Establishing the Minimal Clinically Important Difference and Patient-Acceptable Symptomatic State After Arthroscopic Meniscal Repair and Associated Variables for Achievement

PURPOSE

To establish the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) after arthroscopic meniscal repair and identify the factors associated with achieving these outcomes.

METHODS

This is a retrospective study with prospectively collected data. Patient-reported outcome measures (PROMs) were collected from April 2017 to March 2020. All patients who underwent arthroscopic meniscal repair and completed both preoperative and postoperative PROMs were included in the analysis. MCID and PASS were calculated via half the standard deviation of the delta PRO change from baseline (for International Knee Documentation Committee Score [IKDC]) and via anchor-based methodology (Knee Injury and Osteoarthritis Outcome Score [KOOS] subscales).

RESULTS

Sixty patients were included in the final analysis. The established MCID threshold values were 10.9 for IKDC, 12.3 for KOOS Symptoms, 11.8 for KOOS Pain, 11.4 for KOOS Activities of Daily Living (ADL), 16.7 for KOOS Sport, and 16.9 for KOOS Quality of Life (QoL). Postoperative scores greater than the following values corresponded to the PASS: 69.0 for IKDC, 75.0 for KOOS Symptoms, 80.6 for KOOS Pain, 92.7 for KOOS ADL, 80.0 for KOOS Sport, and 56.3 for KOOS QoL. Higher preoperative PRO scores were associated with lower likelihood of achieving MCID. Concomitant ligament procedures were associated with a higher likelihood of achieving PASS. Tears to both menisci were associated with decreased likelihood of achieving MCID and PASS for IKDC. Horizontal tears were associated with decreased likelihood of achieving PASS for IKDC and KOOS. Complex tears were associated with decreased likelihood of achieving MCID for KOOS.

CONCLUSION

Clinically meaningful outcomes such as MCID and PASS were established for meniscal repair surgery using selected PROMs for IKDC and KOOS subscales. Variables more likely to be associated with achieving these outcomes include lower preoperative PRO score and concomitant ligament procedure, whereas higher preoperative PRO score, tearing of both medial and lateral menisci, and horizontal and complex tear classifications were associated with decreased likelihood of achieving these outcomes.

LEVEL OF EVIDENCE

IV, retrospective case series.

The Minimally Clinically Important Difference and Substantial Clinical Benefit in Anterior Cruciate Ligament Reconstruction: A Time-to-Achievement Analysis

This study examined the time-dependent course of the minimally clinically important difference (MCID) and the substantial clinical benefit (SCB) achievement for International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales following anterior cruciate ligament reconstruction (ACLR). A prospective institutional registry was queried for patients receiving ACLR. The patient-reported outcome measures (PROMs) of interest included the IKDC score and KOOS sub-scales. One hundred forty-three patients (mean±SD age, 30.86±12.78 years; mean±SD body mass index, 25.51±4.64 kg/m²) were included in the analysis. Threshold values for the MCID/SCB were 18.9 of 29.6 on IKDC score, 15.7 of 25.3 on KOOS Symptom, 11.9 of 15.5 on KOOS Pain, 13.3 of 20.0 on KOOS ADL, 25.9 of 35.8 on KOOS Quality of Life (QoL), and 27.0 of 43.0 on KOOS Sport (area under the curve, 0.74-0.91). Overall, MCID achievement rates increased from 28.0% to 42.7% at 6 months to 41.9% to 70.8% at 12 months. Achievement rates of SCB increased from 16.1% to 30.4% at 6 months to 29.3% to 51.8% at 12 months. Statistically significant increases in MCID achievement (chi-square=47.95-79.36, all P<.001) and SCB achievement (chi-square=26.02-53.24, all P<.001) occurred from preoperative to 6-month time points across PROMs. From 6-month to 12-month time points, increases in MCID achievement occurred on IKDC score and KOOS QoL (chi-square=5.53-15.11, P<.001-.009). Statistically significant increases in MCID and SCB achievement occurred from preoperative to 6-month time points across IKDC score and KOOS subscales; however, statistically significant increases in achievement rates from 6 months to 1 year occurred on IKDC score, KOOS QoL, and KOOS Sport. This study underlines the importance of considering psychological factors and rehabilitative milestones when examining the achievement MCID and SCB after ACLR. [Orthopedics. 2021;44(5):299-305.].

