nova Scotia B3H 2E1 Canada ()
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Birmingham TB, Moyer R, Leitch K, Chesworth B, Bryant D, Willits K, Litchfield R, Fowler PJ, Giffin JR. Changes in biomechanical risk factors for knee osteoarthritis and their association with 5-year clinically important improvement after limb realignment surgery. Osteoarthritis Cartilage 2017; 25:1999-2006. [PMID: 28888904 DOI: 10.1016/j.joca.2017.08.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 07/18/2017] [Accepted: 08/30/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate 5-year outcomes after lower limb realignment and test the hypothesis that surgery-induced changes in selected biomechanical risk factors for medial knee osteoarthritis (OA) are associated with clinically important improvements. DESIGN We prospectively evaluated patient-reported outcomes, full-limb standing radiographs and gait biomechanics before, 6 months (surgery-induced change) and 5 years after medial opening wedge high tibial osteotomy (HTO) in 170 patients (46.4 ± 8.9 years, 135 males) with knee OA and varus alignment. Logistic regression tested the associations of 6-month changes in mechanical axis angle and knee adduction moment with achieving an increase of ≥10 points in the Knee injury and Osteoarthritis Outcome Score (KOOS)4 at 5 years, with and without adjusting for covariates. Gait data were also compared to existing data from healthy controls. RESULTS Mean 5-year changes (95% confidence interval (CI)) were: KOOS4: +14.2 (10.8, 17.6); mechanical axis angle: +8.21° (7.58, 8.83); knee adduction moment: -1.49 %BW*Ht (-1.35, -1.63). The postoperative knee adduction moments were typically lower than values for healthy controls. When divided into quartiles, although all strata improved significantly, patients with reductions in knee adduction moment of 1.14-1.74 %BW*Ht (neither largest nor smallest changes) had highest 5-year KOOS4 scores. The 6-month change in knee adduction moment (odds ratios (OR) = 0.38; 95% CI: 0.22, 0.67), preoperative KOOS4 (OR = 0.96; 95% CI: 0.94, 0.99) and preoperative medial tibiofemoral narrowing grade (OR = 0.62; 95% CI: 0.37, 1.00) were negatively associated with having a 5-year clinically important improvement (C-statistic = 0.70). CONCLUSIONS Substantial improvements in biomechanical risk factors and patient-reported outcomes are observed 5 years after medial opening wedge HTO. The surgery-induced change in load distribution during walking is significantly associated with long-term clinically important improvement.
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Affiliation(s)
- T B Birmingham
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - R Moyer
- School of Physiotherapy, Faculty of Health Professions, Dalhousie University, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - K Leitch
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - B Chesworth
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - D Bryant
- School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - K Willits
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - R Litchfield
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - P J Fowler
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
| | - J R Giffin
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London Health Sciences Centre, Ontario, Canada; Bone and Joint Institute, University of Western Ontario, Canada.
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Somerville LE, Willits K, Johnson AM, Litchfield R, LeBel ME, Moro J, Bryant D. Clinical Assessment of Physical Examination Maneuvers for Superior Labral Anterior to Posterior Lesions. Surg J (N Y) 2017; 3:e154-e162. [PMID: 29018839 PMCID: PMC5629079 DOI: 10.1055/s-0037-1606829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 08/08/2017] [Indexed: 01/02/2023] Open
Abstract
Purpose
Shoulder pain and disability pose a diagnostic challenge owing to the numerous etiologies and the potential for multiple disorders to exist simultaneously. The evidence to support the use of clinical tests for superior labral anterior to posterior complex (SLAP) is weak or absent. The purpose of this study is to determine the diagnostic validity of physical examination maneuvers for SLAP lesions by performing a methodologically rigorous, clinically applicable study.
Methods
We recruited consecutive new shoulder patients reporting pain and/or disability. The physician took a history and indicated their certainty about each possible diagnosis (“certain the diagnosis is absent/present,” or “uncertain requires further testing”). The clinician performed the physical tests for diagnoses where uncertainty remained. Magnetic resonance imaging arthrogram and arthroscopic examination were the gold standards. We calculated sensitivity, specificity, and likelihood ratios (LRs) and investigated whether combinations of the top tests provided stronger predictions.
Results
Ninety-three patients underwent physical examination for SLAP lesions. When using the presence of a SLAP lesion (Types I–V) as disease positive, none of the tests was sensitive (10.3–33.3) although they were moderately specific (61.3–92.6). When disease positive was defined as repaired SLAP lesion (including biceps tenodesis or tenotomy), the sensitivity (10.5–38.7) and specificity (70.6–93.8) of tests improved although not by a substantial amount. None of the tests was found to be clinically useful for predicting repairable SLAP lesions with all LRs close to one. The compression rotation test had the best LR for both definitions of disease (SLAP tear present = 1.8 and SLAP repaired = 1.67). There was no optimal combination of tests for diagnosing repairable SLAP lesions, with at least two tests positive providing the best combination of measurement properties (sensitivity 46.1% and specificity 64.7%).
Conclusion
Our study demonstrates that the physical examination tests for SLAP lesions are poor diagnostic indicators of disease. Performing a combination of tests will likely help, although the magnitude of the improvement is minimal. These authors caution clinicians placing confidence in the physical examination tests for SLAP lesions rather we suggest that clinicians rely on diagnostic imaging to confirm this diagnosis.
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Affiliation(s)
- Lyndsay E Somerville
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Andrew M Johnson
- School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marie-Eve LeBel
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jaydeep Moro
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dianne Bryant
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada.,Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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23
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Wolff M, Litchfield R. Learning Outside the Classroom: Evaluation of Strategies to Influence Student Cultural Competence and Social Justice Attitudes. J Acad Nutr Diet 2017. [DOI: 10.1016/j.jand.2017.06.260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Somerville LE, Willits K, Johnson AM, Litchfield R, LeBel ME, Moro J, Bryant D. Diagnostic Validity of Patient-Reported History for Shoulder Pathology. Surg J (N Y) 2017; 3:e79-e87. [PMID: 28825026 PMCID: PMC5553515 DOI: 10.1055/s-0037-1601878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 02/28/2017] [Indexed: 12/26/2022] Open
Abstract
Objective The purpose of this article is to determine whether patient-reported history items are predictive of shoulder pathology and have the potential for use in triaging patients with shoulder pathology to orthopaedic outpatient clinics. Setting It is set at two tertiary orthopaedic clinics. Patients All new patients reporting pain and/or disability of the shoulder joint were prospectively recruited. A total of 193 patients were enrolled, 15 of whom withdrew, leaving 178 patients composing the study sample. Design Patients completed a questionnaire on the history of their pathology, then the surgeon took a thorough history indicating the most likely diagnosis. The clinician then performed appropriate physical examination. Arthroscopy was the reference standard for those undergoing surgery and magnetic resonance imaging (MRI) with arthrogram for all others. We calculated the sensitivity, specificity, and likelihood ratios (LRs) of history items alone and in combination. We used the LRs to generate a clinical decision algorithm. Main Outcome Measures Diagnosis was determined through arthroscopy or MRI arthrogram. Reporting was standardized to ensure review of all structures. Results The physical examination and history agreed in 75% of cases. Of those that did not agree, the physical examination misdirected the diagnosis in 47% of our cases. In particular, history items were strong predictors of anterior and posterior instability and subscapularis tears and were combined in a tool to be utilized for screening patients. Conclusion The patient-reported history items were effective for diagnosing shoulder pathology and should be considered for use in a triaging instrument.
