bluuebunny/crossref_metadata_2025 huggingface dataset:
A Novel Injective Approach For Osgood-schlatter Disease
Authors: Nakase Junsuke , Numata Hitoaki , Oshima Takeshi , Takata Yasushi , Tsuchiya Hiroyuki
Published: July 2016

Objectives:

Despite first being reported more than 100 years ago, Osgood-Schlatter disease(OSD) currently has no effective treatment. The recent use of ultrasonography in the orthopedic surgery and sports medicine fields revealed that patellar tendinopathy and deep infrapatellar bursitis contributes to the pain experienced by patients with OSD. Considering the reported effectiveness and safety of hyperosmolar dextrose injection for patellar tendinopathy, here we investigated the efficacy and safety of hyperosmolar dextrose injection as a novel treatment for OSD. Our hypothesis was that hyperosmolar dextrose injection would be safe and well tolerated by patients with OSD.

Methods:

We performed this prospective randomized double-blind clinical trial between April 2012 and June 2015. A total of 44 knees in 36 boys (average age, 12.3 ± 1.1 years) for whom conventional conservative therapy for >1 month was ineffective were randomly assigned to the double-blind injection of 1% lidocaine (1 mL) with saline (1 mL) (Saline group) or 1% lidocaine (1 mL) with 20% dextrose (1 mL) (Dextrose group). Half of the solution was injected into the distal attachment of the patellar tendon, while the remaining half was injected into the deep infrapatellar bursa or infrapatellar fat pad under ultrasound guidance. Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate pain.

Results:

A total of 40 knees in 33 boys were included in this clinical trial. The mean pre-injection VISA scores of the Dextrose and Saline groups were 59.6 ± 19.1 and 62.5 ± 16.6, while those at the final follow-up were 83.6 ± 19.3 and 84.1 ± 19.1, respectively. There were no significant differences in the two group pre-injection versus at the final follow-up (P = 0.61 and 0.93, respectively). In contrast, the mean VISA score significantly increased in both group between pre-injection and final follow-up (P < 0.01). There were no adverse effects of the injection.

Conclusion:

We were not able to prove the efficacy of the Dextrose injection compared with control; however, our results suggest superior symptom reduction efficacy of injection therapy for both treatments compared to usual care in the treatment of OSD. Thus, injection over the distal attachment of the patella tendon and into the deep infrapatellar bursa or infrapatellar fat pad under ultrasound guidance may become a new treatment method for OSD.
Do Age and Weight Bearing Films Affect Lateral Joint Space and Fibular Height Measurements in Patients with Discoid Lateral Meniscus?
Authors: Milewski Matthew David , Krochak Ryan , Duarte Andrew J. , Marchese Joseph , Pace James Lee , Broom Alexander M. , Solomito Matthew
Published: July 2016

Objectives:

Several radiographic parameters have been associated with discoid lateral meniscus. We sought to determine the effect of age and weight bearing (WB) on radiographic parameters associated with lateral discoid menisci in pediatric patients.

Methods:

Radiographs of patients with arthroscopically confirmed lateral discoid meniscus were compared to age, side, sex matched individuals with confirmed normal menisci. The radiographs were measured by a pediatric orthopaedic sports medicine attending and two orthopaedic residents for the following parameters: lateral joint space width (LJSW), fibular head height (FHH), width of the distal femur (WDF), tibial spine height (TSH), cupping of the lateral tibial plateau (CLTP), and obliquity of the lateral tibial plateau (OLTP). The results of this review focus on FHH and LJSW only.

Results:

68 knees with discoid lateral menisci with a mean age of 11.6 ± 3.3 (15 WB films) were compared to 67 control knees with a mean age of 11.9 ± 3.2 (15 WB films). Results indicated that there were significant differences between the discoid and control groups when comparing LJSW (8.7 ± 2.2 mm discoid compared to 7.6 ± 2.1 mm control p=0.002) and FHH (13.5 ± 4.5 mm discoid compared to 18.6 ± 3.9 mm control p<0.001). Inter-rater reliability was satisfactory for LJSW and FHH (ICC 0.635 and 0.759 respectively). WB films were noted to have better inter-rater reliability compared to NWB films for LJSW (ICC 0.729 vs 0.514 respectively) but reduced inter-rater reliability for FHH (ICC 0.625 vs 0.868 respectively). Subgroup analysis based on age was also done comparing patients under 10 years old, patients between 10-14 years old, and patients over 14 years old. The FHH measurement was significantly decreased (indicative of a high fibular head) in the discoid group in all age groups. However, LJSW was only noted to be significantly different in patients over the age of 14.

Conclusion:

Increased lateral joint space width and a high fibular head were associated with discoid lateral menisci and also showed satisfactory inter-rater reliability. Weightbearing films showed better inter-rater reliability for LJSW but decreased reliability for FHH. Higher fibular height was consistently seen across age groups but increased LJSW was only significantly different in the over 14 years old group. Fibular height might be a better radiographic parameter for discoid lateral meniscus evaluation across all age groups while lateral joint space may be better in older adolescent patients.
Sex, Age, and Graft Size as Predictors of ACL Re-tear
Authors: Nguyen Duong
Published: July 2016

Objectives:

The minimum size required for a successful quadrupled hamstring autograft ACL reconstruction remains controversial. The risks of ACL re-tear in younger patients who tend to participate in a higher level of sports activity, and female athletes who have numerous predisposing factors, are poorly defined. Purpose: To identify risk factors for graft re-tears within 2 years of ACL surgery. The hypotheses are that female sex, a smaller size graft, and younger patients will increase the odds of failure. Study Design Cohort Study. Level of evidence, 3.

