Return to Sports After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) tears are one of the most common orthopedic injuries among athletes. Although a small proportion of patients with isolated tears can return to sports after completing a nonsurgical rehabilitation program, ACL reconstruction is frequently recommended for young athletes, especially those with concomitant knee injuries or symptomatic knee instability. Alongside emerging evidence for the effect of prehabilitation, the current standard of care for postoperative ACL physical therapy includes pain control, range of motion, quadriceps strengthening, weight bearing, postoperative bracing, and dynamic limb stabilization and control. The early rehabilitation period includes non-weight-bearing exercises and passive range of motion, which is followed by a longer period of gradual strengthening focused on regaining preinjury strength, proprioception, and control with progressively more demanding dynamic movements. The total rehabilitation period is expected to take around 9 months, during which the patient should be evaluated at frequent intervals by a licensed physical therapist in addition to a daily home exercise program. Prior to discharge from the rehabilitation program, patients should be evaluated by both the surgeon and physical therapist. Patients are encouraged to return to sports once they meet a set of perceptual, subjective, objective, neuromuscular, functional, sport-specific drills, and load management testing criteria.

In Patients with Early-Onset Scoliosis, Can Growing Rods Be Removed Without Further Instrumentation? An Evidenced-Based Review

Early-onset scoliosis (EOS) is defined by the presence of spinal deformity in children 10 years of age or younger. Left untreated, patients with EOS are at high risk for thoracic insufficiency and early demise. This article provides a critical review of a recent prospective cohort study of children with EOS: "Graduation Protocol After Growing-Rod Treatment: Removal of Implants without New Instrumentation Is Not a Realistic Approach," by Kocyigit and colleagues (J Bone Joint Surg Am. 2017;99(18):1554-1564). Treatment for EOS requires deformity correction while accommodating the growing spine. Dual growing rod implantation is a well-described technique that consists of the placement of two telescoping rods anchored to vertebrae proximal and distal to the apex of the curve. Multiple lengthening procedures are then performed as the child grows. Management of the endpoint of growing rod treatment remains controversial, with high complication rates associated with final fusion. As an alternative to final fusion or implant retention, Kocyigit and colleagues examined the removal of growing rods without spinal fusion and found that this procedure resulted in substantial worsening of the deformity in nine out of ten patients. This treatment group was terminated on ethical grounds. We believe this important result demonstrates that the removal of implants without fusion is an unacceptable treatment strategy that leads to poor outcomes.

Ankle Arthroscopy for Diagnosis of Full-thickness Talar Cartilage Lesions in the Setting of Acute Ankle Fractures

PURPOSE

To delineate the prevalence of chondral lesions, in particular full-thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture open reduction-internal fixation (ORIF) and evaluate the impact on clinical outcomes.

METHODS

We conducted a retrospective chart review of prospectively collected registry data at our institution from 2012 to 2016. Consecutive patients who underwent acute ankle fracture ORIF with concurrent arthroscopy were identified. Charts were reviewed to determine the prevalence and grade of chondral lesions, fracture type, and associated factors. Clinical outcomes with a minimum of 1 year of follow-up were assessed using the Foot and Ankle Outcome Score.

RESULTS

The study included 116 consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy. A chondral lesion was identified in 78% (90 of 116). A full-thickness talar dome chondral lesion was identified in 43% of these patients (39 of 90). Patient age was a significant predictor, with patients younger than 30 years being less likely to have a chondral injury than those aged 30 years or older (59% vs 85%, P = .0077). Of the patients who sustained a dislocation at the time of injury, 100% had a chondral lesion (P = .039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, P = .013). Patients with chondral lesions had statistically significantly worse clinical outcomes than those without them (Foot and Ankle Outcome Score, 81.2 vs 92.1; P = .009).

