Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 - March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using Chi-squared or Student's T-test was performed to identify associations between preoperative variables and two postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (P = 0.009, 0.005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (P = 0.021, 0.005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Augmenting ACL Repair With Suture Tape Improves Knee Laxity: A Biomechanical Study.

Background: Anterior cruciate ligament (ACL) repair is an alternative to reconstruction; however, suture tape support may be necessary to achieve adequate outcomes. Purposes: To investigate the influence of suture tape augmentation (STA) of proximal ACL repair on knee kinematics and to evaluate the effect of the 2 flexion angles of suture tape fixation. Study Design: Controlled laboratory study. Methods: Fourteen cadaveric knees were tested using a 6 degrees of freedom robotic testing system under anterior tibial (AT) load, simulated pivot-shift (PS) load, and internal rotation (IR) and external rotation loads. Kinematics and in situ tissue forces were evaluated. Knee states tested were (1) ACL intact, (2) ACL cut, (3) ACL repair with suture only, (4) ACL repair with STA fixed at 0° of knee flexion, and (5) ACL repair with STA fixed at 20° of knee flexion. Results: ACL repair alone did not restore the intact ACL AT translation at 0°, 15°, 30°, or 60° of flexion. Adding suture tape to the repair significantly decreased AT translation at 0°, 15°, and 30° of knee flexion but not to the level of the intact ACL. With PS and IR loadings, only ACL repair with STA fixed at 20° of flexion was not significantly different from the intact state at all knee flexion angles. ACL suture repair had significantly lower in situ forces than the intact ACL with AT, PS, and IR loadings. With AT, PS, and IR loadings, adding suture tape significantly increased the in situ force in the repaired ACL at all knee flexion angles to become closer to that of the intact ACL state. Conclusion: For complete proximal ACL tears, suture repair alone did not restore normal knee laxity or normal ACL in situ force. However, adding suture tape to augment the repair resulted in knee laxity closer to that of the intact ACL. STA with fixation at 20° of knee flexion was superior to fixation with the knee in full extension. Clinical Relevance: The study findings suggest that ACL repair with STA fixed at 20° could be considered in the treatment of femoral sided ACL tears in the appropriate patient population.

Economic and Performance Impact of Anterior Cruciate Ligament Injury in National Basketball Association Players.

BACKGROUND: Anterior cruciate ligament (ACL) tears are one of the most devastating injuries seen in the National Basketball Association (NBA). No previous studies have examined the economic impact of ACL tears in the NBA. PURPOSE/HYPOTHESIS: The purpose of this study was to examine the economic impact of ACL tears on NBA players and teams by calculating the costs of recovery (COR) and classifying players based on preinjury success level (All-Star or equivalent, starter, or reserve) and salary (in US$ million: <1.5, 1.5-4, or >4 per season). It was hypothesized that players with a lower preinjury salary or primarily a reserve role would have decreased costs, lower rates of return to play (RTP), and shorter careers. STUDY DESIGN: Descriptive epidemiology study. METHODS: We reviewed the publicly available records of NBA players treated with ACL reconstruction from 2000 to 2015. Data collected included player demographics, player salaries, statistical performance using player efficiency rating (PER), and specifics regarding time missed and RTP rate. RESULTS: A total of 35 players met the study inclusion criteria. The cumulative economic loss from ACL injuries in the NBA from 2000 to 2015 was $99 million. The average COR was $2.9 million per player. RTP rate was 91% overall, with 70% retention at 3 years. Players that made a salary of less than $1.5 million per season before the injury had a significant drop in PER (difference of -7), RTP rate of 63%, and only 37% retention at 3 years. Conversely, recovering All-Star players also had a significant drop in PER (-6.2), and no players repeated as All-Stars in the season after ACL reconstruction (0%), although they did have a 100% RTP rate and an average career length of 5.6 seasons postinjury. CONCLUSION: While the RTP rate in NBA athletes remained high, ACL reconstruction can result in decreased statistical performance and/or inability to return to prior levels of play. Players who made less than $1.5 million preinjury or played primarily in a reserve role were associated with lower RTP and retention in the NBA at 3 years.

Heat-Related Complications from Radiofrequency and Electrocautery Devices Used in Arthroscopic Surgery: A Systematic Review.

