David P. Trofa

Silver-Impregnated Occlusive Dressing Reduces Rates of Acute Periprosthetic Joint Infection After Total Joint Arthroplasty

BACKGROUND Commercial silver-impregnated occlusive dressings (such as AQUACEL® Ag SURGICAL Cover Dressing) have been touted as antimicrobial dressings to be used following total joint arthroplasty. Given the increased cost of an AQUACEL® Ag SURGICAL Cover Dressing over a standard dressing for total joint arthroplasty, the objective of this study was to determine whether AQUACEL® Ag SURGICAL Cover Dressing is effective in reducing the rates of acute periprosthetic joint infection (PJI) compared to standard sterile dressing. METHODS We retrospectively reviewed the charts of 1173 consecutive patients who underwent a total knee or total hip arthroplasty between 2007 and 2015 by 1 surgeon. The surgeon switched from using a standard xeroform/gauze dressing to an AQUACEL® Ag SURGICAL Cover Dressing in June 2011, with no other major changes in antimicrobial management. Charts were reviewed for evidence of acute PJI (within 3 months of surgery). RESULTS There were a total of 11 cases of acute PJI in this patient cohort (0.94%). The incidence of acute PJI for patients managed with a sterile xeroform dressing was 1.58% (9 of 568 patients), compared to 0.33% (2 of 605 patients) with the use of AQUACEL® Ag SURGICAL Cover Dressing. Univariate analysis showed this to be statistically significant (P = .03), and a multiple logistic regression model supported AQUACEL® Ag SURGICAL Cover Dressing as a protective factor with an odds ratio of 0.092 (95% confidence interval, 0.017-0.490; P = .005). CONCLUSION This 4-fold decrease in acute PJI with the use of AQUACEL® Ag SURGICAL Cover Dressing supports the use of silver-impregnated occlusive dressings for the reduction of acute PJI.

Professional Athletes' Return to Play and Performance After Operative Repair of an Achilles Tendon Rupture.

Background: Most Achilles tendon ruptures are sports related. However, few studies have examined and compared the effect of surgical repair for complete ruptures on return to play (RTP), play time, and performance across multiple sports. Purpose: To examine RTP and performance among professional athletes after Achilles tendon repair and compare pre- versus postoperative functional outcomes of professional athletes from different major leagues in the United States. Study Design: Cohort study; Level of evidence, 3. Methods: National Basketball Association (NBA), National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) athletes who sustained a primary complete Achilles tendon rupture treated surgically between 1989 and 2013 were identified via public injury reports and press releases. Demographic information and performance-related statistics were recorded for 2 seasons before and after surgery and compared with matched controls. Statistical analyses were used to assess differences in recorded metrics. Results: Of 86 athletes screened, 62 met inclusion criteria including 25 NBA, 32 NFL, and 5 MLB players. Nineteen (30.6%) professional athletes with an isolated Achilles tendon rupture treated surgically were unable to return to play. Among athletes who successfully returned to play, game participation averaged 75.4% (P < .001) and 81.9% (P = .002) of the total games played the season before injury at 1 and 2 years postoperatively, respectively. Play time was significantly decreased and athletes performed significantly worse compared with preoperative levels at 1 and 2 years after injury (P < .001). When players were compared with matched controls, an Achilles tendon rupture resulted in fewer games played (P < .001), decreased play time (P = .025), and worse performance statistics (P < .001) at 1 year but not 2 years postoperatively (P > .05). When individual sports were compared, NBA players were most significantly affected, experiencing significant decreases in games played, play time, and performance. Conclusion: An Achilles tendon rupture is a devastating injury that prevents RTP for 30.6% of professional players. Athletes who do return play in fewer games, have less play time, and perform at a lower level than their preinjury status. However, these functional deficits are seen only at 1 year after surgery compared with matched controls, such that players who return to play can expect to perform at a level commensurate with uninjured controls 2 years postoperatively.