CONCLUSIONS

Ankle arthroscopy performed concomitantly with ankle ORIF is a useful tool in diagnosing chondral injuries. Chondral lesions are common with ankle fractures. An ankle with a dislocation at presentation or a syndesmotic injury may be more likely to present with a chondral lesion and should thus prompt evaluation. The presence of a talar chondral injury may be associated with a negative impact on clinical outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Ankle Arthroscopy for Diagnosis and Treatment of Full Thickness Cartilage Lesions in the Setting of Ankle Fracture

Category:

Ankle, Arthroscopy, Sports

Introduction/Purpose:

Ankle fractures treated with anatomic open reduction and internal fixation (ORIF) can still be associated with poor clinical outcomes. The presence of radiographically occult intra-articular chondral injury is a known entity, however the clinical relevance in the setting of ankle fractures is not well established. The purpose of this study aims to evaluate the prevalence of chondral lesions, in particular full thickness talar dome lesions, with concurrent arthroscopy in acute ankle fracture ORIF and determine if there is a correlation with patient and fracture characteristics. In addition, we aimed to evaluate the treatment effect on clinical outcomes to establish the role of concurrent arthroscopy in ankle fracture management.

Methods:

A retrospective chart review was conducted from prospectively collected registry data at the investigators’ institution from 2011 to 2016. All patients that underwent an acute ankle fracture ORIF with concurrent arthroscopy were identified. Patients with concomitant injuries were excluded. Baseline patient and fracture characteristics were recorded. Fracture type by the Lauge-Hansen classification as well as by anatomic location were determined. Charts were reviewed to determine the prevalence and grade of chondral lesions. The treatment performed for each chondral lesion was determined. Clinical outcomes with a minimum of one year follow up were assessed using the Foot and Ankle Outcome Score (FAOS).

Results:

One hundred and sixteen consecutive patients undergoing acute ankle fracture ORIF with concurrent arthroscopy were included. A chondral lesion was identified in 78% (90/116). Of those, a Grade IV full thickness talar dome chondral lesion was identified in 43% (39/90). Patient age was a significant predictor, with patients less than thirty being less likely to have a chondral injury compared to those greater than thirty (59% vs 85%, p=0.0077). Of the patients that sustained a dislocation at the time of injury, 100% had a chondral lesion which was statistically significant (p=0.039). Patients with complete syndesmosis disruption and instability were also more likely to have a chondral lesion (96% vs 73%, p=0.013). Patients with chondral lesions had statistically significant worse clinical outcomes than those without (Table).

Conclusion:

Arthroscopy performed concomitantly with ankle ORIF is useful in diagnosing chondral injuries. In particular, full thickness talar dome chondral lesions are quite common. Increased fracture severity, as indicated by the presence of a dislocation at presentation, and a syndesmotic injury may be more likely to present with a chondral lesion and thus should raise suspicion and prompt evaluation. The presence of a concurrent talar chondral injury has a negative impact on clinical outcomes. Concurrent arthroscopy allows for simultaneous diagnosis and acute treatment of full thickness talar lesions.

Current trends in rotator cuff repair: surgical technique, setting, and cost

PURPOSE

The purpose of this study was to evaluate national trends in the surgical setting and hospital costs of shoulder arthroscopy and rotator cuff repair (RCR) using the Florida State surgical database and national inpatient database.

METHODS

In part I we analyzed population-adjusted shifts in RCR technique (arthroscopic v open) in the Florida surgical database from 2000-2007 and quantified the procedural codes associated with arthroscopic and open RCR. In part II we analyzed the Nationwide Inpatient Sample database from 2001-2009 for the total number of inpatient RCRs, the inpatient hospital type (rural, urban non-teaching, or urban teaching), and the cost.

RESULTS

Part I showed a 163% increase in outpatient procedures in Florida, with a 353% increase in arthroscopic RCRs. There was a concurrent decrease in open RCRs; however, the overall trend was a 2-fold increase in total RCRs. Associated procedures such as subacromial decompression, distal clavicle resection, and extensive glenohumeral debridement increased by 440%, 589%, and 1,253%, respectively. Part II showed an overall 58.8% decrease in inpatient RCRs that was similar across all hospital settings, with an increase in RCR-associated hospital charges by 144.9%, whereas hospital costs only increased by 85.2%.

CONCLUSIONS

The study confirms a shift toward arthroscopic RCR and associated procedures in the outpatient setting. The increased financial cost partly explains the shift; nevertheless, future studies are needed to further examine national trends.

