Body Mass Index Between 15 and 30 Does Not Influence Patient-Reported Outcomes After Anterior Cruciate Ligament Surgery Using a 10-mm-Diameter Bone-Tendon-Bone Graft.

Purpose: To investigate the relation between body mass index (BMI) and outcomes after anterior cruciate ligament reconstruction (ACLR) using 10-mm-diameter bone-patellar tendon-bone grafts. Methods: In this retrospective study, the Surgical Outcome System was used to measure patient-reported outcomes before and after ACLR between 2015 and 2019. The inclusion criteria consisted on patients undergoing primary ACLR performed by the senior surgeon, with recorded age of 15 years or older and BMI of 15.0 to 30. The exclusion criteria included revisions, concomitant procedures, age younger than 15 years, and unknown BMI. Patients were divided into cohorts to evaluate the Marx Activity Rating Scale (MARS), Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores at various time points from injury to 2 years postoperatively. Results: A total of 137 patients (100 male and 37 female patients) with an average age of 33 years (95% confidence interval, 30.6-35.4 years) and average BMI of 23.58 (95% confidence interval, 23.1-24.0) were divided into those with a BMI of 15 to 23.4 (group A, n = 69) and those with a BMI of 23.5 to 30 (group B, n = 68). A significant difference in MARS scores was found between the BMI groups before treatment, with mean scores of 11.55 (group A) and 9.41 (group B) (P = .011), and Tegner scores showed significance at 2 years, with scores of 6.45 and 5.41 for groups A and B, respectively (P = .009). Daily function scores were all insignificant. Female patients exhibited no significant differences across any patient-reported outcome measures or time points. Contrarily, male patients showed a significant difference in pretreatment MARS scores (14.30 in group A vs 9.96 in group B, P = .011). Additionally, scores at 2 years depicted Tegner values of 7.40 in group A versus 5.30 in group B (P = .012) and IKDC values of 96.92 in group A versus 90.47 in group B (P = .048). All results for female and male patients aged 30 years or younger indicated no significance. Conclusions: Regardless of patient age or sex, BMI is not significantly associated with patient-reported outcomes after ACLR using 10-mm-diameter bone-patellar tendon-bone grafts. Level of Evidence: Level III, retrospective cohort study.

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology.

Purpose: To investigate the influence of lateral meniscal and cartilage pathology on the outcome after anterior cruciate ligament (ACL) reconstruction in patients who participate in pivoting sports. Methods: Using a single-surgeon patient registry, patients undergoing an anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee scales. Patients were divided into 3 groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty. Results: A total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, we found that Marx scores were greater in patients who additionally underwent a partial lateral meniscectomy at 1 year (P = .016). There were no significant differences between the ACL-only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the patients with red-white zone tears with the patients with white-white zone tear, we found there were no significant differences when compared with the ACL-only control. There were no significant differences appreciated between groups using the International Knee Documentation Committee, Lysholm, and Tegner scales. Conclusions: ACL reconstruction using bone-patellar tendon-bone autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient-reported outcomes compared with if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly greater Marx scores at 1 and 2 years' postoperatively. Level of Evidence: Level III, retrospective cohort study.

Establishing Normal Variances and Expectations for Quadriceps Limb Symmetry Index Benchmarks Based on Time from Surgery After Anterior Cruciate Ligament Reconstruction.