Time Required to Achieve Clinically Significant Outcomes After Arthroscopic Rotator Cuff Repair

BACKGROUND

Recent literature has focused on correlating statistically significant changes in outcome measures with clinically significant outcomes (CSOs). CSO benchmarks are being established for arthroscopic rotator cuff repair (RCR), but more remains to be defined about them.

PURPOSE

To define the time-dependent nature of the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptomatic State (PASS) after RCR and to define what factors affect this time to CSO achievement.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

An institutional registry was queried for patients who underwent arthroscopic RCR between 2014 and 2016 and completed preoperative, 6-month, 1-year, and 2-year patient-reported outcome measures (PROMs). Threshold values for MCID, SCB, and PASS were obtained from previous literature for the American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), and subjective Constant score. The time in which patients achieved MCID, SCB, and PASS was calculated using Kaplan-Meier analysis. A Cox multivariate regression model was used to identify variables correlated with earlier or later achievement of CSOs.

RESULTS

A total of 203 patients with an average age of 56.19 ± 9.96 years and average body mass index was 30.29 ± 6.49 were included. The time of mean achievement of MCID, SCB, and PASS for ASES was 5.77 ± 1.79 months, 6.22 ± 2.85 months, and 7.23 ± 3.81 months, respectively. The time of mean achievement of MCID, SCB, and PASS for SANE was 6.25 ± 2.42 months, 7.05 ± 4.10 months, and 9.26 ± 5.89 months, respectively. The time of mean achievement of MCID, SCB, and PASS for Constant was 6.94 ± 3.85 months, 7.13 ± 4.13 months, and 8.66 ± 5.46 months, respectively. Patients with dominant-sided surgery (hazard ratio [HR], 1.363; 95% CI, 1.065-1.745; P = .014) achieved CSOs earlier on ASES, while patients with workers' compensation status (HR, 0.752; 95% CI, 0.592-0.955; P = .019), who were current smokers (HR, 0.323; 95% CI, 0.119-0.882; P = .028), and with concomitant biceps tenodesis (HR, 0.763; 95% CI, 0.607-0.959; P = .021) achieved CSOs on ASES at later timepoints. Patients with distal clavicle excision (HR, 1.484; 95% CI, 1.028-2.143; P = .035) achieved CSOs earlier on SANE. Patients with distal clavicle excision (HR, 1.689; 95% CI, 1.183-2.411, P = .004) achieved CSOs earlier on Constant, while patients with workers' compensation insurance status (HR, 0.671; 95% CI, 0.506-0.891; P = .006) and partial-thickness tears (HR, 0.410; 95% CI, 0.250-0.671; P < .001) achieved CSOs later on Constant. Greater preoperative score was associated with delayed achievement of CSOs for ASES, SANE (HR, 0.993; 95% CI, 0.987-0.999; P = .020), and Constant (HR, 0.941; 95% CI, 0.928-0.962; P < .001).

CONCLUSION

A majority of patients achieved MCID by 6 months after surgery. Dominant-sided surgery and concomitant distal clavicle excision resulted in faster CSO achievement, while workers' compensation status, concomitant biceps tenodesis, current smoking, partial-thickness rotator cuff tears, and higher preoperative PROMs resulted in delayed CSO achievement.

Effect of Fatigue Protocols on Upper Extremity Neuromuscular Function and Implications for Ulnar Collateral Ligament Injury Prevention

Background

As the incidence of overuse injuries to the medial elbow in overhead athletes continues to rise, recent evidence suggests a link between these injuries and alterations in biomechanics produced by athlete fatigue. Previous studies have evaluated the effect of fatigue on elbow injuries using a wide array of fatigue protocols/athletic tasks, and, as a consequence, the results have been heterogeneous.

