bluuebunny/crossref_metadata_2025 huggingface dataset:
The Influence of Graft Tensioning Sequence on Tibiofemoral Orientation during Bicruciate and Posterolateral Corner Knee Ligament Reconstruction: A Biomechanical Study
Authors: Moatshe Gilbert , Chahla Jorge , Brady Alex , Dornan Grant , Muckenhirn Kyle , Kruckeberg Bradley , Engebretsen Lars , LaPrade Robert F.
Published: July 2018

Objectives:

During a multiple knee ligament reconstruction, the graft tensioning order may influence the final tibiofemoral orientation and corresponding knee kinematics. Therefore, the objective of this study was to biomechanically evaluate the effect of different graft tensioning sequences on knee tibiofemoral orientation following multiple knee ligament reconstruction in a bicruciate ligament (anterior cruciate ligament [ACL] and posterior cruciate ligament [PCL]) with posterolateral corner [PLC] injured knee.

Methods:

Ten non-paired, fresh-frozen human cadaveric knees were utilized for this study. Following reconstruction of both cruciate and posterolateral corner ligaments and proximal graft fixation, each knee was randomly assigned to each of four graft tensioning order groups: (1) PCL → ACL → PLC, (2) PCL → PLC → ACL, (3) PLC → ACL → PCL and (4) ACL → PCL → PLC. The tibiofemoral orientation after graft tensioning was measured and compared to the intact states.

Results:

Tensioning the ACL first (tensioning order 4) resulted in posterior displacement of the tibia at 0° by 1.7 ± 1.3 mm compared to the intact state (p=0.002) (Figure 1). All tensioning orders resulted in significantly increased anterior tibial translation compared to the intact state at higher flexion angles ranging from 2.7 mm to 3.2 mm at 60° and 3.1 mm to 3.4 mm at 90° for tensioning orders 1 and 2 respectively (all p<0.001). There was no significant difference in tibiofemoral orientation in the sagittal plane between the tensioning orders at higher flexion angles. All tensioning orders resulted in increased internal tibial rotation (all p<0.001). Tensioning and fixing the PLC first (tensioning order 3) resulted in the most increases in internal rotation of the tibia; 2.4° ± 1.9°, 2.7° ± 1.8° and 2.0° ± 2.0° at 0°, 30° and 60° respectively (Table 1).

Conclusion:

None of the tensioning orders restored intact knee tibiofemoral orientation. Tensioning the posterolateral corner first should be avoided in bicruciate knee ligament reconstruction with a concurrent posterolateral corner reconstruction because it significantly increased tibial internal rotation. We recommend that the PCL be tensioned first, followed by the ACL to avoid posterior translation of the tibia in extension where the knee is primarily loaded with most activities and finally the PLC. [Figure: see text][Table: see text]
Bacterial Biofilms Are Associated With Tunnel Widening In Failed ACL Reconstructions
Authors: Flanigan David C. , Everhart Joshua Scott , DiBartola Alex , Moley James , Dusane Devendra , Magnussen Robert A. , Kaeding Christopher C. , Stoodley Paul
Published: July 2018

Objectives:

Technical errors, traumatic re-injury, and biologic failure all play a potential role in failure after ACL reconstruction (ACLR). Recent work has demonstrated the frequent presence of biofilms on failed ACLR grafts. Tunnel widening is commonly observed upon presentation for revision ACLR but the relationship between biofilm presence and tunnel widening is unclear. The purpose of this study is to determine whether tunnel widening is associated with bacterial biofilms in failed ACL reconstructions.

Methods:

34 consecutive revision ACLR cases and 5 primary ACLR controls were included. Tissue biopsies were obtained from tibial, femoral, and intra-articular segments of revision cases and torn native ligament as well as excess hamstring graft after fixation from primary ACLR controls. Clinical cultures as well as PCR for bacterial DNA with a universal primer were obtained on all patients. Fluorescence microscopy was used to visually confirm presence of biofilm. No patients had clinical signs of infection. Tunnel diameters were measured on pre-operative 3-dimensional imaging.

Results:

Bacterial DNA was present in 87% of cases and 20% of controls. Cultures were only positive (coagulase negative staphyloccous sp.) in one revision case, the widest measured tunnel diameters were in this same case (20.1 mm for the tibial tunnel and 16.9 mm for the femoral tunnel) Bacterial DNA was positively associated with wider femoral tunnels (median 10.6 mm with detectable bacterial DNA, median 7.6 mm without detectable bacterial DNA; p=0.04 Wilcoxon rank-sum). There was a trend toward higher rates of bacterial DNA in tibial tunnels with diameters greater than 12.5 mm (LR chi square p= 0.12). Fluorescence microscopy confirmed presence of staphylococcal biofilms adherent to the soft tissue graft surface (Figure 1) as well as inert fixation material including monofilament suture, braided suture, and PEEK and metal interference screws.