Methods:

A cohort of 503 athletes undergoing primary, autograft hamstring ACL reconstruction, performed by a single surgeon using the same surgical technique and rehabilitation protocol, between September-December 2012, was followed for a total duration of 2 years. Return to play was allowed between 6 and 12 months post-surgery upon completion of functional testing. Exclusion criteria included infections, revisions, double bundle techniques, multi-ligament injuries, non-compliance, BTB/allografts/hybrid grafts. Primary outcome consisted of binary data (ACL graft re-tear or no tear) as measured on physical exam (Lachman and pivot shift) and MRI. Multivariate logistic regression statistical analysis with model fitting was used to investigate the predictive value of sex, age, and graft size on ACL re-tear. Secondary sensitivity analyses were performed on the adolescent subgroup, age and graft size as categorical variables, and testing for interactions among variables. Sample size was calculated based on the rule of 10 events per independent variable for logistic regression.

Results:

The mean age of the 503 athletes was 27.5 (SD 10.6; range = 12-61). There were 235 females (47%) and 268 males (53%) with a 6% rate of re-tears (28 patients; 17 females). Mean graft size was 7.9 (SD 0.6; range = 6-10). Univariate analyses of graft size, sex, and age only in the model showed that younger age (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80-0.93; P = .001] and smaller graft size (OR = 0.36; 95% CI = 0.18-0.70; P = .003) were significantly predictive of re-tear. Female sex was correlated with re-tear but was not significant (OR = 1.8; 95% CI = 0.84-3.97; P = .13). Multivariate analysis with all 3 variables in the model showed similar significant results. Graft size < 8 mm (OR = 2.95; 95% CI = 1.33-6.53; P = .008) and age < 25 (OR = 7.01; 95% CI = 2.40-20.53; P = .001) were significantly predictive of re-tear. Entire model was statistically significant (Omnibus test P = .001; Hosmer-Lemeshow statistic P = .68; Receiver Operating Curve [ROC] = 0.8).

Conclusion:

Surgeons should counsel their patients who are female, younger than 25 and with a graft size less than 8 mm accordingly and consider modifying their surgical or rehabilitation techniques to mitigate these re-tear risks.
Vascularity Visualized by Doppler Sonography as a Predictor of Healing Potential of the OCD of the Humeral Capitellum
Authors: Kida Yoshikazu , Morihara Toru , Kotoura Yoshihiro , Sukenari Tsuyoshi , Furukawa Ryuhei , Kabuto Yukichi , Onishi Okihiro , MInami Masataka , Tsujihara Takashi , Hojo Tatsuya , Fujiwara Hiroyoshi , Kubo Toshikazu
Published: July 2016

Objectives:

The significance of vascularity visualized by Doppler sonography in osteochondritis dissecance (OCD) lesion of the humeral capitellum is unclear. The objectives of this study were twofold: 1) to evaluate the relationship between Doppler ultrasound (US) signals observed in OCD lesion of the humeral capitellum and X-ray stage; 2) to determine if the presence of Doppler US signals in OCD lesion of the humeral capitellum could be the predictor of healing potential.

Methods:

Fifty patients with OCD of the humeral capitellum treated conservatively were enrolled in this study. During the conservative treatment period, Doppler sonography was performed on affected elbow to assess the presence of vascularity in the OCD lesion (Figure 1), and radiographic examination were evaluated on the same day to determine the X-ray stage (stage I: radiolucent stage, stage II: fragmentation stage, and stage III: loose body stage) of the OCD lesion (Figure 2). Radiographic examination of the elbow was examined after 6 weeks to evaluate the healing of the lesion. If the size of the lesion decreased or new bone formations were observed around the fragments, the healing of the lesion was considered to be improve. The χ2 test was used to determine if the presence of Doppler US signals were related to X-ray stage and the improvement of the healing. P < 0.05 was considered significant for all statistical analyses.

Results:

The Doppler US signals in OCD lesions were positive in 23 patients and negative in 27 patients. Of these patients, 19 were X-ray stage I, 17 were stage II, and 9 were stage III. The healing of OCD lesions improved in 78.2% for the positive Doppler US signal group, but only 18.5% for the negative Doppler US signal group (Figure 3). The presence of the Doppler US signal was significantly related to the improvement of healing (P = 0.00002). The Doppler US signal were positive in 78.9% for stage I, 36.4% for stage II, and 0.0% for stage III (Figure 4). The presence of Doppler US signal was significantly related to early X-ray stage (P = 0.0002).

Conclusion:

From this study, the presence of vascularity in the OCD lesion of the humeral capitellum is important for the improvement of healing during the conservative treatment period. The vascularity visualized by Doppler sonography could be a useful predictor for healing potential of the OCD of the humeral capitellum when treated conservatively.
MRI Predictors of Failure in Non-operative Management of Ulnar Collateral Ligament Injuries in Professional Baseball Pitchers
Authors: Lynch Thomas Sean , Frangiamore Salvatore , Vaughn Michael Derek , Soloff Lonnie , Schickendantz Mark S.
Published: July 2016

Objectives:

Ulnar collateral injuries (UCL) of the elbow are prevalent among professional baseball pitchers. The decision on initial operative versus nonoperative management of these injuries remains subjective in many cases, with reported success rates with nonoperative management ranging from 42 to 93% in professional throwing athletes. No studies to date have identified objective characteristics specific to success or failure of nonoperative intervention. The purpose of this study was to identify radiologic predictors for success or failure in nonoperative management of ulnar collateral ligament injuries in professional pitchers.

