bluuebunny/crossref_metadata_2025 huggingface dataset:
Symptomatic Femoroacetabular Impingement
Authors: Clohisy John C. , Nepple Jeffrey J.
Published: September 2013

Objectives:

The purpose of this study was to compare the clinical, radiographic and intraoperative characteristics of symptomatic FAI in males and females, to determine gender-specific differences in FAI presentation.

Methods:

We retrospectively identified consecutive cohorts of 50 male and 50 female patients treated for symptomatic FAI by a single surgeon. Established clinical and radiographic methods were used for disease characterization. Statistical analysis was performed to identify significant differences in clinical, radiographic, and intraoperative findings between males and females.

Results:

Statistical differences in age, BMI, and pain chronicity by gender were not detected. Modified Harris hip scores and UCLA activity scores were significantly lower in females (54.4 vs. 63.7, p 0.005 and 6.8 vs. 8.1, p 0.014, respectively). Females were significantly more likely to have a component of lateral hip pain (38% vs. 20%, p 0.047), in addition to anterior/groin pain. Females had significantly more internal rotation range of motion in flexion than males (16.4° vs. 6.9°, p<0.001), with 58.0% and 86.0% having less than 20°, respectively (p 0.002). Males were significantly more likely than females to have elevated alpha angle (>50 in 94% vs. 70%, p 0.002) and decreased head-neck offset (<0.17 in 96% vs. 78%, p 0.007). Elevated alpha angles on the AP pelvis radiographs were more common in males with FAI compared to females (72% vs. 28%, p<0.001). A crossover sign greater than 10 mm from the acetabular sourcil was significantly more likely in males than in females (64.3% vs. 23.5%, p 0.001). Acetabular articular cartilage cleavage or defects were significantly more common in males (56% vs 24%, p 0.001). The distribution of labral lesions was not significantly different (82% vs 80% detachment).

Conclusion:

Significant differences in disease characteristics exist between males and females with FAI. Female patients have greater disability at presentation and are less active than males with FAI at presentation, despite less advanced acetabular cartilage pathology. Female patients generally had milder cam-type deformities and less acetabular retroversion than males.
The Demographics of High-level and Recreational Athletes With Intra-articular Hip Injury
Authors: Tibor Lisa M. , Bedi Asheesh , Oltean Hanna N. , Gagnier Joel Joseph , Kelly Bryan T.
Published: September 2013

Objectives:

The pathoanatomy that causes femoroacetabular impingement (FAI) is common, but not everyone develops hip pain or arthrosis. Symptomatic FAI is likely due to a combination of anatomy and biomechanical demands, including sports participation. The primary purpose of this study was to determine demographic differences between high-level and recreational athletes undergoing hip arthroscopy. The secondary purpose of this study was to look at the demographics of high-level athletes grouped by sports with similar mechanical demands on the hip. We hypothesize that high-level and recreational athletes will differ by age, gender, and need for bilateral surgery. We also predict that demographics for high-level athletes will differ for sports with unique demands for hip kinematics.

Methods:

Using our hip preservation center registry, a retrospective review of prospectively collected data from patients undergoing hip arthroscopy between March 2010 and April 2012 was performed. Athletes were categorized as high-level (high school, collegiate, Olympic/international, or professional) or recreational. Subgroup analysis was performed for high-level athletes, looking at differences between contact, rotational running, impingement, overhead/asymmetric, endurance, and flexibility sports.

Results:

288 high-level athletes and 334 recreational athletes were included. Being a high level athlete was associated with younger age (average age 20.2 vs 33.0, OR=0.69, P<0.001) and male gender (61.5% vs 53.6%, OR=1.75, P=0.03). The percentage of high-level athletes undergoing bilateral surgery was higher than for recreational athletes (28.4% vs 15.9%); however, this association was found to be confounded by age in multivariate analysis The most common sports for high-level athletes were soccer, hockey, and football. Athletes participating in rotational running sports were significantly younger than flexibility, contact, or impingement athletes. Similarly, endurance athletes were significantly younger than athletes in impingement sports.

Conclusion:

There are significant differences between high-level and recreational athletes that are likely to be important when counseling patients and reporting surgical outcomes. This study also provides important information about sports that provoke hip pain. Identifying biomechanical mechanisms that place young athletes at risk for hip injury enables anticipatory guidance and preventative strategies for these patients.
Comparison of the Amount of Iliopsoas Tendon Lengthening That Occurs after ArthroscopicLabral-Level and Lesser Trochanteric Tenotomies
Authors: Bayer Jennifer L. , Keene James S.
Published: September 2013

Objectives:

The success of arthroscopic iliopsoas tenotomies (AIT’s) performed at the level of the lesser trochanter for treatment of a painful snapping tendon is well documented. Currently, iliopsoas labral-level tenotomies have been advocated for treatment of this problem. However, a recent study reported a high incidence (∼50%) of recurrent snapping after iliopsoas tendon (IT) releases at this level (1). The purpose of this study was to determine if there is a difference in the amount of tendon separation/lengthening following AIT’s at the labral and lesser trochanteric levels. To date, the amount of tendon separation that occurs after releases at these two sites has not been reported.

