Henry B. Ellis

The belly-press test for the physical examination of the subscapularis muscle: electromyographic validation and comparison to the lift-off test☆

The purpose of this study was to determine the validity of the belly-press test as a clinical test for the subscapularis muscle with the use of electromyography (EMG). In addition, the belly-press and lift-off tests were compared to determine whether the two physical examination techniques are equivalent in their evaluation of the upper and lower portions of the subscapularis muscle. EMG data of 7 muscles (upper subscapularis, lower subscapularis, infraspinatus, latissimus dorsi, teres major, pectoralis major, and supraspinatus) were studied in 16 healthy volunteers. Average EMG amplitudes were contrasted within and between tests. Both the belly-press and lift-off tests activated the upper and lower portions of the subscapularis muscle greater than all other muscles, indicating that both tests are valid and specific for evaluation of the subscapularis muscle (P <.05). The belly-press test was found to activate the upper subscapularis muscle significantly more than the lift-off test (P <.05), whereas the lift-off test was found to pose a significantly greater challenge to the lower subscapularis muscle than the belly-press test (P <.05). These findings may improve the clinical testing and assessment of the subscapularis muscle.

Subscapularis Muscle Activity during Selected Rehabilitation Exercises

Background The upper and lower portions of the subscapularis muscle are independently innervated and activated. Hypothesis Upper and lower portions of the subscapularis muscle demonstrate different activation levels and require different exercises for rehabilitation. Study Design Controlled laboratory study. Methods Fifteen healthy subjects performed seven shoulder-strengthening exercises. Electromyographic data were collected from the latissimus dorsi, teres major, pectoralis major, infraspinatus, supraspinatus, and upper and lower subscapularis muscles. Results Upper subscapularis muscle activity was greater than lower subscapularis muscle activity for all exercises except for internal rotation with 0° of humeral abduction. The push-up plus and diagonal exercises consistently stressed the upper and lower subscapularis muscles to the greatest extent. Conclusions Humeral abduction was found to have a strong influence on the selective activation of the upper versus the lower subscapularis muscle and thus supported the design of different exercise continuums. In addition, the push-up plus and diagonal exercises were found to be superior to traditional internal rotation exercises for activating both functional portions of the subscapularis muscle. Clinical Relevance Our results showing that the upper and lower portions of the subscapularis muscle are functionally independent may affect training or rehabilitation protocols for the rotator cuff muscles.

Outcomes and Revision Rate After Bone–Patellar Tendon–Bone Allograft Versus Autograft Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years or Younger With Closed Physes

PURPOSE The purpose of this study was to compare revision rates and outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone (BPTB) autografts versus BPTB allografts in patients aged 18 years or younger with closed physes. METHODS Institutional review board approval was obtained for this study. This study included 90 consecutive patients aged 18 years or younger with closed physes who underwent primary ACL reconstruction by a single surgeon between 1998 and 2009, with either BPTB autograft (n = 70) or BPTB allograft (n = 20). Patients who had concomitant ligament injuries were excluded. Outcome measures included the Lysholm score, Tegner activity scale, and patient satisfaction (0, very unsatisfied; 10, very satisfied). Failures were defined as cases requiring ACL revision surgery. RESULTS Of the 90 patients, 79 (88%) were contacted (20 of 20 with allografts and 59 of 70 with autografts). Of these 79 patients, 9 (11%) required revision ACL reconstruction. In the autograft group, 3% (2 of 59) required revision ACL reconstruction at a mean of 15.4 months (range, 13.0 to 17.7 months) after the index procedure. In the allograft group, 35% (7 of 20) required revision ACL reconstruction at a mean of 9.1 months (range, 5.3 to 12.0 months) after the index procedure. The allograft group was 15 (95% confidence interval [CI], 2 to 123) times more likely to require revision reconstruction than the autograft group (P = .001). The mean Lysholm score at follow-up was 85 (95% CI, 80.4 to 90.3) for the autograft group and 91 (95% CI, 88.1 to 97.3) for the allograft group (P = .46). The median Tegner activity scale was 7.0 (95% CI, 6.9 to 8.0) for autograft group and 6.5 (95% CI, 4.9 to 8.4) for the allograft group (P = .27). Median patient satisfaction score was 10 of 10 in both cohorts. No failures were seen in either group at 2 years postoperatively. Five of seven allograft failures occurred because of a premature return to sports. CONCLUSIONS No significant differences in function, activity, or satisfaction were found between allograft and autograft reconstructions in this patient population. The allograft group had a failure rate 15 times greater than that in the autograft group, with all failures occurring within the first year after reconstruction. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Innovation in hip arthroscopy: is hip arthritis preventable in the athlete?