Methods:

A retrospective review of pitchers sustaining UCL injuries between 2006 and 2015 from one professional baseball organization (one major league team and all minor league teams included) was performed. UCL injuries were identified in 38 players based on clinical and radiographic findings. Six players underwent initial surgical intervention without attempted nonoperative intervention and were excluded from analysis. This left 32 (84%) professional pitchers who underwent an initial trail of nonoperative treatment for partial UCL tears. Success was defined as return to same level of play (RTSP) or higher for >1 year. Failure was defined as recurrent pain or weakness requiring surgical intervention after a minimum of 3 months’ rest when attempting a return to throw rehabilitation program. MRI findings were classified as high or low grade sprains, proximal or distal location of injury, and with or without the presence of concomitant chronic findings.

Results:

Of the 32 patients who underwent nonoperative management, 10 (36%) failed and required subsequent ligament reconstruction. Between the success and failure groups, there was no significant difference seen in total shoulder arc of motion (P=.7776), shoulder internal rotation deficit (P=.3846) or loss in elbow extension (P=.0644) at the time of injury. When comparing MRI findings between the groups, distal tears were found in 90% (9/10) of those who failed nonoperative management compared to 18.2% (4/22) who were successful nonoperatively (P=<.0001). No significant difference was seen with high grade tears (P=.0817) between the groups. When adjusting for age, location and evidence of chronic changes on MRI, the likelihood of failing nonoperative management was 22.7 times greater (P=.001) with distal tears. No other variable reached significance, and no combination of variables showed a greater likelihood than distal location alone.

Conclusion:

In professional pitchers, distal ulnar collateral ligament tears described on MRI show significantly higher rates of failure with nonoperative management compared to proximal tears. This information provides an objective measure for evaluating operative versus nonoperative management of ulnar collateral ligament injuries in throwing athletes.
The Prevalence and Clinical Characteristics of Medial Epicondyle Apophysitis in Juvenile Baseball Player - Ultrasonographic Assessment of 2,926 Cases
Authors: Otoshi Kenichi
Published: July 2016

Objectives:

Apophysitis of humeral medial epicondyle, often referred to as “Little Leaguer’s Elbow, is one of the major throwing injuries in juvenile baseball players as common as osteochondritis dissecans of humeral capitellum. Repetitive valgus stress to the skeletally immature elbow can result in fragmentation, hypertrophy, or separation of the medial epicondyle apophysis, and these injuries may induce elbow pain and adversely influence on elbow function and throwing performance. Although several reports have described various morphological variations of the medial epicondyle apophysis, little is known about the natural course and clinical significance of these variations. The purpose of this study was to investigate the prevalence of these variations in each age group and clarify the association with elbow pain using the large epidemiologic data from medical check-ups of juvenile baseball players.

Methods:

Of 3,626 juvenile baseball players aged 6 to 17 years, 2,926 players were enrolled in this study. Experience of elbow pain was rated by self-completed questionnaires. Ultrasonographic assessment was used to assess the morphological variations of the antero-inferior medial epicondyle (MEC) and humeral capitellum. Regarding MEC lesion, enthesis of medial ulnar collateral ligament (MUCL) was classified into four types: normal, irregular (IR), fragmentation (FG), and hypertrophy (HT). Osteochondral lesion (OCL) of humeral capitellum was judged by the irregularity or fragmentation of subchondral bone. The prevalence of these lesions was investigated in each age group and evaluated the influence on elbow pain using multivariable logistic regression analysis.

Results:

The overall prevalence of MEC lesions and capitellum OCL was 49.9% (IR:6.7%, FG:11.7%, HT:31.5%) and 2.1%, respectively. The prevalence of IR and FG gradually increased until reaching its highest at 11-12 years of age. At 12-17 years of age, the prevalence of IR was decreased with age, whereas that of FG persisted at approximately 10% after a temporally decrease. Conversely, the prevalence of HT increased while those of IR and FG simultaneously decreased (Figure 1). Age- and position adjusted multivariable analysis revealed that the presence of MEC lesions were high risk of elbow pain, and significantly higher risk for FG (odds ratio [OR]: 4.25, 95% confidence interval [CI]: 3.23-5.62) compared to IR (OR:3.17, 95%CI:2.31-4.39) and HT (OR:2.12, 95%CI:1.76-2.55). Capitellum OCL of was also significantly high risk of elbow pain (OR:,2.69, 95%CI:1.42-5.45) (Table 1).

Conclusion:

Our study demonstrated that morphology of MEC apophysis in juvenile baseball player varied with age. As the presence of FG was a significantly high- risk factor for elbow pain as compared to HT, appropriate management of “Little Leaguer’s Elbow” in the preadolescent period might be quite important to accelerate the bony healing of medial epicondyle apophysitis and decrease preventable adulthood elbow pain.
Treatment of Low Energy Lisfranc Joint Injuries in a Young Athletic Population
Authors: Cochran Grant , Renninger Christopher , Tompane Trevor , Bellamy Joseph , Kuhn Kevin
Published: July 2016

Objectives:

Acute Lisfranc joint injuries have historically been associated with high-energy trauma, and high quality data exists describing injury patterns and recommended treatment protocols. There is a lack of comparable data investigating injuries associated with low energy mechanisms. The objective of this study is to report low energy injury patterns and to retrospectively compare primary arthrodesis with open reduction and internal fixation in a young athletic population.