The anticipated timeline for muscle strength as well as return to running and sports are some of the most common inquiries by patients undergoing anterior cruciate ligament reconstruction. Despite the popularity of this procedure, the answers to these inquiries are not well described in the literature. The purpose of this study was to evaluate the range of quadriceps strength percentage and function benchmarks at various points after anterior cruciate ligament reconstruction surgery based on sex, age, and graft. Design: Observational Cohort Study. Methods: Patients who underwent anterior cruciate ligament reconstruction (ACLR) were evaluated at various points after their surgery with handheld dynamometer assessments. Additional hop and balance testing was performed and patients were evaluated for clearance for running and sport via a physical therapist directed functional movement assessment (FMA). The progression of quadriceps symmetry throughout the postoperative period was examined with multi-level models, estimates of time to reach 70%, 80%, and 90% quadriceps symmetry were obtained from the fitted model. Results: A total of 164 patients were evaluated. Patients either received bone-tendon-bone (BTB) autograft (n=118) or BTB allograft (n=46) for their ACL graft. Average age was 31.1 years-of-age (SD: 13.6). Males undergoing ACLR using BTB autograft (n=53) were able to achieve 80% quadriceps symmetry earlier than females (n=65) (5.7 months vs 7.1 months), were cleared to return to run sooner (5.6 months vs 6.8 months) and passed an FMA exam earlier (8.5 months vs 10 months). Males undergoing ACLR with allograft (n=13) were able to achieve 80% quadriceps symmetry earlier than females (n=33) (3.9 months vs 5.4 months) and were cleared to run sooner (4.5 months vs 5.8 months). Conclusion: Patients undergoing BTB autograft obtain 80% quadriceps symmetry at an average of 5.7 months for males and 7.1 months for females. Individuals under the age of 25 obtain their quadriceps symmetry faster and are cleared to return to running faster than individuals over 25. Male sex is associated with decreased amount of time to obtain clearance for running and for full activity. Male sex is associated with decreased amount of time to regain quadriceps symmetry however this was not significant. Level of Evidence: 4 (Case series).

Anterior Cruciate Ligament Reconstruction Using Allograft in Adults Older Than the Age of 40 Years Shows Similar Patient-Reported Outcomes Between Male and Female Patients.

Purpose: To evaluate patient-reported outcomes in patients undergoing anterior cruciate ligament (ACL) reconstruction using allograft in patients 40 years of age or older divided by sex. Methods: Patients age 40 years of age or older who underwent ACL reconstruction by the same surgeon using allograft via anteromedial portal technique were retrospectively identified. Patient-reported outcomes (International Knee Documentation Committee [IKDC], Knee Injury and Osteoarthritis Outcome Score, Tegner, Lysholm, Marx, and Single Assessment Numeric Evaluation) were evaluated and recorded, and outcomes were analyzed by sex. Results: In total, 159 patients undergoing primary ACL reconstruction were reviewed. Two-year outcomes were obtained. All patients noted improvement in patient-reported outcome measures. Male patients had overall greater postoperative patient-reported outcomes measures at all time points for IKDC, Tegner, Lysholm, Marx, and Single Assessment Numeric Evaluation scores; however, the only significant time points were IKDC 6 months (P = .016), 1 year (P = .012) and Marx 1 year (P = .007) and 2 year (P = .016). Knee Injury and Osteoarthritis Outcome Score scores similarly showed greater postoperative scores at all time points and statistical significance at 3 months (P = .002), 6 months (P = .033), and 1 year (P = .031). Conclusions: ACL reconstruction in individuals older than the age of 40 years using allograft results in good outcomes compared with preoperative status. Patient-reported outcomes were similar between male and female patients regarding most patient-reported outcome measures. Level of Evidence: Level III, retrospective cohort study.

Editorial Commentary: The Statistical Fragility Index of Medical Trials Is Low By Design: Critical Evaluation of Confidence Intervals Is Required.

The Fragility Index (FI) provides the number of patients whose outcome would need to have changed for the results of a clinical trial to no longer be statistically significant. Although it's a well-intended and easily interpreted metric, its calculation is based on reversing a significant finding and therefore its interpretation is only relevant in the domain of statistical significance. Its interpretation is only relevant in the domain of statistical significance. A well-designed clinical trial includes an a priori sample size calculation that aims to find the bare minimum of patients needed to obtain statistical significance. Such trials are fragile by design! Examining the robustness of clinical trials requires an estimation of uncertainty, rather than a misconstrued, dichotomous focus on statistical significance. Confidence intervals (CIs) provide a range of values that are compatible with a study's data and help determine the precision of results and the compatibility of the data with different hypotheses. The width of the CI speaks to the precision of the results, and the extent to which the values contained within have potential to be clinically important. Finally, one should not assume that a large FI indicates robust findings. Poorly executed trials are prone to bias, leading to large effects, and therefore, small P values, and a large FI. Let's move our future focus from the FI toward the CI.

