Surgical Treatment of Meniscal Extrusion: A Biomechanical Study on the Role of the Medial Meniscotibial Ligaments With Early Clinical Validation.

BACKGROUND: Meniscal extrusion refers to meniscal displacement out of the joint space and over the tibial margin, altering knee mechanics and increasing the risk of osteoarthritis. The meniscotibial ligaments have been shown to have an important role in meniscal stability. However, it remains unclear whether an isolated lesion of the medial meniscotibial ligaments will result in meniscal extrusion and whether repairing the detached ligament will reduce extrusion. HYPOTHESIS: A lesion of the medial meniscotibial ligament will result in meniscal extrusion, and repairing the joint capsule will eliminate the extrusion by returning the meniscus back to its original position. STUDY DESIGN: Controlled laboratory study. METHODS: Fresh-frozen human cadaveric knees (N = 6) were used for biomechanical testing. The test protocol involved 100 flexion-extension cycles. In full extension, meniscal extrusion was measured using ultrasound, in both an otherwise unloaded state and while subjected to a 10-N·m varus load. Each knee was tested in its native condition (baseline), after creating a detachment of the medial meniscotibial ligament, and finally with the joint capsule repaired using 3 knotless SutureTak anchors. We also performed a retrospective review of 15 patients who underwent meniscotibial ligament repair with a minimal follow-up of 5 weeks (mean, 14 weeks; range, 5-35 weeks). RESULTS: During biomechanical testing, the mean absolute meniscal extrusion at baseline was 1.5 ± 0.6 mm. After creation of the meniscotibial ligament lesion, the mean absolute meniscal extrusion was significantly increased (3.4 ± 0.7 mm) (P < .001). After repair, the extrusion was reduced to 2.1 ± 0.4 mm (P < .001). Clinically, a reduction in absolute meniscal extrusion of approximately 48% was reached (1.2 ± 0.6 vs 2.4 ± 0.5 mm preoperatively; P < .001). CONCLUSION: This study indicates that the medial meniscotibial ligaments contribute to meniscal stability as lesions cause the meniscus to extrude and that repair of those ligaments can significantly reduce extrusion. Early clinical results using this meniscotibial ligament repair technique support our biomechanical findings, as a significant reduction in meniscal extrusion was achieved. CLINICAL RELEVANCE: Our biomechanical findings suggest that repair of medial meniscotibial ligaments reduces meniscal extrusion and clinically may improve meniscal function, with the possible long-term benefit of reducing the risk for osteoarthritis.

Repair and InternalBrace Augmentation of the Medial Ulnar Collateral Ligament.

"For more than 4 decades, reconstruction of the ulnar collateral ligament (UCL) using some type of autograft tissue has been the standard of care for UCL-injured athletes. This article reviews the history of UCL repair including the rationale for the revival of interest in primary repair of the UCL as an option for the treatment of select athletes as well as the early clinical results indicating the short-term successful outcomes of the procedure in properly selected athletes."

Epidemiology and Impact of Knee Injuries in Major and Minor League Baseball Players.

Few studies have explored the frequency and impact of lower extremity injuries, such as those to the knee, among professional baseball players. The purpose of this study was to detail the epidemiology of knee injuries in Major League Baseball (MLB) and Minor League Baseball (MiLB) players during the 2011-2014 seasons. It was hypothesized that knee injuries are a common occurrence in these athletes, and represent a significant source of time away from play. The MLB Health and Injury Tracking System database was searched to identify all patients diagnosed with knee injuries during the 2011-2014 seasons. All injuries that occurred during the preseason, regular season, and postseason that resulted in time away from play were included. Injury data analyzed included total number of knee injuries, specific diagnoses, injury mechanisms, locations, player positions, and time lost. Descriptive statistics were conducted and injury rates per athlete-exposures were calculated. During the 2011-2014 seasons, a total of 2171 knee injuries occurred in MLB and MiLB players, representing 6.5% of all injuries in professional baseball. The knee injury rate across both the MLB and MiLB was 1.2 per 1000 athlete-exposures. The mean number of days missed per injury across both leagues was 16.2 with a total of 30,449 days of missed play amongst all athletes over the 4 seasons. Injuries to the knee were the fifth most common cause of missed time in all of baseball, and the fourth most common reason for missed games in the MLB alone. Approximately 12% of all injuries required surgical intervention. The most common mechanism of injury was noncontact (44%), and base runners were injured more frequently than any other position (24%). The infield (30%) and home plate (23%) were the most common locations in which injuries occurred. These data can be utilized for targeted injury prevention initiatives.

