Search

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture., Study Design: Cohort study; Level of evidence, 2., Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR., Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03)., Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Background Declines in the ability to rapidly generate quadriceps muscle torque may underlie disability in individuals with tibiofemoral osteoarthritis. Objective To determine whether quadriceps rate of torque development (RTD) predicts self-reported disability and physical performance outcomes in individuals with tibiofemoral osteoarthritis. Methods This controlled laboratory, cross-sectional study assessed quadriceps strength and RTD in 76 individuals (55% female; mean ± SD age, 61.83 ± 7.11 years) with symptomatic and radiographic tibiofemoral osteoarthritis. Early (0-50 milliseconds), late (100-200 milliseconds), and overall peak RTDs were quantified in the symptomatic (involved) and contralateral limbs and used to calculate bilateral average values. Disability was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function subscale and 3 physical performance tests, including the (1) 20-m fast-paced walk, (2) 30-second chair stand, and (3) timed stair climb. Separate univariate regression models were used to determine the unique associations among measures of quadriceps RTD, WOMAC function score, and physical performance outcomes after accounting for quadriceps strength (change in R 2 ). Results Greater involved-side late RTD and greater bilateral average early RTD were associated with faster walking (change in R 2 = 0.05, P = .013 and change in R 2 = 0.05, P = .043, respectively). Greater bilateral average late RTD was associated with faster walking (change in R 2 = 0.20, P<.001) and faster stair climb (change in R 2 = 0.11, P = .001). No quadriceps RTD variable was significantly associated with WOMAC function score (change in R 2 range, <0.01-0.017). Conclusion Involved-limb quadriceps RTD was weakly associated with physical performance outcomes, but not self-reported disability, in individuals with tibiofemoral osteoarthritis. Bilateral average quadriceps RTD was moderately associated with walking speed. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther 2018;48(9):694-703. Epub 22 May 2018. doi:10.2519/jospt.2018.7898.

Objective: To determine whether walking speed, collected at 6 and 12 months following anterior cruciate ligament reconstruction (ACLR), is associated with inter-extremity differences in proteoglycan density, measured via T1ρ magnetic resonance imaging, in tibiofemoral articular cartilage 12 months following ACLR., Methods: Twenty-one individuals with a unilateral patellar-tendon autograft ACLR (10 women and 11 men, mean ± SD age 23.9 ± 2.7 years, mean ± SD body mass index 23.9 ± 2.7 kg/m 2 ) were recruited for participation in this study. Walking speed was collected using 3-dimensional motion capture at 6 and 12 months following ACLR. The articular cartilage of the medial femoral condyle (MFC) and lateral femoral condyle and medial and lateral tibial condyles was manually segmented and subsectioned into 3 regions of interest (anterior, central, and posterior) based on the location of the meniscus in the sagittal plane. Inter-extremity mean T1ρ relaxation time ratios (T1ρ ACLR extremity / T1ρ contralateral extremity) were calculated and used for analysis. Pearson product-moment correlations were used to determine associations between walking speed and inter-extremity differences in T1ρ relaxation time ratios., Results: Slower walking speed 6 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the MFC of the ACLR extremity 12 months following ACLR (posterior MFC, r = -0.51, P = 0.02; central MFC, r = -0.47, P = 0.04). Similarly, slower walking speed at 12 months post-ACLR was significantly associated with higher T1ρ relaxation time ratios in the posterior MFC ACLR extremity (r = -0.47, P = 0.04) 12 months following ACLR., Conclusion: Slower walking speed at 6 and 12 months following ACLR may be associated with early proteoglycan density changes in medial femoral compartment cartilage health in the first 12 months following ACLR., (© 2017, American College of Rheumatology.)

Background: To determine the association between time from injury to ACL reconstruction (Time Injury-ACLR ) and biochemical markers of cartilage metabolism and inflammation six months following ACL reconstruction (ACLR)., Methods: Individuals with a unilateral ACL injury were enrolled at initial presentation in the orthopedic clinic; blood was collected six months following ACLR. Enzyme-linked immunosorbent assays were used to analyze the ratio of serum concentrations of type-II collagen breakdown (C2C) to synthesis (CPII), plasma matrix metalloproteinase-3 (MMP-3), interleukin-6 (IL-6), and serum aggrecan neoepitope (ARGS). We used separate linear regressions to assess associations between biochemical markers and Time Injury-ACLR ., Results: Twenty-two participants (50% females, mean [SD], age 21.9 [4.5] years old; BMI 23.8 [2.6] kg/m 2 ) completed the study. Time Injury-ACLR ranged from nine to 67days (31.0 [14.4days]). Greater Time Injury-ACLR predicted greater serum C2C:CPII ratios six months following ACLR (C2C:CPII=0.15 [0.02], R 2 =0.213, P=0.030). Males (R 2 =0.733, P=0.001) but not females (R 2 =0.030, P=0.609) demonstrated a significant association between greater C2C:CPII and Time Injury-ACLR at the six-month follow-up exam. Time Injury-ACLR did not associate with IL-6, MMP-3, or ARGS at six months., Conclusions: Greater time between injury and ACL reconstruction was associated with greater serum C2C:CPII six months following ACLR in males but not females, and IL-6, MMP-3, and ARGS levels were not associated with Time Injury-ACLR in males or females. The time between ACL injury and ACLR may affect collagen metabolism in males and should be further investigated in a larger study along with other patient-relevant outcomes., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage., Hypothesis: Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction., Study Design: Case-control study; Level of evidence, 3., Methods: Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery., Results: A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had <33% of the medial meniscus excised at the time of the primary reconstruction had 4.8-times greater odds of progression of articular cartilage injury than those with an intact medial meniscus ( P = .02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age ( P ≤ .02). For the patellofemoral compartment, the use of allograft in primary reconstruction was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft ( P < .001). Each 1-unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage ( P = .046) in the patellofemoral compartment., Conclusion: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

Background: Aberrant walking-gait and jump-landing biomechanics may influence the development of post-traumatic osteoarthritis and increase the risk of a second anterior cruciate ligament injury, respectively. It remains unknown if individuals who demonstrate altered walking-gait biomechanics demonstrate similar altered biomechanics during jump-landing. Our aim was to determine associations in peak knee biomechanics and limb-symmetry indices between walking-gait and jump-landing tasks in individuals with a unilateral anterior cruciate ligament reconstruction., Methods: Thirty-five individuals (74% women, 22.1 [3.4] years old, 25 [3.89] kg/m 2 ) with an anterior cruciate ligament reconstruction performed 5-trials of self-selected walking-gait and jump-landing. Peak kinetics and kinematics were extracted from the first 50% of stance phase during walking-gait and first 100 ms following ground contact for jump-landing. Pearson product-moment (r) and Spearman's Rho (ρ) analyses were used to evaluate relationships between outcome measures. Significance was set a priori (P ≤ 0.05)., Findings: All associations between walking-gait and jump-landing for the involved limb, along with the majority of associations for limb-symmetry indices and the uninvolved limb, were negligible and non-statistically significant. There were weak significant associations for instantaneous loading rate (ρ = 0.39, P = 0.02) and peak knee abduction angle (ρ = 0.36, p = 0.03) uninvolved limb, as well as peak abduction displacement limb-symmetry indices (ρ= - 0.39, p = 0.02) between walking-gait and jump-landing., Interpretation: No systematic associations were found between walking-gait and jump-landing biomechanics for either limb or limb-symmetry indices in people with unilateral anterior cruciate ligament reconstruction. Individuals with an anterior cruciate ligament reconstruction who demonstrate high-involved limb loading or asymmetries during jump-landing may not demonstrate similar biomechanics during walking-gait., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Lower proteoglycan density (PGD) of the articular cartilage may be an early marker of osteoarthritis following anterior cruciate ligament (ACL) reconstruction (ACL-R). The purpose this study was to determine associations between the Knee Injury and Osteoarthritis Outcomes Score (KOOS) and PGD of the articular cartilage in the femur and tibia 12-months following ACL-R., Methods: We evaluated KOOS pain, symptoms, function in activities of daily living (ADL), function in sport and recreation (Sport), and quality of life (QOL), as well as PGD using T1rho magnetic resonance imaging in 18 individuals 12.50±0.70months (these are all mean±standard deviation) following unilateral ACL-R (10 females, eight males; 22.39±4.19years; Marx Score=10.93±3.33). Medial and lateral load-bearing portions of the femoral and tibial condyles were sectioned into three (anterior, central and posterior) regions of interest (ROIs). T1rho relaxation times in the ACL-R knee were normalized to the same regions of interest in the non-surgical knees. Alpha levels were set at P≤0.05., Results: Worse KOOS outcomes were significantly associated with greater T1rho relaxation time ratios in the posterior-lateral femoral condyle [pain (r=-0.54), ADL (r=-0.56), Sport (r=-0.62) and QOL (r=-0.59)] central-lateral femoral condyle [Sport (r=-0.48) and QOL (r=-0.42)], and the anterior-medial femoral condyle [Sport (r=-0.46) and QOL (r=-0.40)]. There were no significant associations between the KOOS and T1rho outcomes for tibial ROI., Conclusions: Lower PGD of the femoral cartilage in the ACL-R knees was associated with worse patient-reported outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Musculoskeletal injuries in pediatric patients are on the rise, including significant increases in anterior cruciate ligament (ACL) injuries. Previous studies have found major anatomical changes during skeletal growth in the soft tissues of the knee. Specifically, the ACL and the posterior cruciate ligament (PCL) change in their relative orientation to the tibial plateau throughout growth. In order to develop age-specific treatments for ACL injuries, the purpose of this study was to characterize orientation changes in the cruciate ligaments of the Yorkshire pig, a common pre-clinical model, during skeletal growth in order to verify the applicability of this model for pediatric musculoskeletal studies. Hind limbs were isolated from female Yorkshire pigs ranging in age from newborn to late adolescence and were then imaged using high field strength magnetic resonance imaging. Orientation changes were quantified from the magnetic resonance images using image segmentation software. Statistically significant increases were found in the coronal and sagittal angles of the ACL relative to the tibial plateau during pre-adolescent growth. Additional changes were observed in the PCL angle, Blumensaat angle, intercondylar roof angle, and the aspect ratio of the intercondylar notch. Only the sagittal angle of the ACL relative to the tibial plateau experienced statistically significant changes through late adolescence. The age-dependent properties of the ACL and PCL in the female pig mirrored results found in female human patients, suggesting that the porcine model may provide a pre-clinical platform to study the cruciate ligaments during skeletal growth. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2725-2732, 2017., (© 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

