Patients’ expectations of shoulder instability repair

Purpose

To analyze and compare patient expectations of primary and revision shoulder stabilization and to assess the factors associated with patients’ expectations.

Methods

Pre-operative patient expectations after shoulder instability repair were prospectively assessed using a self-designed questionnaire. The survey included questions on the expected level and type of return to sports, instability, pain, risk of osteoarthritis, and overall shoulder condition.

Results

One-hundred and forty-five patients (99 primary; 46 revision repair) were included. A return to sport at the same level with slight to no restrictions was expected in 95%, a return to high-risk activities in 34%, to moderate in 58%, and to low-risk activities in 9%. No pain [instability] independent of the activity level was expected by 71% [79%] and occasional pain [instability] during contact and overhead activities by 25% [19%]. 61% expected to have no risk of glenohumeral osteoarthritis, 37% a slight, and 2% a significant risk. The overall expectation for the post-operative shoulder was indicated to be normal or nearly normal in 99% of patients. The revision group did not differ from the primary repair group in any variable. High pre-operative sport performance was positively correlated with post-operative sport expectations. The number of dislocations, the duration of instability, and the subjective instability level were negatively correlated with return to sport expectations.

Conclusion

Patient expectations for primary and revision shoulder instability repair are high. Realistic patient expectations regarding the surgical procedure are necessary to avoid low patient satisfaction, especially in pre-operatively highly active and demanding athletes. The surgeon must not solely base the treatment on the pathology and possible risk factors for failure but should also take the individual expectation of the patient into account.

Level of evidence

III.

     

Arthroscopic all-inside meniscal repair—Does the meniscus heal?

Objective  

The purpose of this study was to correlate clinical and radiological results using a 3-T MRI to verify meniscal healing after arthroscopic all-inside meniscus repair.     

Double row repair: is it worth the hassle?

In the operative management of rotator cuff disease, comparable functional results have been reported after open or mini-open repair and arthroscopic fixation. Surgical repair aims to re-establish an anatomical configuration of the tendon-bone construct for restoring its mechanical performance. Single row repair is the most commonly used technique, but recently some authors have proposed to re-establish the rotator cuff footprint with 2 rows of suture anchors ("double row" repair). In regard to imaging assessment, at time zero double row repair results being more anatomic and allows for structurally sound restoration of the rotator cuff footprint. However, this does not seem to translate into superior clinical outcomes for the double row repair when evaluating all different sizes of rotator cuff tears as a whole. The scientific basis for recommending single or double row repair as preferred treatment for patients with rotator cuff tear is questionable, as minimal differences have been measured on clinical and functional rating scales.     

Recurrent post-traumatic anterior shoulder dislocation – open versus arthroscopic repair

A total of 41 consecutive patients (11 women and 30 men, median age 29 (18–51) years) with unilateral, isolated, posttraumatic, recurrent anterior shoulder dislocation and a Bankart lesion were operatively repaired, either by an arthroscopic technique including a capsular plication, or by an open procedure with Mitec anchors. All the patients were followed prospectively and evaluated after a median of 36 (30–52) months follow-up by a “blind” observer. Nineteen patients in each group had excellent or good results, and one in each group was graded as fair. One patient in the arthroscopic group had a traumatic dislocation 5 months after the operation and was graded as poor. Three patients experienced subluxations postoperatively, one in the arthroscopic and two in the open group. There was no significant difference in anterior-posterior shoulder laxity measured objectively with Donjoy. The open Bankart repair group had a statistically significantly longer hospitalization (P = 0.001), a slight decrease in external range of motion, and more frequent cosmetic complaints. Apart from this, the results revealed no major differences between the two methods after a median of 36 months in this selected group of patients with longstanding problems. Received: 27 April 1998 Accepted: 1 October 1998     

Autologous osteochondral mosaicplasty or TruFit™ plugs for cartilage repair

Purpose

Autologous osteochondral mosaicplasty and TruFit? Bone graft substitute plugs are methods used to repair symptomatic articular cartilage defects in the adult knee. There have been no comparative studies of the two techniques.