Methods:

From the senior author’s data base of 900 hip arthroscopies, 80 patients who had arthroscopic iliopsoas tenotomies performed:1) at the level of the labrum (40 patients); or 2) at the lesse rtrochanter (40 patients) were identified. The amount of tendon separation/lengthening in these 80 patients was determined either from direct intra-operative measurements (40 patients) or from measurements made off of the intra-operative photographs. Image magnification on the intra-operative photographs was controlled for by basing the measurements of tendon separation on the known dimensions of the radiofrequency probe or 5 mm cannula that was present in each iliopsoas release picture (Figure 1). Two sample t tests were used for data analysis with p = <0.05 defined as significant.

Results:

Average age of the 40 patients with labral-level (LL) tenotomies was 36 years (range 16-58 years), and there were 9 males and 31 females and 19 left and 21 right hips in this group. Average age of the 40 patients with lesser trochanteric (LT) tenotomies was 32 years (range 17-55 years), and there were 8 males and 32 females, and 11 left and 29 right hips in this group. In the LL tenotomy group, the average tendon separation was 8.3 ± 2.04 mm. In the LT tenotomy group, the average tendon separation was 13.3 ± 3.01 mm. The 0.5 cm difference in the amount of tendon separation between the two groups was statistically significant at the p<0.001 level.

Conclusion:

An arthroscopic, lesser trochanteric iliopsoas tenotomy produces significantly greater (0.5 cm) tendon separation than tenotomies performed at the level of the labrum. The difference in the amount of tendon separation that occurs at these two sites may explain the high rates of recurrent snapping (∼50%) that have been reported with arthroscopic and open labral-level releases.
Early Complications with Femoral Transcondylar Pin Fixation for ACL reconstruction
Authors: Kahlenberg Cynthia A. , Deshmane Prashant , Han Brian S. , Edwards Sara L.
Published: September 2013

Objectives:

Bioabsorbable transcondylar fixation has remained a popular femoral fixation option for anterior cruciate ligament (ACL) reconstruction using hamstring graft. We report the incidence of failure and complications related to this particular fixation device in a single surgeon consecutive series of 56 patients.

Methods:

Fifty-six consecutive arthroscopic ACL reconstructions using hamstring autograft done by single surgeon between March 2010 and Dec 2011 were reviewed retrospectively after IRB approval. Transcondylar femoral fixation was achieved using Bio-Transfix (Arthrex, Naples, FL) pin in all patients. Mean follow up was 18.2 months. Intra-operative and post-operative follow up data were reviewed to assess failure. Failure was categorized as either graft failure due to re-injury or implant related failure due to persistent pain at pin insertion site and/or pin breakage.

Results:

13 (23.2%) patients were deemed as failures following surgery. Five patients needed revision surgery (persistent pain at pin insertion site n= 2, and pin breakage n=3). Two additional patients had a pin breakage and refused surgery and five additional patients had pain at the transfix pin site but opted for conservative treatment. One patient had a mid-substance graft failure due to sports injury unrelated to implant type. Remaining 43 patients did not report any symptoms of pain and or instability following surgery.

Conclusion:

This single surgeon consecutive series of ACL reconstruction using transcondylar pin fixation device demonstrates a slightly higher failure rate (23.2%) as compared to previous isolated reports of pin breakage or pain at insertion site in literature. Further radiographic studies are necessary to understand the natural history of osteointegration of this bio-device, such as implant thinning, tunnel widening by osteolysis, points of stress risers in implant and possible modification in routine accelerated rehabilitation following this implant as method for ACL reconstruction.
Comparison of Two Methods to Measure Return to Sports after Anterior Cruciate Ligament (ACL) Reconstruction
Authors: Yabroudi Mohammad A. , Muller Bart , Lai Chung-Liang , Andrew Lynch , Oostdyk Alicia , Fu Freddie H. , Harner Christopher D. , Irrgang James J.
Published: September 2013

Objectives:

Return to sports (RTS) is a primary goal for ACL reconstruction. Recent studies indicate that return to prior level of sports participation is poor with only 45% of patients having returned to sport.1 The purpose of this study was to evaluate return to pre-injury level of sports participation after ACL reconstruction using a strict comprehensive definition for RTS.

Methods:

Participants who were 1 to 5 years after ACL reconstruction completed a survey to determine their pre-and post-surgery sports activity levels. Comprehensive return to pre-injury level of sports (comprehensive RTS) was operationally defined as returning to the same type and frequency of sports and same Marx Activity Score (MAS) as before injury. Patients also answered a global question on whether they had returned to their pre-injury level of sports (global RTS). The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) was used to compare symptoms and function between patients who did and did not meet comprehensive RTS criteria.

Results:

One hundred sixty eight participants (mean age, 28.8±10.9 years) completed the survey. Using comprehensive RTS criteria, 69 (41.1%) participants returned to their pre-injury level of sports. Based on the global RTS, 79 (47%) reported they had returned to their pre-injury level of sports. Fifty nine (74.7%) of the 79 individuals that reported global RTS met the comprehensive RTS criteria. Patients who met the comprehensive RTS criteria had fewer symptoms and better function based on the IKDC-SKF than those who did not (87.5±10.6 vs. 80.1±13.7, p<0.001). Of the 93 patients who did not meet comprehensive RTS criteria, 46 (49.5%) did not return because of fear of re-injury, 32 (34.4%) due to ongoing problems with their knee, 31 (31.3%) lacked confidence in the knee, 20 (21.5%) work or family obligations, and 6 (6.5%) were no longer eligible for participation in competitive sports.

