Faculty Bibliography

The suture anchor and transosseous drill hole techniques for reattachment of the distal biceps tendon to the radius have been found to have similar clinical and biomechanical outcomes. However, a comparison of the cost effectiveness of these techniques is lacking. The purpose of this study was to determine whether the use of suture anchors decreases operative time enough to offset the additional cost of the implants. The records of all patients undergoing a distal biceps tendon reattachment were reviewed to determine the method of fixation, operative time, and associated surgical costs. Two surgeons used a technique of fixing the tendon directly to the bone (transosseous group), whereas 3 surgeons used suture anchors. Given the standard nature of the surgical procedure (other than the fixation technique), only the costs that differed between the 2 groups were included. Surgical center costs were obtained from the local outpatient surgical center in 2011 US dollars. Five surgeons treated 70 men (mean age, 45.9±9.2 years). Mean time from injury to surgery was 14 days. Mean operative times for the transosseous and suture anchor groups were 97.6±14.9 and 95.8±25.8 minutes, respectively (P=.74). Two anchors were used in 79% of the anchor cases. The use of anchors cost $474.33 more per patient. However, this value is sensitive to the cost of the individual anchors, intersurgeon variation in operative time, and per-minute value of saved operative time. No operative time was saved with the use of suture anchors. This cost comparison framework can be used to evaluate the balance in surgical resource use due to implant cost vs savings in operative time.

The authors present a rare case of primary intracranial leiomyosarcoma (LMS) in a young, immunocompetent boy. The patient presented with an expanding right forehead mass. Diagnostic workup revealed multiple large intracranial tumors. The largest mass was resected, and pathological analysis revealed LMS. Given the poor prognosis of this tumor, the family declined further care, and the child died 3 months later. Primary LMSs are extremely rare tumors in the pediatric population, especially in patients who are not immunocompromised.

BACKGROUND:Arthroscopic meniscal repair techniques are continuing to evolve. Most studies to date comparing the healing rate of inside-out to all-inside meniscal repair techniques are confounded by associated anterior cruciate ligament reconstruction or deficiency. PURPOSE/OBJECTIVE:This review was conducted to compare the effectiveness and complications of the inside-out repair technique to that of the all-inside repair technique in isolated unstable peripheral longitudinal ("bucket-handle") meniscal tears. STUDY DESIGN/METHODS:Systematic review. METHODS:Computerized keyword searches of MEDLINE, EMBASE, CINAHL, ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were performed. Two reviewers independently performed searches and article reduction. Studies that included stratified data for isolated unstable longitudinal meniscal tears in stable knees, repaired with either an inside-out or all-inside repair technique, were selected. Data on clinical failure, subjective outcome measures, and complications were summarized. RESULTS:Nineteen studies included data specific to isolated meniscal tears. The rate of clinical failure was 17% for inside-out repairs and 19% for all-inside repairs. Lysholm scores and Tegner activity scores were similar between the 2 repair methods (87.8 vs 90.2 and 5.6 vs 5.5, respectively). The prevalence of nerve injury/irritation was higher with the inside-out technique (9% vs 2%). All-inside techniques had a higher rate of local soft tissue irritation, swelling, and implant migration or breakage. The use of older generation, rigid, all-inside implants is associated with chondral injury. CONCLUSION/CONCLUSIONS:There are no differences in clinical failure rate or subjective outcome between inside-out and all-inside meniscus repair techniques. Complications are associated with both techniques. More nerve symptoms are associated with the inside-out repair and more implant-related complications are associated with the all-inside technique. CLINICAL RELEVANCE/CONCLUSIONS:Rates of structural healing and complications are comparable for inside-out and all-inside repair techniques for isolated meniscal injury. Differences in observed healing rates after meniscal repair may be more dependent on tear pattern and associated anterior cruciate ligament reconstruction rather than an inside-out versus all-inside surgical approach.