Hemoglobin A1c Levels >6.6% Are Associated With Higher Postoperative Complications After Anterior Cruciate Ligament Reconstruction.

Purpose: To investigate the relation between hemoglobin A1c (HbA1c) levels and postoperative complications after primary anterior cruciate ligament reconstruction (ACLR). Methods: A retrospective review was performed of consecutive patients with an isolated anterior cruciate ligament tear, preoperative diagnosis of diabetes, and documented HbA1c within 90 days of primary ACLR between 2000 and 2019. Data collected included demographic and surgical characteristics, 90-day medical complications, and subsequent surgeries on the ipsilateral knee. A receiver operating curve was constructed for each HbA1c level in relation to postoperative complications and the optimal cutoff identified via Youden's J statistic. Multivariable logistic regression was performed to assess the relation between postoperative complications and age, sex, graft type, diabetes subtype, and HbA1c. Results: Nineteen patients (7 females, 12 males) fulfilled inclusion criteria with preoperative HbA1c ranging from 5.5 to 10. Complications included septic knee (n = 1) and cyclops lesions requiring arthroscopic lysis (n = 3). Patients with HbA1c of 6.7% or higher were 25 times more likely to experience any postoperative complication (P = .04) and 16 times more likely to require lysis of adhesions (P = .08). On multivariable regression, HbA1c remained significantly associated with any complication (P = .005) and developing arthrofibrosis (P = .02) independent of age, sex, graft type, and diabetes subtype. Conclusions: Diabetic patients undergoing primary ACLR with a preoperative HbA1c of 6.7% or higher were 25 times more likely to require repeat surgical intervention for a postoperative complication. These complications included arthrofibrosis and infection. Strict glycemic control may help minimize the risk of postoperative complications after ACLR. Level of Evidence: Level III, retrospective cohort study.

Effect of Tibiofemoral Rotation Angle on Graft Failure After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Coronal and sagittal malalignment of the knee are well-recognized risk factors for failure after anterior cruciate ligament (ACL) reconstruction (ACLR). However, the effect of axial malalignment on graft survival after ACLR is yet to be determined. PURPOSE: To evaluate whether increased tibiofemoral rotational malalignment, namely, tibiofemoral rotation angle (TFA) and tibial tubercle-trochlear groove (TT-TG) distance, is associated with graft failure after ACLR. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: In this retrospective matched control study of a single center's database, 151 patients who underwent revision ACLR because of graft failure (ACLR failure group, defined as symptomatic patients with anterior knee instability and an ACL graft tear appreciated on magnetic resonance imaging [MRI] and confirmed during arthroscopic surgery) were compared with a matched control group of 151 patients who underwent primary ACLR with no evidence of failure after ≥2-year follow-up (intact ACLR group). Patients were matched by sex, age, and meniscal injury during primary ACLR. Axial malalignment was assessed on preoperative MRI through the TFA and the TT-TG distance. Sagittal alignment was measured through the posterior tibial slope on MRI. The optimal TFA cutoff associated with graft failure was identified by a receiver operating characteristic curve. The Kaplan-Meier curve with log-rank analysis was performed to evaluate the influence of the TFA on ACLR longevity. RESULTS: The mean age was 25.7 ± 10.4 years for the ACLR failure group and 25.9 ± 10.0 years for the intact ACLR group. Among all the included patients, 174 (57.6%) were male. In the ACLR failure group, the mean TFA was 5.8°± 4.5° (range, -5° to 16°), while it was 3.0°± 3.3° (range, -3° to 15°) in the intact ACLR group (P < .001). Neither the TT-TG distance nor the posterior tibial slope presented statistical differences between the groups. The receiver operating characteristic curve suggested an optimal TFA cutoff of 4.5° for graft failure (area under the curve = 0.71; P < .001; sensitivity, 68.2%; specificity, 75.5%). Considering this a threshold, patients who had a TFA ≥4.5° had 6.6 times higher odds of graft failure compared with patients with a TFA <4.5° (P < .001). Survival analysis demonstrated a 5-year survival rate of 81% in patients with a TFA <4.5°, while it was 44% in those with a TFA ≥4.5° (P < .001). CONCLUSION: An increased TFA was associated with increased odds of ACLR failure when the TFA was ≥4.5°. Measuring the TFA in patients with ACL tears undergoing reconstruction may inform the surgeon about additional factors that may require consideration before ACLR for a successful outcome.