Purpose

To determine whether there is a uniform alteration in neuromuscular function or biomechanics as the overhead athlete fatigues. Furthermore, this study sought to determine whether player fatigue should be accounted for in ulnar collateral ligament (UCL) injury prevention programs.

Study Design

Systematic review.

Methods

A systematic review of the literature using PubMed and MEDLINE databases was performed. Keywords included fatigue, upper extremity, baseball, pitcher, throwing, and muscle activity. Inclusion criteria consisted of original research articles in the English language involving healthy athletes, use of fatigue protocols, and the evaluation of at least 1 upper limb biomechanical variable.

Results

A total of 35 studies involving 644 athletes (90 females, 554 males; mean age, 20.2 years) met the inclusion criteria. General fatigue protocols were used in 2 investigations, peripheral protocols were used in all 35 studies, and 5 different athletic tasks were studied (simulated baseball game, overhead throwing, high-effort swimming, simulated tennis game, and overhead serving). There was a uniform decrease in muscle force production and proprioception in athletes after completing a fatigue protocol. However, there was no consistency among studies when evaluating other important upper limb biomechanical factors. The fatigue protocols did not consistently produce statistically significant changes in elbow torque, pitching biomechanics, or ball velocity.

Conclusion

A uniform decrease in muscle force production and proprioception was found after fatigue protocols; however, a majority of fatigue protocols published in the current literature are inconsistently measured and produce heterogeneous results. Therefore, currently, no recommendations can be made for changes in UCL injury prevention training programs to account for potential effects of fatigue. The effect of muscle force production and proprioception on upper extremity injuries should be evaluated in future studies.

Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons

PURPOSE

Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction.

LEVEL OF EVIDENCE

Cross sectional study, Level IV.

METHODS

Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport.

RESULTS

A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery.

CONCLUSION

Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.

Orthopedic Practice Patterns Relating to Anterior Cruciate Ligament Reconstruction in Elite Athletes

We conducted an online survey of National Hockey League (NHL), Major League Soccer (MLS), and US Olympic/World Cup Ski/Snowboard (Olympic) team orthopedic surgeons to determine practice patterns relating to anterior cruciate ligament (ACL) reconstruction in elite athletes. Of the 94 team orthopedic surgeons surveyed, 47 (50%) responded. Mean (SD) experience as a team physician was 7.73 (5.33) years for NHL, 6.77 (6.64) years for MLS, and 1.14 (0.36) years for Olympic. Mean (SD) number of ACL reconstructions performed in 2012 was 101 (51) for NHL, 78 (38) for MLS, and 110 (105) for Olympic. Overall, 33 surgeons (70.2%) indicated they would use bone-patellar tendon-bone (BPTB) autograft to treat their starting athletes. Twenty-one (44.7%) drilled the femoral tunnel through a transtibial portal, 36.2% through an anteromedial portal, and 12.8% by a 2-incision technique. All the surgeons used a single-bundle technique. Thirty-three (70.2%) did not recommend a brace for their elite athletes during play on return to sport (RTS). Twenty-seven NHL and MLS surgeons (81.8%) recommended RTS only after an athlete has passed a series of RTS tests (eg, Vail, single-leg hop). Most of the NHL, MLS, and Olympic team orthopedic surgeons who were surveyed perform their ACL reconstructions using BPTB autograft, using a single-bundle technique, and through a transtibial portal, and do not require bracing for their athletes returning to sport. Most required their athletes to complete a series of RTS tests before resuming competitive play.

Synovial chemokine expression and relationship with knee symptoms in patients with meniscal tears

OBJECTIVE

In patients with knee OA, synovitis is associated with knee pain and symptoms. We previously identified synovial mRNA expression of a set of chemokines (CCL19, IL-8, CCL5, XCL-1, CCR7) associated with synovitis in patients with meniscal tears but without radiographic OA. CCL19 and CCR7 were also associated with knee symptoms. This study sought to validate expression of these chemokines and association with knee symptoms in more typical patients presenting for meniscal arthroscopy, many who have pre-existing OA.

