bluuebunny/crossref_metadata_2025 huggingface dataset:
The Influence of Preoperative Full-Thickness Chondral Defects on Outcomes Following Meniscal Allograft Transplantation
Authors: Saltzman Bryan M. , Meyer Maximilian A. , Leroux Timothy Sean , Gitelis Matthew E. , Debot Margaret , Yanke Adam Blair , Cole Brian J.
Published: July 2017

Objectives:

The impact of full-thickness chondral defects (FTD) on outcomes after meniscus allograft transplantation (MAT) remains unknown. The purpose of this study was to determine the impact of FTD on outcomes following MAT.

Methods:

Patients undergoing MAT between 9/1997-3/2013 with minimum two-year follow-up were identified and split into two groups based upon presence or absence of FTD identified intra-operatively: No defect (“ND’, Outerbridge Grade 0/I) or FTD (Outerbridge Grade IV). All FTD were treated with cartilage restoration procedures (microfracture, osteochondral allo/autograft, DeNovo or autologous chondrocyte implantation). Reoperations, failures (revision MAT or conversion to arthroplasty), and patient-reported outcomes (PROs) were reported at six-months, one-year, two-years and final follow-up. Inter-group comparisons were made using unpaired student t-tests.

Results:

A total of 91 patients - 22 with ND and 69 with a FTD were identified and followed for a mean 4.48 and 3.84 years, respectively. There were no significant between-group differences in age, body mass index (BMI), or number of prior surgeries. One complication occurred in the FTD group (1.3%), and no complications in the ND group. There were no significant differences in number of subsequent surgeries or failures. Comparison of the cohorts found no differences in PROs preoperatively. At 6-months postoperative, significantly greater values were reported in the FTD cohort for KOOS-Pain and KOOS-ADL and greater values for the ND cohort for WOMAC-Function and WOMAC-Total. At 1-year postoperative, significantly greater values were reported for the ND cohort for KOOS-Symptoms and KOOS-QOL, but at 2-years postoperative and final follow-up, no further significant differences in any PROs were present. At final follow-up, the ND and FTD cohorts reported significant improvements in the majority of PRO categories, with a greater number of PRO subscales demonstrating significance in the FTD group (Figure 1; Table 1).

Conclusion:

FTD when treated at the time of MAT have no significant influence on outcome following MAT, including PROs, failures or reoperations. Clinicians performing MAT in meniscus deficient patients with full-thickness chondral defects should counsel their patients that if these defects are treated concomitantly with MAT that they can expect similar outcomes to patients without full-thickness chondral defects at long-term follow-up. [Table: see text]
The LM Posterior Root Stabilizes the ACL Deficient Knee
Authors: Moatshe Gilbert , Frank Jonathan M. , Dornan Grant , Brady Alex , Slette Erik , LaPrade Robert F.
Published: July 2017

Objectives:

The menisci have an important role in stabilizing the knee joint. The biomechanical effects of lateral meniscal posterior root tears with or without meniscofemoral ligament (MFL) tears in anterior cruciate ligament (ACL) deficient knees have not been studied in detail. The aim of this study was to determine the biomechanical effects of disruption of the lateral meniscus posterior root attachment in ACL-intact and ACL-deficient knees. It was hypothesized that disruption of the posterior horn lateral meniscal root attachment would cause a significant increase in both anterior tibial translation (ATT) and internal rotation during a simulated pivot shift and also in internal rotation tests in the ACL-deficient knee, both with and without intact meniscofemoral ligaments.

Methods:

Ten paired (n = 20) fresh-frozen cadaveric knees were mounted in a 6 degree-of-freedom robot for testing and divided into two sequential cutting groups. The sectioning order for group 1 was (1) ACL, (2) lateral meniscus posterior root and (3) MFL. The sectioning order for group 2 was (1) lateral meniscus posterior root, (2) ACL, and (3) MFL. For each cutting state, displacements and rotations of the tibia were measured and compared to the intact state following a simulated pivot shift test (5 Nm internal rotation torque combined with a 10 Nm valgus torque) at 0°, 20°, 30°, 60° and 90° of knee flexion; an anterior translation load (88 N) at 0°, 30°, 60° and 90° of knee flexion; and internal and external rotation (5-Nm) at 0°, 30°, 60°, 75° and 90° of knee flexion.

Results:

Cutting the LM root and MFLs significantly increased ATT during a simulated pivot shift test at 20° and 30° when compared to the ACL cut state (p<0.05) (Figure 1). Cutting the LM root in ACL intact knees significantly increased internal rotation by between 0.4° ± 0.4° and 1.3° ± 0.9° (p<0.05), except at 0° (p=0.136). When the ACL + LM root cut state was compared to the ACL cut state, the increase in internal rotation was significant (p<0.05) at higher flexion angles (75° and 90°) but not between 0°- 60°. For an anterior translation load, cutting the LM root in ACL deficient knees significantly increased ATT at 30° (p<0.05).