Conclusion:

Bacterial biofilms are commonly encountered on failed ACLR grafts. These biofilms do not cause clinically apparent infection symptoms but are associated with tunnel widening and may contribute to biologic failure.
Internal Brace ACL Repair is Associated with High Failure Rate in the First Two Years Post-Surgery
Authors: Gagliardi Alexia Georgia , Carry Patrick M. , Daoud Ariel Kiyomi , Parikh Harin Bhavin , Albright Jay C.
Published: July 2018

Objectives:

To compare graft/internal brace survival, self-reported functional outcomes, and joint laxity in adolescents who underwent quadriceps tendon patellar autograft (QPA) reconstruction versus ACL repair with internal brace ligament augmentation.

Methods:

We identified all adolescent and pediatric subjects who underwent primary ACL reconstruction or repair with internal brace augmentation between January 2013 and January 2016. Only subjects with a minimum of 6 months of follow-up were included. Graft failure, range of motion (ROM), complications, and demographic information including age and gender was collected. Failure was defined as the need for revision surgery or MRI-confirmed graft/internal brace failure. Subjects were prospectively contacted by telephone and were invited to either schedule a follow-up appointment or to complete research questionnaires over the phone. Objective joint laxity measures, KT1000, were obtained from a subset of subjects (N=25 QPA and N=6 repair group) that completed the research visit. Wilcoxon rank sum tests were used to compare IKDC and joint laxity measure. Multi-variable Cox proportional hazards regression analyses were used to compare failure-free survival in the two groups during the first 24 months post-surgery.

Results:

The final cohort included 132 patients in the QPA group (52% female) and 19 patients in the repair group (53% female). The repair group tended to be younger (mean: 14.1 yrs, ±2.9 vs 15.5 yrs, ±1.8). Median duration of follow-up was 2.1 years [range: 0.5-4 years] in the repair group compared to 1.2 years [range: 0.5-4 years] in the QPA group. Within the first 24 months post-surgery, the cumulative incidence of failure was 3.8% (5/132) in the QPA group compared to 52.6% (10/19) in the repair group. After adjusting for age, the hazard of failure in the repair group was 22.1 [95% CI: 6.7 to 73.2, p <0.0001] times the hazard of failure in the QPA group. KT-1000 side-to-side joint laxity measures in the repair group [Median: 2.5 mm, range: -1 mm to 7 mm] were significantly [p=0.0212] higher than the joint laxity measures in the QPA group [Median: 1.0 mm, range: -1 mm to 4 mm]. There was no difference [p= 0.3826] in IKDC scores in the repair group [N=53, median: 97, range: 58-100] compared to the QPA group [N=10, median: 94, range: 32-100].

Conclusion:

Failure rate and joint laxity measures were significantly increased in the internal brace repair group relative to the QPA group. Failure-free survival in the repair group was less than 50% at two years.The high failure rate in the repair group should be considered when selecting the appropriate intervention for the pediatric adolescent athlete with an ACL injury.
Relationship Between Pitcher Fatigue and Medial Elbow Torque in Baseball Pitchers: A Simulated Game Analysis
Authors: Makhni Eric C. , Meldau Jason E. , Stephens Jeff , Okoroha Kelechi , Lizzio Vincent A. , Meta Fabien , Ahmad Christopher S. , Moutzouros Vasilios
Published: July 2018

Objectives:

The incidence of overuse injury to the elbow in baseball pitchers continues to rise, despite exhaustive efforts at pitch count regulations and emphasis on proper throwing mechanics. The goal of this study was to determine if the medial elbow experiences increased torque levels as the pitcher fatigues through the course of a simulated game.

Methods:

Competitive baseball pitchers were recruited for this simulated game study. Medial elbow torque was assessed using a validated mobile sensor that recorded medial elbow torque during the throwing motion. A radar gun was used to capture pitch velocity for each recorded pitch. Each pitcher completed a simulated game consisting of 6 innings and a standardized pitching scheme of fastballs, curveballs, and change-ups. Visual analog scores (VAS) measuring fatigue were recorded in between each inning. In total, each pitcher threw 90 pitches. Data was recorded every pitch to include ball velocity, medial elbow torque, arm speed, arm rotation, and arm slot.

Results:

A total of 11 pitchers (average age 17.6 years; range 15-20 years) completed the study. No adverse outcomes were noted with use of the mobile sensor. VAS scores increased 0.716 points per inning pitched (p<0.001). Medial elbow torque also was found to increase with successive innings, with an increase of 0.836 Nm each inning (p<0.001), while average pitch velocity was found to decrease as the game progressed (0.28 mile per hour decrease per inning; p<0.001). Fastballs generated the highest amount of medial elbow torque. There were no differences found in arm rotation or arm speed as the game progressed. However, the arm slot was found to decrease with each successive inning (0.731 degree decrease per inning; p<0.001).

Conclusion:

In this simulated game analysis, pitchers were noted to experience increase fatigue after each successive inning. While the average fastball velocity decreased from inning-to-inning, the medial elbow torque was found to increase, signifying a possible risk factor for overuse injury to the medial elbow.
Increasing Numbers of Pre-operative Shoulder Injections are Associated with a Higher Rate of Subsequent Revision Rotator Cuff Surgery
Authors: Desai Vishal Shwetal , Camp Christopher L. , Cancienne Jourdan M. , Dines Joshua S. , Brockmeier Stephen F. , Werner Brian C.
Published: July 2018

Objectives:

Subacromial steroid injections are frequently used in the initial conservative management of rotator cuff (RC) tears, however, the long-term effect of this treatment in patients who eventually undergo rotator cuff repair (RCR) is not well defined in the literature. The objective of this study is to identify any dose-dependent association between injections prior to rotator cuff repair (RCR) and subsequent revision surgery.