Visualization of the Capitellum During Elbow Arthroscopy: A Comparison of 3 Portal Techniques

Background: Capitellar osteochondritis dissecans (OCD) is a debilitating condition of unknown etiology for which various arthroscopic treatments are available. Prior data suggest that greater than 75% of the capitellum can be visualized arthroscopically through a dual lateral portal approach. However, there is no literature assessing arthroscopic visualization of the capitellum via alternative portals. Purpose: To determine the percentage of capitellum visualized using the dual lateral, distal ulnar and soft spot, and posterolateral and soft spot portal configurations in a cadaver model. Study Design: Descriptive laboratory study. Methods: Arthroscopy was performed on 12 fresh-frozen cadaver elbows, 4 for each of the following approaches: dual lateral, distal ulna, and posterolateral. Electrocautery was used to mark the most anterior, posterior, medial, and lateral points seen on the capitellum. The radiocapitellar joint was subsequently exposed through an extensile posterior dissection, and the surface anatomy was reconstructed using the Microscribe 3D digitizing system. Using Rhinoceros software, the percentage of capitellum surface area visualized by each approach was determined. Results: The mean percentage of capitellum visualized for the dual lateral, distal ulna, and posterolateral approaches was approximately 68.8%, 66.3%, and 63.5%, respectively. There was no significant difference between the percentage of capitellum seen among approaches (P = .68). On average, 66.5% of the capitellum was visible through these 3 arthroscopic approaches to the elbow. Conclusion: Approximately 66.5% of the capitellum is visualized through the popularized posterior arthroscopic portals, with no significant differences found between the 3 investigated approaches. Clinical Relevance: As determined in this cadaveric model investigation, each portal technique provides equivalent visualization for capitellar OCD pathology.

The Impact of Body Checking on Youth Ice Hockey Injuries

Background: Body checking is a common cause of youth ice hockey injuries. Consequently, USA Hockey raised the minimum age at which body checking is permitted from the Pee Wee level (11-12 years old) to the Bantam level (13-14 years old) in 2011. Purpose/Hypothesis: The purpose of this investigation was to determine the impact of body checking on the distribution of injuries reported in youth ice hockey players. We hypothesized that the elimination of body checking at the Pee Wee level would lower the frequency of serious injuries, particularly concussions. Study Design: Descriptive epidemiology study. Methods: Injury data from the National Electronic Injury Surveillance System (NEISS), a United States Consumer Product Safety Commission database, were analyzed for Pee Wee and Bantam players between January 1, 2008 and December 31, 2010 and again between January 1, 2013 and December 31, 2015. Data on the location of injury, diagnosis, and mechanism of injury were collected. The location of injury was categorized into 4 groups: head and neck, upper extremity, lower extremity, and core. Diagnoses investigated included concussions, fractures, lacerations, strains or sprains, internal organ injuries, and other. The mechanism of injury was broken down into 2 categories: checking and other. Results: Between the 2008-2010 and 2013-2015 seasons, overall injuries decreased by 16.6% among Pee Wee players, with injuries caused by body checking decreasing by 38.2% (P = .012). There was a significant change in the distribution of diagnoses in the Pee Wee age group during this time frame (P = .007): strains or sprains, internal organ injuries, and fractures decreased in frequency, while the number of concussions increased by 50.0%. In the Bantam age group, recorded injuries decreased by 6.8%, and there was no change in the distribution of the location of injury, diagnosis, or mechanism of injury (P > .05). Conclusion: There was an observed reduction in the total number, mechanism, and type of injuries when body checking was eliminated from the Pee Wee level. There was, however, an unexpected increase in the number of concussions.

Rehabilitation variability following medial patellofemoral ligament reconstruction

ABSTRACT Background: Medial patellofemoral ligament (MPFL) reconstruction is an increasingly utilized surgical option for recurrent patellar instability. Recent studies have highlighted the potential benefits of accelerated functional rehabilitation; however, no validated MPFL rehabilitation guidelines currently exist. Objective: To assess the variability of MPFL reconstruction rehabilitation protocols published online by academic orthopaedic programs. Methods: Online MPFL rehabilitation protocols from U.S. teaching orthopaedic programs were reviewed. A comprehensive scoring rubric was developed to assess each protocol for both the presence of various rehabilitation components and the timing of their introduction. Results: Thirty-one protocols (20%) were identified from 155 U.S. academic orthopaedic programs. Thirty protocols (97%) recommended immediate postoperative knee bracing. Twenty protocols (65%) allowed for weight-bearing as tolerated using crutches immediately postoperatively, whereas seven protocols (23%) recommended partial weight-bearing and four protocols (13%) recommended toe-touch weight-bearing. For those protocols advising partial and toe-touch weight-bearing, advancement to full weight-bearing was achieved at averages of 4.7 (range, 3–8) weeks and 6.3 (range, 6–7) weeks, respectively. There was considerable variation in range of motion (ROM) goals; however, most protocols (97%) recommended achieving 90 degrees of knee flexion at an average of 1.4 (range, 0–6) weeks. Significant diversity was found in the inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular exercises. Twenty-five protocols (81%) recommended return to training after completing specific athletic criteria. Conclusions: A minority of U.S. teaching orthopaedic institutions publish MPFL reconstruction rehabilitation protocols online. Furthermore, there is a high degree of variability in both the composition and timing of rehabilitation modalities across these protocols.

