bluuebunny/crossref_metadata_2025 huggingface dataset:
Lumbar Spine Injury/Pathology as a Predictor of Outcomes in National Football League Athletes
Authors: Lynch Thomas Sean , Schroeder Greg , Gibbs Daniel , Chow Ian , LaBelle Mark , Savage Jason W. , Patel Alpesh , Hsu Wellington , Nuber Gordon W.
Published: August 2014

Objectives:

The purpose of this study is to determine if a pre-existing lumbar diagnosis such as spondylosis, a herniated lumbar disc, or spondylolysis affects a football player’s draft status or his performance and longevity in the NFL.

Methods:

The written medical evaluations and imaging reports of prospective professional American football athletes from 2003-2011 from one NFL franchise during the NFL combine (annual college football player evaluation prior to the NFL draft) were compiled and evaluated. All players were evaluated for a pre-existing lumbar diagnosis which were compiled from previous injury/medical records including radiographic imaging reports. Those players with a lumbar spine diagnosis and with appropriate radiograph, MRI and CT imaging were included in this study. These athletes were then matched by age, position, year, and round drafted to control draftees without a lumbar spine diagnosis. Career statistics were compiled including length of play and number of games started. Additionally, a previously established “Performance Score” was calculated for all players excluding offensive linemen. The continuous variables of each cohort were compared using a two-sided (tailed) Student’s t-test for normally distributed data. A chi-squared analysis was performed to analyze the categorical data. Statistical significance was accepted with a p < 0.05.

Results:

Out of a total of 2,965 athletes evaluated from the NFL combine, 414 players were identified with a pre-existing lumbar spine diagnosis. Athletes who attended the NFL combine without a lumbar spine diagnosis were significantly more likely to be drafted than those with one (74% vs. 61% respectively, p < 0.01). There was no difference between the investigational and control group with regard to round drafted, age, year drafted, or position. Overall, athletes with a lumbar spine injury compared to the control group had no difference in the number of years played (4.0 vs. 4.3 years, respectively, p = 0.13), games played (46.5 vs. 50.7, respectively, p = 0.15), games started (28.1 vs. 30.6, respectively, p = 0.39) or performance score (1.4 vs. 1.8, respectively, p = 0.3) (Figure 1).

Conclusion:

The data in this study suggests that a pre-existing lumbar spine diagnosis was associated with a significantly lower draft status for NFL athletes. However, the data in our study suggests that such a diagnosis did not affect a player’s career longevity or performance. Further study will be required to determine the individual effects of specific conditions on performance.
Eccentric Strengthening at Long Muscle Lengths Reduces Hamstring Strain Recurrences: Results of Long Term Follow-up
Authors: Tyler Timothy F. , Schmitt Brandon , Gellert Joshua M. , McHugh Malachy P.
Published: August 2014

Objectives:

Hamstring injuries are among the most common injuries in sports involving sprinting and have a high recurrence rate (20-33% recurrence rates reported in the literature). Rehabilitation protocols that can prevent recurrences are needed. The purpose of this study was to determine if a protocol emphasizing eccentric strength training with the hamstrings in a stretched position resulted in a low recurrence rate after return to play.

Methods:

Forty-eight athletes (age 35±16 yr; 31 men, 17 women) with unilateral hamstring strains (3 G1, 41 G2, 4 G3; 27 recurrent injuries) followed a 3-phase rehabilitation protocol (phase 1: isometric and isotonic strengthening at short to intermediate muscle lengths; phase 2: eccentric strengthening at short to intermediate lengths; phase 3: eccentric strengthening in a stretched position). Athletes progressed to the next phase when pain free with maximum contractions and were discharged to sports when pain free with maximal eccentric contractions in a stretched position and with functional tests. Prior to discharge, isometric strength was assessed bilaterally at 80º, 60º, 40º and 20º knee flexion in sitting with the thigh flexed to 40º above horizontal. Eight athletes chose to return to play prior to completing the rehabilitation and were categorized as noncompliant (5 completed phase 2, 3 completed phase 1). Reinjury rates and hamstring strength were compared between compliant and noncompliant athletes using Fisher exact tests and analysis of variance.

Results:

None of the 40 compliant athletes had sustained a reinjury at an average of 20±13 months after returning to sports (18>2 yr, 7 1-2 yr, 15<1 yr). Three of the 8 noncompliant athletes sustained reinjuries between 3 and 5 months after return to play (P<0.01 vs. compliant athletes). At time of return to sport, noncompliant athletes had significant hamstring weakness, which was progressively worse at longer muscle lengths (20% deficit at 80º, 23% at 60º, 31% at 40º, 43% at 20º; Angle effect P<0.001). Compliant athletes had symmetrical strength at all angles (P=0.99). Compliant athletes averaged 17±7 treatments over 11±7 wks versus 12±7 treatments over 13±11 wks for noncompliant athletes (P=0.11, P=0.53).