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Affiliation(s)
- Lyndsay E Somerville
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Andrew M Johnson
- School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marie-Eve LeBel
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jaydeep Moro
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dianne Bryant
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada.,School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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25
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Getgood A, LaPrade RF, Verdonk P, Gersoff W, Cole B, Spalding T, Amis A, Bin SI, Bugbee W, Caborn D, Carter T, Chan KM, Cohen C, Cohen M, Condello V, DeBerardino T, Dirisamer F, Engebretsen L, Farr J, Gomoll A, Harner C, Heard M, Hiemstra L, Kim JG, Kim J, Kim JM, Kon E, Laggae K, Lee BS, Litchfield R, Marcacci M, McCormack R, McDermott I, Monlau JC, Myers P, Noyes F, Patsch C, Robinson J, Rodeo S, Seo SS, Sherman S, Siebold R, Snow M, Stone K, Tashman S, Thompson P, van Arkel E, van der Merwe W, Verdonk R, Williams A, Zaffagnini S. International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation. Am J Sports Med 2017; 45:1195-1205. [PMID: 27562342 DOI: 10.1177/0363546516660064] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Meniscal allograft transplantation (MAT) has become relatively commonplace in specialized sport medicine practice for the treatment of patients with a symptomatic knee after the loss of a functional meniscus. The technique has evolved since the 1980s, and long-term results continue to improve. However, there still remains significant variation in how MAT is performed, and as such, there remains opportunity for outcome and graft survivorship to be optimized. The purpose of this article was to develop a consensus statement on the practice of MAT from key opinion leaders who are members of the International Meniscus Reconstruction Experts Forum so that a more standardized approach to the indications, surgical technique, and postoperative care could be outlined with the goal of ultimately improving patient outcomes.
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Affiliation(s)
- Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, University of Western Ontario, London, Ontario, Canada
| | | | - Peter Verdonk
- Antwerp Orthopedic Center, Monica Hospitals, Antwerp, Belgium
| | - Wayne Gersoff
- Advanced Orthopedic and Sports Medicine Specialists, Denver, Colorado, USA
| | - Brian Cole
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, USA
| | - Tim Spalding
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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26
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Vundelinckx B, Herman B, Getgood A, Litchfield R. Surgical Indications and Technique for Anterior Cruciate Ligament Reconstruction Combined with Lateral Extra-articular Tenodesis or Anterolateral Ligament Reconstruction. Clin Sports Med 2016; 36:135-153. [PMID: 27871655 DOI: 10.1016/j.csm.2016.08.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After anterior cruciate ligament (ACL) rupture, anteroposterior and rotational laxity in the knee causes instability, functional symptoms, and damage to other intra-articular structures. Surgical reconstruction aims to restore the stability in the knee, and to improve function and ability to participate in sports. It also protects cartilage and menisci from secondary injuries. Because of persistent rotational instability after ACL reconstruction, combined intra-articular and extra-articular procedures are more commonly performed. In this article, an overview of anatomy, biomechanical studies, current gold standard procedures, techniques, and research topics are summarized.
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Affiliation(s)
- Bart Vundelinckx
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Benjamin Herman
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Alan Getgood
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada
| | - Robert Litchfield
- Department of Surgery, Fowler Kennedy Sport Medicine Clinic, Western University, 3M Centre, 1151 Richmond Street, London, Ontario N6A 3K7, Canada.
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27
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Bryant D, Holtby R, Willits K, Litchfield R, Drosdowech D, Spouge A, White D, Guyatt G. A randomized clinical trial to compare the effectiveness of rotator cuff repair with or without augmentation using porcine small intestine submucosa for patients with moderate to large rotator cuff tears: a pilot study. J Shoulder Elbow Surg 2016; 25:1623-33. [PMID: 27545050 DOI: 10.1016/j.jse.2016.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 05/26/2016] [Accepted: 06/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The rate of rotator cuff repair failure is between 13% and 67%. Porcine small intestine submucosa (SIS) may be suitable to augment the repair. METHODS There were 62 patients with moderate and large cuff tears randomized to repair alone (control) or augmentation with SIS (Restore Orthobiologic Implant; DePuy, Warsaw, IN, USA). Primary outcome was repair failure using magnetic resonance arthrography. Randomization occurred on completion of the repair. Patients and assessors were blind to group. Assessments occurred preoperatively and postoperatively at 2 and 6 weeks and 3, 6, 12, and 24 months. RESULTS There were 62 patients randomized (34 SIS, 28 control). Patient demographics, rotator cuff tear characteristics, and repair details were similar between groups. At 1 year, risk of failure was 52.9% (18/34) in the SIS group and 65.4% (17/26) in the control group for a risk difference of 12% (80% confidence interval, -7% to 32%) or relative risk of 0.81 (95% confidence interval, 0.53-1.24, P = .33) in favor of SIS. At 1 and 2 years, the mean difference between groups for patient-reported outcomes was small and consistent with chance but did not exclude the possibility of a clinically important difference. There was no statistically significant difference (P = .50) between the SIS group (59.6 ± 38.9; range, 3-112) and the control group (52.7 ± 38.6; range, 5-112) in number of days to being narcotic and pain free (<20 mm on a 100-mm visual analog scale). CONCLUSION We found no evidence that SIS-augmented rotator cuff repair provides superior outcomes in patients with moderate rotator cuff tears.
