bluuebunny/crossref_metadata_2025 huggingface dataset:
The Effects of Ulnar Collateral Reconstruction on Major League Pitching Performance
Authors: Keller Robert A. , Steffes Matt , Zhuo David , Bey Michael J. , Moutzouros Vasilios
Published: August 2014

Objectives:

A tremendous stress is placed on the elbow while pitching a baseball. Due to these stresses, Major League Baseball (MLB) pitchers are at increased risk for Ulnar Collateral Ligament (UCL) injuries. Previous studies have been limited in sample size, but have shown most players return to previous uninjured statistical levels after undergoing UCL reconstruction. We sought the largest cohort of MLB pitchers who have undergone UCL reconstruction and hypothesized that MLB pitchers do not return to their pre-injury statistical level after undergoing UCL reconstruction.

Methods:

The statistics for 168 major league pitchers, who threw at least one season at the Major League level and subsequently underwent UCL reconstruction, were reviewed. Statistical data including earned run average (ERA), walks and hits per innings pitched (WHIP), win percentage, innings pitched, and salary were compared for the 3 years before and 3 years after undergoing UCL reconstruction. This data was compared to 178 age matched controlled MLB pitchers. All data was analyzed to determine the effects of UCL injury/reconstruction on pitching performance. Risk factors for reconstruction were analyzed using a multivariable generalized estimating equation (GEE) model

Results:

Of the pitchers undergoing UCL reconstruction surgery 87% returned to the Major League Level. Of the pitchers that returned, they had a statistically significant decline in their ERA (P=0.001), WHIP (P=0.011), Innings Pitched (0.026), compared to pre-reconstruction performance. Reconstructed pitchers had a statistically significant decline in their pitching statistical performance in the season before their surgery (ERA p=0.014, WHIP p=0.036, Innings pitched p<0.001, Win Percentage p=0.004). Approximately 60% of pitchers requiring UCL reconstruction had surgery with in the first 5 years of being in the Major Leagues. Compared to age matched controls, the reconstructed pitchers had statistically more major league experience at the same age suggesting that arm stress from earlier Major League experience contributed to injury. This was validated by a multivariable GEE model that examined risk factors showing an increase in MLB experience being a risk factor for requiring surgery (p<0.001).

Conclusion:

This is the largest cohort of MLB pitchers, to date, that have undergone UCL reconstruction. Its results suggest that UCL reconstructive surgery does a tremendous job in allowing players to return to their same level of sport. This study is the first to describe a decline in pitching performance after undergoing reconstruction. It also found that there is a statistically significant decline in pitching performance the year before reconstructive surgery and this decline was found to be a risk factor for requiring surgery. We also found that there is an increased risk of players requiring surgery if they enter the Major Leagues at a younger age.
MRI Evaluation of the Anterolateral Ligament of the Knee In The Setting of ACL Rupture
Authors: Wodicka Ross , Jose Jean , Baraga Michael G. , Kaplan Lee D. , Lesniak Bryson P.
Published: August 2014

Objectives:

The anterolateral ligament (ALL) of the knee was recently described in the literature. It was hypothesized to help control internal tibial rotation and affect the pivot shift phenomenon. The purpose of this study was to identify the normal appearance of the ALL on magnetic resonance imaging (MRI) and to examine its role in stability of the knee.

Methods:

A retrospective chart review was performed and 50 patients from a single surgeon’s practice with full thickness anterior cruciate ligament tears over a 2 year period were selected at random. Operative reports detailing the pivot shift examination under anesthesia were documented. Preoperative MRIs were reviewed by a fellowship trained musculoskeletal radiologist. Axial, sagittal, and coronal cuts were used to identify the presence and degree of injury to the ALL (Grade 0-3). The popliteus tendon, lateral collateral ligament, biceps femoris tendon, and iliotibial band were analyzed and graded 0-3. The presence or absence of a Segond fracture was noted.

Results:

The ALL was identified in 100% of the anterior cruciate ligament deficient knees evaluated. In 27 knees, there was no MRI evidence of ALL injury (Grade 0). A grade 1 injury was noted in 18 knees. A grade 2 injury was noted in 2 knees. A grade 3 injury was observed in only 1 knee. This was the same knee in which the single Segond fracture among the group was noted. Eighty four percent (42/50) of knees showed a positive pivot shift on examination under anesthesia. A positive pivot shift was noted in 37 patients who had no (Grade 0) or mild (Grade 1) ALL injury. Thirteen MRIs showed evidence of injury to the posterolateral corner structures, with 92% (12/13) consisting of mild (Grade 1) injuries.

Conclusion:

The anterolateral ligament of the knee is readily identifiable on MRI. Its structural integrity was maintained in the overwhelming majority of knees with a complete tear of the ACL, both with and without the presence of rotatory instability on examination. We found no correlation between degree of injury to the ALL and degree of instability. The only complete rupture of the ligament was in the setting of complete rupture of the IT band, which supports its identity as an extension of the IT band. Therefore, we propose that the ALL in itself plays a minimal if any role in stability of the knee. Further biomechanical studies are needed to confirm this.
Autograft vs Allograft ACL Reconstructions: A Prospective, Randomized Clinical Study with Minimum 10 Year Follow-up
Authors: Bottoni Craig R. , Smith Eric L. , Raybin Sarah G. , Shaha James S. , Shaha Steven H. , Tokish John M. , Rowles Douglas J.
Published: August 2014

Objectives:

To evaluate the long-term results of primary Anterior Cruciate Ligament (ACL) reconstructions using either allograft or autograft.

