Eric W. Carson

Complications Related to Anatomic Reconstruction of the Coracoclavicular Ligaments

Background: Anatomic reconstruction of the coracoclavicular (CC) ligaments has become a popular surgical treatment for high-grade acromioclavicular (AC) dislocations, but little has been reported about complications related to these newer surgical techniques. Purpose: We sought to review the complications related to several new techniques for the anatomic reconstruction of the CC ligaments for the treatment of AC separations. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective review of the operative treatment of AC separation utilizing anatomic reconstruction of the CC ligaments by reviewing the case logs of 3 fellowship-trained orthopaedic surgeons at a single academic sports medicine center for the past 5 years using appropriate current procedural terminology codes. The medical records and postoperative radiographs were assessed for complications. Results: Twenty-seven cases of anatomic reconstruction of the CC ligaments were reviewed. All patients had an autograft or allograft ligament reconstruction utilizing either a coracoid tunnel (10 cases) or a loop around the coracoid base (17 cases). Eight complications (80%) were noted in the coracoid tunnel group including 2 coracoid fractures (20%), 5 patients with some loss of reduction (more than 5-mm increased CC interval displacement on subsequent postoperative radiographs) (50%), and 1 patient with an intraoperative failure of the coracoid button fixation (10%). Six patients developed complications in the coracoid loop group (35%) including 3 clavicle fractures (18% within group, 11% overall), 1 patient with loss of reduction (6%), 1 patient with loss of reduction and an infection (6% within group, 4% overall), and 1 patient with adhesive capsulitis postoperatively (6% within group, 4% overall). Conclusion: Newer techniques for the anatomic reconstruction of the CC ligaments may have steep learning curves associated with complications such as coracoid and clavicle fractures. Loss of reduction continues to be associated with the operative treatment of high-grade AC separations. Further refinement of surgical technique and experience with the operative treatment of AC separation is warranted.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Minimum Two Year Clinical Outcomes

Objectives: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. The goal of this study is to compare the clinical outcomes of open subpectoral biceps tenodesis and arthroscopic suprapectoral tenodesis. Our null hypothesis is that both methods yield satisfactory results with regards to shoulder and biceps function, postoperative shoulder scores, pain relief and complications. Methods: Retrospective cohort study. Patients who underwent either arthroscopic suprapectoral or open subpectoral biceps tenodesis for superior labral or long head biceps pathology with a minimum follow-up of 2 years were included in the study. Patients were excluded if they underwent significant additional shoulder procedures, including rotator cuff repair or procedures to address glenohumeral instability, if there was significant pre-operative range of motion deficits due to frozen shoulder or glenohumeral arthritis, or if they had significant contralateral shoulder pathology or surgery. Subjects were evaluated with several clinical outcome measures and physical examination including range of motion and strength. Range of motion and strength measurements were normalized to the asymptomatic contralateral limb. Power analysis indicated that a minimum of 17 subjects were required in each group (34 total) to determine a clinically meaningful difference in the outcome measures. Results: Between 2007 and 2011, 79 patients met all inclusion and exclusion criteria, which included 30 arthroscopic suprapectoral tenodesis (ASPBT) patients and 49 open subpectoral biceps tenodesis (OSPBT) patients. 23 of 30 (76.7%) ASPBT and 28 of 49 (57.1%) OSPBT patients completed clinical follow-up at an average of 3.1 year postoperative (range 2.2 - 4.3 years). The cohorts were similar in terms of age, gender, BMI, smoking and workers compensation status. Overall outcomes for both procedures were satisfactory. No significant differences were noted in post-operative Constant Murley (ASPBT: 89, OSPBT: 92, p = 0.567), ASES (ASPBT: 89, OSPBT: 88, p = 0.845), SANE (ASPBT: 86, OSPBT: 86, p = 0.982), SST (ASPBT: 10, OSPBT: 10, p = 0.597), LHB Score (ASPBT: 91, OSPBT: 94, p = 0.329), or VR-36 (ASPBT: 80, OSPBT: 79, p = 0.833). No significant range of motion or strength differences (expressed as percent of asymptomatic contralateral limb) were noted between procedures. (Table I). Conclusion: Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology. No significant differences in clinical outcomes as determined by several validated outcomes measures were found between the two tenodesis methods, nor were any range of motion or strength deficits noted at minimum two-years post-operatively.

Anatomic and Radiographic Comparison of Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis Sites

Background: Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/Hypothesis: The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis. Study Design: Controlled laboratory study. Methods: A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks. Results: Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach. Conclusion: The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure. Clinical Relevance: This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.

