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Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Background: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. Purpose: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. Results: A total of 159 patients (13%) underwent tunnel grafting—64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group ( P≤ .001). Patients who required 2-stage grafting had more previous ACLRs ( P < .001) and were less likely to have received a bone–patellar tendon–bone or a soft tissue autograft at primary ACLR procedure ( P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone–patellar tendon–bone allograft ( P≤ .008) and less likely to receive a soft tissue autograft ( P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) ( P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. Conclusion: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

The thrower's shoulder has been a subject of great interest for many decades. Different theories have been proposed to clarify the pathophysiology, clinical presentation, and treatment options for this condition. In this review article, we summarize the relevant anatomy and pathophysiology and how these translate into signs, symptoms, and imaging findings. Also, a historical review of the treatment methodologies in the setting of an evolving concept is presented.The initial event in the cascade is thickening and contracture of the posteroinferior capsule resulting from repetitive tensile forces during the deceleration phase of throwing. This is known as "the essential lesion" and is clinically perceived as glenohumeral internal rotation deficit (GIRD), and a Bennett lesion may be found on radiographs.Change in the glenohumeral contact point leads to a series of adaptations that are beneficial for the mechanics of throwing, specifically in achieving the so-called "slot," which will maximize throwing performance.The complexity of the throwing shoulder is the result of an interplay of the different elements described in the cascade, as well as other factors such as pectoralis minor tightness and scapular dyskinesis. However, it is still unclear which event is the tipping point that breaks the balance between these adaptations and triggers the shift from an asymptomatic shoulder to a painful disabled joint that can jeopardize the career of a throwing athlete. Consequences are rotator cuff impingement and tear, labral injury, and scapular dyskinesis, which are seen both clinically and radiographically.A thorough understanding of the pathologic cascade is paramount for professionals who care for throwing athletes. The successful treatment of this condition depends on correct identification of the point in the cascade that is disturbed. The typical injuries described in the throwing shoulder rarely occur in isolation; thus, an overlap of symptoms and clinical findings is common.The rationale for treatment is based on the pathophysiologic biomechanics and should involve stretching, scapular stabilization, and core and lower-body strengthening, as well as correction of throwing mechanics, integrating the entire kinetic chain. When nonoperative treatment is unsuccessful, surgical options should be tailored for the specific changes within the pathologic cascade that are causing a dysfunctional throwing shoulder.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon- dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting post-operative infections. Allografts had a higher risk of infection than autografts (odds ratio=6.8; 95% CI: 0.9-54.5; p=0.045). Diabetes (odds ratio=28.6; 95% CI: 5.5-149.9; p=0.004) was a risk factor for infection. Patient age, sex, BMI and smoking status were not associated with risk of infection after rACLR. STATEMENT OF CLINICAL SIGNIFICANCE: While there is a low rate of infection following rACLR, use of allograft and comorbidity with diabetes are associated with a higher risk of infection following this surgery.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

Most patients undergoing total knee arthroplasty (TKA) experience favorable outcomes. Some patients, however, experience prolonged post-operative knee pain and tenderness at the joint line. This has been attributed in some cases to soft tissue impingement due to pseudomeniscus. The purpose of this study is to evaluate patient outcomes for arthroscopic excision of pseudomeniscus for persistent knee pain after TKA and to perform a review of literature for pseudomeniscus after knee arthroplasty.A retrospective analysis of patients undergoing arthroscopy to remove soft tissue causing persistent knee pain after previous TKA was performed. Outcome scores were asked at three time points: prior to knee arthroplasty, prior to arthroscopy, and post-arthroscopy at final follow-up. Subjective satisfaction with surgery and willingness to repeat procedures were also recorded. A two-tailed distribution pairedNine out of eleven patients were considered eligible to be assessed for post-operative satisfaction. Seven out of nine patients reported complete satisfaction and eight participants stated they would undergo the procedures again if they have to. Among 9 included patients, five patients have successfully completed the clinical score evaluation survey. The mean age of the patients with clinical score evaluation at the time of TKA was 61 years (range, 53-72) and the time between TKA and undergoing arthroscopy was 8 months (range, 5-13). The average follow-up period for patient-determined assessment after the arthroscopic procedure was 71 months (range, 16-115). All 5 patients reported improved Oxford Knee Scores (Arthroscopic removal of pseudomeniscus after TKA provides promising results in patients who experience persistent knee joint line pain and tenderness. Considering our results and review of literature, we recommend including pseudomeniscus in the differential for post arthroplasty knee pain.Case series with a review of literature.

