David A. Porter

Anterior cruciate ligament-medial collateral ligament injury: Nonoperative management of medial collateral ligament tears with anterior cruciate ligament reconstruction A preliminary report

We present the results of a series of patients who had nonoperative management of the medial collateral lig ament with anterior cruciate ligament reconstruction. From February 1983 through December 1989, 84 of 90 consecutive patients were available for followup (mini mum, 1 year; mean, 3.1 years) with a combined anterior cruciate ligament-medial collateral ligament injury (an terior cruciate ligament rupture and medial collateral ligament tear) received surgical management by the same physician. The last 68 of these 84 patients who met the inclusion criteria underwent patellar tendon graft for anterior cruciate ligament reconstruction, with concomitant nonoperative management of medial col lateral ligament tears. Follow-up evaluation consisted of physical examina tion for medial laxity, range of motion, and isokinetic and KT-1000 testing. Brace use and postoperative level of competition were also recorded. In addition, the patients completed a subjective assessment question naire rating pain, swelling, and stability. They also rated overall activity level, and any changes in their ability to do the activities tested: walk, climb stairs, run, jump, or twist. Our results indicate that proper reconstruction of the anterior cruciate ligament, in conjunction with nonoperative management of tears of the medial collat eral ligament in combined anterior cruciate ligament- medial collateral ligament injuries, can give excellent stability and good to excellent functional outcome in patients with combined anterior cruciate ligament-me dial collateral ligament injuries.

Fifth Metatarsal Jones Fracture Fixation With a 4.5-mm Cannulated Stainless Steel Screw in the Competitive and Recreational Athlete A Clinical and Radiographic Evaluation

Background Fifth metatarsal Jones fractures are common in the athletic population. Optimal screw selection for operative treatment has not been determined. Hypothesis A 4.5-mm cannulated screw used for fixation of the fifth metatarsal Jones fractures in athletes is an effective treatment approach. Study Design Case series; Level of evidence, 4. Methods The authors studied 23 consecutive athletes (24 feet) who were treated surgically with a 4.5-mm cannulated screw for fifth metatarsal fractures (Jones fracture) with clinical and radiographic assessments. Results There have been no refractures to date. Clinical healing was 100%. The mean percentage healing as shown on radiographs was 98.9%, with a range of 90% to 100%. All athletes returned to sport at a mean time of 7.5 weeks (range, 10 days to 12 weeks). Two athletes experienced a “reinjury” without need for operative treatment. All athletes were recommended to wear orthoses until their competitive careers were completed. Conclusion Fixation with a stainless steel 4.5-mm cannulated screw gives 100% clinical healing and near-100% healing as shown on radiographs. Clinical Relevance The 4.5-mm cannulated screws can yield reliable and effective healing as evidenced by clinical assessment and radiographs of fifth metatarsal Jones fractures in athletes.

Potential Risk of Rerupture in Primary Achilles Tendon Repair in Athletes Younger Than 30 Years of Age

Background Complete Achilles tendon ruptures are found more often in athletes who participate in sports involving explosive acceleration or maximal effort. In most studies, the consensus for athletes is surgery. This form of treatment has been shown to exhibit the best functional performance with a lower rerupture rate. Hypothesis Achilles tendon ruptures in a young population (<30 years) have a higher rerupture rate than similar injuries in an older age group (31-50 years), in which the injury is more common. Study Design Cohort study; Level of evidence, 4. Methods Retrospective study was carried out by chart review. Magnetic resonance images were obtained comparing appearance of repair in young and old patients at 8 to 12 weeks after operation. Results There were a total of 4 reruptures in the 89 Achilles tendon repairs. This was an overall rerupture rate of 4.5%, which was consistent with the literature. When the reruptures were critically analyzed, it was noted that the 4 reruptures of the repaired tendon occurred in a young population. Of the 89, there was a subgroup of athletes (n = 24) who were 30 years of age or younger at the time of injury. The incidence of rerupture for these individuals was 16.6%. In the remaining athletes (n = 65) older than 30 years, the incidence of rerupture was zero. There were no significant differences (P=. 05) in all parameters measured (average days in a boot, average days to active range of motion, average time to full weight-bearing, average days to bike or use a stair climbing machine, average return to sports) between age groups except in the time from injury to surgery (7.1 days, for athletes = 30 years vs 2.65 days for athletes >31 years). Conclusions The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good. However, caution may need to be taken in the younger athlete (= 30 years) during rehabilitation. Clinical Relevance Although the authors recommend aggressive rehabilitation for Achilles tendon repairs, caution should be observed in the younger athlete.