The purpose of our study was to determine the association between biomechanical outcomes of walking gait (peak vertical ground reaction force [vGRF], vGRF loading rate [vGRF-LR], and knee adduction moment [KAM]) 6 months following anterior cruciate ligament reconstruction (ACLR) and biochemical markers of serum type-II collagen turnover (collagen type-II cleavage product to collagen type-II C-propeptide [C2C:CPII]), plasma degenerative enzymes (matrix metalloproteinase-3 [MMP-3]), and a pro-inflammatory cytokine (interleukin-6 [IL-6]). Biochemical markers were evaluated within the first 2 weeks (6.5 ± 3.8 days) following ACL injury and again 6 months following ACLR in eighteen participants. All peak biomechanical outcomes were extracted from the first 50% of the stance phase of walking gait during a 6-month follow-up exam. Limb symmetry indices (LSI) were used to normalize the biomechanical outcomes in the ACLR limb to that of the contralateral limb (ACLR/contralateral). Bivariate correlations were used to assess associations between biomechanical and biochemical outcomes. Greater plasma MMP-3 concentrations after ACL injury and at the 6-month follow-up exam were associated with lesser KAM LSI. Lesser KAM was associated with greater plasma IL-6 at the 6-month follow-up exam. Similarly, lesser vGRF-LR LSI was associated with greater plasma MMP-3 concentrations at the 6-month follow-up exam. Lesser peak vGRF LSI was associated with higher C2C:CPII after ACL injury, yet this association was not significant after accounting for walking speed. Therefore, lesser biomechanical loading in the ACLR limb, compared to the contralateral limb, 6 months following ACLR may be related to deleterious joint tissue metabolism that could influence future cartilage breakdown. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2288-2297, 2017., (© 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction., Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes., Study Design: Case-control study; Level of evidence, 3., Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction., Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort., Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR., Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR., Study Design: Case-control study; Level of evidence, 3., Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation., Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged <20 years had twice the odds of patients aged 20 to 29 years to undergo a reoperation. The use of an allograft at the time of revision ACLR (odds ratio [OR], 1.79; P = .007) was a significant predictor for reoperations at 2 years, while staged revision (bone grafting of tunnels before revision ACLR) (OR, 1.93; P = .052) did not reach significance. Patients with grade 4 cartilage damage seen during revision ACLR were 78% less likely to undergo subsequent operations within 2 years. Sex, body mass index, smoking history, Marx activity score, technique for femoral tunnel placement, and meniscal tearing or meniscal treatment at the time of revision ACLR showed no significant effect on the reoperation rate., Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age <20 years and the use of allograft tissue at the time of revision ACLR.

Purpose: Tissue engineering and regenerative medicine approaches have the potential to overcome the challenges associated with current treatment strategies for meniscus injuries. 3D-Bioplotted scaffolds are promising, but have not demonstrated the ability to guide the formation of aligned collagenous matrix in vivo, which is critical for generating functional meniscus tissue. In this study, we evaluate the ability of 3D-Bioplotted scaffold designs with varying interstrand spacing to induce the deposition of aligned matrix in vivo., Materials and Methods: 3D-Bioplotted polycaprolactone scaffolds with 100, 200, or 400 μm interstrand spacing were implanted subcutaneously in a rat model for 4, 8, or 12 weeks. Scaffolds were harvested, paraffin-embedded, sectioned, and stained to visualize cell nuclei and collagen. Quantitative image analysis was used to evaluate cell density, matrix fill, and collagen fiber alignment within the scaffolds., Results: By 4 weeks, cells had infiltrated the innermost scaffold regions. Similarly, collagenous matrix filled interstrand regions nearly completely by 4 weeks. By 12 weeks, aligned collagen was present in all scaffolds. Generally, alignment along the scaffold strands increased over time for all three interstrand spacing groups. Distribution of collagen fiber alignment angles narrowed as interstrand spacing decreased., Conclusions: 3D-Bioplotted scaffolds allow for complete cell infiltration and collagenous matrix production throughout the scaffold. The ability to use interstrand spacing as a means of controlling the formation of aligned collagen in vivo was demonstrated, which helps establish a design space for scaffold-based meniscus tissue engineering.

Decreased voluntary activation contributes to quadriceps weakness following anterior cruciate ligament reconstruction (ACLR). Alterations in neural excitability are likely responsible for reductions in quadriceps voluntary activation, and may be due to specific alterations in intracortical inhibition and facilitation. Therefore, we sought to determine if intracortical inhibition (SICI) and intracortical facilitation (ICF) associate with quadriceps voluntary activation in individuals with ACLR. Twenty-seven participants with a primary, unilateral ACLR were enrolled in this study. Bilateral central activation ratio (CAR) and paired-pulse transcranial magnetic stimulation were used to assess quadriceps voluntary activation, as well as SICI and ICF in the vastus medalis, respectively. Pearson Product Moment correlations were used to determine the association between CAR and (1) SICI, and (2) ICF in each limb. Lesser CAR associated with lesser SICI amplitude (r = 0.502, P = 0.008) in the ACLR limb. No associations in the contralateral limb were significant. Our results suggest greater intracortical inhibition associates with lesser voluntary activation in individuals with ACL. Implementing interventions that target intracortical inhibition may aid in restoring quadriceps voluntary activation following ACLR.