Conclusion:

Rehabilitation with an emphasis on eccentric strength training with the hamstrings in a stretched position resulted in zero recurrent injuries at an average of 1.7 years after return to play.
The Efficacy Of The Fifa 11+ Injury Prevention Program In The Collegiate Male Soccer Player
Authors: Silvers Holly J. , Mandelbaum Bert R. , Adeniji Ola , Insler Stephanie , Bizzini Mario , Dvorak Jiri
Published: August 2014

Objectives:

To examine the efficacy of the FIFA 11+ injury prevention program in Men’s NCAA collegiate soccer.

Methods:

A prospective randomized controlled trial was conducted in Division I and Division II NCAA men’s soccer teams during the Fall, 2012 season. Every athletic director, head soccer coach and head athletic trainer from each Divion I and Division II member institution with a men’s collegiate soccer program (N=411) was contacted via a formal letter, email and phone call. Sixty-one member institutions consented to participate. Human ethics review board approval was obtained through Quorum IRB, Seattle, WA, USA. After randomization was completed, the intervention group received an instructional DVD, teaching manual and exercise placards thoroughly describing the FIFA 11+ intervention. An injury surveillance database was utilized (HealtheAthleteTM, Overland Park, Kansas). Every athletic exposure, injury incurred, utilization of the 11+ program and compliance data was entered weekly. Sixty-one institutions completed the study: 34 control institutions (N=850 athletes) and 27 intervention institutions (N=675 athletes). The FIFA 11+ program served as the intervention program over the course of one collegiate season. The warm-up was utilized two to three times per week for the duration of the season.

Results:

In the intervention Group (IG), 285 Injuries were reported (mean=10.56 injuries/team+/-3.64) compared to 665 Injuries (mean=20.15 injuries +/- 11.01) in the control group (CG). The number of athletic exposures was 35,226 (Games: 10,935 AE, Practice: 24,291 AE) for the IG and 44,212 (Games: 13,624 AE, Practice: 30,588 AE) in the CG). The incidence rate (IR) was 8.09/1,000 AE (95% CI) in the IG compared to 15.04/1000 AE (CI=95%) in the CG (p=0.00117). Total days missed due to injury was 2824 (mean=9.94) in the IG compared to 8776 days (mean =13.20) in the CG.

Conclusion:

The FIFA 11+ was shown to significantly reduce injury rates and time loss in the competitive male collegiate soccer player in a statistically significant manner. There was a significant reduction in ACL injuries, hamstring injuries and ankle sprains in the intervention group compared to the control group. A biomechanical analysis has been planned in order to fully understand the neuromuscular changes imparted onto the participating athlete by the FIFA 11+ program.
The Effect of Femoral Nerve Block on Strength and Patient-reported Outcomes Following ACL Reconstruction
Authors: Magnussen Robert A. , Pottkotter Kristy , DiStasi Stephanie , Paterno Mark V. , Wordeman Samuel Clayton , Schmitt Laura , Flanigan David C. , Kaeding Christopher C. , Hewett Timothy E.
Published: August 2014

Objectives:

Femoral nerve block (FNB) has been proposed for pain control following anterior cruciate ligament (ACL) reconstruction. Although numerous high level studies have assessed the efficacy of FNB’s, there has been little to no research into the effect of such blocks on post-operative strength and patient-reported outcomes. Exacerbation of post-operative quadriceps weakness by a FNB could negatively impact recovery, particularly in the early post-operative period. We hypothesized that performance of a FNB would result in decreased quadriceps strength and poorer patient-reported outcome score in the first three months following ACL reconstruction.

Methods:

Thirty patients scheduled to undergo hamstring autograft ACL reconstruction following an acute ACL injury were randomized to a single shot FNB group or a control group. The surgical procedure and post-operative rehabilitation were performed identically in both groups. Pre-operatively, all patients completed a KOOS and isokinetic quadriceps strength testing at 60 deg/s. At 6 weeks post-operative, all patients completed a KOOS and isometric quadriceps strength testing at 90 deg. At 12 weeks post-operative, all patients but three completed a KOOS and isokinetic strength testing. Quadriceps strength limb symmetry indices (LSI) were calculated at all time points by dividing the strength of the involved limb by the strength of the uninvolved limb. LSI and KOOS subscales for Activities of Daily Living (ADL), Pain, and Symptoms at 6 weeks and 12 weeks were compared with pre-operative values.

Results:

Patients who underwent nerve block demonstrated a significant decrease in their LSI from pre-operative (0.80 ± 0.14) to 6 weeks post-operative (0.67 ± 0.29) (p = 0.05). Patients who did not undergo nerve block demonstrated no significant difference in the pre-operative (0.77 ± 0.23) and 6-week post-operative (0.78±0.28) LSI (p = 0.99). At 12 weeks post-operative, both groups demonstrated LSI values that were not statistically different from pre-operative. Patients who had a FNB demonstrated no change in their KOOS subscales from pre-op to 6 weeks post-op, while those patients who did not undergo FNB demonstrated a statistically significant increase in KOOS ADL, pain, and symptoms subscales from pre-operative to 6 weeks post-operative (Figure 1). All patients, regardless of group, demonstrated significant increases in KOOS subscales at 12 weeks relative to pre-operative (Figure 1).

