George A. Paletta

Incidence and trends of anterior cruciate ligament reconstruction in the United States

Background: Anterior cruciate ligament (ACL) injury is among the most commonly studied injuries in orthopaedics. The previously reported incidence of ACL injury in the United States has varied considerably and is often based on expert opinion or single insurance databases. Purpose: To determine the incidence of ACL reconstruction (ACLR) in the United States; to identify changes in this incidence between 1994 and 2006; to identify changes in the demographics of ACLR over the same time period with respect to location (inpatient vs outpatient), sex, and age; and to determine the most frequent concomitant procedures performed at the time of ACLR. Study Design: Descriptive epidemiological study. Methods: International Classification of Diseases, 9th Revision (ICD-9) codes 844.2 and 717.83 were used to search the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) for the diagnosis of ACL tear, and the procedure code 81.45 was used to search for ACLR. The incidence of ACLR in 1994 and 2006 was determined by use of US Census Data, and the results were then stratified based on patient age, sex, facility, concomitant diagnoses, and concomitant procedures. Results: The incidence of ACLR in the United States rose from 86,687 (95% CI, 51,844-121,530; 32.9 per 100,000 person-years) in 1994 to 129,836 (95% CI, 94,993-164,679; 43.5 per 100,000 person-years) in 2006 (P = .015). The number of ACLRs increased in patients younger than 20 years and those who were 40 years or older over this 12-year period. The incidence of ACLR in females significantly increased from 10.36 to 18.06 per 100,000 person-years between 1994 and 2006 (P = .0003), while that in males rose at a slower rate, with an incidence of 22.58 per 100,000 person-years in 1994 and 25.42 per 100,000 person-years in 2006. In 2006, 95% of ACLRs were performed in an outpatient setting, while in 1994 only 43% of ACLRs were performed in an outpatient setting. The most common concomitant procedures were partial meniscectomy and chondroplasty. Conclusion: The incidence of ACLR increased between 1994 and 2006, particularly in females as well as those younger than 20 years and those 40 years or older. Research efforts as well as cost-saving measures may be best served by targeting prevention and outcomes measures in these groups. Surgeons should be aware that concomitant injury is common.

Contact Pressures at Osteochondral Donor Sites in the Knee

The purposes of this study were to determine whether any of the commonly recommended osteochondral donor sites are nonarticulating throughout a functional range of knee motion, and to determine the differential contact pressures for these sites. Ten commonly recommended sites for osteochondral harvest were evaluated with pressure-sensitive film through a functional range of motion with a model that simulated nonweightbearing resistive extension of the knee. All 10 donor sites demonstrated a significant contact pressure through 0° to 110° of knee motion. The different color density measurements between donor sites were also significant. Although donor sites 1, 2, 9, and 10 demonstrated significantly less contact pressure than the sites with the greatest contact pressure, the difference in mean pressures was small. No osteochondral donor site tested was free from contact pressure. It is currently unknown whether articular contact at these osteochondral donor sites will lead to degenerative changes or any other problems.

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome)

OBJECTIVES The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. METHODS A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. RESULTS Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01). CONCLUSIONS Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.

The Modified Docking Procedure for Elbow Ulnar Collateral Ligament Reconstruction 2-Year Follow-up in Elite Throwers

Background Ulnar collateral ligament injury is most common in the overhead-throwing athlete. Jobe et al published the first report of ulnar collateral ligament reconstruction in throwing athletes with a 62.5% success rate. Recently, Altchek developed a new docking technique for reconstruction of the ulnar collateral ligament. The authors report the first series using a further modification of the docking technique using a 4-strand palmaris longus graft for reconstruction of the ulnar collateral ligament. Hypothesis The modified docking technique yields a high rate of successful return to preinjury level of competition in elite baseball players. Study Design Case series; Level of evidence, 4. Methods The authors retrospectively reviewed 25 elite professional or scholarship collegiate baseball players who underwent elbow ulnar collateral ligament reconstruction using the modified docking procedure with a minimum 2-year follow-up. Results Twenty-three of 25 (92%) were able to return to their preinjury levels of competition. The mean time to return was 11.5 months (range, 10-16 months). Complications included 1 transient postoperative ulnar nerve neurapraxia and 1 stress fracture of the ulnar bone bridge that occurred at 14 months postoperatively, after a full return to pitching. Conclusion The modified docking technique yields highly successful return to preinjury level of competition rates (92%) in a select group of elite baseball players.