Comparison of 4.5- and 5.5-mm Cannulated Stainless Steel Screws for Fifth Metatarsal Jones Fracture Fixation:

Background: Complications including delayed and nonunions, and extensive time nonweightbearing with conservative treatment of fifth metatarsal Jones fractures, have led authors to recommend surgical fixation for this fracture in athletes who wish to return to activity quickly. The optimal surgical procedure, however, has not been determined. The purpose of this study was to evaluate the effectiveness of 5.5-mm cannulated screw fixation for fifth metatarsal stress fractures in athletes and compare them to an earlier cohort treated with a 4.5mm screw. Materials and Methods: Twenty athletes were treated surgically with a 5.5-mm cannulated screw and postoperatively wore a removable walking boot, applied cold compression, initiated immediate range of motion, and used crutches for 1 week. Fractures were evaluated for clinical and radiographic healing. These findings were compared to a group that used 4.5-mm screws. Results: Average radiographic healing was 96.7% and all fractures healed clinically. Athletes returned to sports in an average of 9.3 weeks. There were three re-injuries that were treated with 2 weeks in a walking boot. No patients have required screw removal or have experienced pain at the hardware site, besides the three re-injuries. When compared to the earlier study, no differences were found. However, there were no re-fractures in the 4.5-mm study, but there were three bent screws. Conclusion: The current study demonstrates the clinical effectiveness of the 5.5-mm screw. However, with the numbers available, we were unable to demonstrate significant improvement over the 4.5-mm screw and thus cannot conclude that a larger screw is more effective. Level of Evidence: III, Retrospective Case Control Study

Acute Achilles Tendon Repair Strength Outcomes After an Acute Bout of Exercise in Recreational Athletes

Background: This is the first study to evaluate the effect of an acute bout of exercise on strength evaluation after Achilles tendon (AT) rupture and repair. Methods: Forty patients sustained an acute AT injury and met inclusion criteria for this study. At a minimum of 12 months after operative repair, patients were measured for (1) calf circumference, (2) bilateral isokinetic strength on a Cybex dynamometer before and after 30 minutes of walking at 70% maximal exertion, and (3) subjective evaluation by AAOS lower limb core and foot and ankle modules. Follow-up occurred at a mean of 32.4 ± 20.7 (range, 12-80) months after surgery, and patients were on average 44.4 ± 8.6 (range, 20-62) years old. One-tailed Student’s paired t tests analyzed significance for strength and fatigue between the involved and uninvolved ankle (P < .05). Results: The calf circumference of the involved ankle was significantly smaller than the uninvolved ankle by 1.9 cm, or 4.7%. Plantarflexion deficits of the involved ankle ranged from 12% to 18% for peak torque (P < .0001) and from 17% to 25% for work per repetition (P < .0001), but both ankles fatigued at equal proportions as measured after exercise. Dorsiflexion strength of the involved ankle increased 6% to 11% for peak torque (P = .070) and 1% to 25% for peak work (P = .386). Reported AAOS lower limb core and foot and ankle scores averaged 99.8 and 96.0, respectively. Conclusion: After an AT rupture with repair, patients had less plantarflexion strength, and equal dorsiflexion strength in the operative leg compared to the uninvolved, normal leg. However, subjective results indicated near normal pain and function despite mild plantarflexion strength deficits. Dorsiflexion strength was normal after repair and remained normal even after an acute bout of exercise. Plantarflexion strength ratios postexercise remained similar to pre-exercise after acute exercise bouts. Athletes reported a “flat tire” feeling while running, which suggests a probable gait adjustment as cause for long-term plantarflexion strength deficits. Level of Evidence: Level III, cohort study.