Tramadol Provides Similar Pain Relief and a Better Side Effect Profile than Oxycodone (or Hydrocodone) Alone or in Combination With Tramadol After Anterior Cruciate Ligament Reconstruction or Arthroscopic Knee Debridement.

Purpose: To evaluate whether tramadol provides similar postoperative pain relief after anterior cruciate ligament (ACL) reconstruction surgery or arthroscopic debridement surgery compared to oxycodone (or hydrocodone) or a combination of tramadol and oxycodone. Methods: Patients over the age of 14 undergoing ACL surgery or arthroscopic debridement surgery performed by the same surgeon were provided a postoperative pain diary over the first 10 postoperative days. Patients were either provided tramadol, oxycodone (or hydrocodone), or a combination of tramadol in addition to oxycodone (or hydrocodone). Pain scores were measured on visual analog scale (VAS), including average pain, maximum pain, and minimum pain throughout the day. Additionally, side effects and number of over-the-counter analgesics were recorded. Results: 121 patient surveys were reviewed. Tramadol alone for ACL with autograft provided lower average pain scores on postoperative day 1-3 (VAS 3.3 vs oxycodone 6.1 and hybrid of 5.1) with lowest maximum pain on postoperative day 1 (VAS 5.3 vs oxycodone 6.6 and hybrid 5.1) and the lowest number of average nights awakened by knee pain (3.6 vs oxycodone 6.0 and hybrid 8.5). Tramadol alone provided the lowest number of days of constipation (3 vs oxycodone 4.68 and hybrid 4.08), nausea (0.42 vs oxycodone 1.48 and hybrid 1.72), and dizziness (0.68 vs oxycodone 0.84 vs hybrid 1.28). Individual medication group breakdown of ACL surgery with allograft, as well as arthrosopic knee debridements did not have a large enough quantity to have three separate comparison groups. Conclusions: Tramadol provides similar, and in most cases better, pain relief for ACL reconstruction and arthroscopic knee debridements compared to oxycodone (or hydrocodone) alone or a combination of tramadol with oxycodone (or hydrocodone), while providing a lower side-effect profile. Clinical Relevance: Alternative analgesic therapies outside of traditional opioids (like oxycodone and hydrocodone) are lacking in popularity or reputation. This retrospective comparative study cohort evaluation can help provide clinicians an alternative analgesic therapy for various knee surgeries that have comparable pain relief with less addictive properties and less side effects.

Fellow Efficiency During Anterior Cruciate Ligament Reconstruction Improves Over Time, Yet Is Less Than Experienced Physician Assistant But With No Significant Difference in Patient-Reported Outcomes.