Methods:

From June 2002 to August 2003, patients with a symptomatic ACL deficient knee were randomized to either hamstring autograft (AUTO) or tibialis posterior allograft (ALLO). All allografts were from a single tissue bank, aseptically processed and fresh frozen without terminal irradiation. Graft fixation was identical in all knees. All patients followed the same post-operative rehabilitation protocol, blinded to the therapists. Preoperative and postoperative assessments were performed via examination and/or telephonic and internet-based questionnaire to ascertain functional and subjective status using established knee metrics. The primary outcome measures were graft integrity, subjective knee stability and functional status.

Results:

There were 99 patients (100 knees); 87 were male and 95 active duty military. Both groups were similar in demographics and preoperative activity level. The mean and median age of both groups was identical at 29 and 26, respectively. Concomitant meniscal and chondral pathology, microfracture and meniscal repairs performed at the time of reconstruction were similar in both groups. At a minimum 10 years (range: 120-134 mos) from surgery, 96 pts (97 knees) were contacted (2 patients were deceased and 1 was unable to be located). There were 4 (8.3%) autograft and 13 (26.5%) allograft failures which required revision reconstruction. In the remaining patients whose graft was intact, there was no difference in the mean SANE, Tegner, or IKDC scores.

Conclusion:

At a minimum of 10 years following ACL reconstruction in a young athletic population, over 80% of all grafts were intact and had maintained stability. However, those patients who had an allograft, failed at a rate over three times higher than those reconstructed with a autograft.
ACL Injury, Return To Play And Reinjury In The Elite, Collegiate Athlete: An Analysis Of A Single, Division I NCAA Cohort
Authors: Kamath Ganesh V. , Murphy Timothy , Creighton Robert A. , Taft Timothy N. , Spang Jeffrey T.
Published: August 2014

Objectives:

Graft survivorship, reinjury rates, and career length are poorly understood after ACL reconstruction in the elite, NCAA Division-I athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a Division-I athlete cohort.

Methods:

Retrospective chart review was performed of all Division-I athletes at a single, public university from 2000 to 2009 until completion of eligibility. Athletes with a Pre-collegiate (PC) and Intra-collegiate (IC) ACL reconstruction were separated into two cohorts. Graft survivorship, reoperation rates, and career length information was collected.

Results:

35 athletes were identified with a pre-collegiate (PC) ACL reconstruction; 60 with an intra-collegiate (IC) reconstruction. The PC group had a 17.1% injury rate to the original graft, with a 20.0% rate of contralateral ACL injury. For the IC group, the reinjury rates were 1.9% to the ACL graft, with a 9.2% rate of contralateral ACL injury after an IntraCollegiate ACL reconstruction. The PC group used 78% of their total eligibility (avg 3.11 yrs). Athletes in the IC group used an average of 77% of their remaining NCAA eligibility. 88.3% of the IC group played an additional non-redshirt year after their injury. Reoperation rate for the PC group was 51.4% and 20.3% for the IC group.

Conclusion:

Reoperation and reinjury rates are high after ACL reconstruction in the Division-I athlete. Pre-collegiate ACL reconstruction is associated with a very high rate of repeat ACL reinjury to the graft or opposite knee (37.1%). The majority of athletes are able to return to play after successful reconstruction.
Lateral Tibial Slope is Increased with Patients with Early Graft Failure Following ACL Reconstruction
Authors: Christensen Joshua , Engasser William , Vanhees Matthias , Collins Mark S. , Dahm Diane L.
Published: August 2014

Objectives:

To determine the relationship between lateral tibial slope and probability of early graft failure in patients who have undergone anterior cruciate ligament (ACL) reconstruction.

Methods:

Fifty-eight patients were initially identified who experienced graft failure following primary ACL reconstruction and were revised between 1989 and 2009. Exclusion criteria were: clinical follow-up of less than four years, graft failure occurring greater than two years from primary surgery, skeletal immaturity, deep infection, lack of availability of preoperative MRI imaging, and history of previous trauma to the proximal tibia. This left 35 cases of early (within 2 years) failure of primary ACL reconstruction. These cases were matched to 35 controls that had undergone ACL reconstruction with a minimum of 4 years of clinical follow-up and no evidence of graft failure. Patients were matched by age, gender, date of primary surgery, and graft type. Lateral tibial slope was then determined on MRI imaging in blinded fashion.

Results:

All 35 cases failed within 2 years of primary ACL reconstruction. Mean time to failure in this group was 1 year (range 0.6-1.4 years). Mean follow-up of the matched control group was 6.9 years (range 4.0-13.9 years). Mean lateral tibial slope in the early ACL failure group was found to be 8.4 degrees, which was significantly larger than the control group at 6.5 degrees (p=0.02). The odds ratio for failure considering a 2 degree increase in tibial slope was 1.5 (95% CI 1.02-2.2), and continued to increase to 2.2 (95% CI 1.1-4.6) and 3.3 (95% CI 1.1-10) with 4 degree and 6 degree increases in tibial slope, respectively (Fig 1). No significant association was identified between graft type and primary ACL reconstruction failure.