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS–Sports and Recreation ( P = .04), and KOOS–Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Purpose To summarize currently available data regarding the use of bone marrow aspirate concentrate (BMAC) for the treatment of focal chondral lesions of the knee in experimental animal models and human clinical studies. Methods A systematic review searching for the terms “(bone marrow)” AND “(aspirate OR concentrate)” AND “(cartilage OR chondral OR osteochondral)” was performed in the databases PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar regarding the use of BMAC for the treatment of focal chondral lesions of the knee. The inclusion criteria were animal and clinical studies published in English that used autologous BMAC to treat focal chondral defects of the knee. We excluded studies that evaluated nonconcentrated preparations of bone marrow aspirate or preparations that were culture expanded. Results A total of 23 studies were included: 10 studies performed in animal models and 13 human clinical studies. Animal studies showed inconsistent outcomes regarding the efficacy of BMAC for the treatment of chondral or osteochondral lesions, assessed by gross morphology, second-look arthroscopy, magnetic resonance imaging, histology, immunohistochemistry, mechanical testing, and micro-tomography. Chondral defect filling was achieved with fibrocartilage or “hyaline-like” cartilage. Cells present in BMAC did not meet the criteria to be characterized as mesenchymal stem cells according to the International Society for Cell Therapy because freshly isolated cells failed to show tri-lineage differentiation. Overall, all clinical studies, independent of the study group or level of evidence, reported improved clinical outcomes and higher macroscopic, magnetic resonance imaging, and histology scores. Comparative trials favored BMAC over microfracture and reported equivalent outcomes between BMAC and matrix-induced autologous chondrocyte implantation. However, clinical studies were scant and showed low scientific rigor, poor methodologic quality, and low levels of evidence on average. Conclusions Although clinical success in short-term and midterm applications has been suggested for the application of BMAC for the restoration of cartilage defects in lesions of the knee, current study designs are generally of low scientific rigor. In addition, clinical applications of this technology in animal model investigations have shown inconsistent outcomes. Thus, clinicians should apply this technology cautiously. Level of Evidence Level IV, systematic review of Level II, III, and IV evidence studies.

OBJECTIVESagittal craniosynostosis is managed with a wide variety of operative strategies. The current investigation compares the clinical outcomes of two widely performed techniques: pi craniectomy and minimally invasive endoscopic strip craniectomy (ESC) followed by helmet therapy.METHODSThis IRB-approved retrospective study examined patients diagnosed with nonsyndromic, single-suture sagittal craniosynostosis treated with either pi craniectomy or ESC. Included patients had a minimum postoperative follow-up of 5 months.RESULTSFifty-one patients met the inclusion criteria (pi 21 patients, ESC 30 patients). Compared to patients who underwent ESC, the pi patients were older at the time of surgery (mean age 5.06 vs 3.11 months). The mean follow-up time was 23.2 months for ESC patients and 31.4 months for pi patients. Initial cranial index (CI) was similar between the groups, but postoperatively the ESC patients experienced a 12.3% mean increase in CI (from 0.685 to 0.767) compared to a 5.34% increase for the pi patients (from 0.684 to 0.719), and this difference was statistically significant (p < 0.001). Median hospital length of stay (1 vs 2 days) and operative duration (69.5 vs 93.3 minutes) were significantly less for ESC (p < 0.001 for both). The ESC patients showed a trend toward better results when surgery was done at younger ages. Craniectomy width in ESC cases was positively associated with CI improvement (slope of linear regression = 0.69, p = 0.026).CONCLUSIONSWhile both techniques effectively treated sagittal craniosynostosis, ESC showed superior results compared to pi craniectomy. ESC showed a trend for better outcomes when done at younger ages, although the trend did not reach statistical significance. A wider craniectomy width (up to 2 cm) was associated with better outcomes than smaller craniectomy widths among the ESC patients.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background Sequential assembly of the human spliceosome on RNA transcripts regulates splicing across the human transcriptome. The core spliceosome component PRPF8 is essential for spliceosome assembly through its participation in ribonucleoprotein (RNP) complexes for splice-site recognition, branch-point formation and catalysis. PRPF8 deficiency is linked to human diseases like retinitis pigmentosa or myeloid neoplasia, but its genome-wide effects on constitutive and alternative splicing remain unclear. Results Here, we show that alterations in RNA splicing patterns across the human transcriptome that occur in conditions of restricted cellular PRPF8 abundance are defined by the altered splicing of introns with weak 5′ splice sites. iCLIP of spliceosome components reveals that PRPF8 depletion decreases RNP complex formation at most splice sites in exon–intron junctions throughout the genome. However, impaired splicing affects only a subset of human transcripts, enriched for mitotic cell cycle factors, leading to mitotic arrest. Preferentially retained introns and differentially used exons in the affected genes contain weak 5′ splice sites, but are otherwise indistinguishable from adjacent spliced introns. Experimental enhancement of splice-site strength in mini-gene constructs overcomes the effects of PRPF8 depletion on the kinetics and fidelity of splicing during transcription. Conclusions Competition for PRPF8 availability alters the transcription-coupled splicing of RNAs in which weak 5′ splice sites predominate, enabling diversification of human gene expression during biological processes like mitosis. Our findings exemplify the regulatory potential of changes in the core spliceosome machinery, which may be relevant to slow-onset human genetic diseases linked to PRPF8 deficiency. Electronic supplementary material The online version of this article (doi:10.1186/s13059-015-0749-3) contains supplementary material, which is available to authorized users.