Methods:

Two large databases were queried for patients undergoing arthroscopic RCR. Patients with one year of pre-operative database exposure and a minimum of two years post-operative follow-up were included. In each database, three study groups were formed, stratified by the number of ipsilateral injections given within the year prior to RCR: one, two and three or more injections. A control group without any prior injection was identified and matched to the single injection group in each database. The outcome of interest was ipsilateral revision arthroscopic or open rotator cuff repair, or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision surgery rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. This allowed for identification of the independent association between the number of injections and the need for subsequent revision surgery.

Results:

108,516 patients from the Medicare database and 11,360 patients from the private database were included (Table 1A-B). There was no association between a single injection within the year prior to RCR and revision surgery in either database. In the Medicare database, two or more injections was associated with a substantial increase in the risk of requiring revision surgery (OR 2.40-2.62, P < 0.0001). A similar association was noted in the private insurance database for patients with two or more injections (OR 2.09-2.42, P < 0.0001) (Table 1A-B).

Conclusion:

A single shoulder injection within a year prior to arthroscopic RCR is not associated with any increased risk of revision surgery. Two or more injections within a year prior to RCR appears to be associated with a substantially increased risk of revision surgery. While causality cannot be established on the basis of this database review, caution is recommended when considering more than one shoulder injection in patients with potentially repairable RC tears. [Table: see text][Table: see text]
The Use of a Bio-Inductive Collagen Patch to Supplement Repair of Large and Massive Rotator Cuff Tears Including Revisions: Clinical and Radiographic Outcomes at 2-year Follow Up
Authors: Thon Stephen , O’Malley Lawrence K. , O’Brien Michael John , Savoie Felix H.
Published: July 2018

Objectives:

Failures of large, massive, and revision rotator cuff repairs is a challenging problem within orthopedics. Poor tendon tissue and vascularity are known causes for failure of rotator cuff repairs. The purpose of this study was to assess the outcomes and healing rates when large and massive rotator cuff repairs are augmented with a bio-inductive collagen scaffold patch.

Methods:

Twenty-three patients undergoing repair of large (two tendon) or massive (three tendon) rotator cuff tears augmented with a bio-inductive collagen patch were followed prospectively for 2 years. Postoperative ultrasound (US) assessed tendon thickness at 3, 6, 12, and 24 months. MRI was utilized to confirm healing and tendon thickness at least 6 months post-operatively.

Results:

16 of 23 patients had previous failed rotator cuff repairs. Eleven patients had large rotator cuff tears while twelve patients had massive rotator cuff tears. 21 of 23 patients successfully healed their rotator cuff repairs and new tissue formation was appreciated in all 23 patients. Ultrasound rotator cuff thickness ranged from 4.5-9mm at most recent follow-up. Overall, a 91% (21/23) success rate was confirmed on US and MRI.

Conclusion:

Clear indications for the use of this bio-inductive collagen scaffold have yet to be established. Our results show that it may have utility in improving the healing rates of large and massive rotator cuff repairs. New tendon formation was apparent on both US and MRI with relatively high healing rates at two years. While these early results are promising, long term-follow up is needed to identify the proper indications for its use.

Level of Evidence::

Level IV - Case series.
Clinical Outcomes of Multiple Osteochondral Allograft Transplantation of the Knee: An Analysis of Snowman Technique and Multifocal Lesions
Authors: Cotter Eric J. , Hannon Charles P. , Lansdown Drew A. , Frank Rachel M. , Waterman Brian Robert , Cole Brian J.
Published: July 2018

Objectives:

To report the clinical outcomes of snowman technique osteochondral allograft transplantation (OCA) and clinical outcomes of multifocal OCA.

Methods:

Consecutive patients who underwent either a primary snowman OCA or multifocal (i.e. bipolar patellofemoral, patellofemoral and a condyle or bicondylar) with a minimum 2-year follow-up by a single surgeon from 4/2003 to 4/2015 were isolated. Failure was defined as revision OCA, conversion to arthroplasty, or gross appearance of graft degeneration on 2nd look arthroscopy.

Results:

Twenty-six patients (28 knees) were isolated with 22 patients (24 knees; 85.7%) having 2-year clinical follow-up. Nine of 11 patients (81.8%) who underwent isolated condylar snowman allografts met inclusion criteria at mean follow-up of 7.4±3.6 years, while 13 additional patients (15 knees; 88.2%) underwent multifocal OCA at mean follow-up of 6.4±3.9 years. All 9 patients who received isolated snowman OCA were to the medial femoral condyle. Reoperations were common with 44.4% (N=4) of the snowman group and 20% of multifocal OCA (N=3) undergoing at least 1 reoperation. There were 3 failures (33.3%) in the snowman technique group at a mean 7.7±5.5 years and 1 failure in the multifocal OCA group at 4.5 years. All 4 failures underwent TKA. Patients who underwent multifocal OCA demonstrated significant improvements in the International Knee Documentation Committee score, Knee Injury and Osteoarthritis subscores, Western Ontario and McMaster Universities Osteoarthritis Index subscores, and the Short-Form-12 physical component (P <0.05 for all). Patients who underwent snowman OCA demonstrated significant improvement in KOOS pain subscore and WOMAC overall scores (P<0.05 for both) Table 1].