Introduction The hip is the second most common area for injury in collegiate athletes and may account for 2–5% of all sports injuries. Hip and groin pain in the athlete has long been associated with structural abnormalities of the femoral neck, acetabulum and labral pathology. Review The relationship between osteoarthritis and femoroacetabular impingement (FAI) is well established now with clinical studies, radiographic studies and computer simulations. Treatment The successful treatment of the athlete with FAI and subsequent labral and chondral damage has been well documented. New techniques, such as labral reconstruction, are being developed to address the more complex injuries seen in athletes, while helping to protect the joint surfaces and decrease the risk of early onsite osteoarthritis. Conclusion The athletes painful hip, which is becoming an increasingly more common complaint, is being identified and treated with greater chances of returning to play without compromising long-term hip function and the progression of hip osteoarthritis.

Prevalence of Discoid Meniscus During Arthroscopy for Isolated Lateral Meniscal Pathology in the Pediatric Population.

Background: Meniscus tears in the young patient are becoming more prevalent. Knowledge of presenting characteristics and morphology can affect treatment decisions. The purpose of this study was to review and evaluate all the isolated lateral meniscus pathology that required arthroscopic treatment in a pediatric sports medicine practice and compare presenting characteristics between those with a discoid meniscus and those with normal meniscal morphology. Methods: We performed a retrospective review of all isolated lateral meniscus arthroscopic procedures from 2003 to 2012 in a high-volume pediatric sports practice. Presentation, radiographs, and intraoperative findings were reviewed. The prevalence and clinical findings of a discoid meniscus in this population and among all age groups were compared with those with a meniscus tear occurring in a normal meniscus. Results: Two hundred and sixty-one arthroscopies were performed for symptomatic isolated lateral menisci pathology. Of these, 75% were discoid in nature; the remainder was tears occurring in normal menisci. Ninety-six of 99 patients (97%) with lateral meniscus pathology under the age of 13 had a discoid meniscus and 66% presented with no injury. There was a transition within the population at 14 years of age, with a rise in the incidence of normal meniscal body tears. Even after this transition point, meniscal pathology incidence remained notable; 59% of isolated lateral meniscus pathology in patients between the ages of 14 and 16 years old were a discoid meniscus. Magnetic resonance imaging criteria for discoid meniscus (3 consecutive sagittal cuts or coronal mid-compartment measure) were unreliable after the age of 13 years old. The ratio of complete to incomplete discoids in all age groups was 4 to 3. Conclusions: In conclusion, discoid menisci have a high prevalence in isolated lateral meniscus pathology requiring knee arthroscopy. Clinical presentation, imaging, characteristics, and treatment may be different among different age groups. In the adolescent age group (14 to 16 y old), the presentation of a discoid meniscus may not be different from a meniscus tear with normal morphology. Level of Evidence: Level III—diagnostic.

Glenoid Bone Loss in Traumatic Glenohumeral Instability in the Adolescent Population.

