Angelo J. Colosimo

Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes A Prospective Study

Background Female athletes participating in high-risk sports suffer anterior cruciate ligament injury at a 4- to 6-fold greater rate than do male athletes. Hypothesis Prescreened female athletes with subsequent anterior cruciate ligament injury will demonstrate decreased neuromuscular control and increased valgus joint loading, predicting anterior cruciate ligament injury risk. Study Design Cohort study; Level of evidence, 2. Methods There were 205 female athletes in the high-risk sports of soccer, basketball, and volleyball prospectively measured for neuromuscular control using 3-dimensional kinematics (joint angles) and joint loads using kinetics (joint moments) during a jump-landing task. Analysis of variance as well as linear and logistic regression were used to isolate predictors of risk in athletes who subsequently ruptured the anterior cruciate ligament. Results Nine athletes had a confirmed anterior cruciate ligament rupture; these 9 had significantly different knee posture and loading compared to the 196 who did not have anterior cruciate ligament rupture. Knee abduction angle (P <. 05) at landing was 8° greater in anterior cruciate ligament-injured than in uninjured athletes. Anterior cruciate ligament-injured athletes had a 2.5 times greater knee abduction moment (P <. 001) and 20% higher ground reaction force (P <. 05), whereas stance time was 16% shorter; hence, increased motion, force, and moments occurred more quickly. Knee abduction moment predicted anterior cruciate ligament injury status with 73% specificity and 78% sensitivity; dynamic valgus measures showed a predictive r2 of 0.88. Conclusion Knee motion and knee loading during a landing task are predictors of anterior cruciate ligament injury risk in female athletes. Clinical Relevance Female athletes with increased dynamic valgus and high abduction loads are at increased risk of anterior cruciate ligament injury. The methods developed may be used to monitor neuromuscular control of the knee joint and may help develop simpler measures of neuromuscular control that can be used to direct female athletes to more effective, targeted interventions.

No Association of Time From Surgery With Functional Deficits in Athletes After Anterior Cruciate Ligament Reconstruction Evidence for Objective Return-to-Sport Criteria

Background: Release for full activity and return to sport after anterior cruciate ligament reconstruction (ACLR) is often dictated by time from surgery and subjective opinion by the medical team. Temporal guidelines for return to sport may not accurately identify impaired strength and neuromuscular control, which are associated with increased risk for second injury (contralateral and/or ipsilateral limb) after ACLR in athletes. Hypotheses: Athletes undergoing ACLR and returning to sport would demonstrate functional deficits that would not be associated with time from surgery. Study Design: Controlled laboratory study. Methods: Thirty-three male (n = 10) and female (n = 23) athletes with unilateral ACLR, who were cleared by a physician to return to their sport after surgery and rehabilitation, performed the single-legged vertical hop test for 10 seconds on a portable force plate. Matched teammates of each patient were recruited to serve as sex-, sport-, and age-matched controls (CTRL; n = 67). Maximum vertical ground-reaction force (VGRF) was measured during each single-limb landing. Single-limb symmetry index (LSI) was calculated as the ratio of the involved divided by uninvolved limb, expressed as a percentage. Results: The single-limb vertical jump height LSI was reduced in the ACLR group, 89% (95% confidence interval [CI], 83%-95%), compared with the matched CTRL group, 101% (95% CI, 96%-105%; P < .01). The LSI for VGRF normalized to potential energy achieved during flight of the hop was increased in ACLR at 112% (95% CI, 106%-117%) relative to the CTRL group at 102% (95% CI, 98%-106%; P < .01). Linear regression analysis indicated that time from surgery was not associated with limb symmetry deficits in the ACLR group (P > .05; R2 = .002-.01). Conclusion: Deficits in unilateral force development (vertical jump height) and absorption (normalized VGRF) persist in an athlete’s single-limb performance after ACLR and full return to sports. These symmetry deficits appear to be independent of time after reconstruction. Clinical Relevance: On the basis of these results, clinicians should consider assessment of single-limb power performance in the decision-making process for return-to-sport release. Persistent side-to-side asymmetries may increase the risk of contralateral and/or ipsilateral injury.