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Affiliation(s)
- Dianne Bryant
- Western University, London, ON, Canada; McMaster University, Hamilton, ON, Canada
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28
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Marsh JD, Birmingham TB, Giffin JR, Isaranuwatchai W, Hoch JS, Feagan BG, Litchfield R, Willits K, Fowler P. Cost-effectiveness analysis of arthroscopic surgery compared with non-operative management for osteoarthritis of the knee. BMJ Open 2016; 6:e009949. [PMID: 26758265 PMCID: PMC4716206 DOI: 10.1136/bmjopen-2015-009949] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the cost-effectiveness of arthroscopic surgery in addition to non-operative treatments compared with non-operative treatments alone in patients with knee osteoarthritis (OA). DESIGN, SETTING AND PARTICIPANTS We conducted an economic evaluation alongside a single-centre, randomised trial among patients with symptomatic, radiographic knee OA (KL grade ≥ 2). INTERVENTIONS Patients received arthroscopic debridement and partial resection of degenerative knee tissues in addition to optimised non-operative therapy, or optimised non-operative therapy only. MAIN OUTCOME MEASURES Direct and indirect costs were collected prospectively over the 2-year study period. The effectiveness outcomes were the Western Ontario McMaster Osteoarthritis Index (WOMAC) and quality-adjusted life years (QALYs). Cost-effectiveness was estimated using the net benefit regression framework considering a range of willingness-to-pay values from the Canadian public payer and societal perspectives. We calculated incremental cost-effectiveness ratios and conducted sensitivity analyses using the extremes of the 95% CIs surrounding mean differences in effect between groups. RESULTS 168 patients were included. Patients allocated to arthroscopy received partial resection and debridement of degenerative meniscal tears (81%) and/or articular cartilage (97%). There were no significant differences between groups in use of non-operative treatments. The incremental net benefit was negative for all willingness-to-pay values. Uncertainty estimates suggest that even if willing to pay $400,000 to achieve a clinically important improvement in WOMAC score, or ≥$50,000 for an additional QALY, there is <20% probability that the addition of arthroscopy is cost-effective compared with non-operative therapies only. Our sensitivity analysis suggests that even when assuming the largest treatment effect, the addition of arthroscopic surgery is not economically attractive compared with non-operative treatments only. CONCLUSIONS Arthroscopic debridement of degenerative articular cartilage and resection of degenerative meniscal tears in addition to non-operative treatments for knee OA is not an economically attractive treatment option compared with non-operative treatment only, regardless of willingness-to-pay value. TRIAL REGISTRATION NUMBER NCT00158431.
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Affiliation(s)
- Jacquelyn D Marsh
- Faculty of Health Sciences; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Trevor B Birmingham
- School of Physical Therapy, Faculty of Health Sciences; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - J Robert Giffin
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Wanrudee Isaranuwatchai
- Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey S Hoch
- Department of Public Health Sciences, University of California, Davis (UCD); Center for Healthcare Policy and Research, UCD; Centre for Excellence in Economic Analysis Research (CLEAR), St. Michael's Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Brian G Feagan
- Departments of Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry; Robarts Clinical Trials, Robarts Research Institute; Western University, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
| | - Peter Fowler
- Department of Surgery, Schulich School of Medicine and Dentistry; Fowler Kennedy Sport Medicine Clinic; Bone and Joint Institute; Western University, London, Ontario, Canada
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Abstract
Injuries to the posterolateral corner (PLC) can be difficult injuries to successfully treat and are often associated with other injuries around the knee. Patients with varus malalignment can be even more difficult to manage when they have a PLC injury, resulting in double or triple varus and subsequent varus thrust during gait. A high tibial osteotomy (HTO) is a useful and necessary operation in patients with varus malalignment and a PLC injury, particularly in the chronic setting. The biomechanics, indications, surgical approach, and outcomes of HTO in the setting of PLC injury are reviewed in this article.
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Affiliation(s)
- Benjamin Herman
- Department of Surgery, University of Western Ontario, Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, University of Western Ontario, Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
| | - Alan Getgood
- Department of Surgery, University of Western Ontario, Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
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Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc 2015; 23:3186-95. [PMID: 24929656 DOI: 10.1007/s00167-014-3117-z] [Citation(s) in RCA: 228] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 06/01/2014] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to verify and characterize the anatomical properties of the anterolateral capsule, with the aim of establishing a more accurate anatomical description of the anterolateral ligament (ALL). Furthermore, microscopic analysis of the tissue was performed to determine whether the ALL can morphologically be classified as ligamentous tissue, as well as reveal any potential functional characteristics. METHODS Three different modalities were used to validate the existence of the ALL: magnetic resonance imagining (MRI), anatomical dissection, and histological analysis. Ten fresh-frozen cadaveric knee specimens underwent MRI, followed by anatomical dissection which allowed comparison of MRI to gross anatomy. Nine additional fresh-frozen cadaveric knees (19 total) were dissected for a further anatomical description. Four specimens underwent H&E staining to look at morphological characteristics, and one specimen was analysed using immunohistochemistry to locate peripheral nervous innervation. RESULTS The ALL was found in all ten knees undergoing MRI and all nineteen knees undergoing anatomical dissection, with MRI being able to predict its corresponding anatomical dissection. The ALL was found to have bone-to-bone attachment points from the lateral femoral epicondyle to the lateral tibia, in addition to a prominent meniscal attachment. Histological sectioning showed ALL morphology to be characteristic of ligamentous tissue, having dense, regularly organized collagenous bundles. Immunohistochemistry revealed a large network of peripheral nervous innervation, indicating a potential proprioceptive role. CONCLUSION From this study, the ALL is an independent structure in the anterolateral compartment of the knee and may serve a proprioceptive role in knee mechanics.
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Affiliation(s)
- Scott Caterine
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Marjorie Johnson
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Blaine Chronik
- Department of Physics and Astronomy, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada.