Conclusion:

Increased lateral tibial slope is associated with an increased risk for early ACL graft failure, regardless of graft type. Orthopaedic surgeons should consider measuring lateral tibial slope as part of the preoperative assessment of ACL-injured patients.
Combined Meniscus and Osteochondral Allograft Transplantation: Minimum Two-Year Follow-up with an Analysis of Failures
Authors: Abrams Geoffrey D. , Hussey Kristen , Harris Joshua David , Cole Brian J.
Published: August 2014

Objectives:

The purpose of this investigation was to report mid- and long-term follow-up on the clinical outcomes of patients undergoing combined MAT and osteochondral allograft procedures for symptomatic knee pain in the setting of meniscal deficiency and focal cartilage damage. We hypothesized that patients undergoing combined MAT and osteochondral allograft will demonstrate improved pain and functional scores following surgery.

Methods:

This was a prospective case series. Thirty two patients with a minimum two-year follow-up were identified who initially presented with persistent symptoms following meniscectomy and an isolated International Cartilage Repair Society (IRCS) Grade 3 or 4 defect of the femoral condyle underwent combined MAT and fresh osteochondral allograft transplantation. Demographic and intra-operative data, including condylar defect size, was recorded as well as pre- and post-operative International Knee Documentation Committee (IKDC), Short Form-12 (SF-12), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scores. Pre- and post-operative data was compared with paired t-tests while the association between functional scores and condylar defect size, age, gender, and involved compartment were analyzed with regression analysis. An alpha value of 0.05 was set as significant with Bonferroni correction utilized in the case of multiple comparisons.

Results:

Average follow up was 4.2 years (range 2-11). Mean condylar defect size was 4.7 ± 2.0 cm2 at the time of index procedure. Lysholm, IKDC, and all KOOS subdomains showed significant improvement from pre- to post-operatively (p < 0.001). Patients with a condylar defect of less than 4 cm2 had a significantly greater increase in pre- versus post-operative IKDC (p = 0.010), Lysholm (p = 0.018), and KOOS (p = 0.016) versus those with greater than 4 cm2. Femoral condyle defect size was also significantly inversely correlated with post-operative IKDC (p = 0.015), KOOS (p = 0.003), and Lysholm score (p = 0.010). Patient satisfaction with the procedure was 82%.

Conclusion:

Patients undergoing combined MAT and osteochondral allograft showed improved functional scores following surgery. There was an inverse association between post-operative functional scores and the size of the condylar defect.
Survivorship and Complications of the Distal Femoral Osteotomy
Authors: Ramanathan Deepak , Keudell Arvind Von , Minas Tom , Gomoll Andreas H.
Published: August 2014

Objectives:

Distal femoral osteotomy (DFO) is a useful procedure in the young patient with symptomatic unicompartmental osteoarthritis and valgus malalignment to avoid or postpone knee arthroplasty. Distal femoral osteotomy can be technically demanding and various complications are reported in the literature. Our retrospective study aims to evaluate the outcomes and analyze survivorship of the distal femoral osteotomy until eventual conversion to knee arthroplasty.

Methods:

We performed a retrospective review of 78 open-wedge distal femoral osteotomies done on 74 patients at our institution between 2001 and 2011. The average patient age at surgery is 33 ± 11 years with mean BMI of 28 ± 6. All surgeries were performed by two of the senior authors and 60.3% were done in conjunction with cartilage repair procedures such as autologous chondrocyte implantation and osteochondral graft transfer. Other associated procedures included lateral release, tibial tubercle osteotomy, quadricepsplasty and ACL reconstruction. The average follow-up duration was 43 ± 31 months and the need for further procedures (such as arthroscopic adhesiolysis, hardware removal, revision osteotomy and eventual progression to arthroplasty) was identified with relation to complications. Statistical analyses for survivorship were performed using MedCalc for Windows, version 12.5 (MedCalc Software, Ostend, Belgium).

Results:

Of the 71 patients who followed -up beyond six months post-operatively, seven eventually converted to total knee arthroplasty (9.9%). The most common complication was hardware pain (20.5%) followed by arthrofibrosis (12.8%). All cases of arthrofibrosis were noted to have had intra-articular surgical manipulation for associated procedures such as cartilage repair. Other less common complications included hardware failure (3.8%), septic arthritis (3.8%) and nonunion (2.6%). Osteotomy hardware removal was performed in fourteen cases (17.9%). Kaplan - Meier survivorship analysis estimates mean survival time of 123 ± 8 months (with 95% confidence interval of 107 - 138) and survival probability at 10 years follow-up is estimated at 78%.

