The Effect of Abnormal Vitamin D Levels in Athletes.

Vitamin D is a lipophilic prohormone integral to musculoskeletal, autoimmune, oncologic, cardiovascular, and mental health. Of particular importance to the orthopedic surgeon is the role of vitamin D in the regulation of bone mass, muscle strength, and physical performance. Although vitamin D-related skeletal pathologies are rare in industrialized nations, emerging research in the field has shown that most American adults have inadequate levels of vitamin D. Even among athletes, there is a high prevalence of vitamin D deficiency, which may place competitors at risk of stress fractures, illness, and delayed muscle recovery. Adequately identifying vitamin D-deficient individuals in need of supplementation is important to help optimize performance and prevent future injury. The goal of this review is to describe the epidemiology of vitamin D deficiency and its effects on athletic performance and musculoskeletal health. Future double-blinded studies of vitamin D supplementation in athletes are needed. We recommend treating athletes who have insufficient or deficient vitamin D levels.

Evaluating the Femoral-Side Critical Corner in Posterior Cruciate Ligament Reconstruction: The Effect of Outside-In Versus Inside-Out Creation of Femoral Tunnels on Graft Contact Pressure in a Synthetic Knee Model.

PURPOSE: To characterize and compare the graft contact characteristics of outside-in (OI) and inside-out (IO) femoral tunnels during single-bundle reconstruction of the anterolateral bundle of the posterior cruciate ligament in a synthetic knee model. METHODS: Femoral tunnels were separately made in 16 synthetic femora (8 OI and 8 IO). Achilles tendon allografts were fixed using suspensory fixation with a pressure sensor between the allograft and femoral tunnel. Grafts were cyclically loaded; force, contact area, contact pressure, and peak pressure at the aperture were measured. This process was repeated using the same allograft to assess the other tunnel angle in a separate specimen. RESULTS: IO specimens showed higher mean contact pressure at all loading cycles, with significance shown at 50 N (P = .02). Peak pressure was also greater in IO specimens at all loading cycles and reached statistical significance at 100 N (P = .04). IO specimens had a lower contact area at 150 N (P = .04). No statistically significant differences in force were observed between the 2 groups. CONCLUSIONS: OI creation of the femoral tunnel for anterolateral bundle reconstruction of the posterior cruciate ligament resulted in decreased mean and peak contact pressures at the femoral aperture compared with IO tunnel creation at the specific trajectories and loading parameters tested in this synthetic femoral model. These biomechanical data suggest that OI creation of the femoral tunnel may help reduce in vivo graft contact pressure at the femoral aperture. CLINICAL RELEVANCE: These data suggest that a tunnel drilled from OI may result in less graft pressure at the femoral aperture, which may prevent graft elongation and optimize graft survival.

Hemiarthroplasty for the treatment of distal humeral fractures: midterm clinical results.

BACKGROUND: Total elbow arthroplasty is a treatment for unreconstructable distal humeral fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humeral hemiarthroplasty (DHH) offers an alternative with multiple advantages. METHODS: This is a retrospective study of 10 patients who underwent DHH for distal humeral fractures during a 4-year period (2008-2012) by a single surgeon. Patients underwent testing of range of motion, Mayo Elbow Performance Score, Disabilities of Arm, Shoulder and Hand, visual analog scale, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores. Average patent age at surgery was 71.9 years (range, 56-81 years); average follow-up was 73.2 months (range, 36-96 months). RESULTS: Patients maintained improvements in Mayo Elbow Performance Scores (mean, 89.23; range, 75-100) and Disabilities of Arm, Shoulder and Hand scores (mean, 33.71; range 11.2-55.1), along with no significant decrease in range of motion compared with 1 year after surgery. Mean visual analog scale was 2.43 (range, 0-5), Single Assessment Numeric Evaluation was 74.14 (range, 50-100), and American Shoulder and Elbow Surgeons score was 72.14 (range, 48.33-100). Participants had an average flexion of 128.7° (range, 95°-142°), extension deficit of 27.1° (range, 0°-45°), supination of 79.1° (range, 45°-90°), and pronation of 73.3° (range, 50°-90°). No heterotopic ossification, elbow dislocations, or subluxations were observed. Complications included 1 fracture and 1 complaint of prominent hardware. Two patients died, and 1 patient was lost to follow-up. CONCLUSION: This midterm review suggests that DHH may be an effective treatment for certain distal humeral fractures. The data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies. Additional studies must be conducted to further define the role of DHH for complex fractures of the distal humerus.