Background: Glenoid bone loss can affect the outcome and treatment for posttraumatic recurrent anterior glenohumeral instability. Clinical presentation in the adolescent age group with shoulder instability and glenoid bone loss is largely unknown. On the basis of this information, we believe there will be a high incidence of glenoid bone loss in adolescent patients with recurrent glenohumeral instability. We hypothesize that high-impact injuries, sports injuries, and reductions requiring sedation will be factors associated with glenoid bone loss. Methods: We performed a retrospective cross-sectional cohort study reviewing consecutive adolescent patients (n=114) with recurrent traumatic glenohumeral instability between 2004 and 2012. Chart analysis included demographic, presenting, and radiographic data. Glenoid bone loss was interpreted from plain radiographs, computed tomography (2D and/or 3D), magnetic resonance imaging, and/or arthroscopy. We compared possible risk factors between subjects with and without glenoid bone defects using the &khgr;2 test or 2 sample t tests. Results: Glenoid bone loss was seen in 55 patients (48.2%) with 15 of these patients (27%) having critical bone loss. Forty-five percent of appreciated glenoid bone loss was not visualized on plain radiographs. The average age was 15.1 years (range, 6.5 to 18.1) with male to female ratio 3.7:1. Male sex, older age, and taller stature were all statistically associated with glenoid bone loss (P=0.02, 0.01, and 0.02, respectively). Primary dislocations that occurred during sports were more likely to have glenoid bone loss (55.9% vs. 78.2%, P=0.01). The presence of an apprehension sign on physical examination was positively correlated with bone loss (P=0.008). Conclusions: The presence of glenoid bone loss in primary traumatic glenohumeral instability in the adolescent population is high, however, not as high as previously reported. Factors associated with glenoid bone loss include male sex, older age, taller stature, sports injuries, and the presence of apprehension on physical examination. Level of Evidence: This study establishes patients who may be at high risk for glenoid bone loss based on mechanism of injury and physical examination findings. This prognostic study is a level II retrospective study.

A comparison of distal femoral physeal defect and fixation position between two different drilling techniques for transphyseal anterior cruciate ligament reconstruction.

The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm2 (1.2%) in the transtibial group versus 0.99 cm2 (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.

Intra-articular Physeal Fractures of the Distal Femur: A Frequently Missed Diagnosis in Adolescent Athletes

Background: Intra-articular physeal fractures of the distal femur are an uncommon injury pattern, with only a few small case series reported in the literature. Purpose: To pool patients from 3 high-volume pediatric centers to better understand this injury pattern, to determine outcomes of surgical treatment, and to assess risk factors for complications. Study Design: Case series; Level of evidence, 4. Methods: A multicenter retrospective review of all patients presenting with an intra-articular physeal fracture between 2006 and 2016 was performed. Patient demographic and injury data, surgical data, and postoperative outcomes were documented. Radiographs were evaluated for fracture classification (Salter-Harris), location, and displacement. Differences between patients with and without complications were compared by use of analysis of variance or chi-square tests. Results: A total of 49 patients, with a mean age of 13.5 years (range, 7-17 years), met the inclusion criteria. The majority of fractures were Salter-Harris type III fractures (84%) involving the medial femoral condyle (88%). Football was responsible for 50% of the injuries. The initial diagnosis was missed in 39% of cases, and advanced imaging showed greater mean displacement (6 mm) compared with radiographs (3 mm). All patients underwent surgery and returned to sport with “good to excellent” results after 2 years. Complications were more common in patients with wide-open growth plates, patients with fractures involving the lateral femoral condyle, and patients who were casted (P < .05). Conclusion: Clinicians evaluating skeletally immature athletes (particularly football players) with acute knee injuries should maintain a high index of suspicion for an intra-articular physeal fracture. These fractures are frequently missed, and advanced imaging may be required to establish the diagnosis. Leg-length discrepancies and angular deformities are not uncommon, and patients should be monitored closely. Surgical outcomes are good when fractures are identified, with high rates of return to sport.

