Treatment of Glenoid Chondral Defect Using Micronized Allogeneic Cartilage Matrix Implantation

Abstract: Focal chondral lesions of the glenohumeral joint, though less common than chondral defects in the knee or ankle, can be a significant source of pain in an active population. For patients in whom nonsurgical management fails, promising results have been reported after arthroscopic microfracture surgery to treat such lesions. However, microfracture leads to growth of fibrocartilage tissue and is biomechanically less durable than native hyaline cartilage. Recently, augmentation of the microfractured defect with micronized allogeneic cartilage and platelet-rich plasma has been described to restore hyaline-like cartilage and potentially protect the subchondral bone from postsurgical fracture biology within the base of the defect. We present a simple arthroscopic technique of implanting dehydrated, micronized allogeneic cartilage scaffold to treat an isolated chondral lesion of the glenoid. C artilage injury in the shoulder may be caused by trauma, shoulder instability, osteonecrosis, infection, chondrolysis, osteochondritis dissecans, inflammatory arthritis, rotator cuff arthropathy, and osteoarthritis. Although symptomatic glenohumeral chondral lesions in elderly and less active patients can be successfully treated with shoulder arthroplasty, focal chondral lesions in the younger, active patient population demand alternative treatment strategies that preserve the joint because of the high rate of glenoid component failure and need for revision surgery in younger patients treated with shoulder arthroplasty

Effect of Simulated Shoulder Thermal Capsulorrhaphy Using Radiofrequency Energy on Glenohumeral Fluid Temperature

Purpose: To determine joint fluid temperatures at different time intervals during treatment with radiofrequency energy (RFE) applied in intermittent and continuous treatment manners under flow or no-flow conditions using a simulated shoulder joint model. Type of Study: In vitro measurement of simulated joint fluid temperature during RFE treatment. Methods: A custom-built jig with a chamber (volume size, 25 mL) was used to mimic the adult human shoulder. Three RFE systems: Vulcan EAS plus TAC-S probe (Smith & Nephew Endoscopy, Andover, MA); VAPR II plus End-Effect Electrode (Mitek, Westwood, MA); and ArthroCare 2000 plus TurboVac 90°probe (ArthroCare, Sunnyvale, CA) were tested in the chamber with saline solution initially set at 23°C. Each RFE probe was applied in a paintbrush pattern on the capsular tissue in the chamber and a fluoroptic thermometry probe was placed 1 cm above the RFE treatment probe to record the fluid temperature. Both intermittent and the continuous treatment manners were tested under flow and no-flow conditions. For each probe/manner/flow combination, 6 bovine capsular tissue specimens were tested (n ϭ 6). All data were recorded using a HyperTerminal software program (Hilgraeve Inc, Monroe, MI) into a personal computer. Results: When using intermittent and continuous treatment manners with flow, all recorded chamber fluid temperatures for all tested RFE probes at each time interval were below 40°C. Under no-flow conditions, with intermittent treatment, the ArthroCare probe caused joint fluid temperatures to exceed 50°C after 70 seconds of RFE treatment. With the continuous treatment, the ArthroCare caused chamber fluid temperatures to exceed 65°C after 2 minutes of treatment. The highest mean recorded chamber fluid temperature was caused by ArthroCare probe, which reached 80°C at 3 minutes. For all probes, continuous treatment caused significantly higher chamber fluid temperatures than intermittent treatment. Conclusions: The results of this study indicate that using flow during thermal capsulorrhaphy could lower joint fluid temperature to prevent heated joint fluid from killing chondrocytes of articular cartilage, and the intermittent treatment manner caused lower fluid temperature compared with continuous treatment within the RFE-treated shoulder joint. Clinical Relevance: Articular cartilage of the humeral head may suffer potential thermal injury from heating of joint fluid during RFE thermal capsulorrhaphy

Systematic Review The Role of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review With Quantitative Synthesis

Purpose: Despite the theoretic basis and interest in using platelet-rich plasma (PRP) to improve the potential for rotator cuff healing, there remains ongoing controversy regarding its clinical efficacy. The objective of this systematic review was to identify and summarize the available evidence to compare the efficacy of arthroscopic rotator cuff repair in patients with full-thickness rotator cuff tears who were concomitantly treated with PRP. Methods: We searched the Cochrane Central Register of Controlled Trials, Medline, Embase, and PubMed for eligible studies. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data. Pooled analyses were performed using a random effects model to arrive at summary estimates of treatment effect with associated 95% confidence intervals. Results: Five studies (2 randomized and 3 nonrandomized with comparative control groups) met the inclusion criteria, with a total of 261 patients. Methodologic quality was uniformly sound as assessed by the Detsky scale and Newcastle-Ottawa Scale. Quantitative synthesis of all 5 studies showed that there was no statistically significant difference in the overall rate of rotator cuff retear between patients treated with PRP and those treated without PRP (risk ratio, 0.77; 95% confidence interval, 0.48 to 1.23). There were also no differences in the pooled Constant score; Simple Shoulder Test score; American Shoulder and Elbow Surgeons score; University of California, Los Angeles shoulder score; or Single Assessment Numeric Evaluation score. Conclusions: PRP does not have an effect on overall retear rates or shoulder-specific outcomes after arthroscopic rotator cuff repair. Additional well-designed randomized trials are needed to corroborate these findings. Level of Evidence: Level III, systematic review of Level I, II, and III studies

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Fresh Osteochondral Allograft Transplantation for Focal Chondral Defect of the Humerus Associated With Anchor Arthropathy and Failed SLAP Repair

