bluuebunny/crossref_metadata_2025 huggingface dataset:
Forearm Flexor Injuries in Major League Baseball Players: Epidemiology, Performance, and Associated Injuries
Authors: Hodgins Justin Lane , Donohue Steve , Littlefield Mark , Schuk Mike , Ahmad Christopher S.
Published: July 2017

Objectives:

The flexor-pronator mass provides dynamic support to the valgus stresses in the throwing elbow and is protective to the ulnar collateral ligament (UCL). Despite evidence highlighting the importance of the forearm flexor muscles in baseball pitching, no studies have reported the epidemiology, return to play, or associated injuries in elite baseball players. The purpose of this study examine the incidence, treatment, and outcomes of forearm flexor injuries in both Major and Minor League Baseball pitchers.

Methods:

Injury data attributed to forearm flexor injury in Major League Baseball (MLB) and minor league teams was reviewed from 2010 to 2014. This included the numbers of players, seasonal timing of injury, days of competition missed, pre and post-injury performance data, and subsequent elbow surgery. Performance data collected consisted of ERA (earned run average), WHIP (walks plus hits per innings pitched), walks, strikeouts, and percent strikes.

Results:

In MLB, 134 forearm flexor injuries occurred with a mean player age of 28.6 years and 111 (82.8%) were pitchers. In the minor leagues, 629 injuries occurred with a mean age of 22.8 years where 494 (78.5%) were pitchers. The highest percentage of injuries occurred in the month of July in both MLB (17.2%) and the minor leagues (17%). The median time spent on the disabled list (DL) for MLB players was 42 days (mean 128.1) compared to 28 days (mean 105.7) in the minor leagues. Of the players in MLB who sustained a forearm injury, subsequent injuries included 50 shoulder (37.3%), 48 elbow (35.8%), and 24 forearm (17.9%) injuries. Over the study period, 26 (19.4%) MLB and 56 minor league players (8.9%) required UCL reconstruction within 365 days of sustaining a forearm injury. Performance declined in virtually all categories in the season leading to the injury when compared to the previous season (n = 75) and significant differences were present in walks plus hits per inning pitched (WHIP) (from 1.24 to 1.34, P = 0.04) and strike percentage (63% to 62%, P = 0.036).

Conclusion:

Flexor-pronator injuries are responsible for considerable time on the DL in elite pitchers. Injury may be preceded with declines in performance and be associated with subsequent injuries to the shoulder and elbow. [Table: see text]
Risk Factors for Reoperation and Performance-based Outcomes following Surgical Fixation of Foot Fractures in the Professional Athlete: A Cross-Sport Analysis
Authors: Singh Sameer Kumar , Larkin Kevin , Kadakia Anish R. , Hsu Wellington
Published: July 2017

Objectives:

Professional athletes are predisposed to fractures of the foot due to large stresses placed on the lower extremity; these players are concerned with efficiently returning to play at a high level. Return to play rates following operative treatment have been previously reported, yet performance outcomes following such treatment are generally unknown in this population. The purpose of this study was to assess and compare performance-based outcomes following foot fracture fixation among professional athletes of the 4 major North American sports.

Methods:

Athletes in the National Basketball League (NBA), National Football League (NFL), (Major League Baseball) MLB, and National Hockey League (NHL) undergoing operative fixation of a foot fracture were identified through a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were collected for each sport. League participation and game performance were collected before and after surgery. Statistical analysis was performed with significance accepted as P ≤ .05.

Results:

A total of 77 players undergoing 84 procedures met the inclusion criteria. Overall, 98.7% of players were able to return to play with an average time to return across all sports of 172 ± 22 days. Players returned to preoperative performance levels within one season of surgery. Six players (7.8%) sustained re-fracture requiring reoperation, all of whom were in the NBA. Percentage of games started during the season after primary surgical treatment was a predictive factor for re-injury (99% vs 40%, p = .001).

Conclusion:

Athletes returned to play following foot fracture fixation at a high rate with excellent postoperative performance levels, regardless of sport and fracture location. NBA athletes sustaining fifth metatarsal and navicular fractures are at a higher risk of re-injury compared to other athletes. Returning to high levels of athletic participation soon after surgery may predispose athletes to re-fracture and subsequent reoperation.
Magnetic Resonance Imaging Comparison of Repaired versus Non-Repaired Hip Capsule in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Double-Blind, Randomized Controlled Trial
Authors: Mei-Dan Omer Y. , Strickland Colin , Garabekyan Tigran , Chadayammuri Vivek , Brick Matthew , Kraeutler Matthew John
Published: July 2017

Objectives:

Techniques used in hip arthroscopy continue to evolve and controversy surrounds the need for capsule repair following surgical intervention. The purposes of this study were to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair.

Methods:

A multicenter clinical trial was performed with 35 patients (50 hips) undergoing hip arthroscopy for treatment of FAI. Each hip was preoperatively randomized to capsular repair versus non-repair. MRI evaluation was performed by a radiologist at 6 and 24 weeks postoperatively. Patients and the radiologist were blinded to the randomization. Capsular defect size and the thickness of the capsule at the capsulotomy site and at locations both proximal and distal to the defect were recorded on each scan to determine their change over time.