Conclusion:

While in a small cohort, patients who underwent snowman OCA had a high rate of reoperation (44.4%) and a high rate of failure (33.3%). Comparatively, patients who underwent multifocal OCA had reoperation and graft survival rates comparable to published literature for focal OCA. [Table: see text]
Prospective Evaluation of Glenoid Bone Loss After First-Time and Recurrent Anterior Glenohumeral Instability Events
Authors: Dickens Jonathan F. , Slaven Sean E. , Cameron Kenneth L. , Pickett Adam M. , Posner Matthew A. , Campbell Scot , Owens Brett D.
Published: July 2018

Objectives:

Determining the amount of glenoid bone loss in patients following anterior glenohumeral instability events is critical to guiding appropriate treatment. One of the challenges in managing shoulder instability in young athletes is the absence of clear data showing the impact of each event. The purpose of this study was to prospectively determine the amount of bone loss associated with a single instability event, in the setting of both first-time and recurrent instability.

Methods:

We conducted a prospective cohort study of 714 athletes followed for four years. Baseline assessment included a subjective history of shoulder instability. Bilateral shoulder MRIs were obtained in all participants with and without a history of previous shoulder instability. The cohort was prospectively followed during the study period and those who sustained an anterior glenohumeral instability event were identified. A post-injury MRI was obtained and compared to the screening MRI. Glenoid width was measured for each patient’s pre- and post-injury MRI. The projected total glenoid bone loss was calculated and compared for patients with a prior history of shoulder instability.

Results:

Of the 714 athletes that were prospectively followed during the four-year period, 23 shoulders in 22 subjects sustained a first-time anterior instability event (5 dislocations, 18 subluxations), and six subjects with a previous history of instability sustained a recurrent anterior instability event (1 dislocation, 5 subluxations). On average, there was statistically significant glenoid bone loss (1.84 ± 1.47 mm) following a single instability event (p<0.001), equivalent to 6.8% (95% CI: 4.46%, 9.04%, range 0.71%-17.6%) of the glenoid width. Twelve shoulders (52%) demonstrated glenoid bone loss ≥ 5%, 4 shoulders demonstrated glenoid bone loss ≥13.5% and no shoulders had ≥20% glenoid bone loss after a first-time instability event. Pre-existing glenoid bone loss in subjects with a history of instability was 10.2% (95% CI: 1.96%, 18.35%, range 0.6% - 21.0%). This bone loss increased to 22.8% (95% CI: 20.53%, 25.15%, range 21.2% to 26.0%) following an additional instability event (P=0.0117). All six shoulders with recurrent instability had >20% glenoid bone loss.

Conclusion:

Glenoid bone loss of 6.8% was observed after a first-time anterior instability event. In the setting of recurrent instability, the total calculated glenoid bone loss was 22.8% with a high prevalence of bony Bankart lesions (5/6). The findings of this study support early stabilization of young, active subjects following a first-time anterior glenohumeral instability event. [Figure: see text][Table: see text]
Non-operative Management of Posterior Shoulder Instability: An Assessment of Survival and Predictors for Conversion to Surgery at 1 to 13 Years After Diagnosis
Authors: Woodmass Jarret Murray , Lee Julia , Johnson Nick R. , Camp Christopher L. , Dahm Diane L. , Krych Aaron John
Published: July 2018

Objectives:

Among patients treated non-operatively for 1 year following a diagnosis of posterior shoulder instability (PSI), little is known about the the incidence of surgery between 1-13 years after injury. The purpose of this study is to define the frequency and evaluate the factors predictive for late surgical intervention of symptomatic PSI.

Methods:

This study included a population-based cohort of 115 patients (14 females, 101 males) diagnosed with PSI between January 1994 and July 2012 with a minimum 5-years follow-up (mean:13.9 years; range: 5-23 years). Landmark survival analysis was performed to evaluate incidence of surgery after 1 year. Survival was estimated using Kaplan Meier method and predictors of late surgical intervention were analyzed using Cox proportional hazards regression.

Results:

A total of 61/115 (53%) patients were treated non-operatively for 1 year following diagnosis of PSI. Of these, 24/61 (39%) converted to surgery for symptomatic PSI. The overall survival free of surgery at 1 and 5 years was 53.0% (95% CI 434.7-63.0) and 37.1% (95% CI 29.1-47.1), respectively. BMI >35 (p=0.04, HR 3.3) was predictive for late conversion to surgery. Age, gender, occupation, or history of glenohumeral dislocation were not significant. Assessing surgery as a time dependent covariate, a patient undergoing surgery was at an increased risk for radiographic progression of osteoarthritis (p=0.02, HR=4.0, 95% CI 1.2-13.2).

