Alexis C. Colvin

National Trends in Rotator Cuff Repair

BACKGROUND Recent publications suggest that arthroscopic and open rotator cuff repairs have had comparable clinical results, although each technique has distinct advantages and disadvantages. National hospital and ambulatory surgery databases were reviewed to identify practice patterns for rotator cuff repair. METHODS The rates of medical visits for rotator cuff pathology, and the rates of open and arthroscopic rotator cuff repair, were examined for the years 1996 and 2006 in the United States. The national incidence of rotator cuff repairs and related data were obtained from inpatient (National Hospital Discharge Survey, NHDS) and ambulatory surgery (National Survey of Ambulatory Surgery, NSAS) databases. These databases were queried with use of International Classification of Diseases, Ninth Revision (ICD-9) procedure codes for arthroscopic (ICD-9 codes 83.63 and 80.21) and open (code 83.63 without code 80.21) rotator cuff repair. We also examined where the surgery was performed (inpatient versus ambulatory surgery center) and characteristics of the patients, including age, sex, and comorbidities. RESULTS The unadjusted volume of all rotator cuff repairs increased 141% in the decade from 1996 to 2006. The unadjusted number of arthroscopic procedures increased by 600% while open repairs increased by only 34% during this time interval. There was a significant shift from inpatient to outpatient surgery (p < 0.001). CONCLUSIONS The increase in national rates of rotator cuff repair over the last decade has been dramatic, particularly for arthroscopic assisted repair.

Trends in hip arthroscopy

BACKGROUND Recent advances in diagnosis and instrumentation have facilitated the arthroscopic treatment of hip pathology. However, little has been reported on trends in the utilization of hip arthroscopy. The purpose of this study was to examine changes in the use of hip arthroscopy as reflected in the American Board of Orthopaedic Surgery (ABOS) database. We also surveyed directors of both sports and joint reconstruction fellowships to determine attitudes toward hip arthroscopy training. METHODS The number of hip arthroscopy cases in the ABOS database during 1999 through 2009 was determined. A survey was devised to determine the type of hip arthroscopy training that was currently being offered at the fellowship level. RESULTS The number of hip arthroscopy procedures performed by ABOS candidates increased significantly from 0.02 cases per candidate in 1999 to 0.36 cases per candidate in 2009 (p < 0.0001). From 2003 through 2009, a significantly greater percentage of ABOS candidates with sports fellowship training (10.4%) than candidates without such training (2.9%) performed hip arthroscopy (p < 0.0001). During this same time period, candidates in the Northeast and Northwest performed the most hip arthroscopy procedures as a percentage of total procedures (p < 0.0001). Nearly half of the sports and joint reconstruction fellowships that included hip arthroscopy as a component of the training in 2010 had added it within the past three years. Fellows performed fewer than twenty hip arthroscopy cases per year in the majority of training programs. CONCLUSIONS The number of hip arthroscopy procedures performed by candidates taking Part II of the ABOS examination increased eighteenfold between 1999 and 2009. This increase is likely the result of several factors, including an increase in the number of programs offering training in hip arthroscopy.

The Role of Concussion History and Gender in Recovery From Soccer-Related Concussion

Background This study was designed to investigate differences in recovery in male and female soccer athletes. Hypotheses Soccer players with a history of concussion will perform worse on neurocognitive testing than players without a history of concussion. Furthermore, female athletes will demonstrate poorer performance on neurocognitive testing than male athletes. Study Design Cohort study (prognosis): Level of evidence, 2. Methods Computer-based neuropsychological testing using reaction time, memory, and visual motor-speed composite scores of the ImPACT test battery was performed postconcussion in soccer players ranging in age from 8 to 24 years (N = 234; 141 females, 93 males). A multivariate analysis of variance was conducted to examine group differences in neurocognitive performance between male and female athletes with and without a history of concussion. Results Soccer players with a history of at least 1 previous concussion performed significantly worse on ImPACT than those who had not sustained a prior concussion (F = 2.92, P = .03). In addition, female soccer players performed worse on neurocognitive testing (F = 2.72, P = .05) and also reported more symptoms (F = 20.1, P = .00001) than male soccer players. There was no significant difference in body mass index between male and female players (F = .04, P = .85). Conclusion A history of concussion and gender may account for significant differences in postconcussive neurocognitive test scores in soccer players and may play a role in determining recovery. These differences do not appear to reflect differences in mass between genders and may be related to other gender-specific factors that deserve further study.