Methods:

All surgically managed low-energy (sustained during athletic activity, ground level twisting, or fall from less than three feet) Lisfranc injuries were identified at a single military tertiary referral center from July 2010 to June 2015. The injury pattern, time to diagnosis, and method of treatment (open reduction internal fixation (ORIF) or primary arthrodesis) were reviewed. Complication rates, secondary procedures, VAS pain score, and return to full military activity (defined as the ability to perform their primary job functions and participate in mandatory athletic activity) were reviewed.

Results:

Of the thirty-three injuries identified, twenty (60.6%) were primarily ligamentous. Only one patient had evidence of lateral column instability. Average patient age was twenty-eight. Eleven injuries (33%) were initially missed, delaying diagnosis an average of thirty-four days. Primary arthrodesis was performed in fifteen patients; most were secondary to subacute or chronic presentation. ORIF was performed on the remaining eighteen patients. All fixation constructs included solid screws, dorsal plates, or a combination of both. Minor complications occurred in twelve patients and included sensory changes, superficial infection treated with antibiotics, and symptomatic hardware. Complications requiring surgery other than hardware removal were seen in two patients including one ORIF patient who underwent secondary arthrodesis. VAS pain at final evaluation averaged 1.6. Thirty-one of thirty-three (93.9%) were able to return to full military activity. There were no significant differences in demographic data, injury patterns, complication rates, VAS pain score, and return to full activity. Hardware removal was performed in thirteen ORIF and two arthrodesis patients (p<0.005). The arthrodesis group returned to full activity at an average of 4.7 months while the ORIF returned at an average of 6.7 months (P<0.05).

Conclusion:

Low energy Lisfranc injuries are most commonly ligamentous, almost always spare the lateral column, and are commonly missed on initial presentation. Arthrodesis and ORIF consistently result in the ability to resume work and athletic activity with low rates of serious complication. Predictably, hardware removal is more common with ORIF. In this study, primary arthrodesis led to earlier return to work and athletic activity by an average of two months.
Recreational Athletes Return to Sport at a Comparable Rate to Elite Athletes Following Hip Arthroscopy for Femoroacetabular Impingement
Authors: Weber Alexander E. , Kuhns Benjamin , Cvetanovich Gregory , Levy David , Nho Shane Jay
Published: July 2016

Objectives:

The objective of the current study was to evaluate patient reported outcomes and return to sport in a cohort of distinctly recreational and amateur level athletes following hip arthroscopy for femoroacetabular impingement (FAI).

Methods:

Following IRB approval, clinical data was retrospectively retrieved for 66 consecutive FAI patients (26 men, 40 women) who had undergone hip arthroscopy and identified themselves as recreational or amateur athletes on intake forms. Two-year patient-reported outcomes (PRO) included a sport-specific questionnaire, modified Harris Hip Score (mHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales were analyzed.

Results:

The mean age and BMI of all subjects was 26.8 ± 7.6 years and 23.9 ± 3.2 kg/m2, respectively. Athletes had withdrawn from sport for an average of 9.5 ± 6.7 months prior to surgery and on average required 9.7 ± 5.1 months to return to sport. After two years, all mean PRO scores had improved significantly (Figure 1), and 57 patients (92%) had returned to play and continued participation. Patients who had withdrawn from sport for greater than 8 months before surgery returned to sport significantly more slowly than those who had withdrawn for less than 8 months (p=0.01). Greater withdrawal from sport prior to surgery also correlated with lower postoperative improvements in HOS-ADL and HOS-SS scores. Bivariate analysis revealed that increasing body-mass index (BMI) was associated with lower improvements in PROs.

Conclusion:

Recreational athletes, following hip arthroscopy for FAI, return to play at a high rate. Increasing BMI and preoperative withdrawal from sport both significantly prolong return to play and diminish two-year PROs. Most return-to-play studies following hip arthroscopy for FAI have focused on professional athletes, with limited generalizability to the average sports medicine surgeon practice. This is the first study of its kind to focus on the recreational athlete and demonstrates comparable return-to-play rates while increasing the generalizability to the average sports medicine practice.
The Fate of the Contralateral Hip in Femoroacetabular Impingement
Authors: Nepple Jeffrey J. , Louer Craig , Clohisy John C.
Published: July 2016

Objectives:

The pathophysiology of femoroacetabular impingement (FAI) remains to be better understood. Only a fraction of all individuals with bony FAI morphology will ever develop hip symptoms or osteoarthritis. The purpose of the current study was to determine (1) rates of initial and subsequent symptom development in the contralateral hip of patients with symptomatic ipsilateral FAI and (2) to identify predictors of symptomatic contralateral FAI.