Conclusion:

Conservative management was performed for at least one year in over half of patients diagnosed with PSI. However, long-term follow-up demonstrates that nearly 40% of these patients eventually require surgery. Increased BMI was predictive for late failure of while age, gender, history of dislocation and occupation did not show an effect. Patients who underwent surgery were at an increased risk of radiographic progression of arthritis.
Arthroscopic Superior Capsular Reconstruction in Males Provides Superior Outcomes to Reverse Total Shoulder or Debridement for Irreparable Rotator Cuff Tears
Authors: Tokish John M. , Kissenberth Michael J. , Shanley Ellen , Tolan Stefan John , Adams Kyle J. , Alexander Ryan , Babrowicz Sarah A. , Hawkins Richard J. , Thigpen Charles A.
Published: July 2018

Objectives:

Early results following arthroscopic superior capsular reconstruction(SCR) in patients with massive, irreparable rotator cuff tears are promising. However, no studies have compared patient reported outcomes between SCR or reverse total shoulder(rTSA) and rotator cuff debridement for these patients. Therefore, the purpose of this study was to compare 1-year outcomes between patients with massive irreparable rotator cuff tears who underwent a SCR, rTSA, or rotator cuff debridement with a concurrent biceps tenotomy or tenodesis.

Methods:

Patients(n=63) who underwent either SCR(n=21), rTSA(21), or cuff debridement(n=21) and biceps tenotomy or tenodesis for a massive, irreparable rotator cuff tear treated with a minimum 1-year follow up were retrospectively reviewed. Age, sex, BMI, smoking status, Charlson Index, Hamada classification, and ASES scores were recorded and compared using a multivariate ANOVA were used to compare between surgical approaches. A Chi Square analyses were used to compare sex distribution and the Charlson Deyo Index between groups (α=0.05).

Results:

Overall, patients across the 3 groups were not statistically different in age or follow up ASES score at minimum 14 month follow up ( P> 0.05). There was a significant interaction effect between surgery group and sex (P=0.02) on ASES score but not age ( P=0.08). Univariate F tests revealed that male patients who received an SCR displayed a 10-14% better outcome at follow up compared to other groups (Table 1) which exceeds the reported ASES score MCID.

Conclusion:

Our results show comparable results across surgical options for massive irreparable cuff tears with good patient reported outcomes. Male patients displayed clinically important greater ASES scores at 1 year follow up. Future studies should evaluate these preliminary results to assess if these preliminary results hold up at longer follow up times.
Suprapectoral vs. Intra Articular Biceps Tenodesis: A Comparison of Clinical Outcomes
Authors: Godshaw Brian M. , Kolodychuk Nicholas , Browning Benjamin Bryan , Williams Gerard , Burdette Rachel , Jones Deryk G.
Published: July 2018

Objectives:

The long head of the biceps tendon is a frequent pain generator within the shoulder. It is subjected to trauma and wear within the glenohumeral joint and within the intertubercular groove. Tenodesis of this tendon is a common treatment option for patients experiencing biceps tendon related pain. There are several different techniques to perform this procedure. Proximal intra-articular tenodesis can be performed but leaves the tendon within the intertubercular groove. Alternatively, suprapectoral tenodesis can be performed removing the tendon from the bicipital groove and sheath while avoiding conversion to an open procedure. Further, suprapectoral tenodesis limits complications associated with an open distally based incision. Several studies have compared these techniques to tenotomy or open-subpectoral tenodesis. This is the first study to directly compare patient outcomes between intra-articular and suprapectoral bicep tenodeses.

Methods:

Retrospective review of patients undergoing intra-articular or suprapectoral arthroscopic biceps tenodesis from 2010 - 2015. Clinical outcomes were measured at set intervals post-operatively (3 months, 6 months, and 12 months) and compared to pre-operative scores. Outcome measures included short form-12, both physical (PSF) and mental (MSF) component scores, and the American Shoulder and Elbow Surgeons score (ASES).

Results:

A total of 96 patients were available for this study, 43 had intra-articular tenodesis and 56 had suprapectoral tenodesis. There was no difference in functional outcomes between intra and extra articular biceps tenodesis at 1-year post-operative. The intra-articular group had a quicker improvement in scores with the greatest increase at 3 months post-operatively, specifically in PSF group (p=0.016): however, this difference leveled off at 1-year follow up (p=0.238). The intra-articular group had greater absolute scores at all measured time points, but not significantly. Both groups showed improvement in all outcome measures and there was found to be no difference in changes for ASES, PSF, or MSF (p=0.262, p=0.489, and p=0.907 respectively).

Conclusion:

This study demonstrates that both intra-articular and surpapectoral techniques are acceptable options for biceps tenodesis. Despite leaving the biceps tendon within the glenohumeral joint and intertubercular groove, the intra-articular technique offers similar improvement in outcome measures to the suprapectoral technique.
Endoscopic Repair of Partial Thickness Under-Surface Tears of The Abductor Tendon (pusta): Clinical Outcomes with Minimum Two-year Follow-up
Authors: Hartigan David Edward , Perets Itay , Ho Sherwin S.W. , Walsh John P. , Yuen Leslie , Domb Benjamin G.
Published: July 2018

Objectives:

To report the minimum two-year outcomes of trans-tendinous repairs of Partial Thickness Undersurface Tears of the Abductor (PUSTA) tendon using patient reported outcomes (PROs), visual analog scale (VAS), and patient satisfaction scores.

