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Background: Approximately 100,000 anterior cruciate ligament (ACL) reconstructions (ACLRs) occur annually in the United States, and postoperative surgical-site infection is a relatively rare but devastating complication, often leading to graft failure or septic arthritis of the knee, necessitating repeat surgery. Wrapping allografts in vancomycin-soaked gauze has been adopted as a common sterilization technique in the operating room to reduce surgical-site infection; however, identifying effective alternatives to vancomycin has not been extensively pursued. Hypothesis: Tobramycin would be as effective as vancomycin in reducing the concentrations of Staphylococcus epidermidis bacteria on tendon allografts. Study Design: Controlled laboratory study. Methods: S. epidermidis strain ATCC 12228 was inoculated onto the human cadaveric gracilis tendon. The tendons were wrapped in sterile gauze saturated with tobramycin or vancomycin at various experimental concentrations. Bacteria remaining on the tendon were dislodged, serially diluted, and plated for colony counting. Statistical analysis was performed utilizing 2-way analysis of variance testing. Results were considered statistically significant when P <.05. Results: Vancomycin (P =.0001) and tobramycin (P <.0001) reduced bacterial concentration. Tobramycin was found to produce a statistically significant reduction in bacterial concentration at concentrations as low as 0.1 mg/mL (P <.0001 and P =.01 at 10 and 20 minutes), while vancomycin produced a statistically significant reduction at a concentration as low as 2.5 mg/mL (P <.0001 at both 10 and 20 minutes). Conclusion: This study demonstrates that tobramycin is as effective as vancomycin in bacterial concentration reduction but can achieve this reduction level at lower doses. Further studies clarifying the biomechanical and cytotoxic effects of tobramycin on tendon tissue are indicated to solidify its use as a clinical alternative to vancomycin in ACLR. Clinical Relevance: These results will begin establishing tobramycin as an alternative to vancomycin in ACL graft decontamination. Because of relatively frequent shortages of vancomycin, establishing tobramycin as an alternative agent is a useful option for the orthopaedic surgeon. [ABSTRACT FROM AUTHOR]

Background: Articular cartilage and meniscal damage are commonly encountered and often treated at the time of anterior cruciate ligament reconstruction (ACLR). Our understanding of how these injuries and their treatment relate to outcomes of ACLR is still evolving. Hypothesis/Purpose: The purpose of this study was to assess whether articular cartilage and meniscal variables are predictive of 10-year outcomes after ACLR. We hypothesized that articular cartilage lesions and meniscal tears and treatment would be predictors of the International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS) (all 5 subscales), and Marx activity level outcomes at 10-year follow-up after ACLR. Study Design: Cohort study (prognosis); Level of evidence, 1. Methods: Between 2002 and 2008, individuals with ACLR were prospectively enrolled and followed longitudinally using the IKDC, KOOS, and Marx activity score completed at entry, 2, 6, and 10 years. A proportional odds logistic regression model was built incorporating variables from patient characteristics, surgical technique, articular cartilage injuries, and meniscal tears and treatment to determine the predictors (risk factors) of IKDC, KOOS, and Marx outcomes at 10 years. Results: A total of 3273 patients were enrolled (56% male; median age, 23 years at time of enrollment). Ten-year follow-up was obtained on 79% (2575/3273) of the cohort. Incidence of concomitant pathology at the time of surgery consisted of the following: articular cartilage (medial femoral condyle [MFC], 22%; lateral femoral condyle [LFC], 15%; medial tibial plateau [MTP], 4%; lateral tibial plateau [LTP], 11%; patella, 18%; trochlea, 8%) and meniscal pathology (medial, 37%; lateral, 46%). Variables that were predictive of poorer 10-year outcomes included articular cartilage damage in the patellofemoral (P <.01) and medial (P <.05) compartments and previous medial meniscal surgery (7% of knees; P <.04). Compared with no meniscal tear, a meniscal injury was not associated with 10-year outcomes. Medial meniscal repair at the time of ACLR was associated with worse 10-year outcomes for 2 of 5 KOOS subscales, while a medial meniscal repair in knees with grade 2 MFC chondrosis was associated with better outcomes on 2 KOOS subscales. Conclusion: Articular cartilage injury in the patellofemoral and medial compartments at the time of ACLR and a history of medial meniscal surgery before ACLR were associated with poorer 10-year ACLR patient-reported outcomes, but meniscal injury present at the time of ACLR was not. There was limited and conflicting association of medial meniscal repair with these outcomes. [ABSTRACT FROM AUTHOR]