Methods

This retrospective study assessed functional outcome of patients using the EQ-5D, Knee Injury and Osteoarthritis Outcome Score (KOOS) and Modified Cincinnati scores at follow-up of 1–5 years.

Results

There were 66 patients in the study (35 TruFit and 31 Mosaicplasty): 44 males and 22 females with a mean age of 37.3 years (SD 12.6). The mean BMI was 26.8. Thirty-six articular cartilage lesions were due to trauma, twenty-six due to osteochondritis dissecans and three due to non-specific degenerative change or unknown. There was no difference between the two groups age (n.s.), sex (n.s.), BMI (n.s.), defect location (n.s.) or aetiology (n.s.). The median follow-up was 22 months for the TruFit cohort and 30 months for the mosaicplasty group. There was no significant difference in the requirement for re-operation (n.s). Patients undergoing autologous mosaicplasty had a higher rate of returning to sport (p = 0.006), lower EQ-5D pain scores (p = 0.048) and higher KOOS activities of daily living (p = 0.029) scores. Sub-group analysis showed no difference related to the number of cases the surgeon performed. Patients requiring re-operation had lower outcome scores regardless of their initial procedure.

Conclusion

This study demonstrated significantly better outcomes using two validated outcome scores (KOOS, EQ-5D), and an ability to return to sport in those undergoing autologous mosaicplasty compared to those receiving TruFit plugs.

Level of evidence

IV.     

The partial-thickness rotator cuff tear: is acromioplasty without repair sufficient?

We evaluated the clinical outcome of arthroscopic acromioplasty and debridement in 162 patients who had either normal rotator cuffs, grade 1 (frayed tendon) partial-thickness tears, or grade 2 (less than 50% of the tendon) partial-thickness tears. The mean time from surgery to the response to the L'Insalata outcome questionnaire was 52.7 months (4.5 years) among the 105 respondents (107 shoulders). The mean score was 90 points; eight patients (8%) scored less than 70 points (range, 30 to 65.5), and their treatment failed early on. The patients with grade 2B (bursal) partial-thickness rotator cuff tears had a significantly higher failure rate (38%). Although the clinical outcome of patients with partial-thickness tears of the rotator cuff comprising less than 50% of the tendon (grade 1 and 2) was not significantly different from that of patients without partial rotator cuff tears, the subgroup of patients with grade 2B partial tears had a statistically significantly higher failure rate and may have been better served with primary repair. With follow-up to 10 years, there was no evidence that clinically relevant or symptomatic intrinsic rotator cuff pathologic conditions progress in those patients with partial-thickness tears treated with arthroscopic anterior acromioplasty.     

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.     

Nucleotide excision repair proteins and their importance for radiation‐enhanced transfection

Purpose: Irradiated cells transfect more efficiently than unirradiated cells because of a radiation‐induced increase in plasmid integration. However, the molecular mechanism is unclear. Because of recent observations that nucleotide excision repair (NER) proteins can be involved in certain types of recombination in yeast, it was hypothesized that NER proteins might play a role in this radiation‐enhanced integration.

Materials and methods: Hamster and human cells with inactivating mutations in NER genes were irradiated at doses from 0 to 6?Gy and then immediately transfected with a linearized selectable marker plasmid. Transfection‐enhancement ratios (TERs) were calculated as the ratio of the number of drug‐resistant colonies in unirradiated cells to the number of transfectants in irradiated cells, corrected for cytotoxicity from radiation.

Results: Transfection into unirradiated rodent cells was unaffected by NER mutation status. Transfection into unirradiated human cells, however, was increased by NER mutation. The TERs were 5 and 100 for CHO and primary human fibroblasts, respectively, after exposure of the cells to 6?Gy. Mutations in ERCC1, XPA, XPB, XPC, XPF, XPG and CSB dramatically reduced TER. Mutations in ERCC1, XPC, XPF, XPG and CSB suppressed transfection so that the TER was significantly below 1.