Revision Anterior Cruciate Ligament Reconstruction with a Reharvested Ipsilateral Patellar Tendon

The patellar tendon remains the most popular graft choice for anterior cruciate ligament reconstruction and has been proven to be the strongest substitute. Between 1991 and 1998, we performed revision anterior cruciate ligament reconstruction using the reharvested central third of the ipsilateral patellar tendon in 15 patients. Adequate follow-up was obtained in 13 of these 15 patients. The results in these 13 patients (mean age, 27.2 years) were reviewed. At an average postoperative follow-up of 39.4 months (range, 24 to 65), 11 patients had good or excellent results and 2 patients had fair results. Clinical examination revealed an average Tegner knee score of 5.8 (range, 3 to 9) and an average Lysholm knee score of 77.6 (range, 61 to 98). Postoperative KT-1000 arthrometer results showed an average side-to-side difference of 1.92 mm (range, -2.0 to 4.0). No patient demonstrated any loss of range of motion and only one reported patellofemoral problems, which were moderate. These favorable results demonstrate that, with appropriate patient selection, the use of a reharvested central third patellar tendon is a viable option for revision of a failed anterior cruciate ligament reconstruction.

Arthroscopic Laser-Assisted Capsular Shift in the Treatment of Patients with Multidirectional Shoulder Instability

Background In recent years, various investigators have begun using lasers in the treatment of shoulder instability. Hypothesis Arthroscopic laser-assisted capsular shift is an effective treatment for patients with multidirectional shoulder instability. Study Design Retrospective cohort study. Methods We retrospectively identified 28 patients (30 shoulders) with multidirectional shoulder instability who were unresponsive to nonoperative management and who had undergone the laser-assisted capsular shift procedure. Twenty-five patients (27 shoulders) with an average follow-up of 28 months were available for review. All patients underwent a physical examination and completed a general questionnaire; the University of California, Los Angeles, shoulder rating scale; the Western Ontario Shoulder Instability Index; and the Short-Form 36 quality of life index. Results In 22 shoulders, results of the procedure were considered a success because the patients had no recurrent symptoms and at latest follow-up had required no further operative intervention. In five shoulders, results were considered a failure because of recurrent pain or instability and the need for an open capsular shift procedure. With recurrent instability as a measure of failure, the overall success rate was 81.5%. Conclusions Our results with laser-assisted capsular shift are comparable with the results of other open and arthroscopic techniques in relieving pain and returning athletes to their premorbid function.

Case report: Revision anterior cruciate ligament reconstruction

A case report is presented in which a professional football player, who was 4 years status post anterior cruciate ligament (ACL) reconstruction with autogenous patellar tendon, ruptured his graft. The contralateral patellar tendon was not available as a graft because of a more recent ACL reconstruction using that autogenous patellar tendon. This case reports the use of a previous donor site for supplying a patellar tendon autograft. Biopsy of the donor graft was consistent with normal tendon. The use of a healed patellar tendon donor site is a viable option for revision anterior cruciate reconstructive surgery. This option prevents the possibility of disease transmission with use of an allograft. We have shown grossly and histologically that the donor site has the potential to regenerate to tissue that has the appearance of normal tendon. This option could be available for revision surgery, but would not be recommended if the initial surgery was < 18 months-2 years in the past.

Aseptic Foreign Body Reaction to Dacron Graft Material Used for Coracoclavicular Ligament Reconstruction after Type III Acromioclavicular Dislocation

Surgical treatment of traumatically induced type III acromioclavicular separations using a Dacron graft to reconstruct the coracoclavicular ligament has been described by several authors. 2,3,,5,7,9,1 2 ,1 6 ,1 9 We describe two cases in which the patients who underwent this procedure developed an aseptic foreign body reaction to Dacron. This clinical problem has not been previously reported.

Thigh compartment syndrome in a football athlete: a case report and review of the literature

Although contusions of the thigh are common in all sports, a compartment syndrome from closed blunt trauma without a femur fracture is rare. Thigh compartment syndrome is unusual due to increased compliance of the thigh to accommodate increased expansion from hematoma or third space fluid. Compartment syndrome of the thigh is characterized by unrelenting pain, swelling, and limited knee range of motion. A single case of a thigh compartment syndrome caused by a direct blow to the anterior aspect of the thigh from a football helmet during kickoff occurred. Immediate thigh fasciotomy was performed. Early diagnosis with appropriate emergency treatment can avoid serious and permanent complications.

