Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures.

OBJECTIVE: To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques. DESIGN: A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons. RESULTS: There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm2) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm2), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint. CONCLUSIONS: Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.

Osteochondral Autograft Transfer for Focal Cartilage Lesions of the Knee With Donor-Site Back-Fill Using Precut Osteochondral Allograft Plugs and Micronized Extracellular Cartilage Augmentation.

Osteochondral autograft transfer (OAT) allows for the treatment of focal chondral lesions of the femoral condyles. Patients undergoing OAT have been shown to have the greatest rate and quickest return to sport of any cartilage-restoration procedure. Disadvantages encountered with the OAT procedure include limited donor sources, small treatable lesion size, and donor-site morbidity. Here, we describe our preferred technique of open OAT with donor-site back-filling using precut fresh osteochondral allograft plugs and micronized extracellular cartilage augmentation. Advantages to this technique include single-stage transfer of living autologous osteochondral grafts allowing for early ambulation, predictable return to sport, enhanced long-term graft survival, and decreased donor-site morbidity secondary to fresh osteochondral allograft back-fill.

Ulnar Collateral Ligament Tear Location May Affect Return-to-Sports Rate but Not Performance Upon Return to Sports After Ulnar Collateral Ligament Reconstruction Surgery in Professional Baseball Players.

BACKGROUND: The number of ulnar collateral ligament (UCL) tears in professional baseball players is increasing. UCL reconstruction (UCLR) is the treatment of choice in players with failed nonoperative treatment who wish to return to sports (RTS). It is unknown if UCL tear location influences the ability of players to RTS or affects their performance upon RTS. PURPOSE/HYPOTHESIS: The purpose was to compare the RTS rate and performance upon RTS in professional baseball players who underwent UCLR based on UCL tear location (proximal vs distal). It was hypothesized that no difference in RTS rate or performance upon RTS will exist between players with proximal or distal UCL tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All professional baseball players who underwent primary UCLR by a single surgeon between 2016 and 2018 were eligible for inclusion. Players with purely midsubstance tears or revision UCLR were excluded. Tear location was determined based on preoperative magnetic resonance imaging (MRI) and intraoperative findings. RTS rate and performance were compared between players with proximal versus distal UCL tears. RESULTS: Overall, 25 pitchers (15 proximal and 10 distal tears) and 5 position players (2 proximal and 3 distal) underwent primary UCLR between 2016 and 2018. Of the 25 pitchers, 84% were able to RTS. Of the 5 position players, 80% were able to RTS. Among the total cohort of pitchers and position players, 12 out of 17 (71%) players with proximal tears were able to RTS, while of the 13 distal tears, 13 out of 13 (100%) players were able to RTS (P = .05). With regard to performance data, pitchers with distal tears had higher utilization postoperatively and, as such, allowed statistically more hits (P = .03), runs (P = .015), and walks (P = .021) postoperatively. However, the WHIP ([walks + hits]/innings pitched) was not different between players with proximal or distal tears, indicating that efficacy in games was not significantly different between groups. CONCLUSION: Professional baseball players who sustain a distal UCL tear and undergo UCLR may be more likely to RTS than those who sustain a proximal UCL tear and undergo UCLR. Players with distal UCL tears who underwent UCLR saw higher utilization postoperatively than those with proximal UCL tears. Further work is needed in this area to confirm this result.

Technology Used in the Prevention and Treatment of Shoulder and Elbow Injuries in the Overhead Athlete.

PURPOSE OF REVIEW: To review the current technology available for the prevention and treatment of shoulder and elbow injuries in the overhead athlete. RECENT FINDINGS: Shoulder and elbow injuries are common in recreational and high-level overhead athletes. Injury prevention in these athletes include identifying modifiable risk factors, offering effective preventative training programs, and establishing safe return-to-sport criteria. The advent and use of technologies and wearable devices with concomitant development of software and data analytic programs has significantly changed the role of sports technology in injury identification and prevention. Over the last few decades, leveraging new technologies to better understand and treat patients has become an increasing focus of healthcare. Technologies currently being applied to the treatment of the overhead athlete include kinesiotaping, heart rate monitors, accelerometers/gyroscopes, dynamometers/force plates, camera-based monitoring systems (optical motion analysis), and inertial sensor monitoring units. Advances in technology have made it possible to acquire large amounts of data on athletes that may be used to guide treatment and injury prevention programs; however, literature validating the clinical efficacy of many of these technologies is limited. Further research is needed to continue to allow team physicians to provide better, cost-efficient, and individualized care to the overhead athlete using technology.

Recurrent Patellofemoral Instability in the Pediatric Patient: Management and Pitfalls.