Athletic Hip Injuries in Major League Baseball Pitchers Associated With Ulnar Collateral Ligament Tears

Background: Ulnar collateral ligament (UCL) reconstruction is a reliable treatment for elite overhand throwers with UCL tears. In recent years, this procedure has become increasingly common among Major League Baseball (MLB) pitchers. Predisposing factors and associated comorbidities, however, have not been fully elucidated. Purpose/Hypothesis: The purpose of this study was to determine whether professional baseball pitchers who underwent UCL reconstruction had an increased incidence of hip or groin injuries 4 years before or after surgery. We hypothesized that MLB pitchers who sustain hip or groin injuries may be more likely to develop UCL tears because of alterations and overcompensation in the kinetic chain during overhand throwing. Study Design: Cohort study; Level of evidence, 3. Methods: A comprehensive list of all 247 MLB players who underwent UCL reconstruction between 2005 and 2017 was created using publicly accessible online data. The application of inclusion criteria yielded a final sample size of 145 athletes. These athletes’ injury histories were identified and cross-referenced with the official MLB disabled list. Matched controls were generated for a comparison of results. Results: Of the 145 MLB pitchers who underwent UCL reconstruction between 2005 and 2017, 40 (27.6%) endured a proximal lower extremity injury within 4 years of their surgery. Specifically, 16 pitchers sustained hip injuries, 13 suffered hamstring injuries, and 14 experienced groin injuries. A significantly lower rate of hip- and groin-related injuries (17.9%) was identified in matched controls during a similar time frame (P = .049). Conclusion: The results of this study demonstrate that MLB pitchers who required UCL reconstruction sustained a higher frequency of proximal lower extremity injuries both before and after surgery compared with matched controls. This finding is significant as the treatment of antecedent hip lesions, as well as an emphasis on hip and core muscle mobility and strengthening, may help reduce injuries to the UCL.

Variability of United States Online Rehabilitation Protocols for Proximal Hamstring Tendon Repair

Background: The optimal postoperative rehabilitation protocol following repair of complete proximal hamstring tendon ruptures is the subject of ongoing investigation, with a need for more standardized regimens and evidence-based modalities. Purpose: To assess the variability across proximal hamstring tendon repair rehabilitation protocols published online by United States (US) orthopaedic teaching programs. Study Design: Cross-sectional study. Methods: Online proximal hamstring physical therapy protocols from US academic orthopaedic programs were reviewed. A web-based search using the search term complete proximal hamstring repair rehabilitation protocol provided an additional 14 protocols. A comprehensive scoring rubric was developed after review of all protocols and was used to assess each protocol for both the presence of various rehabilitation components and the point at which those components were introduced. Results: Of 50 rehabilitation protocols identified, 35 satisfied inclusion criteria and were analyzed. Twenty-five protocols (71%) recommended immediate postoperative bracing: 12 (34%) prescribed knee bracing, 8 (23%) prescribed hip bracing, and 5 (14%) did not specify the type of brace recommended. Fourteen protocols (40%) advised immediate nonweightbearing with crutches, while 16 protocols (46%) permitted immediate toe-touch weightbearing. Advancement to full weightbearing was allowed at a mean of 7.1 weeks (range, 4-12 weeks). Most protocols (80%) recommended gentle knee and hip passive range of motion and active range of motion, starting at a mean 1.4 weeks (range, 0-3 weeks) and 4.0 weeks (range, 0-6 weeks), respectively. However, only 6 protocols (17%) provided specific time points to initiate full hip and knee range of motion: a mean 8.0 weeks (range, 4-12 weeks) and 7.8 weeks (range, 0-12 weeks), respectively. Considerable variability was noted in the inclusion and timing of strengthening, stretching, proprioception, and cardiovascular exercises. Fifteen protocols (43%) required completion of specific return-to-sport criteria before resuming training. Conclusion: Marked variability is found in both the composition and timing of rehabilitation components across the various complete proximal hamstring repair rehabilitation protocols published online. This finding mirrors the variability of proposed rehabilitation protocols in the professional literature and represents an opportunity to improve patient care.