Background: Despite the significance of anterior cruciate ligament (ACL) injuries, these conditions have been under-researched from a population-level perspective. It is important to determine the economic effect of these injuries in order to document the public health burden in the United States., Purpose: To describe the cost of outpatient arthroscopic ACL reconstruction and health care utilization among commercially insured beneficiaries in the United States., Study Design: Economic and decision analysis; Level of evidence, 3., Methods: The study used the Truven Health Analytics MarketScan Commercial Claims and Encounters database, an administrative claims database that contains a large sample (approximately 148 million) of privately insured individuals aged <65 years and enrolled in employer-sponsored plans. All claims with Current Procedural Terminology (CPT) code 29888 (arthroscopically aided ACL reconstruction or augmentation) from 2005 to 2013 were included. "Immediate procedure" cost was computed assuming a 3-day window of care centered on date of surgery. "Total health care utilization" cost was computed using a 9-month window of care (3 months preoperative and 6 months postoperative)., Results: There were 229,446 outpatient arthroscopic ACL reconstructions performed over the 9-year study period. Median immediate procedure cost was $9399.49. Median total health care utilization cost was $13,403.38. Patients who underwent concomitant collateral ligament (medial [MCL], lateral [LCL]) repair or reconstruction had the highest costs for both immediate procedure ($12,473.24) and health care utilization ($17,006.34). For patients who had more than 1 reconstruction captured in the database, total health care utilization costs were higher for the second procedure than the first procedure ($16,238.43 vs $15,000.36), despite the fact that immediate procedure costs were lower for second procedures ($8685.73 vs $9445.26)., Conclusion: These results provide a foundation for understanding the public health burden of ACL injuries in the United States. Our findings suggest that further research on the prevention and treatment of ACL injuries is necessary to reduce this burden., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: Major funding for this research came from a grant provided by the University of North Carolina Junior Development Award. The University of North Carolina Injury Prevention Research Center is partially supported by an award (R49CE002479) from the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. J.L.L. receives research funding from the UNC K12 Oncology Clinical Translational Research Training Program (5K12CA120780) and salary support from the PhRMA Foundation to the Department of Epidemiology at University of North Carolina at Chapel Hill (UNC).

Purpose: To identify and quantify patient- and procedure-related risk factors for post-arthroscopic knee infections using a large dataset., Methods: An administrative health care database including 8 years of records from 2 large commercial insurers and Medicare (a 5% random sample) was queried to identify all knee arthroscopies performed on patients aged at least 15 years using Current Procedural Terminology (CPT) codes. Each CPT code was designated as a high- or low-complexity procedure, with the former typically requiring accessory incisions or increased operative time. Deep infections were identified by a CPT code for incision and drainage within 90 days of surgery. Superficial infections were identified by International Classification of Diseases, Ninth Revision infection codes without any record of incision and drainage. Patients were compared based on age, sex, body mass index, tobacco use, presence of diabetes, and Charlson Comorbidity Index., Results: A total of 526,537 patients underwent 595,083 arthroscopic knee procedures. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections, respectively (P < .001; relative risk of 1.90 and 2.19, respectively). There were also higher infection rates among patients undergoing relatively high-complexity arthroscopies, men, obese patients, diabetic patients, and younger patients (in order of decreasing relative risk). Increased Charlson Comorbidity Index was associated with superficial and total infections (P < .001)., Conclusions: Post-arthroscopic knee infections were more frequent among morbidly obese patients, tobacco users, patients undergoing relatively complex procedures, men, obese patients, diabetic patients, relatively young patients, and patients with increased comorbidity burdens in this study population. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk., Level of Evidence: Level IV, cross-sectional study., (Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Rotator cuff tears have a lifetime incidence between 25% and 40% in the United States, but optimum treatment strategies and protocol have not yet been widely accepted. This study evaluated the proportions of patients treated with nonoperative and operative modalities and how this proportion has changed during an 8-year period (2005-2012) among patients with Medicare., Methods: Using the PearlDiver patient record database, we identified Medicare patients having been diagnosed with a rotator cuff tear. These patients were then stratified on the basis of treatment with physical therapy, subacromial/glenohumeral injection, or rotator cuff repair. We analyzed the data in regard to standard demographic information, comorbidities, and the Charlson Comorbidity Index., Results: During the study period, 878,049 patients were identified and 397,116 patients had rotator cuff repair. The proportion of patients treated initially with physical therapy dropped from 30.0% in 2005 to 13.2% in 2012, and the subacromial/glenohumeral injection proportion decreased from 6.00% to 4.19% (P < .001). The proportion of patients who had rotator cuff repair increased from 33.8% to 40.4% from 2005 to 2012 (P < .001). Charlson Comorbidity Indexes were significantly lower in operative patients compared with each nonoperative treatment examined., Discussion: This analysis demonstrates a significant decrease in the initial trial of nonoperative treatment and an increase in the rate of surgery. Patients undergoing rotator cuff repair had fewer comorbidities than those undergoing nonoperative treatments. It also demonstrates that patients who had a trial of injection had a higher incidence of eventual rotator cuff repair compared with the patients with an initial trial of physical therapy., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Purpose: Persistent voluntary quadriceps activation deficits are common after anterior cruciate ligament reconstruction (ACLR), but the direct causes are unclear. The primary purpose of this study was to determine whether spinal reflex excitability deficits are present in individuals with a history of ACLR, and secondarily to determine whether spinal reflex excitability predicts which individuals possess full voluntary quadriceps activation., Methods: One hundred and forty-seven individuals (74 healthy and 73 ACLR) participated in this cross-sectional case-control study. Quadriceps spinal reflex excitability was quantified using the Hoffmann reflex normalized to the maximal muscle response (H:M ratio). Voluntary quadriceps activation was evaluated with the burst superimposition technique and calculated via the central activation ratio (CAR). Separate 2 × 2 ANCOVA tests were used to compare between-limb and between-group differences for H:M ratio and CAR. A receiver operating characteristic curve was used to determine the accuracy of H:M ratio to predict if ACLR participants present with full voluntary activation (CAR ≥ 0.95)., Results: The ACLR H:M ratio was not different between limbs or compared with the healthy group (P > 0.05). Although ACLR CAR was lower bilaterally compared with the healthy group (P < 0.001), it did not differ between limbs. The H:M ratio has poor accuracy for predicting which individuals exhibit full voluntary activation (receiver operating characteristic area under the curve = 0.52, 95% CI = 0.37,0.66; odds ratio = 2.2, 95% CI = 0.8, 5.9)., Conclusions: Spinal reflex excitability did not differ between limbs in individuals with ACLR or compared with healthy participants. The level of quadriceps spinal reflex excitability has poor accuracy at predicting which ACLR individuals would demonstrate full voluntary quadriceps activation.

Background: The meniscus plays a crucial role in knee joint stability, load transmission, and stress distribution. Meniscal tears are the most common reported knee injuries, and the current standard treatment for meniscal deficiency is meniscal allograft transplantation. A major limitation of this approach is that meniscal allografts do not have the capacity to remodel and maintain tissue homeostasis due to a lack of cellular infiltration. The purpose of this study was to provide a new method for enhanced cellular infiltration in meniscal allografts., Methods: Twenty medial menisci were collected from cadaveric human sources and split into five experimental groups: (1) control native menisci, (2) decellularized menisci, (3) decellularized menisci seeded with human adipose-derived stem cells (hASC), (4) decellularized needle-punched menisci, and (5) decellularized needle-punched menisci seeded with hASC. All experimental allografts were decellularized using a combined method with trypsin EDTA and peracetic acid. Needle punching (1-mm spacing, 28 G microneedle) was utilized to improve porosity of the allograft. Samples were recellularized with hASC at a density of 250 k/g of tissue. After 28 days of in vitro culture, menisci were analyzed for mechanical, biochemical, and histological characteristics., Results: Menisci maintained structural integrity and material properties (compressive equilibrium and dynamic moduli) throughout preparations. Increased DNA content was observed in the needle-punched menisci but not in the samples without needle punching. Histology confirmed these results, showing enhanced cellular infiltration in needle-punched samples., Conclusions: The enhanced infiltration achieved in this study could help meniscal allografts better remodel post-surgery. The integration of autologous adipose-derived stem cells could improve long-term efficacy of meniscal transplantation procedures by helping to maintain the meniscus in vivo.

Bioinks play a central role in 3D-bioprinting by providing the supporting environment within which encapsulated cells can endure the stresses encountered during the digitally driven fabrication process and continue to mature, proliferate, and eventually form extracellular matrix (ECM). In order to be most effective, it is important that bioprinted constructs recapitulate the native tissue milieu as closely as possible. As such, musculoskeletal soft tissue constructs can benefit from bioinks that mimic their nanofibrous matrix constitution, which is also critical to their function. This study focuses on the development and proof-of-concept assessment of a fibrous bioink composed of alginate hydrogel, polylactic acid nanofibers, and human adipose-derived stem cells (hASC) for bioprinting such tissue constructs. First, hASC proliferation and viability were assessed in 3D-bioplotted strands over 16 days in vitro. Then, a human medial knee meniscus digitally modeled using magnetic resonance images was bioprinted and evaluated over 8 weeks in vitro . Results show that the nanofiber-reinforced bioink allowed higher levels of cell proliferation within bioprinted strands, with a peak at day 7, while still maintaining a vast majority of viable cells at day 16. The cell metabolic activity on day 7 was 28.5% higher in this bioink compared to the bioink without nanofibers. Histology of the bioprinted meniscus at both 4 and 8 weeks showed 54% and 147% higher cell density, respectively, in external versus internal regions of the construct. The presence of collagen and proteoglycans was also noted in areas surrounding the hASC, indicating ECM secretion and chondrogenic differentiation.