Purpose: To evaluate the intraoperative efficiency and patient outcomes of anterior cruciate ligament reconstruction (ACLR) assisted by a sports medicine fellow over the course of the academic year compared with an experienced physician assistant (PA). Methods: A single-surgeon cohort of primary ACLRs with either bone-tendon-bone autograft or bone-tendon-bone allograft (without any other significant time-consuming procedures such as meniscectomy/repair) were evaluated using a patient registry system over 2 years assisted by an experienced PA compared with an orthopaedic surgery sports medicine fellow. There were 264 primary ACLRs included in this study. Outcomes included evaluation of surgical time, tourniquet time, and patient-reported outcome measures. Results: The surgical efficiency of the fellow (as measured by surgical time and tourniquet time) improved over each academic quarter. Patient-reported outcomes between the 2 first-assist groups showed no significant difference over 2 years with both ACL graft groups combined. ACLRs assisted by the PA showed shorter tourniquet times by 22.1% and shorter total surgical times by 11.9% compared with the sports medicine fellows when both grafts were combined (P < .001). The surgical and tourniquet times (minutes) for the fellow (standard deviation of surgical time 19.5-25.0 and tourniquet time 19.5-25.0) did not average out to be more efficient in any of the 4 quarters of the year compared with the PA-assisted group (standard deviation of surgical time 14.4-14.8 and tourniquet time 14.8-22.4). Autografts showed more efficient tourniquet (18.7%) and skin-to-skin surgical times (11.1%) in the PA group compared with the fellow group (P < .001). Allografts showed more efficient tourniquet (37.7%) and skin-to-skin surgical times (12.8%) in the PA group compared with the fellow group (P < .001). Conclusions: The surgical efficiency of the fellow during primary ACLRs improves over the academic year. Patient-reported outcomes are similar in cases assisted by the fellow compared with an experienced physician assistant. Cases assisted by the PA were performed more efficiently compared with the sports medicine fellow. Clinical Relevance: The intraoperative efficiency of a sports medicine fellow objectively improves over the academic year for primary ACLRs but may not be as efficient as an experienced advanced practice provider; however, there appears to be no significant differences in patient-reported outcome measures between the 2 groups. This helps quantify the time commitment for attendings and academic medical institutions as the "cost of education" of trainees such as fellows.

Editorial Commentary: Blood Flow Restriction Therapy Prior to Anterior Cruciate Ligament Reconstruction: Small Effects Require Accurate Measurements.

A recent research study showed that blood flow restriction (BFR) therapy was safe and well tolerated but failed to demonstrate efficacy as a modality that provides greater gains in quadriceps strength when added to a standard home program in patients awaiting anterior cruciate ligament (ACL) reconstruction. Despite employing a validated method of measurement, the results were highly variable, indicating the need for measurements with sufficient accuracy to detect the small, but potentially meaningful, gains in quadriceps strength that's been attributed to BFR. The results inform future investigations of BFR prior to ACL surgery by demonstrating the need for accurate methods of measurements when the anticipated effects are small.

Return to Play After Shoulder Surgery in Professional Baseball Players: A Systematic Review and Meta-analysis.

Background: The current literature lacks an updated review examining return to play (RTP) and return to prior performance (RTPP) after shoulder surgery in professional baseball players. Purpose: To summarize the RTP rate, RTPP rate, and baseball-specific performance metrics among professional baseball players who underwent shoulder surgery. Study Design: Systematic review; Level of evidence, 4. Methods: A literature search was performed utilizing the PubMed, MEDLINE, and CINAHL databases and according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were English-language studies reporting on postoperative RTP and/or RTPP in professional baseball players who underwent shoulder surgery between 1976 and 2016. RTP rates, RTPP rates, and baseball-specific performance metrics were extracted from qualifying studies. A total of 2034 articles were identified after the initial search. Meta-analysis was performed where applicable, yielding weighted averages of RTP and RTPP rates and comparisons between pitchers and nonpitchers for each type of surgery. Baseball-specific performance metrics were reported as a narrative summary. Results: Overall, 26 studies featuring 1228 professional baseball players were included. Patient-level outcome data were available for 529 players. Surgical interventions included rotator cuff debridement (n = 197), rotator cuff repair (RCR; n = 43), superior labrum from anterior to posterior repair (n = 124), labral repair (n = 103), latissimus dorsi/teres major (LD/TM) repair (n = 21), biceps tenodesis (n = 17), coracoclavicular ligament reconstruction (n = 15), anterior capsular repair (n = 5), and scapulothoracic bursectomy (n = 4). Rotator cuff debridement was the most common surgical procedure, while scapulothoracic bursectomy was the least common (37.2% and 0.8% of interventions, respectively). Meta-analysis revealed that the RTP rate was highest for LD/TM repair (84.5%) and lowest for RCR (53.5%), while the RTPP rate was highest for LD/TM repair (100.0%) and lowest for RCR (27.9%). RTP and RTPP rates were generally higher for position players than for pitchers. Nonvolume performance metrics were unaffected by shoulder surgery, while volume statistics decreased or remained similar. Conclusion: RTP and RTPP rates among professional baseball players were modest after most types of shoulder surgery. Among surgical procedures commonly performed on professional baseball players, RTP and RTPP rates were highest for LD/TM repair and lowest for RCR.