Conclusion:

The LM posterior root was a significant primary stabilizer of the knee for internal rotation and anterior tibial translation during pivoting activities at lower flexion angles and internal rotation at higher flexion angles. Lateral meniscal posterior root tears should be repaired concurrently with ACL reconstruction. Increased knee instability due to lateral meniscal root deficiency may contribute to increased functional limitations in patients and potentially to ACL reconstruction graft failure.
Lateral Extra-articular Tenodesis Does Not Influence Knee Abduction Moment During Drop Vertical Jump Following ACL Reconstruction
Authors: Getgood Alan M. , Daniluk Michal , Hewison Christopher , Bryant Dianne , Litchfield Robert B. , Willits Kevin , Birmingham Trevor
Published: July 2017

Objectives:

The combination of anterior cruciate ligament (ACL) reconstruction plus lateral extra-articular tenodesis (LET) has shown promising results during preclinical biomechanical and clinical testing at reducing anterolateral rotatory laxity; however, no studies have examined its effectiveness during a dynamic functional task. Therefore, we used the drop vertical jump (DVJ) to compare in vivo biomechanics of ACL reconstructed patients with and without LET from a subset of patients within the Stability randomized clinical study. We hypothesized that there would be a difference in peak knee abduction moment (KAM) between the two treatment groups at six months following surgery.

Methods:

This is a subset of patients taken from one center, within a pragmatic, multicenter prospective randomized clinical trial. Thirty patients were randomized to receive ACL reconstruction alone (n=16) or ACL reconstruction plus LET (n=14). At six months postoperative, all patients performed a drop vertical jump test and knee kinetics and kinematics were measured using three-dimensional motion analysis. Biomechanical variables of interest included peak initial contact and stance values for knee abduction moment and angle, knee flexion moment and angle and knee internal rotation moment and angle. Independent groups t-tests were used to assess kinetic and kinematic differences between the injured limbs of both treatment groups.

Results:

There was no significant difference in peak KAM between those who received ACL reconstruction alone (1.31 %BW×ht) and those who received an ACL reconstruction plus LET (1.14 %BW×ht) (Mean Difference, 0.17; 95% CI, -0.50 to 0.84, p = 0.60). Similarly, there were no differences in peak knee flexion moment or peak knee internal rotation moment between treatment groups (p=0.59 and p=0.37 respectively). There were also no significant differences in knee abduction angle, knee flexion angle or knee internal rotation angle at initial contact (p=0.40, p=0.08, p=0.23 respectively) or peak stance phase (p=0.10, p=0.44, p=0.19 respectively).

Conclusion:

We found no significant biomechanical differences between treatment groups at six months postoperative. However, these are the preliminary results of a larger continuing study and, at this time, no definitive conclusions can be made.
The Latarjet Procedure at the National Football League Scouting Combine: An Imaging and Outcome Analysis
Authors: Provencher Matthew T. , Lebus George , Chahla Jorge , Sanchez George , Ferrari Marcio Balbinotti , Moatshe Gilbert
Published: July 2017

Objectives:

The Latarjet procedure is commonly implemented in the treatment of shoulder instability in the setting of glenoid bone loss, particularly in contact athletes such as American football players; however, little is known regarding the outcomes and failures rates of this procedure in collegiate football players prior to participating in the National Football League (NFL). The purposes of this study were to 1) determine the prevalence, clinical features, and imaging findings of National Collegiate Athletic Association (NCAA) football athletes who presented to the NFL scouting Combine having undergone the Latarjet procedure and 2) to evaluate the impact of this procedure, including imaging findings on these athletes’ performance as they entered the NFL.

Methods:

All NFL football players at the NFL Combine from 2009 to 2016 were reviewed. Inclusion criteria were any player who had a documented Latarjet procedure in the past and participated in medical and performance testing at the NFL Combine. Medical records, imaging, games and position played, and draft position of each player who had undergone a Latarjet procedure was then analyzed. In addition, radiographic features of each players with a Latarjet were evaluated including type of fixation, hardware complications, position of the bone block, degenerative changes, and healing/union/bony resorption were all assessed. NFL performance outcomes (draft position and number of games played and started within first two years) were assessed.

Results:

Of the 2285 players who participated in the NFL combine between 2009 and 2016, there were 13 athletes (0.6%) who had undergone a Latarjet procedure. Six patients had a two-screw fixation of the bone block while 7 had only one screw, with two patients evidencing a broken hardware (one with one screw and one with 2 screws) and two patients with bent screws (one with one screw and one with 2 screws). Screw prominence was observed in 1 patient. Eight of the 13 patients identified underwent computed tomography (CT) scans. All had evidence of bony resorption of the bone block on CT imaging. The majority of these (5) had evidence of minimal resorption (<25%). One had a moderate amount of resorption (<50%) and two others had almost resorption of the bone block.

Conclusion:

Only a small percentage of players at the NFL combine (0.6%) had undergone a Latarjet procedure in the past. Nevertheless, a high number of postoperative complications were observed including broken or bent screws and prominent hardware. Optimal graft positioning was observed in the majority of the patients. However, bone resorption was found in most of them.
Shoulder Injuries in Collegiate Football Athletes: Impact on Draft Status and Professional Performance
Authors: Frangiamore Salvatore Joseph , Mannava Sandeep , Sanchez George , Ferrari Marcio Balbinotti , Frank Rachel M. , Bradley James P. , Provencher Matthew T.
Published: July 2017

Objectives:

Shoulder injuries remain among the most common traumatic injuries in high-level football players. However, there remains a paucity of information available on the impact of shoulder on draft prospect and professional performance. The purpose of this study is to define the epidemiology of shoulder injuries in NFL athletes, and to determine the impact of associated injuries on draft status and performance in the NFL.