Linemen are at high risk for knee eartilage injuries and osteoarthritis. High-intensity movements from squatting positions (eg, 3-point stance) may produce high joint loads, increasing the risk for cartilage damage. We hypothesized that knee moments and joint reaction forces during lineman-specific activities would be greater than during walking or jogging. Data were collected using standard motion analysis techniques. Fifteen NCAA linemen (mean ± SD: height = 1.86 ±0.07 m, mass = 12I.45 ± 12.78 kg) walked, jogged, and performed 3 unloaded lineman-specific blocking movements from a 3-point stance. External 3-dimensional knee moments and joint reaction forces were calculated using inverse dynamics equations. MANOVA with subsequent univariate ANOVA and post hoc Tukey comparisons were used to determine differences in peak kinetic variables and the llexion angles at which they occurred. All peak moments and joint reaction forces were significantly higher during jogging than during all blocking drills (all P < .001). Peak moments occurred at average knee llexion angles > 70° during blocking versus < 44° in walking or jogging. The magnitude of moments and joint reaction forces when initiating movement from a 3-point stance do not appear to increase risk for cartilage damage, but the high llexion angles at which they occur may increase risk on the posterior femoral condyles. [ABSTRACT FROM AUTHOR]

Background: Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood. Purpose/Hypothesis: The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years. Study Design: Systematic review. Methods: A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure. Results: Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm2 to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm2 ($127,782) became cost-ineffective over 10 years. Conclusion: Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm2. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously. [ABSTRACT FROM AUTHOR]

Purpose: Knowledge of epidemiologic trends of meniscal injuries in young active populations is limited. Better awareness of injury patterns is a first step to lowering injury rates. Our hypothesis was that meniscal injuries in high school athletes would vary by gender, sport, and type of exposure. Methods: During the 2007/2008 and 2012/2013 academic years, a large nationally disperse sample of US high schools reported athlete exposure and injury data for 22 sports by having certified athletic trainers complete an internet-based data collection tool. Results: One thousand and eighty-two meniscal injuries were reported during 21,088,365 athlete exposures for an overall injury rate of 5.1 per 100,000 athlete exposures. The overall rate of injury was higher in competition (11.9) than practice (2.7) (RR = 4.4; 95% CI 3.9-5.0), and 12/19 sports showed significantly higher injury rates in competition compared to practice. Of all injuries, 68.0% occurred in boys, yet among the gender-comparable sports of soccer, basketball, track and field, lacrosse, and baseball/softball injury rates were higher for girls than boys (5.5 and 2.5, respectively, RR = 2.2; 95% CI 1.8-2.7). Contact injury represented the most common mechanism (55.9%). Surgery was performed for the majority of injuries (63.8%), and 54.0% of athletes had associated intra-articular knee pathology. Conclusions: Meniscal injury patterns among high school athletes vary by gender, sport, and type of exposure. Our study is clinically relevant because recognition of distinct differences in these injury patterns will help drive evidence-based, targeted injury prevention strategies and efforts. Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

Background: Patellofemoral instability injuries, including dislocations and subluxations, are relatively rare in the general population but are believed to be much more common in young athletic patient populations, such as high school athletes. In spite of the relatively high risk, the epidemiology of such injuries in this population has not been clearly elucidated. Purpose: To provide a comprehensive understanding of the epidemiology of patellofemoral instability injuries among high school athletes in the United States. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Data were obtained from the National High School Sports-Related Injury Surveillance System, High School RIO (Reporting Information Online), an Internet-based sports injury surveillance system. Athletic trainers from high schools across the country uploaded data regarding athlete exposures (defined as practice or game participation) and injuries across 22 sports from 2007-2008 through 2012-2013. Data were collected regarding athlete demographics, injury mechanism and details, practice versus competition, return to sport, and the need for surgery. Results: A total of 421 patellar instability (143 dislocations and 278 subluxations) injuries occurred during 21,556,515 athlete exposures (AEs) during the study period, for an overall injury rate of 1.95 per 100,000 AEs. The highest injury rates were noted in girls' gymnastics (6.19 per 100,000 AEs), boys' football (4.10), and boys' wrestling (3.45). The overall injury rate was significantly lower for girls than boys (1.66 and 2.15, respectively; rate ratio [RR], 0.77; 95% CI, 0.62-0.94). In contrast, among only the sex-comparable sports, the injury rate was higher for girls than boys (1.47 and 0.88, respectively; RR, 1.67; 95% CI, 1.19-2.34). The rate of injury was higher in competition (3.72) than practice (1.34) (RR, 2.78; 95% CI, 2.29-3.36). A no-contact injury mechanism was the most commonly reported mechanism (37.8% of injuries), followed by player-to-player contact (36.8%). When all contact subcategories are combined, the overall contact mechanism represents 59.3% of injuries. Return to play after a patellofemoral instability injury occurred within 3 weeks for 59.5% of athletes. Return to play in >3 weeks (16.0%) and loss of the remainder of the season (20.0%) were less common outcomes. Conclusion: Patellofemoral instability injury rates vary by sport, sex, and type of exposure (competition vs practice). A better understanding of such patterns of patellofemoral instability injury will help drive formulation of new injury prevention strategies and decrease the risk for patellofemoral instability injury among high school athletes. [ABSTRACT FROM AUTHOR]

