bluuebunny/crossref_metadata_2025 huggingface dataset:
Moderate Return to High Impact Function after Fresh Osteochondral Allograft Transplantation for Chondral Defects of the Knee
Authors: Waterman Brian R. , Thomas Dimitri
Published: July 2017

Objectives:

The purpose of this investigation was to report the patient-reported and occupational outcomes of military servicemembers after fresh osteochondral allograft transplantation (OCA) of the knee at mid-term follow-up.

Methods:

A query of the Military Health System was performed to identify all United States Army service members undergoing OCA for Outerbridge grade 3 or 4 chondral lesions between January 2009 and June 2013 with minimum 2-year follow-up. Exclusion criteria were applied to individuals with the following: insufficient follow-up or documentation; treatment of bipolar lesions; and use of cryopreserved, fresh-frozen, or fresh osteochondral allografts used greater than 28 days after harvest. Demographic information, lesion characteristics, and clinical outcomes (Visual Analog Scale for pain, functional duty limitations, and/or revision rates) were extracted from the military electronic medical records system. Statistical measures such as the Chi square test and Poisson multivariable regression analysis were utilized to evaluate for variables associated with rate-limiting, knee disability and/or surgical revision.

Results:

At 3.8 follow-up, 61 patients met the inclusion criteria with an average age was 32 yrs±8.0. Medial femoral condyles were most common (n=40;65.6%), followed by the patella (n=11;18.0%), lateral femoral condyle (n=8;13.1%), and trochlea (3;5.0%). The average cross-sectional size of treated lesions was 364 mm2±193 (48-707 mm2). Thirty-seven knees (61.7%) were treated without concomitant procedure, and 21 knees (34.4%) had staged or simultaneous periarticular osteotomies. Average VAS pain scores significantly decreased from 4.1 to 2.5 postoperatively (p<0.01). At final follow up, 65.6% of patients returned to unrestricted or modified military function, whereas 21(34.4%) individuals were unable to return due to persistent knee limitations. Nine (14.7%) patients experienced preoperative complications, Seven patients (11.5%) required secondary revision after OCA, 3 patients underwent chondroplasty, and 1 patient (1.6%) underwent subsequent total knee arthroplasty. Lesion size was not associated with any adverse clinical or surgical outcomes (p>0.05), and lateral femoral condyle and trochlear lesions had a higher rates of revision, although this failed to achieve significance (p=0.22;p=0.26, respectively). Higher preoperative BMI (OR 1.15;p=0.045) and postoperative VAS(OR 1.36;p<0.01) values were associated with increased risk of knee disability.

Conclusion:

Fresh OCA can reliably decrease knee pain in a highly-active population, with nearly two-thirds of all patients return to military function. However, approximately one in eight individuals may undergo revision after return to preoperative activities, and individuals of high BMI may be at heightened risk of clinical failure.
Return to Play After Shoulder Instability in National Football League Athletes
Authors: Okoroha Kelechi R. , Taylor Kevin , Keller Robert A. , Marshall Nathan E. , Varma Vishal , Moutzouros Vasilios
Published: July 2017

Objectives:

To determine the rate and timing of return to NFL play after a shoulder instability event and to determine what factors predict ability to Return to Play (RTP).

Methods:

A total of 83 NFL players who sustained an in-season shoulder instability event while playing in the NFL were identified and evaluated. Return to NFL play, incidence of surgery, time to return, recurrent instability events, seasons and games played after injury, and demographic data were collected. Overall RTP was determined and players who had surgery were compared to those who did not have surgery. Playing time after RTP was compared with age, position, size and experience matched control players.

Results:

Ninety-one percent of NFL players returned to NFL regular season play at an average of 1.6 ± 1.9 weeks (mean ± SD) in those sustaining a shoulder subluxation and 3.7 ± 5.4 weeks in those sustaining a dislocation; p = .53. In players who were able to RTP without surgery, those having a left shoulder instability event were able to return faster (1 week) than those having a right shoulder event (4 weeks); p = .03. A majority of players (62%) underwent surgical stabilization and 86% returned to play the following season. Players who had surgery were more likely to have a second instability event in their career (58% versus 9%); p = .01. No difference was found when comparing playing time after return with matched controls.

Conclusion:

There is a high rate of RTP following shoulder instability events in NFL players. Players sustaining subluxations in their non-dominant arm return to play at a faster rate. Surgical stabilization of the shoulder following an instability event may not ly eliminate potential for subsequent recurrent events as a high percentage of surgically treated players were found to have another instability event.
A Prospective Outcome Evaluation of Humeral Avulsions of the Glenohumeral Ligament (HAGL) Tears in an Active Population
Authors: Provencher Matthew T. , McCormick Francis , Sanchez George , LeClere Lance E. , Dewing Christopher B. , Solomon Daniel J.
Published: July 2017

Objectives:

Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss. The purpose of this study is to prospectively evaluate the clinical history, examination findings, and surgical outcomes of patients with HAGL lesions.

Methods:

Over a 6-year period, patients with shoulder dysfunction and a HAGL lesion confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination and surgical findings were documented. Outcomes of return to activity and SANE and WOSI scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a mini-open approach, while reverse (rHAGL) lesions were repaired arthroscopically.