Results:

Compared to patients without capsular repair, those with capsular repair demonstrated significantly decreased mean capsular gapping at articular and muscular portions of the hip capsule at 6 weeks postoperatively (p < 0.001). This difference normalized between the two cohorts by 24 weeks postoperatively, with a significantly decreased mean capsular gapping at articular and muscular attachment sites of the hip capsule compared to 6 weeks postoperatively (p < 0.03). Defects were readily apparent on MRI imaging in regions where the capsule was not repaired. In contrast, irregular capsular thickening without a discrete defect was visible in most cases where the capsule was repaired at the time of arthroscopy. The appearance was variable after 24 weeks. The capsular defects that did close universally showed closure of the defect beginning at the muscular side of the capsule with bridging of capsular tissue then filling in on the articular side.

Conclusion:

Arthroscopic hip capsule repair results in significantly less capsule gapping at 6-week follow-up compared with non-repair, though the difference in gap size normalizes by 24-week follow-up.
Meniscal Repair Outcomes in Revision ACL Reconstructions
Authors:   MARS Group
Published: July 2017

Objectives:

Meniscal preservation has been demonstrated to contribute to long term knee health. This has been a successful intervention in the isolated and ACL reconstructed patient. The results of meniscus repair in the setting of revision ACL reconstruction have never been documented to any significant extent. The MARS group offers with its large cohort of revision ACL reconstructions the opportunity to explore this issue.

Methods:

The MARS Group was assembled with the aim of determining what impacts outcome in an ACL revision setting, and to identify potentially modifiable factors that could improve these outcomes. This collaboration consists of a group of 83 sports medicine fellowship trained surgeons across 52 IRB approved sites. Surgeons are a near equal mix of academic and private practitioners. Surgeons document surgical technique and intraarticular findings including meniscal and chondral damage and their treatment.All revision ACL reconstruction with meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by both phone and email to determine whether any subsequent surgery had occurred to either knee since their initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify pathologic condition and treatment.

Results:

1215 patients were enrolled. 235 repairs were performed in 218 patients (19.5% of the cohort): 170 were medial, 65 lateral and 17 medial and lateral. 178 (76%) were performed with all-inside techniques. 17 repairs failed by 2 year follow up: 15 medial (8.8%; 13 all inside, 2 outside in) and 2 lateral (3.1%; both all inside). 4 of the medial failures were treated in conjunction with a subsequent repeat revision reconstruction.

Conclusion:

Meniscus repair in the revision setting is a successful treatment choice when appropriate. Failure rates for medial and lateral tears were both less than 10% and consistent with primary ACL reconstruction meniscus repair success rates. Medial tears underwent reoperation for failure at a statistically significant higher rate than lateral tears.
Subsequent Surgery and Prevalence of Osteoarthritis Following Arthroscopic Meniscus Posterior Root Repair: Association with Patient Age and Body Mass Index
Authors: Lamplot Joseph D. , Lillegraven Olivia , Wojahn Robert D. , Brophy Robert H.
Published: July 2017

Objectives:

Posterior meniscus root tears disrupt the tibial plateau attachment, leading to a loss of hoop stresses and significant increases in tibiofemoral contact forces. As a result, there is growing interest in surgical repair of these tears. The purpose of this study is to report rates of recurrent surgery and prevalence of osteoarthritis following posterior meniscus root repairs, and associated patient factors, in a North American population.

Methods:

Arthroscopic posterior meniscus root repair using a pullout trans-tibial suture method was performed by a single surgeon in the United States. Eligible patients d the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported any subsequent surgeries at minimum two-year follow-up. Patients were categorized as having clinical OA based on their KOOS score. When available, post-operative radiographs were evaluated for radiographic OA using the Kellgren-Lawrence classification and the OA Research Society International (OARSI) atlas. The association of factors with the incidence of clinical and radiographic OA was evaluated.

Results:

Follow up was collected on 28 of 32 eligible patients (87.5%) at a mean follow up of 2.46 years (range 2.05-3.76 years). At time of surgery, mean age was 44.6 years and mean BMI was 32.7. At follow-up, two patients had undergone subsequent surgery (7%). 14 patients (50.0%) met KOOS criteria for clinical OA. Among the 11 patients with available follow up radiographs, 4 (36%) met OARSI atlas criteria for knee OA. For medial posterior root tears, patients over the age of 45 with BMI over 35 were significantly more likely to develop clinical (85.7% versus 35.0%, p=0.033) and radiographic OA (80.0% versus 0.0%, p=0.015), and undergo additional surgery (40% versus 0%, p=0.036).

Conclusion:

Arthroscopic repair of posterior root tears in a North American population has a low rate of subsequent surgery despite developing clinical and radiographic OA. Older and heavier patients have a higher incidence of clinical and radiographic OA. Further study is needed to determine optimal treatment for root tears in these patients. [Table: see text]
Partial Meniscectomy Provides No Benefit for Symptomatic Degenerative Medial Meniscus Posterior Root Tears
Authors: Krych Aaron John , Johnson Nick R. , Mohan Rohith , Dahm Diane L. , Levy Bruce A. , Stuart Michael J.
Published: July 2017

Objectives:

Medial meniscus posterior root tears (MMPRTs) are recognized as a source of pain and dysfunction, but treatment options remain a clinical challenge. Currently, outcomes are unknown following partial meniscectomy for these lesions. To determine (1) the efficacy of partial meniscectomy to treat MMPRTs compared to a matched group of non-operatively treated MMPRTs, and (2) risk factors for worse clinical and radiographic outcome.