Conclusion:

Femoral nerve block is associated with decreased quadriceps strength at 6 weeks post-operative, slowing the post-operative improvement in patient-reported outcome scores. While strength returns to pre-operative levels at 12 weeks post-operative, the effect of early quadriceps weakness on movement patterns and functional outcome at later time points has yet to be determined.
Thromboembolic Events after Arthroscopic Knee Surgery: Increased Risk at High Altitude
Authors: Tyson Jared J. , Bjerke Brian , Genuario James , Noonan Thomas J.
Published: August 2014

Objectives:

The purpose of this study was evaluate the incidence of thromboembolic events in patients undergoing arthroscopic surgery of the knee in surgery centers located at elevations near sea level and comparing those rates with the patients undergoing the same operations at surgery centers located in cities at high altitude.

Methods:

A retrospective review was conducted using a database of a major health care system with surgery centers located throughout the United States. Over 115 surgery centers located in 15 different states were analyzed for any reported thromboembolic events including deep vein thromboses (DVT) and pulmonary embolism (PE) in patients who had undergone knee arthroscopy over a 2 year period. The surgical centers located at elevations lower than 1000 ft were considered sea level centers. Those centers located at elevations above 4000 ft were considered high altitude centers. Any surgical center located between 1000 ft and 4000 ft elevation was excluded.

Results:

35,877 patients underwent a knee arthroscopy procedure at a low altitude center between 2011-2012. 10,181 patients underwent a knee arthroscopy procedure at a high altitude center between 2011-2012. During that same time period, 45 total VTEs including 12 PEs occurred at centers considered low altitude while 50 VTEs including 4 PEs occurred at centers considered high altitude. The incidence of VTE at centers considered low altitude was 0.13%. The incidence of VTE at centers considered high altitude was 0.49%. The difference was statistically significant with a p-value <0.0001. The relative risk of developing a VTE was 3.8 times higher at high altitude.

Conclusion:

Patients undergoing arthroscopic procedures of the knee in cities located at high altitude are at higher risk of developing a VTE than those undergoing the same procedures at cities located at elevations near sea level.
Does Relief from Intra-articular Anesthetic Injection Predict Outcome after Hip Arthroscopy?
Authors: Engasser William , Kuzma Scott , Krych Aaron John , Levy Bruce A.
Published: August 2014

Objectives:

Arthroscopy is being used more frequently as a treatment for intra-articular hip pathology due to femoroacetabular impingement (FAI). Prior to surgery, intra-articular anesthetic injection is commonly performed as a diagnostic test to localize the source of pain. Currently, there is a paucity of data correlating post-injection pain relief and functional outcomes after hip arthroscopy for FAI. The purpose of this study is to determine whether the amount of pain relief after preoperative intra-articular anesthetic injection predicts clinical and functional outcomes following hip arthroscopy with minimum one year follow-up. We hypothesize that increased pain relief (>50%) will correlate with better outcomes after surgery.

Methods:

The records of patients undergoing hip arthroscopy for FAI at our institution between April 2007 and April 2012 were reviewed. We identified patients who underwent pre-operative intra-articular anesthetic injection and subsequent hip arthroscopy. Inclusion criteria were: ultrasound or fluoroscopic guided intra-articular anesthetic injection performed at our institution, documented pre- and post-injection Numerical Rating Scale (NRS) pain scores, no prior ipsilateral hip surgery, and minimum 1 year follow-up. Pre-operative radiographs were reviewed and degree of osteoarthritis was determined using the Tonnis classification system. Outcomes were assessed with Modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). Univariate and multivariate models were performed to assess whether percent pain relief correlated with outcome scores.

Results:

57 hips in 55 patients met our inclusion criteria and included 37 females (67%) and 18 males (33%) with a mean age of 42.6 ± 14.7 (range 15-68) years. 8 patients had Tonnis grade 0, 35 had Tonnis grade 1, and 14 had Tonnis grade 2. Mean pain relief after intra-articular injection was 74.4 ± 31.9 (range 0-100) percent. 13 patients (23%) had ≤50% pain relief while 44 (77%) had >50% pain relief. Outcome scores were obtained at a mean 25.5 (range 12- 60) months. Mean MHHS, HOS-ADL, and HOS-Sport scores were 82.1 ± 17.4 (range 42.9-100), 85.0 ± 16.6 (range 39.7-100), and 71.8 ± 28.1 (range 11.1-100) respectively. There was no correlation between percent pain relief and MHHS, HOS-ADL, or HOS-Sport scores. There was no significant difference in outcome scores between those with ≤50% and >50% pain relief. When adjusting for Tonnis grade there was no correlation between percent relief and any of the outcome scores measured.