The Relationship of the Femoral Origin of the Anterior Cruciate Ligament and the Distal Femoral Physeal Plate in the Skeletally Immature Knee An Anatomic Study

We defined the anatomic relationship of the anterior cruciate ligament femoral origin to the distal femoral physis in the skeletally immature knee with use of 12 fresh-frozen human fetal specimens (ages, 20 to 36 weeks). Each specimen underwent magnetic resonance imaging, was dissected free of soft tissue, sectioned in the sagittal plane, and stained. The spatial relationship of 1) the epiphyseal side of the physeal proliferative zone to the nearest point of bony attachment of the anterior cruciate ligament and 2) the origin of the anterior cruciate ligament to the over-the-top position were measured. The same measurements were made in 13 skeletally immature knees (ages, 5 to 15 years). We found that the femoral origin of the fetal anterior cruciate ligament developed as a confluence of ligament fibers with periosteum at 20 weeks, vascular invasion into the epiphysis at 24 weeks, and establishment of a secure epiphyseal attachment by 36 weeks. In the fetus, the distance from the anterior cruciate ligament femoral origin to the epiphysis was 2.66 ± 0.18 mm (range, 2.34 to 2.94). There was no significant change in this distance in adolescent specimens (2.92 ± 0.68 mm; range, 2.24 to 3.62). The over-the-top position was at the level of the distal femoral physis.

Patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers.

To determine if the incidence and patterns of meniscal injury associated with acute anterior cruciate ligament injury in skiers are different from those seen in individ uals injured in nonskiing athletic activities, we reviewed the records of 150 patients with acute anterior cruciate ligament injuries. All patients had undergone arthro scopic evaluation within 21 days from the time of injury. There were 75 individuals who were injured while skiing and 75 individuals who sustained an injury in some other high-load athletic activitiy. Associated meniscal injury was documented at the time of arthroscopy and characterized by location, region, zone, depth, shape, size, and stability. Thirty-one of 75 skiers had an associated meniscal injury as compared to 47 of 75 of the nonskiers. This suggested a strong trend of decreased incidence of meniscal injury in the skier group, but the nonskiers had a higher incidence of major meniscal tears that required repair or partial meniscectomy. The location of the meniscal tear was also significantly different. The incidence of isolated lateral meniscal injury in skiers was higher than in nonskiers. There was a strong trend of increased incidence of medial meniscal involvement in the nonskiers than in the skiers. While there was no difference in the zone or region of tear between the two groups, the skier group was more likely to have a longitudinal tear of the posterior horn of the lateral meniscus. In both groups, lateral meniscal tears were more likely to require conservative treatment or partial meniscectomy while medial meniscal tears were more likely to be repaired than excised.

Biomechanical Evaluation of 2 Techniques for Ulnar Collateral Ligament Reconstruction of the Elbow

Background Elbow medial ulnar collateral ligament tears often result in pain and instability that may be career threatening in overhead-throwing athletes. Surgical reconstruction is frequently chosen to treat this injury. Ulnar collateral ligament reconstruction as described by Jobe is the most commonly used technique. Testing of this construct has not demonstrated that the biomechanical parameters of the native ligament are restored. A more recent construct, the docking technique, may more reliably reproduce these factors. Hypothesis Increasing the number of strands of palmaris longus tendon graft used in ulnar collateral ligament reconstruction and tensioning them using the docking technique result in a construct with improved biomechanical parameters as compared with the Jobe technique. Study Design Controlled laboratory study. Methods Thirty-three fresh-frozen human cadaveric elbows were randomized into 3 subgroups: Jobe (11), docking (12), and native (10). The Jobe and docking groups underwent reconstruction using their described palmaris tendon graft constructs. The ulnar collateral ligament was left intact in the native group. Elbows were potted and tested using a servohydraulic materials testing machine to apply a valgus moment at 30° of elbow flexion. Maximal moments to failure, stiffness, and strain at maximal moment and with a 3 N·m force applied were determined using a 2-camera motion analysis system to track reflective markers spanning the site. Results The docking (14.3 N·m) and native (18.8 N·m) subgroups resulted in higher maximal moment to failure than did the Jobe (8.9 N·m) subgroup (P <. 001). There was no significant difference between native and docking groups (P >. 05). Native ligaments were stiffer (301.4 N·m) than were Jobe (74.3 N·m) or docking (80.8 N·m; P <. 001). Native ligaments demonstrated lower strain at maximal force (0.087 mm/mm) and 3 N·m forces (0.030 mm/mm) than did the Jobe (0.198/0.057 mm/mm) or docking (0.287/0.042 mm/mm) subgroups. There was no difference in stiffness or strain between the Jobe and docking subgroups (P >. 05). Conclusion Neither technique reproduced the biomechanical profile of the native ulnar collateral ligament; the findings of this study suggest that the docking construct may offer initial biomechanical advantage over the Jobe construct.