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 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.

Purpose (1) To determine whether examination under anesthesia (EUA) and/or magnetic resonance imaging (MRI) is an accurate means for determining patient selection for a selective-bundle reconstruction, (2) to determine whether the preoperative clinical assessment correlates with the arthroscopic examination, and (3) to examine histologically whether a partial anterior cruciate ligament (ACL) tear is truly partial in terms of vascular insult. Methods This prospective, nonrandomized cohort study included 95 patients who underwent primary ACL reconstruction from January 2013 through May 2014. All patients underwent an EUA, MRI, and arthroscopic evaluation. In patients with partial ACL tears, the intact bundle was resected and underwent histologic examination. The χ2 test was used to compare EUA and MRI in the detection of partial tears. Results Of the 95 patients included, 40 (42%) had EUA findings consistent with a partial ACL tear whereas 22 (23%) had MRI findings interpreted as showing a partial ACL tear. Arthroscopic examination confirmed a partial ACL tear in only 11 patients (12%). The sensitivity of EUA and MRI in the detection of partial ACL tears was 100% and 90.9%, and the specificity was 65% and 85.7%, respectively. The χ2 test suggested statistically significant associations between the method of evaluation and diagnostic outcome [χ2(1) = 7.83, P = .005]. MRI was 1.24 times more likely to correctly identify a partial tear (95% confidence interval, 1.06-1.45). EUA was 2.23 times as likely to incorrectly identify a partial tear (95% confidence interval, 1.24-4.02). The histologic analysis showed increased numbers of lymphocytes, absent polymorphonuclear leukocytes, predominant fibroblasts, neovascularization, and variable collagen orientation. Conclusions There is a disparity between EUA, MRI, and arthroscopic findings in the evaluation of partial ACL tears. Arthroscopy remains the gold standard for diagnosing the macroscopic integrity of the intact bundle. Microscopic analysis reveals that the integrity of the remaining intact ligament material is altered and may show a histologic response similar to a complete ACL rupture. Level of Evidence Level III, prospective, nonrandomized cohort study.

This study aims to compare the actual patellar tendon width with the skin and magnetic resonance imaging (MRI) measurements and to describe a more accurate method to predict the actual patellar tendon width before anterior cruciate ligament reconstruction (ACLR).Thirty-nine patients undergoing primary ACLR were identified. Patients with patellar tendon width of less than 30 mm by skin or MRI measurements were excluded from the study. The actual patellar tendon width was measured as an intraoperative reading taken after surgical exposure. Mean difference between the skin and actual measurement and mean difference between the MRI and actual measurement was calculated. Paired t-test was run to determine any significant differences. A difference was also calculated between the actual measurement and the average sum of skin and MRI measurements for each patient. Skin thickness was compared to Δ (Δ = preincision skin measurement of patellar tendon width minus postincision actual measurement) by Spearman's correlation test. Mean difference between skin and actual measurements was 2.5 mm, with p = 0.001. Mean difference between MRI and actual measurement was −2.7 mm with p = 0.001. However, the mean difference between the actual and the average sum of skin and MRI measurements was 0.13 mm with p = 0.76. The Pearson's correlation coefficient, r s, between average sum of skin and MRI measurements and the actual measurement was 0.6 with p = 0.001. There was no correlation found between the skin thickness and Δ∙. This study indicates that there is a significant difference between the actual patellar tendon width and the measurement of the tendon taken using a ruler on the skin or using MRI image software. However, the average sum of skin and MRI measurements, which is not significantly different from the actual width, can accurately predict the actual patellar tendon width before ACLR. The study reflects level IV evidence.

Background:Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions.Purpose/Hypothesis:The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes.Conclusion:Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels.Registration:NCT00625885

BACKGROUND Clostridium difficile infection (CDI) is an important cause of hospital-acquired morbidity and mortality. OBJECTIVE To evaluate the incidence of, predictors for, and effects on outcome by CDI after aneurysmal subarachnoid hemorrhage. METHODS Data were extracted from the Nationwide Inpatient Sample (2002-2011). Patients with subarachnoid hemorrhage who underwent microsurgical or endovascular aneurysm repair were included. Multivariate logistic regression was used to determine the independent predictors of developing CDI. Additional models were constructed to assess the impact of CDI on mortality, length of stay, and discharge disposition. RESULTS Of the 18 007 patients who were included, 1.9% (n = 346) developed CDI. Patients who developed CDI were significantly older and had more comorbidities (P ≤ .001). Independent predictors of developing CDI were Medicaid payer status; ventriculostomy; mechanical ventilation; a greater number of noninfectious complications; and the development of a urinary tract infection; pneumonia; meningitis/ventriculitis; and sepsis (all P ≤ .02). Only 1.5% of patients with CDI required gastrointestinal surgery. Although CDI was not associated with differential mortality, it was associated with increased adjusted odds of a hospital stay of at least 24 days (odds ratio, 3.16; 95% confidence interval, 2.32-4.29; P < .001) and of a nonroutine hospital discharge (odds ratio, 1.64; 95% confidence interval, 1.13-2.39; P = .01). CONCLUSION In this nationwide analysis, both infectious and noninfectious complications, as well as ventriculostomy, mechanical ventilation, and insurance status were independent predictors of CDI. Although CDI was not associated with mortality, it was associated with a longer hospital stay and nonroutine hospital discharge.