Methods:

All NFL-caliber athletes who attended the NFL Scouting Combine between 2009 and 2015 were analyzed for history of shoulder injury. The impact of shoulder injury on NFL draft pick status and NFL performance, including games started, games played, and position-specific performance outcomes, were analyzed, and compared to control Combine athletes, which were defined as athletes with no history of shoulder injury in college, no surgical history, and no history of missing > 2 total games in college.

Results:

A total of 1143/2198 (52%) at the Combine had a history of shoulder injury, including 527 acromioclavicular joint (ACJ) injuries (46%), 90 posterior labrum injuries (8%), 77 anterior labrum injuries (7%), 69 clavicle injuries (6%), 42 rotator cuff injuries (4%), 14 superior labrum anterior to posterior (SLAP) lesions (1%), 14 sternoclavicular joint injuries (1%), and 16 biceps injuries (1%). In addition, 267 athletes (23%) had “complex” injuries, indicating multiple sites about the shoulder, while 207 athletes (18%) had shoulder injuries designated as “other.” Combine athletes with shoulder injuries were more likely to go undrafted compared to controls (34% undrafted, vs. 27.3% for controls), and had a higher undrafted rate with biceps (43.8%), SLAP (42.9%), ACJ (35.9%), ACJ (35.6%), labrum (33%), and complex injuries (35.6%) Similarly, of the drafted athletes, those with shoulder injuries were more likely to have a higher (worse) overall draft pick compared to controls. In general, athletes with shoulder injuries played and started fewer games in their first two seasons in the NFL than controls (played: 23.7±7.7, started 11.1±10.5), with sternoclavicular injuries associated with the lowest numbers of games played (17±8.5) and started (10.3±11.2).

Conclusion:

History of shoulder injury in NFL-caliber players is associated with reduced overall draft rates, higher (worse) overall draft pick, and reduced performance in the NFL compared to control athletes without shoulder injury. Overall, ACJ injuries are the most prevalent of shoulder injuries among NFL-caliber athletes. Additional analysis is warranted to determine the overall impact of specific types of shoulder injuries, as well as shoulder surgery, on position-specific performance and career longevity.
Arthroscopic 360-Degree Capsular Release for Idiopathic Adhesive Capsulitis in the Lateral Decubitus Position
Authors: Romeo Anthony A. , Cvetanovich Gregory L. , Leroux Timothy Sean , Bernardoni Eamon , Saltzman Bryan M. , Verma Nikhil N.
Published: July 2017

Objectives:

Idiopathic glenohumeral adhesive capsulitis impairs patient motion and function. If conservative management fails, arthroscopic capsular release is classically performed in the beach-chair position with incapsule release and manipulation under anesthesia. We report outcomes following arthroscopic 360-degree capsular release in lateral decubitus position followed by limited manipulation to confirm restoration of range of motion.

Methods:

A retrospective case series of patients undergoing arthroscopic capsular release in the lateral decubitus position for idiopathic adhesive capsulitis with minimum 2-year follow-up was conducted. Patient demographics, preoperative range of motion (ROM), postoperative ROM, and postoperative outcome scores were recorded. Complications and reoperations were recorded. Paired t-tests were used to compare preoperative and postoperative ROM, with p<0.05.

Results:

Overall, 43 patients were identified, of which 10 were excluded due to posttraumatic etiology. Of the remaining 33 patients, 27/33 (81.8%) completed a minimum follow-up of 2-years. The mean age was 54.8+/-7.4 years and 73% female, with duration of symptoms 16.2+/-21.0 months (range 2 to 125). Hypothyroidism was present in 6% and diabetes present in 33%. Pre-operatively, patients had 1.8+/-1.1 preoperative corticosteroid injections (range 0-5). Active forward flexion improved from 115.0+/-21.9 degrees to 156.2+/-16.1 degrees at final follow-up (mean difference 41.2, 95% confidence interval [33.7,48.7], p<0.001). Active external rotation with the arm adducted improved from 28.1+/-16.3 degrees preoperatively to 56.8+/-15.7 degrees at final follow-up (mean difference 27.7, 95% confidence interval [19.1,36.3], p<0.001). Significant range of motion improvements were seen even as early as 2-weeks postoperative (Figure). Overall, final outcomes were excellent, including VAS pain of 0.2+/-0.5, SANE 96.3+/-4.9, SST 11.3+/-1.2, and ASES 97.0+/-4.7. There were no revision surgeries and no complications.

Conclusion:

Arthroscopic 360-degree capsular release in the lateral decubitus position for idiopathic adhesive capsulitis results in a significant early and lasting improvement in range of motion, excellent functional outcomes, and low revision and complication rates.
Arthroscopic Superior Capsule Reconstruction (ASCR) vs Latissimus Dorsi Transfer (LDT): A Comparison of Early Clinical Outcomes
Authors: Pogorzelski Jonas , Horan Marilee P. , Fritz Erik M. , Katthagen Jan Christoph , Godin Jonathan Alexander , Millett Peter J.
Published: July 2017

Objectives:

Arthroscopic superior capsule reconstruction (ASCR) has been introduced as an alternative to latissimus dorsi transfer (LDT) for the treatment of irreparable rotator cuff tears in young patients. The hypothesis of this study is that preliminary clinical outcomes for SCR patients will not significantly differ from those of LDT patients for irreparable and massive rotator cuff tears.

