Anthony Sanchez

Subtalar staple arthroereisis for planovalgus foot deformity in children with neuromuscular disease

Twenty-two patients (34 feet) with severe, flexible, planovalgus feet due to neuromuscular conditions were treated with subtalar staple arthroereisis. Patients were followed up for an average of 5 years (range, 2.5-9 years). Of the 34 feet, 18 did not require revision surgery; however, the remaining 16 feet required revision at an average of 39 months after surgery (range, 9-63 months). Revision procedures consisted of hardware removal in four cases, repeated subtalar stapling in one, triple arthrodesis in two, and calcaneal with or without cuboid and cuneiform osteotomy in nine feet. The long-term results of subtalar staple arthroereisis were unpredictable, and although it was effective in approximately half of our patients, we no longer recommend this procedure for the correction of the neuromuscular planovalgus foot deformity.

Arthroscopically assisted treatment of acute septic knees in infants using the micro-joint arthroscope

Five infants with an acute hematogenous septic arthritis of the knee were treated with arthroscopically assisted drainage using the Micro-Joint Arthroscope (MJA; Linvatec, Largo, FL) combined with antibiotic therapy and early postoperative motion. The average patient age was 16 months (range, 4 to 24 months). No surgical or anesthetic complications occurred. All knees were clinically and radiologically normal at an average follow-up of 26 months.

Latarjet Technique for Treatment of Anterior Shoulder Instability With Glenoid Bone Loss

Anterior glenohumeral instability is a common clinical entity, particularly among young athletic patient populations. Nonoperative management and arthroscopic treatment of glenohumeral instability have been associated with high rates of recurrence, particularly in the setting of glenohumeral osseous defects. Coracoid transfer, particularly the Latarjet procedure, has become the treatment of choice for recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency. The following Technical Note provides a diagnostic approach for suspected glenohumeral instability, as well as a detailed description of the congruent-arc Latarjet procedure, performed with a deltoid split, with its postoperative management.

Understanding the Hill-Sachs Lesion in Its Role in Patients with Recurrent Anterior Shoulder Instability

Purpose of ReviewThe purpose of this study is to provide an update to the orthopedic field in regard to treatment of the Hill-Sachs lesion and anterior shoulder instability. The review highlights the most current knowledge of epidemiology, clinical evaluation, and surgical methods used to treat Hill-Sachs lesions. It also details the relevant clinical and surgical findings that have been made throughout the literature in the past couple of years.Recent FindingsThe most recent literature covering the Hill-Sachs lesion has focused on the relatively new and unexplored topic of the importance of concomitant injuries while treating a humeral head defect. The glenoid track concept has been clinically validated as a method to predict engagement. 3D-CT has become the “gold standard” for Hill-Sachs imaging; however, it has been noted that 3D-MRI produces results that are not significantly different from CT. Also, it has been found that when the arm is in a position of abduction during the primary injury, there is a higher risk of engagement and subsequent dislocation. Recent studies have demonstrated successful results stemming from purely arthroscopic procedures in treating Hill-Sachs lesions.SummaryAnterior shoulder instability, specifically the Hill-Sachs lesion, is an area of orthopedic study that is highly active and constantly producing new studies in an attempt of gaining the best outcomes for patients. The past few years have yielded many excellent discoveries, but there is still much more work to be done in order to fully understand the role of the Hill-Sachs lesion in anterior shoulder instability.

Anatomic Humeral Head Reconstruction With Fresh Osteochondral Talus Allograft for Recurrent Glenohumeral Instability With Reverse Hill-Sachs Lesion

The treatment of recurrent glenohumeral instability, especially with a concomitant bony lesion, remains challenging. This is especially true in the case of posterior instability given its less common incidence. Moreover, the presence of an engaging reverse Hill-Sachs lesion in combination with posterior instability will result in the need for a more aggressive treatment option. In comparison with a Hill-Sachs lesion, a reverse Hill-Sachs lesion features greater chondral deficiency that must be addressed during treatment. We propose the talus allograft as a potential allograft for treatment of an engaging reverse Hill-Sachs lesion. The superior articular surface of the talus may be used to reconstruct the articular surface of the humeral head. In this technical note, we describe our preferred primary technique for treatment of an engaging reverse Hill-Sachs lesion with recurrent glenohumeral instability through use of a fresh osteochondral talus allograft, as well as discuss the advantages and disadvantages of this allograft option.