Partial tears of the anterior cruciate ligament (ACL) recently regained attention due to a better understanding of the two distinct bundles of the ligament and the possibility of single-bundle reconstruction procedures. An accurate diagnosis is important as it influences treatment options and patient prognosis. The aim of this study was to evaluate the value of examination under anesthesia (EUA) and magnetic resonance imaging (MRI) for differentiating partial from complete ACL tears. For this purpose, this prospective case series included 95 consecutive patients undergoing primary ACL reconstruction surgeries. MRI, EUA, and MRI combined with EUA were performed preoperatively, and results were compared with arthroscopy. Our data showed that ACL lesions were diagnosed as partial tears in 42.1% (n = 40) of EUA, 23.2% (n = 22) of MRI, and 11.6% (n = 11) of arthroscopies. EUA and MRI demonstrated sensitivity of 100 and 90.1%, and specificity of 65.5 and 85.6%, respectively. Combined EUA and MRI demonstrated sensitivity of 100% and specificity of 83.1%. Our study revealed that preoperatively MRI and EUA may help surgeons early identify partial ACL tears and influence treatment decisions.

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: 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 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

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up ( P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment ( P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores ( P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC ( P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale ( P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale ( P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores ( P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft ( P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Hypothesis and background Baseball players commonly present with decreases in internal rotation (IR) and concurrent increases in external rotation (ER) motion. Several glenohumeral (GH) adaptations have been theorized to cause these changes in motion, including humeral retroversion (HR) and posterior capsule thickness (PCT). However, limited data exist examining the inter-relationship between HR and PCT. Therefore, the purpose of this study was to measure HR, GH IR and ER rotation, and PCT. Materials and methods HR and PCT were measured with an ultrasound system (Sonosite Titan; Sonosite, Bothell, WA, USA), and GH IR and ER were measured with a digital inclinometer. Results The dominant arm had significantly more HR (15.6°, P = .0001) than the nondominant arm. Pearson correlation coefficients showed a significant negative relationship between HR and GH IR (–0.472, P = .001) and a significant positive relationship between HR and GH ER (0.295, P = .042). A significant positive correlation was also found between HR and PCT (0.427, P = .003). Discussion This was the first study to identify a relationship between HR and PCT in addition to GH IR and ER. The identification of these multiple correlations appears to suggest that the loss of IR caused by HR may be placing additional stress on the posterior capsule during the deceleration phase of the throw, thereby causing a fibroblastic healing response. Conclusions HR has previously been identified as a positive adaptation because of the increase in ER without anterior capsule attenuation. However, this study suggests that HR may be contributing to the negative adaptation of PCT.

BackgroundPartial distal biceps tears are difficult to diagnose clinically. The purpose of this study was to evaluate the accuracy of the direct radial tuberosity compression test in diagnosing partial distal biceps tendon avulsions.MethodsA consecutive series of 24 patients with partial distal bice

Blood samples were drawn from 6 National Football League players for baseline measures and then prior to morning practice on days 3, 5, and 9. Mean blood sodium level was lower on days 3 (136.9±0.6 mmol·L -1 ) and day 5 (138.1±0.6 mmol·L -1 ) compared to baseline (140.4±0.4 mmol·L -1 ) and day 9 (140.3±0.4 mmol·L -1 ). Mean blood potassium level was higher on day 5 (4.16±0.13 mmol·L -1 ) and day 9 (4.36±0.08 mmol·L -1 ) compared to baseline (3.77±0.15 mmol·L -1 ). Mean plasma volume was lower on day 3 (-4.9%±2.4%) compared to day 5 (4.5%±1.9%), and mean mass (days 2 through 9) was below baseline before and after practices. Blood sodium level declined by day 3 of preseason and was maintained at low normal levels at the expense of contracted plasma volume. Increased resting blood potassium levels on days 5 and 9 indicated rhabdomyolysis. Increased consumption of sodium is important for professional football players to maintain plasma volume during the first week of preseason.