Methods:

Patients who underwent either a LDT or an ASCR and were a minimum of 6 months (mean, 12 months) out from surgery were included. In the SCR technique, a 3-mm acellular human dermal allograft was customized to the exact size of the defect. Surgical, objective, and demographic data were prospectively collected and retrospectively reviewed. Patient-reported outcome (PRO) measures included ASES, SANE, QuickDASH, SF-12 and satisfaction scores. Acromiohumeral distance (AHD) was measured and Hamada classification applied. Patients progressing to reverse shoulder arthroplasty (rTSA) or patients with a graft disruption were considered failures.

Results:

34 patients (13 women, 21 men) with a mean age of 52±7.4 years were included in this study. 16 patients underwent SCR reconstruction while 18 patients underwent LDT. Compared to the SCR group, the LDT group was significantly younger (49 years vs. 56 years; p=.006) and had a higher percentage of Workman’s Compensation cases (61% vs. 6%; p=.001). Failure of the repair occurred in one patient in the ASCR group (6.2%), who suffered a graft tear seen on MRI at 141 days postoperatively, and two patients (11%) in the LDT group, both of whom progressed to rTSA. Two additional patients (11%) in the LDT group had subsequent surgery around one-year postoperatively - an arthroscopic cuff repair and hardware removal. In those who did not fail, pain significantly decreased postoperatively in both groups (p<0.05). Only patients who underwent ASCR had a statistically significant functional improvement (p=0.002 vs. p=0.161). Mean change in abduction and flexion were -7.3° and 0.6°, respectively, in the LDT group, compared to 56.0° and 21.7°, respectively, in the ASCR group. At final follow-up, satisfaction was a median 8/10 points in both groups.

Conclusion:

Patients who underwent ASCR had significantly improved clinical scores and improved range of motion compared to patients who underwent LDT, but longer follow-up is needed.
Electromyographic and Motion Capture Analysis of the Elbow and Forearm in the Overhead Football Throw
Authors: Smith Jarrod , Winnier Scott , Douglas Lonnie , Ostrander Roger V. , Anz Adam William , Andrews James R.
Published: July 2017

Objectives:

Muscle activation patterns and the kinetics of overhead throwing have been well described in the baseball athlete but not in the football athlete. Injury patterns vary between these two populations. The purpose of this controlled laboratory study was to describe the muscle activation patterns of the elbow and forearm during the overhead football throw. A better understanding of muscle activation patterns and kinetics will help clinicians understand the difference in injury between these two populations, with an objective of preventing injury in both groups. The hypothesis was that the unique grip and obligatory pronation upon ball release will cause the elbow and forearm muscles to have a unique activation pattern during the overhead football throw.

Methods:

IRB approval was obtained. Electromyographic (EMG) and motion capture data was collected on eight male quarterbacks. An EMG direct transmission system measuring at 1200 Hz with 9 surface electrodes was used to collect EMG data, with signals normalized to maximal voluntary contraction values for each subject. EMG sensors were placed on the biceps, triceps, brachialis, brachioradialis, anconeus, extensor digitorum communis, flexor digitorum superficialis, pronator teres, and pronator quadratus. A 13 camera motion capture system measuring at 240 Hz with a full body marker set of 39 retro-reflective 9mm markers was used to capture motion data. The throwing motion was divided into four event segments: early cocking, late cocking, acceleration, and follow through.

Results:

All athletes had NCAA experience and were aged 18-30 years old. The anconeus (26.9%, 36.3%, 57.6%, and 105.8% MVCs), extensor digitorum communis (22.7%, 28.0%, 31.0%, and 42.8% MVCs), and flexor digitorum superficialis (19.4%, 39.3%, 22.3%, and 104.7% MVCs) had high levels of activity throughout all phases of the football throw. The brachioradialis (56.8%MVC) and anconeus (57.6%MVC) were the most active muscles during the acceleration phase. The pronator teres (78.4%MVC), pronator quadratus (90.9%MVC), and flexor digitorum superficialis (104.7% MVCs) have very high levels of activation during the follow through phase.

Conclusion:

High levels of activity of the anconeus suggest that it functions as a dynamic stabilizer during all phases of the throwing motion. High levels of activity of the extensor digitorum communis and flexor digitorum superficialis suggest that they are important for grip. The pronator teres and pronator quadratus are important at ball release to produce a spiral motion of the football. High activity of the medial sided musculature may impart dynamic stability to the elbow. These findings may explain why quarterbacks have a lower rate of UCL injury and a higher return to play without surgery.
A Novel Non-operative Protocol for the Acute Management of In-season Acromioclavicular Separations
Authors: Heard Wendell M.R. , O’Brien Michael John , Taylor Daniel , Massey Andrew , STEWART GREGORY W. , Savoie Felix H.
Published: July 2017

Objectives:

Traditional treatment of acromioclavicular (AC) sprains has been a sling with rest and rehabilitation. We have developed a protocol that uses a static scapular retraction brace (Figure 1) to reduce the displaced upper extremity back to the clavicle. We hypothesized that the brace in combination with oral and injected steroid and a rehabilitation protocol that emphasizes postural restoration, facilitates a more anatomic reduction of the AC joint that quickly eliminates discomfort, allows for more anatomic healing and a rapid return to normal activities in type 1, 2, and 3 AC separations.