Methods:

The study cohort included 179 consecutive patients presenting for surgical treatment of FAI. Patients were excluded if they had previously underwent contralateral surgery. At baseline and postoperative follow-up time points, patients recorded standardized outcome questionnaires, including the presence of symptoms in the contralateral hip. Significant symptoms were defined as the presence of at least mild pain, while none or slight pain was not included. All patients underwent AP pelvis and bilateral 45 degree Dunn lateral radiographs at baseline. Patients developing symptoms in the contralateral hip were subclassified as having symptoms at presentation (initial symptoms) or developing symptoms during the follow-up period (symptom development). Patients were followed over a minimum of one year time period postoperatively. Multivariate logistic regression was performed to identify independent predictors of symptoms development.

Results:

The study cohort had a mean age of 30.2 years and included 60.3% females. FAI was classified as isolated cam in 63.1% (n=113), isolated pincer 1.1% (n=2), and combined type in 35.8% (n=64). Forty-two (23.5%) of patients had initial symptoms in the contralateral hip. Twenty-two additional hips developed symptoms during the follow-up period (16.1% of initially asymptomatic hips). For multivariate logistic regression of any symptoms development (initial or subsequent), competitive athletes (p=0.041) and contralateral HNO ratio on AP pelvis (p=0.009). However, the overall model poorly predicted symptoms development.

Conclusion:

Approximately one in four patients with FAI presents with symptoms in the contralateral hip. Additionally, 16% of initially asymptomatic contralateral hips will develop symptoms during the next several years. A variety of clinical, radiographic, and physical examination factors poorly predict the development of symptoms. Competitive athletes may be less likely to have contralateral symptoms, while significant contralater al cam deformity on the AP pelvis radiograph may make a patient more likely to have contralateral symptoms.
Pectoralis Major Tendon Repair
Authors: Cordasco Frank A. , Degen Ryan , Mahony Gregory Thomas , Tsouris Nicholas
Published: July 2016

Objectives:

Systematic reviews of the literature have identified 365 reported cases of Pectoralis Major Tendon (PMT) injuries. While surgical treatment has demonstrated improved outcomes compared to non-operative treatment, there is still relatively limited data on the functional outcome, return to sport and need for 2nd surgery in athletes following PMT repair. This study comprises the largest series of athletes following PMT repair reported to date. The Objective is to report on the functional outcomes, return to sport and need for 2nd surgery in a consecutive series of PMT tears.

Methods:

From 2009, 81 patients with PMT tears were enrolled in this prospective series. Baseline evaluation included patient demographics, mechanism of injury, physical examination and PMT specific MRI for confirmation of the diagnosis and analysis of the extent of injury. Each patient underwent surgical repair by the senior author utilizing a previously published surgical technique. Patients were then followed at 2 weeks, 6 weeks, 3 months and 6 months and further follow-up was conducted annually thereafter with functional outcome scores and adduction strength testing. The return to sport and incidence of 2nd surgery data were recorded. This study includes the first 40 athletes to reach the 2-year post-operative period.

Results:

All athletes were male, with an average age of 34.4 years (range 23-59). The patient cohort consisted of 4 professional NFL players and 36 recreational athletes. Average follow-up duration was 2.5 years (range 2 - 6.0 years). The most common mechanisms of injury occurred during the bench press (n=26) and contact sport participation (n=14). Sixteen injuries were complete avulsions involving both the clavicular and sternocostal heads, while 24 were isolated sternocostal head avulsions. Average pre-injury bench press of 396 lbs (range 170-500 lbs) was restored to 241 lbs post-operatively (range 140-550 lbs). Single Assessment Numeric Evaluation (SANE) scores averaged 93.6 (range 62-100) with an average overall patient satisfaction rated at 9.6 out of 10 (range 6-10). All athletes returned to their pre-injury level of activity at average 5.5 months post-op (range 4.5-6.5 months). Isokinetic evaluation assessing adduction strength revealed an average decrease of <11% (avg. 9.9%, range -18 - 41%) compared with the contralateral extremity. Application of the Bak criteria revealed 50% of athletes scored as excellent, 35% as good and 15% as fair. One athlete developed a pulmonary embolus 10 days post-op. Two athletes required a 2nd surgery (5%), both were re-injured within 3 weeks of surgery.

Conclusion:

As demonstrated in this consecutive series, which represents the largest cohort of PMT repairs reported to date, surgical repair resulted in 96% patient satisfaction, with 85% good to excellent restoration of function and adduction strength. The athletes returned to sport on average at 5.5 months post-operatively and the incidence of 2nd surgery was 5%.
Incidence, Mechanisms, and Severity of Game-Related High School Football Injuries across Artificial Turf Systems of Various Infill Weight
Authors: Meyers Michael Clinton
Published: July 2016

Objectives:

Today’s new generations of artificial turf are increasingly being installed to duplicate or exceed playing characteristics of natural grass. Rather than playing on the polyethylene turf fibers, shoe: surface interaction actually occurs between the cleat and the various proprietary sand/rubber infill composites of varying weight. At this time, the influence of surface infill weight on football trauma is unknown. Therefore, this study was conducted to quantify incidence, mechanisms, and severity of game-related high school football trauma across artificial turf systems of various infill weight.

Methods:

Artificial turf systems were divided into four sand/rubber infill weight groups based on lbs per square foot: (A) > 9.0, (B) 6.0 - 8.9, (C) 3.1 - 5.9 and, (D) 0.0 - 3.0. A total of 52 high schools participating across four states over 5 competitive seasons were evaluated for injury incidence, injury category, time of injury, injury time loss, player position, injury mechanism and situation, primary type of injury, injury grade and anatomical location, field location at time of injury, injury severity, head, shoulder, and lower extremity trauma, elective imaging and surgical procedures, cleat design, turf age, and environmental factors.

