Medial patellofemoral ligament reconstruction with a looped semitendinosus tendon, using knotless anchor fixation on the patella and hybrid fixation on the femur.

Medial patellofemoral ligament (MPFL) reconstruction is a reliable surgical method for stabilizing a dislocating patella, with multiple techniques previously described. Although outcomes are generally favorable, the procedure is technically demanding and relies on precise identification of native MPFL insertion sites, secure fixation of the graft to these sites, and appropriate graft tension. We describe a technique for MPFL reconstruction with a looped semitendinosus tendon. The 2 free limbs of the graft are secured into blind-end patellar sockets with knotless anchors, and the looped end is initially secured into a medial femoral socket with a button on the opposite (lateral) cortex. Use of an adjustable-loop button allows for gradual adjustment of graft tension, as well as re-tensioning after cycling of the knee, before final aperture fixation on the femur with an interference screw.

Distal biceps tendon injuries--current treatment options.

Three percent of all biceps tendon ruptures occur at the distal aspect, where the tendon inserts into the radial tuberosity. Distal bicep tendon ruptures typically occur in middle-aged males after an eccentric extension load is applied to the elbow. Patients usually complain of a sudden, sharp, and painful tearing sensation in the antecubital region, with a palpable defect. The biceps squeeze and hook tests are specific maneuvers by which to diagnose distal biceps ruptures on physical examination. Magnetic resonance imaging (MRI) or ultrasound maybe be helpful to distinguish between partial and complete tears. Anatomic studies suggest there are two distinct insertions for the short and long heads of the distal biceps. The short head may be a more powerful flexor, and the long head may be a more powerful supinator. Nonoperative treatment typically results in loss of flexion and supination strength and endurance. Early anatomic re-attachment is the goal. Surgical approaches include one- or two-incision techniques, and tendon fixation methods include the use of suture anchors, bone tunnels, an endobutton, or biotenodesis screws. Biomechanical studies have shown that endobuttons have higher load-to-failure strengths, compared to the other fixation methods. However, clinical studies have demonstrated that patients do well regardless of surgical approach or fixation method. Possible complications include nerve injuries, heterotopic ossification, postoperative fracture, tendon rerupture, complex regional pain syndrome, and wound infection. Partial ruptures are significantly less common and initially can be treated conservatively. Chronic tears are more difficult to treat because of possible tendon retraction and poor tissue quality. Tendon grafts using semitendinosus, fascia lata, hamstring, Achilles (calcaneal), or flexor carpi radialis have been successfully used for length restoration in these cases.

Assessment of arthroscopic training in U.S. orthopedic surgery residency programs--a resident self-assessment.

BACKGROUND: There has been an increasing number of arthroscopic surgeries performed in general orthopedic surgery practice, as well as a rapid evolution of arthroscopic techniques. The objective of this investigation was to assess the adequacy of arthroscopic training in U.S. orthopedic residency programs from a resident and program director perspective. MATERIALS AND METHODS: The study was performed with a mail-in survey to orthopaedic surgery residents and program directors. Out of 151 programs contacted, we received responses from 24 program directors (15.9%) and 272 residents (11.1% of 2447 possible residents in years 2 through 5 in 2006). Program demographics and resident and program director assessments of arthroscopic surgical training was obtained from the questionnaire. Assessment of open surgical techniques was used as a control. The responses from fifth-year residents (83 of a possible 612 in 2006 (13.6%)) and program directors were used for detailed analysis. RESULTS: Only 32% (27/83) of fifth-year residents felt there was adequate time dedicated to arthroscopic training, compared to 66% (16/24) of program directors (p < 0.01). Thirty-four percent (28/83) of fifth-year residents felt as prepared in arthroscopy as open techniques, in contrast to 58% (14/24) of program directors, who felt fifth-year residents were appropriately prepared in arthroscopic techniques (p = 0.03). The amount of surgery that residents are allowed to perform correlated significantly (p < 0.01) with confidence levels. CONCLUSIONS: Fifth-year residents who were surveyed felt less prepared in arthroscopic training, compared to open surgical procedures. Program directors surveyed over estimated confidence levels in fifth-year residents performing arthroscopic procedures. To ensure that graduating residents are appropriately prepared for the current demands of a clinical setting, it may be necessary to reexamine residency requirements to ensure adequate practice in developing arthroscopic surgical skills.

