Angela Pedroza

Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction: Predictors of Failure From a MOON Prospective Longitudinal Cohort.

Background: Tearing an anterior cruciate ligament (ACL) graft is a devastating occurrence after ACL reconstruction (ACLR). Identifying and understanding the independent predictors of ACLR graft failure is important for surgical planning, patient counseling, and efforts to decrease the risk of graft failure. Hypothesis: Patient and surgical variables will predict graft failure after ACLR. Study Design: Prospective cohort study. Methods: A multicenter group initiated a cohort study in 2002 to identify predictors of ACLR outcomes, including graft failure. First, to control for confounders, a single surgeon’s data (n = 281 ACLRs) were used to develop a multivariable regression model for ACLR graft failure. Evaluated variables were graft type (autograft vs allograft), sex, age, body mass index, activity at index injury, presence of a meniscus tear, and primary versus revision reconstruction. Second, the model was validated with the rest of the multicenter study’s data (n = 645 ACLRs) to evaluate the generalizability of the model. Results: Patient age and ACL graft type were significant predictors of graft failure for all study surgeons. Patients in the age group of 10 to 19 years had the highest percentage of graft failures. The odds of graft rupture with an allograft reconstruction are 4 times higher than those of autograft reconstructions. For each 10-year decrease in age, the odds of graft rupture increase 2.3 times. Conclusion: There is an increased risk of ACL graft rupture in patients who have undergone allograft reconstruction. Younger patients also have an increased risk of ACL graft failure. Clinical Relevance: Given these risks for ACL graft rupture, allograft ACLRs should be performed with caution in the younger patient population.

Activity Level and Graft Type as Risk Factors for Anterior Cruciate Ligament Graft Failure A Case-Control Study

Background Anterior cruciate ligament (ACL) graft failure is an uncommon but devastating event after reconstruction, and risk factors for graft failure are not well understood. Hypothesis Returning to a high activity level after ACL reconstruction and use of an allograft are risk factors for ACL graft failure. Study Design Case-control study; Level of evidence, 3. Methods Twenty-one patients with ACL graft failure were identified over a 2-year period. Forty-two age- and sex-matched controls were identified over the same period. A 1:2 matched case-control design was used to evaluate activity level after reconstruction and graft type as risk factors for ACL graft failure. Logistic regression analysis was used to determine odds ratios for activity level after reconstruction and for graft type among cases and controls. Association (interaction) between activity level after reconstruction and graft type was evaluated comparing stratum-specific odds ratios. Results Univariate logistic regression models showed an increased odds of ACL graft failure for those with high activity level compared with low activity level (odds ratio [OR], 5.53; 95% confidence interval [CI], 1.18–28.61; P = .03) and for allografts compared with autografts (OR, 5.56; 95% CI 1.55–19.98; P = .009). A bivariate logistic regression model showed a 35% change in the odds ratio for activity level (OR, 4.33; 95% CI, 0.89–21.16; P = .07) and a 13% change in the odds ratio for allograft compared with autograft (OR, 4.93; 95% CI, 1.34–18.20; P = .02). Stratum-specific odds ratios between activity level and graft type show a multiplicative interaction between higher activity level and allograft for much greater odds of ACL graft failure. Conclusion Higher activity level after reconstruction and allograft use for reconstruction are risk factors for ACL graft failure. Stratum-specific odds ratios show a multiplicative interaction between higher activity level after ACL reconstruction and allograft use, greatly increasing the odds for ACL graft failure.