Background: The complex interactions between capsuloligamentous structures and muscle-recruitment strategies that maintain glenohumeral stability remain unclear. The purposes of the present study were to determine whether stiffness regulation and muscle-activation strategies differed under varying joint positions and levels of contraction in the shoulder and to determine the relationship between generalized joint laxity, glenohumeral joint laxity, and joint stiffness. Methods: Forty healthy, physically active subjects with a mean age (and standard deviation) of 25.2 ± 4.6 years, a mean height of 174.7 ± 6.7 cm, and a mean mass of 73.1 ± 13.8 kg were tested. Shoulder stiffness and the activation of muscles (including the rotator cuff and the anterior deltoid) were measured at two levels of internal rotation torque (0% and 50% of maximum) and two joint positions (0° and 90% of maximum external rotation) before and after a 5° external rotation perturbation. Generalized laxity and glenohumeral joint laxity (in the anterior, posterior, and inferior directions) were also assessed. Results: Stiffness was 77% greater at 50% of maximum internal rotation torque than at 0% of maximum internal rotation torque (p < 0.001) but was not significantly different between joint positions (p = 0.73). From 0% to 50% of maximum internal rotation torque, preparatory and reactive recruitment of the subscapularis increased significantly more (p < 0.05) than those of the other muscles. Also, subscapularis preparatory activity was 36% greater in 0° of external rotation than in 90% of maximum external rotation (p < 0.01). Generalized joint laxity (as indicated by a score of ≥4) was present in 20% of the subjects. Glenohumeral joint laxity (as indicated by a grade of ≥2) was present in the anterior, posterior, and inferior directions in 13%, 15%, and 15% of the subjects, respectively. No correlation existed between passive stiffness and generalized or glenohumeral laxity (r = −0.12 to 0.29; p = 0.08 to 0.48). Conclusions: Moderate levels of muscle contraction can significantly increase glenohumeral joint stiffness and stability. Preactivation of the subscapularis appears to be the primary dynamic stabilizer with the arm in 0° of external rotation. However, with the arm in 90% of maximum external rotation (the apprehension position), less subscapularis activity is observed and the maintenance of stability may shift toward other musculoskeletal structures because joint stiffness does not change. A relationship between generalized joint laxity, glenohumeral laxity, and stiffness was not observed in healthy subjects. Clinical Relevance: Clinically, healthy populations have comparable levels of stiffness, or joint stability, in 0° of external rotation and in 90% of maximum external rotation (the apprehension position).

Background Football players lose 3.5 to 5 kg of body weight during preseason practices because of heavy sweating. This fluid may be difficult to replace when practices occur 2 times per day on consecutive days. Hypothesis Football players are hypohydrated during twice-a-day preseason training in a hot, humid environment. Study Design Descriptive laboratory study Methods In 10 college football players, body weight was measured, and blood and urine samples were obtained before and after practices on days 2 through 8 of preseason training. Baseline samples were obtained when subjects were euhydrated. Blood samples were used to calculate plasma volume changes. Urine samples were analyzed for specific gravity, sodium, and potassium. Sweat rate was calculated. Core temperature was monitored during half- and full-padded practices. Results Mean wet bulb temperatures were 23.3°C during morning practices and 23.7°C during afternoon practices. Plasma volume was below baseline on day 2 and expanded by day 6. Urine specific gravity was higher than baseline for 12 of 20 measurements over the 8 days. It was 1.0175 ± 0.006 at baseline but subsequently ranged from 1.0214 ± 0.007 to 1.0321 ± 0.004. Mean daily urine sodium dropped from baseline to day 2 (194 ± 43 vs 43 ± 38 mmol × L-1), remaining lower on days 3, 4, and 6 (40 ± 39, 39 ± 39, and 68 ± 40 mmol × L-1, respectively). Urine potassium was lower on days 6 and 8 compared with baseline and day 3. Body weight was below baseline before and after both daily practices. Core temperature was higher in full pads; sweat rate and body weight loss were not different between half and full pads. Conclusion Body weight, plasma volume, urine specific gravity, and urine sodium indicate that football players become dehydrated by day 2 of preseason training. Urine sodium increased to near baseline by day 8; urine specific gravity was elevated. Clinical Relevance Football players struggle to maintain euhydration during preseason twice-a-day sessions.

The relationship between a team physician and an athlete differs significantly from the traditional doctor-patient relationship. To better define the ethical norms and ideals in sports medicine, we surveyed the views of practicing team physicians in the Ivy, National Football, and National Hockey Leagues and compared them with responses offered by professional ethicists. Six hypothetical cases were presented, each representing a distinct area of ethical conflict: advertising, conflicting healthcare goals, confidentiality, innovative treatments, enabling dangerous behavior, and treating children. Thirty-one ethicists and 131 team physicians responded to the surveys. Subjects were asked to rate agreement or disagreement with statements that followed the case description. Responses were converted to scores ranging from 0 to 100. A priori, a difference greater than 20 points was set to represent significant disagreement. By that standard, there was agreement between the physicians and ethicists for 18 of 23 statements. We concluded that team physicians and ethicists share many of the same ethical views on common ethical issues in sports medicine. The high degree of variance in the responses in both groups, however, suggests that many unresolved areas remain in the field of ethics in sports medicine.

Pneumomediastinum can result from blunt chest trauma in sports. Diagnosis is made using chest radiography. The natural history of isolated pneumomediastinum is benign; however, it can be associated with more serious injuries, such as disruption of the tracheobronchial tree or a perforated digestive viscus. Patients with isolated pneumomediastinum should be monitored with serial chest radiographs. Patients may return to full activity once their chest radiographs have returned to normal, they exhibit no symptoms, and they have regained their stamina.