Incidence and trends of anterior cruciate ligament reconstruction in the United States.

BACKGROUND: Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases. PURPOSE: To determine the incidence of ACL reconstruction (ACLR) in the United States; to identify changes in this incidence between 1994 and 2006; to identify changes in the demographics of ACLR over the same time period with respect to location (inpatient vs outpatient), sex, and age; and to determine the most frequent concomitant procedures performed at the time of ACLR. STUDY DESIGN: Descriptive epidemiological study. METHODS: International Classification of Diseases, 9th Revision (ICD-9) codes 844.2 and 717.83 were used to search the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) for the diagnosis of ACL tear, and the procedure code 81.45 was used to search for ACLR. The incidence of ACLR in 1994 and 2006 was determined by use of US Census Data, and the results were then stratified based on patient age, sex, facility, concomitant diagnoses, and concomitant procedures. RESULTS: The incidence of ACLR in the United States rose from 86,687 (95% CI, 51,844-121,530; 32.9 per 100,000 person-years) in 1994 to 129,836 (95% CI, 94,993-164,679; 43.5 per 100,000 person-years) in 2006 (P = .015). The number of ACLRs increased in patients younger than 20 years and those who were 40 years or older over this 12-year period. The incidence of ACLR in females significantly increased from 10.36 to 18.06 per 100,000 person-years between 1994 and 2006 (P = .0003), while that in males rose at a slower rate, with an incidence of 22.58 per 100,000 person-years in 1994 and 25.42 per 100,000 person-years in 2006. In 2006, 95% of ACLRs were performed in an outpatient setting, while in 1994 only 43% of ACLRs were performed in an outpatient setting. The most common concomitant procedures were partial meniscectomy and chondroplasty. CONCLUSION: The incidence of ACLR increased between 1994 and 2006, particularly in females as well as those younger than 20 years and those 40 years or older. Research efforts as well as cost-saving measures may be best served by targeting prevention and outcomes measures in these groups. Surgeons should be aware that concomitant injury is common.

Factors affecting rotator cuff healing.

Several studies have noted that increasing age is a significant factor for diminished rotator cuff healing, while biomechanical studies have suggested the reason for this may be an inferior healing environment in older patients. Larger tears and fatty infiltration or atrophy negatively affect rotator cuff healing. Arthroscopic rotator cuff repair, double-row repairs, performing a concomitant acromioplasty, and the use of platelet-rich plasma (PRP) do not demonstrate an improvement in structural healing over mini-open rotator cuff repairs, single-row repairs, not performing an acromioplasty, or not using PRP. There is conflicting evidence to support postoperative rehabilitation protocols using early motion over immobilization following rotator cuff repair.

Pediatric ACL injuries: evaluation and management.

The anterior cruciate ligament (ACL) is a stabilizing structure to both anterior translation of the tibia with respect to the femur as well as rotation of the knee joint. Children and adolescents are susceptible to these injuries, and there are some who believe the incidence of ACL injuries in this population is increasing due to year round single sport participation. Pediatric ACL injuries are typically seen in several forms: tibial avulsion fractures, partial ACL tears, and full thickness ligament tears. There were and still are some who feel that ACL injuries should be treated non-operatively in the pediatric and adolescent population; however, recent literature refutes this notion. Several factors must be considered during pediatric and adolescent ACL reconstruction, each of which will be examined in this manuscript, including: status of the physis, reconstruction technique, and graft source.

Paget-schroetter syndrome: a review of effort thrombosis of the upper extremity from a sports medicine perspective.

Paget-Schroetter is a rare diagnosis in the general population; however, it is more common in younger, physically active individuals. Clinicians must be familiar with the symptoms, physical examination, and initial imaging and treatment to expedite care and prevent possible life-threatening complications. Urgent referral to a regional specialist may improve the opportunity for thrombolysis to restore blood flow through the subclavian vein and to decrease the chance of pulmonary embolus, recurrent thrombosis, or need for vein grafting, as well as to improve the time to return to full activity (athletics and/or manual labor).

Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete.

OBJECTIVES: To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment. METHODS: A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management. RESULTS: Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynaud's (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up. CONCLUSIONS: Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).

OBJECTIVES: The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. METHODS: A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. RESULTS: Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01). CONCLUSIONS: Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.