Results:

A total of 27 of 28 patients (96%) d the study requirements at a mean of 36.2 months (range 24-68 months). There were 12 females (44%) and 15 males (56%) with a mean age of 24.9 years (range 18-34). The primary complaint was pain in 23 patients (85%) and only 4 (15%) patients complained of instability symptoms. There were 14 patients (52%) with aHAGL lesions, 10 patients (37%) with rHAGL lesions, and 3 patients (11%) with combined anterior and posterior HAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) presented with an isolated HAGL lesion. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a mini-open surgical repair, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery outcomes improved from WOSI = 54%, SANE = 50% to WOSI = 88%, SANE = 91% (p<0.01).

Conclusion:

This study demonstrated that patients with symptomatic HAGL lesions complain predominantly of pain and shoulder dysfunction and present with few instability complaints or findings. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and patient satisfaction.
Arthroscopic Treatment of Shoulder Instability with Glenoid Bone Loss Using Distal Tibia Allograft Augmentation
Authors: Wong Ivan , Amar Eyal , Coady Catherine M. , Smith Ben , Glazebrook Mark , Konstantinidis George , Dillman Daryl B.
Published: July 2017

Objectives:

The purpose of this study was to retrospectively analyze prospectively collected data to present the clinical and radiological short term outcomes of patients who underwent anatomic glenoid reconstruction using distal tibia allograft to treat shoulder instability with glenoid bone loss.

Methods:

Over four years, 44 patients (31 patients were male and 13 female with mean age of 29.73 years) underwent arthroscopic stabilization with capsulelabral Bankart repair and allograft bony augmentation of the glenoid for recurrent shoulder instability with significant bone loss by the same surgeon. 14 patients were revision cases of previous surgery. Preoperative and postoperative functional assessment was performed with the Western Ontario Shoulder Instability Index (WOSI) questionnaire, and radiological assessment was performed with radiographs and CT scans. The Average follow-up was 2 years.

Results:

97% (43/44) patients had no dislocations or subluxations at the most recent followup. The mean pre and postoperative WOSI scores were 40.54 and 72.65 respectively (p<0.001). No patients developed nerve injury. One patient presented with hardware failure at 3 years post-op. Two other patients had graft absorption and 6 patients had partial graft resorption but none had symptoms of instability. The mean postoperative active shoulder range of motion was forward flexion 170.1o, abduction 168.9o, internal rotation 69.5o and external rotation 57.5o. Grafts positioning was flush with the glenoid in 93% of cases, vertical positioning was excellent in 89% (35 o’clock).

Conclusion:

Arthroscopic stabilization of the shoulder with distal tibia allograft augmentation is a good safety profile technique with good results at average of two years follow up.
Equivalent Knee injury and Osteoarthritis Outcome Score after 1 and 2-year following Anterior Cruciate Ligament Reconstruction - Results from The Swedish National Knee Ligament Register
Authors: Samuelsson Kristian , Magnussen Robert A. , Alentorn-Geli Eduard , Spindler Kurt P. , Forssblad Magnus L. , Karlsson Jon
Published: July 2017

Objectives:

It is not clear if there is an additional value to assess the Knee injury and Osteoarthritis Outcome Score (KOOS) at both 1 and 2-years after primary Anterior Cruciate Ligament (ACL) reconstruction. The purpose was to investigate within individual patient if there is an equivalence between KOOS at 1 and 2-years after primary ACL reconstruction in The Swedish National Knee Ligament Register.

Methods:

This cohort study was based on data from the Swedish National Knee Ligament Register during the period of January 1, 2005, through December 31, 2013. The longitudinal KOOS scores for each individual at 1-year and 2-year follow-up were assessed through the Two One-Sided Test procedure with an acceptance criterion of 4. Subset analysis was also performed with patients classified by sex, age, graft type and by patients with meniscus and/or cartilage injury.

Results:

A total of 23 952 patients were eligible for analysis after applied exclusion criteria’s (women, n=10,116; 42.2% and men, n=13,836; 57.8%). The largest age group was between 16 and 20 years of age (n=6,599; 27.6%). The most common ACL graft was hamstring tendon (n=22,504; 94.0%) of which the combination semitendinosus and gracilis was the most common. A total of 7,119 patients reported on the KOOS Pain domain at both 1 and 2-year follow-up with a mean difference of 0.21 (13.1 SD, 0.16 SE, [90% CI, -0.05 - 0.46], p<0.001). The same results were found for the other KOOS subscales: symptoms (mean difference -0.54, 14.1 SD, 0. SE, [90% CI, -1.05 - -0.39], p<0.001), ADL (mean difference 0.45, 10.8 SD, 0.13 SE, [90% CI, 0.24 - 0.66], p<0.001), sports and recreation (mean difference -0.35, 22.7 SD, 0.27 SE, [90% CI, -0.79 - 0.09], p<0.001), quality of life (mean difference -0.92, 20.0 SD, 0.24 SE, [90% CI, -1.31 - -0.44], p<0.001) and in the combined KOOS-4 score (mean difference -0.41, 14.5 SD, 0.17 SE, [90% CI, -0.70 - -0.13], p<0.001). Analysis with specific subsets of patients all showed equivalent results between the two follow-ups.