Positional compression of the axillary artery causing upper extremity thrombosis and embolism in the elite overhead throwing athlete

OBJECTIVES To describe the spectrum of axillary artery pathology seen in high-performance overhead athletes and the outcomes of current treatment. METHODS A retrospective review of patients that had undergone management of axillary artery lesions in a specialized center for thoracic outlet syndrome (TOS). Treatment outcomes were assessed with respect to arterial pathology and operative management. RESULTS Nine male athletes were referred for arterial insufficiency in the dominant arm between January 2000 and August 2010, representing 1.6% of 572 patients treated for TOS (19% of 47 patients treated for arterial TOS). Seven were elite baseball pitchers (six professional, one collegiate), and two were professional baseball coaches with practice pitching responsibilities, with a mean age of 30.9 ± 2.9 years. Presenting symptoms included arm fatigue (five), finger numbness (four), cold hypersensitivity/Raynauds (two), rest pain (one), and cutaneous fingertip embolism (one). Three patients underwent transcatheter thrombolysis prior to referral, including one with angioplasty and stenting. At angiography and surgical exploration 2.5 ± 0.8 weeks after symptom presentation (range, 1-8 weeks), six patients had occlusion of the distal axillary artery opposite the humeral head either at rest (three) or with arm elevation (three), one had axillary artery dissection with positional occlusion, and two had thrombosis of circumflex humeral artery aneurysms. Five patients had embolic arterial occlusions distal to the elbow. Treatment included segmental axillary artery repair with saphenous vein (n = 7; five interposition bypass grafts and two patch angioplasties), ligation/excision of circumflex humeral artery aneurysms (n = 2), and distal artery thrombectomy/thrombolysis (n = 2). Mean postoperative hospital stay was 3.8 ± 0.5 days, and the time until resumption of unrestricted overhead throwing was 10.8 ± 2.7 weeks. At a median follow-up of 15 months (range, 3-123 months), primary-assisted patency was 89%, and secondary patency was 100%. All nine patients had continued careers in professional baseball, although one retired during long-term follow-up. CONCLUSIONS Repetitive positional compression of the axillary artery can cause a spectrum of pathology in the overhead athlete, including focal intimal hyperplasia, aneurysm formation, segmental dissection, and branch vessel aneurysms. Prompt recognition of these rare lesions is crucial given their propensity toward thrombosis and distal embolism, with positional arteriography necessary for diagnosis. Full functional recovery can usually be anticipated within several months of surgical treatment, consisting of mobilization and segmental reconstruction of the diseased axillary artery or ligation/excision of branch aneurysms, as well as concomitant management of distal thromboembolism.

Effort Thrombosis in the Elite Throwing Athlete

Background: Upper extremity vascular injuries are uncommon in the elite throwing athlete. However, the extreme stresses that are placed on the upper extremity of elite baseball players, especially pitchers, puts them at risk for such injuries. One such injury is upper extremity venous thrombosis or “effort thrombosis.” Purpose: We wanted to review the common initial clinical symptoms and physical examination findings of effort thrombosis in elite baseball players and to review the associated clinical conditions such as hypercoagulable states and pulmonary embolism. Study Design: Retrospective review of a series of cases. Methods: A retrospective review of the medical records of a Major League Baseball organization and a Division I college was performed for the period 1987 to 1997. Results: We located four cases of effort thrombosis involving elite baseball players. Contrast venography was used to confirm the diagnosis in all cases. All patients were successfully treated with transluminal catheter-directed urokinase thrombolysis followed by first rib resection and systemic anticoagulant therapy for up to 3 months. All four players returned to play at or above their previous level of competition with no long-term chronic sequelae. Conclusions: Prompt clinical recognition, diagnosis, and treatment of effort thrombosis in the elite baseball player provides the player with an excellent prognosis for return to the previous level of play.

Elbow Range of Motion in Professional Baseball Pitchers

Background Physicians involved with the care of baseball players have noted elbow range of motion changes in pitchers. Objective data regarding the extent of these changes have rarely been documented. Hypothesis Dominant and nondominant elbow range of motion differences are common in baseball pitchers, and these differences are related to player age, amount and length of time professionally pitched, and history of surgical procedures on the dominant extremity. Study Design Cross-sectional study; Level of evidence, 4. Methods Thirty-three professional pitchers were evaluated for elbow range of motion during spring training preseason physical examination. Dominant and nondominant elbow range of motion including flexion, extension, supination, and pronation were measured with a goniometer. Range of motion measures from the dominant and nondominant sides were compared. Baseball records were reviewed for arm dominance, age, years of professional pitching, professional innings pitched, and history of elbow surgery. These factors were evaluated for their possible association with range of motion for each side and the difference between sides. Results Statistically significant differences between dominant and nondominant sides were noted for elbow extension (dominant decreased 7.9° ± 7.4°, P <. 0001), flexion (dominant decreased 5.5° ± 7.8°, P =. 0003), and total flexion-extension arc (dominant decreased 13.3° ± 13.7°, P <. 0001). No significant difference between sides was found for the supination or pronation measures. No correlation was noted for age, pitching history, surgery, or arm dominance and the motion differences. Conclusion Professional pitchers demonstrate elbow flexion and extension differences between dominant and nondominant elbows. No correlation was found between motion differences and age, pitching history, surgery, or arm dominance.