The Influence of Hamstring Autograft Size on Patient- Reported Outcomes and Risk of Revision After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study

PURPOSE The purpose of this study was to evaluate the effect of graft size on patient-reported outcomes and revision risk after anterior cruciate ligament (ACL) reconstruction. METHODS A retrospective chart review of prospectively collected cohort data was performed, and 263 of 320 consecutive patients (82.2%) undergoing primary ACL reconstruction with hamstring autograft were evaluated. We recorded graft size; femoral tunnel drilling technique; patient age, sex, and body mass index at the time of ACL reconstruction; Knee Injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee score preoperatively and at 2 years postoperatively; and whether each patient underwent revision ACL reconstruction during the 2-year follow-up period. Revision was used as a marker for graft failure. The relation between graft size and patient-reported outcomes was determined by multiple linear regression. The relation between graft size and risk of revision was determined by dichotomizing graft size at 8 mm and stratifying by age. RESULTS After we controlled for age, sex, operative side, surgeon, body mass index, graft choice, and femoral tunnel drilling technique, a 1-mm increase in graft size was noted to correlate with a 3.3-point increase in the KOOS pain subscale (P = .003), a 2.0-point increase in the KOOS activities of daily living subscale (P = .034), a 5.2-point increase in the KOOS sport/recreation function subscale (P = .004), and a 3.4-point increase in the subjective International Knee Documentation Committee score (P = .026). Revision was required in 0 of 64 patients (0.0%) with grafts greater than 8 mm in diameter and 14 of 199 patients (7.0%) with grafts 8 mm in diameter or smaller (P = .037). Among patients aged 18 years or younger, revision was required in 0 of 14 patients (0.0%) with grafts greater than 8 mm in diameter and 13 of 71 patients (18.3%) with grafts 8 mm in diameter or smaller. CONCLUSIONS Smaller hamstring autograft size is a predictor of poorer KOOS sport/recreation function 2 years after primary ACL reconstruction. A larger sample size is required to confirm the relation between graft size and risk of revision ACL reconstruction. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort.

Background: Anterior cruciate ligament (ACL) reinjury results in worse outcomes and increases the risk of posttraumatic osteoarthritis. Purpose: To identify the risk factors for both ipsilateral and contralateral ACL tears after primary ACL reconstruction (ACLR). Study Design: Cohort study; Level of evidence, 3. Methods: Data from the Multicenter Orthopaedic Outcomes Network (MOON), a prospective longitudinal cohort, were used to identify risk factors for ACL retear. Subjects with primary ACLR, no history of contralateral knee surgery, and a minimum of 2-year follow-up data were included. Age, sex, Marx activity score, graft type, lateral meniscal tear, medial meniscal tear, sport played at index injury, and surgical facility were evaluated to determine their contribution to both ipsilateral retear and contralateral ACL tear. Results: A total of 2683 subjects with average age of 27 ± 11 years (1498 men; 56%) met all study inclusion/exclusion criteria. Overall there were 4.4% ipsilateral graft tears and 3.5% contralateral ACL tears. The odds of ipsilateral ACL retear were 5.2 times greater for an allograft (P < .01) compared with a bone–patellar tendon–bone (BTB) autograft; the odds of retear were not significantly different between BTB autograft and hamstring autograft (P = .12). The odds of an ipsilateral ACL retear decreased by 0.09 for every yearly increase in age (P < .01) and increased by 0.11 for every increased point on the Marx score (P < .01). These odds were not significantly influenced by sex, smoking status, sport played, medial or lateral meniscal tear, or consortium site (P > .05). The odds of a contralateral ACL tear decreased by 0.04 for every yearly increase in age (P = .04) and increased by 0.12 for every increased point on the Marx score (P < .01); these odds were not significantly different between sex, smoking status, sport played, graft type, medial meniscal tear, or lateral meniscal tear (P > .05). Conclusion: Younger age, higher activity level, and allograft graft type were predictors of increased odds of ipsilateral graft failure. Higher activity and younger age were found to be risk factors in contralateral ACL tears.