Conclusion:

Equivalent results within a patient can be found in KOOS in 1-year and 2-year follow-up after ACL reconstruction. The finding is consistent across all KOOS subscales and for all evaluated subsets of patients. The implication of this research is that there is no additional value to capture both 1 and 2-year KOOS outcomes following ACL reconstruction. [Table: see text]
Economic Impact of Community Sports Coverage by Outreach Athletic Trainers on a Health System: Implications for Program Growth and Sustainability
Authors: Buckner Jeannie , Hewson Kirstie , Barr Michael , Woolf Shane K. , Crawford Thomas , Slone Harris
Published: July 2017

Objectives:

Coverage of high school and community athletics integrated within a comprehensive sports medicine program is becoming the standard of care to optimize medical treatment of athletes. While the economic benefit of clinic-based athletic trainers (AT) has been clearly demonstrated, there has been little published on the benefit of outreach AT. The purpose of the present investigation is to examine the cost-effectiveness of outreach AT for both orthopaedic providers and the health system as a whole.

Methods:

Review of an electronic prospective database of the outreach AT referrals to our institution was conducted for a four-year fiscal period (July 2011-June 2015). New patients as well as patients with established care at our institution were identified, and cumulative referred episodes of care and downstream revenue were recorded from billing records. New patients were defined as having no association with the hospital in the three years prior to the initial referral. All episodes of care included in this review were referred initially through the AT program; Data were recorded for the ensuing fiscal year of service.

Results:

Eight thousand five hundred and seventy total episodes of care resulted from 843 patients referred into the system, yielding $2,286,733 in total revenue (Table 1). There were 187 new patients, yielding 1602 referred episodes of care across both professional-based and hospital-based services. On average, each referred patient generated 10.17 episodes of care, with each episode generating an average of $267. Combining revenue from both professional-based and hospital-based care, an average of $2712 per patient was generated through the AT program over the four year period. Combining musculoskeletal revenue from hospital-based services and orthopaedic revenue from professional-based services yielded $761,052 in total revenue, indicating a 33% capture rate of the total profit of the program; the remaining 66% was distributed across the health system.

Conclusion:

Affiliation between high school and community sports teams and orthopaedists through outreach AT is an economically sustainable, symbiotic relationship. Additionally, there is not only a positive economic impact for providers, but a distinct benefit to the entire health system. [Table: see text]
Return to Sport as Outcome Measure for Shoulder Instability: Surprising Findings in Non-Operative Management in a High School Athlete Population
Authors: Shanley Ellen , Tokish John M. , Thigpen Charles A. , Ruffrage Lauren , Wyland Douglas J. , Kissenberth Michael J.
Published: July 2017

Objectives:

Recurrence rates have traditionally been used as a proxy for “failure” when comparing conservatively vs. operatively managed patients with anterior shoulder instability. Return to sport has been evaluated as an outcome proxy after surgical intervention, but no study has compared conservative vs. operative management using sustained return to sport as the main outcome measure. The purpose of this study was to compare the results between conservatively and operatively treated patients as to their ability to return a patient to uninterrupted sport in a subsequent season after an anterior instability event.

Methods:

We identified and followed 179 scholastic athletes who were treated for a confirmed diagnosis of anterior shoulder instability. 97 were treated initially with conservative management, and 32 were managed surgically. Patients were excluded if they did not have remaining eligibility to play a subsequent season of athletics (high school seniors), or if they were treated with benign neglect (neither conservative nor operative treatment). “Ultimate success” was defined as return and completion of the subsequent season without time loss due to any shoulder related diagnosis. We substratified by age, sport, and type of instability event (subluxation vs. dislocation) using ANOVA and binary logistic regression.

Results:

In the conservatively managed group, 85% met the definition of ultimate success by returning to play a subsequent season of scholastic athletics in the same sport without any time loss due to a shoulder condition. In the surgical group, 72% were able to achieve this status (p<0.05). Age did not differ between the two groups. Patients were 5x less likely to return to sport if they had sustained a dislocation requiring reduction compared to a subluxation confirmed as an anterior instability event (OR: 4.96, 95%CI= 1.2-9.6).

Conclusion:

Patients who were treated conservatively for an anterior shoulder instability event were far more likely to have a “successful” outcome than published results if the definition of outcome is changed from no recurrence to completion of a subsequent season in their same sport. Patients sustaining a subluxation were nearly uniformly successful in doing so. While surgical success using this definition was quite lower, there was likely a selection bias in the decision making process due to bone loss, surgeon preference or other factor. Nevertheless, this data would suggest that if a patient’s goal is to return to the same level of sport and “next season”, conservative management is highly effective. Further study to determine whether these results hold out with longer term follow up are warranted, but the routine fixation of the first time dislocator based on better outcomes, is called into question depending on what one’s definition of success is.
High Return to Sports after TSA Under 55
Authors: Garcia Grant , Degen Ryan , Liu Joseph N. , Dines David M. , Gulotta Lawrence Vincent
Published: July 2017

Objectives:

Young, active shoulder arthroplasty candidates are a unique group of patients. Not only due they demand longevity and improved function, but they also desire a return to physical activities. Our objective was to determine the rate of return to sports in total shoulder arthroplasty patients’ age 55 and younger.