Methods:

All patients who underwent endoscopic trans-tendinous gluteus medius repair between October 2009 and May 2013 at one institution were prospectively evaluated. Exclusion criteria consisted of less than two-year follow-up, previous hip surgery, inflammatory arthritis, open surgery, full thickness abductor tear, and worker’s compensation patients. All patients had a documented pre-operative physical exam with strength testing (0-5) and observation of their gait. Patient satisfaction and PRO scores were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PRO scores collected were mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS. Preoperative strength and gait were compared to latest follow-up.

Results:

There were 25 patients that fit our criteria. Significant improvement in PRO scores were demonstrated for mHHS, HOS-ADL, HOS-SSS, NAHS, and VAS from 54.9-76.2, 50.2-80.6, 30.1-67.3, 51.9-82.4, and 7.1-2.7 respectively (p<0.001). There were 11 patients with objective weakness prior to surgery; seven of these patients moved up at least one strength grade by final follow-up. There were 14 patients who had a Trendelenbrug gait pre-operatively, 12 of them had a normal gait at latest follow-up (p-<0.001). Average patient satisfaction was 7.5. There were no revision surgeries, and no complications noted.

Conclusion:

PUSTA lesions can be treated successfully with endoscopic trans-tendinous repair preserving the intact attachment of superficial fibers of the gluteus medius. We recommend this treatment for partial undersurface tears recalcitrant to non-operative treatment, as patients demonstrated clinical benefit at greater than 2 years follow up that exceeds substantial clinical benefit and minimally clinical important difference.
Prevention of Elbow Injuries in Young Baseball Players: A 6-year Longitudinal Study
Authors: Kotoura Yoshihiro , Morihara Toru , Kida Yoshikazu , Sukenari Tsuyoshi , Furukawa Ryuhei , Hojo Tatsuya , Fujiwara Hiroyoshi , Kubo Toshikazu
Published: July 2018

Objectives:

Injuries in young baseball players are on the rise. However, there are few large-scale related to injury prevention activities. We have continued an injury prevention project in Kyoto, Japan since 2010. The aim of this study was to verify the preventive effect of our project.

Methods:

We offered medical screening of elbow for elementary and junior high school players. We examined their elbow manually, performed ultrasonography and guided the players how to check their elbow themselves. Additionally, we instructed baseball coaches and parents regarding injury prevention annually. In this study, a cumulative total of 2624 baseball players (mean age 11.0±0.6) who participated in our injury prevention project (2010-2016) were enrolled. We asked them to answer the questionnaire to investigate the experience of elbow pain and evaluated the tenderness of humeral medial epicondyle and range of motion. Ultrasonography of humeral capitellum and medial epicondyle was examined. Subjects with abnormalities on ultrasonography were further examined through radiographic study and osteochondritis dissecans of the humeral capitellum (OCD) was diagnosed. Humeral medial epicondyle apophysitis was diagnosed with abnormalities of ultrasonography, and physical findings. The annual incidence were investigated and analyzed statistically. P < 0.05 was considered significant for all statistical analysis.

Results:

The mean prevalence rate of OCD was 1.1% and flexion restriction was 12.3%. There were no significant differences in annual incidence. However, the experience rate of elbow pain was 14.4% in 2010 and 4.4% in 2016, tenderness of humeral epicondyle was 32.2% and 5.8%, extension restriction was 12.5% and 6.9%, and humeral medial epicondyle apophysitis was 22.1% and 5.3%, respectively, that significantly reduced year by year (Table 1).

Conclusion:

There has been increasing recognition for the importance of preventing the overuse injuries among young baseball players. However, large-scale and longitudinal evaluation studies for preventing elbow injuries have not been reported. The prevalence rates of elbow injuries have generally reduced year by year, which indicates that annual medical screening and educational project for young baseball players, coaches and parents would be an effective approach for preventing elbow injury. [Table: see text]
Jones Fractures Identified at the National Football League Scouting Combine: Assessment of Prognostic Factors, Computed Tomography Findings, and Initial Career Performance
Authors: Spang Robert C. , Haber Daniel B. , Beaulieu-Jones Brendin , Stupay Kristen , Sanchez George , Whalen James M. , Van Allen Joseph J. , Price Mark D. , Provencher Matthew T.
Published: July 2018

Objectives:

Jones fractures, which result in loss of playing time and subsequent dysfunction, remain a significant issue for elite contact athletes. The objectives of the present study are to (1) describe the epidemiology, surgical treatment, and impact on early National Football League (NFL) career of Jones fractures identified at the NFL Scouting Combine and (2) establish the value of computed tomography (CT) to determine healing following a Jones fracture in prospective NFL players.

Methods:

All players who attended the NFL Scouting Combine (2009-2015) were retrospectively reviewed to identify those who previously sustained a Jones fracture with position of play, treatment method, and number of missed collegiate games recorded. Overall mean draft pick, number of games started and played, snap percentage, and position-specific performance scores (Fantasy Score) were compared between Jones fracture athletes and controls without any major injury prior to the NFL Combine and during first three years of NFL career. A classification system, based on the grading of four individual quadrants (plantar, dorsal, medial, lateral), was applied by three orthopaedic surgeons.