Methods:

This retrospective comparative study was performed to include 27 patients with MMPRTs that were treated with arthroscopic partial meniscectomy (PMM) and a minimum 2-year follow-up. These patients were then matched by age, gender, and BMI to a group of 27 patients with MMPRTs treated non-operatively (control group). Demographic data, radiographic findings, final Tegner and IKDC scores were obtained and compared between the two groups. Risk factors for worse clinical and radiographic outcome in the PMM group alone, including age, sex, BMI, initial K-L grade, subchondral edema, and insufficiency fracture on MRI were determined.

Results:

Overall, 54 patients were included in the study. 27 patients (10M: 17F) with a mean age of 55±9 and a mean BMI of 32.8±5.3 were treated with PMM and followed for a mean of 5.5±2 years (range 2.3-9.3 years). In the PMM group, final median Tegner score was 3, mean IKDC scores were 67.8±20, median KL grades on weight-bearing AP films demonstrated progressive arthritis (median grade 1 to 2, p=0.001) and more patients had grade II or higher arthritis at final follow-up than baseline (91.3% vs. 36% p<0.01. Overall, 14 of the 27 patients (52%) treated operatively progressed to total knee arthroplasty at a mean of 54.3 months. When comparing the PMM and control groups, there was no significant difference in final median Tegner scores, mean IKDC, median K-L grades, progression to arthroplasty, or overall failure rate. Following PMM, female patients had lower final IKDC scores (74.6±16.7 vs. 44.00±2.8, p=0.02) compared to males, as well as a higher rate of arthroplasty (70.6% vs, 20.0%, p=0.009). Higher BMI correlated with lower IKDC scores (r=-0.91, p=0.01) and meniscal extrusion was associated with higher rate of arthritis at final follow-up (100% vs. 57%, p=0.02).

Conclusion:

Partial meniscectomy for a MMRT provides no benefit in halting arthritic progression. Patients who undergo arthroscopic debridement for MMPRTs still progress to significant arthritis, poor clinical outcomes and a high arthroplasty rate (52%) at over 5-year follow-up. Compared to a non-operative control group, there was no benefit in any subjective or objective outcome measures from the arthroscopic partial meniscectomy. Female patients, higher BMI, and presence of meniscus extrusion were associated with worse outcomes and a higher rate of subsequent knee arthroplasty.
Performance-Based Outcomes after Operative Management of Athletic Pubalgia / Core Muscle Injury in National Football League Players
Authors: Lynch Thomas Sean , Kosanovic Radomir , Gibbs Daniel Bradley , Park Caroline , Bedi Asheesh , Larson Christopher M. , Ahmad Christopher S.
Published: July 2017

Objectives:

Athletic pubalgia is a condition in which there is an injury to the core musculature that precipitates groin and lower abdominal pain, particularly in cutting and pivoting sports. These are common injury patterns in the National Football League (NFL); however, the effect of surgery on performance for these players has not been described.

Methods:

Athletes in the NFL that underwent a surgical procedure for athletic pubalgia / core muscle injury (CMI) were identified through team injury reports and archives on public record since 2004. Outcome data was collected for athletes who met inclusion criteria which included total games played after season of injury / surgery, number of Pro Bowls voted to, yearly total years and touchdowns for offensive players and yearly total tackles sacks and interceptions for defensive players. Previously validated performance scores were calculated using this data for each player one season before and after their procedure for a CMI. Athletes were then matched to control professional football players without a diagnosis of athletic pubalgia by age, position, year and round drafted. Statistical analysis was used to compare pre-injury and post-injury performance measures for players treated with operative management to their case controls.

Results:

The study group was composed of 32 NFL athletes who underwent operative management for athletic pubalgia that met inclusion criteria during this study period, including 18 offensive players and 16 defensive players. The average age of athletes undergoing this surgery was 27 years old. Analysis of pre- and post-injury athletic performance revealed no statistically significant changes after return to sport after surgical intervention; however, there was a statistically significant difference in the number of Pro Bowls that affected athletes participated in before surgery (8) compared to the season after surgery (3). Analysis of durability, as measured by total number of games played before and after surgery, revealed no statistically significant difference.

Conclusion:

National Football League players who undergo operative care for athletic pubalgia have a high return to play with no decrease in performance scores when compared to case-matched controls. However, the indications for operative intervention and the type of procedure performed are heterogeneous. Further research is warranted to better understand how these injuries occur, what can be done to prevent their occurrence, and the long term career ramifications of this disorder.
Sports Hernia: Diagnosis, Management and Operative Treatment
Authors: Emblom Benton A.
Published: July 2017

Objectives:

Athletic Pubalgia, also known as sports hernia or core muscle injury, causes significant dysfunction in athletes. Increased recognition of this specific injury distinct from inguinal hernia pathology has led to better management of this debilitating condition. We hypothesize that patients who undergo our technique of athletic pubalgia repair will recover and return to high-level athletics.

Methods:

Using our billing and clinical database, patients who underwent sports hernia repair by single surgeon at a single institution were contacted for Harris hip score, functional outcome, and return to play data.

Results:

Of 101 patients who met criteria, 43 were contacted. 93% of patients were able to return to play at an average of 4.38 mo. Normal activities were rated at 95.5% and athletic function was rated at 88.9%. Negative predictors were female sex, multiple operations, and prior inguinal hernia repair. Overall complication rate was 4.6%, and reoperation rate was 4.6%.