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31
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Litchfield R. Is It All in the Genes? Commentary on an article by S. Gumina, MD, PhD, et al.: "Subacromial Space Width: Does Overuse or Genetics Play a Greater Role in Determining It? An MRI Study on Elderly Twins". J Bone Joint Surg Am 2015; 97:e67. [PMID: 26491139 DOI: 10.2106/jbjs.o.00790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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32
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Bergin P, Jayabal J, Walker E, Jones P, Yates K, Thornton V, Dalzeil S, Litchfield R, Roberts L, Timog J, Bennett P, Te Ao B, Parmer P, Feigin V, Davis S, Beghi E, Rossetti A. Use of epinet database for observational study of status epilepticus in Auckland, New Zealand. J Neurol Sci 2015. [DOI: 10.1016/j.jns.2015.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Whelan D, Leiter J, Sasyniuk T, Litchfield R, Randle J, Hughes S, MacDonald P. Double-row repair of the distal attachment of the superficial medial collateral ligament: a basic science pilot study. Knee Surg Sports Traumatol Arthrosc 2015; 23:2820-4. [PMID: 26342694 DOI: 10.1007/s00167-015-3773-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Accepted: 08/25/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE To describe a novel repair for tibial-sided superficial medial collateral ligament (sMCL) lesions and determine whether it restores medial joint opening to uninjured state. Agreement among experienced knee surgeons when evaluating medial joint laxity was also explored. METHODS On a series of eight human cadaveric knees, surgical elevation of the distal insertion of the sMCL was performed to replicate injury. The cut ligament was repaired using a novel double-row 'suture-bridge' technique. Valgus stress fluoroscopic images were taken with the ligament in three states: (I)ntact, (C)ut and (R)epaired, in two positions: 0 and 20° flexion. Joint opening was measured on calibrated fluoroscopic images (in mm) based on methods described by LaPrade. Joint space opening was also estimated by three experienced knee surgeons without fluoroscopy. RESULTS On fluoroscopy, no significant differences in mean joint opening were observed between an intact versus repaired ligament in 0 and 20° flexion [0.5 mm (95 % CI -1.6, 0.73; n.s.) and 0.3 mm (95 % CI -1.17, 1.71; n.s.)], respectively. Agreement among surgeons was substantial (ICC = 0.622, 95 % CI 0.52, 0.73). CONCLUSION The surgical technique adequately restored joint opening to an intact state with response to valgus stress. Agreement among surgeons when quantifying joint opening in mm was substantial. This paper addresses a technically difficult problem and provides pragmatic and practical information for surgeons who manage complicated multi-ligament knee injuries.
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Affiliation(s)
| | - Jeff Leiter
- Pan Am Clinic, University of Manitoba, Winnipeg, MN, Canada
| | | | - Robert Litchfield
- Fowler Kennedy Clinic, University of Western Ontario, London, ON, Canada
| | - John Randle
- Southlake Regional Hospital, Newmarket, ON, Canada
| | - Scott Hughes
- Pan Am Clinic, University of Manitoba, Winnipeg, MN, Canada
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Somerville LE, Willits K, Johnson AM, Litchfield R, LeBel ME, Moro J, Bryant D. Clinical Assessment of Physical Examination Maneuvers for Rotator Cuff Lesions. Am J Sports Med 2014; 42:1911-9. [PMID: 24936584 DOI: 10.1177/0363546514538390] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shoulder pain and disability pose a diagnostic challenge for clinicians owing to the numerous causes that exist. Unfortunately, the evidence in support of most clinical tests is weak or absent. PURPOSE To determine the diagnostic validity of physical examination maneuvers for rotator cuff lesions. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 1. METHODS Consecutive shoulder patients recruited for this study were referred to 2 tertiary orthopaedic clinics. A surgeon took a thorough history and indicated his or her certainty about each possible diagnosis. A clinician performed the physical examination for diagnoses where uncertainty remained. Arthroscopy was considered the reference standard for patients who underwent surgery, and MRI with arthrogram was considered the reference for patients who did not. The sensitivity, specificity, and likelihood ratios were calculated to investigate whether combinations of the top tests provided stronger predictions of the presence or absence of disease. RESULTS There were 139 participants. None of the tests were highly sensitive for diagnosing rotator cuff tears or tendinosis. Tests for subscapularis tears were all highly specific. No optimal combination of tests improved the ability to correctly diagnose rotator cuff tears. Closer analysis revealed the internal rotation and lateral rotation lag sign did not improve the ability to diagnose subscapularis or supraspinatus tears, respectively, although the lateral rotation lag sign demonstrated a discriminatory ability for tear size. CONCLUSION No test in isolation is sufficient to diagnose a patient with rotator cuff damage. A combination of tests improves the ability to diagnose damage to the rotator cuff. It is recommended that the internal rotation and lateral rotation lag signs be removed from the gamut of physical examination tests for supraspinatus and subscapularis tears.
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Affiliation(s)
- Lyndsay E Somerville
- Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Kevin Willits
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Andrew M Johnson
- School of Health Studies, Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada
| | - Robert Litchfield
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Marie-Eve LeBel
- Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Jaydeep Moro
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dianne Bryant
- Faculty of Health Sciences, The University of Western Ontario, London, Ontario, Canada Department of Surgery, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada Department of Clinical Epidemiology & Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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35
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Abstract
