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Background: Numerous studies have reported the incidence and outcomes of injuries in the men’s and women’s National Basketball Association (NBA and WNBA, respectively). Purpose: To synthesize published data regarding the incidence and outcomes of all injuries in the NBA and WNBA in a comprehensive review. Study Design: Systematic review; Level of evidence, 4. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched 3 electronic databases (PubMed, MEDLINE, Embase) for studies of all levels of evidence since 1990 pertaining to injuries sustained by active players in the NBA and WNBA. Studies were excluded if the cohort of interest included ≤3 active players. Results: The initial search of the 3 databases yielded 1253 unique studies, of which 49 met final inclusion criteria for this review. Only 4 studies included athletes in the WNBA. Based on the mean annual incidence, the 5 most common orthopaedic sports injuries sustained in the NBA were concussions (9.5-14.9 per year), fractures of the hand (3.5-5.5 per year), lower extremity stress fractures (4.8 per year), meniscal tears (2.3-3.3 per year), and anterior cruciate ligament tears (1.5-2.6 per year). Cartilage defects treated using microfracture, Achilles tendon ruptures, and anterior cruciate ligament injuries were 3 injuries that led to significant reductions in performance measurements after injury. Conclusion: With advances in sports technology and statistical analysis, there is rapidly growing interest in injuries among professional basketball athletes. High-quality prospective studies are needed to understand the prevalence and effect of injuries on player performance and career length. This information can inform preventative and treatment measures taken by health care providers to protect players and guide safe return to play at a high level.

BACKGROUND Anterior cruciate ligament (ACL) graft position within the anatomic femoral footprint of the native ACL and the flexion angle at which the graft is fixed (i.e., fixation angle) are important considerations in ACL reconstruction surgery. However, their combined effect on ACL graft force remains less well understood. HYPOTHESIS During passive flexion, grafts placed high within the femoral footprint carry lower forces than grafts placed low within the femoral footprint (i.e., high and low grafts, respectively). Forces carried by high grafts are independent of fixation angle. All reconstructions impart higher forces on the graft than those carried by the native ACL. STUDY DESIGN Controlled laboratory study. METHODS Five fresh-frozen cadaveric knees were mounted to a robotic manipulator and flexed from full extension to 90° of flexion. The ACL was sectioned and ACL force was calculated via superposition. ACL reconstructions were then performed using a patellar tendon autograft. For each knee, four different reconstruction permutations were tested: high and low femoral graft positions fixed at 15° and at 30° of flexion. Graft forces were calculated from full extension to 90° of flexion for each combination of femoral graft position and fixation angle again via superposition. Native ACL and ACL graft forces were compared through early flexion (by averaging tissue force from 0 to 30° of flexion) and in 5° increments from full extension to 90° of flexion. RESULTS When fixed at 30° of flexion, high grafts carried less force than low grafts through early flexion bearing a respective 64 ± 19 N and 88 ± 11 N (p = 0.02). Increasing fixation angle from 15° to 30° caused graft forces through early flexion to increase 40 ± 13 N in low grafts and 23 ± 6 N in high grafts (p

Objective Distal femoral varus osteotomy (DFVO) is an effective treatment for unloading valgus knee malalignment; however, there is limited evidence on the ability for patients to return to athletics following this procedure. The purpose of this study is to report the functional outcomes and rate of return to sport for athletes that underwent DFVO. Design A consecutive series of athletes that had undergone DFVO were retrospectively reviewed. Radiographs were assessed to determine preoperative and postoperative alignment. Institutional registries were used to collect preoperative and postoperative Marx Activity Scale, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form scores, and return to sport. Results Thirteen patients (8 males, 5 females) with a mean age of 24 years (range 17-35 years) and a mean follow-up of 43 months (range 24-74 months) were included in the study. Six patients underwent medial closing wedge DFVO versus 7 patients who underwent lateral opening wedge DFVO. Nine of 13 had concomitant chondral, meniscal, or ligamentous procedures performed. The mean alignment correction was 8° (range 5°-13°). All patients were able to successfully return to sport at a mean of 11 months (range 9-13 months). Furthermore, all 13 patients demonstrated an improvement in both Marx Activity Scale (4-11; P < 0.01) and IKDC scores (53-89; P < 0.01) after surgery. Conclusions Correction of valgus knee malalignment through DFVO—either medial closing wedge or lateral opening wedge—can reliably result in improvement in function and return to sport. Concomitant chondral, meniscal, and ligamentous pathology should be addressed.