PURPOSE: To investigate the occurrence of heat-related complications from radiofrequency and electrocautery devices in patients undergoing arthroscopic surgery. METHODS: A systematic review was performed using the PubMed/Medline, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane databases, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting complications after arthroscopy using electrosurgery devices were included. Only English- and Dutch-language articles were included. Basic science/nonclinical studies/human cadaveric studies and animal studies were excluded. Article selection was performed by 2 separate reviewers. Interobserver agreement of the selection procedure was determined by Cohen's kappa. All included articles were critically appraised using an adapted version of the ROBINS-I tool. RESULTS: Twenty-five studies were included in this systematic review. A total of 309 cases of heat-related complications were identified. Chondrolysis was present in 45 cases and dermal burns in 15 cases. Axillary nerve injuries were reported in 197 cases of arthroscopic adhesive capsulitis release. However, it was unclear whether these injuries were directly related to the overheating of the arthroscopic fluid. No one specific risk factor for thermal complications was identified, but related factors included the leakage of the arthroscopy fluid, use of a thermal device continuously for a long period of time, proximity of the thermal device to the tissue, intra-articular local anesthetic injection or the use of intra-articular pain pumps, and certain surgical procedures, such as thermal capsulorrhaphy, capsular release, and synovectomy. CONCLUSIONS: The most common heat-related complications in arthroscopy are dermal burns and chondrolysis. Risk factors include leakage of arthroscopy fluid, use of a thermal device, intra-articular anesthetics/pain pumps, and performing specific surgical procedures. LEVEL OF EVIDENCE: Systematic review of level III-IV studies.

Suture tape augmentation improves laxity of MCL repair in the ACL reconstructed knee.

PURPOSE: Medial collateral ligament (MCL) injury is very common and surgical repair is sometimes necessary. Especially in the setting of simultaneous anterior cruciate ligament reconstruction (ACLR) as the ACL is the secondary restraint against valgus stress. The goal of this study was to evaluate knee biomechanics after suture repair of the MCL augmented with suture tape, as compared to MCL repair alone, in the setting of concomitant ACL reconstruction (ACLR). METHODS: Fifteen fresh-frozen human cadaveric knees were tested using a six-degrees-of-freedom robotic system under four loadings: (a) an 89.0 N anterior tibial load, (b) a 5.0 Nm internal and external rotation torque, (c) a 10.0 Nm valgus load, (d) a 7.0 Nm valgus load combined with 5.0 Nm internal rotation torque as a static simulated pivot-shift. The tested conditions were ACLR with the following states: (1) MCL intact, (2) MCL deficient, (3) MCL Repair, and (4) MCL repair augmented with suture tape (MCL Repair + ST). Under the different knee loadings, the tibial displacement, and the force in either the intact MCL, suture repaired MCL or repaired MCL-suture tape complex was measured. RESULTS: While neither the MCL Repair nor the MCL Repair + ST restored valgus rotation to the MCL intact state, displacement was significantly smaller after MCL Repair + ST (p < 0.05). The knee rotation under external rotation torque in MCL Repair + ST did not differ MCL intact (n.s.), while with MCL Repair the rotation was significantly greater (p < 0.05). MCL Repair + ST did not cause an over-constraint of the knee in any of the tested loading conditions. CONCLUSION: In a combined ACL-reconstruction-MCL-repair model, MCL Repair augmented with suture tape improved valgus and external rotation laxity when compared to MCL suture repair alone. Suture tape augmentation may provide this additional means of stabilization and can be added at the time of surgical repair of the MCL. Clinically this may result in lower failure rates and less residual laxity after MCL repair, as well as shorter immobilization times and faster return to play.

Notchplasty alters knee biomechanics after anatomic ACL reconstruction.