Conclusion:

Our method of adductor to rectus abdominis turn up flap is a safe procedure with high return to play success. Patients who had previously undergone inguinal hernia repair or other hip/pelvic related surgery had a worse outcome.
Medial Posterior Capsular Plication Reduces Anterior Shoulder Instability Similar to Remplissage without Restricting Motion in the Setting of an Engaging Hill Sachs Defect
Authors: Werner Brian C. , Chen Xiang , Camp Christopher L. , Kontaxis Andreas , Dines Joshua S. , Gulotta Lawrence Vincent
Published: July 2017

Objectives:

In the present study, the efficacy of a posterior medial capsular plication in addition to Bankart repair was examined as an arthroscopic management strategy for an engaging Hill-Sachs defect.

Methods:

8 fresh-frozen human cadaveric shoulders were utilized for the study. After testing baseline translation and motion, 30% Hill Sachs lesions were created in each specimen. Three experimental groups were created: 1) isolated bankart repair (HSD), 2) bankart repair with remplissage (RM) and 3) bankart repair with posterior medial capsular plication (PL). Biomechanical testing was performed to determine anterior translation, range of motion and Hill Sachs engagement. Translation and motion measurements were normalized to the baseline laxity measures for each specimen.

Results:

Significant reduction in anterior translation was noted at 60° of abduction and 60° of ER for both PL and RM groups compared to the HSD group throughout most of the joint loads tested (p < 0.05) [Figure 1], but no significant differences were noted between PL and RM at any load. The RM group had significantly less normalized ER at 60° of abduction compared to the HSD and PL groups (p < 0.05). There were no differences in IR between the groups. All 8 HSD specimens engaged, while no specimens in the RM and PL groups engaged (p < 0.001).

Conclusion:

In a cadaveric model, medial posterior capsular plication as an adjunct to Bankart repair offers similar resistance to anterior translation and Hill-Sachs engagement as compared to remplissage in the setting of an engaging Hill-Sachs defect. Medial posterior capsular plication results in less restriction of external rotation compared to remplissage without any significant limitation of internal rotation.
Validity and Responsiveness of the Single Alpha-numeric Evaluation (sane) for Shoulder Patients
Authors: Thigpen Charles A. , Shanley Ellen , Tokish John M. , Kissenberth Michael J. , Tolan Stefan John , Hawkins Richard J.
Published: July 2017

Objectives:

The is an ever-increasing demand within the emerging health care arena to demonstrate the efficacy of orthopedic interventions. Widespread implementation of patient reported outcomes are limited in part due to the barriers of clinical infrastructure and resources in a busy orthopedic practice. Prior studies have shown the single alpha-numeric evaluation (SANE) score to correlate at a single point in time with the American Shoulder and Elbow Surgeons(ASES) score. However, no study has validated the SANE in terms of test-retest reliability, responsiveness or clinical utility. Therefore, the purpose of this study was to validate SANE compared to the ASES across a sample of patients with the most common orthopedic shoulder diagnoses.

Methods:

Shoulder patients (n=105 age=52.7 ± 1.2; female=67) undergoing rotator cuff repair (cuff=44), total shoulder replacement (TSA=23), or physical therapy (PT=38) were administered the SANE and ASES less than 14 days apart prior to surgery and again at their 3 month follow up from initial care or surgery. Interclass Correlation Coefficients (ICC(2,1)) and standard error of the measure(SEM) were used to evaluate the test-retest reliability of the SANE and the validity between the SANE and ASES scores. An ANOVA (treatment group by time) was used to evaluate the responsiveness to treatment, and a Receiver Operating Curve was used to establish the minimally important clinical difference (MCID) for the SANE compared to the ASES (α =0.05).

Results:

The SANE demonstrated good reliability (ICC(2,1) =0.76 ± 3.4) similar to the ASES (ICC(2,1) =0.82 ± 3.4) pre-treatment. The SANE demonstrated good agreement with the SANE across all treatment groups (Cuff= ICC(2,1) 0.85 ± 3.4; TSA- ICC(2,1) =0.72 ± 5.2;PT- ICC(2,1) =0.82 ± 2.9) pre and post treatment. The SANE displayed similar responsiveness to the ASES after treatment (Figure 1) with similar mean change and standard deviations within each treatment group. The ROC curve revealed an area under the curve of .79 (SE, 0.62; P<.001) and a cutoff of 9.5% on the SANE with a sensitivity of 83% and a specificity of 31% to establish the MCID.

Conclusion:

Our study is the first to demonstrate the SANE is valid across a range of common shoulder diagnoses to assess patient outcomes across operative and non-operative treatment for shoulder complaints. The MCID of 9.5% is similar to the ASES (11%) suggesting that the SANE is a simple and efficient tool to assess treatment effects for shoulder disorders. Future studies are warranted to confirm these results and compare across other body parts and diagnoses.
Return to Play After Multi-Ligament Knee Injuries in National Football League (NFL) Athletes
Authors: Bakshi Neil K. , Khan Moin , Finney Fred Tolbert , Stotts Jeffrey , Sikka Robby Singh , Bedi Asheesh
Published: July 2017

Objectives:

Return to play (RTP) of NFL athletes following isolated ACL tears has been reported in the literature. However, there have been no studies reporting on RTP of NFL athletes following multi-ligament knee injuries. The authors hypothesize that NFL athletes with multi-ligament knee injuries will have lower RTP rates and longer time to RTP compared to athletes with isolated ACL tears, as reported in the literature. We also hypothesize that athletes with ACL and MCL injuries will have higher RTP rates and shorter time to RTP compared to athletes with an ACL tear and a PCL and/or LCL tear(s).