Introduction/purpose: Quadriceps strength is a useful clinical predictor of self-reported function after anterior cruciate ligament reconstruction (ACLR). However, it remains unknown if quadriceps strength normalized to body mass (QBM) or quadriceps strength limb symmetry index (QLSI) is the best predictor of self-reported function in individuals with ACLR. We sought to determine whether QBM and QLSI are able to predict individuals with ACLR who self-report high function (≥90% on the international knee documentation committee (IKDC) index)., Methods: Ninety-six individuals with a history of a primary unilateral ACLR were recruited for a multisite cross-sectional descriptive laboratory experiment. Bilateral isometric quadriceps strength was collected at 90° of knee flexion to calculate QBM and QLSI (ratio of the ACLR limb to the contralateral limb). Area under the curve (AUC) values were calculated using receiver operating characteristic curve analyses to determine the capacity of QBM and QLSI to predict individuals with high self-reported function on the IKDC index., Results: QBM displayed high accuracy (AUC = 0.76; 95% confidence interval, 0.66-0.86) for identifying participants with an IKDC index ≥90%. A QBM cutoff score of 3.10 N·m·kg was found to maximize sensitivity (0.61) and specificity (0.84), and displayed 8.15 (3.09-21.55) times higher odds of reporting high function. QLSI displayed a moderate accuracy (AUC = 0.62, 0.50-0.73) for identifying participants with an IKDC index ≥90%. A QLSI cutoff score of 96.5% maximized sensitivity (0.55) and specificity (0.70), and represented 2.78 (1.16-6.64) times higher odds reporting high function., Conclusion: QBM is a stronger predictor of high self-reported function compared with QLSI in individuals with ACLR. Rehabilitation guidelines may benefit from incorporating the use of QBM measurements for the purpose of predicting participants that may maintain high self-reported function.

Objective: To determine whether or not self-selected walking speed associates with serum biomarkers of cartilage (collagen and proteoglycan) breakdown in anterior cruciate ligament reconstructed (ACLR) individuals., Methods: Twenty individuals with a history of a primary unilateral ACLR participated in this cross-sectional study. Resting blood was collected from each participant prior to completing 5 walking gait trials at a self-selected comfortable speed. Walking speed was evaluated in a 3-dimensional motion capture laboratory and determined from the velocity of the pelvic center of mass. Sera were assessed for collagen type II cleavage product (C2C) and proteoglycan (aggrecan) concentrations using commercially available specific enzyme-linked immunosorbent assays. Pearson's product-moment (r) and Spearman's (ρ) correlations were used to evaluate associations between walking speed and biomarkers of cartilage breakdown metabolism. Partial correlations were used to determine whether covariates influenced associations between walking speed and biomarkers of cartilage breakdown., Results: ACLR individuals with a slower walking speed demonstrated higher concentrations of serum C2C (r = -0.52, P = 0.02), while there was no significant association between walking speed and aggrecan concentrations (ρ = -0.29, P = 0.31). After accounting for the variance associated with stance phase duration, ACLR individuals with a slower walking speed still demonstrated greater serum C2C concentrations (partial r = -0.53, P = 0.02)., Conclusion: ACLR individuals who habitually walk slower may experience a greater degree of collagen breakdown, suggesting that walking speed may be a future useful clinical indicator for identifying individuals with higher levels of cartilage breakdown and preradiographic osteoarthritic joint changes., (© 2016, American College of Rheumatology.)

Background: Individuals who have sustained an anterior cruciate ligament (ACL) injury and undergo ACL reconstruction (ACLR) are at higher risk of developing knee osteoarthritis. It is hypothesized that altered knee loading may influence the underlying joint metabolism and hasten development of posttraumatic knee osteoarthritis., Purpose: To explore the associations between serum biomarkers of cartilage metabolism and peak vertical ground-reaction force (vGRF) and vGRF loading rate in the injured and uninjured limbs of individuals with ACLR., Study Design: Descriptive laboratory study., Methods: Patients with a history of a primary unilateral ACLR who had returned to unrestricted physical activity (N = 19) participated in the study. Resting blood was collected from each participant before completing 5 walking gait trials at a self-selected comfortable speed. Peak vGRF was extracted for both limbs during the first 50% of the stance phase of gait, and the linear vGRF loading rate was determined between heel strike and peak vGRF. Sera were assessed for collagen breakdown (collagen type II cleavage product [C2C]) and synthesis (collagen type II C-propeptide [CPII]), as well as aggrecan concentrations, via commercially available specific enzyme-linked immunosorbent assays. Pearson product-moment correlations (r) and Spearman rank-order correlations (ρ) were used to evaluate associations between loading characteristics and biomarkers of cartilage metabolism., Results: Lower C2C:CPII ratios were associated with higher peak vGRF in the injured limb (ρ = -0.59, uncorrected P = .007). There were no significant associations between peak vGRF or linear vGRF loading rate and CPII, C2C, or aggrecan serum concentrations., Conclusion: Lower C2C:CPII ratios were associated with higher peak vGRF in the ACLR limb during gait, suggesting that higher peak loading in the ACLR limb is related to lower type II collagen breakdown relative to type II collagen synthesis., Clinical Relevance: These data suggest that type II collagen synthesis may be higher relative to the amount of type II collagen breakdown in the ACLR limb with higher lower extremity loading. Future study should determine if metabolic compensations to increase collagen synthesis may affect the risk of developing osteoarthritis after ACLR., (© 2015 The Author(s).)

Subchondral insufficiency fractures are non-traumatic fractures that occur immediately below the cartilage of a joint. Although low bone density may be present concurrently, it is not the underlying cause of subchondral insufficiency fractures in the majority of patients. Patients with subchondral insufficiency fracture characteristically have unremarkable plain radiographs, while MRI examination may reveal extensive bone marrow oedema and subchondral bone collapse. This article presents a 51-year-old postmenopausal woman, a physician, who had subchondral insufficiency fractures of the knee associated with prolonged standing during clinical work. She was treated with partial weight bearing on crutches until 14 months after the injury, viscosupplementation at 4 months to treat osteoarthritis and teriparatide treatment to improve bone healing at 7 months. By 26 months after the injury, she tolerated independent walking with a fabric knee support but still experienced mild posterolateral knee pain and numbness on prolonged standing., (2015 BMJ Publishing Group Ltd.)