DESIGN

Synovial fluid (SF) and biopsies were collected from patients undergoing meniscal arthroscopy. Synovial mRNA expression was measured using quantitative RT-PCR. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was administered preoperatively. Regression analyses determined if associations between chemokine mRNA levels and KOOS scores were independent of other factors including radiographic OA. CCL19 in SF was measured by ELISA, and compared to patients with advanced knee OA and asymptomatic organ donors.

RESULTS

90% of patients had intra-operative evidence of early cartilage degeneration. CCL19, IL-8, CCL5, XCL1, CCR7 transcripts were detected in all patients. Synovial CCL19 mRNA levels independently correlated with KOOS Activities of Daily Living (ADL) scores (95% CI [-8.071, -0.331], P = 0.036), indicating higher expression was associated with more knee-related dysfunction. SF CCL19 was detected in 7 of 10 patients, compared to 4 of 10 asymptomatic donors.

CONCLUSION

In typical patients presenting for meniscal arthroscopy, synovial CCL19 mRNA expression was associated with knee-related difficulty with ADL, independent of other factors including presence of radiographic knee OA.

Does Double-Bundle Anterior Cruciate Ligament Reconstruction Improve Postoperative Knee Stability Compared With Single-Bundle Techniques? A Systematic Review of Overlapping Meta-analyses

PURPOSE

Multiple meta-analyses of randomized controlled trials, the highest available level of evidence, have been conducted to determine whether double-bundle (DB) or single-bundle (SB) anterior cruciate ligament reconstruction (ACL-R) provides superior clinical outcomes and knee stability; however, results are discordant. The purpose of this study was to conduct a systematic review of meta-analyses comparing SB and DB ACL-R to discern the cause of the discordance and to determine which of these meta-analyses provides the current best available evidence.

METHODS

We evaluated available scientific support for SB as compared with DB ACL-R by systematically reviewing the literature for published meta-analyses. Data on patient clinical outcomes and knee stability (as measured by KT arthrometry and pivot-shift testing) were extracted. Meta-analysis quality was judged using the Oxman-Guyatt and Quality of Reporting of Meta-analyses systems. The Jadad algorithm was then applied to determine which meta-analyses provided the highest level of evidence.

RESULTS

Nine meta-analyses were included, of which 3 included Level I Evidence and 6 included both Level I and Level II Evidence. Most studies found significant differences favoring DB reconstruction on pivot-shift testing, KT arthrometry measurement of anterior tibial translation, and International Knee Documentation Committee objective grading. Most studies detected no significant differences between the 2 techniques in subjective outcome scores (Tegner, Lysholm, and International Knee Documentation Committee subjective), graft failure, or complications. Oxman-Guyatt and Quality of Reporting of Meta-analyses scores varied, with 2 studies exhibiting major flaws (Oxman-Guyatt score <3). After application of the Jadad decision algorithm, 3 concordant high-quality meta-analyses were selected, with each concluding that DB ACL-R provided significantly better knee stability (by KT arthrometry and pivot-shift testing) than SB ACL-R but no advantages in clinical outcomes or risk of graft failure.

CONCLUSIONS

The current best available evidence suggests that DB ACL-R provides better postoperative knee stability than SB ACL-R, whereas clinical outcomes and risk of graft failure are similar between techniques.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Rehabilitation Following Hip Arthroscopy - A Systematic Review

Context

Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy.

Objectives

(1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, (2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols, and (3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy.

Data sources

Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.

Study selection

Level I–IV evidence clinical studies with minimum 2-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included.

Data extraction

All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the modified Coleman methodology score.

Results

Eighteen studies were included (2,092 subjects; 52% male, mean age 35.1 ± 10.6 years, mean follow-up 3.2 ± 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return to sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported.

Conclusion

The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. Strengths and limitations in the literature were identified. Future studies should recognize and report the essentials of rehabilitation following hip arthroscopy.