Can the Bio-Transfx pin fail during initial ACL graft insertion?

BACKGROUND: The Bio-Transfix pin is a biodegradable device used for femoral tunnel anterior cruciate ligament (ACL) graft fixation. Recent clinical studies have suggested the possibility of the pin's postoperative failure. METHODS: This investigation evaluates the initial strength of several Bio-Transfix pin ACL fixations in a simulated femoral tunnel model. The forces generated by five surgeons during simulated ACL graft tensioning were also measured. RESULTS: Average strengths of the pins ranged from 1075 to 2160 N for 10 and 8 mm tunnels, respectively, whereas the maximum surgeon-generated forces were 535 N. CONCLUSIONS: These results imply that initial fracture of the pin itself is unlikely; however, failure of the supporting bone or a decrease in pin strength due to biodegradation could account for early loss of the fixation.

A double-blind, randomized, saline-controlled study of the efficacy and safety of EUFLEXXA for treatment of painful osteoarthritis of the knee, with an open-label safety extension (the FLEXX trial).

OBJECTIVE: To report the FLEXX trial, the first well-controlled study assessing the safety and efficacy of Euflexxa (1% sodium hyaluronate; IA-BioHA) therapy for knee osteoarthritis (OA) at 26 weeks. METHODS: This was a randomized, double-blind, multicenter, saline-controlled study. Subjects with chronic knee OA were randomized to 3 weekly intra-articular (IA) injections of either buffered saline (IA-SA) or IA-BioHA (20 mg/2 ml). The primary efficacy outcome was subject recorded difference in least-squares means between IA-BioHA and IA-SA in subjects' change from baseline to week 26 following a 50-foot walk test, measured via 100-mm visual analog scale (VAS). Secondary outcome measures included Osteoarthritis Research Society International responder index, Western Ontario McMaster University Osteoarthritis Index VA 3.1 subscales, patient global assessment, rescue medication, and health-related quality of life (HRQoL) by the SF-36. Safety was assessed by monitoring and reporting vital signs, physical examination of the target knee following injection, adverse events, and concomitant medications. RESULTS: Five hundred eighty-eight subjects were randomized to either IA-BioHA (n = 293) or IA-SA (n = 295), with an 88% 26 week completion rate. No statistical differences were noted between the treatment groups at baseline. In the IA-BioHA group, mean VAS scores decreased by 25.7 mm, compared with 18.5 mm in the IA-SA group. This corresponded to a median reduction of 53% from baseline for IA-BioHA and a 38% reduction for IA-SA. The difference in least-squares means was -6.6 mm (P = 0.002). Secondary outcome measures were consistent with significant improvement in Osteoarthritis Research Society International responder index, HRQoL, and function. Both IA-SA and IA-BioHA injections were well tolerated, with a low incidence of adverse events that were equally distributed between groups. Injection-site reactions were reported by 1 (<1%) subject in the IA-SA group and 2 (1%) in the IA-BioHA group. CONCLUSIONS: IA-BioHA therapy resulted in significant OA knee pain relief at 26 weeks compared with IA-SA. Subjects treated with IA-BioHA also experienced significant improvements in joint function, treatment satisfaction, and HRQoL.

Hyaluronic acid viscosupplementation and osteoarthritis: current uses and future directions.

Intra-articular hyaluronic acid viscosupplementation is gaining popularity as a treatment option in the nonoperative management of patients with osteoarthritis. Recent clinical studies have demonstrated that the anti-inflammatory, anabolic, and chondroprotective actions of hyaluronic acid reduce pain and improve patient function. With evidence mounting in support of the efficacy of this treatment modality for patients with osteoarthritis, its potential use in additional patient populations and for other pathologies affecting the knee is being investigated. The current article reviews the use of intra-articular hyaluronic acid viscosupplementation in the management of knee osteoarthritis and presents the potential for expanding its indications for other joints and alternative patient subpopulations. Additionally, future directions for the use of hyaluronic acid and areas of active research are discussed.

Rugby injuries: a review of concepts and current literature.