Background: Access to care is limited for patients with Medicaid with many conditions, but data investigating this relationship in the orthopaedic literature are limited. The purpose of this study was to investigate the relationship between health insurance status and access to care for a diverse group of adult orthopaedic patients, specifically if access to orthopaedic care is influenced by population density or distance from academic teaching hospitals., Methods: Two hundred and three orthopaedic practices within the state of North Carolina were randomly selected and were contacted on two different occasions separated by three weeks. An appointment was requested for a fictitious adult orthopaedic patient with a potential surgical problem. Injury scenarios included patients with acute rotator cuff tears, zone-II flexor tendon lacerations, and acute lumbar disc herniations. Insurance status was reported as Medicaid at the time of the first request and private insurance at the time of the second request. County population density and the distance from each practice to the nearest academic hospital were recorded., Results: Of the 203 practices, 119 (59%) offered the patient with Medicaid an appointment within two weeks, and 160 (79%) offered the patient with private insurance an appointment within this time period (p < 0.001). Practices in rural counties were more likely to offer patients with Medicaid an appointment as compared with practices in urban counties (odds ratio, 2.25 [95% confidence interval, 1.16 to 4.34]; p = 0.016). Practices more than sixty miles from academic hospitals were more likely to accept patients with Medicaid than practices closer to academic hospitals (odds ratio, 3.35 [95% confidence interval, 1.44 to 7.83]; p = 0.005)., Conclusions: Access to orthopaedic care was significantly decreased for patients with Medicaid. Practices in less populous areas were more likely to offer an appointment to patients with Medicaid than practices in more populous areas. Practices that were farther from academic hospitals were more likely to offer an appointment to patients with Medicaid than practices closer to academic hospitals., Clinical Relevance: This study illustrates the barriers to timely outpatient orthopaedic care that patients with Medicaid face. The findings from our study imply that patients with Medicaid in more populous areas and in areas closer to academic medical centers are less likely to obtain an outpatient orthopaedic appointment than patients with Medicaid in less populous areas and in areas more distant from academic medical centers. A shift in policy to enhance access to orthopaedic care for patients with Medicaid, especially those in urban areas and areas close to academic medical centers, will become increasingly important as more patients become eligible for Medicaid through the Patient Protection and Affordable Care Act of 2010., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: After failure of nonoperative treatment, repair has long been the primary treatment option for symptomatic superior labrum anterior and posterior (SLAP) lesions of the shoulder. There is growing evidence to support both biceps tenotomy and tenodesis as effective alternative treatments for SLAP lesions., Hypotheses: For patients with isolated SLAP lesions, the frequency of SLAP repair has decreased, while treatment with biceps tenodesis and tenotomy has increased. Similar trends are expected in patients with SLAP lesions undergoing concomitant rotator cuff repair., Study Design: Cohort study; Level of evidence, 3., Methods: A query of the American Board of Orthopaedic Surgery part II database was performed from 2002 to 2011. The database was searched for patients with isolated SLAP lesions undergoing SLAP repair, open biceps tenodesis, arthroscopic biceps tenodesis, or biceps tenotomy. The database was then queried a second time for patients undergoing arthroscopic rotator cuff repair with concomitant SLAP repair, biceps tenodesis, or biceps tenotomy., Results: From 2002 to 2011, there were 8963 cases reported for the treatment of an isolated SLAP lesion and 1540 cases reported for the treatment of SLAP lesions with concomitant rotator cuff repair. For patients with isolated SLAP lesions, the proportion of SLAP repairs decreased from 69.3% to 44.8% (P < .0001), while biceps tenodesis increased from 1.9% to 18.8% (P < .0001), and biceps tenotomy increased from 0.4% to 1.7% (P = .018). For patients undergoing concomitant rotator cuff repair, SLAP repair decreased from 60.2% to 15.3% (P < .0001), while biceps tenodesis or tenotomy increased from 6.0% to 28.0% (P < .0001). There was a significant difference in the mean age of patients undergoing SLAP repair (37.1 years) versus biceps tenodesis (47.2 years) versus biceps tenotomy (55.7 years) (P < .0001)., Conclusion: Practice trends for orthopaedic board candidates indicate that the proportion of SLAP repairs has decreased over time, with an increase in biceps tenodesis and tenotomy. Increased patient age correlates with the likelihood of treatment with biceps tenodesis or tenotomy versus SLAP repair., (© 2014 The Author(s).)

Background: Graft survivorship, reinjury rates, and career length are poorly understood after anterior cruciate ligament (ACL) reconstruction in the elite collegiate athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a National Collegiate Athletic Association (NCAA) Division I athlete cohort., Study Design: Case series; Level of evidence, 4., Methods: A retrospective chart review was performed of all Division I athletes at a single public university from 2000 to 2009 until completion of eligibility. Athletes were separated into 2 cohorts: those who underwent precollegiate ACL reconstruction (PC group) and those who underwent intracollegiate reconstruction (IC group). Graft survivorship, reoperation rates, and career length information were collected., Results: Thirty-five athletes were identified with precollegiate reconstruction and 54 with intracollegiate reconstruction. The PC group had a 17.1% injury rate with the original graft, with a 20.0% rate of a contralateral ACL injury. For the IC group, the reinjury rates were 1.9% with an ACL graft, with an 11.1% rate of a contralateral ACL injury after intracollegiate ACL reconstruction. The athletes in the PC group used 78% of their total eligibility (average, 3.11 years). The athletes in the IC group used an average of 77% of their remaining NCAA eligibility; 88.3% of those in the IC group played an additional non-redshirt year after their injury. The reoperation rate for the PC group was 51.4% and was 20.4% for the IC group., Conclusion: Reoperation and reinjury rates are high after ACL reconstruction in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL reinjuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction., (© 2014 The Author(s).)

Background: Low compliance with training programs is likely to be one of the major reasons for inconsistency of the data regarding the effectiveness of current anterior cruciate ligament (ACL) injury prevention programs. Training methods that reduce training time and cost could favorably influence the effectiveness of ACL injury prevention programs. A newly designed knee extension constraint training device may serve this purpose., Hypothesis: (1) Knee extension constraint training for 4 weeks would significantly increase the knee flexion angle at the time of peak impact posterior ground-reaction force and decrease peak impact ground-reaction forces during landing of a stop-jump task and a side-cutting task, and (2) the training effects would be retained 4 weeks after completion of the training program., Study Design: Controlled laboratory study., Methods: Twenty-four recreational athletes were randomly assigned to group A or B. Participants in group A played sports without wearing a knee extension constraint device for 4 weeks and then played sports while wearing the device for 4 weeks, while participants in group B underwent a reversed protocol. Both groups were tested at the beginning of week 1 and at the ends of weeks 4 and 8 without wearing the device. Knee joint angles were obtained from 3-dimensional videographic data, while ground-reaction forces were measured simultaneously using force plates. Analyses of variance were performed to determine the training effects and the retention of training effects., Results: Participants in group A significantly increased knee flexion angles and decreased ground-reaction forces at the end of week 8 (P ≤ .012). Participants in group B significantly increased knee flexion angles and decreased ground-reaction forces at the ends of weeks 4 and 8 (P ≤ .007). However, participants in group B decreased knee flexion angles and increased ground-reaction forces at the end of week 8 in comparison with the end of week 4 (P ≤ .009)., Conclusion: Knee extension constraint training for 4 weeks significantly altered lower extremity movement patterns and transferred these changes in lower extremity movement patterns to stop-jump and side-cutting tasks in which ACL injuries frequently occur. Training effects were retained 4 weeks after the training was completed but were diminished in magnitude., Clinical Relevance: A knee extension constraint device may be a useful training tool in future ACL injury prevention programs to alter movement patterns without extra training time.

Background: Access to orthopaedic care for pediatric patients has been shown in previous studies to be decreased for patients with Medicaid compared with those with private insurance. The relationship between type of insurance and access to care for adult patients with acute rotator cuff tears has not yet been examined. This study aimed to determine if type of health insurance would have an impact on access to care for an adult patient with an acute rotator cuff tear., Methods: Seventy-one orthopaedic surgery practices within the state of North Carolina were randomly selected and contacted on 2 different occasions separated by 3 weeks. The practices were presented with an appointment request for a fictitious 42-year-old man with an acute rotator cuff tear. Insurance status was reported as Medicaid for the first call and as private insurance during the second call., Results: Of the 71 practices contacted, 51 (72%) offered the patient with Medicaid an appointment, whereas 68 (96%) offered the patient with private insurance an appointment. The difference in these rates was statistically significant (P < .001). The likelihood of patients with private insurance obtaining an appointment was 8.8 times higher than that of patients with Medicaid (95% CI: 2.5, 31.5)., Conclusion: For patients with acute rotator cuff tears, access to care is decreased for those with Medicaid compared with those with private insurance. Patients with private insurance are 8.8 times more likely than those with Medicaid to obtain an appointment., Level of Evidence: Basic science, survey study., (Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate the biomechanical strength of two 4.5-mm screws and three 3.5-mm screws for fixation of the tibial tubercle after anteromedialization osteotomy., Methods: Anteromedialization of the tibial tubercle was performed on 5 pairs of fresh-frozen cadaveric lower extremities. One leg from each pair was randomized to fixation with two 4.5-mm screws and the contralateral leg to fixation with three 3.5-mm screws. Each specimen was loaded cyclically to simulate an active straight-leg raise and then to failure while displacement of the tubercle fragment was recorded., Results: There was no difference in mean tubercle fragment displacement under cyclic loading at any cycle number (P > .352). Maximum failure load for osteotomies secured with two 4.5-mm screws was 1,459 ± 540 N, and for three 3.5-mm screws it was 1,360 ± 707 N. This was not a statistically significant difference (P = .723). Tubercle migration of 7 mm was chosen as clinical failure. At this amount of displacement, mean load was 1,085 ± 398 N and 764 ± 313 N in the 4.5-mm and 3.5-mm groups, respectively, which was also not significantly different (P = .146)., Conclusions: Both 2 × 4.5-mm and 3 × 3.5-mm screw constructs after tibial tubercle anteromedialization are equally capable of withstanding physiologic forces like those encountered during an active straight-leg raise and have similar failure strength., Clinical Relevance: Although both configurations are comparable, the use of the smaller 3.5-mm screws may reduce the need for hardware removal related to prominence and soft tissue irritation., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Currently, no clinical midterm results have been reported on arthroscopically assisted reduction of the acutely dislocated acromioclavicular (AC) joint using suture-button devices for fixation., Hypothesis: Athroscopically assisted reduction of the acutely dislocated AC joint yields satisfactory clinical outcomes without loss of reduction, clavicle migration, or AC joint degeneration at midterm follow-up evaluation., Study Design: Case series; Level of evidence, 4., Methods: The clinical and radiographic outcomes of 23 of 30 consecutive patients (21 men, 2 women) who underwent anatomic reduction for acute AC joint dislocation using 2 suture-button devices between 2006 and 2007 were reviewed. Radiographic evaluation was performed by measurement of coracoclavicular (CC) distance and AC displacement. Clinical evaluation included a visual analog scale (VAS) for pain, the Constant score, the simple shoulder test, and the Short Form-36. Previously, this same patient collective was reviewed after 2 years of follow-up using similar methods., Results: All 23 patients were available for midterm follow-up examination 58 months postoperatively. There were 3 Rockwood type III, 3 type IV, and 17 type V acromioclavicular joint separations. Mean ± SD follow-up was 58 ± 5.6 months (range, 51-67 months). Most patients (96%) remained very satisfied or satisfied with the procedure outcome. The VAS and Constant score improved significantly when compared with baseline (0.3 ± 0.6 and 91.5 ± 4.7 at 58 months postoperatively vs 4.5 ± 1.9 and 34.5 ± 6.9 at baseline) and remained essentially unchanged when compared with the 2-year outcome scores (0.3 ± 0.6 and 91.5 ± 4.7 at 58 months postoperatively vs 0.25 ± 0.5 and 94.3 ± 3.2 at 2 years). Radiographs showed 8 radiographic failures (undercorrection, posterior displacement, or both) and 4 additional overcorrections of the CC distance. When comparing with 24-month data, 17 of 20 radiographs remained unchanged; 1 case of previous overcorrection drifted into normal AC alignment and 2 cases increased in posterior subluxation of the clavicle., Conclusion: Arthroscopically assisted reduction of the acutely dislocated AC joint provides satisfactory clinical results 58 months after surgery. Compared with the baseline, all patients improved significantly. Two of 23 patients revealed an increased posterior dislocation compared with evaluation 24 months after surgery. No further migration of the clavicle or AC joint degeneration was observed.