BACKGROUND The traditional treatment for primary anterior shoulder dislocations has been immobilization in a sling with the arm in a position of adduction and internal rotation. However, recent basic science and clinical data have suggested recurrent instability may be reduced with immobilization in external rotation after primary shoulder dislocation. QUESTIONS/PURPOSES We performed a randomized controlled trial to compare the (1) frequency of recurrent instability and (2) disease-specific quality-of-life scores after treatment of first-time shoulder dislocation using either immobilization in external rotation or immobilization in internal rotation in a group of young patients. METHODS Sixty patients younger than 35 years of age with primary, traumatic, anterior shoulder dislocations were randomized (concealed, computer-generated) to immobilization with either an internal rotation sling (n = 29) or an external rotation brace (n = 31) at a mean of 4 days after closed reduction (range, 1-7 days). Patients with large bony lesions or polytrauma were excluded. The two groups were similar at baseline. Both groups were immobilized for 4 weeks with identical therapy protocols thereafter. Blinded assessments were completed by independent observers for a minimum of 12 months (mean, 25 months; range, 12-43 months). Recurrent instability was defined as a second documented anterior dislocation or multiple episodes of shoulder subluxation severe enough for the patient to request surgical stabilization. Validated disease-specific quality-of-life data (Western Ontario Shoulder Instability index [WOSI], American Shoulder and Elbow Surgeons evaluation [ASES]) were also collected. Ten patients (17%, five from each group) were lost to followup. Reported compliance with immobilization in both groups was excellent (80%). RESULTS With the numbers available, there was no difference in the rate of recurrent instability between groups: 10 of 27 patients (37%) with the external rotation brace versus 10 of 25 patients (40%) with the sling redislocated or developed symptomatic recurrent instability (p = 0.41). WOSI scores were not different between groups (p = 0.74) and, although the difference in ASES scores approached statistical significance (p = 0.05), the magnitude of this difference was small and of uncertain clinical importance. CONCLUSIONS Despite previous published findings, our results show immobilization in external rotation did not confer a significant benefit versus sling immobilization in the prevention of recurrent instability after primary anterior shoulder dislocation. Further studies with larger numbers may elucidate whether functional outcomes, compliance, or comfort with immobilization can be improved with this device. LEVEL OF EVIDENCE Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel B Whelan
- Department of Surgery, St Michael's Hospital and University of Toronto, 55 Queen Street East (800), Toronto, ON, M5C 1R6, Canada,
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36
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Caterine S, Litchfield R, Johnson M, Chronik B, Getgood A. A cadaveric study of the anterolateral ligament: re-introducing the lateral capsular ligament. Knee Surg Sports Traumatol Arthrosc 2014. [PMID: 24929656 DOI: 10.1007/s00167-014-3117-z.] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The purpose of this study was to verify and characterize the anatomical properties of the anterolateral capsule, with the aim of establishing a more accurate anatomical description of the anterolateral ligament (ALL). Furthermore, microscopic analysis of the tissue was performed to determine whether the ALL can morphologically be classified as ligamentous tissue, as well as reveal any potential functional characteristics. METHODS Three different modalities were used to validate the existence of the ALL: magnetic resonance imagining (MRI), anatomical dissection, and histological analysis. Ten fresh-frozen cadaveric knee specimens underwent MRI, followed by anatomical dissection which allowed comparison of MRI to gross anatomy. Nine additional fresh-frozen cadaveric knees (19 total) were dissected for a further anatomical description. Four specimens underwent H&E staining to look at morphological characteristics, and one specimen was analysed using immunohistochemistry to locate peripheral nervous innervation. RESULTS The ALL was found in all ten knees undergoing MRI and all nineteen knees undergoing anatomical dissection, with MRI being able to predict its corresponding anatomical dissection. The ALL was found to have bone-to-bone attachment points from the lateral femoral epicondyle to the lateral tibia, in addition to a prominent meniscal attachment. Histological sectioning showed ALL morphology to be characteristic of ligamentous tissue, having dense, regularly organized collagenous bundles. Immunohistochemistry revealed a large network of peripheral nervous innervation, indicating a potential proprioceptive role. CONCLUSION From this study, the ALL is an independent structure in the anterolateral compartment of the knee and may serve a proprioceptive role in knee mechanics.
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Affiliation(s)
- Scott Caterine
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada.,Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Robert Litchfield
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Marjorie Johnson
- Department of Anatomy and Cell Biology, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Blaine Chronik
- Department of Physics and Astronomy, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada
| | - Alan Getgood
- Fowler Kennedy Sport Medicine Clinic, 3M Centre, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada.
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Abstract
BACKGROUND Previously reported complications in medial opening wedge (MOW) high tibial osteotomy (HTO) vary considerably in both rate and severity. PURPOSE (1) To determine the rates of adverse events in MOW HTO classified into different grades of severity based on the treatments required and (2) to compare patient-reported outcomes between the different adverse event classifications. STUDY DESIGN Case series; Level of evidence, 4. METHODS All patients receiving MOW HTO at a single medical center from 2005 to 2009 were included. Internal fixation was used in all cases, with either a nonlocking (Puddu) or locking (Tomofix) plate. Patients were evaluated at 2, 6, and 12 weeks; 6 and 12 months; and annually thereafter. Types of potential surgical and postoperative adverse events, categorized into 3 classes of severity based on the subsequent treatments, were defined a priori. Medical records and radiographs were then reviewed by an independent observer. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were compared in subgroups of patients based on the categories of adverse events observed. RESULTS A total of 323 consecutive procedures (242 males) were evaluated (age, mean ± standard deviation, 46 ± 9 years; body mass index, mean ± standard deviation, 30 ± 5 kg/m(2)). Adverse events requiring no additional treatment (class 1) were undisplaced lateral cortical breaches (20%), displaced (>2 mm) lateral hinge fracture (6%), delayed wound healing (6%), undisplaced lateral tibial plateau fracture (3%), hematoma (3%), and increased tibial slope ≥10° (1%). Adverse events requiring additional or extended nonoperative management (class 2) were delayed union (12%), cellulitis (10%), limited hardware failure (1 broken screw; 4%), postoperative stiffness (1%), deep vein thrombosis (1%), and complex regional pain syndrome (CRPS) type 1 (1%). Adverse events requiring additional or revision surgery and/or long-term medical care (class 3) were aseptic nonunion (3%), deep infection (2%), CRPS type 2 (1%), and severe hardware failure with loss of correction (1%). Additional surgery rate was 3%. Class 1 and 2 adverse events did not affect patient-reported outcomes at 6, 12, or 24 months postoperatively. Patients with class 3 adverse events had significantly lower total WOMAC scores at 6 months but not at 12 or 24 months postoperatively. CONCLUSION The most common adverse event in MOW HTO requiring extended nonoperative treatment (class 2) is delayed union (12%). The rate of severe adverse events requiring additional surgery and/or long-term medical care (class 3) is low (7%).