Arthroscopic Tenodesis of the Long Head of the Biceps

The long head of the biceps (LHB) is commonly implicated in shoulder pathology due to its anatomic course and intimacy with the rotator cuff and superior labrum of the glenoid. Treatment of tendinosis of the LHB may be required secondary to partial thickness tears, instability/subluxation, associated rotator cuff tears, or SLAP (superior labrum, anterior to posterior) lesions. Treatment options include open or arthroscopic techniques for tenodesis vs tenotomy. Controversy exists in the orthopedic literature regarding the preferred procedure. The all-arthroscopic biceps tenodesis technique is a viable and reproducible option for treatment. This article provides a review of the all-arthroscopic biceps tenodesis technique using proximal interference screw fixation and its subsequent postoperative regimen. All-arthroscopic biceps tenodesis maintains elbow flexion and supination power, minimizes cosmetic deformities, and leads to less fatigue soreness after active flexion. Thus, arthroscopic biceps tenodesis should be offered and encouraged as a treatment option for younger, active patients.

Corticosteroid Injections Hasten Return to Play of National Football League Players Following Stable Ankle Syndesmosis Sprains

Objectives: Injuries to the ankle syndesmosis are common in contact athletes and may result in significant time lost from sport. Syndesmosis sprains require more treatment and time off for recovery as compared to lateral ankle sprains. A previous study of collegiate football players described an average of 31 days lost from these injuries treated with standard conservative measures and rehabilitation protocols. Treatment methods for stable syndesmosis sprains are not well documented in the literature. The purpose of this study was to compare our series of stable ankle syndesmosis sprains treated with or without corticosteroid injections. Methods: A retrospective review of ankle syndesmosis sprains from two National Football League (NFL) teams over an eight-year period (2003-2011) was performed. All players were evaluated with standard radiographs as well as magnetic resonance imaging (MRI) to confirm their diagnosis. All players were subsequently treated with (Group 1) or without (Group 2) a corticosteroid injection into the syndesmosis within 72 hours of injury and progressed through a nonoperative rehabilitation program based on the treatment practices of the team. Time lost was calculated as total days from date of onset before returning to unrestricted activity including practice and games. Results: A total of 31 stable ankle syndesmosis sprains were identified. All injuries confirmed with MRI were reviewed. Thirteen players received a corticosteroid injection (Group 1) within the syndesmosis and had an average return of 15 days (5-26). Eighteen players did not receive a corticosteroid injection (Group 2) within the syndesmosis and had an average return of 25 days (1-43). This difference in return was statistically significant (p=0.0097). All players in both groups returned to play. There was one recurrence in Group 1 and two recurrences in Group 2. Conclusion: Ankle syndesmosis sprains are debilitating injuries for NFL players and result in significant time lost from sport. Compared to our control group, the use of corticosteroid injection coupled with standard rehabilitation for acute stable ankle syndesmosis sprains hastened return to play by an average of 40% (10 days). In a highly competitive athlete, this may represent a significant clinical difference.

Effect of Intraoperative Platelet-Rich Plasma Treatment on Postoperative Donor Site Knee Pain in Patellar Tendon Autograft Anterior Cruciate Ligament Reconstruction: A Double-Blind Randomized Controlled Trial:

Background: Donor site morbidity in the form of anterior knee pain is a frequent complication after bone–patellar tendon–bone (BPTB) autograft anterior cruciate ligament (ACL) reconstruction. Hypothesis/Purpose: The purpose was to examine the effect of the intraoperative administration of platelet-rich plasma (PRP) on postoperative kneeling pain. It was hypothesized that PRP treatment would reduce knee pain. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Fifty patients (mean ± SD age, 30 ± 12 years) undergoing BPTB ACL autograft reconstruction were randomized to the PRP (n = 27) or sham (n = 23) treatment. In either case, 10 mL of venous blood was drawn before the induction of anesthesia and either discarded (sham) or processed (PRP) for preparation of a PRP gel to be later mixed with donor site bone chips and inserted into the patellar defect. At 12 weeks, 6 months, 1 year, and 2 years after surgery, patients completed International Knee Documentation Committee (IKDC) forms and visual analog scale pain scores for activities of daily living and kneeling. Healing indices at the donor site were assessed by routine noncontrast magnetic resonance imaging (MRI) at 6 months. Mixed-model analysis of variance was used to assess the effect of PRP on patient symptoms and MRI indices of donor site healing, as measured by the width of the donor site defect. Results: Kneeling pain, pain with activities of daily living, and IKDC scores were not different between treatment groups at any of the time intervals (P = .08-.83). Kneeling pain improved from 12 weeks to 6 months and from 1 to 2 years (P < .05). IKDC scores improved substantially from 12 weeks to 6 months (P < .001) and continued to improve to 2 years (PRP, 86 ± 19; sham, 89 ± 10). MRI indices of donor site healing were not different between treatment groups (P = .53-.90). Conclusion: Whether randomized to receive PRP in their patellar defect or not, patients continued to have similar levels of kneeling pain and patellar defect sizes after autograft BPTB ACL reconstruction. Registration: NCT01765712 (ClinicalTrials.gov identifier).