PURPOSE/OBJECTIVE:To develop an evidence-based algorithm for the treatment of combined complete tears of the anterior cruciate ligament (ACL) and medial collateral ligament (MCL). METHODS:We performed a systematic review using computerized keyword searches of Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ACP Journal Club, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported stratified outcomes data after the treatment of combined complete tears of the ACL and MCL were included. Data on clinical measures of laxity, range of motion, and strength, as well as subjective outcome measures, were summarized. RESULTS:Five different treatment approaches were reported. Outcomes were better if the ACL was reconstructed and reconstruction was delayed to allow a return of knee range of motion. In many cases, this delay may allow the MCL to heal. MCL repair or reconstruction may be required if valgus instability remains after an appropriate rehabilitation period. CONCLUSIONS:ACL reconstruction should be performed in a subacute time frame once full motion has returned. Valgus instability should be assessed at that time and MCL repair or reconstruction performed in those patients with persistent valgus instability. LEVEL OF EVIDENCE/METHODS:Level IV, systematic review of Level I to IV studies.

BACKGROUND:There have been no long-term follow-up studies comparing a predominantly home-based rehabilitation program with a standard physical therapy program after anterior cruciate ligament (ACL) reconstruction. Demonstrating the long-term success of such a cost-effective program would be beneficial to guide future rehabilitation practice. PURPOSE/OBJECTIVE:To determine whether there were any differences in long-term outcome between recreational athletes who performed a physical therapy-supervised rehabilitation program and those who performed a primarily home-based rehabilitation program in the first 3 months after ACL reconstruction. STUDY DESIGN/METHODS:Randomized clinical trial; Level of evidence, 1. METHODS:Patients were randomized before ACL reconstruction surgery to either the physical therapy-supervised (17 physical therapy sessions) or home-based (4 physical therapy sessions) program. Eighty-eight of the original 129 patients returned 2 to 4 years after surgery to assess their long-term clinical outcomes. Primary outcome was the ACL quality of life questionnaire (ACL QOL). Secondary outcomes were bilateral difference in knee extension and flexion range of motion, sagittal plane knee laxity, relative quadriceps and hamstring strength, and objective International Knee Documentation Committee score. Unpaired t tests and a chi-square test were used for the comparisons. RESULTS:The home-based group had a significantly higher mean ACL QOL score (80.0 +/- 16.2) than the physical therapy-supervised group (69.9 +/- 22.0) a mean of 38 months after surgery (P = .02, 95% confidence interval [CI]: 1.7, 18.4). The mean change in ACL QOL score from before surgery to follow-up was not significantly different between the groups (physical therapy = 40.0, home = 45.8, P = .26, 95% CI: -15.8, 4.4). There were no significant differences in the secondary outcome measures. CONCLUSION/CONCLUSIONS:This long-term study upholds the short-term findings of the original randomized clinical trial by demonstrating that patients who participate in a predominantly home-based rehabilitation program in the first 3 months after ACL reconstruction have similar 2- to 4-year outcomes compared with those patients who participate in a more clinically supervised program.

BACKGROUND:Previous studies have noted that the use of antifibrinolytic medications can help reduce blood loss and transfusion requirements during cardiac, total joint arthroplasty, and spine surgery. Tranexamic acid (TXA) has been investigated in these patient groups but consensus with respect to the dosing regimen has not been achieved, especially in the pediatric scoliosis literature. The purpose of this study was to compare the effects of 2 TXA dosing regimens on reducing transfusion requirements. METHODS:A retrospective chart review was performed on all idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion from 2005 to 2006 to determine total perioperative transfusion requirements. Transfusion requirements for those patients receiving either a low (10 mg/kg loading, 1 mg/kg/h infusion) or high (20 mg/kg loading, 10 mg/kg/h infusion) dose of TXA were compared. RESULTS:High-dose TXA (n = 11) showed a trend toward a reduction in transfusion requirements compared with the low dose (n = 15) for idiopathic scoliosis patients undergoing posterior only instrumentation and fusion (687.9 +/- 778.1 mL vs 1372.6 +/- 1077.3 mL; P = 0.07; 95% confidence interval for the mean difference, -66.3 mL to 1435.7 mL). Although substantial, this difference was underpowered to show a difference. CONCLUSIONS:The use of the higher dose of TXA resulted in a 50% reduction in transfusion requirements for idiopathic scoliosis patients. Given previous studies, there appears to be a dose-response effect. A prospective dose-ranging study is now required to determine the optimal dose for pediatric patients with idiopathic scoliosis. LEVEL OF EVIDENCE/METHODS:III, retrospective cohort study.