Methods:

This was a retrospective review of consecutive patients who underwent total shoulder arthroplasty at a single institution. Exclusion criteria included age at surgery greater than 55 years and less than 2 years of follow up. Final follow-up consisted of a patient-reported sports questionnaire, ASES and VAS scores.

Results:

61 shoulders were included with an average follow-up of 61.0 months (23-103) and average age at surgery of 48.9 years (25-55). VAS improved from 5.6 to 0.9 (p<0.001), and ASES improved from 39.3 to 88.4 (p<0.001). 80.3% (49) were done for osteoarthritis. 4 shoulders returned to the operating room, none were for glenoid loosening. There was a 93.2% satisfaction rate and 67.7% (40) stated they had their surgery to return to sports. 96.4% (55/57) restarted at least one sport at an average of 6.7 months. Direct rates of return were as follows: fitness sports (97.2%), golf (93.3%), singles tennis (87.5%), swimming (87.5%), basketball (75%) and flag football (66.7%). 82.4% (47) returned to similar or higher level of sport. 90.3% returned to a high demand sport and 83.8% returned to a high upper extremity use sport. There was no significant difference in rate of return to sport by BMI, sex, age, preoperative diagnosis, revision status, and dominant extremity.

Conclusion:

In patients age 55 and younger undergoing total shoulder arthroplasty, there was a 96.4% rate of return to sports at an average of 6.7 months. Furthermore, at an average follow up of 5 years, no patients needed revision of their glenoid component despite an 83.8% rate of return to high upper extremity use sports. While caution should still be advised in young active patients undergoing total shoulder replacement, these results demonstrate a high satisfaction rate and improved ability to return patients to most sports after surgery.
Outcomes Following Single-Stage Revision Anterior Cruciate Ligament Reconstruction versus Two-Stage Revision with Tunnel Bone Grafting
Authors: Cinque Mark , Mitchell Justin J. , Chahla Jorge , Dean Chase S. , Matheny Lauren M. , LaPrade Robert F.
Published: July 2017

Objectives:

Revision anterior cruciate ligament reconstruction (ACLR) is becoming increasingly common as the number of primary ACLR cases continues to rise. Despite this, there is limited data discussing the outcomes of revision ACLR, and even less information specifically addressing the differences in single-stage revision reconstructions versus those performed in a two stage fashion after reconstruction tunnel bone grafting. Our goal was to compare the outcomes, patient satisfaction and failure rates of single-stage versus two-stage revision ACLR.

Methods:

Following Institutional Review Board approval, a retrospective analysis of prospectively collected data was performed. All patients undergoing a revision ACLR between 2010 and 2014 by a single surgeon were collected, and skeletally mature individuals over the age of 17 were included. Patients were excluded if they were skeletally immature, had a previous intraarticular infection in the ipsilateral knee, underwent a prior alignment correction procedure, cartilage repair or transplant procedure, meniscal allograft transplantation, or had an intra-articular fracture. Patients completed a subjective questionnaire preoperatively and at a minimum two years postoperatively. MRI and CT scans of all knees were obtained preoperatively to assess for associated injuries and to evaluate ACL reconstruction tunnel size and location. Patients with malpositioned tunnels which would critically overlap with an anatomically placed tunnel or those with tunnels >14 mm in size underwent bone grafting.

Results:

A total of 88 patients met inclusion criteria for this study. There were 39 patients in the single-stage revision surgery group (19 males, 20 females), and 49 patients in the staged revision surgery group who underwent a first-stage tunnel bone grafting (27 males, 22 females). In both groups, the SF-12 PCS, the WOMAC score, the Lysholm score, and the Tegner activity scale significantly improved from preoperative to postoperative status. There was no significant difference in the SF-12 MCS score before and after surgery in either group. Furthermore, there was no significant difference in failure rates or other demographic data between groups. We observed four failures in the one-stage procedure group (10.3%) and three failures in the staged reconstruction group (6.1%).

Conclusion:

In this study, objective outcomes and subjective patient scores and satisfaction were not significantly different between one-stage and two-stage ACL revision surgeries. Both procedures resulted in significantly improved outcomes and patient subjective outcomes without notable differences in failure rates. Further longitudinal studies comparing one-stage and two-stage ACL revision over a longer time frame are recommended.
The Psychosocial Trauma of ACL Ruptures in Young Athletes
Authors: Padaki Ajay Shridar , Popkin Charles Aaron , Noticewala Manish Suresh , Ahmad Christopher S.
Published: July 2017

Objectives:

Sustaining severe injuries requiring operative fixation causes emotional harm in addition to physical damage in young athletes. While the fear of re-injury following an anterior cruciate ligament ruptures and reconstruction has been established, the extent of the psychosocial trauma, including hyperarousal and intrusion, is largely unknown. We hypothesize that post-traumatic stress disorder symptoms are present young athletes with strong athletic identities following ACL ruptures.