Methods:

Data was prospectively collected and retrospectively reviewed on all collegiate football AC separations at an NCAA division I university. Data included treatment, the number of practices missed, the number of games missed, and time to full return to play. Inclusion criteria were all consecutive in-season Type I-III AC separations sustained during football activities that requiring medical attention. Exclusion criteria include fractures, glenohumeral dislocations, rotator cuff tears, nerve injuries, other concomitant shoulder injuries, and injuries sustained during the last game of the season. The end points measured were number of games missed and time to full return to play.

Results:

During seven football seasons (2008-2014), 56 acromioclavicular separations occurred. Fifty-two (52) AC separations are included in the current study. Full return to play ranged from 0-31 days, with an average 5.7 days to full return to play. On average, athletes missed 0.25 games (range 0-3 games). Quarterbacks missed the most time, and an injury to the quarterback’s throwing shoulder required the most time to return to full play (mean 26 days and 3 games). The return to play in our group of athletes was more rapid and than that reported in the literature.

Conclusion:

The unique aspect of this protocol is anatomic reduction of the AC joint with the use of a static, three-point brace to pull and rotate the entire forequarter back to the clavicle. It is common in fracture reduction to reduce the distal piece to the proximal segment to achieve anatomic restoration. This principle attempts to do the same. A secondary effect of the static reduction is the diminution of rotator cuff pain due to opening the subacromial space by scapular retraction, thus decreasing pressure on the contused supraspinatus tendon and allowing more rapid resolution of the inflammation. This study represents a specific non-operative protocol for the in-season management of AC injuries to quickly and safely return athletes to play.
Clinical Utility of Continuous Radial MRI Acquisition at 3T in Patellofemoral Kinematic Assessment
Authors: Kaplan Daniel James , Campbell Kirk A. , Alaia Michael Joseph , Strauss Eric Jason , Jazrawi Laith M. , Chang Gregory , Burke Christopher
Published: July 2017

Objectives:

Continuous gradient-echo (GRE) acquisition or “dynamic magnetic resonance imaging”, allows for high-speed examination of pathologies based on joint motion. We sought to assess the efficacy of a radial GRE sequence with in the characterization of patellofemoral maltracking.

Methods:

Patients with suspected patellofemoral maltracking and asymptomatic volunteers were scanned using GRE (Siemens LiveView WIP; Malvern, PA, USA) at 3T in the axial plane at the patella level through a range of flexion-extension (0-30°). The mean time to perform the dynamic component ranged from 3-7 mins. Lateral maltracking (amount patella moved laterally through knee ranging) was measured. Patella lateralization was categorized as normal (≤ 2mm), mild (2-5mm), moderate (5-10mm), or severe (>10mm). Tibial tuberosity:trochlear groove (TT:TG) distance, trochlea depth, Insall-Salvati ratio, and patellofemoral cartilage quality (according to the modified Outerbridge grading system) were also assessed.

Results:

Eighteen symptomatic (6 men; 12 women, age range 14-51 years) and 10 asymptomatic subjects (6 men; 4 women, age range 25-68 years) were included. Two symptomatic patients underwent bilateral examinations. Lateralization in the symptomatic group was normal (n=10), mild (n=2), moderate (n=5) and severe (n=3). There was no abnormal maltracking in the volunteer group. Lateral tracking significantly correlated with TT:TG distance (F=38.0; p<.0001), trochlea depth (F=5.8; p=.023), Insall-Salvati ratio (F=4.642; p=.04) and Outerbridge Patella score (F=6.6; p=.016). Lateral tracking did not correlate with Outerbridge Trochlear score.

Conclusion:

Lateral tracking measured on GRE was found to significantly correlate with current measures of patellar instability including, TT:TG, trochlea depth, and the Insall-Salvati ratio. GRE is a rapid and easily performed addition to the standard protocol for kinematic patellofemoral motion and can add dynamic information on patellofemoral tracking. This may be help determine if an isolated MPFL or an MPFL reconstruction and tibial tubercle osteotomy is needed to treat patella instability.
Combined Reconstruction of the Medial Patellofemoral Ligament (MPFL) and Medial Quadriceps Tendon - Femoral Ligament (MQTFL) for Patellar Instability in Children and Adolescents: Surgical Technique and Outcomes
Authors: Redler Lauren H. , Spang Robert C. , Tepolt Frances , Davis Eric A. , Kocher Mininder S.
Published: July 2017

Objectives:

A variety of surgical options exist to treat the challenging problem of recurrent patellar instability in skeletally immature patients. The current study describes a combined reconstruction technique involving both the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon - femoral ligament (MQTFL) and reports patient outcomes of a single-surgeon series.

Methods:

All patients studied underwent combined MPFL and MQTFL reconstruction for patellar instability. Demographic data, pre- and post-operative radiographic data were collected. Reconstruction was performed using gracilis allograft. The graft midportion was fixed to the MPFL insertion on the femur via suture anchor. One arm of the graft (MPFL) was tunneled under medial retinaculum to the medial border of the patella and fixed there via suture anchor, while the other (MQTFL) arm was tunneled, delivered under the VMO and brought through the medial distal quadriceps tendon and sutured in place. Subjective outcome scores (Kujala, Pedi-IKDC, Lysholm) were collected via questionnaires mailed to patients more than one year from surgery.