Results:

Overall, the number of Jones fractures among athletes who attended the NFL Combine (2009-2015) was 72/2285 (3.2%) with all athletes treated via intramedullary (IM) screw fixation. Position-specific performance scores for players with a previous Jones fracture were lower than controls across all positions with a significant difference in running backs and defensive linemen. Subgroup CT scan analysis demonstrated a mean overall score of 2.5±1.3 with kappa values of 0.6 and 0.64 for inter- and intra-observer reliability, respectively. 16 Jones fractures (50%) were healed or nearly healed,12 (37.5%) were partially healed, and 4 (12.5%) showed little or no healing. The plantar cortex demonstrated least healing (56%), followed by the lateral cortex (46.9%).

Conclusion:

Although infrequent, Jones fractures are encountered at the NFL Combine with the highest prevalence at the tight end position and lowest at the running back position. Based on CT, 50% of all players with a previous Jones fracture demonstrate inhealing with least healing at the plantar and lateral cortices. Moreover, position-specific performance scores demonstrate worst performance at all positions for players with a previous Jones fracture versus controls.
Efficacy of an Arthroscopic Virtual Based Simulator for Orthopedic Surgery Residents by Year in Training
Authors: Yari Shahram , Jandhyala Chanakya , Sharareh Behnam , Athiviraham Aravind , Shybut Theodore B.
Published: July 2018

Objectives:

Arthroscopic virtual-reality stimulators are an attractive option for resident training and are increasing across training programs. However, no study has analyzed the utility of the simulator for trainees based on their post-graduate level of training (PGY-level). The primary aim of this study was to determine the utility of the ArthroSTM arthroscopic simulator for orthopedic trainees based on their level of training (to determine at what point in training the simulator offers the most benefit for trainees). We hypothesized that all levels would show similar improvements in performance following completion of the training modules.

Methods:

Eighteen orthopedic surgery residents performed pre-training diagnostic knee and shoulder tasks on the ArthoSTM simulator. Subjects completed a series of training modules, then repeated the diagnostic tasks. Mean composite scores were calculated. Group differences for discrete variables were evaluated using ANOVA (analysis of variance). Correlation coefficients (R2) were calculated for improvements in mean composite score as a function of subject year-in-training.

Results:

Average improvement in composite score for participants as a whole was 11.2 points [SD 10; p-value 0.0003] for the knee simulator and 14.9 points [SD 10.9; p-value 0.0352] for the shoulder simulator. When broken down by PGY-level, all groups showed improvement, with greater improvements seen for junior-level residents in the knee simulator and greater improvements seen for senior-level residents in the shoulder simulator. ANOVA for the score improvement variable in the knee simulator data amongst the different PGY-groups yielded an f-value of 1.640 (p-value 0.2258) and that for the shoulder simulator data amongst the different PGY-groups yielded an f-value of 0.2292 (p-value 0.917). The correlation coefficient (r2) was -0.866 for the knee score improvement and 0.887 for the shoulder score improvement (Image 1).

Conclusion:

We found that residents training on a virtual arthroscopic simulator made significant improvements in both knee and shoulder arthroscopic skills. Most importantly, we report for the first time that the knee simulator appears to be more beneficial for junior residents, while the shoulder simulator appears to be more beneficial for senior residents. Our study adds to the mounting evidence supporting virtual arthroscopic simulator-based training for orthopedic surgery residents.
Tunnel Bone Grafting in Revision Anterior Cruciate Ligament Reconstruction Cruciate Ligament Reconstruction
Authors: Owens Brett D. , Group Mars
Published: July 2018

Objectives:

Bone grafting of lytic or malpositioned tunnels may be required in ACL revision reconstructive surgery. Little is known of the characteristics of these patients and the impact of this practice on the results following revision ACL reconstruction (rACLR). The purpose of this study was to report the differences in preoperative characteristics, surgical assessment, and 2-year outcomes for rACLR patients undergoing tunnel bone grafting procedures.

Methods:

1205 patients who underwent rACLR were enrolled in the Multicenter ACL Revision Study (MARS) consortium between 2006 and 2011, comprising the prospective cohort. Two-year questionnaire follow-up was obtained on 989 (82%), while telephone follow-up was obtained on 1112 (92%). Subjects undergoing previous or concurrent bone grafting of ACL tunnels were compared with subjects without tunnel grafting. Group characteristics were compared using chi-squared and ANOVA statistical analyses.

Results:

At total of 158 subjects (13%) underwent tunnel grafting procedures compared to 1,047 who did not. Of these, 95 underwent prior staged bone grafting and 63 underwent concomitant bone grafting. Femoral bone grafting was performed on 31 subjects, tibial grafting in 39, and combined grafting in 88. Significant differences were noted in baseline patient reported outcomes (KOOS sports/recreation, KOOS QOL, and Marx activity) favoring the control group. Significant differences were noted in the number of prior ACL reconstructions, prior graft type, prior femoral fixation method, prior femoral and tibial tunnel locations between the two groups. Significant differences were also noted in the current choice of ACL revision reconstruction technique including graft selection, method of femoral tunnel drilling, femoral fixation, tibial fixation and aperture assessment. Both femoral and tibial bone quality was deemed to be abnormal in 20% of revision surgeries in the bone graft group, compared with 6 and 7% in control group (both p<0.001). Two-year patient reported outcomes were inferior in the bone graft group (KOOS sports/recreation, KOOS QOL, and Marx activity).