Methods:

The impact of events scale, the athletic identity measurement score, and a novel specialization instrument were administered to 7 to 21 year old patients following ACL rupture. These instruments represent a modified post-traumatic stress disorder screening tool psychometrically validated in children, a validated tool to measure athletic identity, and an athlete specialization questionnaire designed by the authors respectively. Athletes were recruited from the sports medicine clinic at the senior authors’ academic institution and the instruments were administered upon the patients’ first orthopedic visit following the diagnosis of an ACL rupture. The full extent of the knee injury and any history of prior knee injuries were also assessed.

Results:

Twenty-one patients with a mean age of 14.9 ± 2.9 years completed the emotional trauma assessment and 52.2% of respondents were female. The most common concurrent injury was a meniscal tear (47.8%) and 9.5% of patients reported a prior ACL rupture and reconstruction. Regarding specialization, one-third of athletes played one sport only, 52.4% of athletes played multiple sports while focusing on one above the others, and 14.2% of athletes balanced their sports equally. Single-sport athletes scored significantly higher on the athletic identity questionnaire (single-sport mean 57.2; multi-sport mean 52.1; p = .02). The majority of patients experience traumatic symptoms in all three major categories as 86.4% endorsed avoidance symptoms, 81.8% admitted intrusion symptoms, and 81.8% admitted hyperarousal symptoms. Older athletes were significantly more likely to experience stronger emotionally traumatic symptoms (p = .03) as 16 - 21 year old athletes scored a mean of 62.6 on the Impact of Events Scale compared to 39.6 for 7 - 15 year old athletes. While male patients experienced stronger traumatic symptoms than female patients, the separation was not found to be statistically significant (male 50.2; female 43.6; p = .12).

Conclusion:

The emotional trauma for young athletes following ACL ruptures extends beyond the avoidance symptoms that have been previously established. Psychological evaluation and support is imperative to providing holistic care following this injury. [Table: see text]
Prospective Clinical Outcomes Following Microfracture Surgery For Isolated and Multi-Site Defects: Mid-Term Follow-Up
Authors: Erickson Brandon J. , Locker Philip H. , Cvetanovich Gregory L. , Tilton Annemarie K. , Gitelis Matthew E. , Weber Alexander E. , Yanke Adam Blair , Cole Brian J.
Published: July 2017

Objectives:

The purpose of the current study was: 1) to evaluate the outcomes of patients who underwent microfracture and 2) to determine the patient-related and defect-related factors associated with outcomes including factors predicting additional surgery.

Methods:

Patients who underwent microfracture for focal chondral defect(s) of the knee were eligible. Patients were excluded if concomitant procedures violated the subchondral bone. Outcomes were determined using preoperative and final follow-up patient reported outcomes (PROs) including; IKDC, KOOS, WOMAC, SF-12 and Overall Satisfaction. Patient-related factors and defect-related factors were analyzed for correlations with outcome. All patient-related and defect-related factors were also analyzed as predictors for subsequent surgery.

Results:

Overall 101 patients (55M/46F) mean age: 35.9±12.5 years, BMI 26.3±5.5 kg/m2, mean defect size: 2.64±1.81 cm2 underwent microfracture and met enrollment criteria. Lesion location included: 44.90% medial femoral condyle, 21.43% trochlea, 11.22% lateral femoral condyle, 10.20% multiple site, 8.16% patella, and 4.08% tibial plateau. In 72 of 101 (71%) knees, microfracture was performed in insolation. At mean follow-up of 5.7±2.5 years, statistically significant and clinically meaningful improvements (MCID and MCD) were seen in all PROs (p<0.05), aside from SF-12 mental scores which improved although not significantly (p=0.07) (Figure 1). Increased age, higher BMI, isolated tibial microfracture, multi-site microfracture and increased defect size all correlated with lower final follow-up PROs (p<0.05). Males demonstrated greater magnitude of improvement in KOOS symptoms and sports subscales (p=0.006 and p=0.037). In the multivariate analysis, larger defect size (>3.6 cm2) and prior knee surgery were independent risk factors for additional knee surgery.

Conclusion:

Following microfracture all patients demonstrated significant and clinically meaningful improvements in outcomes at a mean of 5.7 years. Increasing age and BMI are the patient-related factors that may predict a poor outcome. Defect-related predictors of poor outcome include microfracture of tibial lesions and multi-site microfracture as compared to isolated femoral defect microfracture. Larger lesion size (>3.6 cm2) and a history of prior knee surgery may predict the need for additional knee surgery following microfracture.
Lower Mental Component Scores are Associated with Lower Return-to-Work Rates after Patellofemoral Autologous Chondrocyte Implantation
Authors: Jacobs Cale A. , Burnham Jeremy M. , Whale Caitlin , King Patrick M. , Jochimsen Kate N. , Howard Jennifer S. , Malempati Chaitu S. , Mattacola Carl G. , Lattermann Christian
Published: July 2017

Objectives:

Autologous chondrocyte implantation (ACI) is a well established treatment for articular cartilage defects of the knee. However, few studies have examined return-to-work rates among ACI patients, and even fewer have investigated the effect of mental health on postoperative outcomes. The purpose of this study was to examine the effect of preoperative mental health on return to work and patient-reported outcomes.