Background: Bankart repair with multiple anchor holes concentrated in the anterior-inferior glenoid may contribute to glenoid weakening and potentially may induce glenoid failure., Purpose: To compare the biomechanical strength of a Bankart repair construct that used 3 single-loaded suture anchors versus a repair construct that used 2 double-loaded suture anchors., Study Design: Comparative laboratory study., Methods: A standard Bankart lesion was created in 18 human cadaveric shoulders (9 matched pairs). Within each matched pair, 1 repair construct used 3 single-loaded anchors, whereas the other used 2 double-loaded suture anchors. Measured outcomes (load, stiffness, and energy absorbed) were recorded at failure and at 2 mm of labral displacement. Constructs were loaded to failure with a materials testing device that had differential variable reluctance transducers for displacement measurements., Results: The double-loaded anchor construct had a significantly higher ultimate tensile load (944 ± 231 vs 784 ± 287 N; P = .03). For the other measures (load at 2 mm of displacement, energy absorbed at failure and at 2 mm of displacement and stiffness), there were no significant differences between tested constructs., Conclusion: A Bankart repair construct that used 2 double-loaded anchors was either superior to or equal to a repair construct that used 3 single-loaded anchors in all measured outcomes., Clinical Relevance: Using 2 double-loaded suture anchors for a Bankart repair may limit anchor holes in the glenoid and reduce the risk of postsurgical glenoid fracture while providing a stable repair construct.

Context: Shoulder injuries are common in swimmers because of the demands of the sport. Muscle imbalances frequently exist due to the biomechanics of the sport, which predispose swimmers to injury. To date, an effective shoulder-injury-prevention program for competitive swimmers has not been established., Objective: To assess the effectiveness of a 6-wk strengthening and stretching intervention program on improving glenohumeral and scapular muscle strength and scapular kinematics in collegiate swimmers., Design: Randomized control trial., Setting: University biomechanics research laboratory., Participants: Forty-four Division I collegiate swimmers., Interventions: The intervention program was completed 3 times per week for 6 wk. The program included strengthening exercises completed using resistance tubing-scapular retraction (Ts), scapular retraction with upward rotation (Ys), scapular retraction with downward rotation (Ws), shoulder flexion, low rows, throwing acceleration and deceleration, scapular punches, shoulder internal rotation at 90° abduction, and external rotation at 90° abduction-and 2 stretching exercises: corner stretch and sleeper stretch., Main Outcome Measurements: Scapular kinematics and glenohumeral and scapular muscle strength assessed preintervention and postintervention., Results: There were no significant between-groups differences in strength variables at pre/post tests, although shoulder-extension and internal-rotation strength significantly increased in all subjects regardless of group assignment. Scapular kinematic data revealed increased scapular internal rotation, protraction, and elevation in all subjects at posttesting but no significant effect of group on the individual kinematic variables., Conclusions: The current strengthening and stretching program was not effective in altering strength and scapular kinematic variables but may serve as a framework for future programs. Adding more stretching exercises, eliminating exercises that overlap with weight-room training and swim training, and timing of implementation may yield a more beneficial program for collegiate swimmers.

Purpose: The purpose of this study was to determine the interobserver reliability of 3 commonly used classification systems in describing preoperative magnetic resonance imaging (MRI) studies of patients undergoing surgery for full-thickness rotator cuff tears., Methods: Thirty-one patients who underwent arthroscopic rotator cuff repair and had preoperative MRI studies available were selected over a 2-year period. Three board-certified shoulder surgeons independently reviewed these images. Each was instructed in the published method for determining the Patte score on the T2 coronal images, supraspinatus and infraspinatus atrophy on the T1 sagittal images as described by Warner et al., and the Goutallier score of fatty infiltration of the supraspinatus on the T1 coronal/sagittal images. Statistical analysis was then performed to determine the interobserver agreement using the κ statistic, with the level of significance set a priori at P < .01., Results: None of the classification systems studied yielded excellent or high interobserver reliability. The strongest agreement was found with the Patte classification assessing tendon retraction in the frontal plane (κ = 0.58). The Goutallier classification, which grades fatty infiltration of the supraspinatus, showed moderate interobserver agreement (κ = 0.53) when dichotomized into none to mild (grades 0, 1, and 2) and moderate to severe (grades 3 and 4). Muscle atrophy of both the supraspinatus and infraspinatus yielded the worst interobserver reliability, with only 28% agreement., Conclusions: The Goutallier, Patte, and Warner MRI classification systems for describing rotator cuff tears did not have high interobserver reliability among 3 experienced orthopaedic surgeons. Fatty infiltration of the supraspinatus and tendon retraction in the frontal planes showed only moderate reliability and moderate to high reliability, respectively. These findings have potential implications in the evaluation of the literature regarding the preoperative classification of rotator cuff tears and subsequent treatment algorithms., Level of Evidence: Level III, diagnostic agreement study with nonconsecutive patients., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Subscapularis dysfunction following total shoulder arthroplasty can result in permanent loss of function. The lesser tuberosity osteotomy (LTO) has been proposed as a method which utilizes bone-to-bone healing to improve subscapularis function. This study evaluates the biomechanical properties of two described techniques for LTO repair. We hypothesized that a Dual Row repair would be stronger and demonstrate less cyclic displacement than a Backpack repair., Materials and Methods: Ten matched pairs of cadaveric humeri were dissected, leaving the subscapularis intact, and a lesser tuberosity osteotomy was performed. Matched shoulders were randomized to either a Backpack repair or a Dual Row repair. Repairs were subjected to cyclic loading to 180 N for 500 cycles, followed by ramp-up loading to ultimate failure. Clinical failure was defined as displacement >5 mm after 500 cycles., Results: Displacement after 500 cycles was significantly greater for the Backpack repair (6.9 mm) than for the Dual Row repair (4.6 mm) (P = .007). Most displacement occurred on the first cycle (Backpack, 4.6 mm; Dual Row, 2.1 mm) (P < .001). There was a trend toward a higher clinical failure rate for the Backpack repair (8/10) than the Dual Row repair (3/10). Ultimate tensile strength was significantly greater for the Dual Row repair (632.3 N) than for the Backpack repair (510.9 N) (P = .01)., Conclusion: The Dual Row technique is significantly stronger and demonstrates less cyclic displacement than the Backpack technique. Clinical studies are needed to determine the impact of LTO repair technique on subscapularis function following shoulder arthroplasty., (Copyright © 2011. Published by Mosby, Inc.)