PURPOSE: The aims of this study were (1) to study the biomechanics of single-bundle anatomic ACL reconstructed knees with and without notchplasty using a robotic testing system and (2) to determine if there would be a difference between performing a small or large notchplasty. METHODS: Fifteen fresh-frozen specimens were used in this study. The ACL reconstruction (ACL-R) was performed using an anatomic single-bundle technique with the 8 mm soft tissue graft fixed at 30° with suspensory fixation on the femoral side and a screw and washer on the tibial side. The notchplasty was then created with a burr. The following knee states were compared: (1) ACL-R, (2) ACL-R with a small (3 mm) notchplasty, and (3) ACL-R with a large (6 mm) notchplasty. Four loading conditions were applied: (1) an anterior drawer with an 89 N anterior tibial load, (2) simulated pivot-shift loading, (3) a 5 Nm internal rotational moment, and (4) a 5 Nm external rotational moment. RESULTS: Under anterior tibial loading, anterior tibial translation increased, and graft force decreased significantly after ACL-R + 3 mm notchplasty and ACLR + 6 mm notchplasty compared to ACL-R alone at FE, 15° and 30° of knee flexion. There were no changes in either anterior tibial translation or graft force under simulated pivot-shift loading, internal rotational moment, or external rotational moment. CONCLUSION: When added to anatomic ACL reconstruction, notchplasty increased anterior tibial translation and decreased graft forces during low knee flexion angles. There was no difference between a small and large notchplasty. The findings of this study are clinically relevant as the purpose of anatomic ACL reconstruction is to restore normal knee laxity, and while notchplasty may be helpful in avoiding graft impingement and improving visualization, removing even 3 mm of bone leads to biomechanical changes.

Atypical Lipomatous Tumors: Does Our Inconsistent Terminology Have Patient Repercussions? Results of a Meta-Analysis.

OBJECTIVES: Misnaming low-grade lipomatous tumors poses a clinical and medicolegal challenge, potentially subjecting patients to expensive and unnecessary surgeries. The terms atypical lipomatous tumor (ALT) and "well-differentiated" liposarcoma (WDL) have been used interchangeably in pathology reports, scholarly works and consensus recommendations, creating vagaries between low-virulence extremity tumors and retroperitoneal disease with metastatic potential. METHODS: A systematic review was performed on all studies that reported on the local recurrence rate and metastasis of ALTs and WDLs in living human subjects. Local recurrence and metastases were compared using Fisher's Exact Test. RESULTS: In total, 20 studies evaluated ALTs (n=936), whereas 13 studied WDLs (n=626). Mean follow-up was 6.6±2.0 years (median, 7.0 y). No metastatic disease was observed among ALTs, whereas 15 patients with WDLs (2.7%, P<0.0001) had metastases. The local recurrence rate of ALTs was significantly lower than WDLs after both marginal (15.1%, 141/936 vs. 46.0%, 288/626, P<0.0001) and wide excisions (3.3%, 2/59 in ALT vs. 17.4%, 19/109, P=0.007). CONCLUSIONS: ALT should be reserved for extremity lesions meeting appropriate histopathologic criteria that represent nonmetastatic disease, reducing over-diagnosis, over-treatment, and patient risk.

Medial Patellofemoral Ligament Reconstruction Using Achilles Tendon Allograft With Bone Block.

Recurrent patellar instability is a common problem and often leads to a tear of the medial patellofemoral ligament. Multiple reconstruction techniques for the medial patellofemoral ligament (MPFL) exist. This Technical Note presents a technique for performing MPFL reconstruction using Achilles tendon allograft with a bone block. The advantages of this technique include (1) bone-to-bone healing in femoral tunnel; (2) docking the bone block in the femoral tunnel obviates the knee for calculating graft and tunnel length; (3) fixing the femoral side before the patellar side allows graft tensioning under direct visualization and avoids over-constraint; (4) the fanned portion of the Achilles tendon allows broad-based MPFL footprint coverage on the medial patellar ridge; and (5) it avoids the need for bone tunnel drilling in the patella, reducing the risk to penetration of the drill holes into the articular cartilage surface as well as the risk for patellar fracture.

Bioelectric Silver-Zinc Dressing Equally Effective to Chlorhexidine in Reducing Skin Bacterial Load in Healthy Volunteers.