Background: There is increased interest in understanding the preoperative determinants of postoperative outcomes. Return to play (RTP) and the patient-reported minimal clinically important difference (MCID) are useful measures of postoperative outcomes after anterior cruciate ligament reconstruction (ACLR). Purpose: To define the MCID after ACLR and to investigate the role of preoperative outcome scores for predicting the MCID and RTP after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: There were 294 active athletes enrolled as part of an institutional ACL registry with a minimum 2-year follow-up who were eligible for inclusion. A questionnaire was administered to elicit factors associated with RTP. Patient demographic and clinical data as well as patient-reported outcome measures were captured as part of the registry. Outcome measures included the International Knee Documentation Committee (IKDC) subjective knee evaluation form, Lysholm scale, and 12-Item Short Form Health Survey (SF-12) physical component summary (PCS) and mental component summary (MCS). Preoperative outcome score thresholds predictive of RTP were determined using a receiver operating characteristic (ROC) with area under the curve (AUC) analysis. The MCID was calculated using a distribution-based method. Multivariable logistic models were fitted to identify predictors for achieving the MCID and RTP. Results: At a mean (±SD) follow-up of 3.7 ± 0.7 years, 231 patients were included from a total 294 eligible patients. The mean age and body mass index were 26.7 ± 12.5 years and 23.7 ± 3.2 kg/m2, respectively. Of the 231 patients, 201 (87.0%) returned to play at a mean time of 10.1 months. Two-year postoperative scores on all measures were significantly increased from preoperative scores (IKDC: 50.1 ± 15.6 to 87.4 ± 10.7; Lysholm: 61.2 ± 18.1 to 89.5 ± 10.4; SF-12 PCS: 41.5 ± 9.0 to 54.7 ± 4.6; SF-12 MCS: 53.6 ± 8.1 to 55.7 ± 5.7; P < .001 for all). The corresponding MCID values were 9.0 (IKDC), 10.0 (Lysholm), 5.1 (SF-12 PCS), and 4.3 (SF-12 MCS). Preoperative score thresholds predictive of RTP were the following: IKDC, 60.9; Lysholm, 57.0; SF-12 PCS, 42.3; and SF-12 MCS, 48.3. These thresholds were not independently predictive but achieved significance as part of the multivariable analysis. In the multivariable analysis for RTP, preoperative SF-12 PCS scores above 42.3 (odds ratio [OR], 2.73; 95% CI, 1.09-7.62) and SF-12 MCS scores above 48.3 (OR, 4.41; 95% CI, 1.80-10.98) were predictive for achieving RTP; an ACL allograft (OR, 0.26; 95% CI, 0.06-1.00) was negatively predictive of RTP. In the multivariable analysis for the MCID, patients with higher preoperative scores were less likely to achieve the MCID ( P < .0001); however, a higher preoperative SF-12 MCS score was predictive of achieving the MCID on the IKDC form (OR, 1.27; 95% CI, 1.11-1.52) and Lysholm scale (OR, 1.08; 95% CI, 1.00-1.16). Medial meniscal injuries, older age, and white race were also associated with a decreased likelihood for achieving the MCID. Conclusion: Preoperative SF-12 MCS and PCS scores were predictive of RTP after ACLR; patients scoring above 42.3 on the SF-12 PCS and 48.3 on the SF-12 MCS were more likely to achieve RTP. Additionally, we defined the MCID after ACLR and found that higher SF-12 MCS scores were predictive of achieving the MCID on knee-specific questionnaires.

Purpose To investigate differences between sport types for patient-reported outcome after anterior cruciate ligament reconstruction (ACLR). Methods Included patients were enrolled as part of a prospective institutional ACL registry. Inclusion criteria were preoperative self-identification as a competitive athlete, maximum score on the preoperative Marx Activity Scale, and minimum 2-year follow-up. Demographic, intraoperative, and outcome data were extracted from the registry. Outcome tools administered as part of the registry included International Knee Documentation Committee (IKDC), Lysholm-Tegner Scales, Marx Activity Scale (MAS), and 12-Item Short Form Health Survey (SF-12). Results A total of 294 patients with a mean age of 25.5 years (standard deviation 12.1) met the study inclusion criteria; mean follow-up was 3.7 years. Included sports categories were soccer (n = 92; 31.3%), skiing (n = 67; 22.8%), basketball (n = 56; 19.1%), lacrosse (n = 38; 12.9%), football (n = 29; 9.9%), and Tennis (n = 12; 4.1%). At baseline, compared with other sports, lacrosse players have higher outcome scores while skiers had lower scores. At 2-year follow-up, however, across all outcome tools, football players demonstrated significantly higher outcome scores than all other athletes (IKDC, 93.2, P = .001; Lysholm, 93.2, P = .03; MAS, 13.1, P = .03; SF-12 Mental Component Summary, 57.9, P = .0002). Conversely, at 2-year follow-up, soccer players demonstrated a significantly lower Lysholm (86.7, P = .02) and a trend toward lower IKDC (85.6, P = .09) scores. Conclusions Patient-reported outcomes after ACLR among active athletes are comparable. Football players demonstrate quantitatively higher outcome scores whereas soccer players have lower scores. However, these outcome score differences may not be clinically significant and may be subject to confounding variables. Continued attention should be paid to understanding sport-specific outcome after ACLR. Level of Evidence Level IV, therapeutic case series.

Surgical fixation of displaced, intra-articular glenoid fractures represents a clinical challenge. These fractures have traditionally been treated through open approaches to the glenohumeral joint; however, the morbidity associated with open surgery may be reduced with arthroscopic techniques. Previously described arthroscopic methods commonly use clamps and/or Kirschner wires to obtain and maintain provisional fixation. We describe our technique for minimally invasive, arthroscopic fixation of glenoid rim fractures using labral repair as an indirect reduction maneuver, followed by final fixation with an extra-articular screw. This method is safe, efficient, and reliable, and it can be used to approach a variety of intra-articular glenoid fractures.

Patients who experience distal biceps tendon avulsions generally benefit from surgical intervention. Compared with nonoperative treatment, surgery has shown improved muscle endurance as well as increased flexion and supination strength. Although a number of surgical techniques exist, repair of the distal biceps through a single incision is gaining popularity. This may be due in part to patient preference and emerging technologies such as cortical button fixation, suture anchors, and intraosseous screws. In this report, we present a simple technique for anatomically repairing distal biceps injuries using an intramedullary tenodesis button. This technique has the benefit of using a single unicortical drill hole in the radius while allowing the surgeon to sequentially tighten the tendon to its desired level of tension. When appropriate surgical steps are followed, it can be completed in a reliable, safe, and efficient manner through a single incision.

Open reduction internal fixation of proximal humerus fractures is often accomplished with proximal humerus locking plates. While these plates have a good track record, they can become symptomatic and require removal once the fracture has healed. Open hardware removal is associated with a number of additional risks to the patient, including infection, scarring, nerve damage, and blood loss. In addition, the recovery time after open hardware removal may be prolonged, thereby predisposing the patient to postoperative stiffness. The purpose of this article is to describe a technique for removing proximal humerus locking plates arthroscopically. Although technically demanding, the benefits of this technique include smaller incisions, quicker recovery time, decreased risk of infection, and reduced blood loss. Arthroscopy also provides the surgeon with the ability to address concomitant intra-articular pathology at the time of surgery. Additionally, we use a bone-void filler to reduce the risk of fracture through stress caused by previous screw holes.