CLINICAL RELEVANCE

This study examining RCR trends by hospital type, cost, and setting further elucidates how orthopaedic surgery practice is evolving with the implementation of arthroscopic RCR in the past decade.

Abnormal tibiofemoral kinematics following ACL reconstruction are associated with early cartilage matrix degeneration measured by MRI T1rho

PURPOSE

Altered kinematics following ACL-reconstruction may be a cause of post-traumatic osteoarthritis. T(1ρ) MRI is a technique that detects early cartilage matrix degeneration. Our study aimed to evaluate kinematics following ACL-reconstruction, cartilage health (using T(1ρ) MRI), and assess whether altered kinematics following ACL-reconstruction are associated with early cartilage degeneration.

METHODS

Eleven patients (average age: 33 ± 9 years) underwent 3T MRI 18 ± 5 months following ACL-reconstruction. Images were obtained at extension and 30° flexion under simulated loading (125 N). Tibial rotation (TR) and anterior tibial translation (ATT) between flexion and extension, and T(1ρ) relaxation times of the knee cartilage were analyzed. Cartilage was divided into five compartments: medial and lateral femoral condyles (MFC/LFC), medial and lateral tibias (MT/LT), and patella. A sub-analysis of the femoral weight-bearing (wb) regions was also performed. Patients were categorized as having "abnormal" or "restored" ATT and TR, and T(1ρ) percentage increase was compared between these two groups of patients.

RESULTS

As a group, there were no significant differences between ACL-reconstructed and contralateral knee kinematics, however, there were individual variations. T(1ρ) relaxation times of the MFC and MFC-wb region were elevated (p ≤ 0.05) in the ACL-reconstructed knees compared to the uninjured contralateral knees. There were increases (p ≤ 0.05) in the MFC-wb, MT, patella and overall average cartilage T(1ρ) values of the "abnormal" ATT group compared to "restored" ATT group. The percentage increase in the T(1ρ) relaxation time in the MFC-wb cartilage approached significance (p=0.08) in the "abnormal" versus "restored" TR patients.

CONCLUSIONS

Abnormal kinematics following ACL-reconstruction appear to lead to cartilage degeneration, particularly in the medial compartment.

Interchannel nonlinear transmission penalties in polarization-multiplexed 2 x 10 Gbit/s differential phase-shift keying transmission

We discuss the performance of a multichannel 2 x 10 Gbit/s polarization-multiplexed differential phase-shift keying transmission system. Through simulations and transmission experiments we find that, despite the constant power envelope of non-return-to-zero phase-shift keying modulation formats, polarization multiplexing strongly reduces the nonlinear tolerance and transmission performance at a 2 x 10 Gbit/s line rate with multichannel transmission. This results in a 10 dB power penalty when comparing single- and nine-channel transmission. Additionally, multichannel impairments in differential phase-shift keying and on-off keying are compared for 2 x 10 Gbit/s polarization-multiplexed transmission.

Pulmonary clearance of 99mTc-DTPA during halothane anaesthesia

We studied the integrity of the alveolo-capillary barrier during different forms of anaesthesia by measuring the pulmonary clearance of inhaled 99mTc-DTPA. We studied four groups of rabbits. Groups I and II were anaesthetized with nembuthal only and the fractional concentration of inspired oxygen (F1O2) was 0.30 and 1.00, respectively. Groups III and IV were anaesthetized with 1% halothane and F1O2 was 0.30 and 0.99, respectively. 99mTc-DTPA was administered as a fine aerosol and the clearance of the tracer from the lungs was subsequently measured with a gamma camera. The mean half-life of the tracer in the lungs in Groups I-IV was 60, 58, 59 and 26 min, respectively. The rapid pulmonary clearance of 99mTc-DTPA in Group IV indicates that halothane in combination with high oxygen concentration increases the permeability of the alveolo-capillary barrier. This may be due to effects on the pulmonary surfactant system and/or the alveolar epithelium.