PURPOSE OF REVIEW: The purpose of the review is to discuss the relevant pathoanatomy, management, complications, and technical considerations for recurrent patellofemoral instability (PFI) in the pediatric population. Special consideration is given to recent literature and management of the patient with repeat instability following surgery. RECENT FINDINGS: Patellar stabilization surgery is in principle dependent upon restoration of normal patellofemoral anatomy and dynamic alignment. Historically, treatment options have been numerous and include extensor mechanism realignment, trochleoplasty, and more recently repair and/or reconstruction of the medial patellofemoral ligament (MPFL) as a dynamic check rein during initial knee flexion. In skeletally immature patients, preference is given to physeal-sparing soft tissue procedures. While medial patellofemoral ligament reconstruction has become a popular option, postoperative failure is a persistent issue with rates ranging from 5 to 30% for PFI surgery in general without any single procedure (e.g., distal realignment, MPFL reconstruction) demonstrating clear superiority. Failure of surgical patellar stabilization is broadly believed to occur for three main reasons: (1) technical failure of the primary stabilization method, (2) unaddressed static and dynamic pathoanatomy during the primary stabilization, and (3) intrinsic risk factors (e.g., collagen disorders, ligamentous laxity). PFI is a common orthopedic condition affecting the pediatric and adolescent population. Treatment of repeat instability following surgery in the PFI patient requires understanding and addressing underlying pathoanatomic risk factors as well as risks and reasons for failure.

Radiographic and functional outcomes of bisphosphonate use in lumbar fusion: a systematic review and meta-analysis of comparative studies.

PURPOSE: To date, there are conflicting reports with no consensus on the influence of bisphosphonates on lumbar fusion. The goal of this study was to compare the radiographic and functional outcomes of patients that had lumbar fusion with and without bisphosphonates. METHODS: A systematic search of multiple medical reference databases was conducted for studies comparing bisphosphonate use to controls following spinal fusion. Meta-analysis was performed using the random-effects model for heterogeneity. Radiographic outcome measures included fusion rates and risk of screw loosening, cage subsidence and vertebral fracture. Functional outcomes measures included Oswestry Disability Index and visual analog scale score for back and leg pain. RESULTS: Bisphosphonate use was statistically suggestive of a higher fusion rate compared to controls (OR 2.2, 95% CI 0.87-5.56, p = 0.09). There was no difference in screw loosening rates between the bisphosphonate group and controls (OR 0.45, 95% CI 0.14-1.48, p = 0.19). However, bisphosphonate use was associated with decreased odds of cage subsidence and vertebral fractures compared to controls (cage subsidence: OR 0.29, 95% CI 0.11-0.75, p = 0.01; vertebral fracture: OR 0.18, 95% CI 0.07-0.48, p = 0.0007). CONCLUSION: Bisphosphonate use does not appear to impair successful lumbar fusion compared to controls. Additionally, bisphosphonate use was associated with decreased odds of cage subsidence and vertebral fractures compared to controls that had lumbar fusion. These slides can be retrieved under Electronic Supplementary Material.

Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States.

BACKGROUND: Intraoperative neuromonitoring (ION), such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP), and electromyography (EMG), is used to detect impending neurological injuries during spinal surgery. To date, little is known about the trends in the use of ION for scoliosis surgery in the United States. METHODS: A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. RESULTS: There were 3618 patients who had scoliosis surgery during the study period. Intraoperative neuromonitoring was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (P < .0001). Multimodal ION was used more commonly than unimodal ION (64.6% versus 35.4%). The most commonly used modality was combined SSEP and EMG, while the least used modality was MEP only. Neurological injuries occurred in 1.8 and 2.0% of patients that had surgery with and without ION, respectively (P = .561). Intraoperative neuromonitoring was used most commonly in patients <65 years of age and in the Northeastern part of the United States (age P = .006, region P < .0001). CONCLUSIONS: The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in nonelderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.

Open Tibial Inlay PCL Reconstruction: Surgical Technique and Clinical Outcomes.

PURPOSE OF REVIEW: To review the current literature on clinical outcomes following open tibial inlay posterior cruciate ligament (PCL) reconstruction and provide the reader with a detailed description of the author's preferred surgical technique. RECENT FINDINGS: Despite earlier biomechanical studies which demonstrated superiority of the PCL inlay technique when compared to transtibial techniques, recent longitudinal cohort studies have shown no significant differences in clinical or functional outcomes at 10-year follow-up. Furthermore, no significant clinical differences have been shown between graft types used and/or single- versus double-bundle reconstruction methods. The optimal treatment for the PCL-deficient knee remains unclear. Open tibial inlay PCL reconstruction is safe, reproducible, and avoids the "killer turn" that may potentially lead to graft weakening and failure seen in transtibial reconstruction methods. No significant differences in subjective outcomes or clinical laxity have been shown between single-bundle versus double-bundle reconstruction methods.

Demographic Trends in the Use of Intraoperative Neuromonitoring for Scoliosis Surgery in the United States.