Methods:

NFL injury surveillance data was reviewed for all multi-ligament knee injuries between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited due to reasons unrelated to the injury such as suspension, unrelated injury, or personal matters. Extracted data included injury, RTP, time to return to play (months), number of games played, percent of possible games played, and performance.

Results:

51 NFL athletes were found to have multi-ligament knee injuries between 2000 and 2016 that met inclusion and exclusion criteria. 47.1% (24/51) of athletes had ACL and MCL tears. 52.9% (27/51) of athletes had ACL and PCL and/or LCL tears. Of the players with ACL and PCL/LCL tears, there were 8 frank knee dislocations. The overall return to play rate following multi-ligament knee injuries was 62.7%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, while the athletes with ACL and PCL/LCL tears had an RTP rate of 55.6% (p=.26). Athletes with frank knee dislocations had a 50% RTP rate. Mean time to RTP for all 51 athletes was 11.9 ± 3.52 months. The mean time to RTP for athletes with ACL/MCL injuries was 10.4±1.6 months compared with 13.7±4.3 for those with combined ACL and PCL/LCL injuries, and for frank dislocations was 20 ±6.1 (p<.001). Athletes with ACL/MCL injuries were more likely to return to prior performance levels 46% vs 18% compared to those with ACL and PCL/LCL injuries (p < .001).

Conclusion:

This study is the first to provide important prognostic information for NFL players sustaining multi-ligament knee injuries. The RTP rate for athletes with multi-ligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a higher likelihood of returning to prior performance than athletes with combined ACL and PCL/LCL tears.
Adductor Canal vs. Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial
Authors: Xerogeanes John W. , Premkumar Ajay , Godfrey William , Samady Heather , Gottschalk Michael Brandon , Dalwadi Poonam , Karas Spero G.
Published: July 2017

Objectives:

Peripheral nerve blocks are commonly performed as a part of multimodal pain control regimens, especially for outpatient surgical procedures. Femoral nerve blocks (FNB) have been the traditional gold standard nerve block in the setting of ACL reconstruction; however, adductor canal blocks (ACB) have emerged as a promising alternative. While early findings show less quadriceps strength deficits following adductor canal blocks, results comparing analgesia from adductor canal nerve blockade to femoral nerve blockade are inconsistent. The purpose of this study was to compare adductor canal nerve block to femoral nerve block for pain control following ACL reconstruction.

Methods:

This study was a prospective, single-blinded, randomized, controlled, parallel single-center trial. 77 adult patients receiving ACL reconstruction were enrolled between December 2015 and April 2016. All patients received either a traditional FNB or an ACB immediately prior to surgery. All patients were given a post-operative smartphone application to record medication usage, pain scores, hours of sleep, and time to straight leg raise for one week following ACL reconstruction.

Results:

Of the 77 patients recruited, 64 patients were analyzed (83.1%). 13 patients were lost to follow-up. There were no statistically significant differences in post-operative pain, home medication use, recovery room time, or hours of sleep between the two study groups. Patients receiving an ACB had significantly shorter time to straight leg raise and reported greater satisfaction with acute post-operative pain control.

Conclusion:

Adductor canal nerve blockade had similar analgesic outcomes, improved post-operative mobility, and greater patient satisfaction with pain control than femoral nerve blockade. Our study supports the use of adductor canal block as a viable alternative to femoral nerve block following ACL reconstruction.
The Relation Between Volume of ACL Reconstruction and Future Knee Surgery
Authors: Schairer William W. , Marx Robert G. , Dempsey Brendan , Ge Yile , Lyman Stephen
Published: July 2017

Objectives:

A large body of volume-outcomes literature has now demonstrated a strong positive relationship between increasing annual surgical volume and improved patient outcomes across a wide variety of surgical procedures, including orthopedics. Unfortunately, most previous research has been limited by methods that arbitrarily assign cutoffs of “low” or “high” volume that may not be clinically meaningful. Thus, it is unknown how many cases should be performed each year to maintain competence in the procedure. The purpose of this study was to determine meaningful annual volume thresholds for ACL reconstruction.

Methods:

We identified ACL reconstructions performed in New York (NY) State hospitals between 2003 and 2014 using the NY-SPARCS hospital in-patient and ambulatory surgery database. These cases were followed until subsequent ipsilateral knee surgery (revision ACL, meniscus/cartilage surgery, or total knee replacement) or until the end of the study period, December 31, 2014. Surgeon volume was calculated as the number of ACL reconstructions performed by that surgeon in the 365 days prior to the case of interest. Stratum specific likelihood ratio (SSLR) analysis is a method to identify clinically meaningful cutpoints by correlating volume with outcomes through evaluating a receiver operating characteristic (ROC) curve. A Cox proportional hazards model was used to measure the effect of surgeon annual ACL reconstruction volume on risk of subsequent ipsilateral knee surgery adjusting for patient characteristics: age, sex, race, and insurance type.

Results:

Between 2003 and 2014, 77,899 ACL reconstructions were performed in NY State by 1,316 surgeons. Mean patient age was 30.8+/- 12.5 years, and patients were 61% male, 65% white race, and 74% covered by private insurance. SSLR analysis revealed 2 meaningful cutpoints in risk of subsequent ipsilateral knee surgery: 17 & 35 cases per year. The Cox proportional hazards model demonstrated a 29% decreased risk of ipsilateral knee surgery for those ACL reconstructions by surgeons performing >35 cases per year compared to those performing <17 (Hazard Ratio [HR] 1.29, 95% confidence interval [CI] 1.23-1.35, p<0.001). Further, surgeons in the mid-range group performing 18-35 ACL reconstructions per year demonstrated a 6% decreased risk of subsequent ipsilateral knee surgery (HR 1.06, 95% CI 1.01-1.11, p=0.014).