Conclusions: The mechanism of radiation‐enhanced plasmid integration was distinct from that of plasmid integration in unirradiated cells, and NER gene products were critical for enhanced integration to occur.     

Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up

Purpose

This study investigated the long-term results of arthroscopic Bankart repair in terms of rates and timelines of recurrence of instability, with special interest in young adult patients aged ≤20 years.

Methods

Between 2000 and 2005, 186 shoulders [182 patients, 50 women, median age 26 (range 15–58) years] were operated on at a university hospital using arthroscopic Bankart repair because of instability after traumatic anteroinferior shoulder dislocation. Medical records were retrospectively reviewed and patients were assessed using postal questionnaires or telephone interview after a minimum of 10 years of follow-up [median 12.2 (range 10–16) years]. The primary outcome measure was recurrence of instability (assessed from 167 shoulders), other outcome measures included Oxford instability score (OIS), subjective shoulder value (SSV), and Western Ontario instability index (WOSI) (assessed from 157 shoulders).

Results

At the end of follow-up, 50/167 shoulders (30%) had recurrence of instability and 30/167 (18%) were subjected to reoperation due to instability symptoms. Twenty-six (52%) failures occurred within ≤2 years, 11 (22%) within 2–5 years, and 13 (26%) >5 years after surgery. Failure rate was 19/35 (54%) for patients aged ≤20 years and 31/132 (24%) for patients aged >20 years; reoperation rates were 11/35 (31%) and 19/132 (14%), respectively. Mean OIS was 20 (SD 9, range 12–50), SSV 83% (SD 21, range 10–100), and WOSI score 80 (SD 22, range 33–100).

Conclusions

Nearly one-third of patients had recurrence of instability after arthroscopic Bankart repair after a minimum of 10-year follow-up. Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients.

Level of evidence

IV.

     

Focus on research: Which disc is a candidate for biological repair?

Low back pain affects the majority of population at some point in their lives.Disc degeneration of lumbar spine has been considered as a main contributor to low back pain.Considering the high prevalence of low back pain in the population, treatment that aims to repair or regenerate the disc degeneration biologically appears promising as a future treatment option in humans.……     

Endovascular repair or medical treatment of acute type B aortic dissection? A comparison

Introduction

The aim of this retrospective study was to compare the outcome of thoracic endovascular aortic repair (TEVAR) to that of medical therapy in patients with acute type B aortic dissection (TBD).

Materials and methods

From July 1996 to April 2008, 88 patients presenting with acute TBD underwent either TEVAR (group A, n = 38) or medical therapy (group B, n = 50). Indications for TEVAR were intractable pain, aortic branch compromise resulting in end-organ ischemia, rapid aortic dilatation and rupture. Follow-up was performed postinterventionally, at 3, 6 and 12 months and yearly thereafter and included clinical examinations and computed tomography (CT), as well as aortic diameter measurements and assessment of thrombosis.

Results

Mean follow-up was 33 months in group A and 36 months in group B. The overall mortality rate was 23.7% in group A and 24% in group B, where 4 patients died of late aortic rupture. In group A, complications included 9 endoleaks and 4 retrograde type A dissections, 3 patients were converted to open surgery and 2 needed secondary intervention. None of the patients developed paraplegia. In group B, 4 patients were converted to open surgery and 2 to TEVAR. The maximal aortic diameter increased in both groups. Regarding the extent of thrombosis, our analyses showed slightly better overall results after TEVAR, but they also showed a tendency towards approximation between the two groups during follow-up.

Conclusion

TEVAR is a feasible treatment option in acute TBD. However, several serious complications may occur during and after TEVAR and it should therefore be reserved to patients with life-threatening symptoms.