Conclusion:

In patients undergoing hip arthroscopy for FAI, our data indicates that the amount of pain relief from intra-articular anesthetic injection does not correlate with minimum 1 year clinical and functional outcomes even when adjusting for Tonnis grade. Although pain relief did not predict outcomes in our study, we still believe it is a useful diagnostic tool to localize the source of pain in patients considering hip arthroscopy.
Increased Posterior Tibial Slope and its Association with ACL Rupture in the Pediatric Population
Authors: O'Malley Michael P. , Milewski Matthew David , Solomito Matthew , Erwteman Andrew , Nissen Carl W.
Published: August 2014

Objectives:

Particular interest has been placed in identifying risk factors for sports related injuries in younger populations. In regards to the relationship between posterior sagittal slope of the tibia as a potential risk factor for ACL injury in the pediatric population, studies at this time remain limited.The purpose of our study is to investigate this relationship between posterior tibial slope and ACL rupture in the pediatric population. Our null hypothesis states that an increased posterior tibial slope does not serve as a contributing risk factor for ACL rupture in pediatric patients with open physes.

Methods:

A retrospective case-control study was performed at an academic pediatric sports medicine center comparing a target population of skeletally immature patients with an ACL rupture with an age-matched control group. Posterior tibial slope was then measured on plain lateral radiographs in both groups by blinded readers (Figure 1), at two separate time intervals, utilizing a previously examined and accepted technique.

Results:

Thirty two patients were included in the ACL rupture with open physes group (average age 13 years old, range 9-17) and compared to 32 patients in the control group (average age 13 years old, range 9-16). These groups were also similar in regards to male:female and left:right distribution. The mean posterior tibial slope in the ACL injured population was 10.0° ± 3° versus 8.5° ± 3° in the control group. Statistical significance was seen in comparing slope measurements between the ACL injury and control groups in two of the three readers (Readers 1 and 3) at both time points (Reader 1: p = 0.0348, p = 0.0051; Reader 3: p = 0.0009, p = .0059). Intra-rater proved superior with values correlating with moderate-to-good reliability (Reader 1 ICC = 0.7387, Reader 2 ICC = 0.8853, Reader 3 ICC = 0.5316), while inter-rater values corresponded with fair-to-moderate reliability (Measure 1 ICC = 0.4657, Measure 2 ICC = 0.5146). The average female posterior tibial slope was 9.5° (range of 3-14°) and similar to the posterior tibial slope for males, which was 9.8° (range of 2-16°).

Conclusion:

The authors reject the null hypothesis and these results uphold that an increased posterior tibial slope serves as a possible risk factor for ACL rupture in a skeletally immature population.
The Hill-Sachs Lesion: Volumetric modeling using Three-Dimensional Computed Tomography Reconstructions
Authors: Bernhardson Andrew , Provencher Matthew
Published: August 2014

Objectives:

The purposes of our study were to identify the volume and relative location of Hill-Sachs lesions, measure the amount of glenoid bone loss in patients who have existing Hill-Sachs lesions, and finally draw any correlations that exist between increased glenoid bone loss and increased Hill-Sachs volume.

Methods:

A total of 217 consecutive three-dimensional (3D) Computed Tomography (CT) scans were reviewed for the presence and measurement of Hill-Sachs volume and location. Hill-Sachs volume was measured by measuring the size of the Hill-Sachs defect in sequential CT images and a 3D model was created to measure the volume of the defect using Osirix (Osirix Imaging Software, Osirix-viewer.com). The Hill-Sachs lesion was then quantified in terms of both location and size. Further, older classification systems were applied to the data to draw comparison. Location of the lesion was measured by utilizing anterior and posterior margins of the lesion in relation to the biceps groove to give a clock face location. The height, depth and length of each lesion were also recorded in its greatest dimension. In addition a 3D model of the individual Hill-Sachs lesion was generated to observe the rough shape of the bony defect.

Results:

The Hill-Sachs lesion was identified in 60% of patients, N=130. The mean volume of the Hill-Sachs lesions was 1.22 cm3, with a range of 0.13 cm3 to 5.3 cm3. The three dimensional shape of the Hill-Sachs lesion was consistently an orange slice. Using prism measurements the average volume was 3.19 cm3 with a range of 0.33 cm3 to 9.76 cm3. Average arc of the circle of each lesion measured at the axial mid point (10 mm below the top of the humeral head) was 68.9° with a range of 9.49° to 165.88°. The average depth of the lesion was 6.7 mm with a range of 2.8 mm to 11.1 mm.

Conclusion:

This study identified a unique yet important way to measure the absolute size of the Hill-Sachs lesion in the shoulder. This method is positively correlated with previous measurement systems, but utilizes novel methods to fully measure the unique shape of Hill-Sachs lesions. Using absolute measures not only increases accuracy, but 3D modeling also shows the nature of the defect and location in order to consider operative repair of the lesion. However, the Hill-Sachs lesion only describes one side of the problem, with this data side by side comparison with glenoid bone loss is needed to fully understand the nature of shoulder instability that is a bipolar problem.
Isolated Pectoralis Minor Release for Scapular Dyskinesis
Authors: Provencher Matthew , Golijanin Petar , Gross Daniel , Campbell Kevin J. , Gaston Tistia , Anthony Shawn
Published: August 2014

Objectives:

Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, causing pseudo-impingement of the subacromial space. Most patients with pathologic tightness of the PM are treated successfully with non-operative treatment, yet a minority of patients experience persistent pain and dysfunction due to a pathologically tight PM. The purposes of this study are to describe the outcomes of operative release of PM tightness recalcitrant to nonoperative measures.