Chronic exertional compartment syndrome is an activity-induced condition that occurs when intracompartmental pressures within an osteofascial envelope increase during exercise, leading to reversible ischemic symptoms such as pain, cramping, numbness, or weakness. Nonoperative treatment options for this condition have shown limited success and are often undesirable for the patient given the requirement for activity modification. Traditional surgical treatment options involving open or subcutaneous fasciotomies have more favorable results, but these techniques are associated with significant morbidity. Endoscopically assisted fasciotomy techniques afford the advantages of being minimally invasive, providing excellent visualization, and allowing accelerated rehabilitation. The purpose of this article is to describe a technique for performing endoscopically assisted fasciotomies for chronic exertional compartment syndrome of the lower leg using an entirely endoscopic thermal ablating device. The endoscopic thermal fasciotomy technique is associated with minimal morbidity, ensures excellent hemostasis, and affords an early return to sports.

Introduction: Intertrochanteric (IT) femur fractures are common in elderly patients who are often in poor general health. Intertrochanteric fractures are classified as stable or unstable, taking into account fracture morphology and involvement of the posteromedial calcar. The purpose of this study is to determine whether IT fracture stability can be used as a marker for general health or as a predictor of postoperative medical complications in elderly patients. Materials and Methods: We reviewed the records of all patients treated for IT fractures at our institution over the past 7 years. We excluded patients who were younger than 60 years, polytraumatized, involved in high-energy mechanisms of injury, managed nonoperatively, with hardware from previous surgery, or missing preoperative radiographs. Ninety-three patients were included in the present series. Three orthopedic surgeons independently reviewed all preoperative radiographs and classified each fracture as either stable or unstable. Interrater reliability was .77 (substantial) and consensus designation was assigned by majority. We reviewed charts for age, gender, time to surgery, length of hospital stay, type of surgery, estimated blood loss, American Society of Anesthesiologists (ASA) classification, and postoperative medical complications. Univariate and multivariate statistical analyses were conducted to determine the relationship of fracture stability on ASA class and medical complications. Results: Intertrochanteric fracture stability had no detectable relationship with ASA class ( P = .497). On univariate analysis, stability was not significantly related to medical complications ( P = .421). Our multivariate analysis found that only ASA was related to medical complications ( P = .004), and fracture stability was not related to complications ( P = .538). Conclusion: Intertrochanteric fracture stability does not appear to be a marker for poor general health or to predict postoperative medical complications in elderly patients in this limited study. ASA class was predictive of medical complications. Interestingly, medical complications were 8% greater in patients with unstable fractures than in patients with stable fractures.

Restoration of posterior condylar offset during TKA is believed to be important to improving knee kinematics, maximizing ROM, and minimizing flexion instability. However, controversy exists regarding whether there are important anatomic differences between sexes and whether a unisex knee prosthesis can restore the anatomy of knees in males and females.The purposes of our study were to determine if sex differences exist in (1) absolute posterior condylar offset size, (2) relative posterior condylar offset size in relation to total condylar height, and (3) posterior condylar articular cartilage thickness.We identified 100 patients (50 men and 50 women) without a history of arthritis, deformity, dysplasia, osteochondral defect, fracture, or surgery about the knee who had MRI of the knee performed. All MR images were ordered by primary care medical physicians for evaluation of nonspecific knee pain. Using a previously described three-dimensional MRI protocol, we measured posterior condylar offset, total condylar height, and articular cartilage thickness at the medial and lateral femoral condyles and compared values to evaluate for potential sex differences. We performed an a priori power calculation using a 2-mm posterior condylar offset difference as the minimum clinically important difference; with 2n = 100, our power to detect such a difference was 99.8%.Compared with females, males had greater medial posterior condylar offset (30 mm [95% CI, 29.3-30.7 mm; SD, 2.5 mm] vs 28 mm [95% CI, 27.0-28.5 mm; SD, 2.7 mm]), lateral posterior condylar offset (27 mm [95% CI, 26.2-27.3 mm; SD, 2.0 mm] vs 25 mm [95% CI, 24.2-25.4 mm; SD, 2.0 mm]), medial condylar height (63 mm [SD, 3.2 mm] vs 57 mm [SD, 4.4 mm]), and lateral condylar height (71 mm [SD, 5.2 mm] vs 65 mm [SD: 4.0 mm]) (all p values0.001). However, the mean ratio of medial posterior condylar offset to medial condylar height (0.48 [SD, 0.04] vs 0.49 [SD, 0.05]) and the mean ratio of lateral posterior condylar offset to lateral condylar height (0.38 [SD, 0.05] vs 0.38 [SD, 0.03]) were not different between sexes (p = 0.08 and p = 0.8, respectively). There also was no sex difference in mean articular cartilage thickness at either condyle (medial condyle: 2.7 mm [SD, 0.5 mm] vs 2.5 mm [SD, 0.7 mm]; lateral condyle: 2.6 mm [SD, 0.6 mm] vs 2.5 mm [SD, 0.8 mm]) (both p values ≥ 0.1).Results of our study showed that knees in males exhibited greater posterior condylar offset and greater total condylar height at the medial and lateral femoral condyles, however, there were no sex differences in the ratio of posterior condylar offset to condylar height at either condyle.These findings suggest that a unisex knee prosthesis design is adequate to recreate the normal posterior condylar offsets for men and women.

The purpose of this systematic review and meta-analysis is to compare patient-specific instrumentation (PSI) versus standard instrumentation for total knee arthroplasty (TKA) with regard to coronal and sagittal alignment, operative time, intraoperative blood loss, and cost. A systematic query in search of relevant studies was performed, and the data published in these studies were extracted and aggregated. In regard to coronal alignment, PSI demonstrated improved accuracy in femorotibial angle (FTA) (P = 0.0003), while standard instrumentation demonstrated improved accuracy in hip-knee-ankle angle (HKA) (P = 0.02). Importantly, there were no differences between treatment groups in the percentages of FTA or HKA outliers (>3 degrees from target alignment) (P = 0.7). Sagittal alignment, operative time, intraoperative blood loss, and cost were also similar between groups (P > 0.1 for all comparisons).