Conclusion:

RTS is more common if based on a global RTS question than if measured by strict comprehensive criteria that combine return to the same type and frequency of sports and MAS. Patients who do not meet comprehensive RTS criteria demonstrate poorer function than those that do. A global rating of RTS may overestimate the true RTS rate by 25%. Fear of re-injury, ongoing knee problems, and lack of confidence play a greater role in preventing RTS than lifestyle changes. These issues need to be addressed to improve RTS after ACL reconstruction
ACL Revision Reconstruction
Authors: Gilmore Carl Jan , Hamann Joshua C. , Gaskin Cree M. , Carroll John Joseph , Hart Joseph M. , Miller Mark D.
Published: September 2013

Objectives:

Failure of ACL grafts poses a substantial challenge to both patient and surgeon. Recent studies regarding ACL revision have shown 24% of failures directly attributable to technical error. Previous mal-position of tunnels and anatomic constraints historically necessitate two stage revision including initial tunnel bone grafting followed by remote ACL reconstruction. Staged revision surgery has an inherently higher complication rate, often diminished outcomes and larger financial burden to the healthcare system. The objective of this study was to evaluate the outcomes of the senior author’s novel single staged technique for ACL revision reconstruction using allograft cloward-dowel type bone grafting of previous tunnels and immediate ACL reconstruction.

Methods:

Study Design: Case Series. We reviewed the charts of patients undergoing ACL revision surgery using the single stage technique from 2002-2012. We were able to contact and enroll 14 patients who had subsequent clinical evaluation including cruciate exam, KT 1000 arthrometry, subjective outcome scores and CT evaluation of bone graft incorporation at a mean of 22 months followup. Means and standard deviations were calculated for descriptive data summary.

Results:

At a mean follow up of 22.2 months (min 4.5mo), CT scans showed excellent graft incorporation in all patients as determined by an orthopaedic surgeon and musculoskeletal radiologist based on ≥75% integration. KT 1000 arthrometry showed mean side-to-side difference between operative and non-operative knees of 0.8mm, and there were no 2+ pivot shift exams in our series. Subjective measures showed mean VAS of 2.6 (SD 2.4), IKDC and KOOS scores were 61.7 (SD 21) and 72.2 (SD 22.1) respectively.

Conclusion:

As illustrated by previous studies, our data shows that revision ACL surgery tends to yield inferior subjective outcomes. However, despite the relatively low mean subjective outcomes scores in our series, the objective outcome measures were very good. We had no failures based on the MARS criteria for ACL revision, the allograft dowels fully incorporated in all patients, and the sided to side difference as measured by KT 1000 was within the range of normal for native knees. This illustrates that a single stage approach to ACL revision reconstruction using this technique yields good reproduction of ACL function. It also supports the use of allograft bone dowels and demonstrates their ability to act as partial fixation for ACL hardware and to integrate very well into the native bone as early as 4.5 months post operatively. Although ACL revision surgery poses a substantial challenge to both patient and surgeon, the ability to perform that surgery in a single stage, regardless of previous tunnel position, helps to limit the morbidity and cost of this procedure.
Biomechanical Evaluation of Knee Kinematics after ACL Reconstructions in Anatomic SB and DB - Technique with Additional Medial Meniscus Suture
Authors: Lorbach Olaf , Herbort Mirco , Engelhardt Martin , Kieb Matthias
Published: September 2013

Objectives:

Biomechanical evaluation of knee laxity after single- and double-bundle ACL reconstruction with additional medial meniscus suture.

Methods:

Kinematics of the intact knee were determined in 12 human cadaver specimens in response to a 134-N anterior tibial load (aTT) and a combined rotatory load of 10 Nm valgus and 4 Nm internal tibial rotation using a robotic/universal force moment sensor testing system. Subsequently, the ACL was resected following the creation of a bucket-handle tear of the medial meniscus. A standard repair of the medial meniscus was performed using 3 inside-out horizontal sutures. Finally, The ACL was reconstructed using an anatomic single-bundle (6) or double-bundle technique (6). Knee kinematics were determined following every sub-step.

Results:

Significant increase of aTT in the ACL-deficient knee was found with significant increase in the ACL-deficient knee with additional medial meniscal injury (p=.003; p=.009). ACL reconstructions significantly decreased aTT compared to the ACL-deficient knee. No significant differences were found between the intact knee and the ACL reconstructed knee with additional meniscal repair. In response to a simulated pivot shift, aTT in the intact knee significantly increased in the ACL-deficient knee as well as in the meniscus injured/meniscus-sutured knee (p=.003;p=.007). No significant differences were found between the ACL-deficient and ACL reconstructed knee with additional meniscal repair. SB as well as DB ACL reconstruction with additional medial meniscal repair restored knee kinematics compared to the intact knee. Comparison of SB versus DB ACL reconstruction did not reveal any significant differences neither in a simulated Lachman test nor in response to a simulated pivot shift (p=.05).

Conclusion:

aTT as well as aTT in response to a combined rotatory load significantly increased with ACL deficiency compared to the intact knee, additional medial meniscal injury further increased aTT. Anatomic ACL reconstruction with medial meniscal repair restored knee kinematics compared to the intact knee. Comparison of anatomic SB vs. DB ACL reconstruction with additional repair of the medial meniscus did not reveal significant differences in aTT as well as aTT under a combined rotatory load.
Osteochondral Allografting for Knee Lesions in the Pediatric and Adolescent Population
Authors: Pennock Andrew T. , Murphy Ryan T. , Bugbee William
Published: September 2013

Objectives:

Osteochondral allografting is a useful reconstructive procedure for large ostechondral lesions of the knee. The purpose of this study was to evaluate the clinical outcome of osteochondral allografting in pediatric and adolescent patients.

