Does Previous Reconstructive Surgery Influence Functional Improvement and Deformity Correction After Periacetabular Osteotomy?

Background  

The Bernese periacetabular osteotomy (PAO) is commonly used to surgically treat residual acetabular dysplasia. However, the degree to which function and radiographic deformity are corrected in patients with more severe deformities that have undergone previous reconstructive pelvic or femoral osteotomies is unclear.     

Does Surgical Timing Influence Functional Recovery After Lumbar Discectomy? A Systematic Review

Background

The impact of the duration of preoperative symptoms on outcomes after lumbar discectomy has not been sufficiently answered in a single study but is a potentially important clinical variable.

Questions/purposes

A systematic review was performed to answer two questions: (1) Does symptomatic duration before surgery influence functional recovery after lumbar discectomy? (2) What is the time point for intervention beyond which the extent of postoperative recovery might be compromised?

Methods

The systematic review began with a query of PubMed using a structured algorithm comprised of medical subject heading terms. This was supplemented by a keyword search in PubMed along with queries of Embase, Scopus, and Web of Science and searches of reference lists as well as the tables of contents of relevant journals. Eligible studies were those that evaluated aspects of recovery after elective discectomy and stratified duration of symptoms before surgery. Included papers were abstracted by two authors and determinations regarding the period of symptom duration and its impact on outcome were recorded. Eleven studies met all inclusion criteria. No prospectively randomized trials addressed our study questions.

Results

Nine of 11 studies, four of which were prospective, maintained that longer symptom duration adversely impacted postsurgical recovery. There were substantial differences among the critical periods of symptom duration reported by individual studies, which ranged from 2 to 12 months. A preponderance of studies (five of nine) reported that surgical interventions could be performed at periods of 6 months or greater without impacting recovery.

Conclusions

Longer symptom duration had an adverse impact on results in most studies after lumbar discectomy. A possible point beyond which outcomes may be compromised is 6 months after symptom onset. Limitations in the literature surveyed, however, prevent firm conclusions.     

How Do Different Anterior Tibial Tendon Transfer Techniques Influence Forefoot and Hindfoot Motion?

Background

Idiopathic clubfoot correction is commonly performed using the Ponseti method and is widely reported to provide reliable results. However, a relapsed deformity may occur and often is treated in children older than 2.5 years with repeat casting, followed by an anterior tibial tendon transfer. Several techniques have been described, including a whole tendon transfer using a two-incision technique or a three-incision technique, and a split transfer, but little is known regarding the biomechanical effects of these transfers on forefoot and hindfoot motion.

Questions/purpose

We used a cadaveric foot model to test the effects of three tibialis anterior tendon transfer techniques on forefoot positioning and production of hindfoot valgus.

Methods

Ten fresh-frozen cadaveric lower legs were used. We applied 150 N tension to the anterior tibial tendon, causing the ankle to dorsiflex. Three-dimensional motions of the first metatarsal, calcaneus, and talus relative to the tibia were measured in intact specimens, and then repeated after each of the three surgical techniques.

Results

Under maximum dorsiflexion, the intact specimens showed 6° (95% CI, 2.2°–9.4°) forefoot supination and less than 3° (95% CI, 0.4°–5.3°) hindfoot valgus motion. All three transfers provided increased forefoot pronation and hindfoot valgus motion compared with intact specimens: the three-incision whole transfer provided 38° (95% CI, 33°–43°; p < 0.01) forefoot pronation and 10° (95% CI, 8.5°–12°; p < 0.01) hindfoot valgus; the split transfer, 28° (95% CI, 24°–32°; p < 0.01) pronation, 9° (95% CI, 7.5°–11°; p < 0.01) valgus; and the two-incision transfer, 25° (95% CI, 20°–31°; p < 0.01) pronation, 6° (95% CI, 4.2°–7.8°; p < 0.01) valgus.

Conclusion

All three techniques may be useful and deliver varying degrees of increased forefoot pronation, with the three-incision whole transfer providing the most forefoot pronation. Changes in hindfoot motion were small.

Clinical Relevance

Our study results show that the amount of forefoot pronation varied for different transfer methods. Supple dynamic forefoot supination may be treated with a whole transfer using a two-incision technique to avoid overcorrection, while a three-incision technique or a split transfer may be useful for more resistant feet. Confirmation of these findings awaits further clinical trials.     

Do Less Medialized Reverse Shoulder Prostheses Increase Motion and Reduce Notching?

Background  

Cuff tear arthropathy is the primary indication for total reverse shoulder arthroplasty. In patients with pseudoparalytic shoulders secondary to irreparable rotator cuff tear, reverse shoulder arthroplasty allows restoration of active anterior elevation and painless shoulder. High rates of glenoid notching have also been reported. We designed a new reverse shoulder arthroplasty with a center of rotation more lateral than the Delta prosthesis to address this problem.     

What Influence Does Progression of a Nonhealing Rotator Cuff Tear Have on Shoulder Pain and Function?