Methods:

From our IRB-approved prospective outcomes registry, we identified 109 ACI patients (mean age = 34.5 years, mean follow-up = 2.8 years) with pre- and postoperative clinical data. Patients were stratified into those with preoperative VR-12 Mental Component Scores in the bottom quartile (LOW MCS) and in the top 3 quartiles (HIGH MCS) based on normative values. Patients with patellar and/or trochlear lesions were placed in the patellofemoral (PF) group, and all other patients were placed in the tibiofemoral (TF) group. Return to work, IKDC scores, and Lysholm scores were individually compared between the LOW MCS and HIGH MCS groups that had undergone either PF or TF ACI. Fisher’s exact tests were used to compare the return to work rates and frequency of IKDC and Lysholm improvements greater than the minimal clinically important difference. One-way ANOVAs were used to examine magnitude of change of IKDC and Lysholm scores.

Results:

Preoperatively, 14/55 (25.5%) TF patients and 17/54 (31.5%) PF patients were included in the LOW MCS group. For PF patients, return to work rates were significantly lower for the LOW MCS group (p=.0005). Return to work rates did not differ in the TF group (p>0.99). Changes in IKDC and Lysholm scores did not differ between the LOW MCS and HIGH MCS groups in TF or PF patients (Table 1).

Conclusion:

Lower preoperative mental component scores were more common in PF ACI patients and were associated with decreased return to work rates in PF ACI patients. The results of this study underscore the need to preoperatively quantify mental health status for this specific patient group in order to set realistic postoperative expectations. [Table: see text]
Tibiofemoral Contact Mechanics with Horizontal CleavageTears and Resection of the Lateral Meniscus in the Human Knee
Authors: Koh Jason L. , Zimmerman Todd A. , Patel Savan , Ren Yupeng , Son Jongsang , Zhang Li-Qun
Published: July 2017

Objectives:

Knee menisci are known to increase contact area, reduce contact pressure and absorb shocks. Meniscectomy is considered likely to lead to arthritic changes to the knee. The effects of a horizontal cleavage meniscus tear, repair and meniscectomy are still not clear for the lateral meniscus. The purpose of this study was to explore the impact of these conditions on tibiofemoral contact mechanics.

Methods:

Eleven fresh frozen human cadaveric knees were used in this study. Testing conditions included the intact meniscus, horizontal cleavage tear, inferior leaf resection and resection of both inferior and superior leaves of the lateral meniscus. The test was performed at 0° and 60° of knee flexion under 800 N axial loading force. Tekscan® pressure sensors were used to measure the tibiofemoral contact area and pressure.

Results:

Horizontal cleavage tears and subsequent repair of the lateral meniscus resulted in no significant changes in contact area and peak contact pressure compared to the intact condition. Resection of the inferior leaf resulted in a significant drop in contact area (34.6 ± 14.1% at 0° and 23.9%[Office1] ±14.8% at 60° knee flexion; p < 0.05). Peak contact pressure after resection of the inferior leaf significantly increased by 27.0 ± 22.1%at 0° and 37.9 ±33.6% at 60° knee flexion (p<0.05). Additional resection of the superior leaf resulted in a further decrease in contact area (49.5 ±7.2% at 0° and 47.9± 16.7% at 60° knee flexion compared to the intact condition; p < 0.05). Peak contact pressure increased correspondingly (by 38.6% ± 24.3 at 0° and 55.5 ±34.7%at 60° knee flexion compared to intact; p < 0.05).

Conclusion:

Resection of the inferior leaf or resection of both leaves of the lateral meniscus after horizontal cleavage tear resulted in decreased contact area and increased peak contact pressure at both knee flexion and extension.
The Effects of Posterior Rotator Cuff Cable Tears on Glenohumeral Biomechanics in a Cadaveric Model of the Throwing Shoulder
Authors: Photopoulos Christos Demetris , ElAttrache Neal S. , Doermann Alex , Akeda Masaki , McGarry Michelle H. , Lee Thay Q.
Published: July 2017

Objectives:

The rotator cuff cable has been postulated to be the primary load bearing substructure of the superior part of the rotator cuff. Tears of the posterior rotator cable are frequently seen in overhead throwing athletes. Although the biomechanical significance of the anterior rotator cable has been well described, our current understanding of the relevance of the posterior cable is limited. The purpose of this study was to examine how partial-thickness tears and full-thickness tears of the posterior rotator cable would alter glenohumeral biomechanics and kinematics in cadaveric shoulder models.

Methods:

Eight fresh-frozen cadaveric shoulder specimens were prepared and tested. To simulate the sequence of glenohumeral positions during the throwing motion, specimens were mounted on a custom shoulder testing system with the humerus positioned at 90° of abduction (30° scapular upward rotation, 60° glenohumeral abduction) and tested at 30, 60, 90, and 120 degrees of external rotation. After a circumferential capsulotomy was performed, rotator cuff muscles were loaded based on physiologic cross-sectional area ratios, and testing for each specimen was performed on each the following three conditions: intact posterior cable, partial-thickness (50%) articular-sided posterior cable tear, and full-thickness posterior cable tear. Primary outcome measures tested for each condition under the various degrees of glenohumeral rotation were: 1) anterior and total glenohumeral translation after application of a 30N anterior force; 2) path of glenohumeral articulation; 3) glenohumeral joint force.