Reliability of Radiographic Assessments of Adolescent Midshaft Clavicle Fractures by the FACTS Multicenter Study Group

Objectives: There is a recent trend toward increased surgical treatment of displaced midshaft clavicle fractures in adolescents. The primary purpose of this study was to evaluate the intrarater and interrater reliability of clavicle fracture classification systems and measurements of displacement, shortening, and angulation in adolescents. The secondary purpose was to compare 2 different measurement methods for fracture shortening. Methods: This study was performed by a multicenter study group conducting a prospective, comparative, observational cohort study of adolescent clavicle fractures. Eight raters evaluated 24 deidentified anteroposterior clavicle radiographs selected from patients 10–18 years of age with midshaft clavicle fractures. Two clavicle fracture classification systems were used, and 2 measurements for shortening, 1 measurement for superior–inferior displacement, and 2 measurements for fracture angulation were performed. A minimum of 2 weeks after the first round, the process was repeated. Intraclass correlation coefficients were calculated. Results: Good to excellent intrarater and interrater agreement was achieved for the descriptive classification system of fracture displacement, direction of angulation, presence of comminution, and all continuous variables, including both measurements of shortening, superior–inferior displacement, and degrees of angulation. Moderate agreement was achieved for the Arbeitsgemeinschaft für Osteosynthesefragen classification system overall. Mean shortening by 2 different methods were significantly different from each other (P < 0.0001). Conclusions: Most radiographic measurements performed by investigators in a multicenter, prospective cohort study of adolescent clavicle fractures demonstrated good-to-excellent intrarater and interrater reliability. Future consensus on the most accurate and clinically appropriate measurement method for fracture shortening is critical.

Distal Femoral Valgus and Recurrent Traumatic Patellar Instability: Is an Isolated Varus Producing Distal Femoral Osteotomy a Treatment Option?

Background: Genu valgum, a risk factor for recurrent patellofemoral instability, can be addressed with a varus producing distal femoral osteotomy (DFO). The purpose of this study is to report 3-year clinical and radiographic outcomes on a series of skeletally mature adolescents with traumatic patellofemoral instability and genu valgum who underwent a varus producing DFO. Methods: Consecutive patients (n=11) who underwent an isolated DFO for recurrent traumatic patellar instability over a 4-year study period (2009 to 2012) were reviewed. All patients were below 19 years of age, skeletally mature, had ≥2 patellar dislocations, genu valgum (≥ zone II mechanical axis) and failed nonoperative treatment. Exclusion criteria included less than three-year follow-up, congenital or habitual patellar instability, osteotomy indicated for pathology other than patellar instability, or biplanar osteotomies. Demographic, clinical, and radiographic data were retrospectively analyzed. Recurrence of instability and outcome measures (Kujala and Tegner Activity Scale) were collected at final followed-up prospectively. Results: Ten of 11 patients (average age, 16 y; range, 14 to 18 y; 4 male individuals: 7 female individuals) with an average follow-up of 4.25 years (range, 3.2 to 6.0 y) met inclusion criteria. The average body mass index (BMI) of all patients was 31.3 (range, 19.7 to 46.8) with 91% considered overweight (BMI>25) and 55% obese (BMI>30). The average preoperative lateral distal femoral angle was 75.4 degrees with an average correction of 10.4 degrees (range, 7 to 12 degrees) (P<0.001). Mean patellar height ratios were reduced; with Caton-Deschamps Index significantly reduced to 1.08 (range, 0.86 to 1.30) (P<0.005). The average postoperative Kujala score was 83.6 (range, 49 to 99) with 7 subjects (70%) reporting good to excellent function (Kujala > 80) and 8 (80%) having no further episodes of instability. The mean postoperative Tegner activity score was 5.5 (range, 3 to 7). Conclusions: A distal femoral varus producing osteotomy may change radiographic parameters associated with patellar instability and improve clinical outcomes by reducing symptomatic patellofemoral instability in this patient population. Level of Evidence: Level IV.