Sports-Related Concussion: Assessment and Management

Most major U.S. professional sports and the National Collegiate Athletic Association (NCAA) have adopted concussion policies. Current National Football League and NCAA guidelines do not permit an athlete with a concussion to return to play on the same day as the injury. No adolescent or high-school athletes with a concussion should be allowed to return to play on the same day regardless of severity. Loss of consciousness is uncommon with concussion. Acute concussion symptoms are generally self-limited, and most symptoms typically resolve within two weeks. Concussion risk and severity may be affected by age, sex, and genetic predisposition. Athletes with a concussion should rest physically and cognitively until symptoms have resolved at rest and with exertion. Rehabilitation following concussion progresses through a stepwise graded fashion. Neuropsychological testing can provide objective data on an athlete after a concussion. However, it alone cannot be used to diagnose a concussion or determine when an athlete is allowed to return to play. Retirement from contact or collision sports may be necessary for an athlete who has sustained multiple concussions or has a history of prolonged symptoms after concussions. Long-term effects of concussions are still relatively unknown, and further research is required to offer guidance for athletes of all levels.

Tissue anchor use in arthroscopic glenohumeral surgery

&NA; Arthroscopic surgery has become the mainstay of treatment of several common glenohumeral pathologies such as tears of the rotator cuff and labrum. Arthroscopic rotator cuff and labral repair provide outcomes comparable to those achieved with traditional open techniques, with the benefits of smaller incisions and less soft‐tissue disruption. Development and improvement of tissue anchors and arthroscopic instrumentation has been integral to the increased popularity of arthroscopic glenohumeral repairs. Current anchors can be categorized by design and material composition. Awareness of the advantages and limitations of these implants may influence anchor selection.

Revision Anterior Cruciate Ligament Reconstruction: The Hospital for Special Surgery Experience

Primary anterior cruciate ligament (ACL) reconstruction continues to be one of the most common procedures performed in orthopedics, resulting in an increasing number of revision cases. Common reasons for primary failure include failure to identify co-existent medial or lateral injury and incorrect tunnel placement, most often involving the femoral side. Our approach to revision surgery involves identification of the mode of failure, meticulous preoperative planning and specific revision techniques to address retained hardware, bone tunnel defects, and incorrect tunnel placement. Results of revision surgery remain inferior to primary reconstruction, and should be regarded as a salvage procedure. However, with improving techniques, successful revision reconstruction can result in a stable knee with acceptable functional outcomes.

Overuse injuries in youth throwing athletes.

Recently, focus has been placed on overuse injuries in youth athletes. What are the most common injuries you see? Eric W. Carson, MD: The one that has gotten the most publicity has been overuse injuries in the shoulders and elbows of throwing athletes, especially those who play baseball, but also sports such as volleyball and other overhead sports. One common problem is glenohumeral internal rotation defi cit (GIRD). David R. Diduch, MD: Primarily, injuries in this group of young athletes involve stress fractures at the growth plates. In addition, the GIRD defi cits that Dr Carson mentioned lead to altered shoulder mechanics and abnormal stressors on the biceps insertion and cause internal impingment problems, superior labrum anterior posterior (SLAP) tears, and rotator cuff partial tears.

Accelerated Return to Play Following Osteochondral Autograft Plug Transfer (OATS)

Objectives: Chondral lesions about the knee are a challenging clinical entity particularly among high performance athletes whose return to play is dependant on the quality and durability of chondral repair. At our institution, we favor osteochondral autograft plug transfer (OATs) when lesion size and location allow, as we believe it results in the most durable cartilage repair currently available due to the transfer of autogenous hyaline cartilage into the area of injury. We further postulate that OATs may allow a more rapid return to play in the athlete population, as the release to full activity is predicated only on adequate time for bony healing and appropriate clinical progress. We investigated the time for return to play in a cohort of competitive athletes who had undergone OATs followed by an accelerated return to play protocol and compared this to previously published timelines for chondral repair procedures. Methods: This was a retrospective chart review of an overall institutional cohort of 152 osteochondral autograft transfer surgeries performed by 4 fellowship trained orthopaedic surgeons over the past 12 years. We identified 20 competitive athletes (average age of 21.6 years) who had undergone isolated OATs procedures of the knee, followed by a physician-directed accelerated progression and return to sports. Athletes were evaluated for clinical outcomes, and time until full return to their prior level of athletic competition. Results: In this cohort, osteochondral autograft transfer was carried out to address femoral condylar lesions in all 20 patients. The donor site was either the superolateral portion of the lateral condyle or the intercondylar notch. The average lesion size was 134mm2 (36-280mm2). The average number of plugs per lesion was 2.15, with a maximum of 4 plugs and 6 patients receiving more than 2. Our bias is to use fewer, larger plugs when possible. All patients were kept partial weight bearing initially, and released to normal ambulation as early as 2 weeks for single plugs and by week 6 for multiple plugs and then advanced as tolerated. The average time until release to play in this cohort was 88.4 days (39-185), with successful resumption of sports in all patients. There were no clinical failures in this cohort and no patient required a revision surgery. Four patients did develop a joint effusion at one point along their recovery course and required aspiration and intra-articular injection. Conclusion: Based on our findings, we assert that an accelerated return to play protocol following osteochondral autograft transfer will allow for a predictable and more rapid return to sports. This has resulted in a substantially reduced time to pre-injury activity levels in our elite athlete population when compared to the currently available literature. The majority of our patients in this cohort (80%) were cleared to resume athletics by 3 months post OATs procedure. When compared to the current literature on return to play after chondral surgery of the knee1, this represents a greater than 50% more rapid return to full activities in these patients.