Allograft reconstruction for extensor mechanism injuries

Previous case reports have documented the successful use of allograft for extensor mechanism reconstruction. We hypothesized that extensor mechanism reconstruction with allograft would restore extensor power and allow patients to return to a relatively high activity level. Between 2000 and 2007, 17 patients (18 knees) underwent extensor mechanism reconstruction with either nonirradiated Achilles or whole bone-patellar tendon-bone allograft at our institution. Two patients were lost to follow-up and one underwent a total knee arthroplasty and was considered a failure. The remaining 14 patients (15 knees) returned for clinical and radiographic evaluation at a minimum 24 months postoperatively. Patients completed questionnaires using the International Knee Documentation Committee (IKDC), Tegner, Lysholm, Knee Injury Osteoarthritis Outcome Score (KOOS), Noyes sports activity, and Short Form-12 (SF-12) scoring systems. Fourteen patients with an average age at surgery of 46.48 years (range, 18-70) returned for evaluation at a median follow-up of 52 months (range, 31-98 months). Twelve of the 14 patients underwent previous surgery before allograft reconstruction. Postoperatively, the median IKDC score was 74 (range, 28-90), Tegner 8 (range, 0.5-10), Lysholm 62 (range, 28-100), KOOS pain 92 (range, 36-100), KOOS symptom 64 (range, 21-100), KOOS ADL 82 (range, 51-100), KOOS sport 50 (range, 5-95), KOOS QOL 44 (range, 12.5-100), Noyes 90 (range, 5-100), SF-12 physical 43 (range, 29-47), and SF-12 mental 49 (range, 28-64). All patients were able to perform a straight leg raise postoperatively. Five patients had an extensor lag at final evaluation averaging 8 degrees (range, 3-18). Thigh girth differential between the surgical and contralateral leg was 1.3 cm diameter. There were no postoperative infections or reruptures. Two patients required additional procedures. We believe extensor mechanism reconstruction with allograft is an effective salvage procedure in this challenging patient population.

Is Tommy John Surgery Performed More Frequently in Major League Baseball Pitchers From Warm Weather Areas?

Background:

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers with symptomatic UCL insufficiency, frequently due to overuse. Warm weather climates afford youth pitchers the opportunity to throw year-round, potentially placing them at risk for overuse elbow injuries.

Purpose/Hypothesis:

To determine whether the proportion of MLB pitchers who underwent medial UCL reconstruction and who pitched competitive youth baseball in warm weather areas is higher than those from cold weather areas. The hypothesis was that MLB pitchers from warm weather areas were more likely to undergo UCL reconstruction than pitchers from cold weather areas.

Study Design:

Descriptive epidemiological study.

Methods:

All MLB pitchers with symptomatic UCL deficiency who underwent UCL reconstruction as of June 1, 2014, were evaluated. The state/country where they played high school baseball was identified from online reference websites. Warm and cold weather areas were defined by latitude distance from the equator and mean annual temperatures. A chi-square test was used to compare the proportion of MLB pitchers from warm versus cold weather areas who underwent UCL reconstruction. The study was 99.6% powered to detect a 100% effect size (eg, 1% vs 2%) and 71.4% powered to detect a 50% effect size (eg, 1% vs 1.5%) with setting α = .05.

Results:

A total of 247 pitchers were identified who had undergone UCL reconstruction; 139 (56.3%) pitched high school baseball in warm weather areas, 108 (43.7%) pitched in cold weather areas. A significantly higher proportion of pitchers who underwent UCL reconstruction (2.2% [95% CI, 1.9%-2.6%]) were from warm weather areas compared with cold weather areas (0.94% [95% CI, 0.78%-1.1%]) (P < .0001). Warm weather pitchers had a mean (±SD) age of 27.6 ± 0.6 years and had played 4.0 ± 0.6 seasons in MLB at the time of surgery, while cold weather pitchers were aged 28.4 ± 0.8 years and had played 5.0 ± 0.9 seasons in MLB (P = .089 and P = .047, respectively).

Conclusion:

MLB pitchers who played high school baseball in warm weather climates have undergone medial UCL reconstruction more frequently and earlier in their MLB careers than pitchers who played in cold weather areas.

Rate of return to pitching and performance after Tommy John surgery in Major League Baseball pitchers

BACKGROUND

Medial ulnar collateral ligament (UCL) reconstruction is a common procedure performed on Major League Baseball (MLB) pitchers in the United States.