INTRODUCTION/BACKGROUND:Endoscopic third ventriculostomy (ETV) is considered by many authors the initial surgical procedure of choice for the treatment of non-communicant hydrocephalus. However, this procedure has early and late complications that neurosurgeons must be aware of when performing it. MATERIALS AND RESULTS/RESULTS:A retrospective study of infants and children treated with ETV at Children's Memorial Hospital (Chicago, IL) between 1993 and 2004 is presented. A total of 136 ETVs in 122 patients were performed with 8.8% early complication rate (hemorrhage, CSF leak, infection, diabetes insipidus, and seizures). There were no fatalities but one patient had severe neurological disturbances due to intracranial hemorrhage at the second ETV. We identified several significant factors that influence the late ETV failure rate: age under 12 months (p=0.012), cases performed early in our experience (p=0.009), patients with hydrocephalus without expansive lesions (p=0.026), patients that had an external ventricular drain (EVD) after ETV (p<0.005), and patients who developed early complications (p=0.035). CONCLUSION/CONCLUSIONS:A careful patient selection and preoperative planning lead to better results of ETV. A higher early and late complication rate in children younger than 1-year-old were noted in our series. There is definitely a learning curve for this technique, and several technical considerations are helpful to avoid adverse events. Most of the early complications are transient, while potential devastating injuries can occur. Long-term follow-up is needed to identify delayed closure of the fenestration. Ventricular access devise is helpful for diagnostic and therapeutic purposes during the follow-up.

BACKGROUND:Because of health care funding and policy changes, there is a need to examine the effects of an evolution toward patient-directed (ie, home-based) rehabilitation programs on clinical outcomes of patients undergoing anterior cruciate ligament reconstruction. HYPOTHESIS/OBJECTIVE:There will be no difference in the effectiveness of a home-based rehabilitation program and a standard physical therapy-supervised rehabilitation program in patients 3 months after nonacute anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts. STUDY DESIGN/METHODS:Randomized controlled clinical trial; Level of evidence, 1. METHODS:There were 145 patients (16-59 years) who attended a presurgery education class. Home-based patients attended 4 physical therapy sessions, and physical therapy-supervised patients attended 17 physical therapy sessions over the first 12 weeks after surgery. All patients followed the same standardized rehabilitation program. Study outcome measures included active-assisted knee flexion and passive knee extension range of motion, knee range of motion during walking, KT computerized arthrometer results, and isokinetic quadriceps and hamstrings strength. Patient outcomes were dichotomized as either clinically acceptable or unacceptable. Rehabilitation programs were compared by the proportion of acceptable patients in each group. RESULTS:The home-based group had a significantly higher percentage of patients with acceptable flexion and extension range of motion compared to the standard physical therapy group (flexion, 67% vs 47%; extension, 97% vs 83%). There were no significant differences between the groups in range of motion during walking, ligament laxity, and strength. CONCLUSION/CONCLUSIONS:A structured, minimally supervised rehabilitation program was more effective in achieving acceptable knee range of motion in the first 3 months after anterior cruciate ligament reconstruction than a standard physical therapy-based program. CLINICAL RELEVANCE/CONCLUSIONS:Recreational athletes undergoing nonacute anterior cruciate ligament reconstruction can successfully reach acceptable rehabilitation goals in the first 3 months after surgery with a limited number of purposeful physical therapy education sessions, allowing recreational athletes more flexibility when integrating the necessary postoperative rehabilitation into their daily activities.

Anterior cruciate ligament (ACL) reconstruction is the treatment of choice for patients who experience episodes of instability and a decreased quality of life after ACL rupture. The bone-patellar tendon-bone and hamstring autografts are the current standards for ACL reconstruction. Primary care physicians, especially sports medicine clinicians, are the first-line providers of nonoperative care for patients who have ACL injuries. Care providers need to know the biologic and biomechanic properties of these grafts, clinical indications for each graft, and rehabilitation considerations to appropriately counsel their patients.