Isolated, full-thickness articular cartilage lesions of the glenohumeral joint can cause pain, mechanical symptoms, and impaired function. Reports on operative management of these injuries with arthroscopic techniques, such as marrow stimulation, have shown improvement in patient symptoms. In cases where the subchondral bone is involved, osteochondral allograft (OCA) transplantation has shown positive results for contained, focal cartilage defects. The technique for OCA transplantation to treat Hill-Sachs lesions has been reported in detail, and there are multiple case series reporting on the outcomes of OCA used for this purpose. This Technical Note shows the application of OCA to treat a case of anchor arthropathy where a glenoid anchor placed during arthroscopic stabilization causes iatrogenic damage to the humeral head. This type of injury can result in cartilage lesions in uncommon locations, such as on the posterior humeral head. In this description, the technical pearls and pitfalls of managing difficult-to-access posterior humeral head lesions are presented along with the senior authors' general technique for OCA to treat focal lesions of the humeral head cartilage

Multiple Osteochondral Allograft Transplantation with Concomitant Tibial Tubercle Osteotomy for Multifocal Chondral Disease of the Knee

Symptomatic patellofemoral chondral lesions are a challenging clinical entity, as these defects may result from persistent lateral patellar maltracking or repetitive microtrauma. Anteromedializing tibial tubercle osteotomy has been shown to be an effective strategy for primary and adjunctive treatment of focal or diffuse patellofemoral disease to improve the biomechanical loading environment. Similarly, osteochondral allograft transplantation has proven efficacy in physiologically young, high-demand patients with condylar or patellofemoral lesions, particularly without early arthritic progression. The authors present the surgical management of a young athlete with symptomatic tricompartmental focal chondral defects with fresh osteochondral allograft transplantation and anteromedializing tibial tubercle osteotomy

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

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

Lateral Opening-Wedge Distal Femoral Osteotomy Made Easy: Tips and Tricks

A lateral opening-wedge distal femoral osteotomy is useful to offload the lateral tibiofemoral compartment for focal chondral defects or isolated lateral compartment arthritis. Although beneficial for these lateral compartment disorders, a distal femoral osteotomy requires careful forethought to optimize correction accuracy and safety. We recommend the following for effective execution of a distal femoral osteotomy: (1) Plan the desired correction preoperatively while accounting for an individual patient’s anatomy and femoral width. (2) Perform an iliotibial band Z-lengthening for large deformity corrections to not overconstrain the lateral structures. (3) Use the plate to help guide the level of the osteotomy, which will facilitate bony contact after the osteotomy and decrease plate prominence. (4) Perform the osteotomy with a saw anteriorly and an osteotome posteriorly for safety and stop the osteotomy approximately 1 cm short of the far cortex. (5) Fashion tricortical wedge grafts at the height of the planned correction to maintain reduction and facilitate plate placement. (6) Control the plate position to lie optimally at the level of the osteotomy, ensuring it is not proud and is parallel with the femoral shaft. With these presurgical and intraoperative steps, a lateral opening-wedge distal femoral osteotomy can be performed effectively

SLAP Lesions: Trends in Treatment

Purpose: To determine the trends in SLAP repairs over time, including patient age, and percentage of SLAP repairs versus other common shoulder arthroscopic procedures. Methods: The records of 4 sports or shoulder/elbow fellowship trained orthopaedic surgeons were used to identify the total number of common shoulder arthroscopic cases performed between 2004 and 2014 using current procedural terminology codes (CPT): 29822, 29823, 29826, 29827, 29806, 29807, 29825, and 29828. The number of SLAP repairs (CPT code 29807) as a combined or isolated procedure were recorded, and the classification of SLAP type was undertaken using operative reports. Patient age was recorded. Linear regression was used to determine statistical significance. Results: There were 9,765 patients who underwent arthroscopic shoulder procedures using the defined CPT codes between 2004 and 2014 by our 4 orthopaedic surgeons. Of these, 619 underwent a SLAP repair (6.3%); average age 31.2 AE 11.9. The age of patients undergoing SLAP repair significantly decreased over time (P < .001, R 2 ¼ 0.794). Most SLAP repairs were performed on type II SLAP tears (P ¼ .015, R 2 ¼ 0.503). The percentage of SLAP repairs compared with the total number of shoulder arthroscopic surgeries and total number of patients who underwent SLAP repair significantly decreased over time (P < .001, R 2 ¼ 0.832 and P ¼ .002, R 2 ¼ 0.674, respectively). Conversely, the number and percentage of biceps tenodeses are increasing over time (P ¼ .0024 and P ¼ .0099, respectively). Conclusions: Over the past 10 years, the total number of biceps tenodeses has increased, whereas the number and relative percentage of SLAP repairs within our practice have decreased. The average age of patients undergoing SLAP repair is decreasing, and most SLAP repairs are performed for type II SLAP tears. Level of Evidence: Level IV, therapeutic case series

Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction

In recent decades, arthroscopic meniscal allograft transplantation (MAT) has been refined as a robust option for the treatment of evolving unicompartmental tibiofemoral arthrosis in the setting of meniscal deficiency. It is imperative that the MAT be performed in a knee with anatomic stability and alignment to reduce aberrant biomechanical forces experienced by the allograft tissue to maintain its durability. Thus, in an anterior cruciate ligament (ACL)–deficient knee, ACL reconstruction (ACLR) must be performed to restore the stable knee environment for the MAT to succeed. Although these operations can be performed in staged fashion, a single-stage procedure with concomitant MAT and ACLR is an option. Its performance is technically demanding and requires careful consideration as to the intraoperative setup, incisions, graft options, surgical tools, and procedural order to properly secure the transplanted meniscal allograft and restore a functional, anatomic ACL. We present our preferred technique for concomitant arthroscopic MAT and ACLR, as well as some potential pitfalls and pearls to avoid pitfalls