David N. M. Caborn

Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability.

Part I of our study consisted of sending a survey questionnaire to all members of the American Shoulder and Elbow Surgeons in which specific questions were asked about their technique of surgical repair in patients with anterior instability who had capsular laxity or injury in conjunction with marked inferior laxity. Part II is a description of the technique and preliminary results in 18 patients of a modified anterior-inferior capsular shift technique that tightens the inferior capsule with the shoulder positioned in abduction and external rotation and the superior capsule with the shoulder in adduction and external rotation. Of the members of the Society of the American Shoulder and Elbow Surgeons who responded to the survey, 80% agreed that preservation of external rotation was important and that shoulder position at the time of capsular repair might influence the ultimate range of motion obtained. However, no more than 50% of the respondents agreed on any one position for the arm when repairing the capsule. The most common responses for each position were flexion 0 degrees (49%) (range, 0 degrees to 40 degrees), abduction 30 degrees (24%) (range, 0 degrees to 80 degrees), and external rotation 30 degrees (37%) (range, 0 degrees to 70 degrees). The average postoperative follow-up period for the 18 patients was 27 months (range, 24 to 39 months). Of the 18 patients, 11 (61%) maintained symmetric motion; the others had minimal loss of external rotation compared with that of the contralateral shoulder. Six of eight patients with repair on the dominant side were able to return to full premorbid recreational throwing or racquet sports, and seven with repair on the nondominant side returned to full participation in overhead sports such as basketball and swimming. We conclude that this method of selective capsular repair may be a useful guideline to gauge the degree of capsular tightening in patients who have capsular injury or laxity.

An anatomic evaluation of T-Fix suture device placement for arthroscopic all-inside meniscal repair.

This investigation documented the locations of endoscopically applied T-Fix suture devices (Acufex Microsurgical, Mansfield, MA) placed in six fresh-frozen cadaveric knees (age, 60 to 72 years) in relationship to the joint capsule, and adjacent neurovascular and musculotendinous structures. Five T-Fix devices were placed in the posterior meniscal regions at approximately 20 degree intervals. Gross dissection enabled T-Fix bar and suture placement identification. Fifty total devices were placed (23 medially and 27 laterally). Lateral: None of the devices penetrated more superficially than the deepest capsular layer (layer III). Six of the 27 devices placed at the posterior horn of the lateral meniscus pierced the popliteus tendon. None of the bars pierced the lateral collateral ligament (layer III). All devices placed at the posterolateral knee were outside the arcuate ligament (layer III) but inside the fabellofibular ligament (layer II). Medial: Seven of the 23 devices pierced the deep medial collateral ligament (MCL, layer III), and 4 pierced the superficial MCL (layer II). Three devices pierced the sartorius tendon (layer I) and one pierced the gracilis tendon (layer II). None of the medial devices created a plicating effect on the posterior capsule. None of the devices were placed near neurovascular structures. Devices placed within the posterior meniscal horns had a > or =1.5-cm buffer zone from the popliteal neurovascular bundle. Most bars (36 of 50) were anchored to the capsular layer (layer III) after piercing the meniscocapsular junction (layer II). T-Fix devices simulating arthroscopic all-inside meniscal repair provided well-positioned, solid suture anchorage through the junction with no neurovascular involvement. Care needs to be taken when placing lateral (popliteus muscle) and medial (gracilis, sartorius tendons and superficial MCL) devices to avoid possible soft tissue tenodesis.

Dynamic Trunk Stabilization: A Conceptual Back Injury Prevention Program for Volleyball Athletes

The sport of volleyball creates considerable dynamic trunk stability demands. Back injury occurs all too frequently in volleyball, particularly among female athletes. The purpose of this clinical commentary is to review functional anatomy, muscle coactivation strategies, assessment of trunk muscle performance, and the characteristics of effective exercises for the trunk or core. From this information, a conceptual progressive 3-phase volleyball-specific training program is presented to improve dynamic trunk stability and to potentially reduce the incidence of back injury among volleyball athletes. Phase 1 addresses low-velocity motor control, kinesthetic awareness, and endurance, with the clinician providing cues to teach achievement of biomechanically neutral spine alignment. Phase 2 focuses on progressively higher velocity dynamic multiplanar endurance, coordination, and strength-power challenges integrating upper and lower extremity movements, while maintaining neutral spine alignment. Phase 3 integrates volleyball-specific skill simulations by breaking down composite movement patterns into their component parts, with differing dynamic trunk stability requirements, while maintaining neutral spine alignment. Prospective research is needed to validate the efficacy of this program.

Frontal plane knee angle affects dynamic postural control strategy during unilateral stance.