Direct Cost Analysis of Outpatient Arthroscopic Rotator Cuff Repair in Medicare and Non-Medicare Populations.

BACKGROUND: Providing high-quality care while also containing cost is a paramount goal in orthopaedic surgery. Increasingly, insurance providers in the United States, including government payers, are requiring financial and performance accountability for episodes of care, including a push toward bundled payments. HYPOTHESIS: The direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Billing and operative reports from 184 outpatient arthroscopic rotator cuff repairs performed by 5 fellowship-trained arthroscopic surgeons were reviewed. Operative time, number and cost of implants, hospital reimbursement, surgeon reimbursement, and insurance type were determined from billing records and operative reports. Patients were stratified by payer (Medicare vs non-Medicare), and these variables were compared. RESULTS: There were no statistically significant differences in the number of suture anchors used, implant cost, surgical duration, or overall cost of arthroscopic rotator cuff repair between Medicare and other insurers. Reimbursement was significantly higher for other payers when compared with Medicare, resulting in a mean per case deficit of $263.54 between billing and reimbursement for Medicare patients. CONCLUSION: Operating room time, implant cost, and total procedural cost was the same for Medicare patients as for patients with private payers. Further research needs to be conducted to understand the patient-specific factors that affect the cost of an episode of care for rotator cuff surgery.

Epidemiology of Operative Procedures in an NCAA Division I Football Team Over 10 Seasons.

BACKGROUND: Injury rates are high for collegiate football players. Few studies have evaluated the epidemiology of surgical procedures in National Collegiate Athletic Association (NCAA) Division I collegiate football players. PURPOSE: To determine the most common surgical procedures performed in collegiate football players over a 10-year period. STUDY DESIGN: Descriptive epidemiological study. METHODS: From the 2004-2005 season through the 2013-2014 season, all surgical procedures performed on athletes from a single NCAA Division I college football team during athletic participation were reviewed. Surgeries were categorized by anatomic location, and operative reports were used to obtain further surgical details. Data collected over this 10-season span included type of injury, primary procedures, reoperations, and cause of reoperation, all categorized by specific anatomic locations and position played. RESULTS: From the 2004-2005 through the 2013-2014 seasons, 254 operations were performed on 207 players, averaging 25.4 surgical procedures per year. The majority of surgeries performed were orthopaedic procedures (92.1%, n = 234). However, there were multiple nonorthopaedic procedures (7.9%, n = 20). The most common procedure performed was arthroscopic shoulder labral repair (12.2%, n = 31). Partial meniscectomy (11.8%, n = 30), arthroscopic anterior cruciate ligament (ACL) reconstruction (9.4% n = 24), and arthroscopic hip labral repair (5.9% n = 15) were the other commonly performed procedures. There were a total of 29 reoperations performed; thus, 12.9% of primary procedures had a reoperation. The most common revision procedure was a revision open reduction internal fixation of stress fractures in the foot as a result of a symptomatic nonunion (33.33%, n = 4) and revision ACL reconstruction (12.5%, n = 3). By position, relative to the number of athletes at each position, linebackers (30.5%) and defensive linemen (29.1%) were the most likely to undergo surgery while kickers (6%) were the least likely. CONCLUSION: In NCAA Division I college football players, the most commonly performed surgeries conducted for injuries were orthopaedic in nature. Of these, arthroscopic shoulder labral repair was the most common, followed closely by partial meniscectomy. Nonorthopaedic procedures nonetheless accounted for a sizable portion of surgical volume. Familiarity with this injury and surgical spectrum is of utmost importance for the team physician treating these high-level contact athletes.

The influence of a dynamic elastic garment on musculoskeletal and respiratory wellness in computer users.

BACKGROUND: Evidence is growing that computer users are at increased risk of developing musculoskeletal disorders, particularly those involving the upper extremity, with significant financial cost and lost productivity. OBJECTIVE: The purpose of this study was to determine the short-term effects of wearing a dynamic elastic garment (Posture Shirt[Formula: see text]; AlignMed, USA) on musculoskeletal wellness and health in the computer workplace. METHODS: Ninety-six computer users were evaluated. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was completed. A functional assessment of posture, lung function, and grip strength was performed after wearing the Posture Shirt[Formula: see text] for 4 weeks. A training log was kept to track usage of the garment, as well as weekly sensations of fatigue, productivity, and energy level. RESULTS: After 4 weeks, there was statistically significant improvement in forward shoulder and head posture, thoracic kyphosis, and grip strength. Improvements in spirometry measures did not meet statistical significance. Postural fatigue and muscular fatigue decreased by 21% and 29%, respectively, and energy level and productivity increased by 20% and 13%, respectively. CONCLUSION: This prospective study demonstrated positive short-term impact of the Posture Shirt[Formula: see text] on both subjective and objective measures of posture, lung function, grip strength, fatigue, and productivity.