Safety and efficacy of xenon in routine use as an inhalational anaesthetic

40 patients (24 male, 16 female, aged 21-59 years) of American Society of Anesthesiologists class I or II who were undergoing routine surgery took part in a randomised, double-blind comparison of the anaesthetic efficacy and potency of xenon and nitrous oxide and their effects on the circulatory and respiratory systems. During anaesthesia, for each rise in blood pressure of more than 20% of the preanaesthetic (baseline) value, the patient received 0.1 mg fentanyl. The total amount of fentanyl required per patient was used as an index of the anaesthetic potency of the study gases. Patients in the xenon group required on average only 0.05 mg fentanyl, whereas those in the nitrous oxide group required 0.24 mg fentanyl; the duration of anaesthesia was similar in the two groups. Changes in blood pressure were significantly greater throughout the study in the nitrous oxide than in the xenon group. Thorax-lung compliance fell during the study period in the nitrous oxide group but not in the xenon group. Thus, xenon is a potent and effective anaesthetic which can be safely used under routine conditions.

Volume-controlled ventilation with superimposed high frequency ventilation during expiration in healthy and surfactant-depleted pig lungs

In the healthy and surfactant-depleted lungs of five pigs the influence of different forms of high frequency ventilation superimposed on conventional mechanical ventilation during the expiratory phase of the ventilatory cycle (SHFVE) on gas exchange and cardiocirculatory parameters was investigated. Subsequently the effects of end-expiratory flushing (EF), i.e. cleaning the large airways and connecting tubes from the ventilator free from end-expiratory CO2, with a volume greater than the dead space of the large airways and connecting tubes was investigated. SHFVE and EF resulted in a significant improvement in CO2 elimination in both healthy and surfactant-depleted lungs. Furthermore, in stiff lungs, at a certain level of oxygenation and CO2 elimination, SHFVE produced the lowest peak and mean airway pressure without any additional depression of cardiocirculatory parameters.

Effects of high frequency jet ventilation on the pulmonary clearance of 99mTc-DTPA in respiratory failure in rabbits

The effects of high frequency jet ventilation (HFJV) at 2 and 15 Hz on the pulmonary clearance of technetium 99m diethylene triamine pentaacetate (99mTc-DTPA) were compared with conventional volume-controlled (VC) ventilation with positive end-expiratory pressure (PEEP), in a model of respiratory failure induced by two lung lavages in adult rabbits. In group 1 the lungs were ventilated with HFJV at 2 Hz, and in group 2 ventilation was with HFJV at 15 Hz; group 3 underwent conventional VC ventilation. Group 4 also had conventional ventilation, but without previous lung lavage and functioned as a control group. In all groups, mean airway pressure was maintained at a value to ensure PaO2 greater than 25 kPa. The measured half-life time (T1/2) of the 99mTc-DTPA (mean (SD] was: group 1, 28 (7.8) min; group 2, 73.5 (7.9) min; group 3, 56.5 (12.4) min and group 4, 92.6 (13.2) min. Assuming that conventional VC with PEEP ventilation causes no additional harm to surfactant depleted lungs, it is concluded that HFJV at 2 Hz leads to further damage of the lungs, whereas HFJV at 15 Hz improves reparative processes, by keeping the lungs constantly inflated.

[Results and critical analysis of the treatment of obesity with the intragastric balloon]

In 54 patients with excessive obesity a silicone balloon was implanted endoscopically into the stomach. The overweight amounted to 76% (median) by Broca's formula. The therapeutical plan included balloon-implantation, dietary treatment, psychotherapeutical guidance, kineto-therapy and balloon-extraction. According to their therapeutical compliance there were three different groups of patients: G1 - maintenance of therapy; G2 - discontinuation of therapy; G3 - no additional therapy at all after balloon implantation. Up to the sixth week a weight reduction of 9.5-20.5 kg could be demonstrated in all groups. Only in the first group a further weight reduction by a mean of 20 kg after 20 weeks was noted. Patients in group 2 and 3 - in some the balloon was still implanted - had a renewed weight increase sometimes surmounting the original weight.

COMPLICATIONS

3 gastric respectively duodenal ulcers, one subileus. The long-term success can only be obtained by a multi-component therapy plan.