The treatment of anterior glenohumeral instability has been a topic of debate in the recent literature. Current surgical management of shoulder instability has included a variety of open and arthroscopic procedures. Open techniques for anterior reconstruction have been quite successful in preventing recurrent dislocations and continue to be the gold standard of care. In an attempt to address some of the disadvantages associated with open procedures, arthroscopic stabilization procedures have been developed. Arthroscopic capsuloligamentous repair presumably has clear advantages including better cosmesis, decreased perioperative morbidity, and a possible decrease in the loss of external rotation. Advances in arthroscopic instrumentation and improved arthroscopic techniques have increased the popularity of arthroscopic stabilization. The art of diagnosing the anatomic pathology associated with instability and proper patient selection continues to evolve. Most previous reports of arthroscopic stabilization have included small numbers of patients, variable patient pathology, and a variety of surgical techniques, making comparisons between stabilization procedures difficult. Arthroscopy can be valuable in both the confirmation of the degree and severity of the instability and to correct the pathoanatomy responsible for the instability.

To analyze a series of postoperative magnetic resonance (MR) images obtained in patients with recurrent signs or symptoms of instability in whom subsequent surgical correlation was performed to determine the accuracy in diagnosing recurrent injury.The authors identified 24 patients who underwent MR imaging after shoulder instability surgery and had recurrent instability requiring repeat surgery. Twelve nonenhanced MR images and six indirect and six direct MR arthrograms were retrospectively reviewed with consensus to determine the presence or absence of recurrent labral or rotator cuff tear. Operative reports were reviewed to confirm the presence or absence of labral or rotator cuff tear. The mean interval between initial surgery and MR imaging was 10 months. The mean interval until repeat surgery was 2 months.Overall, the accuracy of postoperative MR imaging was 79% in depicting recurrent labral tear and 88% in depicting recurrent rotator cuff tear. Indirect MR arthrography had 100% accuracy for recurrent labral tear detection, whereas direct MR arthrography and nonenhanced MR imaging had accuracies of 67% and 75%, respectively. Direct MR arthrography was more sensitive, 100% versus 71%, but less specific, 60% versus 80%, than nonenhanced MR imaging in depicting recurrent labral tears. Direct MR arthrography had 100% accuracy in depicting rotator cuff tear, whereas both indirect MR arthrography and nonenhanced MR imaging had 83% accuracy.MR imaging, indirect MR arthrography in particular, appears to be an accurate means of evaluating the shoulder following instability surgery.

This article presents iatrogenic dermal burn injury as a complication of using a vented bipolar radiofrequency (RF) ablative device in shoulder arthroscopy. We have encountered 4 patients who have sustained second-degree skin burns after shoulder arthroscopy. The burns occurred from arthroscopic shoulder surgeries performed from 2004 to 2008. In each case a vented bipolar RF device was used to help perform a subacromial decompression. The burns appeared to be the result of heated effluent from the outflow tubing of the RF device exposed to the skin of the patients. This case report shows that care should be taken to avoid exposing patients to the elevated temperatures of bipolar RF device effluent to reduce the risk of dermal burn injury.

The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. Percutaneous or arthroscopic-assisted fixation are valuable techniques to employ when prolonged immobilization is a concern. Return to athletic competition has been rapid using these methods. Morbidity has been minimal, and there have been no nonunions to date at the authors' institution.

Anterior cruciate ligament (ACL) reconstruction has gained wide acceptance as the treatment of choice for the functionally unstable ACL-deficient knee. Long-term good or excellent results of primary ACL reconstructions with respect to functional stability, relief of symptoms, and return to activity is between 75% and 95%. As much as 8% of the unsatisfactory results after primary ACL reconstructions are secondary to recurrent instability and graft failure. Failed ACL reconstruction with recurrent instability can be classified into the following three categories based on the primary reason for failure: technical errors, biological failure, and traumatic failure. These causes of failure are not mutually exclusive, and more than one may contribute to failure. Technical reasons are the most common cause of failure, and anterior femoral tunnel placement is by far the most prevalent cause of graft failure and recurrent instability after ACL reconstruction. This article reviews the possible causes of recurrent instability after ACL reconstruction to enable the surgeon to thoroughly delineate the cause of failure before proceeding with revision ACL surgery.

An orthopedic surgeon must carefully evaluate each patient before proceeding with revision anterior cruciateligament (ACL) surgery. A concerted effort directed at delineating the reason(s) for failure of the primary reconstruction should be undertaken to prepare an orthopedic surgeon for revision ACL surgery. The evaluation should include a detailed history from the preoperative period of the primary ACL until the present. Physical examination should evaluate the knee for previous scars as well as associated laxity. Diagnostic studies should at a minimum include plain radiographs and magnetic resonance imaging. In addition, the operative surgeon should be experienced in ACL surgical techniques, have the appropriate tools and fixation devices, and have several graft choices. Finally, if there is any question about the ability to place the tunnels appropriately or obtain solid fixation, strong consideration should be given to staging the revision reconstruction.

