John P. Goldblatt

Pediatric tibial eminence fractures: evaluation and management.

Abstract Tibial eminence fractures result from both contact and noncontact injuries. Skeletally immature persons are especially at risk. In adults, isolated fractures of the tibial eminence are usually associated with higher‐energy mechanisms. The incidence of concomitant intra‐articular injuries with tibial eminence fracture is high; MRI is useful in evaluating this injury. Nondisplaced fractures are amenable to nonsurgical management. Displaced fractures are managed with arthroscopic reduction and fixation with either sutures or screws. Although most fractures heal successfully, residual laxity usually persists because of prefracture anterior cruciate ligament midsubstance attenuation. This does not typically manifest in subjective instability, and reconstruction of the anterior cruciate ligament is rarely required. Patient factors, surgeon experience, and fracture pattern must be carefully considered before undertaking surgical repair.

Unilateral Meniscomeniscal Ligament

Four normal variants of meniscomeniscal ligaments have been previously reported in the anatomy, arthroscopy, and radiology literature. The anterior and posterior transverse meniscal ligaments are the 2 most commonly observed, with a reported frequency of 58% and 1% to 4%, respectively. The last 2 variants include the medial and lateral oblique meniscomeniscal ligaments and account for a combined frequency of 1% to 4%.This article describes 2 patients with unilateral meniscomeniscal ligaments observed on magnetic resonance imaging. One patient had a unilateral lateral meniscomeniscal ligament extending from the anterior horn of the lateral meniscus to the posterior horn of the lateral meniscus and underwent conservative management. The second patient had a unilateral medial meniscomeniscal ligament with a concomitant medial meniscus tear and underwent arthroscopic intervention. The ligament was stable intraoperatively and, therefore, was not resected. Both patients had resolution of their symptoms.These 2 variants are additions to the previously described 4 normal intermeniscal ligament variants. The functions of the 2 new variants described in this article are poorly understood but are thought to involve meniscal stability. Accurate descriptions of normal variants can lead to the proper management of anomalous rare structures and prevent false imaging interpretations because these structures can closely mimic a double posterior cruciate ligament sign. Furthermore, an understanding of the various normal variants of intermeniscal ligaments can prevent unnecessary surgery that could result in further iatrogenic meniscus injury.

Patellar Tendon Rupture with Underlying Systemic Lupus Erythematosus: A Case Report

BACKGROUND There have been few case reports of patellar tendon rupture in patients with underlying systemic lupus erythematosus (SLE). OBJECTIVES We present a unique case to discuss the importance of recognizing patellar tendon rupture in the emergency department (ED). CASE REPORT An 18-year-old man with SLE presented to the ED with pain, swelling, and inability to extend his left knee after a fall. Physical examination demonstrated a palpable defect over the patellar tendon, and plain radiographs showed patella alta. Patellar tendon rupture was diagnosed, and the patient underwent open surgical repair. CONCLUSION In low-energy patellar tendon rupture, the effects of the pathophysiology and the treatment for SLE, which includes systemic corticosteroids, are currently unclear. However, it is important to establish prompt diagnosis and appropriate treatment in the ED to maximize recovery and minimize long-term disability.

Metacarpal Stress Fracture in an Intercollegiate Rower Case Report

exceedingly rare. They are typically reportable occurrences and are conspicuously lacking from large case series. Rowers represent a unique subset of athletes at increased risk for these unusual injuries given the large forces inherent in the rowing stroke and the intensity of training regimens. Spondylolytic defects of the lumbar spine as well as stress fractures of the ribs and clavicle have been described previously in association with rowing. Although cases of metacarpal stress fractures exist in the literature, this is the first reported in a rower.

Suture Anchor and Sutureless Tac Performance in Cyclic Loading Normalized by Bone Mineral Density (SS-36)

*Goldblatt, J (A-Biomet, Inc. and University of Rochester); *Voloshin, I (A-Biomet, Inc. and University of Rochester); +*Maloney, M (A-Biomet, Inc and University of Rochester); **Lerner, A (A-Biomet, Inc and University of Rochester); **Salo, A (A-Biomet, Inc. and University of Rochester) +*Department of Orthopaedic Surgery, University of Rochester, Rochester, NY. 716 275-2988, Fax: 716 756-4725, jgoldblatt@yahoo.com

Functional and Imaging Outcomes of Arthroscopic Simultaneous Rotator Cuff Repair and Bankart Repair After Shoulder Dislocations