Results:

Of the 1,467 high school games documented, 494 games (33.7%) were played on infill (A), 404 (27.5%) on infill (B), 379 (25.8%) on infill (C), and 190 (13.0%) on infill (D). A total of 3,741 injuries were documented, with significantly lower total injury incidence rates (IIR), [18.4 (95% CI, 18.0-18.7) vs 27.5 (26.8-27.9) vs 33.5 (32.7-34.0) and 23.7 (22.7-24.4)], substantial IIRs [3.4 (95% CI, 3.0-3.8) vs 6.6 (6.2-7.1), 8.5 (8.2-8.9) and 6.5 (5.8-7.1)], trauma from shoe: surface interaction during contact [4.6 (95% CI, 4.1-5.0) vs 7.5 (7.0-7.9), 6.4 (5.9-6.9) and 6.9 (6.2-7.5)], playing surface impact trauma [2.4 (95% CI, 2.1-2.8) vs 4.9 (4.4-5.4), 6.1 (5.6-6.6) and 4.4 (3.7-5.1)], and less total elective imaging and surgical procedures [4.6 (95% CI, 4.1-5.0) vs 7.5 (7.0-7.9), 6.4 (5.9-6.9) and 6.9 (6.2-7.5)], while competing on infill weighing >9.0 (A) versus 6.0 -8.9 (B), 3.0 - 5.9 (C), and 0.0-3.0 (D), respectively. Significantly lower trauma (P<.05) was also observed across player-to-player collisions, muscle-tendon overload, injury time loss, injury grade, skill positions, injury mechanism and situation, various cleat styles, adverse weather conditions, and turf age while competing on infill (A) when compared to infill (C).

Conclusion:

As the artificial infill surface weight decreased, the incidence of game-related high school football trauma significantly increased across numerous playing conditions. This is the first study to investigate the influence of artificial infill surface weight on the incidence of game-related high school football trauma. Since this study is in the early stages, initial findings warrant further investigation.
Expected Time to Return to Athletic Participation Following Stress Fracture in Division I Collegiate Athletes
Authors: Jamieson Marissa , Everson Sonsecharae , Siegel Courtney , Miller Timothy Lee
Published: July 2016

Objectives:

The objective of this study was to evaluate and determine the expected time to return to athletic participation in Division I collegiate Track and Field athletes.

Methods:

All stress fractures diagnosed in athletes on a single Division I collegiate men’s and women’s track and field/ cross-country team were recorded over a 4-year period. Site and severity of the injury were recorded and graded based on the Kaeding-Miller Classification System for stress fractures. Time to return to full unrestricted athletic participation was recorded for each athlete and correlated with the site and severity grade of the injury. Time to return to athletic participation was also analyzed for gender differences.

Results:

Fifty-seven stress fractures were diagnosed in 38 athletes over a 4-year period. Thirty-seven of these injuries occurred in women; twenty in men. Mean time to return to participation in women was 13.9 weeks and 11.2 weeks in men. There were 10 athletes who sustained recurrent or multiple stress fractures. Thirty-three stress fractures occurred in the tibia, and 10 occurred in the 2nd through 4th metatarsals. Three occurred in the 5th metatarsal, 6 in the tarsal bones (2 navicular), and 5 in the pelvis. Mean times to return to athletic activity based on site of injury and with extreme outliers removed were as follows: tibia- 13.3 weeks, 2nd through 4th metatarsals- 11.7 weeks, 5th metatarsal- 11.7 weeks, tarsals- 12.1 weeks, and pelvis- 13.0 weeks. There were 31 grade 2 stress fractures, 11 grade 3 stress fractures, and two grade 5 stress fractures that occurred bilaterally in the same patient. Mean times to return to athletic participation again with extreme outliers excluded were as follows: Grade 2- 12.3 weeks, Grade 3- 14.1 weeks, and Grade 5- 17 weeks. There were no Grade 4 (displaced) stress fractures diagnosed in this cohort of patients.

Conclusion:

Stress injuries to bone occur frequently in track and field athletes. Based on data collected from review of all recorded stress fractures diagnosed in members of a single Division I collegiate men’s and women’s track and field team over a period of four seasons, the expected time to return to full unrestricted athletic participation following diagnosis of a stress fracture is 12 to 13 weeks for all injury sites. Greater severity of injury correlated with increased time to return to participation with small numbers in the Grade 5 (nonunion) category making determining expected time to return to activity difficult.
Knee Hyperextension as a Predictor of Failure in Revision ACL Reconstruction
Authors: Cooper Daniel E. , Dunn Warren R. , Wright Rick W. , Haas Amanda , Huston Laura J.
Published: July 2016

Objectives:

We studied the minimum 2 year follow-up outcomes in an ACL revision cohort. The hypothesis is that knees that hyperextend will have a worse outcome and greater odds of graft failure than knees that do not hyperextend. The null hypothesis is that there is no difference in outcomes or graft rupture between the two groups.

Methods:

Revision ACL reconstruction patients were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, surgical technique and pathology, and a series of validated patient reported outcome instruments (IKDC, KOOS, WOMAC, and Marx activity rating score). Patients were followed up for 2 years, and asked to complete the identical set of outcome instruments. A regression model using graft failure as the dependent variable included graft type, age, and hyperextension greater than or equal to 5 degrees yes/no (HE) in order to assess these potential surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.