Background

There have been numerous reports of clinical outcomes associated with tendon healing after repair that suggest a nonhealed tendon has a negative effect on postoperative clinical outcomes. However, to our knowledge, there has been no report on the relationship between tear size progression of nonhealed tendons and clinical outcomes.

Questions/purposes

(1) Do patients with healed arthroscopic rotator cuff repairs have better outcomes, less pain, and more strength than patients whose repair did not heal? (2) In patients with nonhealed rotator cuff tendons, does tear size progression (increase or decrease) affect outcomes, pain, and strength? (3) Is there continued improvement beyond 6 months in outcomes, pain, and strength; and how do the improvements differ based on whether the tear size has increased or decreased?

Methods

Between May 2008 and December 2012, 647 patients underwent arthroscopic rotator cuff repair for full-thickness tears at our institution. Of those, 442 patients (68%) had all MRI and clinical information available to permit inclusion in this retrospective study at a minimum of 2 years followup (mean, 33 ± 4 months; range, 24–43 months). Healing of the repaired tendon and tear size progression were assessed using MRI at 6 months postoperatively. Eighty-two of 442 tears (19%) were not healed. Of the nonhealed tears, 45 (55%) had a decrease and 37 (45%) had an increase in tear size. Shoulder function outcomes using the American Shoulder and Elbow Surgeon (ASES) and Constant scores and pain severity using VAS scores were evaluated preoperatively, at 6 months postoperatively, and at the latest followup. Isometric muscle strength was measured at 6 months postoperatively and at the latest followup.

Results

Compared with patients with nonhealed tendons after arthroscopic rotator cuff repair, patients with healed repairs had improved ASES scores (healed, 93 ± 5; nonhealed, 89 ± 8; mean difference, 4; 95% CI, 3–5; p < 0.001), better Constant scores (healed, 91 ± 5; nonhealed, 85 ± 8; mean difference, 6; 95% CI, 4–7; p < 0.001), and greater strength ([flexion: healed, 96% ± 7%; nonhealed, 85% ± 12%; mean difference, 11%; 95% CI, 9%–13%; p < 0.001]; [external rotation: healed, 92% ± 8%; nonhealed, 80% ± 12%; mean difference, 11%; 95% CI, 9%–14%; p < 0.001]; [internal rotation: healed, 97% ± 8%; nonhealed, 92% ± 8%; mean difference, 5%; 95% CI, 3%–7%; p < 0.001]); however there was no difference in pain level based on VAS scores (healed, 0.9 ± 0.8; nonhealed, 1.0 ± 0.8; mean difference, 0.2; 95% CI, 0.0–0.4; p = 0.226). Compared with patients with increased tear size, patients with decreased tear size had better ASES scores (decreased, 91 ± 6; increased, 8 6 ± 8; p = 0.001), improved Constant scores (decreased, 88 ± 6; increased, 82 ± 9; p = 0.003), greater flexion strength (decreased, 91% ± 9%; increased, 78% ± 11%; p < 0.001), and greater external rotation strength (decreased, 86% ± 10%; increased, 73% ± 11%; p < 0.001). However, the difference does not seem to meet a minimal clinically important difference. Patients with increased tear size differed from those with decreased tear size with respect to flexion and external rotation strength where the former had no improvement. There was no improvement in flexion (6 months, 78% ± 11%; latest followup, 78% ± 11%; p = 0.806) and external rotation strength (6 months, 74% ± 12%; latest followup, 73% ± 11%; p = 0.149).

Conclusions

Patients who had healed tendons after arthroscopic rotator cuff repair had better shoulder function than patients who had nonhealed tendons. Among patients with nonhealed rotator cuff tendons after surgery, those with decreased tear size, observed on their 6-month postoperative MRI, compared with their initial tear size, showed better shoulder function and muscle strength than those with increased tear size beyond 6 months. Although results are statistically different, they seem insufficient to achieve clinically important differences.

Level of Evidence

Level III, therapeutic study.

     

Editorial Commentary: Defining Improvement After Arthroscopic Meniscal Surgery—How Much of a Difference Does a Difference Make?

Patient-centered metrics including the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state have been proposed to determine the clinical significance of patient-reported outcome scores. These values allow clinically meaningfully interpretation of changes in scores such that the degree of improvement (minimal clinically important difference and substantial clinical benefit) and satisfaction (patient acceptable symptom state) can be determined. When derived in the same study, these values allow analyses to be approached from the perspective of which patients are likely to respond to treatment and what level of improvement and satisfaction they might attain. Although limited to the sample from which they are derived, these metrics go beyond a mean value of an outcome score to provide a patient-centered perspective that informs the clinical significance of patient-reported outcome scores.     

What Are the Instability and Infection Rates After Reverse Shoulder Arthroplasty?

Background  

A concern regarding reverse shoulder arthroplasty (RSA) is the possibly higher complication rate compared with conventional unconstrained shoulder arthroplasty.