Methods:

Over a 3-year period, a total of 46 patients were enrolled (mean age 25.5, range 18 to 33) who presented with symptoms of shoulder pain, limited range of overhead motion, and inability to participate in overhead lifting activities, with examination consistent with primary abnormality of scapular dysfunction due to a tight PM with tenderness in the PM tendon. All patients underwent an extended period of physical therapy and stretching program (mean 11.4 months, range 5-23 months), and were followed with serial examinations for resolution of symptoms and scapular tilt. 6/46 (13%) patients were unable to adequately stretch the PM, and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements, pain scales, and ASES and SANE score.

Results:

A total of 40/46 (87%) patients resolved the tight PM and scapular mediated symptoms with a dedicated therapy program (ASES 58 to 91; SANE 50 to 90, VAS 4.9 to 0.8, p<0.01). The 6/46 patients treated with isolated PM release demonstrated improvement in outcomes after failed nonoperative care (ASES 48 to 89; SANE 40 to 90.4; VAS 5.8 to 0.9, p<0.01). Overall, protraction of the scapula increased. The inferomedial scapular border was a mean of 1.2 cm from the chest wall preoperatively, and 0.3 cm postoperatively (p<0.01), similar to nonoperative responders. There were no complications and all those with isolated PM release returned to full or increased duties after release.

Conclusion:

In most patients, PM tightness can be successfully treated with non-operative management. However, in refractory pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms. Additional work is necessary to evaluate the long-term efficiency of isolated PM release.
Incidence, Mechanisms, and Severity of Game-Related High School Football Injuries Across Artificial Turf Systems of Various Infill Weight
Authors: Meyers Michael Clinton
Published: August 2014

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. The purpose of this study was 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) 3.0 - 5.9 and, (D) 0.0 - 3.0. A total of 43 high schools participating across four states over 3 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, cleat design, turf age, and environmental factors.

Results:

Of the 847 high school games documented, 301 games (35.5%) were played on infill (A), 231 (27.3%) on infill (B), 189 (22.3%) on infill (C), and 126 (14.9%) on infill (D). A total of 1,979 injuries were documented, with significantly lower total injury incidence rates (IIR), [18.8 (95% CI, 18.3-19.1) vs 23.3 (22.4-24.0) vs 31.6 (30.5-32.2) and 22.1 (20.8-22.9)], substantial IIRs [3.9 (95% CI, 3.4-4.5) vs 4.8 (4.1-5.4), 7.7 (7.1-8.3) and 6.1 (5.2-5.9)], trauma from player-to-player collisions [8.7 (95% CI, 8.2-9.0) vs 11.0 (10.5-11.5), 16.4 (15.5-17.1) and 9.8 (9.4-10.0)], playing surface impact trauma [2.6 (95% CI, 2.1-3.1) vs 4.2 (3.6-4.8), 5.6 (4.8-6.2) and 4.4 (13.5-5.2)], and less muscle trauma [6.1 (95% CI, 5.5-6.6) vs 9.7 (9.4-9.9), 13.7 (12.8-24.4 and 8.7 (8.0-9.2)], 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 concussions, muscle-tendon overload, time loss, skill positions, injury mechanism and situation, lower and upper extremity joints, 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-elated 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.
Variation in Health Care Cost: Quality, Utilization, and Efficiency Review for ACL Surgery Cost Variance Within a Health Care System
Authors: Shea Kevin G. , Archibald-Seiffer Noah M. , Jacobs John , Saad Charles , Hooft Lahoma , Humphreys Becca
Published: August 2014

Objectives:

Variation in health care costs is an area of focus amongst national policy experts. While cost variation between facilities is an important area of investigation, cost variation within the same institution is recognized as an opportunity for rapid process change to provide better value to patients. The purpose of this study was to perform a Quality, Utilization, Efficiency (QUE) review for ACL surgery.

Methods:

This project was reviewed by an IRB and approved for performance improvement. Using models developed by Intermountain Health Care, a QUE review was done for ACL procedures within a 22 surgeon, 7 hospital system. Cost data from January through June 2013 was reviewed. Four consistent cost categories were identified, and analyzed for cost variation among surgeons: tibial fixation, femoral fixation, graft choice, and tools/disposable instruments.