PURPOSE

To determine (1) the rate of return to pitching (RTP) in the MLB after UCL reconstruction, (2) the RTP rate in either the MLB and minor league combined, (3) performance after RTP, and (4) the difference in the RTP rate and performance between pitchers who underwent UCL reconstruction and matched controls without UCL injuries.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Major League Baseball pitchers with symptomatic medial UCL deficiency who underwent UCL reconstruction were evaluated. All player, elbow, and surgical demographic data were analyzed. Controls matched by age, body mass index, position, handedness, and MLB experience and performance were selected from the MLB during the same years as those undergoing UCL reconstruction. An "index year" was designated for controls, analogous to the UCL reconstruction year in cases. Return to pitching and performance measures in the MLB were compared between cases and controls. Student t tests were performed for analysis of within-group and between-group variables, respectively.

RESULTS

A total of 179 pitchers with UCL tears who underwent reconstruction met the inclusion criteria and were analyzed. Of these, 148 pitchers (83%) were able to RTP in the MLB, and 174 pitchers were able to RTP in the MLB and minor league combined (97.2%), while only 5 pitchers (2.8%) were never able to RTP in either the MLB or minor league. Pitchers returned to the MLB at a mean 20.5 ± 9.72 months after UCL reconstruction. The length of career in the MLB after UCL reconstruction was 3.9 ± 2.84 years, although 56 of these patients were still currently actively pitching in the MLB at the start of the 2013 season. The revision rate was 3.9%. In the year before UCL reconstruction, pitching performance declined significantly in the cases versus controls in the number of innings pitched, games played, and wins and the winning percentage (P < .05). After surgery, pitchers showed significantly improved performance versus before surgery (fewer losses, a lower losing percentage, lower earned run average [ERA], threw fewer walks, and allowed fewer hits, runs, and home runs) (P < .05). Comparisons between cases and controls for the time frame after UCL reconstruction (cases) or the index year (controls) demonstrated that cases had significantly (P < .05) fewer losses per season and a lower losing percentage. In addition, cases had a significantly lower ERA and allowed fewer walks and hits per inning pitched.

CONCLUSION

There is a high rate of RTP in professional baseball after UCL reconstruction. Performance declined before surgery and improved after surgery. When compared with demographic-matched controls, patients who underwent UCL reconstruction had better results in multiple performance measures. Reconstruction of the UCL allows for a predictable and successful return to the MLB.

Paget-schroetter syndrome: a review of effort thrombosis of the upper extremity from a sports medicine perspective

Paget-Schroetter is a rare diagnosis in the general population; however, it is more common in younger, physically active individuals. Clinicians must be familiar with the symptoms, physical examination, and initial imaging and treatment to expedite care and prevent possible life-threatening complications. Urgent referral to a regional specialist may improve the opportunity for thrombolysis to restore blood flow through the subclavian vein and to decrease the chance of pulmonary embolus, recurrent thrombosis, or need for vein grafting, as well as to improve the time to return to full activity (athletics and/or manual labor).

Effect of anterior acetabular rim recession on radiographic parameters: an in vivo study

PURPOSE

The purpose of this study was to validate additional radiographic parameters that detect changes within the acetabular cavity during acetabular rim trimming for pincer-type femoroacetabular impingement in an in vivo setting.

METHODS

Patients who met the inclusion criteria and underwent arthroscopic acetabular rim trimming had their preoperative and postoperative anteroposterior radiographs measured. Intraoperatively, these patients had their labrums detached, acetabular walls trimmed by roughly 3 to 5 mm, and then labrums reattached. Radiographic measurements were subsequently obtained by use of the anterior rim angle (ARA), anterior wall angle (AWA), and anterior margin ratio (AMR).

RESULTS

Statistically significant changes were seen in the postoperative ARA, AWA, and AMR. Mean pre- and post-trimming changes were 83.8° and 87.9°, respectively, for the ARA; 38.8° and 35.8°, respectively, for the AWA; and 0.57 and 0.53, respectively, for the AMR. There were no postoperative complications. No patients had any instability events.