Background: Surgical management of extra-articular distal humerus fractures results in predictable fracture alignment. Open reduction and internal fixation also decrease the soft tissue complications and frequent follow-up required with functional bracing. A triceps-reflecting posterior approach provides excellent exposure to the humerus and minimizes trauma to the triceps. An anatomically precontoured plate on the posterolateral surface of the humerus provides stable fixation of these injuries and is placed directly through the interval developed by the triceps-reflecting approach. Methods: We retrospectively reviewed the trauma databases at 2 level I academic trauma institutions during a 5-year period for all patients with an extra-articular distal humerus fracture treated with a triceps-reflecting approach and an anatomically precontoured posterolateral distal humerus plate. Patient and fracture characteristics were recorded, as were QuickDASH functional scores and visual analog scale scores for pain, function, and quality of life. Results: Forty patients were eligible for our study. Average follow-up was 88 weeks. Thirty-eight (95%) patients went on to union. Seven (20%) patients required a secondary procedure. The average QuickDASH score was 17.5 (range, 2.6-56.8). The average visual analog scale scores were 1.9 (range, 0-7) for pain, 2.3 (range, 0-8) for function, and 1.6 (range, 0-5) for quality of life. Thirty-five (87.5%) patients reported satisfaction with the outcome of their surgery. Discussion: Surgical fixation of extra-articular distal humerus fractures through a triceps-reflecting approach with an anatomically precontoured posterolateral distal humerus plate results in predictable osseous union and overall excellent functional results for patients with this injury. Level of evidence: Level IV, Case Series, Treatment Study. 2014 Journal of Shoulder and Elbow Surgery Board of Trustees.

Restoration of posterior condylar offset (PCO) during total knee arthroplasty is essential to maximize range of motion, prevent impingement, and minimize flexion instability. Previously, PCO was determined with lateral radiographs, which could not distinguish the asymmetries between the femoral condyles. MRI can independently measure both medial and lateral PCO.The purpose of this study is to determine the normal PCO of the knee, to establish the differences in medial and lateral PCO, and to compare PCO measurements obtained from radiographs versus those obtained from MRI.We identified 32 patients without a history of prior knee pathology who had both plain radiographs and MRI scans of the same knee performed. The PCO was measured on lateral radiographs and compared with MRI measurements using a novel three-dimensional protocol.By MRI, the mean medial PCO was 29 (± 3) mm and the mean lateral PCO was 26 (± 3) mm; both values were greater (p0.001 and p = 0.03, respectively) than the mean radiographic PCO of 25 (± 2) mm. The medial PCO, as measured by MRI, was significantly greater than the lateral PCO (p0.001).Plain radiographs underestimate PCO as well as the asymmetry of the medial and lateral PCO compared with MRI. This discrepancy is the result of both articular cartilage thickness and the anatomic differences between medial and lateral condyles. Designers of knee prostheses and instrumentation should take these differences into account.

Background: The so-called gold standard for treatment of periprosthetic joint infection following total knee arthroplasty is two-stage reimplantation. However, it is unclear whether use of static or articulating antibiotic-impregnated spacers during the interim period between these two stages is superior. The purpose of this study was to compare the outcomes of static and articulating spacers in the treatment of infection following total knee arthroplasty. Methods: A systematic review of the peer-reviewed literature indexed by MEDLINE and Embase was performed to identify studies reporting the outcomes of antibiotic spacers in the treatment of infection following total knee arthroplasty. Seven Level-III comparative studies and thirty-two Level-IV case series remained following the screening process. The data in these studies were extracted and aggregated to compare the reinfection rate, range of knee motion, functional scores, and complication rates between static and articulating spacers. Results: The two types of spacers demonstrated similar reinfection rates (7% for articulating and 12% for static, p = 0.2). However, the articulating spacers resulted in significantly greater range of knee motion after reimplantation (101° for articulating and 91° for static, p = 0.0002). Despite this difference in ultimate knee motion, functional scores in the treatment groups were similar. Rates of wound-related and spacer-related complications were similarly low with both types of spacers. Conclusions: Our review failed to identify a significant difference in the ability of static or articulating spacers to eradicate periprosthetic infection following total knee arthroplasty. Compared with static spacers, articulating spacers provided improved knee motion following reimplantation, although functional scores were similar in the two treatment groups. We encourage arthroplasty surgeons to consider both static and articulating spacers in the treatment of infection following total knee arthroplasty and to tailor treatment on the basis of patient-related factors. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Rupture of the short head component of a bifurcated distal biceps tendon is a rare injury that may be difficult to diagnose and to treat. Methods Three cases of patients with selective disruption of the short head of the biceps distal tendon from a single institution are reported. The presenting history, physical examination, imaging studies, operative findings, and treatment strategies are described. Results In each case, the mechanism of injury was forceful flexion of the involved elbow against an eccentric load. Notable physical examination findings included a palpable tendon in the antecubital fossa, a “reverse Popeye” deformity, and pain and weakness with resisted forearm supination and elbow flexion. Careful review of the magnetic resonance imaging studies demonstrated the classic findings for this unique injury. All 3 patients successfully returned to their baseline level of activity after anatomic repair of the short head component with or without independent repair of the long head component (depending on the degree of partial tearing seen intraoperatively). Discussion/Conclusions Rupture of the short head component of a bifurcated distal biceps tendon is a rare injury that can be easily misdiagnosed and mistreated. A meticulous physical examination and evaluation of imaging is required to differentiate this injury from a partial or complete tear of a common distal biceps tendon. Clinicians should maintain a high index of suspicion for this unusual injury pattern. When it is diagnosed appropriately, selective disruption of the short head of the biceps distal tendon may be effectively treated with anatomic repair.