Online Physical Therapy Protocol Quality, Variability, and Availability in Achilles Tendon Repair

Background: Substantial progress has been made in characterizing the benefit of early functional rehabilitation following Achilles tendon repair (ATR). However, standardized ATR rehabilitation guidelines have yet to be produced. Furthermore, as patients increasingly use the Internet to independently retrieve health care content, access to standardized, clinically effective rehabilitation protocols is necessary. Methods: Online ATR physical therapy protocols from US academic orthopaedic programs were reviewed. A comprehensive scoring rubric was designed after reviewing all identified protocols and was used to assess each protocol for both the presence of various rehabilitation components as well as when those components were introduced. Results: Twenty-two of 155 US academic orthopaedic programs published postoperative Achilles rehabilitation protocols online, with a total of 27 individual protocols available for review. Twenty-one protocols (78%) recommended immediate postoperative splinting. Only one protocol recommended short-leg casting. Twenty-six protocols (96%) advised immediate nonweightbearing with progression to weightbearing as tolerated at an average of 3.0 weeks (range, 1-8 weeks) and to full weightbearing at an average of 7.3 weeks (range, 2-12 weeks). Active plantarflexion and dorsiflexion to neutral were included by most protocols (93%) at an average of 3.9 (range, 0-9) weeks and 3.4 (range, 0-8) weeks, respectively. There was considerable variability in the inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular exercises. Fourteen protocols (52%) recommended return to training after meeting certain athletic activity criteria. Conclusion: The purpose of this investigation was to evaluate the quality, variability, and patient accessibility of publicly available rehabilitation protocols for ATR provided by US orthoapedic teaching programs. To this end, we found that a minority of US academic orthopaedic programs publish ATR rehabilitation protocols online. While a trend away from traditional ankle casting is apparent, many programs have not adopted the accelerated weightbearing and controlled mobilization techniques that have been shown to produce better functional outcomes and greater patient satisfaction. There is also a substantial degree of variability in both the composition and timing of rehabilitation components across physical therapy protocols. Levels of Evidence: Level III: Retrospective comparative study

Elbow Arthroscopy for Treatment of Valgus Extension Overload

Valgus extension overload syndrome (VEO) is the result of supraphysiologic stresses placed across the posterior elbow during pitching. Following failure of nonoperative measures, surgical options consist of arthroscopic or limited incision posteromedial decompression. Although technically challenging, arthroscopic treatment offers many advantages over open treatment, including improved joint visualization, decreased soft-tissue dissection, decreased postoperative pain, and quicker rehabilitation. Arthroscopic treatment of VEO consists of soft tissue and bony debridement, loose body removal, and osteophyte resection. This technique report details the steps of arthroscopic treatment of VEO in a patient with a subluxating ulnar nerve.

Distal Knee Medial Collateral Ligament Repair With Suture Augmentation

The medial collateral ligament (MCL) is the most commonly injured ligament of the knee. Given its extra-articular location, the MCL has great healing capacity such that the mainstay of treatment for most injuries remains conservative management. However, certain injury patterns place patients and athletes at risk of residual valgus laxity, which may require delayed surgical care and prolonged time out from sports. As such, identifying the specific injuries known to place patients at risk for failure with nonoperative management is of paramount importance. Although controversy remains regarding the optimal treatment of grade III MCL injuries, it is generally accepted that MCL ruptures from the distal tibia attachment require operative fixation. This technique article with accompanying video provides a detailed description of a technique for repairing the distal MCL attachment with suture augmentation. There are several advantages associated with an augmented direct repair including early, safe rehabilitation; prevention of valgus instability; and avoiding the comorbidities associated with a larger reconstruction.