PURPOSEnCenter of plantar pressure (COPP) location moves toward the forefoot as ankle plantar flexor muscles attempt to maintain postural control during single leg stance. This study evaluated relationships between frontal plane tibiofemoral joint angulation during relaxed bilateral stance and mean COPP locations during vision-denied single leg stance at 20 degrees knee flexion.nnnMETHODSnFifty-six nonimpaired athletes (29 female, 27 male) were evaluated for frontal plane tibiofemoral joint angulation and standing foot angle by using two-dimensional videography (30 Hz). Mean anterior-posterior and mediolateral COPP locations were assessed during single leg stance on a mat (25 Hz, 15 s). One-way ANOVA and Tukey HSD tests evaluated group differences (P < or = 0.05) based on frontal plane tibiofemoral joint angulation.nnnRESULTSnGroup 1 (genu varus or genu valgus < 5 degrees ) displayed a mean anterior-posterior COPP location of 54.2 +/- 6% from the (0,0) coordinate starting point at the anterolateral foot (10.3 +/- 2 cm from the posterior sensor edge). Group 2 (genu varus angulation > or = 5 degrees ) and group 3 subjects (genu valgus angulation > or = 5 degrees ) displayed mean anterior-posterior COPP locations of 60.6 +/- 8% and 60.7 +/- 7% (8.8 +/- 2 cm and 8.7 +/- 2 cm from the posterior sensor edges), respectively. Group 2 (12.5 +/- 3 N x kg(-1)) and group 3 (12.4 +/- 3.1 N x kg(-1)) subjects also displayed greater mean plantar force magnitude/body weight than group 1 (10.3 +/- 2 N x kg(-1)) subjects. Mean ankle plantar flexor moment magnitudes did not differ between groups.nnnCONCLUSIONSnRearfoot directed mean anterior-posterior COPP locations and greater plantar force magnitudes/body weight suggests that subjects with genu varus or genu valgus relied more on the subtalar and midtarsal joint control function of the ankle plantar flexor muscle group for lower extremity dynamic postural control.

Anterior cruciate ligament reconstruction, rehabilitation, and return to play: 2015 update

Anatomical discoveries and a growing appreciation of the knee as a complex organ are driving innovations in patient care decision-making following anterior cruciate ligament (ACL) injury. Surgeons are increasing their efforts to restore combined mechanical-neurosensory ACL function and placing more consideration on when to reconstruct versus repair native anatomical structures. Surgical options now include primary repair with or without reinforcing the injured ACL with suture-based internal bracing, and growing evidence supports biological augmentation using platelet-rich plasma and mesenchymal stem cells to enhance tissue healing. Physical therapists and athletic trainers are increasing their efforts to facilitate greater athlete cognitive engagement during therapeutic exercise performance to better restore nonimpaired neuromuscular control activation amplitude and timing. Knee brace design and use needs to evolve to better match these innovations and their influence on the rehabilitation plan timetable. There is a growing appreciation for the multifaceted characteristics of the rehabilitation process and how they influence neuromuscular, educational, and psychobehavioral treatment goal achievement. Multiple sources may influence the athlete during the return to sports process and clinical outcome measures need to be refined to better evaluate these influences. This update summarizes contemporary ACL surgical, medical, and rehabilitation interventions and future trends.

Whole body, long-axis rotational training improves lower extremity neuromuscular control during single leg lateral drop landing and stabilization.

BACKGROUNDnPoor neuromuscular control during sports activities is associated with non-contact lower extremity injuries. This study evaluated the efficacy of progressive resistance, whole body, long-axis rotational training to improve lower extremity neuromuscular control during a single leg lateral drop landing and stabilization.nnnMETHODSnThirty-six healthy subjects were randomly assigned to either Training or Control groups. Electromyographic, ground reaction force, and kinematic data were collected from three pre-test, post-test trials. Independent sample t-tests with Bonferroni corrections for multiple comparisons were used to compare group mean change differences (P≤0.05/21≤0.0023).nnnFINDINGSnTraining group gluteus maximus and gluteus medius neuromuscular efficiency improved 35.7% and 31.7%, respectively. Training group composite vertical-anteroposterior-mediolateral ground reaction force stabilization timing occurred 1.35s earlier. Training group knee flexion angle at landing increased by 3.5°. Training group time period between the initial two peak frontal plane knee displacements following landing increased by 0.17s. Training group peak hip and knee flexion velocity were 21.2°/s and 20.1°/s slower, respectively. Time period between the initial two peak frontal plane knee displacements following landing and peak hip flexion velocity mean change differences displayed a strong relationship in the Training group (r(2)=0.77, P=0.0001) suggesting improved dynamic frontal plane knee control as peak hip flexion velocity decreased.nnnINTERPRETATIONnThis study identified electromyographic, kinematic, and ground reaction force evidence that device training improved lower extremity neuromuscular control during single leg lateral drop landing and stabilization. Further studies with other populations are indicated.