Purpose: Our goal was to define the utility of contrast-enhanced MRI in the diagnosis of occult muscle injuries on T2 and STIR sequences. Method: We retrospectively reviewed the pre- and postcontrast MR studies of four professional athletes with a clinical diagnosis of suspected muscle injuries. Results: The four cases demonstrated muscle strain injuries not visualized on the conventional T2 and STIR sequences but visualized on the postcontrast MR studies as areas of localized enhancement. Conclusion: We recommend the intravenous administration of gadolinium in the setting of clinically suspected muscle injuries not visualized on T2 and STIR sequences.

The purpose of this study was to quantitate the effect of inferior capsular shift on shoulder volume. Four fresh frozen cadaveric shoulders were analyzed. Volume before and after shift was determined using 3 techniques: (1) Magnetic resonance imaging sequences were digitized to computer and analyzed for volume via a 35-mm camera using Cue 2 software. The capsule was delineated by contrast between light and dark regions. Volume was calculated by summing the total area of respective slices. (2) Ultrasound images, obtained after surgical exposure of the capsule, were digitized. Volume was calculated using the formula for a prolate ellipsoid. (3) An 18-gauge needle was used to inject and evacuate saline via an anterior approach. Quantity of aspirated fluid provided a direct measure of volume. Inferior capsular shift was performed. After the operation, measurements were repeated. Inferior capsular shift reduced volume in all shoulders with each technique. On average, inferior capsular shift reduced joint volume by 57 %). A measurable reduction in shoulder joint volume is an effect of capsular shift. This measurement may have clinical application if volume is an indicator of instability or laxity.

Patellar tendon has been widely used to reconstruct the anterior cruciate deficient knee. The technique involvesharvesting the central third of the patellar tendon, or using a patellar tendon allograft. Attention to detail regarding appropriate tunnel placement is essential. Interference screw fixation provides an immediately stable and rigidly fixed graft. It is necessary to avoid lateral wall or roof encroachment on the patellar tendon graft and to avoid the pitfalls of excessive anterior placement of the femoral and tibial tunnels in order to achieve an optimum result. Rigid fixation of the graft allows immediate aggressive rehabilitation.

Anterior cruciate ligament (ACL) reconstruction has gained, wide acceptance as the treatment of choice for thefunctionally unstable ACL-deficient knee and is now performed on about a half million individuals, per year. The documented long-term good or excellent result rates for functional stability, relief of symptoms, and return to activity for intra-articular ACL reconstructions is approximately 75% to 95%. This leaves a substantial group of patients with an unsatisfactory result secondary to a variety of reasons. Review of the literature reveals that recurrent instability and graft failure are responsible for unsatisfactory results in as high as 8% of these patients. In this article, the factors responsible for graft failure and recurrent instability are discussed. In addition, the planning and difficulties that the orthopedic surgeon must address before, during, and after the procedure, are also reviewed.

Objective: To investigate the accuracy of diagnosing anterior cruciate ligament (ACL) tears with axial MR imaging. Materials and Methods: Two blinded independent observers retrospectively reviewed axial T2 weighted or FSE fat suppressed imaging of the knee from 47 patients. Arthroscopy had demonstrated a complete tear of the ACL in 25 patients and a normal ACL in 22 patients. The two criteria used to diagnose ACL tears on sequential axial imaging were (a) lack of visualization of the ACL in its expected course or (b) focal increased signal in the expected course of the ACL. Results: Observer 1 demonstrated a sensitivity of 92% (23 of 25) and a specificity of 100% (22 of 22) in diagnosing ACL tears (X 2 = 39.6, p < 0.001). Observer 2 demonstrated a sensitivity of 92% (23 of 25) and a specificity of 82% (18 of 22) in diagnosing ACL tears (X 2 = 26.1, p < 0.001). The Kappa value was 0.75 (agreement in 41 of 47 cases), indicating a high degree of intraobserver agreement. Conclusion: Axial T2 weighted or FSE fat suppressed imaging provides an accurate means of confirming the diagnosis of ACL tears.

To assess the accuracy and reliability of multiple signs of anterior cruciate ligament (ACL) tears with magnetic resonance (MR) imaging.Two independent reviewers retrospectively evaluated 103 sets of ACL MR images for the presence of 22 signs of ACL tears. There were 43 patients with ACL tears and 58 patients whose ACLs were proved to be intact at surgery. Although variable imaging protocols were used, T1- and T2-weighted images were obtained in nearly all patients. Direct nonvisualization, intrinisc ACL abnormalities, associated osseous and cartilage abnormalities, and other indirect signs were evaluated.Discontinuity of the ACL in the sagittal and axial planes and failure of the fascicles to parallel the Blumensaat line were the most accurate signs of a tear. Discontinuity of the ACL, disruption of fascicles, a posterolateral tibial bruise, a buckled posterior cruciate ligament, positive posterior cruciate ligament line sign and positive posterior femoral line sign were the best predictors of an ACL tear at logistic regression analysis.Signs other than nonvisualization of the ACL are good predictors of an ACL tear.