CONCLUSIONS

This study shows that significant changes in anterior acetabular anatomy can be evaluated radiographically in the in vivo setting for treatment of pincer-type femoroacetabular impingement. We saw a significant, consistent decrease in both the AWA and AMR and increase in the ARA. This research serves to guide surgeons with preoperative and intraoperative templating while providing the groundwork to investigate these radiographic parameters in an asymptomatic patient population.

CLINICAL RELEVANCE

These novel radiographic measurements can be used by hip arthroscopists to better characterize their surgical role in altering acetabular morphology. In addition, these measurements will be able to better describe acetabular anatomy.

Open repair of retracted latissimus dorsi tendon avulsion

Latissimus dorsi avulsion injuries are rarely reported in the literature and are managed with a variety of strategies. Primary anatomical repair of tendon to bone may offer athletes the best chance for successful return to sports. In this article, we describe a surgical technique for safely repairing an acute or chronic, retracted, avulsed latissimus tendon back to its insertion on the medial aspect of the bicipital groove of the proximal humerus. Using 1 low anterior axillary incision and 1 posterior axillary incision for tendon retrieval when retraction is more than 5 cm, this technique allows for direct anatomical repair of a retracted tendon to bone using 3 points of bony fixation supplemented by soft-tissue repair. The technique also minimizes the risks for neurovascular compromise and cosmetic deformity, while decreasing the risk for postinjury strength deficits.

New radiographic parameters to describe anterior acetabular rim trimming during hip arthroscopy

PURPOSE

The purpose of this study was to describe additional radiographic parameters that may detect changes within the acetabular cavity during acetabular rim trimming for pincer-type femoroacetabular impingement.

METHODS

Cadaveric hips that met the inclusion criteria were stripped of all tissue and had a portion of their labra removed; 5 mm of anterior acetabulum was measured in the 12- to 3-o'clock position and resected with a Dremel device (Robert Bosch Tool, Mount Pleasant, IL). Anteroposterior radiographs were obtained with a C-arm image intensifier. Radiographic measurements were subsequently obtained using the anterior rim angle (ARA), anterior wall angle (AWA), and anterior margin ratio (AMR).

RESULTS

Statistically significant changes were seen in the ARA, AWA, and AMR. Mean pre- and post-trimming changes were 81.0° and 85.7°, respectively, for the ARA; 34.8° and 29.2°, respectively, for the AWA; and 0.66 and 0.57, respectively, for the AMR.

CONCLUSIONS

Although much attention has been focused on the center-edge angle, the anterior aspect of the acetabulum has not previously been characterized. In conjunction with the center-edge angle and Tönnis angle, the new parameters of ARA, AWA, and AMR can be used to provide a more comprehensive description of the acetabulum. The ARA, AWA, and AMR can be used to guide the surgeon intraoperatively and postoperatively in further clarifying acetabular morphology and in determining whether the rim resection was adequate. This study determined that there exist new radiographic parameters with significant changes in the anterior acetabulum as quantified by the ARA, AWA, and AMR that can be used to describe the radiographic changes after acetabular rim resection.

CLINICAL RELEVANCE

The new parameters of ARA, AWA, and AMR can be used to provide a more comprehensive description of the acetabulum. These radiographic measurements can also be used by hip arthroscopists to better describe their surgical contribution to anterior rim trimming.

Synovial fluid from patients with early osteoarthritis modulates fibroblast-like synoviocyte responses to toll-like receptor 4 and toll-like receptor 2 ligands via soluble CD14

OBJECTIVE

Synovial inflammation, a feature of both osteoarthritis (OA) and meniscal injury, is hypothesized to be triggered in part via stimulation of Toll-like receptors (TLRs). We undertook this study to test whether a TLR-2- or TLR-4-stimulating factor in synovial fluid (SF) from patients with early knee OA with meniscal injury could lead to inflammatory activation of synoviocytes.