Purpose: To evaluate single centrifuge platelet concentrate as additive for improved tendon healing. Platelet-rich plasma has been reported to improve tendon healing. Single centrifuge platelet concentration may increase platelet concentration enough to positively affect tendon healing. A single centrifuge process will lead to a blood product with increased platelet concentrations which, when added to a surgically created tendon injury, will improve tendon healing when compared with a saline control., Methods: Lewis rats had a surgical transection of the patellar tendon that was subsequently stabilized with a cerclage suture. Prior to skin closure, the tendon was saturated with either a concentrated platelet solution or saline. At 14 days, all animals were killed, and the extensor mechanism was isolated for testing. Biomechanical testing outputs included ultimate tensile load, stiffness, and energy absorbed., Results: Comparisons between the control group and the concentrated platelet group revealed no differences. A subgroup of the concentrated platelet group consisting of specimens in whom the concentration process was most successful showed significantly higher ultimate tensile load (P < 0.05) and energy absorbed to failure (P < 0.05) when compared to the control group., Conclusion: When successful, single centrifuge platelet concentration yields a solution that improves tendon healing when compared with a saline control. Single-spin platelet concentration may yield a biologically active additive that may improve tendon healing, but more studies must be undertaken to ensure that adequate platelet concentration is possible.

Introduction: A dysplastic trochlea. may be missed on conventional roentgenography due to superimposition effects of the distal femoral groove., Methods: Measurements of (1) the sulcus angle, (2) the lateral trochlear slope angle and (3) the lateral to medial trochlear ratio were compared between plain axial radiographs and axial magnetic resonance images (MRI) in 24 patients suffering from clinical patellofemoral instability. Trochlear dysplasia was classified into type A through D on MR images., Results: Measurements for (1) were significantly different among all dysplasia types. It was 135.6 degrees +/- 19.8 degrees on X-ray while it was above 180 degrees on MRI within dysplasia type D patients. Measurements for (2) were different among all dysplasia types, reaching statistical significance in type B dysplasia patients. Differences between radiographs and MRI for (3) were not significant, while only on MRI the ratio increased with increasing degree of dysplasia., Conclusion: The investigation illustrates that plain axial radiographs do not represent the natural bony trochlear morphology and may mislead further clinical management.

Purpose: Our purpose was to evaluate the effect of meniscectomy and meniscal allograft transplant on anterior cruciate ligament (ACL) and knee biomechanics., Methods: A differential variable reluctance transducer was placed in the ACL of 10 human cadaveric knees to record strain. Tibial displacement from a neutral reference was recorded relative to the position of the femur. Testing was performed at 30 degrees, 60 degrees, and 90 degrees of knee flexion. Six cycles of anterior-posterior loads were applied to the limit of 150 N. After a testing cycle, a medial meniscectomy was performed and the testing cycle was repeated. A meniscal allograft transplant was performed, and a final testing cycle was conducted. ACL strain and tibial displacement in the meniscectomy and meniscal allograft states were compared with the intact-knee state., Results: Tibial displacement after meniscectomy significantly increased at all angles. The meniscal allograft transplant restored tibial displacement to normal values at 30 degrees and 90 degrees. ACL strain increased significantly after meniscectomy at 60 degrees and 90 degrees of flexion, and meniscal allograft transplant returned the strain values to normal at 60 degrees and 90 degrees., Conclusions: In most cases medial meniscectomy produced a significant increase in tibial displacement relative to the femur, and meniscal allograft transplantation restored displacement values to normal. Meniscectomy increased ACL strain and meniscal allograft transplant restored strain values to normal in 2 of 3 tested flexion angles., Clinical Relevance: The absence of the medial meniscus exposes the ACL to increased strain, whereas meniscal allograft lowered the strain on the native ACL. This could have implications for those patients undergoing ACL reconstruction who have concomitant removal of the medial meniscus., ((c) 2010 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: A novel double-row configuration was compared with a traditional double-row configuration for rotator cuff repair., Methods: In 10 matched-pair sheep shoulders in vitro repair was performed with either a double-row technique with corkscrew suture anchors for the medial row and insertion anchors for the lateral row (group A) or a double-row technique with a new tape-like suture material with insertion anchors for both the medial and lateral rows (group B). Each specimen underwent cyclic loading from 10 to 150 N for 100 cycles, followed by unidirectional failure testing. Gap formation and strain within the repair area for the first and last cycles were analyzed with a video digitizing system, and stiffness and failure load were determined from the load-elongation curve., Results: The results were similar for the 2 repair types. There was no significant difference between the ultimate failure loads of the 2 techniques (421 +/- 150 N in group A and 408 +/- 66 N in group B, P = .31) or the stiffness of the 2 techniques (84 +/- 26 N/mm in group A and 99 +/- 20 N/mm in group B, P = .07). In addition, gap formation was not different between the repair types. Strain over the repair area was also not different between the repair types., Conclusions: Both tested rotator cuff repair techniques had high failure loads, limited gap formation, and acceptable strain patterns. No significant difference was found between the novel and conventional double-row repair types., Clinical Relevance: Two double-row techniques-one with corkscrew suture anchors for the medial row and insertion anchors for the lateral row and one with insertion anchors for both the medial and lateral rows-provided excellent biomechanical profiles at time 0 for double-row repairs in a sheep model. Although the sheep model may not directly correspond to in vivo conditions, all-insertion anchor double-row constructs are worthy of further investigation.

We present a technique for double-bundle anterior cruciate ligament (ACL) reconstruction in a 14-year-old female athlete. The patient presented with anterolateral knee rotatory instability following a traumatic injury suffered while practicing judo. The clinical examination revealed positive Lachman and pivot shift tests with no accompanying meniscal pathology. Roentgenograms revealed open physes, and magnetic resonance imaging scans confirmed an isolated midsubstance ACL tear without cartilaginous injury. The decision was made to anatomically reconstruct the ACL because the athlete wished to continue competitive judo. Autologous hamstring tendons were harvested for double-bundle ACL repair. Following arthroscopic retrograde femoral and antegrade tibial tunnel placement, the ligaments were secured using interference screws within the femoral and tibial epiphysis. Postoperative Lachman and pivot shift tests were negative.

Background: Isolated varus osteoarthritis of the knee is a common problem in patients engaged in sports and recreational activities., Hypothesis: Patients will be able to resume sporting activity after high tibial osteotomy., Study Design: Case series; Level of evidence, 4., Methods: A total of 65 patients were surveyed by postal questionnaires to determine their sporting and recreational activities at an average of 36 +/- 8.1 months (range, 14-84) after high tibial osteotomy for the treatment of medial compartment knee osteoarthritis. The clinical evaluation included the Lysholm score, the Tegner activity scale, the Activity Rating Scale, and a visual analog scale for pain., Results: At the time of survey, 90.9% of patients were engaged in sports and recreational activities, compared with 87.9% before surgery (P = .182). The number of different sporting activities declined from 3.5 preoperatively to 3.0 after surgery (P = .178). The sports frequency per week (2.1 sessions) and the activity duration per week (4.1 hours) did not significantly change from preoperative to postoperative (2.3, P = .211; and 4.2 hours, P = .709, respectively). The Lysholm score (42.4) and the visual analog scale (6.9) illustrated significant improvements (69.6, P = .001; and 2.9, P < .001, respectively). No patient returned to competitive sports after surgery, and declines were noted in the Tegner (4.9 +/- 2.3 to 4.3 +/- 1.5, P < .05) and Activity Rating Scale (5.7 +/- 5.2 to 3.3 +/- 4.6, P = .001) scores. After surgery, many patients continued to engage in high-level activities such as downhill skiing or mountain biking., Conclusion: High tibial osteotomy for the treatment of medial compartment knee osteoarthritis in the active patient demonstrated favorable clinical results and allowed patients to return to sports and recreational activities similar to the preoperative level.