Biomechanical evaluation of 2 techniques for ulnar collateral ligament reconstruction of the elbow.

BACKGROUND: Elbow medial ulnar collateral ligament tears often result in pain and instability that may be career threatening in overhead-throwing athletes. Surgical reconstruction is frequently chosen to treat this injury. Ulnar collateral ligament reconstruction as described by Jobe is the most commonly used technique. Testing of this construct has not demonstrated that the biomechanical parameters of the native ligament are restored. A more recent construct, the docking technique, may more reliably reproduce these factors. HYPOTHESIS: Increasing the number of strands of palmaris longus tendon graft used in ulnar collateral ligament reconstruction and tensioning them using the docking technique result in a construct with improved biomechanical parameters as compared with the Jobe technique. STUDY DESIGN: Controlled laboratory study. METHODS: Thirty-three fresh-frozen human cadaveric elbows were randomized into 3 subgroups: Jobe (11), docking (12), and native (10). The Jobe and docking groups underwent reconstruction using their described palmaris tendon graft constructs. The ulnar collateral ligament was left intact in the native group. Elbows were potted and tested using a servohydraulic materials testing machine to apply a valgus moment at 30 degrees of elbow flexion. Maximal moments to failure, stiffness, and strain at maximal moment and with a 3 N.m force applied were determined using a 2-camera motion analysis system to track reflective markers spanning the site. RESULTS: The docking (14.3 N.m) and native (18.8 N.m) subgroups resulted in higher maximal moment to failure than did the Jobe (8.9 N.m) subgroup (P < .001). There was no significant difference between native and docking groups (P > .05). Native ligaments were stiffer (301.4 N.m) than were Jobe (74.3 N.m) or docking (80.8 N.m; P < .001). Native ligaments demonstrated lower strain at maximal force (0.087 mm/mm) and 3 N.m forces (0.030 mm/mm) than did the Jobe (0.198/0.057 mm/mm) or docking (0.287/0.042 mm/mm) subgroups. There was no difference in stiffness or strain between the Jobe and docking subgroups (P > .05). CONCLUSION: Neither technique reproduced the biomechanical profile of the native ulnar collateral ligament; the findings of this study suggest that the docking construct may offer initial biomechanical advantage over the Jobe construct.

The modified docking procedure for elbow ulnar collateral ligament reconstruction: 2-year follow-up in elite throwers.

BACKGROUND: Ulnar collateral ligament injury is most common in the overhead-throwing athlete. Jobe et al published the first report of ulnar collateral ligament reconstruction in throwing athletes with a 62.5% success rate. Recently, Altchek developed a new docking technique for reconstruction of the ulnar collateral ligament. The authors report the first series using a further modification of the docking technique using a 4-strand palmaris longus graft for reconstruction of the ulnar collateral ligament. HYPOTHESIS: The modified docking technique yields a high rate of successful return to preinjury level of competition in elite baseball players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors retrospectively reviewed 25 elite professional or scholarship collegiate baseball players who underwent elbow ulnar collateral ligament reconstruction using the modified docking procedure with a minimum 2-year follow-up. RESULTS: Twenty-three of 25 (92%) were able to return to their preinjury levels of competition. The mean time to return was 11.5 months (range, 10-16 months). Complications included 1 transient postoperative ulnar nerve neurapraxia and 1 stress fracture of the ulnar bone bridge that occurred at 14 months postoperatively, after a full return to pitching. CONCLUSION: The modified docking technique yields highly successful return to preinjury level of competition rates (92%) in a select group of elite baseball players.

Elbow range of motion in professional baseball pitchers.

BACKGROUND: Physicians involved with the care of baseball players have noted elbow range of motion changes in pitchers. Objective data regarding the extent of these changes have rarely been documented. HYPOTHESIS: Dominant and nondominant elbow range of motion differences are common in baseball pitchers, and these differences are related to player age, amount and length of time professionally pitched, and history of surgical procedures on the dominant extremity. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: Thirty-three professional pitchers were evaluated for elbow range of motion during spring training preseason physical examination. Dominant and nondominant elbow range of motion including flexion, extension, supination, and pronation were measured with a goniometer. Range of motion measures from the dominant and nondominant sides were compared. Baseball records were reviewed for arm dominance, age, years of professional pitching, professional innings pitched, and history of elbow surgery. These factors were evaluated for their possible association with range of motion for each side and the difference between sides. RESULTS: Statistically significant differences between dominant and nondominant sides were noted for elbow extension (dominant decreased 7.9 degrees +/- 7.4 degrees, P < .0001), flexion (dominant decreased 5.5 degrees +/- 7.8 degrees, P = .0003), and total flexion-extension arc (dominant decreased 13.3 degrees +/- 13.7 degrees, P < .0001). No significant difference between sides was found for the supination or pronation measures. No correlation was noted for age, pitching history, surgery, or arm dominance and the motion differences. CONCLUSION: Professional pitchers demonstrate elbow flexion and extension differences between dominant and nondominant elbows. No correlation was found between motion differences and age, pitching history, surgery, or arm dominance.