Conclusion:

Distal femoral osteotomy is an acceptable surgical option for the young patient with severe unicompartmental knee osteoarthritis and malalignment. Its combination with various cartilage repair procedures has been shown to further improve outcomes. Careful selection of each surgical candidate is necessary to ensure maximum benefit. The unloading osteotomy is especially useful in the young, active patient as an adjunct procedure for cartilage repair. However, osteoarthritis continues to progress and multiple arthroscopic or open procedures may be required despite a successful osteotomy. When performed at the optimal time in a carefully selected patient, distal femoral osteotomy can provide adequate joint function for many years until arthroplasty becomes inevitable.
Closing Wedge and Opening Wedge High Tibial Osteotomy in the ACL Deficient Knee: A Comparison of Stability and Alignment
Authors: Weeks K. Durham , Khamaisy Saker , Stone Benjamin , Pearle Andrew , Ranawat Anil S.
Published: August 2014

Objectives:

Opening and closing wedge high tibial osteotomies for the treatment of medial compartment arthritis can lead to secondary intended and unintended changes in posterior tibial slope. The effect of slope neutralization using high tibial osteotomies in ACL deficient knees has not been fully defined. The purpose of this study was to quantify the changes in anterior tibial translation and rotational stability in the ACL deficient knee following mulitplanar high tibial osteotomies comparing opening wedge to closing wedge techniques.

Methods:

Anterior drawer, Lachman, and Pivot-shift tests were performed on hip-to-toe cadaveric specimens ( n=16) and translation of the lateral and medial compartments was measured using Praxim navigation system. The ACL was then sectioned and stability testing repeated and compartment translation recorded. Half of the knees then underwent a closing wedge (LCW) high tibial osteotomy using a lateral titanium Tomofix plate and screws ( n=8). The contralateral knees underwent an opening wedge (MOW) high tibial osteotomy using a medial titanium Tomofix plate and screws ( n=8). The goal of both procedures was for an 8-10mm correction with maximal sagittal slope neutralization. Following this procedure, stability testing and translation measurements were once again performed. Pre and post-operative CT scans were performed to assess initial posterior tibial slope and slope correction, as well as coronal plane correction.

Results:

Sectioning the ACL resulted in a significant increase in anterior tibial translation (ATT) during Anterior drawer, Lachman, and Pivot shift testing ( P < 0.05). In the ACL deficient knee the tibia translated on average an additional 2.1mm (±1.2) during Anterior drawer and 4.1mm (±2.1) during Lachman testing. Performing a LCW osteotomy demonstrated a significant decrease in ATT during Lachman testing that approached the native knee kinematics ( P< 0.05), however, this decrease was not found during Anterior Drawer testing. ATT did not significantly improve following MOW osteotomy in the ACL deficient knee during any of the three tests. In fact, absolute translation values were unchanged following this procedure. The pivot shift was not significantly changed following either MOW or LCW. The mean Tibial Coronal alignment correction in the MOW group was 7.2º(±0.95) compared to 5.9º(±1.8) in the LCW group. Although the coronal correction was improved in the MOW, this difference did not reach significance ( P = 0.08). The mean tibial slope neutralization achieved with a LCW was 7.1º(±1.8), which was significantly higher than 5.1 º(±0.9) found using MOW ( P< 0.05).

Conclusion:

LCW HTO shows more reproducible slope neutralization than MOW and this benefits anterior translation during Lachman stability testing. When considering the use of an HTO in the setting of ACL deficiency, LCW should be considered given its favorable post-operative knee kinematics.
Changes in the Hip of Youth Hockey Players over 3 Seasons as Seen on MRI and Physical Exam
Authors: Philippon Marc J. , Ho Charles , Briggs Karen K. , Ommen N. Dawn
Published: August 2014

Objectives:

It has been reported that relative to other sports participants, ice hockey players suffer from cam femoroacetabular impingement (FAI) in higher numbers. Alpha angles have been reported to increase with the likelihood of symptomatic FAI. It is unclear how alpha angle and other factors related to FAI change over early childhood years. The objective of this study was to track youth hockey players over 3 years and determine if factors associated with FAI increased as they aged and increased skating time.

Methods:

15 asymptomatic youth ice hockey players(ages 10 to 16 years) had pre-participation screening prior to starting youth hockey season. All players started in the peewee(ages 10 to 12) division and moved up in divisions over the 3 years. All players had a clinical hip examination consisting of the FABER test, impingement testing, and measurement of hip internal rotation. An limited screening MRI was taken and the hip alpha angle was measured and labral tears were documented.

Results:

These youth hockey players played an average of 42 weeks/year over 3 years. Four goalies were included. Players had significantly increased alpha angle by year 3 of screening. The average alpha angle at year 1 was 56(range 45 to 63), year 2 average was 59 (range 52 to 68) and year 3 average was 75 (range 64 to 88). By year 3, 12/15 had asymptomatic labral tears. The 3 players who did not have labral tears had alpha angles of 60, 62, and 64 degrees. There were no significant changes in internal rotation over the 3 years. There was a trend toward decreased internal rotation in goalies. One goalie reported symptoms after the completion of the 3 rd season when he was 16 years old.