Biceps Tenodesis: How Low Do You Go? A Comparison of Location Between Arthroscopic Suprapectoral and Open Subpectoral Techniques

Objectives: Long head biceps (LHB) tenodesis can be performed open or arthroscopically and can be positioned in a suprapectoral or subpectoral position. Suprapectoral tenodesis is easier to accomplish arthroscopically, whereas the subpectoral tenodesis is performed as an open procedure with a longitudinal skin incision at the lower border of the pectoralis major muscle. Numerous studies have investigated these tenodesis techniques, comparing them to tenotomy, and comparing fixation methods between techniques, however, no study has compared the actual postoperative clinical location of suprapectoral and subpectoral LHB tenodesis. The goal of this study is to compare the radiographic location of clinically-performed arthroscopic suprapectoral and open subpectoral biceps tenodesis. Methods: Study Design: Retrospective study. The charts of all patients who underwent arthroscopic or open biceps tenodesis in the past 5 years were reviewed. We routinely obtained post-operative x-rays in these patients and those with available x-rays and complete preoperative information were included in the study. Analysis: The location of all tenodesis sites were measured on x-rays as the distance from the top of the humeral head. Means and standard deviations were calculated and compared using Student’s t-test. Outliers were identified as patients with tenodesis locations greater than one standard deviation from the mean. Preoperative clinical characteristics of these patients were compared to the remaining tenodesis patients using Student’s t test for continuous variables and chi square tests for categorical variables. Results: We identified 158 patients who met inclusion criteria, which included 66 open subpectoral tenodeses and 92 arthroscopic tenodeses. Power analysis determined that 47 patients in each group (94 total) was the minimum number necessary to determine an 8 mm difference between groups. The average distance from the top of the humerus (TDH) in the arthroscopic suprapectoral group was 4.89 ± 0.8 cm, and in the open subpectoral group, 7.52 ± 1.2 cm. (Fig 1) This difference is statistically significant (p<0.0001). 12 (18%) distal outliers (more than one standard deviation distal) were found in the open subpectoral group. 11 (12%) proximal outliers were found in the arthroscopic suprapectoral group. Analysis determined that increased BMI and male gender were significant predictors for distal placement of an open tenodesis. No significant predictors of proximal arthroscopic tenodesis were found. Published cadaveric data localizes the proximal edge of the pectoralis major tendon to be 5.6 cm distal to the top of the humerus. Our data indicates that arthroscopic suprapectoral tenodesis results in a tenodesis location very near (within 0.7 cm on average) the proximal edge of pectoralis major tendon. Open subpectoral technique results in a truly subpectoral location, 1.9 cm distal to the proximal edge of the tendon, likely representing the clinical height of the pectoralis major tendon at the bicipital groove. Conclusion: Arthroscopic suprapectoral and open subpectoral techniques result in significantly different locations of biceps tenodesis. Surgeons experienced in these techniques can expect, on average, to localize their tenodesis just proximal to the pectoralis major tendon using an arthroscopic technique and just distal to the tendon using an open subpectoral technique. The clinical significance of these findings is currently being studied.

The Effects of Knee Support on the Sagittal Lower-Body Joint Kinematics and Kinetics of Deep Squats

Little work has been done to examine the deep squat position (>130° sagittal knee flexion). In baseball and softball, catchers perform this squat an average of 146 times per nine-inning game. To alleviate some of the stress on their knees caused by this repetitive loading, some catchers wear foam knee supports. OBJECTIVES This work quantifies the effects of knee support on lower-body joint kinematics and kinetics in the deep squat position. METHODS Subjects in this study performed the deep squat with no support, foam support, and instrumented support. In order to measure the force through the knee support, instrumented knee supports were designed and fabricated. We then developed an inverse dynamic model to incorporate the support loads. From the model, joint angles and moments were calculated for the three conditions. RESULTS With support there is a significant reduction in the sagittal moment at the knee of 43% on the dominant side and 63% on the non-dominant side compared to without support. These reductions are a result of the foam supports carrying approximately 20% of body weight on each side. CONCLUSION Knee support reduces the moment necessary to generate the deep squat position common to baseball catchers. Given the short moment arm of the patella femoral tendon, even small changes in moment can have a large effect in the tibial-femoral contact forces, particularly at deep squat angles. Reducing knee forces may be effective in decreasing incidence of osteochondritis dissecans.