Intra-articular Findings in Primary and Revision Anterior Cruciate Ligament Reconstruction Surgery A Comparison of the MOON and MARS Study Groups

Background: At the time of anterior cruciate ligament (ACL) reconstruction, there are usually concurrent meniscal and articular cartilage injuries. It is unclear if there is a significant difference between intra-articular injuries at the time of a primary ACL reconstruction compared with revision ACL reconstruction. Purpose: To compare the meniscal and articular cartilage injuries found at the time of primary and revision ACL reconstruction surgery and to determine associations between primary and revision surgery and specific intra-articular findings. Study Design: Cohort study (prevalence); Level of evidence, 2. Methods: Primary and revision ACL surgeries were identified from the Multicenter Orthopedic Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) study groups, respectively, from January 1, 2007 to November 1, 2008. Demographic data on individual patients were analyzed including age, body mass index (BMI), and gender. Intra-articular findings including the presence of medial or lateral meniscal tears and chondral damage to articular surfaces were analyzed for each patient. Comparisons of intra-articular findings at the time of surgery for the 2 groups were analyzed. Chondral damage in the medial and lateral compartments was analyzed considering previous meniscal tear as a possible confounder. Results: There were 508 patients undergoing primary ACL reconstruction and 281 patients undergoing revision ACL reconstruction who were identified for inclusion. There were no differences in the mean age, BMI, and gender in the 2 study groups. There was a decreased odds ratio (OR) of new untreated lateral meniscal tears (OR, 0.54; P < .01) but not of medial meniscal tears (OR, 0.86; P = .39) in revision compared with primary ACL reconstruction. There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in revision compared with primary ACL reconstruction in the lateral compartment (OR, 1.73; P = .04) and in the patellar-trochlear compartment (OR, 1.70; P = .04) but not in the medial compartment (OR, 1.33; P = .23). There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in patients from both groups having a prior medial meniscectomy on the medial femoral condyle (OR, 1.44; P < .01) and on the medial tibial plateau (OR, 1.63; P < .01). There was an increased OR of Outerbridge grade 3 and 4 articular cartilage injury in patients from both groups having a prior lateral meniscectomy on the lateral femoral condyle (OR, 1.65; P < .01) and on the lateral tibial plateau (OR, 1.56; P < .01). Conclusion: Meniscal tears are a common finding in both primary and revision ACL reconstruction. These results show a decreased OR of new untreated lateral meniscal tears in revision compared with primary ACL reconstruction. A previous medial or lateral meniscectomy increases the OR of articular cartilage damage in the medial or lateral compartments, respectively. Even when controlling for meniscus status, there is an increased OR in revision compared with primary ACL reconstruction of significant lateral compartment and patellar-trochlear chondral damage but not medial compartment chondral damage.

Cannulated Screw Fixation of Jones Fractures: A Clinical and Biomechanical Study

Background Traditional nonsurgical treatment of Jones fractures has high rates of delayed union, nonunion, and refracture. Internal fixation has become the treatment of choice in athletes and active patients. Purpose The purpose of this study was (1) to review the short- and long-term clinical results of cannulated screw fixation of Jones fractures and (2) to perform a biomechanical evaluation of fatigue failure characteristics of several types of screws used in the fixation of Jones fractures. Study Design Retrospective case series and in vitro biomechanical study. Methods Ten male and 5 female patients with Jones fractures fixed with cannulated screws ranging from 4 mm to 6.5 mm in diameter were evaluated by chart review, review of radiographs, and telephone interview. Mean follow-up from surgery to phone survey was 34 months. Screws ranging in size from 2.7 mm to 7.3 mm, both cannulated and noncannulated, stainless steel and titanium, were tested in the laboratory by cyclic loading to 250 N up to a maximum of 200 000 cycles. Results Mean time to healing as shown on radiographs and by full activity after surgery were 7.3 and 7.9 weeks, respectively. All patients were able to return to their previous levels of activity. Screw fatigue data showed that the number of cycles to failure increased with increasing screw diameter. For 4-mm screws, mean number of cycles to failure was 4308 for cannulated titanium screws, 22 012 for cannulated stainless steel screws, and 44 523 for noncannulated stainless steel screws. Conclusions In our patients, cannulated screw fixation of Jones fractures was a procedure that was reliable, had low morbidity, and afforded athletes a quick return to activity. Clinical Relevance The laboratory study suggests that the largest screw possible should be used for surgical fixation of these fractures and that screws less than 4 mm in diameter should be used with caution.