Results:

With a 30N anterior force at 120° of external rotation, there was a significant increase in anterior glenohumeral translation between intact and full-thickness tear specimens (7.28±2.00mm and 17.49±3.75mm, respectively; p<0.05). Similarly, total joint translation at 120° of external rotation significantly increased between intact and full-thickness tear specimens (10.37±3.18mm and 23.37±5.05mm, respectively; p<0.05). No significant differences were apparent at other degrees of rotation (30, 60, 90 degrees), or with partial-thickness tears. Changes in the path of glenohumeral articulation were likewise most evident at 120° of external rotation, with a progressively anterior, inferior, and lateral shift in articulation with sequential sectioning of the posterior cable. Lastly, with regards to alterations in glenohumeral joint force, no significant changes were seen in any of the conditions.

Conclusion:

In this cadaveric shoulder model of the throwing shoulder, tears of the posterior rotator cuff cable lead to altered glenohumeral biomechanics and kinematics. These changes were most profound at 120° of external rotation, suggesting the importance of an intact posterior cable as a potential stabilizer during the late-cocking phase of throwing.
Increased Valgus Carrying Angle at the Elbow correlates with Shoulder and Elbow injuries in Professional Pitchers: A Prospective Study
Authors: Shah Sarav S. , Goldstein Jeffrey A. , Stein Spencer , Gammal Isaac , Gerland Roger , Lucke Jean-Paul C. , Rokito Steven
Published: July 2017

Objectives:

Injuries to the shoulder and elbow continue to be a problem in overhead athletes. To our knowledge, it has not yet been shown how the bony anatomy measured on physical exam, specifically valgus carrying angle at the elbow (VCA), correlates with injury risk. It is known that athletes commonly have an increased VCA thought to be secondary to adaptive changes due to repetitive stress. The purpose of our study was to prospectively determine whether the presence of an increased dominant arm (D) VCA is correlated with the onset of shoulder and elbow injuries.

Methods:

The VCA and elbow flexion contracture (EFC) along with passive range of motion of the glenohumeral joint for D and non-dominant (ND) arms were assessed for all pitchers and position players participating in spring training for three minor league baseball teams for the 2016 season. Investigators performed examinations on a total of 61 athletes (34 pitchers, 27 position players). Any shoulder and/or elbow injury necessitating treatment was recorded during the season by the medical staff and defined as an injury. Using VCA as the predictor variable, we estimated the odd ratio of shoulder and elbow injuries in pitchers from a binary logistic regression model.

Results:

The mean D VCA for pitchers was 13.6° versus 11.1° for players (p=0.04). The mean D EFC was 5.4° for pitchers and 4.8° for position players (p=0.76). No significant differences were noted when comparing D ER, D IR, and D F (Table 2). In addition, a higher mean D VCA was noted in older/more experienced players (14.5° versus 10.9°, p=0.026). There were 10 shoulder and/or elbow injuries with 8 occurring in pitchers. A greater mean VCA was noted for injured pitchers compared with non-injured pitchers (17.5 +/- 4.2 versus 13.1 +/- 5.2). Using logistic regression, a significant association between D VCA and injury was noted. Pitchers with an increased D VCA had a 1.25 times greater odds for injury (P = 0.040; 95% CI, 0.98, 1.59).

Conclusion:

Increased VCA on the throwing side increased the likelihood of a shoulder/elbow injury in pitchers. Additionally, we noted a significant increased mean D VCA in pitchers compared to position players as well as an increased mean D VCA in older/more experienced players. Understanding a relationship between the throwing motion and osseous anatomy may give us further insight into the etiology of shoulder/elbow injuries. Sports medicine clinicians should be aware of this study’s results and develop a plan that addresses this issue in an effort to deter shoulder/elbow injuries in pitchers. [Table: see text][Figure: see text]
Clavicle Fracture after Coracoclavicular Ligament Reconstruction: A Biomechanical and Finite Element Evaluation of Clavicle Fracture Risk
Authors: Gustafson Peter , Geeslin Andrew , Omwansa Mark , Sytsma Mark J.
Published: July 2017

Objectives:

Biomechanical testing supports anatomic reconstruction for high-grade acromioclavicular injuries to achieve improved stability, however, clavicle fractures have been reported following reconstruction. Thus, this study used laboratory experiments and finite element models to investigate the influence of tunnel parameters on the clavicle biomechanical performance.

Methods:

Composite synthetic clavicles were subjected to four-point bending on a servohydraulic load frame. Two established surgical techniques were compared; a single 3 mm tunnel technique and a double 6 mm tunnel technique. Finite element (FE) models were validated against experimental findings. Subsequent FE models explored a broad range of tunnel parameters to determine their biomechanical consequences.

Results:

The single tunnel (3 mm) specimens exhibited a stiffness of 19.9 ± 1.55 Nm2 and failed at 686 ± 45.2 N through the tunnel. The double tunnel technique exhibited a stiffness of 15.8 ± 1.18 Nm2 and failed at 390 ± 31.7 N through the medial tunnel. In FE models of the experiments (Fig. 1), the double tunnel technique has 69% of the strength of the single tunnel (vs 57% in the experiments) and failure was predicted at the medial tunnel. In 200 variations of tunnel configuration, the double tunnel technique exhibited increased stress concentration relative to a single tunnel. Larger tunnels exhibited higher stresses than smaller tunnels. Fig. 1: FE models exhibit greater stress concentration of the double 6 mm tunnel (right) technique compared to the single 3 mm tunnel (left) and technique.