Background. The popularity of ice hockey has grown in recent years and injuries are a concern given the physical nature of the sport. We sought to report the rates, mechanisms, and severity of boys’ US high school ice hockey injuries. We hypothesized that body checking would be a major source of injury and that concussions would be common. We also expected to find that competition would have a higher rate of injury than practice.Design.Descriptive epidemiology study.Methods. Boys’ US high school ice hockey injury data from 2008/2009 through 2012/2013 academic years were obtained from the National High School Sports-Related Injury Surveillance System, High School Reporting Information Online database. The primary outcome was rate of injury per 10,000 athlete exposures (AEs).Results. Overall, 724 boys ice hockey injuries occurred during 311,817 AEs for an injury rate of 23.2 per 10,000 AEs. Injury rates were significantly higher during competition compared to practice (rate ratio = 7.8, 95% confidence interval: 6.5–9.4). Concussion was the most frequent injury reported at a rate of 6.4 per 10,000 AEs. Body checking was the mechanism of injury in over 46% of injuries. The head/face/neck region (33.8%) and upper arm/shoulder region (20.6%) were the most commonly injured body sites. Just over 6% of injuries resulted in surgical intervention.Conclusion. Injuries among high school ice hockey athletes are common. Increases in the number of high school ice hockey injuries will likely parallel the increase in high school ice hockey participation in the United States. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to investigate the epidemiology of knee injuries among U.S. high school athletes between 2005/2006 and 2010/2011. Researchers evaluated U.S. high school sports-related injury data collected for 20 sports using the National High School Sports-Related Injury Surveillance System, High School RIC. They found that from 2005/2006 to 2010/2011, 5,116 knee injuries occurred during 17,172,376 athlete exposures (AE) for an overall rate of 2.98 knee injuries per 10,000 AE, that knee injuries were more common in competition than in practice, that football had the highest knee injury rate and that girls had significantly higher knee injury rates than boys in sex-comparable sports.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR., (© 2020 Orthopaedic Research Society. Published by Wiley Periodicals LLC.)

Objective: While the musculoskeletal (MSK) physical examination (PE) is an essential part of a patient encounter, we believe it is an underemphasized component of orthopedic residency education and that resident PE skills may be lacking. The purpose of this investigation was to (1) assess the attitudes regarding PE teaching in orthopedic residencies today; (2) develop an MSK objective structured clinical examination (OSCE) to assess the MSK PE knowledge and skills of our orthopedic residents., Design: Prospective, uncontrolled, observational., Setting: A major Midwestern tertiary referral center and academic medical center., Participants: The orthopedic surgery residents in our program. Twenty-two of 24 completed the OSCE., Results: Surveys showed that residents agreed that although learning the PE is important, there is not enough time in clinic to actually observe and critique a resident examining a patient. For the 22 residents (postgraduate year [PGY] 2-5) who participated in the OSCE, the overall score was 66%. Scores were significantly better for the trauma scenario (78%; p < 0.05) than for the shoulder (67%), spine (64%), and knee (59%) encounters. The overall scores for each component of the OSCE were: (1) history 53%; (2) PE 60%; (3) 5-question posttest 64%; and (4) communication skills 90%., Conclusions: We have exposed a deficiency in the PE knowledge and skills of our residents. Clinic time alone may be insufficient to both teach and learn the MSK PE. The use of a MSK OSCE, while novel in orthopedics, will allow more direct observation of our residents MSK PE skills and also allow us to follow resident skills longitudinally through their training. We hope that our efforts will encourage other programs to assess their PE curriculum and perhaps prompt change., (Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)