Context: Sweat sodium losses have never been reported in a large cohort of American football players. Objective: To compare sweat rates (SwtRs), sweat sodium concentrations (SwtNa+), and sodium losses in 3 groups of players (backs and receivers [BK], linebackers and quarterbacks [LB/QB], and linemen [LM]) to determine if positional differences and, therefore, size differences exist. Design: Observational study. Setting: Data were collected during practices in the second week of 2 consecutive training camps. The wet bulb globe temperature was 78.5°F ± 3.5°F (25.9°C ± 1.9°C). Patients or Other Participants: Eighteen BK, 12 LB/QB, and 14 LM volunteered. Intervention(s): Sterile sweat patches were applied to the right forearm after the skin was appropriately cleaned. The patches were removed during practice, placed in sterile tubes, centrifuged, frozen, and later analyzed by flame photometry. Main Outcome Measure(s): Sweat rate, SwtNa+, and sodium loss. We calculated SwtR by change in mass adjusted for urine produced and fluids consumed divided by practice time in hours. Results: Other than age, physical characteristics were different among groups (P < .001). The SwtR was different among groups (F2,41 = 7.3, P = .002). It was lower in BK (1.42 ± 0.45 L/h) than in LB/QB (1.98 ± 0.49 L/h) (P < .05) and LM (2.16 ± 0.75 L/h) (P < .01), but we found no differences between SwtRs for LB/QB and LM. The SwtNa+ was not different among groups (BK = 50 ± 16 mEq/L, LB/QB = 48.2 ± 23 mEq/L, and LM = 52.8 ± 25 mEq/L) and ranged from 15 to 99 mEq/L. Sweat sodium losses ranged from 642 mg/h to 6.7 g/h, and findings for group comparisons approached significance (P = .06). On days when players practiced 4.5 hours, calculated sodium losses ranged from 2.3 to 30 g/d. Conclusions: The BK sweated at lower rates than did the midsized LB/QB and large LM, but LB/QB sweated similarly to LM. Sweat sodium concentration and daily sodium losses ranged considerably. Heavy, salty sweaters require increased dietary consumption of sodium during preseason.

Hypothesis We hypothesized that posterior capsule thickness (PCT) would be greater on the dominant arm compared to the non-dominant arm. We also hypothesized that PCT would negatively correlate with glenohumeral internal rotation and scapular upward rotation. In addition, PCT would positively correlate with glenohumeral external rotation. However, currently PCT has not been measured nor have correlations been identified to exist with glenohumeral and scapular motion. Therefore, the purpose of the study was to determine if the posterior capsule was hypertrophied on the dominant arm and to identify if relationships exist with glenohumeral internal rotation (IR), external rotation (ER), and scapular upward rotation (SUR). Materials and methods PCT was measured using a 10-MHz transducer. Glenohumeral IR and ER was measured supine using a digital inclinometer. SUR was measure at 0°, 60°, 90°, and 120° of glenohumeral abduction using a modified digital inclinometer. Results PCT was greater on the dominant compared with the nondominant arm (P = .001). A negative correlation was found between PCT and IR (–0.498, P = .0001). A positive correlation was found between PCT and ER (0.450, P = .002) and between PCT and SUR at 60°, 90°, and 120° of glenohumeral abduction (0.388, P = .006; 0.327, P = .023; 0.304, P = .036, respectively). Discussion This in vivo study demonstrated a hypertrophied posterior capsule and its association with GIRD, ER, and SUR. These observations suggest that PCT does occur on the throwing arm of baseball players and is linked with glenohumeral and scapular alterations. Conclusions This methodology could be used as a noninvasive screening evaluation for overhead athletes to identify those who may be at risk for shoulder injuries due to excessive capsular thickening.

Background Multiple authors have debated the contribution of intertubercular groove morphology to biceps tendon pathology. It has been proposed that the shallow groove, combined with the supertubercular ridge of Meyer, predisposes patients to bicipital disease. In this study we hypothesized that there would be a correlation between bicipital groove morphology and the intraoperative finding of biceps pathology. Methods Seventy-five consecutive patients (average age of 63) undergoing arthroscopic rotator cuff repair surgery had their biceps tendons and intertubercular groove morphologies prospectively evaluated on closed MRI T1 axial cut images. The opening angle and medial wall angle of the bicipital groove was measured for each patient. At the time of surgery, the biceps tendon was classified as normal, inflamed, partially ruptured, or ruptured and the findings correlated to the bicipital groove measurements. Results The average opening angle was 81° for normal biceps tendons and 77° for torn biceps tendons. The average medial wall angle was 47° for normal biceps tendons and 49° for torn biceps tendons. Using Chi-square analysis, we found no statistically significant correlation between the bicipital groove average opening angle and medial wall angle on MRI and intraoperative biceps tendon pathology. Conclusion This study does not support any correlation between intraarticular biceps tendon pathology and bicipital groove morphology.