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Affiliation(s)
- Robin Martin
- J. Robert Giffin, FRCS(C Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada, N6A 3K7. ); and Trevor B. Birmingham, Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada, N6A 3K7 (e-mail: )
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Caterine S, Litchfield R, Johnson M, Sandig M, Getgood A. Structural characterization of the anterolateral capsule of the knee ő a gross anatomic, histological, and magnetic resonance imaging study of the anterolateral ligament (914.6). FASEB J 2014. [DOI: 10.1096/fasebj.28.1_supplement.914.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Scott Caterine
- Anatomy and Cell Biology Western University LondonONCanada
| | | | | | - Martin Sandig
- Anatomy and Cell Biology Western University LondonONCanada
| | - Alan Getgood
- Fowler Kenedy Sport Medicine ClinicLondonONCanada
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Getgood A, Litchfield R. Response to 'Critical comments and questions to the publication "Getgood A, Collins B, Slynarski K, Kurowska E, Parker D, Engebretsen L, MacDonald PB, Litchfield R 2011 Short-term safety and efficacy of a novel high tibial osteotomy system: a case controlled study"'. Knee Surg Sports Traumatol Arthrosc 2013; 21:272-3. [PMID: 22955147 DOI: 10.1007/s00167-012-2189-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 08/17/2012] [Indexed: 11/27/2022]
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James K, Albrecht J, Litchfield R, Weishaar C, Larvick C, Schwarz C, Temple J. Assessing Leftover Food Safety Knowledge and Behaviors from a Social Marketing Campaign Website. J Acad Nutr Diet 2012. [DOI: 10.1016/j.jand.2012.06.279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bryant D, Dill J, Litchfield R, Amendola A, Giffin R, Fowler P, Kirkley A. Effectiveness of bioabsorbable arrows compared with inside-out suturing for vertical, reparable meniscal lesions: a randomized clinical trial. Am J Sports Med 2007; 35:889-96. [PMID: 17337726 DOI: 10.1177/0363546506298582] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Techniques for repairing the meniscus include both open and arthroscopic techniques using sutures and bioabsorbable implants. The purpose of this study was to compare the effectiveness of inside-out suturing and bioabsorbable arrows for repair of vertical meniscal lesions. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 1. METHODS One hundred consecutive patients were randomly assigned to arrows (n = 51) or sutures (n = 49). Sixty-five percent of patients (31 sutures, 34 arrows) underwent a concomitant anterior cruciate ligament reconstruction. A blinded research associate conducted assessments at 6 weeks and 3, 6, 12, and 24 months postoperatively. The primary outcome was retear rate. Secondary outcomes included the Western Ontario Meniscal Evaluation Tool, Anterior Cruciate Ligament Quality of Life Outcome Measure, and side-to-side comparisons of flexion and extension. RESULTS At baseline, groups were similar in age, gender, time from injury to surgery, and length and location of tear. Mean follow-up was 28.0 +/- 8.4 months. There were 22 failed meniscal repairs (11 in each group), which did not represent a significant difference in the rate of failure between groups (P = .92). The mean quality of life scores and side-to-side differences in extension and flexion measurements were not significantly different between groups. Two patients from the arrow group crossed over into the suture group at the time of surgery because of technical difficulties with the device, and in 3 instances, a single suture was needed to keep the tear reduced while arrows were introduced. Two patients required reoperation for removal of a prominent, subcutaneous arrow, and 1 patient in the suture group suffered a transient peroneal nerve palsy during revision suturing. CONCLUSION At intermediate follow-up, there were no statistically significant differences in measured outcomes between meniscal suturing and arrows. Longer term follow-up is necessary to identify differences between these 2 treatments, particularly to estimate the incidence of articular surface damage in patients whose meniscal tear was repaired using arrows.
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Affiliation(s)
- Dianne Bryant
- School of Physical Therapy, Department of Surgery, Orthopaedic Division, University of Western Ontario, Elborn College, London, ON, N6G 1H1, Canada.
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Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J Bone Joint Surg Am 2005; 87:1947-56. [PMID: 16140808 DOI: 10.2106/jbjs.d.02854] [Citation(s) in RCA: 196] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A systematic review of the literature was performed to estimate the impact of hemiarthroplasty compared with total shoulder arthroplasty on function and range of motion in patients suffering from osteoarthritis of the shoulder. METHODS We conducted an electronic search for relevant studies published in any language from 1966 to 2004, a manual search of the proceedings from five major orthopaedic meetings from 1995 to 2003, and a review of the reference lists from potentially relevant studies. Four randomized clinical trials, with similar eligibility criteria and surgical techniques, that compared hemiarthroplasty and total shoulder arthroplasty for the treatment of primary osteoarthritis of the shoulder were found to be eligible. Authors from three of the four studies provided original patient data. Analysis of covariance focused on the two-year outcome and included a comparison of the aggregate University of California at Los Angeles shoulder score, four University of California at Los Angeles domain scores, and range of motion. RESULTS A total of 112 patients (fifty managed with hemiarthroplasty and sixty-two managed with total shoulder arthroplasty), who had a mean age of sixty-eight years, were included in this analysis. A significant moderate effect was detected in the function domain of the University of California at Los Angeles shoulder score (p < 0.001) in favor of total shoulder arthroplasty (mean [and standard deviation], 8.1 +/- 0.3) compared with hemiarthroplasty (mean, 6.6 +/- 0.3). A significant difference in the pain score was found in favor of the total shoulder arthroplasty group (p < 0.0001). However, the large degree of heterogeneity (p = 0.006, I(2) = 80.2%) among the studies decreased our confidence that total shoulder arthroplasty provides a true, consistent benefit with regard to pain. There was a significant difference in the overall change in forward elevation of 13 degrees (95% confidence interval, 0.5 degrees to 26 degrees ) in favor of the total shoulder arthroplasty group (p = 0.008). CONCLUSIONS At a minimum of two years of follow-up, total shoulder arthroplasty provided better functional outcome than hemiarthroplasty for patients with osteoarthritis of the shoulder. Since continuous degeneration of the glenoid after hemiarthroplasty or glenoid loosening after total shoulder arthroplasty may affect the eventual outcome, longer-term (five to ten-year) results are necessary to determine whether these findings remain consistent over time.