Permanent knee sensorimotor system changes following ACL injury and surgery

AbstractThe cruciate ligaments are components of the knee capsuloligamentous system providing vital neurosensory and biomechanical function. Since most historical primary ACL repair attempts were unsuccessful, reconstruction has become the preferred surgery. However, an increased understanding of the efficacy of lesion-site scaffolding, innovative suturing methods and materials, and evolving use of biological healing mediators such as platelet-rich plasma and stem cells has prompted reconsideration of what was once believed to be impossible. A growing number of in vivo animal studies and prospective clinical studies are providing increasing support for this intervention. The significance of ACL repair rather than reconstruction is that it more likely preserves the native neurosensory system, entheses, and ACL footprints. Tissue preservation combined with restored biomechanical function increases the likelihood for premorbid neuromuscular control system and dynamic knee stability recovery. This recovery should increase the potential for more patients to safely return to sports at their desired intensity and frequency. This current concepts paper revisits cruciate ligament neurosensory and neurovascular anatomy from the perspective of knee capsuloligamentous system function. Peripheral and central nerve pathways and central cortical representation mapping are also discussed. Surgical restoration of a more physiologically sound knee joint may be essential to solving the osteoarthritis dilemma. Innovative rehabilitative strategies and outcome measurement methodologies using more holistic and clinically relevant measurements that closely link biomechanical and neurosensory characteristics of physiological ACL functionxa0are discussed. Greater consideration ofxa0task-specific patient physical function and psychobehavioral links should better delineate the true efficacy of all ACL surgical and non-surgical interventions.n Level of evidence IV.

Mesenchymal stem cell therapy in the sports knee: where are we in 2011?

Background: The relationship between biological tissue healing following knee injury or surgery and long-term clinical outcome has come to the forefront of sports medicine practice. This has led many knee surgeons to incorporate biologically mediated healing factors into the management of knee injuries. In particular, the clinical use of mesenchymal stem cells has opened new horizons. Evidence Acquisition: Relevant studies were identified through a search of PubMed from January 2000 to April 2011, combining the term mesenchymal stem cells with articular cartilage, anterior cruciate ligament, and meniscus. Relevant citations from the reference lists of selected studies were also reviewed. Results: Knee injury treatment with mesenchymal stem cells shows potential. Most reports represent animal model studies; few advances have been translated to human clinical applications. Conclusion: Mesenchymal stem cell use to promote healing following knee injury is likely to increase. There are scientific methodological concerns and ethical and legal issues regarding mesenchymal stem cell use for treating knee injuries.

Anatomical Double-Bundle Anterior Cruciate Ligament Reconstruction: Maximizing Benefits While Minimizing Complexity: A Balanced Potential Approach

The rapid development of anatomical double-bundle anterior cruciate ligament (ACL) reconstruction techniques is unprecedented, especially given the 80% to 90% success rate that has been reported for conventional single-bundle ACL reconstruction. However, in vitro and in vivo biomechanical evidence of poor transverse plane rotatory knee control and 10% to 30% complication rates associated with conventional single-bundle ACL reconstruction techniques suggest that a better method of restoring ACL function and improving patient outcomes is needed. Selection of which technique to use and its associated learning curve may decrease its desirability for the average knee surgeon who performs fewer than 10 ACL reconstruction procedures a year. This article describes an anatomical double-bundle ACL reconstruction technique that provides reciprocating double-bundle ACL function and that can be performed using a modified conventional single-bundle ACL reconstruction approach. The double-bundle function provided by this ACL reconstruction technique simulates the native ACL more closely than conventional single-bundle ACL reconstruction techniques. In addition to the aforementioned surgical innovations, there is a dire shortage of well-designed patient outcome studies regarding any of these anatomical double-bundle ACL reconstruction techniques. When considering use of a particular anatomical double-bundle ACL reconstruction technique, the knee surgeon must consider its complexity, how the procedure would influence revision surgery should it be needed, appropriate selection of patients who would benefit the most, additional patient education and behavioral change needs, rehabilitation and conditioning program modifications, and how this procedure may better protect the menisci and mitigate the onset and progression of knee osteoarthritis better than conventional single-bundle ACL reconstruction.

Early surrender to knee arthroplasty…. Not so fast…. Let the knee tissue preservation and function sustainability dialogue begin!

knee sensory components will be removed and replaced with metal and plastic parts. Depending on how the question is proferred the patient’s response may differ considerably. Any difference in the relative appeal between these two offers suggests the need for greater substantive dialogue about the sum consequences of the recommended surgical procedure. Based on both descriptions, knee pain is likely to be reduced. This is a fantastic offer to the patient solely from a pain relief perspective! There is little doubt that TKA when used as an end-stage intervention for knee OA among elderly patients possesses strong efficacy for alleviating pain and improving function. However, its efficacy is considerably less robust if the patient is <70 years of age, is overweight, has less severe joint space narrowing, or displays symptoms of depression or anxiety [1, 2, 4, 10, 11]. Of great concern is an expanding market of younger patients who possess quality-of-life-enhancing activity and societal role interests that necessitate more functionally demanding tasks with highly repetitive and greater magnitude knee impact loading forces and torques [9, 14]. If Suppose a middle-aged patient complains of knee pain and displays compelling radiographic evidence of osteoarthritis at one knee compartment [12]. The surgeon suggests that joint replacement will alleviate this pain. This offer appeals to the patient who has been experiencing escalating knee pain levels for almost a decade. However, perhaps another explanation of the same procedure might not be as appealing. Suppose instead the patient is offered removal of all sensory feedback from the diseased knee through the process of internal knee amputation! With this procedure, all