Analysis of Direct Costs of Outpatient Arthroscopic Rotator Cuff Repair.

Arthroscopic rotator cuff surgery is one of the most commonly performed orthopedic surgical procedures. We conducted a study to calculate the direct cost of arthroscopic repair of rotator cuff tears confirmed by magnetic resonance imaging. Twenty-eight shoulders in 26 patients (mean age, 54.5 years) underwent primary rotator cuff repair by a single fellowship-trained arthroscopic surgeon in the outpatient surgery center of a major academic medical center. All patients had interscalene blocks placed while in the preoperative holding area. Direct costs of this cycle of care were calculated using the time-driven activity-based costing algorithm. Mean time in operating room was 148 minutes; mean time in recovery was 105 minutes. Calculated surgical cost for this process cycle was $5904.21. Among material costs, suture anchor costs were the main cost driver. Preoperative bloodwork was obtained in 23 cases, adding a mean cost of $111.04. Our findings provide important preliminary information regarding the direct economic costs of rotator cuff surgery and may be useful to hospitals and surgery centers negotiating procedural reimbursement for the increased cost of repairing complex tears.

High resolution MRI evaluation of meniscal volume and anthropometric correlations.

The purpose of this study was to digitally determine meniscal volumes, and compare them with linear and surface area anthropometric measurements to evaluate these measurements for meniscal allograft sizing. Eighteen subjects (10 male and 8 female; mean age 37.5 years) underwent 3.0 T knee magnetic resonance imaging (MRI) of the dominant leg. The following morphometric measurements were evaluated: medial meniscal volume (MMV), lateral meniscal volume (LMV), tibial plateau width (TPW), width of the femoral condyles (WFC), and tibial plateau surface area (TPSA). MMV and LMV were compared to TPW, WFC, and TPSA. Meniscal volume and TPW were correlated to height and body-mass index (BMI) and stratified by gender. Statistical analysis included coefficient of determination (r(2)) between MRI-based MMV, LMV, TPW, TPSA, WFC, height, BMI, and gender. Significance was set at the P = 0.05 level. The mean MMV was 2275 mm(3) and the mean LMV was 2102 mm(3). TPW correlated well with meniscal volumes (r(2) > 0.62). WFC and TPSA correlated with meniscal volumes in the range of 0.40 < r(2) < 0.61. Height, BMI, and gender correlated poorly with total meniscal volume and TPW with values of r(2) < 0.44. Medial and lateral menisci have statistically similar volumes. TPW had the greatest utility for volumetric meniscal sizing. MRI-based TPW can be considered as a statistically accurate measurement for determining meniscal volumes and meniscal size.

Anatomy of the femoral footprint of the posterior cruciate ligament: a systematic review.

PURPOSE: The purpose of this study was to summarize the past 10 years of orthopaedic literature to better delineate the femoral origin of the posterior cruciate ligament (PCL). METHODS: A PubMed search was conducted by 2 independent reviewers (M.P., M.V.) using the search terms "posterior cruciate ligament" or "PCL," "femur" or "femoral," and "anatomy" or "origin" or "footprint." Cadaveric and radiographic studies performed between January 1, 2003, and November 30, 2013, were analyzed. RESULTS: Aggregate data from radiographic parameters indicate that the anatomic origin of the anterolateral bundle lies 40% of the distance from the anterior articular surface of the femur and 14.5% of the tangent distance from the Blumensaat line toward the intercondylar notch. The origin of the posteromedial bundle lies 56% from the anterior surface and 36.5% of the tangent distance toward the notch. On the basis of cadaveric data, the center of the anterolateral bundle is 8 mm from the anterior surface (27.5% of the Blumensaat line), 4.7 mm tangent from the Blumensaat line toward the notch (22.5% of the tangent distance), and 3.6 mm from the medial intercondylar ridge; the center of the posteromedial bundle is 11.9 mm from the anterior articular surface (42.5%), 10.9 mm along the tangent line (57.5%), and 3.1 mm from the medial intercondylar ridge. CONCLUSIONS: We were able to precisely delineate the femoral origin of the PCL through our systematic review. CLINICAL RELEVANCE: Our systematic review may assist arthroscopic knee surgeons in placing anatomic tunnels during reconstruction of the PCL.