Conclusion:

Young ice hockey players show increasing alpha angles and development of asymptomatic labral tears. Stresses inherent to ice hockey likely enhance the development of a bony overgrowth on the femoral neck contributing to cam FAI. Further study into the etiology of the increase in the alpha angle in ice hockey players is recommended to determine if preventative measures may be adapted to decrease the incidence of hip symptoms which decrease activity level.
Gender Differences in Outcome After an Acute Achilles Tendon Rupture
Authors: Silbernagel Karin Gravare , Nilsson-Helander Katarin , Olsson Nicklas , Brorsson Annelie , Eriksson Bengt I. , Karlsson Jon
Published: August 2014

Objectives:

There is an indication in the literature that there is a difference in tendon healing between genders. However comparisons in outcome are often not possible due to the small sample size of women with an acute Achilles tendon rupture. In most studies on patients with Achilles tendon rupture the women only account for less then 20% of the patients. The objective of this study was to evaluate if there are any differences in outcome between genders when combining the data from two large randomized controlled trials, which used identical outcome measures.

Methods:

Patients included in two consecutive randomized controlled trials, comparing surgical and non-surgical treatment, were included in the evaluation. Patients who had a re-rupture were excluded from the analysis. A total of 184 patients (154 males, 30 females) mean (SD) age of 40 (11) years were included. 96 (78 males, 18 females) were treated with surgery and 88 (76 males, 12 females) non-surgically. Patient reported outcome was evaluated with the Achilles tendon Total rupture Score (ATRS) and the functional outcome were measured with a single-leg standing heel-rise test (measurement of muscular endurance and heel-rise height) 6 and 12 months after injury in our research laboratory.

Results:

For the whole group there were no significant difference between treatments on ATRS at 6 and 12 months. The surgical group was significantly better then the non-surgical group in heel-rise endurance at 6 and 12 months and in heel-rise height recovery at 6 months (p<0.03). When comparing the genders, disregarding the treatment, there were no significant differences except for at 12 months the males had a greater improvement in heel-rise height (p=0.004). When comparing the genders for each treatment group separately it was found that the females had significantly (p<0.04) more symptoms after surgical treatment (mean (SD) ATRS 61 (24)) compared to the males (74 (19)) at 6 months and (74 (27) vs. 87 (17)) at 12 months. This difference was not found when comparing the genders in the non-surgical treatment group.

Conclusion:

Females has a greater degree of deficit in heel-rise height as compared to males irrespective of treatment. Females have more symptoms compared to males after surgery both at 6 and 12 months but this difference is not found when treated non-surgically. Further research is needed to determine if women will benefit more from non-surgical compared to surgical treatment after an Achilles tendon rupture.
Surgical versus Non-surgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation
Authors: Kweon Christopher Y. , Gagnier Joel Joseph , Robbins Christopher , Bedi Asheesh , Carpenter James E. , Miller Bruce S.
Published: August 2014

Objectives:

Rotator cuff tears are a common shoulder disorder resulting in significant disability to patients and strain on the health care system. While both surgical and non-surgical management are accepted treatment options, little data exist to guide the surgeon in treatment allocation. Defining variables to guide treatment allocation may be important for patient education and counseling, as well as to deliver the most efficient care plan at the time of presentation. The objective of this study was to identify patient characteristics at the time of initial clinical presentation that are associated with allocation to surgical versus non-surgical management for patients with known full-thickness rotator cuff tears.

Methods:

185 consecutive adult patients with known full-thickness rotator cuff tears were enrolled into a prospective cohort study. Robust data were collected for each subject at baseline, including age, gender, body mass index (BMI), shoulder activity score, smoking status, size of cuff tear, duration of symptoms, functional comorbidity index, treating surgeon, the American Shoulder and Elbow Society (ASES) score, the Western Ontario Rotator Cuff Index (WORC), and the Veterans Rand 12 Item Health Survey (VR-12). Logistic regression was performed in order to identity variables associated with treatment allocation, and the corresponding odds ratios were calculated.

Results:

Of the 185 subject enrolled, 100 underwent surgical intervention and 85 non-operative management. While controlling for co-variates, significant baseline patient characteristics predictive of eventual allocation to surgical treatment included the following: non-smoking status [OR .039 (0.005, 0.300) p=0.002], lower functional comorbidity index [OR 0.739 (0.518, 1.055) p=0.096], younger age [OR 0.872 (0.820, 0.927) p<0.001], lower BMI [OR 0.895 (0.826, 0.970) p=0.007], and symptoms present for fewer than 4 months [OR 3.258 (1.070, 9.921) p=0.038]. Factors that were not associated with treatment allocation included gender, tear size, diabetes, treating surgeon, or any of the patient derived outcome scores at presentation (ASES, WORC, VR-12, shoulder activity score).

Conclusion:

This prospective cohort study suggests that the factors predictive of treatment allocation are related more to patient demographics at presentation than patient derived outcome scores or intrinsic characteristics of the rotator cuff such as tear size. Further study is warranted to help define appropriate indications for treatment allocation in patients with rotator cuff tears.
Subpectoral Biceps Tenodesis For The Treatment Of Type Two And Four Slap Lesions
Authors: Gottschalk Michael Brandon , Karas Spero G. , Ghattas Timothy N. , Burdette Rachel
Published: August 2014

Objectives:

Despite unsatisfactory outcomes in middle aged patients with SLAP lesions, surgical repair remains the gold standard for most Type II and Type IV SLAP lesions. Given recent data demonstrating higher SLAP repair failure rates in this subset of patients, biceps tenodesis may offer an excellent alternative. To our knowledge, only one study has investigated biceps tenodesis as an alternative to SLAP repair. This study investigates that subpectoral biceps tenodesis provides satisfactory outcomes for the treatment of Type II and Type IV SLAP lesions in middle aged patients.