Rugby football continues to grow in popularity internation- ally and within the United States. In 1995, rugby union, one form of rugby, turned from amateur to professional through- out Europe, increasing the potential for monetary reward, which, in turn, secondary to higher levels of play, increased the risk of injury. With this increased higher interest and the increasing number of inexperienced and professional players in the U.S., there is a need for a comprehensive analysis of professional rugby union injury in the American literature and increased awareness of rugby injuries, in general, for all levels of players. This paper provides an in-depth analysis of professional rugby union injuries that will assist ortho- paedic surgeons treating these injuries in the U.S. The data described highlights the potential impact of rugby injury in the U.S. and provides an overview of the international data to serve as the basis for future American studies. An additional goal of this review is to stimulate discussion regarding the necessity of implementing additional safety precautions for this high-risk sport. Finally, this analysis highlights the in- consistencies and discrepancies of the literature with respect to rugby union injury and the variability and weak interstudy reproducibility of current rugby injury data.

The modified racking hitch(MRH) knot: a new sliding knot for arthroscopic surgery.

Sliding knots are commonly used in arthroscopic surgery and can be problematic in terms of strength and loop security. A new sliding knot for arthroscopic surgery, a modified racking hitch (MRH) knot, is described. The knot is essentially a modified cow's hitch knot that includes two self-locking loops. By tensioning the loop strands, a snug knot is created without backward sliding and provides excellent knot and loop security. In laboratory testing, the MRH knot provided comparable strength and security to other sliding knots. Experience gained from approximately 5 years of clinical use has added to the promise of the useful application of the MRH knot in arthroscopy.

Lower extremity injuries in the skeletally immature athlete.

The heightened intensity of training and competition among young athletes places them at increased risk for both acute and chronic injuries. Prompt recognition and treatment of such injuries are critical to prevent long-term functional disability and deformity. These injuries occur in patterns unique to the skeletally immature athlete, given their developing epiphyses and ossification centers and supporting ligamentous structures. Children and adolescents who participate in recreational and organized sports are particularly susceptible to a broad spectrum of lower extremity injuries involving both the osseous and soft-tissue structures. Fundamental knowledge of the pathophysiology of injury helps the clinician in determining management. Early recognition of acute traumatic injuries, along with preventive regimens and knowledge of both nonsurgical and surgical treatment protocols, has helped to restore and maintain normal lower extremity function in the skeletally immature athlete.

Outcomes of meniscal repair: minimum of 2-year follow-up.

PURPOSE: The purpose of this study was to determine the success rate of meniscal repair achieved in our sports medicine practice, particularly with interest in characterizing the outcomes observed with the newer all-inside repair devices. TYPE OF STUDY: Retrospective chart review with telephone follow-up. METHODS: 157 patients that had undergone a meniscal repair procedure between 1996 and 2001 were identified. Twenty-four of these patients were lost to follow-up. Thus, the study group consisted of 133 patients providing a follow-up rate of 85%. All patients included had a minimum of two years of follow up. Failure was defined as the need for meniscectomy in the area of the meniscus that was initially repaired. The time interval from injury to surgery was divided into less than six weeks (acute) and greater than six weeks (chronic). The etiology of the meniscal tear was broken down into three categories; sports related trauma, non-sports trauma, and atraumatic. The repair techniques used in these patients included outside-in sutures, inside-out sutures, darts, arrows, meniscal screws, T-fix, FasT-fix, and the RapidLoc. RESULTS: The failure rate was 36%. No association was found between failure and the length of preoperative symptoms, rim width, etiology, concomitant meniscectomy, chondroplasty or anterior cruciate ligament (ACL) reconstruction. There was a higher rate of failure of tears in the medial versus lateral meniscus (20.3% vs. 44.8%). No statistical comparisons could be made between devices due to small sample sizes. CONCLUSIONS: The all-inside meniscal repair devices have simplified the meniscal repair procedure. This may have lead to a broadening of the indications for repair CLINICAL RELEVANCE: The newer generation meniscal repair devices, while simplifying the procedure, do not appear to lead to an increased clinical success rate.

A survey of decision-making processes in the treatment of common shoulder ailments among primary care physicians.