Arthroscopic Superior Capsule Reconstruction Technique in the Setting of a Massive, Irreparable Rotator Cuff Tear

Massive, irreparable rotator cuff tears are challenging to treat and associated with pain and severe limitation in shoulder elevation due to the proximal migration of the humeral head and, consequently, subacromial impingement. Furthermore, retraction of the tendons in combination with fat infiltration and muscular weakness results in unpredictable treatment outcomes. While conservative treatment may be warranted for low-demand patients, surgical treatment is often indicated for a successful return to activities of daily living as well as an improved quality of life. The reported failure rate of rotator cuff repair for the treatment of a massive rotator cuff tear varies. However, this failure is often found at the interface between the tendon and tendon footprint. Several techniques have been reported to address this pathology, including muscular transfer, arthroscopic debridement, augmentation procedures, and superior capsule reconstruction. In particular, superior capsule reconstruction has been reported as a safe and effective method to treat a massive, irreparable rotator cuff tear. The purpose of this Technical Note is to describe our preferred technique of a superior capsule reconstruction for the treatment of a massive, irreparable rotator cuff tear.

Superior Labral Anterior-Posterior (SLAP) Tears in the Military: A Clinical Review of Incidence, Diagnosis, and Treatment Compared With the Civilian Population

Context: Given the notable physical demands placed on active members of the military, comprehension of recent trends in management and outcomes of superior labral anterior-posterior (SLAP) tears in this patient population is critical for successful treatment. Evidence Acquisition: Electronic databases, including PubMed, MEDLINE, and Embase, were reviewed for the years 1985 through 2016. Study Design: Database review. Level of Evidence: Level 5. Results: Active members of the military are at increased risk of sustaining shoulder injuries, particularly SLAP tears. Recent trends in management of SLAP lesions have shifted toward operative intervention. In the correct patient population, repairs of superior labrum tears demonstrate improved function and pain. Surgical repair of SLAP tears, especially in young and active military personnel, is supported. Conclusion: Military personnel are at greater risk of suffering a SLAP tear in comparison with their civilian counterparts. Surgical repair of these lesions is advocated in this subpopulation when the patient is younger than approximately 36 years of age, and if older, biceps tenodesis is likely superior.

Medial Collateral Ligament Injuries Identified at the National Football League Scouting Combine: Assessment of Epidemiological Characteristics, Imaging Findings, and Initial Career Performance

Background: The medial collateral ligament (MCL) is one of the most commonly injured structures in the knee, especially in young athletes. The impact of MCL injury on National Football League (NFL) performance in elite collegiate athletes has not yet been described in the literature. Purpose: We aim to (1) describe the prevalence and severity of MCL injuries in NFL Combine participants, (2) detail injury management, and (3) analyze the impact of MCL injury on NFL performance in terms of draft position, games played, games started, and snap percentage. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed by reviewing medical records and imaging reports from the combine to identify all players with MCL injuries. A control group was developed from the players evaluated at the combine without MCL injury. For each affected knee, the MCL injury was classified by location and severity based on results of magnetic resonance imaging (MRI). Each player’s respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for the first 2 seasons in the league were collected through the use of NFL.com and Pro-Football-Focus, which are web-based, publicly accessible, comprehensive sports statistics databases. Results: A total of 2285 players participated in the NFL Combine between 2009 and 2015. Three hundred one athletes (13.2%) were identified as having MCL injuries; 36 (12%) of the athletes with MCL injury presented with bilateral injuries, for a total of 337 MCL injuries. Additional soft tissue injury was identified on 187 of 337 (55%) MRIs. Players with a history of MCL injury were more likely to play at least 2 years in the NFL compared with those in the control group (P = .003). Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position (P = .034), proportion playing at least 2 seasons in the NFL (P = .022), games played (P = .014), and games started (P = .020) in the first 2 years. No significant difference was found between players who underwent operative versus nonoperative management of their MCL injury. Conclusion: A relatively high percentage of players at the NFL Combine had evidence of MCL injury (13%). A prior history of MCL tear had no negative impact on an athlete’s NFL performance. Players who had isolated MCL injury performed significantly better compared with athletes who had combined injuries with regard to draft position, proportion playing 2 seasons or more in the NFL, and games played and started in the first 2 years.