Predictors of Pain and Function in Patients With Symptomatic, Atraumatic Full-Thickness Rotator Cuff Tears A Time-Zero Analysis of a Prospective Patient Cohort Enrolled in a Structured Physical Therapy Program

Background: Although the prevalence of full-thickness rotator cuff tears increases with age, many patients are asymptomatic and may not require surgical repair. The factors associated with pain and loss of function in patients with rotator cuff tears are not well defined. Purpose: To determine which factors correlate with pain and loss of function in patients with symptomatic, atraumatic full-thickness rotator cuff tears who are enrolled in a structured physical therapy program. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A multicenter group enrolled patients with symptomatic, atraumatic rotator cuff tears in a prospective, nonrandomized cohort study evaluating the effects of a structured physical therapy program. Time-zero patient data were reviewed to test which factors correlated with Western Ontario Rotator Cuff (WORC) index and American Shoulder and Elbow Surgeons (ASES) scores. Results: A total of 389 patients were enrolled. Mean ASES score was 53.9; mean WORC score was 46.9. The following variables were associated with higher WORC and ASES scores: female sex (P = .001), education level (higher education, higher score; P < .001), active abduction (degrees; P = .021), and strength in forward elevation (P = .002) and abduction (P = .007). The following variables were associated with lower WORC and ASES scores: male sex (P = .001), atrophy of the supraspinatus (P = .04) and infraspinatus (P = .003), and presence of scapulothoracic dyskinesia (P < .001). Tear size was not a significant predictor (WORC) unless comparing isolated supraspinatus tears to supraspinatus, infraspinatus, and subscapularis tears (P = .004). Age, tear retraction, duration of symptoms, and humeral head migration were not statistically significant. Conclusion: Nonsurgically modifiable factors, such as scapulothoracic dyskinesia, active abduction, and strength in forward elevation and abduction, were identified that could be addressed nonoperatively with therapy. Therefore, physical therapy for patients with symptomatic rotator cuff tears should target these modifiable factors associated with pain and loss of function.

Transtibial ACL Femoral Tunnel Preparation Increases Odds of Repeat Ipsilateral Knee Surgery

BACKGROUND Recent efforts to improve the results of anterior cruciate ligament (ACL) reconstruction have focused on placing the femoral tunnel anatomically. Medial portal femoral tunnel techniques facilitate drilling of femoral tunnels that are more anatomic than those made with transtibial techniques. Few studies have compared the clinical outcomes of these two femoral tunnel techniques. We hypothesized that the transtibial technique is associated with decreased Knee injury and Osteoarthritis Outcome Scores (KOOS) and an increased risk of repeat surgery in the ipsilateral knee when compared with the anteromedial portal technique. METHODS Four hundred and thirty-six patients who had undergone primary isolated autograft ACL reconstruction with a transtibial (229 patients) or anteromedial portal (207 patients) technique in 2002 or 2003 were identified in a prospective multicenter cohort. A multiple linear regression model was used to determine whether surgical technique (transtibial or anteromedial portal) was a significant predictor of KOOS at six years postoperatively, after controlling for preoperative KOOS, patient age, sex, activity level, body mass index (BMI), smoking status, graft type, and the presence of meniscal and chondral pathology at the time of reconstruction. A multiple logistic regression model was used to determine whether surgical technique was a significant predictor of repeat ipsilateral knee surgery, after controlling for patient age and activity level, graft type, and meniscal pathology at the time of reconstruction. RESULTS Postoperative KOOS were available for 387 patients (88.8%). Femoral tunnel drilling technique was not a predictor of the KOOS Quality of Life subscore (p = 0.72) or KOOS Function, Sports and Recreational Activities subscore (p = 0.36) at the six-year follow-up evaluation. Data regarding the prevalence of repeat surgery were available for 380 patients. Femoral tunnel technique was a significant predictor of subsequent ipsilateral knee surgery (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.30 to 4.78, p = 0.006). CONCLUSIONS Patients who underwent ACL reconstruction with a transtibial technique had significantly higher odds of undergoing repeat ipsilateral knee surgery relative to those who underwent reconstruction with an anteromedial portal technique.