PURPOSE: The aim of the present study was to evaluate and compare the effectiveness of the silver-zinc bioelectric dressing as compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in reducing the bacterial count on the knee. METHODS: Three groups consisting of 48 healthy volunteers were included. Age range was 23 to 54 years old and 60% of participants were male. Each subject had 1 knee serve as the test and the contralateral as the control. The test site was prepared with either 2% chlorhexidine, 4% chlorhexidine, or a silver-zinc bioelectric dressing and after 24 hours skin cultures were taken and examined for bacterial growth. RESULTS: In the 2% chlorhexidine group 23 of 48 unprepped knees had positive cultures, compared with 9 of 48 prepped knees (P = .003; risk reduction, 4.0 times). In the 4% chlorhexidine group 25 of 48 unprepped knees had positive cultures, compared with 14 of 48 prepped knees (P = .027; risk reduction, 2.6 times). In the silver-zinc bioelectric dressing group 29 of 48 unprepped knees had positive cultures, compared with 7 of 48 prepped knees (P < .001; risk reduction, 8.9 times). There was no difference in the positive skin culture rate between the 3 methods. CONCLUSIONS: Application of the silver-zinc bioelectric dressing was equally effective at reducing skin bacterial load when compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in healthy volunteers. LEVEL OF EVIDENCE: Basic Science - Microbiology. CLINICAL RELEVANCE: The findings of this study indicate that the use of a bioelectric dressing after knee surgery can match the standard of care of preparing the skin with an antiseptic before surgery.

Clinical outcomes of anconeus interposition arthroplasty after radial head resection in native and prosthetic radial heads.

BACKGROUND: Radiocapitellar pathology after traumatic injury to the elbow can be challenging to treat. The anconeus interposition arthroplasty has been proposed to treat radiocapitellar or proximal radioulnar joint dysfunction and pain, or both. This study evaluated whether radial head excision (native or prosthetic), followed by an anconeus interposition arthroplasty, relieves pain and improves subjective and objective elbow function in patients with post-traumatic radiocapitellar pathology. METHODS: A retrospective comparative case series was performed of 50 consecutive patients who underwent a native radial head excision or radial head implant excision, followed by an anconeus interposition arthroplasty. Clinical outcome scores, range of motion, and proximal radius migration were evaluated in patients with at least 2 years of follow-up. RESULTS: Included were 23 patients (11 native and 12 prosthetic radial heads) with a mean age of 41 years. Average follow-up was 38 months. Overall, significant improvement was obtained in the Disabilities of the Arm, Shoulder and Hand and visual analog scale scores. Range of motion significantly improved from preoperatively to postoperatively. Patients with a native radial head excision scored better on the Single Assessment Numeric Evaluation (76.8 vs. 56.3, P = .037) and obtained significantly more flexion postoperatively (141° vs. 123°, P = .016). Mild wrist pain developed in 3 patients, but no further intervention was required. The overall complication rate was 13%, and 5 patients required reoperation. CONCLUSIONS: Anconeus interposition arthroplasty performed after radial head resection in native and prosthetic groups is a viable adjunct in the operative treatment of patients with post-traumatic radiocapitellar pathology. However, whether anconeus interposition arthroplasty alone produced the favorable clinical results of this study was difficult to determine.

Suture Tape Augmentation of the Thumb Ulnar Collateral Ligament Repair: A Biomechanical Study.

PURPOSE: This study aimed to evaluate and compare the biomechanical strength of repair of the thumb ulnar collateral ligament (UCL) alone and repair augmented with suture tape. METHODS: Twelve fresh-frozen cadaveric specimens (6 matched pairs) had the UCL divided at its attachment on the base of the proximal phalanx and repaired with or without suture tape augmentation. A material testing machine was used to provide valgus stress at a rate of 0.1 mm/s until failure. The maximum load, load at clinical failure, and mode of failure were recorded. RESULTS: In the specimens with UCL repair augmented with suture tape, the maximum load (46.6 N [SD, 25.6 N]) and load at clinical failure (25.3 N [SD, 18.3 N]) were significantly higher than in the repair-only group (8.02 N [SD, 2.24 N]) and (6.00 N [SD, 2.39 N], respectively). CONCLUSIONS: In this model, thumb UCL repair with suture tape augmentation demonstrated greater maximum and clinical failure loads compared with nonaugmented repair at time 0, that is, without any biological healing. CLINICAL RELEVANCE: Suture tape augmentation of UCL repair may be valuable in the setting of acute tears by decreasing the time of postoperative cast immobilization and, therefore, allowing for earlier thumb metacarpophalangeal joint motion and overall faster clinical recovery.