Arthroscopic Treatment of Osseous Instability of the Shoulder

BackgroundBony deficiency of the anteroinferior glenoid rim as a result of a dislocation can lead to recurrent glenohumeral instability. These lesions, traditionally treated by open techniques, are increasingly being treated arthroscopically as our understanding of the pathophysiology and anatomy of the glenohumeral joint becomes clearer. Different techniques for arthroscopic management have been described and continue to evolve. While the success of the repair is surgeon dependent, the recent advances in arthroscopic shoulder surgery have contributed to the growing acceptance of arthroscopic reconstruction of glenoid bone defects to restore stability.Questions/PurposesThe purpose of this study was to describe arthroscopic surgical management options for patients with glenohumeral osseous lesions and instability.MethodsA comprehensive search of PubMed, Cochrane, and Medline was conducted to identify eligible studies. The reference lists of identified articles were then screened. Both technique articles and long-term outcome studies evaluating arthroscopic management of glenohumeral lesions were included.ResultsStudies included for final analysis ranged from Level II to V evidence. Technique articles include suture anchor fixation of associated glenoid rim fractures, arthroscopic reduction and percutaneous fixation of greater tuberosity fractures, arthroscopic filling (“remplissage”) of the humeral Hill-Sachs lesion, and an all-arthroscopic Latarjet procedure. The overall redislocation rate varied but was consistently <10% with a low complication rate.ConclusionManagement of glenohumeral instability can be challenging but more recent advances in arthroscopic techniques have provided improved means of treating this diagnosis. This manuscript provides a comprehensive review of the arthroscopic treatment of osseous instability of the shoulder. It provides an in depth look at the various treatment options and describes techniques for each.

Proximal Adductor Avulsion Injuries: Outcomes of Surgical Reattachment in Athletes:

Background: Sports-related groin injuries are common among athletes. However, traumatic proximal adductor avulsion injuries are relatively rare groin injuries in the athletic population, with limited case reports describing suture anchor repair. Purpose: To report on the outcomes of surgical reattachment of proximal adductor avulsion injuries in athletes utilizing a suture anchor repair technique. Study Design: Case series; Level of evidence, 4. Methods: Prospective data were collected on patients undergoing surgical reattachment of proximal adductor avulsion injuries from December 2012 to May 2015 by a single surgeon. Six athletes presented after a traumatic sports-related injury with disabling groin pain, adductor weakness, and magnetic resonance imaging confirmation of fibrocartilage avulsion of the proximal adductor with retraction. Patient-reported outcomes (Hip Outcome Score–Activities of Daily Living [HOS-ADL] and Hip Outcome Score–Sport Specific [SS] subscales, modified Harris Hip Score [mHHS], and visual analog scale [VAS] for pain) were collected preoperatively and at a minimum 2-year follow-up. Results: The latest follow-up of each patient averaged 33.4 months postoperatively (range, 25-42.5 months). All patients returned to sporting activities, with 1 minor wound complication that resolved. Paired-samples t tests indicated that the mean latest postoperative scores for all patients were significantly better than their mean preoperative scores (HOS-ADL: 99.0 vs 43.2, HOS-SS: 98.9 vs 8.3, and mHHS: 97.1 vs 44.6, respectively; P < .001 for all). Similarly, there was a significant improvement in mean postoperative VAS scores for all patients (from 89.2 to 2.2; P < .001). Conclusion: Patient-reported outcomes offer an objective measure of hip function and pain control. Surgical reattachment utilizing a multiple suture anchor technique is a successful procedure that allows for a safe return to athletic performance and a predictable return to sport.