Anatomy and histology of the transverse humeral ligament.

The classic literature describes the transverse humeral ligament (THL) as a distinct anatomic structure with a role in biceps tendon stability; however, recent literature suggests that it is not a distinct anatomic structure. The purpose of this study was to evaluate the gross and microscopic anatomy of the THL, including a specific investigation of the histology of this ligament. Thirty frozen, embalmed cadaveric specimens were dissected to determine the gross anatomy of the THL. Seven specimens were evaluated histologically for the presence of mechanoreceptors and free nerve endings. Two tissue layers were identified in the area described as the THL. In the deep layer, fibers of the subscapularis tendon were found to span the bicipital groove with contributions from the coracohumeral ligament and the supraspinatus tendon. Superficial to this layer was a fibrous fascial covering consisting of distinct bands of tissue. Neurohistology staining revealed the presence of free nerve endings but no mechanoreceptors. This study's findings demonstrate that the THL is a distinct structure continuous with the rotator cuff tendons and the coracohumeral ligament. The finding of free nerve endings in the THL suggests a potential role as a shoulder pain generator.

3.0-Tesla MRI and arthroscopy for assessment of knee articular cartilage lesions.

The purpose of this study was to evaluate the ability of 3.0-Tesla magnetic resonance imaging (MRI) to accurately assess knee articular cartilage lesions. Sixteen patients who had knee 3.0-T MRI and underwent knee arthroscopy for partial meniscectomy were included. Three fellowship-trained sports medicine orthopedic surgeons reviewed all images. Articular lesions on MRI were graded from I to IV and compared with arthroscopic grading using the Outerbridge and the International Cartilage Repair Society (ICRS) classifications. The articular surface was divided into 6 regions. Based on MRI findings, of the 288 articular surface evaluations, 113 (39%) surface evaluations were classified as disease-positive (grade 2 to 4). Kappa interrater reliability scores for MRI evaluation, Outerbridge classification, and ICRS classification were 0.13, 0.54, and 0.41, respectively. Using the Outerbridge classification as a reference standard, the sensitivity, specificity, and accuracy were 57%, 71%, and 63%, respectively. Using the ICRS classification, sensitivity, specificity, and accuracy were 59%, 71%, and 69%, respectively. When isolating the articular grading to the senior author on MRI evaluation vs Outerbridge classification, the sensitivity, specificity, and accuracy were 54%, 92%, and 75%, respectively. Based on the current findings, 3.0-T MRI is as an invaluable noninvasive tool with good diagnostic value for assessing articular cartilage lesions of the knee, although it may not be as sensitive and accurate as previously reported.

Tunnel intersection in combined anatomic reconstruction of the ACL and posterolateral corner.

Femoral tunnel intersection in combined anterior cruciate ligament and posterolateral corner reconstruction has been reported to be high. The purpose of this study was to examine the risk of intersection between an anatomic femoral anterior cruciate ligament tunnel created with a retrograde reaming device and femoral lateral collateral ligament reconstruction tunnels of varying trajectory in a synthetic femur model.

Overview of cycling injuries: results of a cycling club survey.

Participation in competitive bicycling has increased substantially over the past decade, and bicycle injuries have increased accordingly. Cycling has been reported in several studies to have higher rates of injury than other sports and recreational activities; accordingly, riders must be cognizant of the potential for injury and protect themselves appropriately. The purpose of the current study was to survey an established competitive Los Angeles-based road cycling team to determine the epidemiology of and circumstances for traumatic cycling injuries.

Hemiarthroplasty for the treatment of distal humerus fractures: short-term clinical results.

Total elbow arthroplasty is the current gold standard of treatment for unreconstructable distal humerus fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humerus hemiarthroplasty offers an alternative and may allow for more durable results. The authors retrospectively evaluated the short-term clinical outcomes of 10 patients who underwent elbow hemiarthroplasty for distal humerus fractures. This short-term review suggests that distal humerus hemiarthroplasty may be an effective treatment for certain distal humerus fractures. Additional studies must be conducted to further define the role of elbow hemiarthroplasty for the treatment of complex fractures of the distal humerus.