Ulnar-Sided Digital Nerve Tumor of the Thumb in the Professional Baseball Player Who Uses Grip-Adjusting Batting Equipment: A Report of 2 Cases.

Neuropathy of the ulnar digital nerve of the thumb is a relatively rare clinical entity. We report 2 cases of ulnar-sided digital nerve tumors of the thumb in 2 professional baseball players who routinely used grip-adjusting batting equipment. Symptomatic relief was achieved with nonsurgical treatment that allowed both players to continue playing during critical times during their season. We postulate that there may be an association with the grip-adjusting batting equipment and the development of digital neuropathy.

Return to Sport after Surgical Treatment of Lisfranc Injuries in Athletes: A Retrospective Case Series.

INTRODUCTION: A Lisfranc injury can be a devastating injury in athletes, and if inadequately treated, may lead to chronic pain and loss of function. The purpose of this study was to determine the rate and time until return to sport after surgical fixation for a ligamentous Lisfranc injury. We hypothesized that open reduction and screw fixation of a ligamentous Lisfranc injury can be a successful treatment in the athletic population and allow patients to return to sport at close to their preinjury level of play. METHODS: All patients who were analyzed underwent repair of a ligamentous Lisfranc injury with open reduction and screw fixation by a single surgeon, were between 18 - 40 years old at time of their final follow up, and were identified as being an athlete (either recreational or competitive). Eligible patients were given a questionnaire that included if they were able to return to sport, time until return to sport, subjective percentage of pre-injury level of play, current pain (0 - 10), and complications. RESULTS: Eleven patients were identified as athletes. Ten (91%) were available for follow-up with a mean of 36.5 months (range, 14 - 60). The average age was 25.4 years (range, 15 - 37) at time of surgery. Eighty percent (8/10) were able to return to sport. The average time until return to sport was 29.4 weeks (range, 22 - 52) with an average subjective value of their pre-injury level of play of 87% (range, 70 - 100%). However, 67% (6/9) of the athletes had occasional pain with sport with an average pain level of 2.1 (range, 0 - 5). Two patients had complications, a superficial infection and a deep vein thrombosis. CONCLUSION: Most athletes were able to return to sport after undergoing open reduction and internal fixation of a ligamentous Lisfranc injury by less than 30 weeks post-surgery with a subjective value of 87% of their previous function. However, the majority of the patients also experienced some residual pain with their respective sport. These findings suggested that athletes with a ligamentous Lisfranc injury can have reliably good outcomes with operative repair.

Anatomic is better than isometric posterior cruciate ligament tunnel placement based upon in vivo simulation.