Results:

There were 1,145 subjects included in the analyses. The median age of the cohort was 26 (IQR= 20, 35), and 58% were male. The proportion that were enrolled for their first revision surgery was 88%, their second 10%, and third or greater 2%. The number of subjects categorized as HE was 375 (33%). The median age of subjects that failed was 18, compared to 26 for those with intact grafts. All three variables included in our regression model were significant predictors of graft failure: younger age, inter-quartile range odds ratio (IQROR) = 3.32 (95%CI 1.5, 7.2) p= 0.002; use of allograft OR = 3.1 (95%CI 1.4, 6.9) p= 0.01, and HE 2.1 (95%CI 1.02, 4.42) p= 0.04.

Conclusion:

The MARS Study Group has previously reported that young age and the use of allograft as a graft source are independent predictors (over 3X odds ratio) of graft rupture after revision ACLR. This study found that knee hyperextension greater than or equal to 5 degrees is present in 1/3 of patients who undergo revision ACLR. HE is also an independent predictor of graft failure after revision ACLR. This is the first study to investigate and confirm knee physiologic hyperextension as a risk factor (over 2X odds ratio) of graft rupture in ACL surgery. Future reports on ACL reconstruction results should separately evaluate the group of knees that hyperextend 5 degrees or more as compared to those that do not.
Pre-operative Thresholds for Achieving Meaningful Clinical Improvement after Arthroscopic Treatment of Femoroacetabular Impingement
Authors: Nwachukwu Benedict U. , Fields Kara G. , Nawabi Danyal H. , Kelly Bryan T. , Ranawat Anil S.
Published: July 2016

Objectives:

Knowledge of the thresholds and determinants for successful femoroacetabular impingement (FAI) treatment is evolving. The primary purpose of this study was to define pre-operative outcome score thresholds that can be used to predict patients most likely to achieve meaningful clinically important difference (MCID) after arthroscopic FAI treatment. Secondarily determinants of achieving MCID were evaluated.

Methods:

A prospective institutional hip arthroscopy registry was reviewed to identify patients with FAI treated with arthroscopic labral surgery, acetabular rim trimming, and femoral osteochondroplasty. The modified Harris Hip Score (mHHS), the Hip Outcome Score (HOS) and the international Hip Outcome Tool (iHOT-33) tools were administered at baseline and at one year post-operatively. MCID was calculated using a distribution-based method. A receiver operating characteristic (ROC) analysis was used to calculate cohort-based threshold values predictive of achieving MCID. Area under the curve (AUC) was used to define predictive ability (strength of association) with AUC >0.7 considered acceptably predictive. Univariate and multivariable analyses were used to analyze demographic, radiographic and intra-operative factors associated with achieving MCID.

Results:

There were 374 patients (mean + SD age, 32.9 + 10.5) and 56.4% were female. The MCID for mHHS, HOS activities of daily living (HOS-ADL), HOS Sports, and iHOT-33 was 8.2, 8.4,14.5, and 12.0 respectively. ROC analysis (threshold, % achieving MCID, strength of association) for these tools in our population was: mHHS (61.6, 78%, 0.68), HOS-ADL (83.8, 68%, 0.84), HOS-Sports (63.9, 64%, 0.74), and iHOT-33 (54.3, 82%, 0.65). Likelihood for achieving MCID declined above and increased below these thresholds. In univariate analysis female sex, femoral version, lower acetabular outerbridge score and increasing CT sagittal center edge angle (CEA) were predictive of achieving MCID. In multivariable analysis sagittal CEA was the only variable maintaining significance (p = 0.032).

Conclusion:

We used a large prospective hip arthroscopy database to identify pre-operative patient outcome score thresholds predictive of meaningful post-operative outcome improvement after arthroscopic FAI treatment. This is the largest reported hip arthroscopy cohort to define MCID and the first to do so for iHOT-33. The HOS-ADL may have the best predictive ability for achieving MCID after hip arthroscopy. Patients with relatively high pre-operative ADL, quality of life and functional status appear to have a high chance for achieveing MCID up to our defined thresholds. Hip dysplasia is an important outcome modifier. The findings of this study may be useful for managing preoperative expectation for patients undergoing arthroscopic FAI surgery.
Minimally Important Differences and Change Across Time in Patients Treated Surgically and Non-Surgically for Full-Thickness Rotator Cuff Tears
Authors: Miller Bruce S. , Robbins Christopher , Gagnier Joel Joseph
Published: July 2016

Objectives:

The minimally important difference (MID) is the smallest change in an outcome measure that is perceived by patients as beneficial. The MIDs for the ASES and WORC scores have not been established in a homogenous population of patients with rotator cuff tears. The objective of the present study was to establish the MIDs for patients with known cuff tears who were treated both surgically and non-surgically, and to compare the MIDs over time.

Methods:

We included 209 subjects with known full-thickness rotator cuff tears who were followed prospectively for two years. The WORC and ASES scores were collected at baseline, 4, 8, 16, 32, and 48 weeks, 1 year and 2 years. At the final follow-up point patients filled out an end-of-study form which included questions regarding change in their condition after treatment.