Tendon‐derived stem/progenitor cell aging: defective self‐renewal and altered fate

Aging is a major risk factor for tendon injury and impaired tendon healing, but the basis for these relationships remains poorly understood. Here we show that rat tendon‐derived stem/progenitor cells (TSPCs) differ in both self‐renewal and differentiation capability with age. The frequency of TSPCs in tendon tissues of aged animals is markedly reduced based on colony formation assays. Proliferation rate is decreased, cell cycle progression is delayed and cell fate patterns are also altered in aged TSPCs. In particular, expression of tendon lineage marker genes is reduced while adipocytic differentiation increased. Cited2, a multi‐stimuli responsive transactivator involved in cell growth and senescence, is also downregulated in aged TSPCs while CD44, a matrix assembling and organizing protein implicated in tendon healing, is upregulated, suggesting that these genes participate in the control of TSPC function.

Avoiding pitfalls in anatomic ACL reconstruction

As interest in double-bundle anterior cruciate ligament (ACL) reconstruction grows, we continue to refine our technique to perform the most anatomic reconstruction possible. Our experience has brought to our attention the potential mistakes that should be avoided when performing an anatomic double-bundle ACL reconstruction. These mistakes include (1) failure to visualize the femoral insertion completely, (2) use of the clock face to reference femoral tunnel positioning, (3) nonanatomic tunnel placement leading to graft impingement, (4) mismatching tibial and femoral tunnels, and (5) failure to restore the native tension pattern of the ACL. It is also important to recognize that a double-bundle ACL reconstruction is not necessarily equivalent to an anatomic double-bundle reconstruction. This article reviews potential mistakes in DB ACL reconstruction and describes our way of avoiding them.

Meniscal Root Suturing Techniques: Implications for Root Fixation

Background: Meniscal root tears have attracted increasing interest in recent years. Fixation is an important factor for rehabilitation and avoidance of early failure. Suture fixations have been the most commonly used techniques. The current study aimed to evaluate the maximum failure load of the native meniscal roots (anteromedial, posteromedial, anterolateral, and posterolateral) and of 3 commonly used meniscal root fixation techniques (2 simple stitches, modified Kessler stitch, and loop stitch). Hypotheses: (1) There will be no difference in maximum failure load between the native meniscal roots. (2) The loop stitch will sustain the greatest maximum load to failure, followed by the modified Kessler stitch and the 2 simple stitches. (3) The maximum failure load of the native meniscal roots will not be restored by the tested fixation methods. Study Design: Controlled laboratory study. Methods: The maximum failure load of the 4 human native meniscal roots was evaluated using 64 human meniscal roots. Additionally, the maximum failure load of the 3 fixation techniques was evaluated on 24 meniscal roots: (1) 2 simple stitches, (2) modified Kessler stitch, and (3) loop stitch using a suture shuttle. Results: The average maximum failure load of the native meniscal roots was 594 ± 241 N (anterolateral: 692 ± 304 N; posterolateral: 648 ± 140 N; anteromedial: 407 ± 180 N; posteromedial: 678 ± 200 N). The anteromedial root was significantly weaker than the posterolateral and posteromedial roots (P = .04 and P = .01, respectively). Regarding fixation techniques, the maximum failure load of the 2 simple stitches was 64.1 ± 22.5 N, the modified Kessler stitch was 142.6 ± 33.3 N, and the loop was 100.9 ± 41.6 N. None of the fixation techniques recreated the strength of the native roots. Conclusion: The native anterolateral root was the strongest meniscal root, and the anteromedial root was the weakest meniscal root. Regarding primary fixation strength, the modified Kessler stitch was the strongest technique compared with the loop and the 2 simple stitches. Clinical Relevance: None of our tested fixation methods restored the strength of native meniscal roots. Thus, rehabilitation after meniscal root fixation should proceed cautiously.