Outcomes After Isolated Medial Patellofemoral Ligament Reconstruction for the Treatment of Recurrent Lateral Patellar Dislocations A Systematic Review and Meta-analysis

Background: A patellar dislocation is a common knee injury in the young, athletic patient population. Recent trends indicate that the use of long-term nonoperative treatment is decreasing, and surgical intervention is more commonly recommended for those patients who fail initial nonoperative management with recurrent patellar dislocations. Medial patellofemoral ligament (MPFL) reconstruction has become increasingly utilized in this regard. Purpose: To evaluate outcomes, particularly return to sports and its relationship to postoperative instability, of isolated MPFL reconstruction for the treatment of recurrent patellar dislocations. Study Design: Systematic review and meta-analysis. Methods: A review of the current literature was performed using the terms “medial patellofemoral ligament reconstruction” and “MPFL reconstruction” in the electronic search engines PubMed and EBSCOhost (CINAHL, MEDLINE, SPORTDiscus) on July 29, 2015, yielding 1113 abstracts for review. At the conclusion of the search, 14 articles met the inclusion criteria and were included in this review of the literature. Means were calculated for population size, age, follow-up time, and postoperative Tegner scores. Pooled estimates were calculated for postoperative Kujala scores, return to play, total risk of postoperative instability, risk of positive apprehension sign, and risk of reoperation. Results: The mean patient age associated with MPFL reconstruction was 24.4 years, with a mean postoperative Tegner score of 5.7. The pooled estimated mean postoperative Kujala score was 85.8 (95% CI, 81.6-90.0), with 84.1% (95% CI, 71.1%-97.1%) of patients returning to sports after surgery. The pooled total risk of recurrent instability after surgery was 1.2% (95% CI, 0.3%-2.1%), with a positive apprehension sign risk of 3.6% (95% CI, 0%-7.2%) and a reoperation risk of 3.1% (95% CI, 1.1%-5.0%). Conclusion: A high percentage of young patients return to sports after isolated MPFL reconstruction for chronic patellar instability, with short-term results demonstrating a low incidence of recurrent instability, postoperative apprehension, and reoperations.

Effects of iontophoretic versus injection administration of dexamethasone.

PURPOSE Sixty-eight skeletally mature New Zealand white rabbits were used to study the effects of iontophoresis- and injection-delivered sodium phosphate dexamethasone (DX) on the morphologic, histologic, microscopic, and biomechanical properties of uninjured rabbit patellar tendons over an initial 14-d period. METHODS Three control (untreated, placebo iontophoresis, and placebo injection) groups and two treatment (iontophoresis and injection) groups underwent serum, ELISA tendon, histology, electron microscopy, and biomechanical analysis. RESULTS Serum DX levels were detectable and quantifiable in both treatment groups at 1 h but were significantly greater (P < 0.05) in the injected group (11.29 ng.mL-1) compared with the iontophoresis group (6.34 ng.mL-1). The most significant histologic finding was a lack of a cellular inflammatory response in the DX-treated groups at 24 h. Ultrastructural analysis produced no significant differences between size or size ratio of collagen fibrils among any groups. Morphologic examination revealed only injection puncture marks seen in appropriate tendons. Biomechanical testing produced disruption at the patellar insertion in 81% of the specimens. No injected tendon failed at the injection site. Normalized biomechanical properties included: 1) Stiffness increased in control and iontophoresis groups from 1 to 24 h, then gradually declined; the DX-injected specimens showed a similar but delayed effect. 2) Peak load at failure for iontophoresis and control groups was greatest at 24 h. The DX-injected group again showed a delayed response. 3) In general, total energy to failure revealed no significant differences between groups at any time period. CONCLUSION It appears that iontophoresis or injection-delivered DX may produce anti-inflammatory effects without significantly altering ultrastructural or biomechanical characteristics of the rabbit patellar tendon within an initial 14-d period.

Acute Traumatic First-Rib Fracture in the Contact Athlete A Case Report

are a rare entity. Isolated first-rib fracture in the trauma patient is well described in trauma and thoracic literature, and there is much literature on stress fracture of the first rib in association with baseball, rowing, weight lifting, dance, tennis, surfing, basketball, and gymnastics. However, there have been only 2 published reports in the past 14 years of acute first-rib fracture in contact athletes. Both cases were secondary to football injuries and were reported by Barrett et al, who described their management of the 2 cases in 1988. Fracture of the first rib sustained during contact sports differs significantly from the more widely reported stress fracture, which occurs as a result of repetitive microtrauma in weakened bone. In contact athletes, the first-rib fracture occurs as a single, acute event in normal bone, the most common area of fracture being in the shallow depression for the subclavian artery, a well-described area of anatomical weakness. In this article, we present another case of a traumatic first-rib fracture sustained by a football player after a collision injury. We also review the pertinent anatomy, biomechanics, and complications associated with the injury.