Results:

The range in costs for these 4 categories to perform an ACL reconstruction ranged from $392.80 to $7,838.73, a difference of $7,445.93 and a mean of $2,128.93. Tibial fixation costs ranged from $42.43 to $580.00 (average $171.78). Femoral fixation ranged from $95.00 to $865.00 (average $287.33). The graft cost ranged from $1,275.00 to $2,545.75 (average $1,976.43). Suture prices for each individual suture, varied from $1.19 to $130.82, a range of $129.63 and mean $28.00. Tools and disposable supplies ranged from $184.00 to $896.00 (average of $346.00).

Conclusion:

The cost difference in ACL reconstructive surgeries showed a twenty-fold increase from minimum to maximum for different cost categories. In some cases, higher costs may be necessary for more complex and revision cases. As health systems and physicians collaborate to improve health care quality and value for patients, accurate information on cost will be important for providers. Rational variation in health care costs, which arise from patient-centered care, is appropriate. Irrational variations in care and procedural costs are not justified, and these variations offer opportunities to provide better care and value to patients. Providing high quality and timely information about costs is critical for engaging physicians in improving quality.
Complications from a Distal Bicep Repair: A Meta-Analysis of a Single Incision Versus Double Incision Surgical Technique
Authors: Toossi Nader , Amin Nirav Hasmukh , Cerynik Douglas L. , Jones Morgan H.
Published: August 2014

Objectives:

Anatomical reinsertion of the distal biceps is critical for restoring elbow flexion and forearm supination strength. Surgical techniques utilizing one and two incisions have been reported in the literature, describing complications and outcomes. However, which technique is associated with a lower complication rate remains unclear.

Methods:

A systematic review was conducted using the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials database to identify articles reporting distal biceps ruptures through August 2013. We included English language publications based on adult patients with a minimum of three cases. Both single and dual incision technique studies were incorporated. The demographic and outcome data of all studies was retrieved and pooled. A Meta-analysis on the pooled data was then conducted to determine the role of surgical technique on different complications. This was adjusted for age, gender and other independent variables.

Results:

Fifty-five articles met the inclusion criteria. The complication rate in the single incision group was 28.3% (222/785) versus 20.9% (104/498) in the double incision group. Neuropraxia was the most common complication in the single incision group at 9.8% (77/785), while heterotopic ossification was the most common in double incision cases at 7% (35/498). Re-rupture and failed reattachment occurred in 2.5% of single incision cases, versus 0.6% of double-incision cases (p < 0.034). Posterior interosseous nerve (PIN) palsy occurred in 2.7 % (13/785) of single incision procedures versus 0.2% (1/498) in the double incision group (p< 0.001). When combining heterotopic ossification and synostosis rates, the double incision group demonstrated complications in 9.8% of cases versus 3.2% for single incision cases.

Conclusion:

Surgical intervention for distal biceps ruptures may help restore function to an active individual; however, this procedure is not without risk of complications. The single incision technique has a higher rate of failed re-attachment and re-rupture compared to the double incision technique. The single incision technique also has a higher rate of overall nerve palsy (PIN, LABC, and Radial Nerve) compared to the double incision technique. The double incision technique does have higher rates of HO compared to the single incision. These complications are important for surgeons to consider and disclose to patients deciding on operative repair.
Validation of the Microsoft Kinect as a Portable and Inexpensive Screening Tool for Identifying ACL Injury Risk
Authors: Gray Aaron D. , Marks Jeff M. , Stone Erik E. , Butler Michael C. , Skubic Marjorie , Sherman Seth Lawrence
Published: August 2014

Objectives:

A widespread screening tool to assess anterior cruciate ligament (ACL) injury risk should ideally be portable, inexpensive, markerless and easy to use. We hypothesize that our software program - for use with the Microsoft Kinect Motion Sensor - fulfills the above requirements. This study compares the measurements of knee abduction during a drop vertical jump (DVJ) between the Microsoft Kinect and the “gold standard” marker-based Vicon motion analysis system.

Methods:

Thirteen participants (10 male: 3 female; age 20-31) took part in this IRB approved study. Each participant performed between 5 and 7 DVJs, yielding a total of 84 DVJs. We simultaneously measured knee valgus motion (KVM) as measured from initial contact (IC) to the point of peak flexion (PF), frontal plane knee angle (FPKA) at both IC and PF, and knee-to-ankle separation (KASR) ratio measured at PF with the Kinect and Vicon systems. The intra-class correlation coefficient (ICC) (two-way, single measure, absolute agreement) was used to assess the degree of agreement between the Kinect and Vicon for each measure.

Results:

KVM had the lowest ICC value; 0.81 and 0.85 for the left and right leg, respectively. The other measures had similar ICC values of approximately 0.89 for both legs. Standard interpretations of the ICC suggest values above 0.75 indicate excellent agreement between the measurements (Table 1).