Web-Based Education Prior to Outpatient Orthopaedic Surgery Enhances Early Patient Satisfaction Scores: A Prospective Randomized Controlled Study.

BACKGROUND: A good patient-surgeon relationship relies on adequate preoperative education and counseling. Several multimedia resources, such as web-based education tools, have become available to enhance aspects of perioperative care. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the effect of an interactive web-based education tool on perioperative patient satisfaction scores after outpatient orthopaedic surgery. It was hypothesized that web-based education prior to outpatient orthopaedic surgery enhances patient satisfaction scores. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: All patients undergoing knee arthroscopy with meniscectomy, chondroplasty, or anterior cruciate ligament reconstruction or shoulder arthroscopy with rotator cuff repair were eligible for inclusion and were randomized to the study or control group. The control group received routine education by the surgeon, whereas the study group received additional web-based education. At the first postoperative visit, all patients completed the OAS CAHPS (Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems) survey. Differences in patient satisfaction scores between the study and control groups were determined with an independent t test. RESULTS: A total of 177 patients were included (104 [59%] males; mean age, 42 ± 14 years); 87 (49%) patients were randomized to receive additional web-based education. Total patient satisfaction score was significantly higher in the study group (97 ± 5) as compared with the control group (94 ± 8; P = .019), specifically for the OAS CAHPS core measure "recovery" (92 ± 13 vs 82 ± 23; P = .001). Age, sex, race, workers' compensation status, education level, overall health, emotional health, procedure type and complexity, and addition of a video did not influence patient satisfaction scores. CONCLUSION: Supplemental web-based patient education prior to outpatient orthopaedic surgery enhances patient satisfaction scores.

Outcomes After Dermal Allograft Reconstruction of Chronic or Subacute Pectoralis Major Tendon Ruptures.

BACKGROUND: Avoiding delay in the surgical management of pectoralis major (PM) ruptures optimizes outcomes. However, this is not always possible, and when a tear becomes chronic or when a subacute tear has poor tissue quality, a graft can facilitate reconstruction. PURPOSE: The primary aim was to evaluate the clinical outcomes of PM reconstruction with dermal allograft augmentation for chronic tears or for subacute tears with poor tissue quality. A second aim was to determine patient and surgical factors affecting outcome. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Nineteen consecutive patients (19 PM ruptures) with a mean ± SD age of 39.1 ± 8.4 years were retrospectively reviewed at 26.4 ± 16.0 months following PM tendon reconstruction with dermal allograft. Surgery was performed at 19.2 ± 41.2 months after injury (median, 7.6 months; range, 1.1-185.4 months). Several outcome scores were recorded pre- and postoperatively, including Disabilities of the Arm, Shoulder, and Hand (DASH), as well as visual analog scale (VAS) (range, 0-10; 0 = no pain) and Single Assessment Numeric Evaluation (SANE). Range of motion, Constant score, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test score, and complications/reoperations were recorded postoperatively. RESULTS: Scores improved significantly for the DASH (preoperative, 34.9; postoperative, 8.0; P < .001) and VAS (preoperative, 5.0; postoperative, 1.5; P = .011). There was a trend toward improved SANE scores (preoperative, 15.0; postoperative, 80.0; P = .097), but the difference was not statistically significant, likely because of the small number of patients having preoperative SANE scores for review. Increased age was associated with higher VAS scores (r = 0.628, P = .016) and less forward flexion (r = -0.502, P = .048) and external rotation (r = -0.654, P = .006). Patients with workers' compensation had lower scores for 3 measures: SANE (75.8 vs 88.4, P = .040), Constant (86.7 vs 93.4, P = .019), and ASES (81.9 vs 97.4, P = .016). Operating on the dominant extremity resulted in lower Constant scores (87.8 vs 95.4, P = .012). A 2-head tendon tear (107.5° vs 123.3°, P = .033) and the use of >1 graft (105.0° vs 121.3°, P = .040) resulted in decreased abduction. CONCLUSION: This was the first large series to observe patients with chronic or subacute PM tendon tears treated with dermal allograft reconstruction. PM tendon reconstruction with dermal allografts resulted in good objective and subjective patient-reported outcomes.