Conclusion:

Experimental and FE results demonstrate that the double 6 mm tunnel reconstruction has a higher stress concentration than the single 3 mm tunnel technique when subjected to four-point bending. The validated FE model supports the use of small tunnels and suggests that a double tunnel configuration may have biomechanical disadvantages that must be weighed against the perceived advantages of “anatomic” reconstruction.
Equivalent Outcomes for Patients Following Trochleoplasty as a Primary or Revision Patellar Stabilizing Procedure
Authors: Burrus Matthew Tyrrell , Cancienne Jourdan M. , Kurkis Gregory M. , Conte Evan J. , Griffin Justin W. , Werner Brian C. , Diduch David R.
Published: July 2017

Objectives:

Patients with trochlear dysplasia often undergo primary procedures other than a trochleoplasty for recurrent patellar instability. When these other procedures fail and a trochleoplasty is performed, it is unknown if these patients do as well as those that had a trochleoplasty as their primary operation. The purpose of this study was to compare the clinical outcomes after trochleoplasty for severe trochlear dysplasia between a group of patients who previously underwent surgery for patellar instability to a group who underwent trochleoplasty as their initial procedure.

Methods:

In this prospective cohort study with IRB approval, 40 patients who underwent a sulcus-deepening trochleoplasty as well as additional related procedures with at least one year follow-up were divided into two cohorts: 1) patients with prior surgery for patellar instability (n=19) [Table 1] and 2) patients with no prior surgery for patellar instability (n=21). Preoperative and postoperative IKDC and Kujala scores, in addition to patient satisfaction scores, recurrent dislocation events, and reoperations were compared between the two cohorts.

Results:

33 females and 7 males with an overall average age of 20.4 years with an average follow-up of 2 years were included in the study. Compared to preoperative scores, significant increases were seen in the postoperative IKDC and Kujala scores in both the primary (26.9 +/- 24.3, 21.5 +/- 22.3, respectively) and revision cohorts (22.7 +/- 23.0, 12.7 +/- 15.7, respectively) [Table 2]. There were no significant differences between outcome scores between cohorts with regard to final scores (p=0.661, 0.810, respectively) or absolute improvement (p=0.624, 0.284, respectively). There were no episodes of recurrent instability in either cohort. 23.8% of the primary cohort and 26.3% of the revision cohort underwent a secondary procedure for arthrofibrosis (p=0.420). There was no significant difference in satisfaction scores between the two cohorts, with an average score of 9.2 +/- 1.8 amongst all patients (p=.404).

Conclusion:

Patients with severe trochlear dysplasia will experience significant improvement postoperatively and will have equivalent outcomes if a trochleoplasty is performed as an index procedure or as a revision procedure following a prior failed patellar stabilizing procedure. [Table: see text][Table: see text]
Treatment of Biceps Lesions in the Setting of the Rotator Cuff Repair: When is Tenodesis Superior to Tenotomy?
Authors: Tokish John M. , Tolan Stefan John , Lee Julia , Shelley Christina , Swinehart S. Dane , Lonergan Keith T. , Kissenberth Michael J. , Hawkins Richard J. , Thigpen Charles A.
Published: July 2017

Objectives:

However, the optimal treatment of biceps pathology is unclear as few studies have compared tenotomy versus tenodesis in the setting of RCTs. Therefore, the purpose of this study is to compare the outcomes of biceps tenodesis versus tenotomy in the setting of RCTs in order to determine if and when an advantage exists for one technique over the other.

Methods:

We retrospectively reviewed 134 patients(age=59.3± 8.6, males=88) following rotator cuff repair with concomitant biceps procedure and minimum 2-year follow up. Validated outcomes scores, including the American Society of Shoulder and Elbow Surgeons(ASES) score was completed before and after surgery. Patients were stratified by age, RCT size and biceps procedure (tenotomy or tenodesis). Separate mixed model ANOVAs (time by group) were performed to compare ASES scores between biceps procedure groups within each RCT size and age group.

Results:

There were 91 tenodeses and 43 tenotomies. There were no differences in baseline ASES scores or demographics between the groups( P>0.05). Overall patients displayed improvements in ASES scores(43±13) post-operatively but there were no differences between biceps treatment selection within each RCT size group( P>0.05). However, Patients < 55 years old with RCTs > 4cm and biceps tenodesis(n=18) demonstrated nearly twice the improvement(52±3) in post-operative ASES scores compared to those with a biceps tenotomy(28±14; P=0.03). This difference was not observed in patients > 55 years old or with rotator cuff tears less than 4cm( P=0.56).

Conclusion:

This is the first study to demonstrate the superiority of tenodesis over tenotomy in setting of RCTs. Specifically, in younger patients with larger tears, tenodesis had nearly double the improvement in ASES score compared to tenotomy. Our results suggest biceps tenodesis should be considered over tenotomy with concurrent greater than 4cm rotator cuff repairs in patients < 55 years old.