Human knee synovial fluid cytokines correlated with grade of knee osteoarthritis--a pilot study.

UNLABELLED: The purpose of this pilot study was to evaluate the cytokine profile of human knee synovial fluid and correlate this with the subject's degree of articular cartilage degradation, radiographic score, and synovial histology. MATERIALS AND METHODS: Synovial fluid was withdrawn before knee meniscectomy in 12 subjects with varying degrees of osteoarthritis and assayed for 21 cytokines, using a multiplex cytokine assay and flow cytometry instrumentation. Articular cartilage surfaces were scored by a single orthopaedic surgeon on the basis of the International Cartilage Repair Society (ICRS) classification during the arthroscopy, and posterior-anterior knee radiographs were graded using the Kellgren-Lawrence (KL) classification. Synovial biopsies were taken in four zones at the time of surgery for histological analysis. RESULTS: Significant concentration differences in IL-2, IL-5, MCP-1, and MIP-1 were found between subjects with advanced arthritis and subjects with little or no arthritis on the ICRS scale (p < .05). No such differences could be appreciated using KL scores. There was no correlation between histology samples and visualized surface osteoarthritis. CONCLUSION: This data suggests a molecular basis of disease progression, with higher levels of cytokines indicative of greater degrees of osteoarthritis. These results add pilot data that can assist investigators in conducting a comparative observational study of the levels of inflammatory cytokines with radiologic and arthroscopic assessments of osteoarthritis.

Anterior cruciate ligament allograft surgery: underreporting of graft source, graft processing, and donor age.

BACKGROUND: There has been much controversy regarding the effects of sterilization techniques and graft history on the structural integrity of allograft ligaments used in reconstruction of the anterior cruciate ligament. The purpose of this review was to comprehensively examine anterior cruciate ligament allograft studies published in the last decade to evaluate the extent to which tissue source, tissue processing techniques, and donor age are reported. METHODS: The authors reviewed 202 articles published from 1999 through November 2009, of which 68 retrospective, prospective, biomechanical, and histology studies evaluating 4689 allografts were included. RESULTS: The majority of studies do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age. Underreporting was particularly prominent in clinical studies as compared with basic science studies. Limited reporting of allograft processing, allograft source, and donor age raises serious questions regarding the generalizability of published studies of allograft tissue for anterior cruciate ligament reconstruction. Conclusion/ CLINICAL RELEVANCE: Orthopaedic surgeons who use allograft tissue must understand the tissue treatments being used (ie, preservation methods, chemical and sterilization processes) to best inform their patients regarding the risks, benefits, and long-term outcomes when such tissues are used. A complete understanding of the implanted tissue, as well as surgeon and recipient demographics, is necessary to ensure appropriate and predictable long-term outcomes.

Sterilization effects on the mechanical properties of human bone-patellar tendon-bone allografts.

Novel allograft processing methods are available from tissue banks to decrease disease transmission. This study evaluated the effects of 3 of these techniques on the initial mechanical properties of bone-patellar tendon-bone (BPTB) allografts: (1) aseptic harvest with low-dose radiation processing, (2) BioCleanse Tissue Processing System, and (3) Clearant Process. Ten-mm BPTB allografts were potted in an MTS 858 machine (MTS Systems Corp, Eden Prairie, Minnesota), cycled, and loaded to failure at a strain rate of 100%/s. Data were critically analyzed for graft dimensions and age and sex of donor. The 10th cycle and last cycle stiffness after 1000 cycles were measured at the toe region and at all points. The 2% yield stress (MPa), Young's modulus (MPa), elongation failure (mm), strain fracture (%), ultimate stress (MPa), and toughness (kJ) were measured. Forty-two tendons were tested (15 control, 11 BioCleanse, and 16 Clearant). No statistically significant differences were detected between the groups at their 10th cycle and last cycle stiffness (P>.05). Yield stress ranged from 19 to 28.8 MPa without a statistically significant difference (P>.05). Young's modulus ranged from 178.3 to 213.8 MPa without a statistically significant difference (P>.05). Similarly, elongation to failure, strain to failure, ultimate stress, and toughness showed no statistically significant differences among the 3 groups (P>.05). These processing techniques did not affect the time zero mechanical properties of the BPTB allograft tendons under these testing conditions. Clinical use of allografts should proceed with caution for selected patients.