Increased stiffness and reoperation rate in partial rotator cuff repairs treated with a bovine patch: a propensity-matched trial

BACKGROUND

Treating high-grade (grade 2 and 3) partial-thickness rotator cuff tears after failed conservative care remains challenging. Arthroscopic repair techniques are often considered with or without subacromial decompression and biological injections. More recently, a bioinductive bovine collagen patch (Regeneten; Smith & Nephew, Memphis, TN, USA) has been proposed to create a healing response and thicken the injured tendon. Although promising early results have been shown, previous studies lacked control subjects or comparison to other surgical treatments. The purpose of this study was to compare the reoperation rates of arthroscopic débridement and repair without a bioinductive collagen patch vs. arthroscopic débridement and repair with a bioinductive collagen patch in patients with high-grade partial-thickness rotator cuff tears in whom a minimum of 6 months of nonoperative treatment failed.

METHODS

Thirty-two patients with high-grade partial-thickness supraspinatus tears were treated with surgical repair with a bioinductive patch. A control group of 32 patients with high-grade partial-thickness supraspinatus tears treated with débridement or tear completion and repair without a bioinductive patch was selected and matched for age, sex, and tear size. Patients were followed up at regular intervals of 6 weeks, 12 weeks, and 6 months postoperatively, and range of motion was assessed at respective clinic visits. Stiffness and reoperations were compared between groups.

RESULTS

Postoperative stiffness was observed in the first 12 weeks in 8 of 32 patients in the patch group compared with 1 of 32 patients in the control group. Six patients in the patch group underwent reoperations compared with no patients in the control group (P < .001). All 6 reoperations in the patch group were performed to address stiffness. There were no differences in race, smoking status, or diabetes between groups (P > .05).

CONCLUSION

Patients in the patch group had a significantly higher rate of postoperative stiffness. In the majority of patients in whom shoulder stiffness developed, reoperation was required.

Risk factors for complications and return to the emergency department after interscalene block using liposomal bupivacaine for shoulder surgery

BACKGROUND

Exparel (liposomal bupivacaine) has recently gained favor for use in interscalene regional blocks for shoulder surgery. While effective for pain relief, this does have adverse effects that can lead to postoperative emergency department (ED) visits. This study aimed to identify any patient risk factors that are associated with complications leading to ED return visits owing to interscalene blocks using Exparel before shoulder surgery.

METHODS

A retrospective chart review was performed for all patients undergoing shoulder surgery with an Exparel interscalene block in an 8-month period. For each patient, demographic information, comorbidities, type of block, postoperative complications, ED return visits, and readmissions were recorded. The 5-factor modified Frailty Index score and the Charlson Comorbidity Index score were calculated. Univariate and multivariate logistic regressions were conducted to identify risk factors associated with increased complications and return to the ED.

RESULTS

Overall, 352 patients were included; most patients were men, were aged between 51 and 70 years, and had a body mass index of 25.0-35.0. Postoperative complications related to the Exparel interscalene block occurred in 58 patients (16.5%), including 37 minor complications (10.5%) and 21 major complications (6.0%) that led to return ED visits. Univariate analysis yielded American Society of Anesthesiologists (ASA) score (P = .03) as a significant predictor of minor complications. Multivariate logistic regression analysis yielded ASA score (P = .096; odds ratio, 1.64) as trending toward being a significant risk factor for minor complications. Univariate analysis yielded age (P = .006), ASA score (P = .009), and Charlson Comorbidity Index score (P = .002) as significant predictors of major complications. Multivariate logistic regression analysis yielded ASA score (P = .049; odds ratio, 2.25) as the only significant risk factor for major complications.

CONCLUSION

Surgeons and anesthesiologists should strongly consider a patient's ASA score, in addition to his or her pulmonary and cardiac history, when deciding whether the patient is an appropriate candidate for an interscalene regional block using Exparel for shoulder surgery.

Surgical fixation of pilon injuries: a comparison of the anterolateral and posterolateral approach

PURPOSE

This study looks to compare patient outcomes in those with pilon fractures fixed with the anterolateral approach versus those with the posterolateral approach.

METHODS

135 patient charts of those with surgically treated pilon fractures over a 7-year period were retrospectively reviewed, recording demographic information, fracture description, surgical intervention timeline, operative outcomes, patient outcomes, and complication rates.

RESULTS

Of the 44 included patients (32 anterolateral and 12 posterolateral), most were older than 40 years of age (65.9%) and male (63.6%). There was no difference seen between anterolateral approach and posterolateral approach tourniquet times (p = 0.80), operating room time (p = 0.40), or estimated blood loss (p = 0.73). There was also no reported difference in decrease in Numerical Rating Scale pain scores (p = 0.38), FOTO (Focus on Therapeutic Outcomes) percent increase (p = 0.13), active flexion-extension axis range of motion (p = 0.35), or inversion-eversion axis (p = 0.25) range of motion after an anterolateral approach versus a posterolateral approach. Finally, statistically similar complication rates (p = 0.75) were seen between anterolateral and posterolateral approaches, but patients who underwent a posterolateral approach surgical fixation were trending towards significantly using more post-operative outpatient opioid medications for pain control compared to those who underwent surgical fixation with an anterolateral approach (p = 0.09).

CONCLUSIONS

Pilon injuries that lend themselves to anterolateral fixation have similar outcomes peri-operatively and post-operatively compared to injuries lending to posterolateral fixation. Both approaches can be used as dictated by the injury not fearing poorer outcomes or increased complication rates. However, surgeons must be wary of high complication rates associated with all pilon injury patterns.

LEVEL OF EVIDENCE

Therapeutic Level IV.

An evaluation of prophylactic treatments to prevent post traumatic joint stiffness

Arthrofibrosis is a major obstacle to restoring joint function after trauma. The objective of this study was to evaluate montelukast, forskolin, and triamcinolone as possible means of prophylaxis against the formation of arthrofibrosis. Forty-eight rats underwent surgical knee trauma with post-operative immobilization in full flexion. The treatment groups were: control (CTL), oral montelukast (3.75 mg/kg/day) (MLK), intra-articular forskolin injections (0.6 mg/kg) (FSK), and intra-articular triamcinolone injections (0.68 mg/kg) (STR). Rats were sacrificed after 14 days and femorotibial contracture angles were measured with the posterior capsule intact and with the posterior capsule cut. A 0.015Nm extension moment was applied to the knee. All treatment groups had significant reductions in contracture angle compared to the control. Mean contractures with the posterior capsule intact were 32°(CTL), 20° (MLK), 22° (FSK), and 7° (STR). Contractures with the posterior capsule cut were 28° (CTL), 19° (MLK), 20° (FSK), and 5° (STR). The STR group was significantly better than FSK and MLK. Triamcinolone injections provided dramatic reductions in stiffness. Both forskolin and montelukast provided significant, though lesser, reductions in stiffness. While the triamcinolone contracture angles were significantly better, the novel treatments of forskolin and montelukast provided encouraging results and should be studied further.