PURPOSE: To elucidate the effects of various tibial and femoral attachment locations on the theoretical length changes and isometry of PCL grafts in healthy knees during in vivo weightbearing motion. METHODS: The intact knees of 14 patients were imaged using a combined magnetic resonance and dual fluoroscopic imaging technique while the patient performed a quasi-static lunge (0°-120° of flexion). The theoretical end-to-end distances of the 3-dimensional wrapping paths between 165 femoral attachments, including the anatomic anterolateral bundle (ALB), central attachment and posteromedial bundle (PMB) of the PCL, connected to an anterolateral, central, and posteromedial tibial attachment were simulated and measured. A descriptive heatmap was created to demonstrate the length changes on the medial condyle and formal comparisons were made between the length changes of the anatomic PCL and most isometric grafts. RESULTS: The most isometric graft, with approximately 3% length change between 0° and 120° of flexion, was located proximal to the anatomic femoral PCL attachments. Grafts with femoral attachments proximal to the isometric zone decreased in length with increasing flexion angles, whereas grafts with more distal attachments increased in length with increasing flexion angles. The ALB and central single-bundle graft demonstrated a significant elongation from 0° to 120° of flexion (p < 0.001). The PMB decreased in length between 0° and 60° of flexion after which the bundle increased in length to its maximum length at 120° (p < 0.001). No significant differences in length changes were found between either the ALB or PMB and the central graft, and between the ALB and PMB at flexion angles ≥ 60° (n.s.). CONCLUSIONS: The most isometric attachment was proximal to the anatomic PCL footprint and resulted in non-physiological length changes. Moving the femoral attachment locations of the PCL significantly affected length change patterns, whereas moving the tibia locations did not. The importance of anatomically positioned (i.e., distal to the isometric area) femoral PCL reconstruction locations to replicate physiological length changes is highlighted. These data can be used to optimize tunnel positioning in either single- or double-bundle and primary or revision PCL reconstruction cases. LEVEL OF EVIDENCE: IV.

The effect of ACL deficiency on the end-to-end distances of the tibiofemoral ACL attachment during in vivo dynamic activity.

PURPOSE: To evaluate the effect of ACL deficiency on the in vivo changes in end-to-end distances and to determine appropriate graft fixation angles for commonly used tunnel positions in contemporary ACL reconstruction techniques. METHODS: Twenty-one patients with unilateral ACL-deficient and intact contralateral knees were included. Each knee was studied using a combined magnetic resonance and dual fluoroscopic imaging technique while the patients performed a dynamic step-up motion (~50° of flexion to extension). The end-to-end distances of the centers of the anatomic anteromedial (AM), posterolateral (PL) and single-bundle ACL reconstruction (SB-anatomic) tunnel positions were simulated and analyzed. Comparisons were made between the elongation patterns between the intact and ACL-deficient knees. Additionally, a maximum graft length change of 6% was used to calculate the deepest flexion fixation angle. RESULTS: ACL-deficient knees had significantly longer graft lengths when compared with the intact knees for all studied tunnel positions (p < 0.01). The end-to-end distances for the AM, PL and SB-anatomic grafts were significantly longer between 0-30° of flexion when compared with the intact knee by p < 0.05 for all. Six percent length change occurred with fixation of the AM bundle at 30° of flexion, PL bundle at 10° and the SB-anatomic graft at 20°. CONCLUSIONS: ACL-deficient knees had significantly longer in vivo end-to-end distances between 0°-30° of flexion for grafts at the AM, PL and SB-anatomic tunnel positions when compared with the intact knees. Graft fixation angles of <30° for the AM, <10° for the PL, and <20° for the SB-anatomic grafts may prevent permanent graft stretch.

An In Vivo Prediction of Anisometry and Strain in Anterior Cruciate Ligament Reconstruction - A Combined Magnetic Resonance and Dual Fluoroscopic Imaging Analysis.

PURPOSE: To evaluate the in vivo anisometry and strain of theoretical anterior cruciate ligament (ACL) grafts in the healthy knee using various socket locations on both the femur and tibia. METHODS: Eighteen healthy knees were imaged using magnetic resonance imaging and dual fluoroscopic imaging techniques during a step-up and sit-to-stand motion. The anisometry of the medial aspect of the lateral femoral condyle was mapped using 144 theoretical socket positions connected to an anteromedial, central, and posterolateral attachment site on the tibia. The 3-dimensional wrapping paths of each theoretical graft were measured. Comparisons were made between the anatomic, over the top (OTT), and most-isometric (isometric) femoral socket locations, as well as between tibial insertions. RESULTS: The area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. The most isometric attachment site was found midway on the Blumensaat line with approximately 2% and 6% strain during the step-up and sit-to-stand motion, respectively. Posterior femoral attachments resulted in decreased graft lengths with increasing flexion angles, whereas anterodistal attachments yielded increased lengths with increasing flexion angles. The anisometry of the anatomic, OTT and isometric grafts varied between tibial insertions (P < .001). The anatomic graft was significantly more anisometric than the OTT and isometric graft at deeper flexion angles (P < .001). CONCLUSIONS: An area of least anisometry was found in the proximal-distal direction just posterior to the intercondylar notch. ACL reconstruction at the isometric and OTT location resulted in nonanatomic graft behavior, which could overconstrain the knee at deeper flexion angles. Tibial location significantly affected graft strains for the anatomic, OTT, and isometric socket location. CLINICAL RELEVANCE: This study improves the knowledge on ACL anisometry and strain and helps surgeons to better understand the consequences of socket positioning during intra-articular ACL reconstruction.