Conclusion:

This study demonstrates good correlation between the Microsoft Kinect and the Vicon system for measuring frontal plane knee kinematics during the DVJ. The DVJ test has been established as an ideal task for evaluating the motions that put athletes at risk for ACL injuries. Screening and early detection of ACL injury risk factors may lead to a relative risk reduction between 30% to 80% with an appropriate ACL injury prevention program. As compared to the “gold standard” Vicon system, the Microsoft Kinect is a portable, inexpensive, marker-less, and expedient system that likely has acceptable accuracy to become a practical means of mass screening of athletes for ACL injury risk factors. Further study will focus on validating the system with a larger and varied sample size and over a variety of functional tasks.
Mechanoreceptor Re-innervation Following Allograft versus Autograft Anterior Cruciate Ligament Reconstruction
Authors: Dragoo Jason L. , Valladares Roberto , Young Simon W.
Published: August 2014

Objectives:

Functional instability following anterior cruciate ligament (ACL) rupture is due to both loss of mechanical restraint, and loss of proprioception that restricts the ability of coordinated muscle activity to compensate and stabilize the knee joint. This lack of coordinated muscle control is thought to be due to diminished or absent sensory feedback from the ACL mechanoreceptors to the neuromuscular system. Clinical, motor and proprioceptive function is known to improve following ACL reconstruction but does not return to normal. While histological studies of human ACL allografts have been unable to demonstrate mechanoreceptor re-innervation, animal data suggests re-innervation occurs when an autograft is used. The aim of this study was to compare the presence or absence of mechanoreceptors in allograft versus autograft in following ACL reconstruction in humans.

Methods:

Eleven patients with previous ACL reconstruction presenting for either revision ACL surgery or knee arthroscopy for other reasons were enrolled in a prospective, comparative study. Six patients had a previous autograft ACL and five patients had an allograft. In the case of revision patients, the previous ACL graft tissue was excised within 6 weeks of ligament rupture, and in arthroscopy patients 2mm biopsies of the ACL graft were taken from the tibial and femoral insertions. ACL tissue was also taken from 2 additional patients within 6 weeks following acute primary ACL rupture as a control. The specimens were fixed with 10% buffered formalin solution and frozen section was performed. Specimens were stained with hematoxylin-eosin (H-E) and monoclonal antibodies against S-100 and neurofilament protein (NFP). Immunohistochemical examination was performed using Freeman and Wyke's criteria to morphologically classify mechanoreceptors.

Results:

Ruffini corpuscles and free nerve endings were shown to be present in the specimens of the control group. Histological examination for mechanoreceptors for six patients with previous autografts and five patients with previous allografts were compared. The average time between original graft and biopsy was 10.7 years (range 0.5 ### 27). There were significantly more mechanoreceptors visible in control (native) ACL tissue than graft tissue.

Conclusion:

We present comparative data demonstrating reduced concentration of mechanoreceptors in ACL grafts compared to native ACL tissue. This may explain the continued proprioceptive deficit known to exist even following ACL reconstruction.
Donor-Site Recovery after Anterior Cruciate Ligament Reconstruction with Contralateral Autogenous Patellar-Tendon Graft
Authors: Shelbourne K. Donald , Beck Matthew B.
Published: August 2014

Objectives:

To evaluate the recovery of the donor site after ACL-reconstruction with a contralateral autogenous patellar tendon graft as compared with an ipsilateral graft. Specifically, we compared the International Knee Documentation Committee (IKDC) subjective scores between groups and compared to established normative data. Furthermore we evaluated quadriceps muscle strength between surgery groups.

Methods:

Between 2007 and 2009, 279 patients who underwent primary ACL reconstruction with an autogenous patellar tendon graft from the contralateral knee met the inclusion criteria of unilateral knee involvement, no evidence of arthritic changes preoperatively, and minimum 2 year follow-up objective and subjective evaluations. A control group was obtained of 58 patients who had the same inclusion criteria, were of the same age, but underwent surgery with ipsilateral graft. Patients underwent a goal-directed and sequential postoperative rehabilitation program that emphasized controlling a hemarthrosis, obtaining full knee range of motion as soon as possible after surgery, increasing leg strength, and functional activities to return patients back to sports. The rehabilitation for the contralateral donor site emphasized high repetition/low resistance exercises beginning the day after surgery to reconstitute the patellar tendon size and strength. IKDC subjective data was compared between surgery groups and established normative data. Quadriceps muscle strength was evaluated in both knees compared to the pre-operative values obtained in the non-involved knee; strength between knees at 2 years postoperatively was also evaluated.

Results:

When comparing quadriceps muscle strength to its pre-operative baseline value, the ipsilateral control group that had statistically significantly less strength in the ACL-reconstructed knee at 105% ± 29% compared with the contralateral group that had 114% ± 28.4% strength in the donor knee ( P < .01) and 116% ± 25% strength in the ACL-reconstructed knee ( P = .0339). When side-to-side strength was evaluated at 2 years post-operatively, the contralateral group had 98.4% ± 13.6% quadriceps muscle strength compared with 92.9% ± 13.0% in the ipsilateral control group ( P < .01). The mean total IKDC scores obtained at the 2-year follow-up was 92.4 ± 9.6 for contralateral donor-knee, 88.8 ± 12.3 in the contralateral ACL-reconstructed knee, and 88.9 ± 11.2 for the control group ACL-reconstructed knee (p=0.960). There was also no statistical significant differences between groups for any of the IKDC sub-scores or total score (All P-values >.136; Table 1). The mean IKDC scores compared with established normative data of noninjured people of the same age and sex showed no large effect size differences between groups.