Conclusion:

Tunnel bone grafting was performed in 13% of ACL revision patients. These patients had inferior baseline and 2-year patient reported outcomes and activity levels compared to patients not undergoing bone grafting.
Advanced Patellar Tendinopathy Is Associated With Increased Rates of Bone-Patellar Tendon-Bone Autograft Failure in Anterior Cruciate Ligament Reconstructions
Authors: Lazarides Alexander Leandros , Alentorn-Geli Eduard , Vinson Emily , Samuelsson Kristian , Toth Alison P. , Moorman Claude T. , Garrett William E. , Taylor Dean C.
Published: July 2018

Objectives:

Revision ACL reconstruction can be potentially devastating for a patient. As such, it is important to identify prognostic factors placing patients at increased risk for re-rupture. There are no data on the effects of patellar tendonopathy on failure of ACL reconstruction when using bone-patellar tendon-bone (BPTB) autograft. The purpose of this study was to investigate the effects of patellar tendinopathy on the risk of graft failure in primary ACL reconstruction when using BPTB autograft.

Methods:

All patients undergoing ACL reconstruction at a single institution from 2005 to 2015 were examined. A total of 168 patients undergoing primary BPTB autograft for primary ACL reconstruction were identified. Patient MRIs were reviewed for the presence and grade of patellar tendinopathy by two musculoskeletal fellowship-trained radiologists; both were blinded to the aim of the study, patient demographics, surgical details and outcomes. Patients were divided into two cohorts: failure and non-failure of the ACL graft, defined as rupture of the ACL graft. Statistical analyses were run to examine the role of patellar tendinopathy in failure of ACL reconstruction using BPTB autograft.

Results:

At a mean follow up of 18 months, there were 7 (4.2%) patients with graft failure. Moderate or high-grade patellar tendinopathy was associated with ACL graft failure (p=0.011). Age, gender and side of reconstruction were not associated with risk of re-rupture, though the majority of patients in our study who failed were younger than 20 years of age. Use of patellar tendon with moderate to severe tendinopathy was associated with a relative risk of rupture of 6.1 as compared to autograft tendon without tendinopathy (95% CI 1.37-27.3).

Conclusion:

The presence of moderate or severe patellar tendinopathy significantly increases the risk of graft failure when using BPTB autograft for primary ACL reconstruction. Consideration of patellar tendinopathy should be made when determining the optimal graft choice for patients undergoing primary ACL reconstruction with autograft tendons.
Performance and Return to Sport Following Latissimus Dorsi and Teres Major Injuries in Professional Baseball Pitchers
Authors: Erickson Brandon J. , Chalmers Peter Nissen , D’Angelo John , Ma Kevin , Romeo Anthony A.
Published: July 2018

Background:

Latissimus dorsi and teres major (LD/TM) tears are becoming an increasing common cause of injury and disability amongst professional baseball pitchers.

Purpose:

To determine the rate of return to sport (RTS) and performance upon RTS in professional baseball pitchers following LD/TM tears treated both operatively and non-operatively, and to see if there is a difference in RTS rate and performance between players who sustained a LD/TM tear and matched controls within each treatment group.

Hypothesis:

There is a high rate of RTS in professional baseball pitchers following LD/TM tears with no significant difference in rate of RTS or performance, specifically related to the primary outcome performance variables of earned run average (ERA), WHIP ((walks +hits)/innings pitched), fielding independent pitching (FIP), and wins above replacement (WAR)) between cases and controls for both operative and non-operative treatment.

Methods:

All professional baseball pitchers who sustained a LD/TM tear between 2011-2016 were included. Demographic and performance data (pre and post injury) for each player was recorded. Performance metrics were then compared between cases and matched controls within both operatively non-operative treatment.

Results:

Overall 120 pitchers sustained a LD/TM tear; 42 (35%) were playing at the major league level at the time of injury. The majority of players (107 (89.2%)) were treated non-operatively. The average time to return to the same level of competition for pitchers treated non-operatively was 170.7 +/- 169.7 days while for those treated operatively was 536.6 +/- 300.4 days. Of the players treated with surgery, the mean time from injury to surgery was 97.5+/-115.5 days (range 12-453 days). The RTS rate among players treated non-operatively and operatively was identical at 75%. Players treated non-operatively had no change in ERA, FIP, or WAR following injury but had a higher WHIP after injury (p=0.039). Players treated operatively had no change in any measured performance metrics following surgery. No difference existed between cases and controls in the primary performance variables

Conclusion:

LD/TM tears occur more frequently than previously reported. The majority of LD/TM tears in professional baseball pitchers are treated non-operatively. RTS rate for professional baseball pitchers following LD/TM tears treated operatively or non-operatively is 75%. No significant difference in performance was seen in these pitchers following tear/surgery compared to matched controls.