Background: Previous studies have investigated outcomes of simultaneous rotator cuff (RC) repair and superior labral injury repair; however, there is limited information in the literature on outcomes of simultaneous RC repair and Bankart lesion repair after acute shoulder dislocations. Purpose: To determine functional and imaging outcomes of simultaneous arthroscopic RC repair and Bankart repair after acute shoulder dislocations and to compare functional outcomes to contralateral, asymptomatic shoulders. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic simultaneous RC repair and Bankart repair with a minimum of 2 years’ follow-up were recruited. All patients had suffered an acute shoulder dislocation. The American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Short Form (SF)–36 scores were obtained. The affected shoulder also underwent ultrasound imaging to assess the integrity of the RC. Results: Thirteen patients (mean age, 58.8 ± 11.2 years; mean follow-up, 38.5 ± 12.3 months) were recruited. In a comparison of the affected versus unaffected shoulder, there were no significant differences in the mean ASES score (89.7 ± 12.6 vs 95.0 ± 6.7, respectively), mean Constant score (80.5 ± 18.9 vs 86.8 ± 7.9, respectively), or mean abduction strength (15.4 ± 6.4 lb vs 15.4 ± 5.2 lb, respectively) (P > .05). The mean SF-36 physical component summary was 48.4. According to ultrasound imaging, there were persistent/recurrent full-thickness tears in 4 patients, and 1 patient had a new full-thickness tear. At follow-up, patients with full-thickness RC tears in the affected shoulder compared with their unaffected shoulder showed similar mean ASES scores (90.9 ± 11.8 vs 97.6 ± 4.3, respectively), mean Constant scores (77.8 ± 20.3 vs 84.8 ± 7.2, respectively), and mean abduction strength (11.5 ± 5.3 lb vs 12.6 ± 4.5 lb, respectively) (P > .05). Conclusion: After simultaneous arthroscopic repair of the RC and a Bankart lesion in patients after shoulder dislocations, the affected extremity had similar functional outcomes compared to the noninjured, asymptomatic side at a mean of 3 years after surgery. Persistent or recurrent RC tears involving the operative extremity were common, but they did not significantly affect functional outcomes in this small study.

Preoperative PROMIS Scores Predict Postoperative Outcomes After Primary ACL Reconstruction

Background: PROMIS (Patient-Reported Outcomes Measurement Information System) scores in patients undergoing anterior cruciate ligament (ACL) reconstruction have not been fully described in the literature to date. The ability of preoperative patient-reported outcome scores to directly predict postoperative outcomes in patients who undergo primary ACL reconstruction is unknown. Hypothesis: Postoperative PROMIS physical function (PF), pain interference (PI), and depression (D) scores in patients who undergo ACL reconstruction will show improvement when compared with preoperative scores. Additionally, preoperative PROMIS PF, PI, and D scores will predict which patients will not achieve a minimal clinically important difference (MCID) postoperatively. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 233 patients who underwent primary ACL reconstruction between 2015 and 2016 and had completed PROMIS measures both preoperatively (within 60 days of surgery) and postoperatively (100-240 days after surgery) were included in this study. PROMIS PF, PI, and D scores were compared. Accuracy analyses were performed to determine whether preoperative PROMIS scores from each domain could predict postoperative achievement of MCID in the same domain. Cutoff scores were then calculated. Results: PROMIS PF, PI, and D scores all showed a significant improvement after ACL reconstruction (all P < .001). Preoperative scores from all 3 PROMIS domains showed a strong ability to predict clinically meaningful improvement, as defined by MCID, with areas under the receiver operating characteristic curve from 0.72 to 0.84. Optimal cutoffs for preoperative PROMIS scores showed that patients with a PF score of <42.5, PI score of >56.2, or D score of >44.8 were more likely to achieve MCID. Conclusion: PROMIS PF, PI, and D scores improved significantly in patients who underwent primary ACL reconstruction. Preoperative PROMIS PF, PI, and D scores were highly predictive of outcome in the early postoperative period. The reported cutoff scores showed high probability in predicting which patients would and would not achieve a clinically meaningful improvement.

The use of PROMIS CAT Physical Function Pre-surgical Scores to Predict Recovery and Establish Pre-surgical Cut-off Values

Objectives: There is a lack of standardized outcome measures or methods to study the effects of treatment and to effectively monitor and document patient outcomes. We have used Patient Reported Outcome Measurement Information System (PROMIS) computed adaptive testing questionnaires collected during routine office visits to describe the pre-surgical and postsurgical physical function scores and to assess the ability of pre-surgical scores to predict scores at 6 month after surgery. Methods: A retrospective analysis of 619 patients undergoing ACL reconstructive surgery at a large academic medical system was conducted to compare the predictive value of baseline PROMIS physical function scores to predict those scores after surgery. Patients with PROMIS physical Function scores within 1 standard deviation of the normal population at baseline were compare to those who fell below that score. Longitudinal comparisons of PROMIS scores between subsets was then made to identify any significant differences. PROMIS scores were assessed for discriminatory ability using receiver operating characteristic (ROC) curve analyses, with overall accuracy summarized using the area under the ROC curve (AUC). Nonparametric estimates and 95% confidence intervals for the AUC were used for each measurement at similar time points. Results: As shown in figure 1 average PROMIS physical function scores at later timepoints were comparable to those who had higher baseline scores. An ANOVA general linear (GROUP x TIME) model found statically significant (p<. 001) differences between the two groups at earlier time points. Further, ROC curve analysis demonstrated that PROMIS physical function scores have moderate to strong predictive ability (AUC>0.826). Using the ROC analysis an “optimal” cut-off pre-surgical score was determined to be a T-Score of 42.6. Conclusion: If fully utilized, these outcome measures can help inform physicians in individual surgical cases, as well as be used to show overall practice trends. Early identification of potential poor outcomes after ACL reconstruction may result in ability to intervene earlier to prevent prolonged disability. This investigation into the use of PROMIS physical function assessment tools has shown some utility in the ability to discriminate between those individuals who go on to have a full recovery over a typical recovery timeline and those who go on to have slower recovery.