Background: A spectrum of acromioclavicular joint injuries may exist between type II acromioclavicular joint disruption (coracoclavicular strain) and type III acromioclavicular joint injuries (coracoclavicular disruption). This may help explain the variability in outcomes seen in patients with type II acromioclavicular injuries., Hypothesis: Injury to either the conoid or trapezoid ligaments would lead to instability of the acromioclavicular joint after complete acromioclavicular joint injury. A secondary hypothesis was that the resulting instability could be recognized with Zanca radiographs., Study Design: Controlled laboratory study., Methods: The acromioclavicular ligaments were sectioned in 40 cadaveric shoulder specimens. Ten intact specimens were loaded to failure to evaluate the normal failure patterns of the coracoclavicular ligaments. Thirty specimens then had either the conoid or trapezoid ligament sectioned after creation of complete acromioclavicular joint injury. Preinjury and postinjury radiographs and stability testing quantified the effect of coracoclavicular joint injury on acromioclavicular joint stability., Results: During failure testing, the conoid always failed first. Sectioning of the conoid led to significant increases in posterior and superior displacement on radiographs and with materials testing. Sectioning of the trapezoid led to significant increases in posterior displacement for materials testing and superior displacement on radiographs., Conclusion: Sectioning of the acromioclavicular ligaments in conjunction with partial disruption of the coracoclavicular ligament complex led to significant changes in both radiographic and mechanical measures of acromioclavicular stability. The conoid fails first when a load is applied to the coracoclavicular complex in a superior direction., Clinical Relevance: Zanca radiograph may detect incomplete injury to the coracoclavicular ligaments associated with acromioclavicular disruption.

Recognition and treatment of distal biceps tendon ruptures is increasing, likely because of greater clinical awareness and the greater activity and demands of the middle-aged population. This article focuses on the proper evaluation and treatment of distal biceps tendon ruptures with special attention focused on recently developed techniques. A review of the recent clinical literature will accompany an overview of pertinent biomechanical studies and an explanation of the risks and benefits of the most popular surgical techniques for distal biceps repair.

Historically, the patellofemoral articulation has been a topic of less interest among orthopaedists and has been subject to fewer studies when compared with other major joints in the body. Patellofemoral arthritis is a common and debilitating condition, and greater awareness of this has led to a new interest and recent increase in the number of clinical investigations pertaining to this condition. It is hoped that an overview of patellofemoral kinematics, forces, and contact patterns will help in understanding the progression of patellofemoral arthritis. Furthermore, this understanding will ultimately allow the surgeon to apply these basic principles to more effective nonsurgical and surgical treatment options. Treatment methods for patellofemoral arthritis include both conservative as well as surgical interventions. Specifically, these treatments range from stretching and water exercises to patellar realignment procedures and the recently developed procedure of custom patellofemoral arthroplasty. In addition, many new and innovative treatments are on the horizon. This renewed interest in the patellofemoral articulation bodes well for patients who suffer from this condition.

Arthroscopic treatment of anterior glenohumeral instability has become increasingly common. As longer-term follow-up studies become available, certain trends dictating the success or failure of arthroscopic stabilization are becoming more evident. Bone defects are important predictors of clinical failure, and the recognition of bone loss and other pathoanatomic variables can help determine which patients will benefit from arthroscopic stabilization for anterior glenohumeral instability. Arthroscopic techniques for anterior shoulder instability must mirror the focus of open methods on retensioning the inferior glenohumeral ligament and restoring the anatomy of the anterior capsulolabral complex. Arthroscopic stabilization for anterior glenohumeral instability has achieved results comparable to those of open stabilization methods in properly selected patients. Advantages of arthroscopic treatment of shoulder instability include lower morbidity, decreased pain, the ability to treat other pathologies, and improved cosmesis. As arthroscopic treatment of recurrent shoulder instability becomes more commonplace, it is crucial to review the factors that influence the success or failure of arthroscopic instability procedures and to understand the guidelines for patient selection, surgical pearls and pitfalls, and adjunctive technical details designed to optimize results.

Objective: To improve the rotational stability of the knee by anatomic reconstruction of the anterior cruciate ligament by socalled double-bundle technique using anteromedial and posterolateral grafts from native semitendinosus and gracilis. The grafts are fixed with bioabsorbable screws utilizing aperture fixation., Indications: Complete tear of the anterior cruciate ligament with positive Lachman sign and pivot shift., Contraindications: Open growth plate. Osteoarthritis > grade 1 according to Jäger & Wirth. Age > or = 50 years with low sports activity (relative contraindication)., Surgical Technique: Graft harvest of the semitendinosus and gracilis tendons via a 3-cm horizontal skin incision parallel to pes anserinus and preparation of the tendons as double-looped grafts. Arthroscopy, resection of the stump of the anterior cruciate ligament, and clearance of its origin and insertion. Tunnel placement by means of aiming devices in the following order: tibial posterolateral, tibial anteromedial, femoral anteromedial (transtibial or via the anteromedial portal in 120 degrees flexion), and femoral posterolateral (via additional medial arthroscopic portal). The anteromedial (semitendinosus tendon) and posterolateral (gracilis tendon) bundles are passed through the tunnels and fixed on the femoral side. Tibial fixation of the graft by bioresorbable interference screw with knee flexion of 45 degrees (anteromedial) and 10 degrees (posterolateral)., Postoperative Management: Depending on the degree of swelling, rehabilitation with partial weight bearing for 14 days and full range of motion. Return to sports after 6 months, no contact sports until 9 months., Results: From May 2004 to June 2005, anatomic double-bundle reconstruction was performed in 19 patients (13 male, six female, average age 31 years [18-48 years]) with isolated anterior cruciate ligament rupture without concomitant lesions. Clinical follow-up examination on average at 21.3 months (16-30 months) postoperatively. The Lysholm Score improved from an average of 65.2 to 94.5 points (75-100 points). The IKDC (International Knee Documentation Committee) Score yielded nine very good and ten good results in the relevant subgroups of motion, effusion and ligament stability. Measurement of anteroposterior translation with the KT-1000 instrument at 134 N showed increased translation of 1.8 mm (-2 to 5 mm) compared to the contralateral knee.

The purpose of this study was to compare suture anchor and EndoButton repair of distal biceps injuries in a human bone-tendon model. Right and left arm repairs were alternately performed with either the EndoButton or 2 single-loaded 5-mm suture anchors. Each construct was cyclically loaded by use of a servohydraulic materials testing machine. Initial and final displacements were recorded. All repairs were then loaded to ultimate failure. Ten millimeters of displacement was designated the clinical failure point. The EndoButton group had more stiffness than the suture anchor group during initial cyclic loading (P = .01). There were no differences in final displacement measured after cyclic loading (2.06 mm for suture anchors and 2.58 mm for EndoButton). The EndoButton group had a 16% greater ultimate tensile load than the suture anchor group (274.77 N vs 230.06 N). The EndoButton group also had a 16% higher load to clinical failure (249.95 N vs 209.56 N). These differences were not statistically significant. The EndoButton and suture anchors provide comparable fixation strength for the repair and rehabilitation of distal biceps tendon ruptures.

Glenoid avulsion of the capsulolabral complex and associated capsular laxity are well-described results of traumatic anterior dislocation. A less common consequence of traumatic anterior instability is the humeral avulsion of the glenohumeral ligaments (HAGL) lesion. An understanding of the arthroscopic pathoanatomy of the HAGL lesion will assist the surgeon in recognizing this uncommon entity. We describe a suture anchor technique for arthroscopic repair of HAGL lesions that anatomically reapproximates the torn edge of the glenohumeral ligament complex to its humeral head insertion. The technique is technically straightforward and does not require special equipment beyond that typical for arthroscopic labral repairs.

This study was performed to determine the material properties of sutures commonly used in orthopedic surgery in order to allow selection of the most appropriate one for securing a hamstring or quadriceps tendon graft in anterior cruciate ligament (ACL) reconstruction. Three suture materials (number 5 Ticron, number 5 Ethibond, and 5 mm Mersilene tape) were tested. The ultimate tensile load (UTL) with and without a knot, modulus of elasticity, effect of conditioning on the behavior of the suture, and plastic deformation were determined for each suture. Prior conditioning significantly improved the plastic deformation characteristics of all three sutures. Mersilene possessed the highest UTL both with and without knots, and its plastic deformation was significantly lower than that of Ticron or Ethibond. We feel that these characteristics make it the best suture for use in securing hamstring or tendon grafts in ACL surgery. Because of the high UTL achieved by Mersilene tape in the knotted surgical loop construct (nearly 500 N), it may be possible to achieve fixation integrity approaching that of interference fixation with bone blocks.