Conclusion:

This study identified three ranges for ACL reconstruction volume that result in different clinical outcomes. The highest cutpoint was 35 ACL reconstructions per year, which resulted in the lowest percentage of future knee surgery. These findings suggest orthopedic surgeons should perform a minimum of 35 ACL reconstructions per year to maintain clinical competence with the procedure.
Femoral Tunnel Drilling Method: Revision Risk After Anterior Cruciate Ligament Reconstruction
Authors: Tejwani Samir , Prentice Heather A. , Wyatt Ronald , Maletis Gregory B.
Published: July 2017

Objectives:

The femoral tunnel in anterior cruciate ligament reconstruction (ACLR) can be created by the transtibial (TT) or tibial-independent (TI) methods. An anatomically located femoral tunnel can be more consistently achieved by TI methods, which include the medial portal (MP) and lateral (outside-in, retrodrill) techniques. Non-anatomic graft placement in ACLR may result in postoperative instability and meniscal or chondral pathology. An anatomically located graft may be subjected to higher postoperative physiologic forces than one placed non-anatomically. The purpose of this study was to examine isolated primary ACLR and determine the risk of aseptic revision based on femoral tunnel drilling method.

Methods:

A retrospective cohort study was conducted using an integrated U.S. healthcare system’s ACLR Registry to identify primary isolated unilateral cases from 2009 to 2014. Bilateral, double-bundle and multi-ligament reconstructions were excluded. Patients were divided into two groups based on femoral tunnel drilling method, TT or TI. Drilling method was evaluated as a risk factor for aseptic revision, with adjustment for age, sex, body mass index (BMI), race, and graft type using multivariable Cox proportional-hazards regression models.

Results:

19,022 primary ACLR patients were included, of whom 6,991 (36.8%) were younger than 22 years old, 11,772 (61.9%) were male, 7,632 (40.1%) had a BMI < 25 kg/m2, 8,894 (46.8%) were White, and 7,403 (38.9%) received an allograft. There were 12,336 (64.9%) ACLRs performed using TI techniques (MP n=10,149, lateral n=2,187) and 6,686 (35.1%) using the TT method. Usage of TI approaches increased from 34% of all ACLR in 2009 to 84% in 2014. The cumulative reoperation probability at 5-year follow-up was lower in the TI group, 7.5% (95% CI 6.6-8.4), compared to the TT group, 8.2% (95% CI 7.4-9.1). After adjusting for the covariates, the cumulative failure probability at 5-year follow-up was higher in the TI group, 6.3% (95% CI 5.6-7.2), compared to the TT group, 5.0% (95% CI 4.3-5.7). [Figure 1] After adjusting for the covariates, the TI group had a higher risk for aseptic revision than the TT group (HR=1.4. 95% CI=1.1-1.7).

Conclusion:

In the largest known study of its type examining femoral tunnel drilling method for primary ACLR, after adjusting for age, sex, BMI, race and graft type, TI techniques were found to have a 1.4 times higher risk of revision than the TT method. Surgeons should be aware that ACLR grafts placed more anatomically by TI methods have a higher risk of revision, possibly due to higher postoperative physiologic graft forces experienced.
Predictors of a Symptomatic Knee Following ACL Reconstruction: 84 Month Follow Up
Authors: Ware J. Kristopher , Akelman Matthew , Owens Brett D. , Fadale Paul D. , Hulstyn Michael J. , Fleming Braden C.
Published: July 2017

Objectives:

ACL reconstruction is effective in restoring knee stability and returning a majority of patients to sports. However, these patients remain at a higher risk of developing knee OA and a subset of patients have persistent pain. It is currently unknown what pre-operative and early post-operative measures can be used to help predict outcomes following ACL reconstruction at 7 years. The purpose of this study was to compare clinical data, patient-reported outcomes and imaging findings of knee arthrosis between symptomatic and asymptomatic subject at 84 month follow up after primary ACL reconstruction.

Methods:

We reviewed prospectively collected data from our previously published randomized controlled trial of outcomes of ACL reconstruction. Clinical, radiographic, and patient-reported outcomes were collected pre-operatively, and at 1,3,5, and 7 years post-operatively. Patient-reported outcome measures included SF-36 and KOOS. Imaging studies were used to evaluate medial joint space width, Osteoarthritis Research Society International (OARSI) radiographic score, and Whole-Organ Magnetic Resonance Imaging Score (WORMS). Symptomatic subjects were defined as those with KOOS-pain subscores, measured at 84 months post-operatively, two standard deviations below the mean for healthy athletic patients with a history of a knee ligament injury. These subjects were compared to the remainder of the study group to identify factors predictive of poor outcomes.

Results:

patient-report outcome measures were available for 72 patients at 84 month follow up. Of these, 7 subjects had KOOS pain scores less than 72.5 and were considered the symptomatic subgroup. Low pre-operative KOOS-ADL and KOOS-sports subscores were associated with low KOOS pain scores at 7 year follow up. SF-36 scores were lower at most time periods in the symptomatic group. In addition, OARSI scores were worse at 1,5, and 7 years, and WORMS showed greater signs of cartilage injury at 3 and 5 years post operatively in the symptomatic group. Medial joint space width was found to be significantly decreased in symptomatic patients at 7 year follow up.