Methods:

This IRB-approved study evaluated 39 patients (43 knees) less than 18 years of age who underwent osteochondral allografting between 1983 and 2010. The mean age was 16.4 years (range, 11.1 to 17.9) and 61% were male. The etiology of the lesions were osteochondritis dissecans in 26 knees (60.5%), avascular necrosis in 7 (16.3%), traumatic chondral injury in 6 (14%), degenerative chondral lesion in 2 (4.7%), and fracture in 2 (4.7%). Thirty-four patients (79%) underwent an average of 1.5 previous surgeries on the operative knee. Surgery was preformed using either a dowel or shell technique with fresh allograft tissue. The mean graft area was 8.4 cm2 (range, 2.2 to 20.8). The majority of grafts (76.7%) were located on the femoral condyle. Function and pain were assessed preoperatively and postoperatively using the International Knee Documentation Committee (IKDC) score, the Knee Society function (KS-F) score, and the modified Merle d’Aubigné-Postel (18-point) scale. Postoperative assessment included patient satisfaction, reoperations, and allograft survivorship. Failure was defined as any further procedure that resulted in removal of the allograft.

Results:

The mean follow-up was 8.4 years (range, 1.7-27.1). The IKDC score improved from 42 to 75 and the KS-F score improved from 69.3 to 89.4 (both p<0.05). Using the modified Merle d’Aubigné-Postel (18-point) scale, 87.5% of patients had a “good” or “excellent” score postoperatively, compared to 17% preoperatively. Patient satisfaction was 88.6%. Sixteen of 43 knees (37.2%) had reoperations following the allograft surgery. Kaplan-Meier survivorship was 92.9% at 5 years and 89.8% at 10 years. Five failures (11.6%) occurred, which were all salvaged with revision allografting.

Conclusion:

Osteochondral allografting was successfully employed to treat complex knee chondral and osteochondral pathology in patients less than 18 years of age. This procedure yielded improved function, decreased pain, and high satisfaction at an average follow-up of 8 years. Failure rates were relatively low, and when they did occur, were successfully revised with a second allograft procedure.
A Predictive Factor in Osteochondritis Dissecans
Authors: Sikka Robby Singh , Wechter John Francis , Alwan Mujtaba , Tompkins Marc
Published: September 2013

Objectives:

Knee alignment is thought to have some bearing on the development of osteochondritis dissecans (OCD) lesions.1 The effect of proximal tibial morphology on the risk of OCD, however, is unknown. The purpose of this study was to evaluate proximal tibial morphology and its relationship to OCD lesions. The null hypothesis was that patients with OCD lesions would have no difference in medial and posterior tibial slope when comparing the affected side to the unaffected side and age matched controls.

Methods:

Using CPT codes, we identified 61 patients with unilateral OCD lesions of the medial femoral condyle seen at our institution from 2005-2010. On plain radiographs, medial tibial slope and posterior tibial slope were assessed by 2 residents and 1 attending. (Figure 1) Measurements were completed on affected, contralateral normal, and control knees. The controls were height, weight, and gender matched. In addition, a comparison was made between OCD patients requiring surgery and those without surgery. Inter-observer reliability for each measurement was determined using intra-class correlation coefficients (ICCs). A student’s t-test was used to compare the results of the affected and normal sides.

Results:

The average patient age was 15.1 years. There were 31 right-sided lesions and 30 left- sided lesions. Medial tibial slope of the affected knee averaged 67.81 ± 3.92 (ICC(2,1) =.771, p<.01) compared to 69.44 ±3.63 (ICC(2,1) =.785, p<.01) for the normal side (p=.0070). The average posterior tibial slope for the affected knee was 80.03 ± 3.91 (ICC(2,1) =.783, p<.01) and 79.62 ± 4.37 (ICC(2,1) =.844, p<.01) for the normal side (p=.19). Matched controls had an average medial tibial slope 68.73° ± 5.81° (ICC(2,1) =.732, p<.01) which was statistically different from affected knees (p=.043). Matched controls had an average posterior tibial slope 81.13° ± 2.90° (ICC(2,1) =.797, p<.01), which was also statistically different from affected knees (p=.0068). Thirty-one patients with OCD lesions had undergone surgery while thirty patients were treated non-operatively. In the operative group, the average medial tibial slope was 69.17° ± 4.64° and the average posterior slope was 76.94° ± 3.55°. The nonoperative group had significantly different values, with a medial slope 66.66° ± 9.04 and posterior slope 80.28° ± 3.77. (p=.040 and.0071).

Conclusion:

For medial OCD lesions, the affected knee had a greater medial tibial slope than the unaffected knee. When compared to matched controls, affected knees had a greater medial and posterior slope. In addition, patients who required surgery for the OCD lesion had greater medial and posterior slopes than did patients who did not require surgery. Future studies will be necessary to determine if these differences are clinically significant.
Acute Complications of Pediatric and Adolescent Knee Arthroscopy
Authors: Ashraf Ali , Christophersen Christy Marie , Hunter Lindsay , Dahm Diane Lynn , McIntosh Amy L.
Published: September 2013

Objectives:

Arthroscopic knee procedures are commonly performed in pediatric/adolescent patients. Reported complications following these procedures are low, however, no childhood specific data exists. Therefore, the purpose of this study is to determine the acute complications (within 6 months) of arthroscopic knee procedures in patients aged 17 years or less.