Conclusion:

With proper rehabilitation after surgery, use of a contralateral bone-patellar tendon-bone autograft with ACL reconstruction does not cause unresolved donor-site strength loss or subjective symptoms.
Smoking Increases the Risk of Early Meniscus Repair Failure
Authors: Blackwell Ryan , Schmitt Laura , Flanigan David C. , Magnussen Robert A.
Published: August 2014

Objectives:

Meniscus tears are among the most common surgically treated knee injuries. Numerous studies have demonstrated increased risk of the development of radiographic signs of osteoarthritis following meniscus loss, leading surgeons to attempt to repair and preserve the meniscus whenever possible. Tear location and morphology, knee stability, the performance of a concurrent anterior cruciate ligament (ACL) reconstruction, and patient age have in various studies been correlated with risk of repair failure. While smoking has been demonstrated to in orthopaedics to impair wound healing, fracture union, and spinal fusion; there are no studies in the literature evaluating the effect of smoking on meniscus repair. We hypothesize that smoking is associated with increased risk of meniscus repair failure, defined as performance of a subsequent partial meniscectomy following initial meniscus repair.

Methods:

Patients who underwent meniscus repair by two surgeons at a single center between 2006 and 2012 were retrospectively identified through chart review. Patient demographics and smoking status were documented. Each smoking patient was subsequently matched to a nonsmoking using patient who underwent meniscus repair in the same period by age (within 5 years), sex, and whether a concurrent ACL reconstruction was performed. Matching was performed without knowledge of outcome. Further chart review was subsequently undertaken to identify whether a subsequent meniscectomy was performed in the same compartment during the follow-up period. Meniscectomy risk was compared between smokers and nonsmokers using McNemar's test.

Results:

Chart review identified 68 smokers who underwent meniscus repair during the study period. The group included 43 males (63.2%), had a mean age of 29.0 ± 8.5 years, and included 49 patients (72.1%) who underwent concurrent ACL reconstruction. The matched group of nonsmokers included 43 males (63.2%), had a mean age of 29.2 ± 8.3 years, and included 49 patients (72.1%) who underwent concurrent ACL reconstruction. At a mean follow-up of 15 months, subsequent partial meniscectomy was performed in 16 smokers (23.5%) and 7 nonsmokers (10.3%) (p = 0.029). The relative risk of subsequent partial meniscectomy in smokers relative to nonsmokers was 2.28 (95% CI: 1.07 to 4.90).

Conclusion:

After controlling for age, sex, and concurrent ACL reconstruction, current smokers were significantly more likely to undergo meniscectomy in the first 15 months following meniscus repair. Further study is necessary to confirm these findings and determine the impact of other factors such as tear location and morphology, meniscal repair technique, and activity level on the findings.
Prospective Evaluation Of Meniscal Allograft Transplantation Revision: A Minimum Of 2-year Follow-up
Authors: Chalmers Peter Nissen , Yanke Adam Blair , Frank Rachel M. , Cole Brian J.
Published: August 2014

Objectives:

Meniscus transplantation (MTx) demonstrates improved clinical outcomes up to 10 years postoperatively in patient with symptomatic meniscal deficiency; however, a subset of patients develop recurrent symptoms secondary to re-injury or meniscus degeneration.In selected patients we have performed revision MTx (RMTx) for clinical failure after primary MTx, herein we report the outcomes of this procedure.

Methods:

A retrospective review of prospectively collected data on a consecutive series of patients who underwent RMTx by the senior author was performed. The pre-operative and more recent follow-up data for the following scoring systems were analyzed for significance using pairwise comparisons: Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee Score, Short Form quality of life score (SF-12), and visual analogue scale for satisfaction. Radiographs were obtained pre-operatively and at final follow-up.

Results:

Eleven patients met inclusion criteria, of which three were lost to follow up. The remaining patients included three males five females with a mean age of 31.6±10.2 years with five lateral and three medial menisci involved. The average time to revision from the index procedure was 3.45±2.52years (1.2-9 years). Mean follow up after RMTx was 3.83±1.3 years (2-5.85 year). Three patients (two lateral and one median menisci) described a new traumatic event that incited their symptoms. On average there was 0.20±1.0 mm of joint space narrowing in the affected compartment at final follow-up as compared to pre-operatively. Concomitant procedures included ACL reconstruction, revision OA graft, distal femoral osteotomy, and high tibial osteotomy. One patient progressed to arthroplasty, otherwise there were no re-operations. Six were mostly satisfied, two were completely satisfied, and subjective satisfaction was 7.6 on a ten-point scale. Seven of eight reported that they would have surgery again. All validated outcome measures were unchanged except for symptom rate which was significantly improved (p=0.011).

Conclusion:

RMTx is a reasonable option for select patients that are young and active, planning to continue an active lifestyle.