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Affiliation(s)
- Dianne Bryant
- Department of Clinical Epidemiology and Biostatistics, Hamilton Health Sciences Center, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
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Krishnan SG, Hawkins RJ, Michelotti JD, Litchfield R, Willis RB, Kim YK. Scapulothoracic arthrodesis: indications, technique, and results. Clin Orthop Relat Res 2005:126-33. [PMID: 15930929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Twenty-two patients (24 shoulders) had a scapulothoracic arthrodesis for various clinical disorders including facioscapulohumeral muscular dystrophy, scapular winging from serratus anterior palsy, painful scapular crepitation, and cleidocranial dysostosis. All patients were extremely disabled with pain and loss of function because of their symptomatic scapular winging, and many of the patients had multiple previous procedures on their shoulders before the scapulothoracic arthrodesis. The surgical indication was stabilization of painful scapulothoracic articulation to provide pain relief and allow functional use of the involved arm for activities of daily living. The surgical technique involved use of a semitubular plate and wire construct along the medial border of the scapula with the use of autograft (iliac crest) or allograft bone or both between the scapula and the rib cage. Patients were immobilized postoperatively for 12 weeks. Complications occurred in more than (1/2) of the patients and included pulmonary complications, hardware failure, pseudarthrosis, and persistent pain. Postoperatively, 20 of 22 (91%) patients thought that the pain in their shoulder complex was improved and were satisfied with their functional outcome. Scapulothoracic arthrodesis can improve function and reduce pain in the shoulder complex in patients with debilitating complex scapulothoracic dysfunction. However, the high incidence of complications with this procedure is a concern. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sumant G Krishnan
- Department of Shoulder Service, W. B. Carrell Memorial Clinic, Dallas, TX, USA
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Alvarez CM, Litchfield R, Jackowski D, Griffin S, Kirkley A. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med 2005; 33:255-62. [PMID: 15701612 DOI: 10.1177/0363546504267345] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rotator cuff tendinosis is a common problem with significant health and economic effects. Nonoperative management includes the widespread use of subacromial steroid injections despite the lack of evidence of its efficacy. HYPOTHESIS A subacromial injection of betamethasone will be more effective than xylocaine alone in improving the quality of life, impingement sign, and range of motion in patients who have chronic rotator cuff tendinosis or partial rotator cuff tears. STUDY DESIGN Randomized controlled clinical trial; Level of evidence, 1. METHODS Patients with rotator cuff tendinosis or partial cuff tear with symptoms longer than 6 months, with failure of 6 weeks of physical therapy and 2 weeks of nonsteroidal anti-inflammatory drugs, who were older than 30 years of age, and who showed >50% improvement with the Neer impingement test were stratified for Workplace Safety and Insurance Board status and previous injection. Outcome measures--the Western Ontario Rotator Cuff Index; American Shoulder and Elbow Surgeons standardized form; Disabilities of the Arm, Shoulder and Hand; active forward elevation; active internal rotation; active external rotation; and the Neer impingement sign--were assessed at 2, 6, 12, and 24 weeks after injection. The injection into the subacromial space contained either 5 mL of 2% xylocaine alone or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone in an opaque syringe. RESULTS In 58 patients (betamethasone group, n = 30; xylocaine group, n = 28), the authors found no statistically significant difference between the 2 treatment groups for all outcomes and time intervals. The scores for the Western Ontario Rotator Cuff Index at 3 months were xylocaine = 45.4% +/- 13% and betamethasone = 56.3% +/- 17% (P = .13). At 6 months, the scores were xylocaine = 51% +/- 32% and betamethasone = 59% +/- 26% (P = .38). All other outcomes showed similar values. As well, similar results were found for 2 and 6 weeks after injection. Both groups showed improvement from baseline in all outcomes. CONCLUSIONS With the numbers available for this study, the authors found betamethasone to be no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone in patients with chronic rotator cuff tendinosis for all follow-up time intervals evaluated.
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Armour T, Forwell L, Litchfield R, Kirkley A, Amendola N, Fowler PJ. Isokinetic evaluation of internal/external tibial rotation strength after the use of hamstring tendons for anterior cruciate ligament reconstruction. Am J Sports Med 2004; 32:1639-43. [PMID: 15494327 DOI: 10.1177/0363546504263405] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Evaluation of the knee after an anterior cruciate ligament reconstruction with the use of the semitendinosus and gracilis (hamstring) autografts has primarily focused on flexion and extension strength. The semitendinosus and gracilis muscles contribute to internal tibial rotation, and it has been suggested that harvest of these tendons for the purpose of an anterior cruciate ligament reconstruction contributes to internal tibial rotation weakness. HYPOTHESIS Internal tibial rotation strength may be affected by the semitendinosus and gracilis harvest after anterior cruciate ligament reconstruction. STUDY DESIGN Prospective evaluation of internal and external tibial rotation strength. METHODS Inclusion criteria for subjects (N = 30): unilateral anterior cruciate ligament reconstruction at least 2 years previously, a stable anterior cruciate ligament (<5-mm side-to-side difference) at time of testing confirmed by surgeon and KT-1000 arthrometer, no history of knee problems after initial knee reconstruction, a normal contralateral knee, and the ability to comply with the testing protocol. In an attempt to minimize unwanted subtalar joint motion, subjects were immobilized using an ankle brace and tested at angular velocities of 60 degrees /s, 120 degrees /s, and 180 degrees /s at a knee flexion angle of 90 degrees . RESULTS The mean peak torque measurements for internal rotation strength of the operative limb (60 degrees /s, 17.4 +/- 4.5 ft-lb; 120 degrees /s, 13.9 +/- 3.3 ft-lb; 180 degrees /s, 11.6 +/- 3.0 ft-lb) were statistically different compared to the nonoperated limb (60 degrees /s, 20.5 +/- 4.7 ft-lb; 120 degrees /s, 15.9 +/- 3.8 ft-lb; 180 degrees /s, 13.4 +/- 3.8 ft-lb) at 60 degrees /s (P = .012), 120 degrees /s (P = .036), and 180 degrees /s (P = .045). The nonoperative limb demonstrated greater strength at all speeds. The mean torque measurements for external rotation were statistically similar when compared to the nonoperated limb at all angular velocities. CONCLUSIONS We have shown through our study that patients who undergo surgical intervention to repair a torn anterior cruciate ligament with the use of autogenous hamstring tendons demonstrate with weaker internal tibial rotation postoperatively at 2 years when compared to the contralateral limb.
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Affiliation(s)
- Tanya Armour
- Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada
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Affiliation(s)
- A Amendola
- Department of Orthopedics, University of Iowa Sports Medicine Center, Iowa City, Iowa 52242, USA
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Abstract
BACKGROUND Although there are many studies describing tests for shoulder instability, there are few assessing the validity of these tests in diagnosing anterior shoulder instability. PURPOSE To assess the validity of the apprehension, relocation, and surprise tests as predictors of anterior shoulder instability. STUDY DESIGN Retrospective review of prospectively collected data. METHODS Forty-six patients with a clear diagnosis of one of the following shoulder disorders were evaluated by four independent, blinded examiners: traumatic anterior instability (18), rotator cuff tendinosis (17), posterior instability (2), glenohumeral osteoarthritis (4), or multidirectional instability (5). Interobserver reliability was also determined. RESULTS In subjects who had a feeling of apprehension on all three tests, the mean positive and negative predictive values were 93.6% and 71.9%, respectively. The surprise test was the single most accurate test (sensitivity = 63.89%; specificity = 98.91%). An improvement in the feeling of apprehension or pain with the relocation test added little to the value of the tests. Interobserver reliability was determined to be 0.83. CONCLUSIONS and CLINICAL RELEVANCE The results of this study suggest that a positive instability exam on all three tests is highly specific and predictive of traumatic anterior glenohumeral instability.