Encapsulated Fat Necrosis Lesion Caused by Morel-Lavallée Lesion in a Professional Ice Hockey Player.

Morel-Lavallée (ML) lesions occur when subcutaneous tissue is stripped from fascia and replaced with hematoma or necrotic fat. Encapsulated fat necrosis lesions, which are rare, can occur with disruption of the blood supply in the subcutaneous area, which occurs with ML lesions. In this article, we report the case of a professional ice hockey player with an ML lesion that caused a symptomatic encapsulated fat necrosis lesion to develop. The encapsulated lesion required surgical removal.

An in Vivo Simulation of Isometry of the Anterolateral Aspect of the Healthy Knee.

BACKGROUND: To assess the isometry of theoretical lateral extra-articular reconstruction (LER), we evaluated theoretical grafts attached to various points on the lateral femoral condylar area and to either Gerdy's tubercle or the anatomic attachment site of the anterolateral ligament to the tibia. METHODS: In 18 subjects, healthy knees with no history of either injury or surgery involving the lower extremity were studied. The subjects performed a sit-to-stand motion (from approximately 90° of flexion to full extension), and each knee was studied using magnetic resonance and dual fluoroscopic imaging techniques. The 3-dimensional wrapping paths of each theoretical LER graft were measured. Grafts showing the least change in length during the sit-to-stand motion were considered to be the most isometric. RESULTS: The most isometric attachment site on the lateral femoral epicondyle to either of the studied tibial attachment sites was posterior-distal to the femoral attachment site of the fibular collateral ligament. The LER graft had a mean change in length of approximately 3%. Moving the femoral attachment site anteriorly resulted in increased length of the graft with increasing flexion; more posterior attachment sites resulted in decreased length with increasing flexion. Moving the attachment site in the proximal-distal direction had a less profound effect. Moving the tibial attachment site from Gerdy's tubercle to the tibial attachment site of the anterolateral ligament affected the overall isometric distribution on the lateral femoral epicondyle. CONCLUSIONS: The most isometric attachment site on the femur for an LER would be posterior-distal to the femoral attachment site of the fibular collateral ligament. Different length changes for LER grafts were identified with respect to different femoral attachment sites. Desirable graft fixation locations for treating anterolateral rotatory instability were found posterior-proximal to the femoral fibular collateral ligament attachment. CLINICAL RELEVANCE: The present data could be used both in biomechanical studies and in clinical studies as guidelines for planning LER surgical procedures.

The Role of Therapeutic Modalities in Surgical and Nonsurgical Management of Orthopaedic Injuries.

Rehabilitation professionals often use therapeutic modalities as a component of the surgical and nonsurgical management of orthopaedic injuries. Myriad therapeutic modalities, including cryotherapy, thermotherapy, ultrasonography, electrical stimulation, iontophoresis, and laser therapy, are available. Knowledge of the scientific basis of each modality and the principles of implementation for specific injuries enables musculoskeletal treatment providers to prescribe these modalities effectively. The selection of specific therapeutic modalities is based on their efficacy during a particular phase of rehabilitation. Therapeutic modalities are an adjunct to standard exercise and manual therapy techniques and should not be used in isolation.