Effect of Posterior Glenoid Labral Tears at the NFL Combine on Future NFL Performance

Background: Posterior labral injuries have been recognized as a particularly significant clinical problem in collision and contact athletes. Purpose: To evaluate the effect that posterior labral tears have on early National Football League (NFL) performance based on position, associated injuries, and operative versus nonoperative management. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all participants in the NFL Combine from 2009 to 2015 was performed using medical and imaging reports documented at the combine. Magnetic resonance imaging scans were analyzed for tear location, associated injuries, and evidence of previous surgical interventions. Each player’s NFL draft position, as well as number of games played, number of games started, and snap percentage in his first 2 NFL seasons were collected for performance analysis and were compared with a control group of uninjured counterparts. Results: Players with posterior labral tears were selected significantly later in the draft than those in the control group (draft position, 171.6 vs 156.1, respectively; P = .017). Although no single individual position was significantly affected by posterior labral tears, linemen (both offensive and defensive) with posterior labral tears were drafted significantly later than those without tears (draft position, 164.0 vs 137.7, respectively; P = .018) and had a significantly lower percentage of snaps in their first NFL season (23.8% vs 27.7%, respectively; P = .014). Players who underwent surgical management before the combine had a significantly higher percentage of snaps in their second NFL season than those who were managed conservatively (31.4% vs 22.3%, respectively; P = .022). None of the concomitant injuries recorded (superior labral anterior-posterior tears, glenoid bone loss, reverse Hill-Sachs lesions, rotator cuff tears, reverse humeral avulsions of the glenohumeral ligament, and posterior labral tears combined with anterior tears) significantly affected the draft position, number of games played, number of games started, or snap percentage for the cohort as a whole or any specific position. Conclusion: Posterior labral tears did negatively and significantly affect early NFL outcomes for collegiate football players across several different metrics, especially among linemen. While operative management did not produce significantly superior performance in most outcome measures, it may allow for better longevity of the shoulder and warrants further investigation. Concomitant shoulder injuries did not significantly affect early NFL outcomes in this cohort.

Effect of Anterior Glenoid Labral Tears and Glenoid Bone Loss at the NFL Combine on Future NFL Performance

Background: Anterior glenohumeral instability is a common abnormality in the young, athletic population, especially in those participating in contact or collision sports. Purpose: To examine the effect of anterior labral tears, their associated injuries, and their management on future National Football League (NFL) performance. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of all NFL Combine participants from 2009 to 2015 was performed using medical and imaging reports compiled at the NFL Combine. These notes and images were reviewed and analyzed for involved structures, associated injuries, and evidence of previous surgical interventions. The respective NFL draft position, number of NFL games played, number of NFL games started, and NFL snap percentage for each player’s first 2 seasons were collected and compared with a control group and within subgroups. Results: Of the 2285 players at the NFL Combine between 2009 and 2015, there were 206 (9%) anterior labral tears confirmed by magnetic resonance imaging, 20 of which were bilateral, for a total of 226 affected shoulders. There were 908 players who fit the criteria for inclusion in the control group. Overall, there were no significant differences between players with anterior labral tears and the control players in terms of draft position (P = .259), games played in their first 2 NFL seasons (P = .391), games started in their first 2 NFL seasons (P = .486), or snap percentage in their first (P = .268) and second (P = .757) NFL seasons. In general, sustaining a concomitant injury with an anterior labral tear (superior labrum from anterior to posterior [SLAP] tear, glenoid bone loss, Hill-Sachs lesion, rotator cuff tear, humeral avulsion of the glenohumeral ligament, and anterior tear combined with posterior tear) negatively affected a player’s NFL draft position when compared with those with an isolated anterior labral tear (P = .003). There was no significant difference between operative and nonoperative management for anterior labral tears in terms of any performance metric. Conclusion: A history of anterior labral tears was not significantly associated with future NFL performance. While players with isolated injuries were drafted significantly earlier than those with concomitant injuries, combined injuries did not affect players’ games played, games started, or snap percentage in their first 2 NFL seasons. Glenoid bone loss did significantly decrease draft position; however, the severity of bone loss did not affect draft position, and there were no significant associations between glenoid bone loss and games played, games started, or snap percentage.