Methods:

Patients who were older than 18 years old and underwent subpectoral biceps tenodesis for isolated Type II or Type IV SLAP lesions by a single board certified shoulder surgeon from 2006-2012 were included. Exclusion criteria included those patients with Type II or Type IV SLAP lesions who underwent biceps tenodesis with rotator cuff repair, Bankart repair, or labral repair. Outcome measures included Visual Analog Pain Scale (VAS), American Shoulder and Elbow Surgeons Scores (ASES), and demographic data.

Results:

Between 2006-2012, 33 patients underwent 36 subpectoral biceps tenodesis for isolated Type II or Type IV SLAP lesions by a single board certified shoulder surgeon. 26 patients with 29 shoulder surgeries consented to participate in the study. Average age was 46.7 years with 16 males and 10 females participating in the study. Average follow up was 29.3 months. A statistically significant improvement in ASES and VAS scores were found with an average of 48.1 and 6.4 preoperatively and an average of 87.5 and 1.5 post-operatively (p < .001). There was no statistically significant difference noted based on SLAP lesion type, age, activity level, or gender. 26 of 29 shoulders (89.65%) were able to return to their previous activity.

Conclusion:

Our study is able to confirm that biceps tenodesis results in statistically significant improvement in pain and functional outcomes for Type II and IV SLAP lesions. The results of biceps tenodesis for Type II and IV SLAP lesions is comparable to historical data. Based on these results, biceps tenodesis is a safe, effective, and technically straightforward alternative to SLAP repair in middle aged patients.
Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the Superomedial Scapular Angle
Authors: Millett Peter J. , Smith Sean , Ho Charles , Spiegl Ulrich
Published: August 2014

Objectives:

Significant Association Between Snapping Scapula Syndrome and Anterior Angulation of the Superomedial Scapular Angle.

Methods:

In this Institutional Review Board approved study, bony morphologies of the scapula were evaluated on the MRIs of 28 patients (28 scapulae) with SSS and 20 patients (22 scapulae) with non-SSS pathologies. Patients with SSS were identified from a prospective surgical registry that had undergone a preoperative shoulder MRI along with scapular bursectomy and/or superomedial angle resection. The non-SSS patients underwent shoulder MRIs for other reasons that subsequently allowed for evaluation of the scapula. The medial scapula corpus angle (MSCA), was measured on axial STIR or PD FSE sequences cranial to the spine of the scapula (Figure 1). Scapula length angled towards rib cage was documented. Scapulae were categorized as straight, s-shaped or concave. Two blinded observers, one radiologist and one orthopedic surgeon, reviewed all MRIs. MSCAs were measured using Stryker OfficePACS Power 4.1 Express Edition (Kalamazoo, MI). Positive MSCAs were defined as anterior scapular angulation towards the thorax in the axial plane whereas negative MSCAs were defined as posterior scapular angulation away from the thorax in the axial plane.

Results:

Axial scapula corpus configurations were identified: 31 scapulae were of the straight type, 14 were s-shaped and 5 were concave. All five concave scapulae had surgically confirmed SSS. The measurement of MSCA had excellent inter-observer agreement of 0.81 [95% CI, 0.68 to 0.89] and a fair to good intra-observer agreement of 0.68 [95% CI, 0.50 to 0.80]. There were significant differences in the mean MSCAs between those with SSS (14.4° ± 19.3°) and those with other pathologies (-3.3° ± 15.3°; p = 0.001). After excluding all concave scapulae (n = 5), the differences in the mean MSCAs between the SSS and non-SSS groups were significant (MSCA for SSS: 15.3° ± 17.5° MSCA for non-SSS: -3.3° ± 15.3°; p < 0.0001). Twenty of 28 (71.4%) scapulae with a positive MSCA had SSS, whereas only 3 of 17 (25%) scapulae with a negative MSCA had SSS (see Figure 1). The mean length of the medial scapula border angled to towards the rib cage was 14.4 mm (± 4.6 mm).

Conclusion:

Anterior angulation of the superomedial angle in the axial plane had an association with SSS. Those patients with a concave-shaped scapula and a positive MSCA may be at risk for SSS. This information may have clinical relevance in the treatment of SSS patients since there are no guidelines on the amount of scapular resection may or may not be needed. The MSCA may prove helpful in determining the location and amount of scapula resection needed to reduce SSS symptoms in patients.
Outcome of All-Inside Second Generation Meniscal Repair: Minimum 5-year Follow-up
Authors: Bogunovic Ljiljana , Haas Amanda , Kruse Lisa , Wright Rick W.
Published: August 2014

Objectives:

In the setting of injury, meniscal repair and preservation is the goal when possible. Current research on second generation all-inside repair systems is limited to a maximum of three year follow-up. The purpose of this study is to evaluate the long-term (> 5 years) clinical success of isolated meniscal repairs and those performed with concomitant ACL reconstruction using a second generation all-inside repair device.