To encourage consistent care for patients with musculoskeletal complaints, the AAOS developed treatment algorithms to aid primary care physicians in the management of these patients. A survey was designed to assess whether a random group of primary care physicians treated their patients in a manner consistent with these algorithms. The AAOS algorithm for shoulder pain was used to develop a questionnaire for primary care physicians. An Internet company provided access to a national base of physicians who volunteered to complete the survey. Ten questions were presented on five shoulder conditions: rotator cuff disease, fractures, instability, arthritis, and frozen shoulder The "correct" answer was based upon the AAOS algorithm. The survey was completed by 706 physicians who treated variable (one to greater than ten) numbers of shoulder patients per month. Forty-eight percent of the physicians treated acute trauma according to the algorithm, 87% treated arthritis, and 58% treated instability. Only 46% of physicians chose the correct answer for an acute rotator cuff tear and 29% for chronic rotator cuff symptoms. Forty-four percent followed the algorithm for frozen shoulder. Overall only 49% of the patients described were treated according to the AAOS algorithms. Based on the number of shoulder patients seen each month, in one month over 2000 patients could be tested by the surveyed physicians in a manner inconsistent with the treatment algorithms, suggesting the need for improved musculoskeletal education for primary care physicians.

Shoulder and elbow injuries in the skeletally immature athlete.

The intensity of training and competition among young athletes can place them at increased risk of acute and chronic injuries, which occur in patterns unique to the skeletally immature athlete. Prompt recognition and treatment of these injuries are critical to prevent long-term functional disability and deformity. Children and adolescents participating in recreational and organized sports are particularly susceptible to a broad spectrum of shoulder and elbow injuries involving both osseous and soft-tissue structures. Understanding the relevant functional anatomy, biomechanics of throwing, and pathophysiology of injury can help the clinician manage common acute traumatic injuries, some of which may result in chronic problems. Over-use injuries occur more frequently than do acute, traumatic injuries, and early recognition, coupled with appropriate treatment or prevention, can help restore and maintain normal shoulder and elbow function.

Athletic ergogenic aids.

Claims championing exotic substances that produce healing or ergogenic powers have been around for centuries. The competitive, peer-pressured environment enveloping today's athletes and adolescence makes these groups particularly susceptible to the uproar surrounding the current ergogenic aid market. Presently, it seems that rumor and anecdotal information overwhelms the available scientific data. While there is evidence that some touted ergogenic aids do indeed enhance performance, there are many unanswered questions about product safety, efficacy, and long-term consequences. A working knowledge of specific ergogenic aids is essential for the treating physician in order to best advise patients and athletes as to the possible benefits and risks of any substance they may be using.

SLAP lesions of the shoulder.

SLAP lesions are becoming a more recognized cause of shoulder pain and disability. The diagnosis of these lesions is difficult due to vague symptoms and high degree of overlap with other shoulder disorders, and this requires a high index of suspicion. Advances in MR arthrography may lead to advances in preoperative diagnosis of labral tears, but definitive diagnosis, classification, and management is greatly facilitated with the use of the shoulder arthroscopy. Further basic science and clinical research should enhance our ability to manage patients with these lesions effectively.

The incidence and outcome of patella fractures after anterior cruciate ligament reconstruction.

PURPOSE: The study was performed to determine the incidence and eventual outcome of patella fractures after anterior cruciate ligament (ACL) reconstructions using bone-patella tendon-bone autograft. TYPE OF STUDY: Retrospective review. METHODS: Between 1989 to 1999, 618 consecutive primary, single-incision bone-patella tendon-bone autograft ACL reconstructive procedures were performed by 3 surgeons at our institution. Of this group, 8 (1.3%) had postoperative patella fracture of the donor knee. The charts of these patients were retrospectively reviewed, and patients were followed with physical examination and outcome questionnaires. RESULTS: The patella fractures occurred at a mean of 57 days after the ACL reconstruction (range, 24-121 days). Five patients sustained indirect trauma, whereas 3 experienced direct trauma. Three patients had nondisplaced transverse fractures treated nonoperatively. Five patients had displaced fractures (3 transverse and 2 Y-shaped) requiring surgical intervention. All 8 patients have full flexion when compared with their opposite knee. Two patients did not regain 5 degrees of hyperextension but were not symptomatic. The mean length of follow-up for the questionnaire was 4 years (range, 1.5 to 6.5 years). The mean score on the Lysholm knee questionnaire was 89.6 (range, 77-98). The mean Single Assessment Numeric Evaluation score was 85.8 (range, 50-100). CONCLUSIONS: Most cases of postoperative patella fractures, in our experience, have caused minor changes postoperatively and no differences in the outcome of these patients. Seventy-five percent of our patients had excellent or good Lysholm scores. This study confirms previous reports in the literature that observed minimal residual sequelae from postoperative patella fractures after ACL reconstruction with bone-patella tendon-bone autograft.