Methods:

This is a retrospective review of patients aged 17 years or less who underwent an arthroscopic knee procedure from 1997 to 2009 at a single institution. Demographic and surgical data was collected, in addition to specific data on intra-operative and post-operative complications. Minor complications included peripheral nerve block failure, regional anesthesia failure requiring conversion to general anesthesia, superficial wound infection/dehiscence, persistent knee effusion requiring aspiration, and sensory nerve dysesthesia. Major complications included death, major medical complication, septic arthritis, wound requiring repeat closure, arthrofibrosis, equipment failure, and revision surgery.

Results:

1015 patients (555 males (54.7%), 460 females (45.3%)) with average age 15.3 (range 4-17) years were analyzed. The average operative time was 133.9 minutes (range 14-520). 467 (46%) underwent ACL reconstruction, 465 (45.8%) underwent synovectomy, treatment of an OCD lesion, meniscal treatment, or lateral release, 52 (5%) had a medial patellofemoral ligament reconstruction +/- tibial tubercle transfer, 17 (1.7%) arthroscopic fixation of a tibial eminence fracture, and 14 (1.4%) other ligament reconstruction. There were 147 (14.5%) total complications recorded. Major complications occurred in 21 (1.4%) of patients and minor complications in 126 (12.4%) of patients. Major complications included: intra-articular instrument breakage in 1(0.098%), septic arthritis in 4 patients (0.394%), 9 wounds requiring repeat closure (0.886%), arthrofibrosis in 5 patients (0.492%), unplanned subsequent surgical procedure in 3 patients (0.002%), and death in 1 patient (0.098%). 2 patients were readmitted to the hospital (1 DIC, 1 a-fib and syncope). There were no pulmonary emboli or DVTs, and no vascular injuries. No patients developed CRPS. Minor complications included:5 patients (0.492%) sensory nerve paresthesias, 10 (0.985%) patients with failed regional anesthetic, 16 (1.57%) patients with post-operative pain pump that required early discontinuation, 18(1.77%) patients with superficial wound infection/irritation, 60 (5.91%) patients with persistent effusion/hemarthrosis requiring arthrocentesis, and 17(1.67%) patients had medical problems that required intervention (asthma exacerbation, urinary retention).

Conclusion:

Major complications following knee arthroscopy in children and adolescents are relatively low 1.4%. Minor complications are more common (12.4%) but did not alter the post-operative course or recovery. DVT, PE, and CRPS did not occur in this patient cohort.
Anatomical Dissection and CT Imaging of the Anterior Cruciate and Medial Collateral Ligaments in Skeletally Immature Cadaver Knees
Authors: Shea Kevin G. , Polousky John , Jacobs John C. , Ganley Theodore J.
Published: September 2013

Objectives:

Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) are increasingly recognized in skeletally immature patients. Although most MCL injuries heal, some may require reconstruction. The purpose of this study was to identify the origin and insertion of the ACL and MCL, and determine the attachment locations in relation to the physes in skeletally immature knees.

Methods:

Seven skeletally immature cadaver knee specimens were dissected. These specimens were divided into two groups: Infants (ages-1, 11, and 11 months), and Children (ages 8, 10, 11, and 11 years). Metallic markers were placed at the midpoint of the femoral origins and tibial insertions of the ACL and MCL. CT scans with 1mm slices were obtained for each specimen and were analyzed using Osirix Imaging Software. The distance from both the ACL and MCL femoral origin midpoints to the distal femoral physis was measured. The distance from the ligaments’ insertion midpoints to the proximal tibial physis was measured.

Results:

The mean distance from the ACL origin midpoint to the femoral physis was 0.63 cm (0.58-0.68 cm) and 0.85 cm (0.75-0.97 cm) distal to the physis for infants and children, respectively. The mean distance from the MCL origin midpoint to the lowest point of the femoral physis was 0.78 cm distal to the physis for one infant. For 2/3 children, this measurement was 0.60 cm distal to the physis, and 0.37 cm proximal to the physis for one child. In three specimens, this measurement could not be taken. The mean distance from ACL insertion midpoint to the proximal tibial physis was 0.39 cm (0.62-1.15 cm) and 1.74 cm (1.46-2.15 cm) proximal to the physis for infants and children, respectively. The mean distance from the MCL insertion midpoint to the tibial physis was 0.76 cm (0-2.28 cm) and 3.52 cm (2.29-4.60 cm) distal to the physis for infants and children, respectively.

Conclusion:

Pediatric cadaver tissue is very difficult to obtain for research, and many anatomic studies in skeletally immature patients are based on MRI sequences. This cadaveric dissection with CT scan clarifies the location of the ACL and MCL with respect to the femoral and tibial physes. This information may be useful to help surgeons avoid physeal injury during ACL/MCL reconstructions in skeletally immature patients.
Peroneal Nerve Injury after Multiligament Knee Injury
Authors: Werner Brian C. , Gwathmey Frank W. , Lyons Matthew L. , Miller Mark D.
Published: September 2013

Objectives:

The incidence of neurologic injury with multi-ligament knee injuries (MLI) ranges from 10% - 40% and most commonly involves the peroneal nerve. Loss of active ankle dorsiflexion and/or eversion with persistent post-traumatic peroneal nerve palsy portends substantial morbidity as patients may require lifetime use of an ankle-foot orthosis (AFO). Neurolysis, nerve grafting, and nerve transfer have limited efficacy in restoring function. For selected patients with footdrop, posterior tibial tendon (PTT) transfer may restore active dorsiflexion and mitigate AFO dependency. The objectives of this study are: 1) to review all MLI over a 12 year period to help clarify the epidemiology of peroneal nerve injuries; and 2) to compare the outcomes of PTT transfer with non-operative management for these injuries.