Knowledge of and Compliance With Pitch Count Recommendations: A Survey of Youth Baseball Coaches

Background: Pain and injuries suffered by youth pitchers are ongoing concerns that have been addressed through the institution of rules and recommendations regarding pitch counts and rest periods. The aim of our study was to see if coaches of youth baseball pitchers in our region were aware of the recommended guidelines and if they followed them. Methods: An Internet-based survey consisting of 18 items including demographic information and questions concerning the USA Baseball Medical and Safety Advisory Committee pitching guidelines was sent to coaches affiliated with a local youth league to assess their knowledge of and reported compliance with these recommendations. Results: Ninety-five of 228 coaches (41.4%) participated in the survey. On average, coaches answered 43% of questions regarding pitch count and rest periods correctly; 73% reported that they followed the recommendations, while only 53% felt that other coaches in the league abided by the recommendations. Thirty-five percent of coaches stated that their pitchers reported shoulder or elbow pain during the season, and 19% reported that one of their pitchers pitched a game with a sore or fatigued arm during the season. No coaches reported any pitching-related injuries among their players requiring surgery. Fewer than 10% of coaches reported that their players pitched in multiple leagues or participated in showcases, while 91% reported that pitchers attended camps or received specific instruction to improve their pitching form. Conclusions: This study shows that this subset of youth baseball coaches is deficient with regard to knowledge of the USA Baseball Medical and Safety Advisory Committee pitching guidelines. This situation may put youth pitchers at increased risk for upper extremity pain and injuries.

Intra- And Inter- Observer Agreement In The Classification And Treatment Of Midshaft Clavicle Fractures

Objectives: The purpose of this study was to determine the intraobserver and interobserver reliability in the classification of midshaft clavicle fractures via standard plain radiographs and to determine the intraobserver and interobserver agreement in the treatment of these fractures. Methods: Charts of patients seen by the two senior authors from 2006 to 2011 were reviewed to identify patients treated for clavicle fractures (CPT 23500 and 23515). AP and 30 degree cephalad radiographs were selected, representing midshaft clavicle fractures treated both operatively and non-operatively. Thirty pairs of radiographs were included in the investigation. The radiographs were standardized for size to allow accurate measurements within a non-PACS program. A PDF file was created with all representative radiographs. Clinical scenarios were created for each set of radiographs, and the evaluators were asked to perform the following tasks: 1) measure the degree of shortening in millimeters; 2) determine the percent displacement; 3) determine whether the fracture was comminuted; and 4) state whether they would treat the fracture operatively or non-operatively. The radiographs and clinical scenario handout, along with instructions on how to use the measuring tool with Adobe Reader, were distributed to 16 shoulder/sports medicine fellowship-trained orthopaedic surgeons who completed the evaluations. The radiographs and scenarios were then reordered and redistributed approximately three months later. Results: Intra and interobserver results are summarized in table 1. The following variables statistically predicted whether surgery was recommended (p< 0.001): 1) odds of surgery are 2.26 if comminution was noted holding displacement and the interaction between displacement and shortening constant, and 2) the odds of surgery are 3.37 if there is displacement > 100% compared to displacement 0-49% holding comminution and shortening constant. Conclusion: Our study demonstrated that there was moderate to strong interobserver and intraobserver agreement for both displacement and comminution when utilizing standard plain radiographs. However, there was only weak to no interobserver agreement and minimal intraobserver agreement on the amount of shortening. Also, there was minimal interobserver and only moderate intraobserver agreement on whether operative treatment should be selected, most likely due to the poor reliability of plain radiographs in determining the degree of shortening. Therefore, other modalities including comparison radiographs of the contralateral clavicle should be considered to more reliably measure the degree of shortening and help determine the need for surgery.