Results:

A total of 25 patients (27 knees), including 15 females and 10 males with an average age of 15.0 ± 2.2 years (range 10.3-18.9), underwent combined MPFL and MQTFL reconstruction. 6/25 (24%) had undergone prior ipsilateral patellofemoral surgery for instability. 5/25 (20%) underwent simultaneous guided growth via hemiepiphysiodesis for valgus deformity at the time of combined reconstruction. Preoperative imaging showed a mean TT-TG of 17.2 ± 3.8, Caton-Deschamps Index (CDI) of 1.13 ± 0.16, and trochlear dysplasia Dejour A/B (22/26 (85%)) or Dejour C/D (4/26 (15%)). A total of 18 patients (19 knees, 72%) returned outcomes questionnaires at a mean 2.0 ± 0.5 years after surgery. Mean Kujala, Pedi-IKDC, and Lysholm scores were 85.9 ± 13.9, 81.5 ± 15.2, and 84.3 ± 13.5, respectively. 2/25 patients (8%) later required a revision procedure (tibial tubercle osteotomy) for recurrent patellar instability, and another patient reported persistent instability not requiring revision. 10/13 patients (77%) were able to return to sports at a mean of 5.8 +/- 3.9 months (range 2-15).

Conclusion:

The current study describes a novel anatomically-validated surgical technique involving the simultaneous reconstruction of both the MPFL and MQTFL in a pediatric patient population. Follow-up data presented demonstrates overall positive results in treating this challenging problem in a young patient population.
Comparison of Scapular Kinematics and Range of Motion Between Normal and Post-operative Shoulders Following Subpectoral Biceps Tenodesis
Authors: Cairns Mark Andrew , Helms Jonathan R. , Hibberd Elizabeth , Myers Joseph , Kamath Ganesh V. , Spang Jeffrey T. , Creighton Robert Alexander
Published: July 2017

Objectives:

Though many surgeons advocate biceps tenodesis for treatment of intra-articular biceps pathology, little is known about the biomechanical effects this may have on the glenohumeral joint. The purpose of the present study is to describe in detail the effect of biceps tenodesis on shoulder muscle strength, range of motion, and scapular motion. We hypothesized that post-surgical shoulders would not show significant differences in range of motion, strength, and kinematics when compared to the uninvolved shoulder.

Methods:

22 patients underwent a subpectoral biceps tenodesis and were evaluated at least 6 months following the procedure. We evaluated range of motion, strength, and scapular kinematics. Measures included glenohumeral abduction, internal and external rotation, elbow flexion and extension, internal and external rotation strength, and scapular kinematics. Subjects also completed the DASH questionnaire.

Results:

The average DASH score was 5.3 +/- 6.3 following surgery. The post-surgical shoulder showed a significant 8.3 degree decrease (p = 0.003) in glenohumeral abduction external rotation compared to the uninvolved shoulder. However, there were no significant differences in other measurements of glenohumeral motion or strength. Kinematic data revealed significantly increased scapular internal rotation (p = 0.02) and anterior tipping (p = 0.019) while reaching for the contralateral shoulder.

Conclusion:

The majority of outcome measures were equivalent when comparing the post-surgical and uninvolved shoulder function and biomechanics. Significant findings include a loss of glenohumeral abduction external rotation after surgery as well as anterior scapular tipping and rotation while reaching for the contralateral shoulder. Overall, subjects expressed minimal disability following surgery, as evidenced by their DASH scores. Nonetheless, we recommend a vigilant focus on regaining external rotation following open subpectoral biceps tenodesis in an attempt to limit or prevent loss of shoulder motion.
Elbow Arthroscopy Complications in Pediatrics and Adults
Authors: Intravia Jessica , Mirzayan Raffy
Published: July 2017

Objectives:

The risks of elbow arthroscopy, have been previously described by Kelly et al (2001) with 473 consecutive elbow arthroscopies from 1980-1998. Since that time, the field of elbow arthroscopy has drastically changed and the complexity of procedures increased. Another report by Nelson et al in 2014, shared the results of 417 consecutive elbow arthroscopy performed over a thirteen year period by three orthopedic surgeons who have completed specialized subspecialty training in shoulder and elbow surgery. While this data set highlights the complication rate of three highly trained surgeons, it may fail to capture the true rate of complications observed with elbow arthroscopy in a community practice. We reviewed the complications of elbow arthroscopy in a community practice with multiple surgeons. In addition, we analyzed the difference in complication rate between adult and pediatric patients.

Methods:

After institutional IRB approval, the database of an integrated healthcare including 13 medical centers with a captured population was reviewed for all elbow arthroscopies that occurred in the eight year period between 2006 and 2014. A chart review was performed on over 349 consecutive elbow arthroscopies in 322 patients performed by 28 board certified orthopedic surgeons. The average length of follow up was 361 days (0-2739 days). Major complications included deep infection, compartment syndrome, vascular injury, re-hospitalization, deep vein thrombosis, and pulmonary embolus. Minor complications include superficial infection, heterotopic ossification and transient nerve palsies.

Results:

Of the 349 procedures, the most common complications include heterotopic ossification (eleven patients), transient nerve palsies (twenty six patients), and loss of range of motion (sixty six patients). Loss of range of motion was defined as greater than 10 degrees loss of flexion/extension arc from preoperative visit to final followup. There were twenty six transient nerve palsies (fourteen ulnar, six radial, three median, three medial antebrachial cutaneous). There was one deep infection and eight superficial infections. Forty six patients required reoperation. No patients had vascular injury, compartment syndrome, deep vein thrombosis, or pulmonary embolism. One patient required re-hospitalization for a deep infection post operatively.