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Affiliation(s)
- Ian K Y Lo
- University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
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Kirkley A, Litchfield R, Thain L, Spouge A. Agreement between magnetic resonance imaging and arthroscopic evaluation of the shoulder joint in primary anterior dislocation of the shoulder. Clin J Sport Med 2003; 13:148-51. [PMID: 12792208 DOI: 10.1097/00042752-200305000-00004] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the effectiveness of magnetic resonance imaging in identifying shoulder pathology in patients with primary traumatic dislocation of the shoulder and to compare these findings with findings at the time of arthroscopic surgery. DESIGN Correlation between arthroscopy and magnetic resonance imaging. PATIENTS Sixteen patients, aged 18 to 30 years, who were randomized to the surgical arm of a study comparing the effectiveness of immediate arthroscopic surgery with immobilization and rehabilitation for primary traumatic anterior dislocation of the shoulder, were included in this study. INTERVENTIONS Each patient underwent magnetic resonance imaging and a videotaped "tour" of the shoulder prior to any surgical intervention. MAIN OUTCOME MEASURE Magnetic resonance scans and videotapes were reviewed for the presence or absence of abnormalities in 8 features of the shoulder, and concordant and discordant findings were evaluated. RESULTS There was moderate correlation for superior labral lesions (kappa = 0.60) and fair agreement for rotator cuff tear (kappa = 0.355). When the joint capsule was assessed, there was only fair agreement for both the presence of an abnormality (kappa = 0.310) and redundancy and tear (kappa = 0.394). Both methods were sensitive for the detection of Hill-Sachs lesions (kappa = 1.0), although there was only moderate agreement (kappa = 0.44) on estimation of size. There was perfect agreement for the detection of Bankart lesions or equivalent capsulolabral disruption (kappa = 1.0). CONCLUSIONS Magnetic resonance imaging can be considered a valuable tool for the detection of Hill-Sachs and Bankart lesions associated with primary traumatic anterior dislocations of the shoulder. Its ability to detect other pathologic lesions, however, is limited.
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Kirkley A, Rampersaud R, Griffin S, Amendola A, Litchfield R, Fowler P. Tourniquet versus no tourniquet use in routine knee arthroscopy: a prospective, double-blind, randomized clinical trial. Arthroscopy 2000; 16:121-6. [PMID: 10705321 DOI: 10.1016/s0749-8063(00)90024-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to determine the effects of tourniquet use for routine knee arthroscopy based on both subjective and objective functional outcome measures. TYPE OF STUDY The study was a prospective, double-blind, randomized clinical trial. MATERIALS AND METHODS There were 120 patients randomized to tourniquet inflation (300 mm Hg) or no tourniquet inflation during routine knee arthroscopy. Patients recorded their average pain on a visual analog scale and their narcotic use for the previous 24 hours, for the first 5 postoperative days. Patients also completed a preoperative and postoperative (2 week, 6 week, 3 month) Western Ontario and McMaster University Osteoarthritis Index (WOMAC), 6-minute walk, 30-second stair climb, 1-leg standing vertical leap, range of motion, and isokinetic strength testing. Time to return to work and sport was documented. RESULTS No statistically significant difference was found between tourniquet-up and tourniquet-down groups for the WOMAC quality of life measure, functional tests, isokinetic muscle strengthening, or time to return to work or sport (t test/repeated measures analysis of variance). However, there was a trend for less early postoperative pain and slightly better isokinetic strength testing at 2 weeks in the tourniquet-down group. Visualization was rated by surgeons to be 3 times better in the tourniquet-up group, although mean operative time did not differ between the groups. CONCLUSION The use of a pneumatic tourniquet at 300 mm Hg does not significantly effect overall patient quality of life or functional outcome following routine knee arthroscopy.
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Affiliation(s)
- A Kirkley
- Fowler.Kennedy Sport Medicine Clinic, University of Western Ontario, London, Ontario, Canada
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Abstract
BACKGROUND The purpose of this study was to compare a custom-made valgus-producing functional knee (unloader) brace, a neoprene sleeve, and medical treatment only (control group) with regard to their ability to improve the disease-specific quality of life and the functional status of patients who had osteoarthritis in association with a varus deformity of the knee (varus gonarthrosis). METHODS The study design was a prospective, parallel-group, randomized clinical trial. Patients who had varus gonarthrosis were screened for eligibility. The criteria for exclusion included arthritides other than osteoarthritis; an operation on the knee within the previous six months; symptomatic disease of the hip, ankle, or foot; a previous fracture of the tibia or femur; morbid obesity (a body-mass index of more than thirty-five kilograms per square meter); skin disease; peripheral vascular disease or varicose veins that would preclude use of a brace; a severe cardiovascular deficit; blindness; poor English-language skills; and an inability to apply a brace because of physical limitations such as arthritis in the hand or an inability to bend over. Treatment was assigned on the basis of a computer-generated block method of randomization with use of sealed envelopes. The patients were stratified according to age (less than fifty years or at least fifty years), deformity (the mechanical axis in less than 5 degrees of varus or in at least 5 degrees of varus), and the status of the anterior cruciate ligament (torn or intact). The patients were randomly assigned to one of three treatment groups: medical treatment only (control group), medical treatment and use of a neoprene sleeve, or medical treatment and use of an unloader brace. The disease-specific quality of life was measured with use of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR), and function was assessed with use of the six-minute walking and thirty-second stair-climbing tests. The primary outcome measure consisted of an analysis of covariance of the change in scores between the baseline and six-month evaluations. RESULTS One hundred and nineteen patients were randomized. The control group consisted of forty patients (thirty-one men and nine women; mean age, 60.9 years); the neoprene-sleeve group, of thirty-eight patients (twenty-seven men and eleven women; mean age, 58.2 years); and the unloader-brace group, of forty-one patients (twenty-eight men and thirteen women; mean age, 59.5 years). Nine patients withdrew from the study. At the six-month follow-up evaluation, there was a significant improvement in the disease-specific quality of life (p = 0.001) and in function (p< or =0.001) in both the neoprene-sleeve group and the unloader-brace group compared with the control group. There was a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to pain after both the six-minute walking test (p = 0.021) and the thirty-second stair-climbing test (p = 0.016). There was a strong trend toward a significant difference between the unloader-brace group and the neoprene-sleeve group with regard to the change in the WOMAC aggregate (p = 0.062) and WOMAC physical function scores (p = 0.081). CONCLUSIONS The results indicate that patients who have varus gonarthrosis may benefit significantly from use of a knee brace in addition to standard medical treatment. The unloader brace was, on the average, more effective than the neoprene sleeve. The ideal candidates for each of these bracing options remain to be identified.
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Affiliation(s)
- A Kirkley
- Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada
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