Methods:

Study Design: Retrospective cohort study. The charts of all patients with MLI over the past 12 years were reviewed. A cohort of MLI patients with peroneal nerve injury (n=18) was compared to the entire cohort of MLI patients (n=215). Patients with peroneal nerve injury managed non-operatively (n=11) were compared to those managed with PTT transfer (n=7). The clinical outcomes in patients who underwent PTT transfer were reviewed. Analysis: Means and ranges were calculated for continuous variables (age, BMI) and compared between cohorts using Student’s t test. Frequencies for categorical variables were compared using chi square tests.

Results:

The peroneal nerve injury cohort had significantly higher BMI, greater prevalence of female gender, higher rate of posterolateral corner (PLC) injury, and lower rate of PCL injury (Table I). Within the peroneal nerve injury cohort, there were no significant demographic differences between patients who underwent non-operative treatment (n=11) and those who had PTT transfer (n=7) (Table II). At an average follow-up of 23.9 months, patients who underwent PTT transfer for peroneal nerve injury demonstrated significant improvement in active ankle dorsiflexion, strength in ankle dorsiflexion and eversion, and elimination of AFO use. (Table III)

Conclusion:

The management of peroneal nerve injury in the setting of multiligament knee injury remains challenging. Understanding the epidemiology of these injuries allows treating surgeons to identify and stratify at-risk patients preoperatively. In appropriately selected patients, posterior tibial tendon transfer is an option to improve ankle function, regain ankle active dorsiflexion and most importantly eliminate the need for a life-long orthosis.
Subpectoral Biceps Tenodesis for Failed Type II SLAP Repair
Authors: Gupta Anil K. , Bruce Benjamin , Klosterman Emma , McCormick Francis , Harris Joshua D. , Romeo Anthony A.
Published: September 2013

Objectives:

Superior Labrum Anterior-Posterior (SLAP) lesions are a common cause of shoulder pain, however, their diagnosis, classification, and treatment remains controversial. The purpose of this study was to evaluate the outcomes of patients undergoing subpectoral biceps tenodesis as a salvage intervention for failed type II SLAP repair. We hypothesized that patients undergoing subpectoral biceps tenodesis for failed type II SLAP tears will demonstrate improved subjective and objective outcomes at a mean two-year follow-up.

Methods:

A retrospective review of prospectively collected data was performed on patients who underwent subpectoral biceps tenodesis for failed type II SLAP repair by a single surgeon between 2008 and 2010. Primary outcome measures included Visual Analog Scale (VAS), American Shoulder and Elbow Score (ASES), and Short Form-12 (SF-12) score. Secondary outcome variables included Simple Shoulder Test (SST) and Single Assessment Numeric Evaluation (SANE) Score. Demographic and intraoperative information was recorded for each patient (Table 1). A paired t-test was performed, with a P-value less than 0.05 considered statistically significant.

Results:

Eleven patients met the study criteria (mean age 40.2, range 22-54). Of these patients, nine completed post-operative surveys (82%) at a mean 26 month follow-up (range 15 to 49 months). Mean VAS scores improved from 4.1 to 2.5 (p=0.03), SST from 5.4 to 9.3 (p=0.005), ASES from 54.5 to 78.0 (p=0.002), and SANE score from 42.5 to 70.4 (p=0.001). SF-12 total improved from 30.5 to 36.1(p=0.06). Furthemore, the improvement in the VAS pain, ASES, and SST scores exceeded the reported minimally clinical important differences (MCID), suggesting that this intervention provided meaningful improvement for the patients (Table 2). There were no failures, perioperative, or postoperative complications, and no patients required additional surgery.

Conclusion:

The findings suggest that patients who undergo subpectoral biceps tenodesis as a salvage procedure for failed type II SLAP repair demonstrate improved results. To our knowledge, the results for this procedure utilized for this indication have not been reported in the literature. Larger scale comparative studies are required to further justify this technique.
Demographic Trends in Arthroscopic and Open Biceps Tenodesis in New York State
Authors: Laible Catherine Noelle , DiBenedetto Michael , Strauss Eric Jason , Jazrawi Laith M.
Published: September 2013

Objectives:

Tenodesis of the long head of the biceps is one of many options to reduce pain caused by proximal long head insertional tendinopathy, tendon instability, or part of a superior labrum anterior-posterior lesion. This technique can be performed either as an open or arthroscopic procedure. The purpose of this study is to compare the relative incidence and demographics of patients who underwent either an arthroscopy or open biceps tenodesis procedure in New York State from 2002-2010.