BACKGROUND: Intraoperative neuromonitoring (ION) such as motor-evoked potential (MEP), somatosensory evoked potentials (SSEP) and electromyography (EMG) are used to detect impending neurological injuries during spinal surgery. To date, little is known on the trends in the use of ION for scoliosis surgery in the United States. METHODS: A retrospective review was performed using the PearlDiver Database to identify patients that had scoliosis surgery with and without ION from years 2005 to 2011. Demographic information (such as age, gender, region within the United States) and clinical information (such as type of ION and rates of neurological injury) were assessed. RESULTS: There were 3618 patients who had scoliosis surgery during the study period. ION was used in 1361 (37.6%) of these cases. The number of cases in which ION was used increased from 27% in 2005 to 46.9% in 2011 (p < 0.0001). Multimodal ION was used more commonly than unimodal ION (64.6% vs. 35.4%). The most commonly used modality was combined SSEP and EMG while the least used modality was MEP only. Neurological injuries occurred in 1.8% and 2.0% of patients that had surgery with and without ION, respectively (p = 0.561). ION was used most commonly in patients < 65 years of age and in the Northeastern part of the United States (age; p = 0.006, region; p < 0.0001). CONCLUSIONS: The use of ION for scoliosis surgery gradually increased annually from 2005 to 2011. Age and regional differences were noted with neuromonitoring being most commonly used for scoliosis surgery in non-elderly patients and in the Northeastern part of the United States. No differences were noted in the risk of neurological injury in patients that had surgery with and without ION. Although the findings from this study may seem to suggest that ION may not influence the risk of neurologic injury, this result must be interpreted with caution as inherently riskier surgeries may utilize ION more, leading to an actual reduction in injuries more dramatic than observed in this study.

Demographic trends in arthroscopic and open biceps tenodesis across the United States.

BACKGROUND: The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis. METHODS: A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient's age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics. RESULTS: There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P = .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P = .009; P = .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders. CONCLUSION: Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes.

Up-regulation of nicotinic acetylcholine receptors in menthol cigarette smokers.

One-third of smokers primarily use menthol cigarettes and usage of these cigarettes leads to elevated serum nicotine levels and more difficulty quitting in standard treatment programmes. Previous brain imaging studies demonstrate that smoking (without regard to cigarette type) leads to up-regulation of ß(2)*-containing nicotinic acetylcholine receptors (nAChRs). We sought to determine if menthol cigarette usage results in greater nAChR up-regulation than non-menthol cigarette usage. Altogether, 114 participants (22 menthol cigarette smokers, 41 non-menthol cigarette smokers and 51 non-smokers) underwent positron emission tomography scanning using the α(4)ß(2)* nAChR radioligand 2-[(18)F]fluoro-A-85380 (2-FA). In comparing menthol to non-menthol cigarette smokers, an overall test of 2-FA total volume of distribution values revealed a significant between-group difference, resulting from menthol smokers having 9-28% higher α(4)ß(2)* nAChR densities than non-menthol smokers across regions. In comparing the entire group of smokers to non-smokers, an overall test revealed a significant between-group difference, resulting from smokers having higher α(4)ß(2)* nAChR levels in all regions studied (36-42%) other than thalamus (3%). Study results demonstrate that menthol smokers have greater up-regulation of nAChRs than non-menthol smokers. This difference is presumably related to higher nicotine exposure in menthol smokers, although other mechanisms for menthol influencing receptor density are possible. These results provide additional information about the severity of menthol cigarette use and may help explain why these smokers have more trouble quitting in standard treatment programmes.

Effect of secondhand smoke on occupancy of nicotinic acetylcholine receptors in brain.

CONTEXT: Despite progress in tobacco control, secondhand smoke (SHS) exposure remains prevalent worldwide and is implicated in the initiation and maintenance of cigarette smoking. OBJECTIVE: To determine whether moderate SHS exposure results in brain α(4)ß(2)* nicotinic acetylcholine receptor (nAChR) occupancy. DESIGN, SETTING, AND PARTICIPANTS: Positron emission tomography scanning and the radiotracer 2-[18F]fluoro-3-(2(S)azetidinylmethoxy) pyridine (also known as 2-[(18)F]fluoro-A-85380, or 2-FA) were used to determine α(4)ß(2)* nAChR occupancy from SHS exposure in 24 young adult participants (11 moderately dependent cigarette smokers and 13 nonsmokers). Participants underwent two bolus-plus-continuous-infusion 2-FA positron emission tomography scanning sessions during which they sat in the passenger's seat of a car for 1 hour and either were exposed to moderate SHS or had no SHS exposure. The study took place at an academic positron emission tomography center. Main Outcome Measure  Changes induced by SHS in 2-FA specific binding volume of distribution as a measure of α(4)ß(2)* nAChR occupancy. RESULTS: An overall multivariate analysis of variance using specific binding volume of distribution values revealed a significant main effect of condition (SHS vs control) (F(1,22) = 42.5, P < .001) but no between-group (smoker vs nonsmoker) effect. Exposure to SHS led to a mean 19% occupancy of brain α(4)ß(2)* nAChRs (1-sample t test, 2-tailed, P < .001). Smokers had both a mean 23% increase in craving with SHS exposure and a correlation between thalamic α(4)ß(2)* nAChR occupancy and craving alleviation with subsequent cigarette smoking (Spearman ρ = -0.74, P = .01). CONCLUSIONS: Nicotine from SHS exposure results in substantial brain α(4)ß(2)* nAChR occupancy in smokers and nonsmokers. Study findings suggest that such exposure delivers a priming dose of nicotine to the brain that contributes to continued cigarette use in smokers. This study has implications for both biological research into the link between SHS exposure and cigarette use and public policy regarding the need to limit SHS exposure in cars and other enclosed spaces.