Practice Patterns for Combined Anterior Cruciate Ligament and Meniscal Surgery in the United States

Purpose The purpose of the study was to compare frequency of meniscal repair to partial meniscectomy in patients undergoing anterior cruciate ligament reconstruction using the American Board of Orthopaedic Surgeons (ABOS) database. Hypotheses (1) Practice patterns are similar with respect to geographic region. (2) Surgeons with fellowship training perform more meniscal repairs compared with general orthopaedic practitioners. (3) Younger patients are more likely to be treated with meniscal repair at the time of anterior cruciate ligament reconstruction. (4) The frequency of meniscal repair in conjunction with anterior cruciate ligament reconstruction has increased over time. Study Design Cross-sectional study; Level of evidence, 3. Methods Information was extracted from the ABOS database from 2002 orthopaedic surgeons who sat for the part II examination from 2003 to 2007. The database was queried for all patients who underwent anterior cruciate ligament reconstruction (Current Procedural Terminology [CPT] code 29888) without or with meniscectomy (CPT 29881) or meniscal repair (CPT 29882). Factors affecting meniscal surgery that were investigated included patient age, geographic region of practice, fellowship training, and declared subspecialty of the surgeon. Results On average there were 52 000 cases per year registered in the ABOS database, approximately 1700 of whom underwent anterior cruciate ligament reconstruction. Meniscal repair was most frequently performed in the Southwest region (18.6%, P < .001) and least frequently in the Northwest region (11.3%, P < .001). Combined anterior cruciate ligament reconstruction and meniscal repair was performed significantly more often by fellowship-trained surgeons (17%) than by surgeons with other fellowship training (12%) or no fellowship training (12%, P < .001) and in patients younger than age 25 years (19%) compared with those age 40 years and older (8%, P < .001). Meniscal repair was performed in 13.9% of anterior cruciate ligament reconstructions in 2003 and in 16.4% of anterior cruciate ligament reconstructions in 2007 (P > .05). Conclusion Combined anterior cruciate ligament reconstruction with meniscal repair was more frequent for younger patients and by surgeons with sports fellowship training. Concomitant meniscal repair is performed by fellowship-trained surgeons in this study in only 18% of anterior cruciate ligament reconstructions.

Sports‐Related Injuries in the Young Female Athlete

The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.

Female athlete triad: past, present, and future directions

Since the passage of Title IX in 1972, female participation in athletics has increased significantly. More girls and young women have been able to experience the psychosocial and physical health-related benefits of organized sports. Hand-in-hand with increased participation, however, has been a dramatic increase in a dangerous yet widely underdiagnosed sports-related condition—the female athlete triad. The triad was originally defined as the presence of disordered eating (DE), amenorrhea, and osteoporosis. Further research revealed these diagnostic criteria to be too narrow in scope however, and today’s definition has evolved into that of a dynamic interrelationship between decreased energy availability (EA), menstrual dysfunction, and low bone mineral density (BMD). If left untreated, long-term consequences include irreversible decreases in BMD and a predisposition to potentially debilitating musculoskeletal injuries. First line therapy is generally non-pharmacological with treatments aimed at altering eating and exercise behavior. In behavior modification refractory cases, certain pharmacological treatments may be utilized but this practice remains controversial. While no pharmacological approach to treatment is yet recommended, a recent clinical trial provides compelling evidence and its implications warrant further investigation.

Withdrawals and Retirements in Professional Tennis Players: An Analysis of 2013 United States Tennis Association Pro Circuit Tournaments.

Background: Injuries and illnesses for professional tennis athletes disrupt training, competition, and progression in the sport and represent a major reason for athlete withdrawal or retirement from a tournament. Few descriptive epidemiological studies have focused on these trends in elite tennis athletes. Purpose: To examine the causes of professional tennis player withdrawal or retirement from United States Tennis Association (USTA) Pro Circuit tournaments during 2013. Study Design: Descriptive epidemiology study. Level of Evidence: Level 4. Methods: Tournament records from the 2013 USTA Pro Circuit season were retrospectively reviewed for incidences of injury and illness that resulted in athlete withdrawal from the tournament. Data were reported as incidence rates per 1000 match exposures and rate ratios. Results: There were 70 medical conditions over the course of 27 competitions (20,988 match exposures), for an overall incidence rate of 3.34 per 1000 match exposures. Women were more likely to injure themselves on clay courts compared with hard courts (rate ratio, 4.67; 95% confidence interval [CI], 1.41-19.85) and in the first half of the season compared with the second half (rate ratio, 3.95; 95% CI, 1.13-21.17). Men had a higher injury rate than women (rate ratio, 1.88; 95% CI, 1.17-3.63), and muscle-/tendon-related injuries were 6 times more likely than all other injuries (95% CI, 2.81-14.69). Conclusion: Women were more likely to experience an injury when playing on clay court surfaces, and they also experienced more injuries during the first half of the season. Injury rates for men often peaked during the months that players could qualify for Grand Slam competitions. There was a predominance of injuries in men compared with women.