Clinical outcomes of a single-tunnel technique for coracoclavicular and acromioclavicular ligament reconstruction.

BACKGROUND: A large number of surgical techniques have been described to treat acromioclavicular (AC) joint separations. Despite the high success rates with double-tunnel reconstruction, this method has been associated with the risk of coracoid and clavicle fractures. This study aimed to evaluate the outcomes of the first cohort of patients who underwent single-tunnel AC and coracoclavicular (CC) ligament reconstruction. It was hypothesized that this technique would result in maintenance of reduction and a minimal risk of fracture of the coracoid and clavicle. METHODS: All patients who underwent single-tunnel AC joint reconstruction between 2012 and 2015 via the technique with 2-year follow-up were included. Objective outcomes recorded were maintenance of reduction as measured by the CC distance on radiographs, shoulder range of motion, strength, return to sports, and complications. Subjective outcomes included maintenance of reduction on visual inspection and various patient-reported outcomes. RESULTS: Seventeen patients were included with a mean age of 41 ± 12 years. Separation types included types III, IV, and V. The mean follow-up period was 29 ± 9 months (range, 16-45 months). The CC distance improved from 37.4 to 30.0 mm on plain radiographs (P = .006), the American Shoulder and Elbow Surgeons score improved from 67.0 to 90.1 (P = .094), and the Single Assessment Numeric Evaluation score improved from 30.5 to 91.1 (P = .025). Reduction on visual inspection was maintained in 16 patients (94.1%). Regarding sports participation, 14 patients (82.4%) returned to their preinjury level. The most common complication was a prominent suture knot stack, occurring in 3 patients (17.6%), which was removed in all 3 in a second procedure. There were no clavicle or coracoid fractures. CONCLUSION: The described technique results in satisfactory objective and patient-reported outcomes and return to sports while avoiding coracoid and clavicle fractures.

Is There a Role for Internal Bracing and Repair of the Anterior Cruciate Ligament? A Systematic Literature Review.

BACKGROUND: Renewed interest has arisen in arthroscopic anterior cruciate ligament (ACL) repair techniques. HYPOTHESIS: ACL repair with or without some form of internal bracing could lead to good outcomes in a carefully selected subset of patients. STUDY DESIGN: Systematic review. METHODS: An electronic database search was performed to identify 89 papers describing preclinical and clinical studies on the outcome of ACL repair. RESULTS: Proximal ACL tear patterns showed a better healing potential with primary repair than distal or midsubstance tears. Some form of internal bracing increased the success rate of ACL repair. Improvement in the biological characteristics of the repair was obtained by bone marrow access by drilling tunnels or microfracture. Augmentation with platelet-rich plasma was beneficial only in combination with a structural scaffold. Skeletally immature patients had the best outcomes. Acute repair offered improved outcomes with regard to load, stiffness, laxity, and rerupture. CONCLUSION: ACL repair may be a viable option in young patients with acute, proximal ACL tears. The use of internal bracing, biological augmentation, and scaffold tissue may increase the success rate of repair.

Magnetic Resonance Imaging for Patellofemoral Chondromalacia: Is There a Role for T2 Mapping?

BACKGROUND: Patellofemoral pain is common, and treatment is guided by the presence and grade of chondromalacia. PURPOSE: To evaluate and compare the sensitivity and specificity in detecting and grading chondral abnormalities of the patella between proton density fat suppression (PDFS) and T2 mapping magnetic resonance imaging (MRI). STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 25 patients who underwent MRI of the knee with both a PDFS sequence and T2 mapping and subsequently underwent arthroscopic knee surgery were included. The cartilage surface of the patella was graded on both MRI sequences by 2 independent, blinded radiologists. Cartilage was then graded during arthroscopic surgery by a sports medicine fellowship-trained orthopaedic surgeon. Reliability, sensitivity, specificity, and accuracy were determined for both MRI methods. The findings during arthroscopic surgery were considered the gold standard. RESULTS: Intraobserver and interobserver agreement for both PDFS (98.5% and 89.4%, respectively) and T2 mapping (99.4% and 91.3%, respectively) MRI were excellent. For T2 mapping, the sensitivity (61%) and specificity (64%) were comparable, whereas for PDFS there was a lower sensitivity (37%) but higher specificity (81%) in identifying cartilage abnormalities. This resulted in a similar accuracy for PDFS (59%) and T2 mapping (62%). CONCLUSION: Both PDFS and T2 mapping MRI were reliable but only moderately accurate in predicting patellar chondromalacia found during knee arthroscopic surgery.