Objectives: Distal femoral varus osteotomy is an effective treatment for unloading valgus knee malalignment; however, there is limited evidence on the ability for patients to return to athletics following this procedure. The purpose of this study is to report the functional outcomes and return to sport for athletic patients that underwent distal femoral varus osteotomy. Methods: A consecutive series of athletic patients that had undergone distal femoral varus osteotomy for symptomatic lateral compartment overload and valgus knee malalignment were prospectively reviewed. All patients had a minimum of 2-year follow-up. Radiographs were assessed to determine pre-operative and post-operative alignment. Details regarding sport of interest, ability to return to sport, and timing of return were obtained from the patients. Prospective institutional registries were utilized to collect pre-operative and post-operative Marx Activity Scale and International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) scores; these values were compared using paired t-tests with p < 0.05 as the threshold for significance. Results: A total of 13 patients with a mean age of 24 years (range: 17-35) and a mean follow-up of 43 months (range: 24-74) were included in the study. Six patients underwent medial closing wedge osteotomy, and seven patients underwent lateral opening wedge osteotomy. The mean alignment correction was 8 degrees (range: 5-13). Nine patients underwent one or more concomitant procedures at the time of the osteotomy: 6 lateral femoral condyle osteochondral allografts, 2 partial lateral meniscectomies, 1 lateral meniscus allograft transplantation, and 1 revision anterior cruciate ligament reconstruction. All patients were able to successfully return to their sport of choice (4 soccer, 2 softball, 2 running, 1 football, 1 basketball, 1 ice hockey, 1 volleyball, 1 rowing) at a mean of 11 months (range: 9-13). Furthermore, all 13 patients demonstrated an improvement in both Marx Activity Scale and IKDC scores after surgery. The mean improvement in Marx Activity Scale was 7 (mean pre-op: 4, mean post-op: 11, p < 0.01), and the mean improvement in IKDC score was 36 (mean pre-op: 53, mean post-op: 89, p < 0.01). Conclusion: Valgus knee malalignment results in overload of the lateral compartment and can severely limit one’s ability to participate in athletic activities. Correction of valgus knee malalignment through distal femoral varus osteotomy - either medial closing wedge or lateral opening wedge - can reliably result in improvement in function and return to sport, provided that concomitant chondral, meniscal, and ligamentous pathology is addressed. Therefore, distal femoral varus osteotomy should be considered in the athletic population for correction of symptomatic valgus knee malalignment.

Metal-on-metal (MOM) hip articulations represent a potential alternative to conventional metal-on-polyethylene total hip arthroplasty (THA). We performed a systematic review of the peer-reviewed literature in search of studies comparing MOM with conventional primary THA with regard to functional outcomes, radiographic outcomes, and complication rates. Four Level I randomized controlled trials remained following our screening process. The data published in these studies were extracted and aggregated using a Mantel-Haenszel cumulative fixed effects meta-analysis. We found no significant difference between MOM and conventional THA with regard to functional outcomes as measured by Harris hip scores and radiographic outcomes as measured by radiolucent lines. Patients with MOM THA did however demonstrate a 3.37 times greater complication rate (1.57, 7.26). In light of the lack of superiority, the increased complication rate, the greater cost, and the potential for adverse medical consequences associated with MOM THA, these bearing surfaces should be used with caution.

Reconstruction of the ulnar collateral ligament (UCL) is one of the most commonly performed surgical procedures in overhead throwing athletes. Since its initial description, the procedure has undergone a number of technical modifications and advancements. This has resulted in multiple described techniques for UCL reconstruction. One of the most commonly performed UCL reconstruction methods is the docking technique. It has the advantages of minimizing injury to the flexor-pronator mass, avoiding the ulnar nerve, allowing robust graft tensioning, and reducing the amount of bone removed from the medial epicondyle compared with previously described techniques. This article provides a detailed description and video demonstration of how to perform this technique. When precise surgical steps are followed and postoperative rehabilitation appropriately progresses, this procedure has a well-documented history of reliably returning athletes to competitive throwing.

Pathology in the long head of the biceps tendon often occurs in patients with rotator cuff tears. Arthroscopic tenotomy is the most common treatment. However, the role of the long head of the biceps at the shoulder and the consequences of surgical detachment on the remaining shoulder structures remain unknown.We hypothesized that detachment of the long head of the biceps, in the presence of supraspinatus and infraspinatus tears, would decrease shoulder function and decrease mechanical and histologic properties of both the subscapularis tendon and the glenoid articular cartilage.We detached the supraspinatus and infraspinatus or the supraspinatus, infraspinatus, and long head of the biceps after 4 weeks of overuse in a rat model. Animals were gradually returned to overuse activity after detachment. At 8 weeks, the subscapularis and glenoid cartilage biomechanical and histologic properties were evaluated and compared.The supraspinatus, infraspinatus, and long head of the biceps group had a decreased change in braking and vertical force. [corrected]. This group also had an increased upper and lower subscapularis modulus but without any differences in glenoid cartilage modulus. Finally, this group had a significantly lower cell density in both the upper and lower subscapularis tendons, although cartilage histology was not different.Detachment of the long head of the biceps tendon in the presence of a posterior-superior cuff tear resulted in improved shoulder function and less joint damage in this animal model.This study provides evidence in an animal model that supports the use of tenotomy for the management of long head of the biceps pathology in the presence of a two-tendon cuff tear. However, long-term clinical trials are required.

Restoration of normal anatomy and proper ligament balance are theoretical prerequisites for reproducing physiological kinematics with bicruciate-retaining total knee arthroplasty (TKA). The purpose of this study was to use a 3D MRI technique to evaluate the topography of the proximal tibia and outline considerations in tibial component design for bicruciate-retaining TKA.We identified 100 consecutive patients (50 males and 50 females) between ages 20 and 40 years with knee MRIs without arthritis, dysplasia, ACL tears, or prior knee surgery. A novel 3D MRI protocol coordinating axial, coronal, and sagittal images was used to measure: 1) medial and lateral posterior tibial slopes; 2) medial and lateral coronal slopes; and 3) distance from the anterior tibia to the ACL footprint.There was no overall difference in medial and lateral posterior tibial slopes (5.5° (95% CI 5.0 to 6.0°) vs. 5.4° (95% CI 4.8 to 6.0°), respectively (p=0.80)), but 41 patients had side-to-side differences greater than 3°. The medial coronal slope was greater than the lateral coronal slope (4.6° (95% CI 4.0 to 5.1°) vs. 3.3° (95% CI 2.9 to 3.7°), respectively (p0.0001)). Females had less clearance between the anterior tibia and ACL footprint than males (10.8mm (95% CI 10.4 to 11.2mm) vs. 13.0mm (95% CI 12.5 to 13.5mm), respectively (p0.0001)).Due to highly variable proximal tibial topography, a monoblock bicruciate-retaining tibial baseplate may not reproduce normal anatomy in all patients.Level IV - Anatomic research study.