Conclusion:

Elbow arthroscopy remains a safe procedure with a 7.4% risk of nerve palsy, with the ulnar nerve being the most frequently nerve injured. These results are comparable to previously published studies. [Table: see text][Table: see text][Table: see text]
Augmentationof a Distal Biceps Repair with an Acellular DermalGraft Restores Native Biomechanical Properties in a Tendon-Deficient Model
Authors: Sethi Paul M. , Conroy Christine , Macken Craig , Franco William Grant , Wei David , Mirzayan Raffy , Pauzenberger Leo , Dyrna Felix , Obopilwe Elifho , Mazzocca Augustus D.
Published: July 2017

Objectives:

The majority of distal biceps tendon injuries can be repaired primarily. In contrast, chronic tears with severe tendon substance deficiency and retraction often require tendon-graft augmentation. In cases with extensive partial tears of the distal biceps, human dermal allograft may be used as an alternative to restore tendon thickness and biomechanical integrity. The objective of this study was to investigate if dermal graft augmentation of an attritionally thinned distal biceps repair improved load to failure and gap formation compared with a non-augmented repair in this same tendon deficient model.

Methods:

18 matched specimens were organized into one of four groups - native tendon, native tendon with dermal graft augmentation, attritional defect tendon, and attritional tendon with graft. To mimic a chronic attritional biceps lesion, a defect was created leaving 30% of the tendon width intact. The repair technique in all groups consisted of a cortical button and interference screw fixation. All specimens underwent cyclical loading for 3000 cycles and were then tested to failure; gap formation and peak load at failure were documented.

Results:

Mean load to failure (320.9N vs. 343.8N, p=0.38) and gap formation (1.6mm vs.1.8mm, p=0.38) did not differ between the native tendon groups with and without graft augmentation. Stiffness for the repairs with the graft was 22.3 N/mm vs.19.6 N/mm (P=0.16). In the tendon deficient model, mean load to failure was significantly improved by graft augmentation (282.1N vs. 199.7N, p=0.004), whereas mean gap formation was significantly reduced (1.2mm vs. 2.7mm, p=0.04). Mean stiffness for the repairs with the graft was 11.8 N/mm vs. 7.7 N/mm (P=0.04).

Conclusion:

In a tendon deficient distal biceps rupture model, acellular dermal allograft augmentation restored the native tendon’s biomechanical properties. The grafted tissue deficient model demonstrated no significant differences in load to failure and gap formation compared to intact tendon. As expected, dermal augmentation of the attritional tendon repair increased the load to failure and stiffness, as well as decreased displacement compared to an un-grafted tissue deficient model. Intact native tendon showed no statistical difference or negative biomechanical consequences of dermal augmentation.
Concomitant Lumbar Spine Pathology in Patients Undergoing Hip Arthroscopy: A Matched Cohort Analysis
Authors: Mahure Siddharth Ashok , Ryan Michael K. , Buckland Aaron , Hamula Mathew , Begly John , Capogna Brian , Looze Chris , Chenard Kristofer E. , Wolfson Theodore , Youm Thomas
Published: July 2017

Objectives:

Hip arthroscopy for femoroacetabular impingement (FAI) and related hip pathology is increasing in volume. Variable presentations of hip pain often lead to confusion with lumbar spine pathology however. We sought to define the relationship between the lumbar spine and the hip joint. Our hypothesis is that patients with concurrent lumbar spine pathology will experience inferior outcomes after hip arthroscopy when compared to patients without lumbar spine pathology.

Methods:

Prospectively-collected data from a single-surgeon database from 2010 to 2014 was used to identify patients who had undergone hip arthroscopy and had documented concurrent lumbar spine pathology. Patients with spine pathology were matched by age, gender, and BMI in a 3:1 fashion to patients without spine pathology. Baseline pre-operative modified Harris Hip Scores (mHHS) were compared to scores at two-year follow-up. “Poor outcome” of initial hip arthroscopy was defined as any combination of: requiring a revision procedure, conversion to THA, or mHHS below 70.

Results:

167 patients met inclusion criteria: 72.5% were “normal” while 27.5% had spine pathology. Baseline demographics were appropriately matched between cohorts (Table I). Preoperative and two-year mHHS scores were significantly different between cohorts (Figure 1). Both cohorts demonstrated significant within-group improvement at two-year follow-up, however normal patients had greater improvements than those with spine pathology (34.0 vs 31.76, p<0.001). Overall revision/THA conversion rate for entire cohort was 14.97%, with nearly twice as many spine co-pathology patients requiring additional surgery than those in the normal cohort (23.91% vs 11.57%, p=0.045). Patients with spine pathology were significantly more likely to have “poor outcomes” than those without spine pathology (36.96% vs 21.49%, p=0.048).