Methods:

This a retrospective review of patients who underwent meniscal repair utilizing the all-inside FasT-Fix meniscal repair system (Smith & Nephew Arthroscopy, Andover, MA) between December 1999 and January 2007. Eighty-three meniscal repairs in 81 patients were identified and follow-up was obtained in 90%. Twenty-six patients (35%) had isolated meniscal repair. Clinical failure was defined as repeat surgical intervention involving resection or revision repair. Clinical outcomes (KOOS, IKDC, Marx Activity) were also assessed.

Results:

Minimum follow-up was 5 years (avg. 7 years). Twelve patients failed meniscal repair (16%). The average time to failure was 47 months (range, 15 - 94). There was no difference in average patient age, sex or number of sutures utilized between successful repairs and failures. There was no difference in failure rate between isolated repairs (11.5% CI: -0.76%-23.76%) and those performed with concurrent ACL reconstruction (18.3% CI: 7.47%-29.13%) and the average time to failure was similar between these two groups (48.1 months versus 46.6 months, p=0.243). Postoperative outcome scores were also similar (KOOS and IKDC).

Conclusion:

This first report of long term (> 5 yrs) follow-up of second generation all-inside meniscal repair demonstrates it is an effective method of primary meniscal repair for both isolated repairs and those performed with concurrent ACL reconstruction. After minimum five year follow-up, over 84% of patients continue to demonstrate successful repair. Treatment success is further supported by favorable results on patient based outcome measures.
Arthroscopy Skills Development with a Surgical Simulator: A Comparative Study in Orthopaedic Surgery Residents
Authors: Rebolledo Brian J. , Leali Alejandro , Hammann Jennifer , Ranawat Anil S.
Published: August 2014

Objectives:

Traditional resident assessment of orthopaedic surgical technical proficiency relies exclusively on subjective parameters. More standardized objective measures are needed to ensure training consistency and surgical competency. The purpose of this study was to determine if orthopaedic surgery residents who train with a virtual reality simulator can lead to improved arthroscopy performance and to determine if a standardized arthroscopic shoulder and knee test were appropriate means for evaluating a resident's arthroscopic skill after completing a training course.

Methods:

Study participants were first and second year orthopaedic surgery residents at a single institution who were randomized to either train on the virtual reality surgical simulator ( Insight Arthro VR) for a total of 2.5 hours (n=8) or receive 2 hours of didactic lectures with models (non-simulator) (n=6). Both groups were then evaluated in both knee and shoulder arthroscopy using a cadaver. Performance was measured by time to completion of a standardized protocol checklist and cartilage grading index (CGI) (scale 0-10).

Results:

All subjects had no previous arthroscopy experience prior to the study. The simulator group had a shorter time to completion in both knee (simulator: 5.1 ± 1.8 min, non-simulator: 8.0 ± 4.4 min; p=0.09) and shoulder (simulator: 6.1 ± 1.5 min, non-simulator: 9.9 ± 3.2 min; p=0.02) arthroscopy. Similarly, the simulator group had improved CGI scores in both the knee (simulator: 4.0 ± 1.1, non-simulator: 5.3 ± 1.5; p=0.07) and shoulder (simulator: 3.4 ± 0.8, non-simulator: 5.5 ± 1.6; p=0.008) arthroscopy.

Conclusion:

This study suggests that surgical simulators are beneficial in arthroscopy skills development for orthopaedic surgery residents. An arthroscopic testing model was able to measure a statistical improvement for a resident's arthroscopic skill. Instituting standardized cadaveric testing based on common orthopaedic surgical procedures such as knee and shoulder arthroscopy will not only ensure graduating residents possess the necessary skills to be technically proficient surgeons but it will also allow objective identification of residents in need of remediation.
Comparison of Transtibial and Tibial Inlay Techniques for Posterior Cruciate Ligament Reconstruction with an Average of 10 Year- Follow-up
Authors: Seon Jong Keun , Song Eun Kyoo , Park Hyoungwon
Published: August 2014

Objectives:

We performd this study to determine the long-term results based on clinical and radiographic outcome comparison following either transtibial or tibial inlay technique, and to find out factors related to osteoarthritis after PCL reconstruction.

Methods:

Seventy-seven patients (77 knees) treated with the PCL reconstruction for chronic injuries constituted the study cohort. The 77 patients were divided into 2 groups, namely, transtibial (44 patients) and tibial inlay (33 patients). The mean time from injury to reconstruction was 12.2 months (range, 2 to 60 months), and their average follow-up was 142 months (range, 97 to 192 months). Outcomes were measured using Lysholm knee scores, Tegner activity scores, laxity test using Telos device, and development of osteoarthritis.

Results:

There was significant improvement of Lysholm knee scores, Tegner activity scores, and laxity test using Telos device between the preoperative values and final follow-up values ( P < .05). However, there was no significant difference in the final follow-up outcomes ( P > .05). The final follow-up radiographs according to International Knee Documentation Committee guidelines showed that 7 patients (22.7%) in transtibial group and 4 patients (18.2%) in tibial inlay group were rated as Grade C. We found correlation between meniscectomy and osteoarthritis, but other factors including reconstruction technique, sex, age, and posterior instability did not influence the arthritic changes in both groups (Fig 1).