Objectives: The purpose of this study was to investigate the role of pre-operative outcome scores for predicting minimal clinically important difference (MCID) and return to play (RTP) after anterior cruciate ligament reconstruction (ACLR). Methods: Patients enrolled as part of a prospective institutional ACL registry were eligible for this study. 294 active athletes with a minimum two-year follow-up were eligible for inclusion. A telephone-based questionnaire was administered to elicit factors associated with RTP. Patient reported outcome measures were captured as part of the registry at pre-operative, one-year and two-year follow-up. Outcome measures captured included: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Lysholm scale, and SF-12 Physical and Mental component scales (PCS and MCS). Pre-operative outcome score thresholds predictive of RTP were determined using receiver operating characteristic (ROC) with area under the curve (AUC) analysis. MCID was calculated using a distribution-based method. Multivariable logistic models were fitted for achieving MCID and RTP while adjusting for age, sex and body mass index (BMI). Results: 231 patients at a mean follow-up of 3.7 years were included from 294 eligible patients. Mean age and BMI was 26.7 (SD+12.5) years and 23.7 (SD+3.1) respectively. Of the 231 patients, 201 returned to play (87.0%) at a mean time of 10.1 months. Mean pre-operative outcome scores on the IKDC, Lysholm, SF-12 PCS and SF-12 MCS were 50.1, 61.2, 41.5, and 53.6 respectively. Mean scores at two-year follow-up were 87.4, 89.5, 54.7 and 55.7 respectively. Corresponding MCID values were 9.0, 10.0, 5.1 and 4.3 on the IKDC, Lysholm, SF-12 PCS, and SF-12 MCS respectively. Pre-operative scores (AUC) most predictive of RTP were 60.9 (0.54), 57.0 (0.52), 42.3 (0.61) and 48.3 (0.63) however none of these score thresholds independently achieved significance. Pre-operative scores on each outcome tool were predictive of achieving MCID on that same tool across all outcome tools (pConclusion: The rate of RTP after ACLR is high. Pre-operative outcome score on each tool is predictive of achieving a meaningful post-operative outcome score on that tool. Additionally, the SF-12 MCS is robustly predictive of achieving MCID across other outcome tools. Both pre-operative SF-12 MCS and PCS scores are independently predictive of RTP. We propose that the SF-12 is a highly useful post-ACL injury screening tool. These findings have implications for screening patients pre-operatively and counseling athletes on expected probabilities for RTP.

Background Recent studies have identified Propionibacterium acnes as the causal organism in an increasing number of postoperative shoulder infections. Most reports have found a high rate of P acnes infection after open surgery, particularly shoulder arthroplasty. However, there are limited data regarding P acnes infections after shoulder arthroscopy. Materials and methods We prospectively collected data on all shoulder arthroscopies performed by the senior author from January 1, 2009, until April 1, 2013. Cultures were taken in all revision shoulder arthroscopy cases performed for pain, stiffness, or weakness. In addition, 2 cultures were taken from each of a cohort of 32 primary shoulder arthroscopy cases without concern for infection to determine the false-positive rate. Results A total of 1,591 shoulder arthroscopies were performed during this period, 68 (4.3%) of which were revision procedures performed for pain, stiffness, or weakness. A total of 20 revision arthroscopies (29.4%) had positive culture findings, and 16 (23.5%) were positive for P acnes . In the control group, 1 patient (3.2%) had P acnes growth. Conclusions The rate of P acnes infection in patients undergoing revision shoulder arthroscopy is higher than previously published and should be considered in cases characterized by refractory postoperative pain and stiffness.

The number of times an article has been cited in the peer-reviewed literature is indicative of its impact on its respective medical specialty. No study has used citation analysis to determine the most influential studies pertaining to the anterior cruciate ligament (ACL). The primary aims of this study were to identify the classic works in ACL research using citation analysis and to characterize these articles to determine which types of studies have had the most influence on the field. A systematic query of ISI Web of Science (Thomson Reuters, Philadelphia, Pennsylvania) was performed for articles pertaining to the ACL, and the 50 most-cited articles were selected for evaluation. The following characteristics were determined for each article: number of citations, citation density, journal, publication year, country of origin, language, article type, article subtype, and level of evidence. The number of citations ranged from 219 to 1073 (mean, 326), and the citation densities ranged from 4.9 to 55.6 citations per year (mean, 18.2). All articles were published in 1 of 11 journals, with the most being published in The American Journal of Sports Medicine (46%) and The Journal of Bone and Joint Surgery American (30%). The most common decades of publication were the 1990s (34%), 1980s (28%), and 2000s (26%). The majority (68%) of articles originated from the United States, and all were written in English. By article type, 42% were basic science, and 58% were clinical. Of the clinical articles, 3% were Level I, 17% were Level II, 28% were Level III, and 52% were Level IV. The articles were heterogeneous with regard to article type, article subtype, and level of evidence and tended to have the following characteristics: high-impact journal of publication, recent publication year, US origin, English language, and low level of evidence. These works represent some of the most popular scientific contributions to ACL research. This list may aid residency and fellowship programs in the compilation of articles for trainee reading curriculums. [ Orthopedics. 2015; 38(4):e297–e304.]

Background Pathology in the long head of the biceps tendon often occurs in patients with rotator cuff tears. Arthroscopic tenotomy is the most common treatment. However, the role of the long head of the biceps at the shoulder and the consequences of surgical detachment on the remaining shoulder structures remain unknown.