Conclusion:

Our results demonstrate that patients undergoing hip arthroscopy with concomitant lumbar spine pathology demonstrate significantly lower total improvement, significantly higher revision/THA conversion rates and significantly higher rates of suboptimal outcomes after hip arthroscopy than patients without spine pathology. [Table: see text][Figure: see text]
Bone Age Assessment Utilizing Knee MRI
Authors: Pennock Andrew T. , Bomar James D.
Published: July 2017

Objectives:

In managing pediatric knee conditions including osteochondritis dissecans, patella instability, and ACL tears, accurate bone age assessment is critical for diagnostic, prognostic, and treatment purposes. Knee MRIs are almost ubiquitously ordered for these conditions. The purpose of this study was to create an atlas of knee MRIs spanning the pediatric and adolescent years that would enable an accurate skeletal age to be assessed and forgo the need for a left hand radiograph.

Methods:

A retrospective analysis was performed on knee MRIs that were obtained for pain or trauma between 2007 and 2015. Patients with radiographic evidence of tumors, infections, skeletal dysplasia, or systemic processes affecting the physes were excluded. In creating the atlas, the assessment of 20 to 25 MRIs was performed for each age group and each gender. Radiographic features specific to the patella, tibia, fibula, and femur were documented for their presence or absence. From this data, age and gender “standards” were created. A separate cohort of MRIs with 10 patients in each age group and gender was then used to validate the reliability and reproducibility of the atlas. Pearson correlation, intraclass correlation coefficient, and basic descriptive statistics were performed using SPSS (version 12; SPSS, Chicago, Illinois).

Results:

In the creation of the atlas, a total of 846 MRIs were reviewed including 413 females and 433 males. The gender distribution and age at presentation of key radiographic features are shown in Table 1. The patella, tibia, fibula, and femur were noted to undergo a consistent and reproducible sequence of skeletal maturation and ossification. The patella provided the best age assessment in early childhood. Features specific to tibia particularly ossification of the tibial spines and the tibial tubercle are of particular importance between the ages of 6 and 12 years. MRI features of the fibula and femur, particularly ossification of the fibular styloid, and closure of both physes, serve a more important role with age assessment later in skeletal maturity. A separate cohort of 323 MRIs (156 female and 167 males) was utilized to subsequently validate the atlas showing a strong correlation between chronologic age and bone age and excellent inter-observer and intra-observer reliability. (Figure 1)

Conclusion:

The predictable ossification and maturation pattern of the patella, tibia, fibula, and femur, enable accurate bone age calculations to be determined from knee MRIs. When treating conditions about the knee that require an MRI, obtaining an additional left hand radiograph for bone age is unnecessary. Using information available on knee MRIs can avoid additional radiation exposure, impart cost savings, and lead to more clinic efficiency. [Figure: see text]
Distal Femoral Morphology is Altered in Skeletally Immature Anterior Cruciate Ligament (ACL)Injured Knees
Authors: Beck Jennifer J. , Ebramzadeh Edward , Lang Pamela J.
Published: July 2017

Objectives:

With an increased incidence of anterior cruciate ligament (ACL) injuries and high rates of re-injury among skeletally immature individuals, investigators have attempted to identify factors that may help risk stratify patients and provide families with prognostic data concerning the risk of re-injury. Osseous morphology of the tibia as described by posterior tibial slope has received attention as a possible risk factor for ACL injury. The purpose of this study is to describe distal femoral morphology in skeletally immature, ACL-injured patients and compare that to age-matched, uninjured individuals. The authors hypothesize that the distal femoral morphology in ACL injured knees differs significantly from that of age-matched normal knees.

Methods:

A retrospective radiographic review of 58 skeletally immature patients treated at a single institution was conducted. Patients were grouped by age with Group A =>12 years and Group B =13+ years. The Blumensaat Epiphyseal Containment of the Knee (BECK) Angle, which assesses the flexion of Blumensaat’s line relative to the distal femoral physis, was measured on the involved knee for each patient on standard lateral knee radiographs. Posterior tibial slope was also measured on lateral radiographs. (Figure 1) Roof angle and posterior tibial slope of the lateral plateau were measured on sagittal T1 magnetic resonance imaging sequences of the involved knee. Paired T-tests compared distal femoral morphology in ACL injured knees to the morphology of uninjured knees.

Results:

Patients in Group A had a significantly decreased mean BECK Angle compared to Group B patients (48° ± 1.87° vs 53.4° ± 6.69°; p=0.045). When comparing Group B to age-matched patients without ACL injuries, there was a significant increase in BECK Angle values found in those with ACL injuries. (53.4° ± 6.69° compared to 48.8° ± 5.9°; p=0.009). Group A patients also tended to have higher BECK Angles compared to their uninjured counterparts, though this did not reach statistical significance (48° ± 1.87° compared to 45.8° ± 5.3°; p=0.38). Conversely, Notch Roof Angle showed significantly increased values in Group A compared to Group B (44 ± 1.581° vs. 41.85° ± 6.347°; p=0.01). Females with ACL injuries showed significantly higher BECK Angle measurements compared to males across both groups (54.56° ± 6.599° vs. 50.84° ± 6.074°; p=0.002). Posterior tibial slope of the lateral plateau on MRI showed a significantly decreased mean value in females compared to males (5.57° ± 3.532° vs 6° ± 3.536°; p=0.051).

Conclusion:

Distal femoral morphology appears to change with age and differ between females and males. Skeletally immature individuals, who have sustained an ACL injury, have significantly different morphology of the distal femur when compared to age-matched patients without ACL injuries. When risk stratifying patients for first time or repeat ACL injury, assessment of the distal femoral BECK Angle can add valuable information.