Methods:

Retrospective review of patients who underwent open or arthroscopic biceps tenodesis surgery were identified from the New York State Statewide Planning and Research Commission (SPARCS) ambulatory surgery database, which includes all outpatient surgeries performed at hospitals, outpatient surgical centers, and rural clinics in New York State. Cases of open and arthroscopic biceps tenodesis were identified by unique Current Procedural Terminology codes (23430, 29828). Data from 2002 to 2010 were available for open procedures and from 2008 to 2010 for arthroscopic procedures. Chi-square test and student’s t-test were used to analyze the data. Variables measured included incidence, age, gender, race, ethnicity, type of operating facility, and primary payor.

Results:

From 2002 to 2010 the incidence of biceps tenodesis rose over 600%. From 2008 to 2010 there were 2672 open biceps tenodesis procedures and 3289 arthroscopic biceps tenodesis procedures performed in New York State. The arthroscopic group contained significantly more women (33%) than the open group (25%, P<.0001). The average age arthroscopic patients was slightly higher (55.33 years) than that of open patients (54.45 years, P<.01). There was a significantly greater proportion of African- American patients in the arthroscopic group. Patients undergoing arthroscopic surgery were more likely to be treated at a hospital as opposed to a free standing clinic. The most common primary payor for open cases was worker’s compensation at 22% of all cases. Of arthroscopic patients, 18% listed worker’s compensation as the primary payor. Medicare patients accounted for 16% of open cases and 19% of arthroscopic patients (P<.001).

Conclusion:

Incidence of biceps tenodesis surgery has increased steadily from 2002 to 2010. There were 23% more arthroscopic procedures performed in 2010 than there were in 2008. Arthroscopic patients are more likely to be older, female, and African American. Arthroscopic biceps tenodeis, which require additional skill and training, were more likely to be performed in a hospital setting.
Glenohumeral Passive Range of Motion and the Correlation to Shoulder Injuries in Professional Baseball Pitchers
Authors: Wilk Kevin E. , Macrina Leonard , Fleisig Glenn S. , Aune Kyle , Porterfield Ron , Harker Paul , Andrews James R.
Published: September 2013

Objectives:

Glenohumeral internal rotation deficit (GIRD) indicates a 20 degree or greater loss of IR on the throwing shoulder compared to the non-throwing shoulder. The purpose of this study was to determine whether GIRD and/or bilateral difference in total rotational motion (TRM) of the glenohumeral joint (external rotation + internal rotation) correlated with shoulder injuries in professional baseball pitchers.

Methods:

This study was conducted over eight competitive seasons (2005-2012). Each year during spring training, the same examiners assessed passive range of motion (PROM) of both the dominant and non-dominant shoulders of professional pitchers using a bubble goniometer. In total, 505 examinations were conducted on 296 pitchers. Glenohumeral joint motion was assessed in supine with the arm at 90 degrees of abduction and in the plane of the scapula for ER and IR. During ER and IR ROM assessment, the scapula was stabilized per methods previously established. Shoulder injuries and days missed due to injury were assessed and recorded by the medical staff of the team.

Results:

Significant differences were noted during side-to-side comparisons (p<0.0001) within subjects. Amongst this cohort, there were 77 shoulder injuries in 52 players accounting for a total of 3131 days missed. GIRD did not correlate to increased risk of shoulder injuries (p=0.8629). Pitchers with a deficit of more than 5 degrees in TRM between shoulders had a 1.9x higher risk of injury (p=0.0290). Players with < 5 more degrees of ER motion in their dominant shoulder at 90 degrees of abduction were 2.2 times as likely to have a shoulder injury (p=0.0112).

Conclusion:

Based on these results, pitchers with bilateral differences in total rotational motion had a significant impact on the risk of shoulder injuries. Loss of ER PROM in the dominant shoulder compared to the non-dominant side appears to contribute to shoulder injury risk as well. Clinicians need to be aware of these findings and plan a program that addresses these issues.
A Prospective Follow-up of Patients Treated Surgically or Non-Surgically for Full-thickness Rotator Cuff Tears
Authors: Gagnier Joel Joseph , Oltean Hanna N. , Bedi Asheesh , Carpenter James E. , Miller Bruce S.
Published: September 2013

Objectives:

The objectives of this project are: (1) to compare the efficacy of surgical versus non-surgical management of full-thickness rotator cuff tears, and (2) to detect variables that predict success within each treatment group.

Methods:

Patients who presented to our care for management of symptomatic full-thickness rotator cuff tears were enrolled in our Shoulder Registry and clinical data were collected prospectively. In addition to baseline demographic information, the following outcome measures were collected at baseline, 6 months, 1 year and annually up to 3 years: Western Ontario Rotator Cuff (WORC) Index, American Shoulder and Elbow Surgeons (ASES) score, Modified Marx Shoulder Activity Level Scale, VR-12, 100-point Single Assessment Numeric Evaluation (SANE) rating, 100-point visual analog scale (VAS) for pain, and a patient satisfaction scale. All patients were allocated treatment as recommended by the attending surgeon. We described all patient demographic characteristics, and performed linear and logistic regression for variables associated with treatment allocation and with treatment effects. We also used Student’ t-tests and Wilcoxon rank-sum tests where appropriate, to explore differences in treatment effects between the groups for all outcome measures at all time points.