Results:

For those that indicated being minimally better, the change from baseline for the ASES score was -20.57 (-2.94 to -38.20) and for the WORC was 418.60 (70.39 to 766.81); both indicated improvement in outcomes. When converted to the percentage change score the WORC change represented 19.93%. The plots of these new MID values for the ASES and WORC indicate that not only does the operative group improve more than the non-operative group but it does so to an extent that is greater than the MID. The non-operative group also improved across time, but the magnitude did not exceed the MID for either the WORC or the ASES.

Conclusion:

We found that the ASES and the WORC MIDs in patients with rotator cuff tears is different from that previously reported, and that the operative group change was greater than the non-operative group change. This information will directly improve our ability to: (1) Determine when patients with RCTs are changing in a meaningful manner; (2) Accurately power clinical studies using these outcome measures; (3) Make more informed choices of treatments in these patients. This is the first study to report MIDs for the ASES and WORC in a population of patients with strictly rotator cuff disease and to explore their changes relative to MIDs across time.
Is There an Association Between the “Critical Shoulder Angle” and Clinical Outcome after Rotator Cuff Repair?
Authors: Kirsch Jacob Matthew , Nathani Amit , Robbins Christopher , Gagnier Joel Joseph , Bedi Asheesh , Miller Bruce S.
Published: July 2016

Objectives:

Variations in scapular morphology have been associated with the development of atraumatic rotator cuff tears (RCT). Current theories suggest a morphologic predisposition for altered shoulder biomechanics favoring the development of RCTs. The critical shoulder angle (CSA) is a radiographic measure that accounts for both glenoid inclination and lateral extension of the acromion, and angles >35 degrees are reported to be correlated with the development of degenerative RCTs. The impact of the CSA on outcomes following rotator cuff repair (RCR) has not previously been investigated. The purpose of this study was to investigate the relationship between the CSA and clinical outcomes after rotator cuff repair.

Methods:

As part of a prospective observational cohort study we obtained CSA measurements for 144 patients with documented full-thickness RCTs who were followed up for a minimum of 48 weeks. Patients were then stratified based on RCT etiology and treatment. Demographic data as well as The Western Ontario Rotator Cuff Index (WORC), American Shoulder and Elbow Surgeons (ASES) score and Visual Analog Scale (VAS) for pain were collected at baseline, four, eight, 16, 32 and 48 weeks. The CSA for all of the patients was measured retrospectively, with all assessors being blinded to the data and we calculated interclass correlation coefficients (ICC) to measure agreement. The statistical analysis included longitudinal multilevel regression modeling to investigate the association of the CSA and the WORC, ASES and VAS for pain.

Results:

Controlling for demographic and clinical characteristics, patients with CSAs less than 38 degrees reported better outcome scores over time compared to those with CSAs greater than 38 degrees (WORC: B=-106.6, p=0.025, ASES: B=4.83, p=0.0001, VAS: B=-12.99, p=0.0001). Interobserver and intraobserver reliability for CSA measurements resulted in an ICC of 0.969 and 0.982 respectively, indicating excellent agreement.

Conclusion:

We found that a CSA less than 38 degrees was associated with better outcomes in patients following surgical repair of atraumatic full-thickness rotator cuff tears. This is the first study to examine the relationship between the CSA and outcomes following RCR. These findings suggest that individual scapular morphology may influence both disease development and surgical outcomes of rotator cuff tears. This association warrants further investigation.
Prospective Randomized Study of Arthroscopic Proximal vs Open Subpectoral Biceps Tenodesis
Authors: Gobezie Reuben , Shishani Yousef , Flocken Janice
Published: July 2016

Objectives:

The biceps tendon is recognized as a significant source of pain in the shoulder for many patients. Operative techniques for tenodesis of the biceps tendon vary widely. No studies have been conducted directly comparing arthroscopic proximal vs. open subpectoral biceps tenodesis using a prospective study. We aim to compare the functional outcomes, pain relief, and complications of proximal vs. subpectoral biceps tenodesis.

Methods:

A prospective randomized study of 129 consecutive patients requiring biceps tenodesis for treatment of biceps tendon tears, biceps instability or superior labral tears was performed. Clinical outcome measures used to conduct the study included active range of motion, VAS pain score, ASES score and SANE scores. Complications and revisions were also documented.

Results:

Mean follow-up was 13.2 months (12-24 months) with 50 subpectoral tenodesis and 46 proximal tenodesis patients reaching minimum follow-up of 12 months. In the subpectoral group, the VAS improved from 5.7 to 2.0 (p < 0.001), ASES score improved from 49.8 to 77.7 (p< 0.001), and SANE scores improved from 42.1% to 77.7% (p<0.001). In the arthroscopic proximal tenodesis group, the VAS pain score improved from 5.9 to 1.8 (p<0.001), ASES score improved from 52.0 to 82.5 (p<0.001), and SANE scores improved from 42.8% to 78.6% (p<0.001). The revision rate for the subpectoral group was 4% (2/50 patients). The revision rate for the arthroscopic proximal tenodesis group was 8.6% (4/46). Twelve patients had persistent tenderness over the bicipital groove: 7 following proximal tenodesis and 5 following subpectoral tenodesis. No significant difference was found between methods in any outcome measures evaluated.

Conclusion:

This study found no difference in the functional outcomes or pain relief between proximal vs subpectoral biceps tenodesis. However, revision rates and occurrence of post-operative persistent bicipital groove pain for arthroscopic proximal tenodesis with internal fixation screw were slightly higher than in the subpectoral approach.