Conclusion:

The clinical and radiographic outcomes between the two surgical techniques of PCL reconstruction were comparable. Osteoarthritis was observed in some patients with a significant proportion showing some loss of joint space, and factors except meniscectomy did not show correlation with development of osteoarthritis.
Prospective Hip and Knee Strength Measures Associated with Increased Risk for Patellofemoral Pain Incidence
Authors: Herbst Kristen , Foss Kim D. Barber , Hewett Timothy E. , Stanfield Denver T. , Myer Gregory D.
Published: August 2014

Objectives:

Hip and knee strength abnormalities have been implicated in patellofemoral pain (PFP) in multiple studies in the recent literature. However, many authors have noted that hip muscle weakness has not yet been defined as having a causal relationship to PFP due to the fact that many studies used subjects already diagnosed with PFP. The purpose of this study was to compare prospective hip and knee isokinetic strength measures in young females who subsequently went on to develop PFP relative to their uninjured healthy peers.

Methods:

Middle and high school female athletes (n=255) were evaluated by a physician for PFP prevalence. Isokinetic strength measurements of the knee (flexion and extension at 300°/sec) and hip (abduction at 120°/sec) were obtained prior to the start of their basketball and soccer seasons. Isokinetic torque measures (newton*meters) were normalized to leg length by mass and are described as a normalized torque (NT). Those diagnosed with PFP at pre-season were excluded and the remaining athletes were monitored by certified athletic trainers for PFP incidence during their competitive seasons. A one-way ANOVA was used to determine significant differences in knee and hip strength measures between the incident PFP and the control groups.

Results:

Young females who developed PFP were not different in age 12.6 ± 0.9 yrs., mass 51.4 ± 13.2 kg, height 158.8 ± 7.3 cm, or leg length 83.8 ± 4.2 cm compared to the referent control group (P>0.05). Females who developed PFP demonstrated increased normalized hip strength 0.013 ± 0.003 NT relative to the referent control group 0.011 ± 0.003 NT (P<0.05). Normalized knee extension and knee flexion strength were not different between the females with incident PFP compared to the referent control group (P>0.05).

Conclusion:

The findings in this study indicate that young females with greater hip abduction strength may be at an increased risk for the development of PFP. Previous studies that have looked at landing biomechanics indicated that those with PFP have increased knee abduction and increased hip adduction during landing. Combining our current data and previous literature, we theorize that greater hip abduction strength may be a resultant symptom of increased eccentric loading of the hip abductors associated with increased dynamic valgus biomechanics demonstrated to underlie increased PFP incidence. Future research is warranted to dissect the relative contributions of hip strength and recruitment and dynamic valgus alignments during landing to the pathomechanics of PFP.
The Effect Of Peroneus Brevis Tendon Anatomy On Stability Of Fractures At The Fifth Metatarsal Base
Authors: Farrow Lutul D. , Morris Parisa M. , Francois Annie G. , Marcus Randall E.
Published: August 2014

Objectives:

Fractures of the fifth metatarsal base are not uncommon. Both fracture management and outcomes can differ greatly depending on fracture location. The purpose of the present study is to evaluate the influence of the peroneus brevis (PB) tendon on proximal fifth metatarsal fracture stability. We hypothesize that proximal fifth metatarsal fractures distal to the PB tendon footprint are inherently less stable than more proximal fractures.

Methods:

We utilized 5 matched pairs of fresh-frozen cadaveric specimens. We carefully exposed the 5th metatarsal and PB tendon. We measured the length of the PB insertion at the base of the fifth metatarsal with calipers. The PB and Achilles tendons were then whip-stitched proximally to facilitate loading. A custom leg holder was fabricated to allow loading and fluoroscopic evaluation. Two conditions were utilized for biomechanical testing; (1) a simulated fracture distal to the PB insertion (Jones equivalent) and (2) a simulated fracture within the footprint of the PB insertion (avulsion equivalent). All fractures were carefully created with a narrow osteotome. Following fracture creation, the plantar flexed foot was statically loaded through the Achilles and PB tendons. Oblique images with and without loading and digital measurements were performed to evaluate for fracture separation. We utilized a paired student T test and intraclass correlation coefficient (ICC) for all statistical analysis.

Results:

The average length of the PB footprint was 15.2 mm. Compared to fractures within the PB footprint, fractures distal to the PB tendon insertion demonstrated greater fracture widening following loading of the PB tendon. Fractures within the PB footprint widened 0.4 mm on loading (Figure 1A to 1B) compared to 1.1 mm of widening in the fractures distal to the PB insertion (Figure 1C to 1D). This difference was significant (p = 0.02). Intraobserver reliability for all radiographic measurements showed substantial agreement.

Conclusion:

Avulsion fractures at the base of the fifth metatarsal have much better healing potential than the so-called Jones fracture. Poor vascularity has been cited as a cause for poor healing potential following Jones fractures. The principal findings of this study demonstrate that proximal fifth metatarsal fractures distal to the PB insertion are significantly more unstable than more proximal fractures. In our study, the PB exerts a deforming force on the proximal fragment of fractures distal to the PB footprint. This deforming force was less pronounced in fractures within the PB footprint. Our findings help support the notion that a mechanical component may contribute to the poor healing potential of Jones fractures secondary to deformation exerted by the PB tendon. This would help explain why screw fixation is often recommended to address Jones fractures. Further research is needed to evaluate the biomechanics of these fractures.