Achilles tendon injuries affect both athletes and the general population, and their incidence is rising. In particular, the Achilles tendon is subject to dynamic loading at or near failure loads during activity, and fatigue induced damage is likely a contributing factor to ultimate tendon failure. Unfortunately, little is known about how injured Achilles tendons respond mechanically and structurally to fatigue loading during healing. Knowledge of these properties remains critical to best evaluate tendon damage induction and the ability of the tendon to maintain mechanical properties with repeated loading. Thus, this study investigated the mechanical and structural changes in healing mouse Achilles tendons during fatigue loading. Twenty four mice received bilateral full thickness, partial width excisional injuries to their Achilles tendons (IACUC approved) and twelve tendons from six uninjured mice were used as controls. Tendons were fatigue loaded to assess mechanical and structural properties simultaneously after 0, 1, 3, and 6 weeks of healing using an integrated polarized light system. Results showed that the number of cycles to failure decreased dramatically (37-fold, p

Meniscal pathology is one of the most common orthopedic diagnoses. Physical examination and basic radiographic evaluation play an important role in the evaluation of knee pain. The diagnosis of and characterization of meniscal tears and associated findings is conducted via the utilization of magnetic resonance imaging. This imaging technique enables a surgeon to associate a prognosis with the pathology and determine a treatment plan. In special circumstances, MR or CT arthrography can also serve as valuable diagnostic tools.

Large rotator cuff tears (supraspinatus and infraspinatus) are common in patients who perform overhead activities (laborers, athletes). In addition, following large cuff tears, these patients commonly attempt to return to pre-injury activity levels. However, there is a limited understanding of the damaging effects on the uninjured joint tissues when doing so. Therefore, the objective of this study was to investigate the effect of returning to overuse activity following a supraspinatus and infraspinatus tear on shoulder function and the structural and biological properties of the intact tendons and glenoid cartilage. Forty rats underwent 4 weeks of overuse followed by detachment of the supraspinatus and infraspinatus tendons and were then randomized into two groups: return to overuse or cage activity. Ambulatory measurements were performed over time and structural and biological properties of the adjacent tendons and cartilage were evaluated. Results demonstrated that animals returning to overuse activity did not have altered shoulder function but despite this, did have altered cartilage and tendon properties. These mechanical changes corresponded to altered transcriptional regulation of chondrogenic genes within cartilage and tendon. This study helps define the mechanical and biological mechanisms leading to joint damage and provides a framework for treating active cuff tear patients.

Background: Presentations at the Annual Meetings of the American Academy of Orthopaedic Surgeons (AAOS) are often used to guide clinical practice, although many corresponding manuscripts are not published. The purpose of this study was to determine the relationship between level of evidence, rate of publication, and time to publication of presentations from an AAOS Annual Meeting. Methods: A comprehensive literature search for all 756 studies (288 papers and 468 posters) presented at the 2001 AAOS Annual Meeting was performed to determine which of these studies were ultimately published in the peer-reviewed literature. The corresponding AAOS abstracts were each assigned a level of evidence (LOE) with use of a consensus approach and The Journal of Bone and Joint Surgery (JBJS)/AAOS LOE classification system. The rate of publication and mean time to publication for each LOE was then calculated and compared. Results: The overall publication rate for the 2001 AAOS paper and poster presentations was 49% after five years, and 58% after ten years. At five and ten-year intervals, respectively, 77% and 85% of Level I presentations were published; 69% and 74% of Level II presentations were published; 58% and 66% of Level III presentations were published; and 39% and 51% of Level IV presentations were published. Overall, there was a significant nonrandom difference in publication rates at both five and ten years by LOE (p values of ≤0.001). Level I and II presentations were 2.9 times more likely than Level III and IV presentations to be published after five years (95% confidence interval 1.9 to 4.5), and 2.5 times more likely to be published after ten years (95% confidence interval 1.6 to 4.0). A similar association between LOE and five and ten-year publication rates was observed for both the paper and poster subgroups. The mean time to publication was 0.9 years for Level I studies, 1.4 years for Level II studies, 2.1 years for Level III studies, and 2.7 years for Level IV studies. Conclusions: The LOE of AAOS presentations is positively related to rate of publication and inversely related to time to publication. Presentations with higher levels of evidence are published in the peer-reviewed literature at a greater and faster rate than those with lower levels of evidence.

Background: Massive and irreparable posterior-superior rotator cuff tears present a difficult treatment problem. The purpose of this systematic review was to critically examine the outcomes of latissimus dorsi tendon transfers for the treatment of irreparable rotator cuff tears. Methods: A systematic review of the literature was performed via a search of electronic databases. Two reviewers independently assessed the methodological quality of, and extracted relevant data from, each included study. In cases in which the outcomes data were similar between studies, data were pooled for the purposes of generating summary outcomes through the use of frequency-weighted values. Results: Ten studies that fulfilled all inclusion and exclusion criteria were included. The frequency-weighted mean age was 58.7 years. Patients were followed for a frequency-weighted mean of 45.5 months (range, twenty-four to 126 months). Patients had a frequency-weighted mean adjusted Constant score of 45.9 preoperatively compared with 73.2 postoperatively (p < 0.001). The frequency-weighted mean active forward elevation improved from 101.9° preoperatively to 137.4° postoperatively (p < 0.001), and the frequency-weighted mean active external rotation improved from 16.8° to 26.7° (p < 0.001). Subscapularis muscle insufficiency, advanced teres minor muscle atrophy, and the need for revision surgery were correlated with poor functional outcomes in some studies. Conclusions: Compiled data and frequency-weighted means demonstrated improvement in shoulder function, range of motion, strength, and pain relief after latissimus dorsi tendon transfer for irreparable rotator cuff tears. Patients and physicians should not expect an outcome of “normal” function or complete pain relief. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fractures of the proximal humerus are relatively common injuries in the elderly population. Given the association between proximal humeral fractures and osteoporosis, elderly patients who sustain these injuries should always undergo a fragility fracture workup. Furthermore, a preoperative assessment of local bone quality can be critical in facilitating decision making regarding surgical and nonsurgical treatment. Modalities for quantifying osteoporosis in the proximal humerus include plain radiography and spiral computed tomography imaging. Optimal management of osteoporotic proximal humeral fractures has evolved and may now includes use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft. This article reviews the demographics of patients who sustain proximal humerus fractures, the appropriate postinjury fragility fracture workup, modalities for quantifying osteoporosis in the proximal humerus, techniques for augmenting fixation of proximal humerus fractures, and the authors' preferred approach to the treatment of these injuries.