Conclusion:

Low preoperative KOOS-ADL and KOOS-sports subscores were found to be associated with worse pain outcomes in primary ACL reconstruction patients at 84 months post-operatively. Additionally, multiple post-operative measures were found to be indicative of the ACL reconstruction patients that would have a symptomatic knee. WORMS collected at 3 and 5 years was shown to identify those subjects that would be symptomatic at 7 years. Also, radiographic changes were evident in this group with significantly decreased medial joint space width relative to control subjects.
Labral Width is Associated with Increased Risk of Severe Cartilage Damage on the Femoral Head
Authors: Locks Renato , Briggs Karen K. , Bolia Ioanna , Philippon Marc J. , Chahla Jorge
Published: July 2017

Objectives:

The objective of this study was to compare the risk of Outerbridge grade 3 or 4 defects in hips with different labrum thickness in patients undergoing primary hip arthroscopy for FAI.

Methods:

Between 2005 and 2014, patients who underwent hip arthroscopy by a single surgeon and met the inclusion criteria were included in this study. The labrum was measured with an arthroscopic ruler at 3 points that corresponded with 9 o’clock, 12 o’clock and 3 o’clock during hip arthroscopy from the chondrolabral junction to the edge of the labrum. Four specific measurements were stablished as a parameter for the labral thickness (4, 5, 6 and 7 cm). The lower labral thickness measurement of the three performed was used as a guide for the groups classification. Patients were compared based on the labrum thickness regarding the prevalence of Outerbridge grade III and IV on the femoral head (FH) and acetabulum. Patients were excluded if they had previous arthroscopic or open hip surgery, had inmeasurement of the labrum or had insurgical data.

Results:

Eight hundred forty-three patients were included on this study, the average age was 31.7 years old, regarding gender, 468 females and 367 males. There was no difference in the sample characterization variables. Hips with small labrums were more likely to have a grade 3 or 4 chondral defect on the femoral head. First, comparing patients with 7 and 6 mm of labral thickness, patients measuring 6mm had an 1.7 relative risk for severe chondral damage on the FH [1.04 to 2.7] p=0.033. Second, when patients with 7 and 5 mm are compared, patients with 5mm of labral thickness have a 4.3 relative risk[2.2 to 4.3]p<0.001. Lastly, when the comparison between 7 and 4 mm is established, patients measuring 4mm have a relative risk 4.5 for severe chondral damage on the femoral head. No difference in the prevalence of chondral damage was found between patients measuring 7 and 8 mm. There was no difference in the prevalence of grade 3 and 4 defects on the acetabulum between the all the labrum measurements evaluated. Regarding the labral procedure performed, patients with 4mm of labral width in at least one point, 28% underwent labral reconstruction. On the other hand, in patients with 7, 6 and 5 mm of labral width, 98.6, 94.9 and 85.8% underwent labral repair, respectively.

Conclusion:

Patients with femoroacetabular impingement with a labrum wide measuring less than 6mm have a higher likelihood to have Grade III and IV chondral damage on the femoral head, but not on the acetabular cartilage. Patients with less than 5mm had a likelihood for labral reconstruction need. [Table: see text]
Do Outcomes of Osteochondral Allograft Transplantation Differ Based on Patient Sex: A Comparative Matched Group Analysis of Male and Female Patients
Authors: Frank Rachel M. , Lee Simon , Poland Sarah Glen , Cole Brian J.
Published: July 2017

Objectives:

Osteochondral allograft transplantation (OAT) is being performed with increasing frequency, though to date, the impact of patient sex on outcomes and failure rates has not been assessed. The purpose of this study was to determine clinical outcomes for male versus female patients undergoing OAT.

Methods:

A retrospective review of prospectively collected data of patients who underwent OAT by a single surgeon with a minimum follow-up of 2 years was conducted. Males who underwent OAT were compared to a matched group of females who underwent OAT (age ± 3 years, gender, BMI ± 5 kg/m2, the presence of previous ipsilateral knee surgeries, and the presence of meniscal transplantation). The reoperation rate, failure rate, timing of reoperation, procedures performed, findings at surgery, and patient reported outcome scores were reviewed. Failure was defined by revision OAT, conversion to knee arthroplasty, or gross appearance of graft failure at 2nd look arthroscopy. Descriptive statistics, fisher’s exact or chi-square testing, and Mann-Whitney U testing were performed, with P<0.05 set as significant.

Results:

A total of 98 patients (average age 32.1±9.9 years, 49 males, 49 females) who underwent OAT with an average follow-up of 4.7±2.33 years (range, 2.1-12.1) were included. These patients underwent an average of 2.6±1.8 prior surgical procedures on the ipsilateral knee prior to OAT. A total of 33 patients underwent reoperation at an average 2.4±2.4 years, with 27% (9/33) undergoing additional reoperations (range, 1-2 additional reoperations). Male patients did not have significantly different reoperation rates (42% vs. 27%), time to reoperation (2.50±2.12 vs. 2.29±1.71 years) or failure rates (20% vs. 8%) compared to female patients (P>0.05 for all). Both male and female patients showed significant improvement in Lysholm, IKCD, KOOS, WOMAC, and SF-12 physical subscale as compared to preoperative values (P>0.05 for all for both groups). The SF-12 mental subscale was not significantly improved at final follow-up for either group (P>0.05). There were no significant differences in patient reported outcomes scores at most recent follow-up when comparing males and females. Males demonstrated significantly larger defect areas compared to females (371.65±168.89 vs. 310.63±117.15 mm2, P=0.037), though the defect:condyle ratio was not significantly different (male: 0.19 vs. female: 0.20, P>0.05).