Juvenile and adolescent elbow injuries in sports.

Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.

Prevalence of the Bennett lesion of the shoulder in major league pitchers.

BACKGROUND: The Bennett lesion is a mineralization of the posterior inferior glenoid noted in overhead throwing athletes. Although previous studies have debated appropriate treatment of the lesion, no studies have indicated the lesion prevalence in throwing athletes. HYPOTHESIS: The Bennett lesion is more common than previously believed and may represent an asymptomatic finding. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Fifty-five asymptomatic major league pitchers underwent routine preseason radiographic screening. Radiographs were reviewed for the presence of a Bennett's lesion. Player demographics, pitching, and baseball records were reviewed to obtain the patient's dominant arm, age, years and innings pitched, and time on the disabled list or surgery. RESULTS: Twelve pitchers (22%) were noted to have a radiographic Bennett lesion. No statistically significant difference was noted in age, years pitched, or innings pitched between pitchers with and without a Bennett lesion. No player who demonstrated a Bennett lesion required surgical treatment for shoulder pain during his time with the club. Two players required time on the disabled list, but neither player had complaints of posterior shoulder pain. CONCLUSIONS: This lesion is a relatively common finding in major league pitchers. Concomitant pathology should be suspected when evaluating throwers with posterior shoulder pain and this lesion.

Shoulder disorders in the skeletally immature throwing athlete.

Shoulder injuries are common in young throwing athletes. Most injuries are overuse types related to excessive pitch counts, premature use of breaking pitches, and improper pitching mechanics. These etiologic factors should be recognized early and treated. Prevention of injuries should play a major role in decreasing shoulder injury.

Complications of treatment of acromioclavicular and sternoclavicular joint injuries.

Although common, AC joint injuries and their treatments are not benign. The injury itself and both nonsurgical and surgical treatments may result in complications yielding persistent pain, deformity, or dysfunction. Sternoclavicular joint injuries are far less common and are typically the result of higher energy trauma. As such, the associated complications may be more serious. Familiarity with the potential complications of these injuries can help the treating physician to develop strategies to minimize their incidence and sequelae.

Special considerations. Anterior cruciate ligament reconstruction in the skeletally immature.

ACL injury in children is being recognized with greater frequency because of improved diagnostic techniques as well as heightened awareness of the condition. Unfortunately, the diagnosis is still missed because the attitude persists that children do not suffer ligament injuries. Hemarthrosis must be considered an indication of a significant intra-articular injury. During the past decade, ACL reconstruction has evolved to a reproducible technique with low morbidity. Aggressive rehabilitation programs allow accelerated return to activity while allowing the biology of graft maturation to progress. The basic principle of diagnosis and the treatment goals in the skeletally immature patient are the same as those in the adult patient. The diagnosis approach to ACL injury in the scholastic-age patient, however, must also include evaluation of the patient's skeletal maturity because it plays a major role in treatment decisions. Maturity is evaluated on the basis of the patient's chronologic age; various physiologic factors, such as family height, patient's projected height, and estimation of sexual development; and radiographic findings in the knee, pelvis (Risser sign), or hand and wrist (bone-age study). Because of the special characteristics of the skeletally immature patient, the orthopedic surgeon must act as "knee counselor" by attempting to identify at-risk patients, particularly those who abuse their knees for any of a variety of reasons. The nonoperative treatment principles are the same as those in an adult. Consideration of surgical treatment must take into account assessment of skeletal maturity. If questions remain about the status of the femoral and tibial physes, polytomography or MRI is used to assess the extent of physeal closure. The surgical reconstruction used reflects the patient's skeletal maturity. As the skeletal maturity threshold is reached, transphyseal reconstructions may be done with diminished reservation about causing sequelae of physeal arrest.