Results:

A total of 292 patients were included with 155 allocated to surgery and 137 to non-surgical treatment. Those allocated to surgery were younger (58.6 years vs 65.2 years; P<.0001), less likely to have diabetes (12% vs 21%; P=0.05), more likely to have a known traumatic injury (71% vs 55%; P=0.002), and tended to be worse off on all outcome measures at baseline then the non-surgical group. Both the surgical group and non-surgical group improved on all outcome measures across the follow up period with several variables predicting changes at each time point. Table 1 contains the list of specific variables that predicted improved outcomes separately for both treatment groups. Also, at one year the surgical group improvement was significantly greater than the non-surgical group on all outcome measures. At both two and three years the surgical group showed a significantly greater degree of improvement than the non-surgical group on both the WORC index and the ASES score.

Conclusion:

We found that patients with rotator cuff tears who undergo surgical or nonsurgical treatment tend to improve, with patients allocated to surgery improving to a greater degree across three years of follow-up. In addition, there appear to be important predictors of improved outcomes that may help us to tailor our treatments to individuals with specific characteristics.
Outcome Compartison of Concomitant Arthroscopic SLAP / Anterior Bankart Repair with SLAP /Posterior Bankart Repair
Authors: Henn Ralph Frank , Carroll Kaitlin M. , Gill Thomas J.
Published: September 2013

Objectives:

Combined unstable tears of the superior labrum (SLAP) and either the anterior or posterior labrum are not uncommon. The goal of this study was to directly compare the results of combined anterosuperiorlabral repairs to combined posterosuperiorlabral repairs.

Methods:

This is a retrospective study of 34 shoulders (34 patients) treated by a single surgeon at a mean follow up of 25 months (range 12 to 67). 18 patients underwent both SLAP and anterior Bankart repair (AS group) and 15 patients underwent both SLAP and posterior Bankart repair (PS group). All patients had glenohumeral instability (humeral head could be translated over the glenoid rim) on examination under anesthesia in the direction of the Bankart tear. Patients were evaluated with the ASES shoulder score, Simple Shoulder Test (SST), and visual analog scale for pain (VAS), subjective shoulder value (SSV), Short Form 12 (SF12), and physical examination. The two groups were compared using chi-square and t-tests.

Results:

The mean age in the AS group was 33 years compared to 35 in the PS group (p=0.63). Fifteen patients in each group were men, with 3 women in the AS group and 1 in the PS group (p=0.30). Outcomes in both groups were excellent, with no significant differences between the groups with respect to the ASES, VAS, SSV, SST, SF12 or range of motion at follow-up. Three months postoperatively, the AS group had significantly (p=0.005) less average external rotation (52±16 degrees) compared to the PS group (67.3±5 degrees). 3 shoulders had adverse outcomes in the AS group (1 recurrent anterior instability and 2 required arthroscopic capsular releases) compared to 1 shoulder (revision posterior Bankart) in the PS group (p=0.56).

Conclusion:

The results of combined Bankart and SLAP repairs are excellent. Combined tears were more common in men. The outcomes were similar in both AS and PS groups at 2-year follow-up. Stiffness was more common in the AS group with a transient deficit in average external rotation at 3 months and two patients that required capsular release.
Spectrum of Childhood Intra-articular Shoulder Pathology
Authors: Edmonds Eric W. , Roocroft Joanna Helena , Parikh Shital
Published: September 2013

Objectives:

With increased sports participation and awareness on behalf of the medical community, there appears to be an increase in childhood musculoskeletal injuries. The spectrum of intra-articular shoulder pathology in this skeletally immature population has not been well described. The purpose of this study was to identify the intra-articular injury pattern seen within the childhood shoulder.

Methods:

A retrospective review was performed at two tertiary-care children’s hospitals between 2008 and 2011 of all patients who underwent MR imaging and subsequent shoulder arthroscopy. Exclusion criteria included: girls > 14 years old, and boys > 16 years old. Demographics, MR and arthroscopic findings were recorded. Labral pathology was grouped into zones: Zone I (Bankart lesions) - 3 to 6 o’clock for right shoulder, Zone II (posterior labral lesions - 6 to 11 o’clock, Zone III (SLAP lesions) - 11 to 1 o’clock, and Zone IV (anatomic variants) - 1 to 3 o’clock.

Results:

115 children met criteria with a mean age of 14.4 years (range 8-16 years). There were 24 girls and 91 boys with 45 left and 70 right shoulders. Football and baseball were the most common activities at the time of shoulder injury. Of 112 children with labral pathology, 72 were Zone I with 14 isolated anterior, 56 were Zone II with 15 isolated posterior, 38 were Zone III with 4 isolated superior, and 2 had an isolated Buford complex. Seventy-six of these children had more than one labral zone injured; moreover, 31 (27%) had injuries to more than two zones. Pathology in Zone 1 included: anterior labral periosteum sleeve avulsions (ALPSA), glenolabral articular disruptions (GLAD), soft and bony Bankart lesions. Non-labral intra-articular pathology included 27 children with partial articular supraspinatus tendon avulsions (PASTA), humeral avulsions of the glenohumeral ligament (HAGL), and greater tuberosity fracture.

Conclusion:

The childhood incidence of intra-articular pathology is different than the adult population. Although, a quarter of our cohort had partial rotator cuff tears, there were no complete tears. In contrast to adults, the primary intra-articular pathology (97.4%) was labral tearing; moreover, 24% of those involved only the posterior labrum ± superior labrum. Sixty-eight percent had labral pathology that involved at least 2 zones and treating surgeons should be prepared to find anterior tears of the glenoid labrum that extend beyond the zone of a classic Bankart lesion.