Conclusion:

Males and females have similar clinical outcomes at 5 years following OAT, though males trended toward increased reoperation rates and increased failure rates. This data implies that overall, similar favorable outcomes may be expected for patients regardless of sex, with an 86% graft survival rate at 5 years. This information can be used to counsel patients when being offered OAT as part of a knee joint preservation strategy.
Medial and Lateral Distal Femoral Condyle Osseous and Articular Cartilage Topography to Determine Graft Matching
Authors: Yanke Adam Blair , Urita Atsushi , Meyer Maximilian A. , Inoue Nozomu , Cole Brian J.
Published: July 2017

Objectives:

Osteochondral allograft transplantation (OAT) for osteochondral defects of the knee typically matches donor laterality and condyle to the recipient defect location. This study aimed to compare subchondral osseous and articular cartilage surface topography between medial femoral condyle (MFC) and lateral femoral condyle (LFC) donor grafts.

Methods:

Human femoral hemi-condyles (11 MFC and 6 LFC) were divided into 2 groups: MFC donor to MFC defect (MM) and LFC donor to MFC defect (LM). Computed tomography images were exported into point-cloud models using Mimics software. Articular cartilage and subchondral bone were individually segmented, creating two distinct point clouds. Circular articular cartilage defects (15 mm diameter and 25 mm diameter) were created in the MFC samples at 3 locations (0°, 45° posterior, and 90° posterior. Medial and lateral donor models were virtually placed into the MFC defect model so that articular surfaces were flush. Distance of articular surface between donor and defect and resulting osseous mismatch were calculated (Figure 1).

Results:

Mean articular surface mismatch was <0.5 mm in both groups, suggesting similar surface matching. Group LM exhibited greater osseous mismatch than Group MM for both 15 mm defects (mean least distance: 0.91 ± 0.45 mm, 0.74 ± 0.20 mm, P = 0.04) and for 25 mm defects (mean least distance: 1.05 ± 0.39 mm, 0.74 ± 0.16 mm, P < .01). Osseous mismatch between groups in the 25 mm defect became significant at 0° (MM, 0.66 ± 0.36 mm and LM, 1.10 ± 1.00 mm, P < .01) and at 45° (MM, 0.76 ± 0.15 mm and LM, 1.06 ± 0.47 mm, P = 0.05).

Conclusion:

LFC donor grafts provide acceptable cartilage surface matching for MFC defects but have greater osseous mismatch than MFC grafts. This mismatch increases with increasing graft size. The implications of subchondral bone mismatch are yet to be determined.
Unique Biology of Shoulder Cartilage in Comparison to the Cartilage Obtained from the Knee and Ankle Joints
Authors: Chubinskaya Susan , Meyer Maximilian A. , Urita Atsushi , Verma Nikhil N. , Romeo Anthony A. , Yanke Adam Blair , Cole Brian J.
Published: July 2017

Objectives:

Glenohumeral joint (GHJ) arthritis in relatively young active patients presents a considerable clinical challenge. Little is known regarding the biology and reparative capacity of GHJ articular cartilage and how it compares to other diarthrodial joints. The objectives of the current study were to 1) describe the histological and morphological appearance of human normal GHJ cartilage; and 2) investigate cellular responses of GHJ cartilage to interleukin-1β (IL-1β), in comparison to cartilage obtained from the knee and ankle of the same donors.

Methods:

GHJ, knee (femoral condyle) and ankle (talus) cartilage was obtained through the Gift of Hope Organ and Tissue Donor Network (Itasca, IL) from nine human donors with no documented history of joint diseases (58-75 yo, both genders). Gross morphology of each joint was assessed using Collins grading on a scale 0 to 4. Cartilage explants (3 mm diameter) were removed from each joint, cultured for 48 hours with or without interleukin-1β (IL-1β; 0.1ng/ml or 10ng/ml), and processed for histology with Safranin O, proteoglycan (PG) synthesis/content, and PCR for key extracellular matrix (ECM) genes: Col2, Agg, and SOX9. Results were compared between uncultured and cultured controls and across all three included joints.

Results:

Unlike grossly normal (Collins grades 0-1) knee and ankle cartilage, grossly normal GHJ cartilage with an intact surface displayed signs of subtle structural changes: loss of Safranin O in the upper layer and in the ECM and increased staining around chondrocytes suggesting elevated metabolic activity. Differences became more apparent with higher Collins grades or in the presence of IL-1β. Treatment with IL-1β (both doses) resulted in more than 2-fold inhibition of PG synthesis in GHJ cartilage (p<0.05), while only high dose IL-1β had the same effect on the knee or ankle cartilage. At the control level, expression of Col2 and Sox9 was comparable between all types of cartilages; Agg expression was the highest in the ankle cartilage. IL-1β increased Agg expression in humeral cartilage and Agg and Col2 genes in glenoid cartilage.

Conclusion:

GHJ cartilage appears to be more susceptible to catabolic processes than cartilage in the knee or ankle. Elevated expression of key ECM genes in the presence of pro-inflammatory mediator IL-1β may suggest an attempted, but failing repair. This study provides new insight into the histological and biochemical characteristics of GHJ cartilage, both of which may contribute to challenges associated with its reconstruction.