The scapula plays a critical role in the association between the upper extremity and the axial skeleton. Fractures of the scapula account for 0.4% to 1% of all fractures and have an annual incidence of approximately 10 per 100,000 inhabitants. Scapular fractures typically result from a high-energy blunt-force mechanism and are often associated with other traumatic injuries. The present review focuses on the presentation, diagnosis, and treatment of fractures of the scapula. Indications for surgical treatment of glenoid fossa, scapular neck, and scapular body fractures are presented in detail. Finally, the authors’ preferred surgical technique, including positioning, approach, reduction, fixation, and post-operative management, is described.

No study has examined infection rates in “clean” cases following “dirty” cases. This study evaluated patients undergoing elective primary total joint arthroplasties performed in operating rooms following cases of known infection for development of postoperative infection. A retrospective review of all elective primary total joint arthroplasties performed over a 5-year period at our institution was conducted. Patients who underwent primary total joint arthroplasties that followed cases of known infection in the same operating room were examined (minimum follow-up of 1 year) to determine the occurrence of infection based on culture data and subsequent procedures. Thirty-nine total joint arthroplasties (27 total knee arthroplasties and 12 total hip arthroplasties) in 35 patients were performed following cases of known infection in the same operating room. Of these patients, 1 (2.6%) developed a periprosthetic joint infection. The infecting organism ( Propionibacterium acnes ) was the same as that isolated from the preceding “dirty” case. Further investigation is necessary to determine whether performing primary total joint arthroplasties immediately following “dirty” cases increases risk of infection.

Capacious diaphyses and poor bone stock in revision arthroplasty can lead to fracture and poor component fixation. Impaction bone grafting can be performed in salvage reconstructions in cases with extensive circumferential bone loss. We present a consecutive series of patients who underwent proximal or distal femoral reconstructions in combination with impaction bone grafting. The average age was 62 years, and the mean follow-up was 36 months (range, 24-84). No revisions were performed for mechanical failure, and radiographs revealed no evidence of implant loosening. No patient complained of end-of-stem thigh pain. There were 3 failures: 1 for periprosthetic fracture, 1 for instability, and 1 for infection. Impaction bone grafting can be used in combination with proximal and distal femoral arthroplasty to successfully manage cases with extensive bone loss after failed hip and knee arthroplasty. The procedure reconstitutes necessary bone stock, improves stress shielding, and provides immediate fixation in capacious canals.

Clavicular nonunion occurs after nonoperative treatment of clavicular fractures, usually after marked displacement and comminution1,2. Nonunions can cause a variety of symptoms, including pain, mechanical irritation, restriction of shoulder movement, weakness, cosmetic deformity, subclavian vein compression, thoracic outlet syndrome, and permanent neurologic deficits. Surgical intervention with open reduction and internal fixation (ORIF) is indicated in the setting of symptomatic nonunion. We report a case of compressive brachial plexopathy after ORIF of a clavicular fracture nonunion. The patient was informed that data concerning the case would be submitted for publication, and she provided consent. A thirty-nine-year-old, right-hand-dominant woman presented seven months after sustaining a displaced right clavicular fracture, which resulted from a fall from a bicycle. She had seen an orthopaedic surgeon one week after the injury; the right arm had been placed in a sling. Because she subsequently became uninsured several weeks after the injury, she had not sought additional care. She presented to us with limited shoulder function and persistent pain at rest and with attempted motion. The medical history was unremarkable, but she smoked half a pack of cigarettes per day. On physical examination, there was gross deformity and tenderness to palpation at the midshaft of the clavicle. Shoulder motion was limited by pain. Neurovascular status was intact. Radiographs of the clavicle demonstrated a widely displaced midshaft clavicular fracture nonunion (Fig. 1). We recommended surgical treatment with ORIF and iliac crest bone graft. Fig. 1 Anteroposterior radiograph of the right clavicle demonstrates an atrophic nonunion of a midshaft clavicular fracture. The patient was placed in the supine position with a 1-L bag of saline solution under the ipsilateral scapula and the head in a neutral position to avoid excessive traction on the brachial plexus. An incision following Langer’s lines was centered over the nonunion site. Dissection …

Background: The American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting is a major international forum for scientific exchange and education. The purpose of this study was to evaluate the level of evidence of papers and posters presented at the 2001, 2004, 2007, and 2010 AAOS meetings to determine trends in the quality of study designs between the years 2001 and 2010. Methods: Abstracts for AAOS presentations from 2001 (288 papers and 468 posters), 2004 (290 papers and 466 posters), 2007 (525 papers and 541 posters), and 2010 (720 papers and 569 posters) were independently evaluated by three reviewers. The level of evidence of each presentation was determined based on the AAOS classification system. The results were subdivided according to orthopaedic subspecialty and type of presentation. Results: In subsequent years, there was a substantial increase in the percentage of Level I studies (2% in 2001, 3% in 2004, 5% in 2007, and 7% in 2010), Level II studies (15% in 2001, 18% in 2004, 23% in 2007, and 29% in 2010), and Level III studies (22% in 2001, 26% in 2004, 29% in 2007, and 33% in 2010), with a concomitant decrease in the percentage of Level IV studies (62% in 2001, 54% in 2004, 43% in 2007, and 31% in 2010). Overall, there was a significant nonrandom improvement in the level of evidence of presentations over the study period (p < 0.001). This trend was consistent across all orthopaedic subspecialties and in both the paper and the poster subgroups. Conclusions: The level of evidence of studies presented at the AAOS Annual Meeting is steadily increasing, which signifies a mark of continual improvement in the quality of the scientific program.