METHODS

SF was obtained from patients with early OA cartilage damage undergoing arthroscopic meniscal procedures. SF was used to stimulate primary cultures of fibroblast-like synoviocytes (FLS) and cell lines transfected with TLR-2 or TLR-4. SF was used either alone or in combination with a TLR-2 stimulus (palmitoyl-3-cysteine-serine-lysine-4 [Pam3CSK4]) or a TLR-4 stimulus (lipopolysaccharide [LPS]). In blocking experiments, SF was preincubated with anti-CD14 antibody.

RESULTS

SF from these patients did not stimulate interleukin-8 (IL-8) release from TLR transfectants. Compared with SF on its own, SF (at concentrations of 0.09-25%) in combination with TLR-2 or TLR-4 ligands resulted in significant augmentation of IL-8 release from both transfectants and primary FLS. Soluble CD14 (sCD14), a coreceptor for TLRs, was measured in SF from patients with early OA at levels comparable to those in patients with advanced OA and patients with rheumatoid arthritis. Blockade with anti-CD14 antibody abolished the ability of SF to augment IL-8 production in response to LPS, and diminished Pam3CSK4 responses.

CONCLUSION

SF augments FLS responses to TLR-2 and TLR-4 ligands. This effect was largely due to sCD14. Our results demonstrate that sCD14 in the setting of OA and meniscal injury sensitizes FLS to respond to inflammatory stimuli such as TLR ligands.

The diagnosis and management of spontaneous and post-arthroscopy osteonecrosis of the knee

Spontaneous osteonecrosis of the knee (SPONK) and osteo necrosis in the postoperative knee (ONPK) are two clinical entities that have the potential to cause significant morbidity in affected patients. In addition to the knowledge of the patient population at risk and the classic presentation and imaging characteristics of SPONK and ONPK, the treating orthopaedic surgeon needs to maintain a high index of suspicion for these disorders since early diagnosis and treatment may allow for an improved clinical outcome. The following review presents the current knowledge regarding these two pathological processes of the knee.

Reconstruction of a chronic distal biceps tendon rupture 4 years after initial injury

Rupture of the distal biceps insertion can produce, on average, a 40% loss of supination strength, a 47% loss of supination endurance, and a 21% to 30% loss of flexion strength at the elbow. In acute biceps tendon ruptures in which a patient will not tolerate resulting functional deficits, anatomical reinsertion of the biceps tendon into the radial tuberosity is usually recommended. The various surgical techniques that have been described for anatomical repair of distal biceps rupture include passage of the tendon stump through a transosseous tunnel and use of suture anchors, interference screws, and EndoButtons (Smith & Nephew, Andover, Mass). Reported results for these techniques have mostly been excellent with respect to restoration of functionality. Chronic cases, however, may involve retraction of the native tendon and extensive scar formation, which preclude anatomical repair. In these situations, one of several described reconstructive techniques, including use of semitendinosus autograft and Achilles tendon allograft, may be needed to reestablish acceptable function. Delayed (< or = 18 months) reconstruction of chronic ruptures, using allograft soft-tissue constructs, has been described in the literature. We present the case of a chronic distal biceps rupture reconstructed 4 years after initial injury using a single-incision technique with free semitendinosus autograft and EndoButton fixation.

The surgical approach to lateral meniscal repair

Peripheral lateral meniscal tears are amenable to meniscal repair. Rasp abrasion and fibrin clot deposition along with vascular access channels are advances that, one hopes will increase healing rates of meniscal repairs. A basic principle that is not emphasized in the literature is how to perform the surgical approach to the lateral meniscus for safe placement of a meniscal repair retractor. This article reviews the anatomical planes of which the surgeon must be cognizant to facilitate retractor placement.

Subacromial Space Injections

In brief When an active person experiences shoulder pain, injecting an anesthetic into the subacromial space may aid diagnosis. Such diagnostic injections may restore or improve the patient's active range of motion, eliminate apparent rotator cuff weakness, and reduce or eliminate pain in certain arcs of motion. This permits the physician to distinguish among diagnoses of impingement syndrome, rotator cuff lesions, adhesive capsulitis, and shoulder instability. Patients who have dramatic reductions in pain or improvements in active motion following a diagnostic injection may benefit from a therapeutic injection of a corticosteroid.