A Single-Tunnel Technique for Coracoclavicular and Acromioclavicular Ligament Reconstruction.

Acromioclavicular (AC) joint separation is a common injury seen in the young adult athletic population. Both the indications for surgical management and the best operative technique remain controversial. One of the most popular reconstruction techniques is the anatomic double-tunnel coracoclavicular (CC) ligament reconstruction. However, there have been several case reports of clavicle fractures with this technique. This article presents a single-tunnel reconstruction technique that aims to restore both the CC and AC ligament function, while minimizing fracture risk.

Are professional handball players at risk for developing a glenohumeral internal rotation deficit in their dominant arm?

OBJECTIVES: Overhead athletes, such as baseball players, have been shown to have adaptive changes in the shoulder range of motion (ROM) of their dominant arm. Professional handball players are a unique subtype of overhead athletes with very different demands from baseball players. The aim of this study was to determine if professional handball players demonstrate differences in shoulder ROM between their dominant and non-dominant arm and try to relate them with new variables. METHODS: Fifty professional male handball players were included and completed a questionnaire regarding age at which they started to play, number of hours they practice a week, field position and arm dominance. ROM measurements were performed including forward flexion (FF), external rotation with the shoulder in abduction (ABER) and with adducted arm (ADER) and internal rotation with shoulder in abduction (IR). Statistical analysis was performed to determine differences in ROM between the dominant and non-dominant shoulder and if there is a relationship between these differences and shoulder load or field position. RESULTS: The dominant arm showed decreased internal rotation (47 vs. 56 degrees, p < 0.001) and increased external rotation both with the arm abducted (99 vs. 88 degrees, p < 0.001) and at the side (62 vs 57 degrees, p = 0.001). This was not correlated with shoulder load for any movement (FF, p = 0.980; ABER, p = 0.741; ADER, p = 0.803; IR, p = 0.085) but was dependent on field position with first line players showing the highest internal rotation deficit (13 degrees vs. 6-7 degrees in the other field positions, p = 0.013). CONCLUSION: This study showed that professional male handball players with a first line position have a significant risk for developing a glenohumeral internal rotation deficit, similar to the phenomenon seen in baseball pitchers.

Can we predict the size of frequently used autografts in ACL reconstruction?

PURPOSE: This study presents a method to measure the size of quadriceps, patellar tendon and hamstring autografts using preoperative magnetic resonance imaging (MRI). METHODS: Sixty-two subjects with a mean age of 25 ± 10 years who underwent ACL surgery between 2011 and 2014 were included. Patient anthropometric data were recorded for all subjects. During surgery, the respective autograft was harvested and measured using commercially available graft sizers. MRI measurements were performed by two raters, who were blinded to the intra-operative measurements. RESULTS: The inter- and intra-rater reliability was ≥0.8 for all MRI measurements. The intra-class correlation coefficient between the MRI measurement of the graft and the actual size of the harvested graft was 0.639. There were significant correlations between quadriceps tendon thickness and height (r = 0.3, p < 0.03), weight (r = 0.3, p < 0.01), BMI (r = 0.3, p < 0.04) and gender (r = -0.4, p < 0.002) and patellar tendon thickness and height (r = 0.4, p < 0.01), weight (r = 0.3, p < 0.01) and gender (r = -0.4, p < 0.012). CONCLUSION: Preoperative MRI measurements of quadriceps, patellar tendon and hamstring graft size are highly reliable with moderate-to-good accuracy. Significant correlations between patient anthropometric data and the thicknesses of the quadriceps and patellar tendons were observed. Obtaining this information can be useful for preoperative planning and to help counsel patients on appropriate graft choices prior to surgery. LEVEL OF EVIDENCE: III.