John-Paul Rue

Systematic Review of Single-Bundle Anterior Cruciate Ligament Reconstruction Outcomes A Baseline Assessment for Consideration of Double-Bundle Techniques

Background:There is increasing interest in comparing the efficacy of single-bundle versus double-bundle anterior cruciate ligament reconstruction. Challenging this comparison, however, has been the lack of an established consensus on the success of single-bundle reconstruction.Hypothesis:The current outcomes of single-bundle reconstruction can be clarified from a large unbiased body of evidence for future comparisons with double-bundle reconstructions.Study Design:Systematic review.Methods:A systematic review of 11 randomized, controlled trials comparing patellar tendon and hamstring tendon grafting is reported. The respective outcomes of each group were combined to assist the orthopaedic surgeon in assessing the current success of single-bundle reconstruction. The primary factors assessed were tibial subluxation and side-to-side differences in laxity. Secondary outcomes included concomitant injuries and treatments, complications, graft failure, range of motion, and radiographic evidence of degenerative c...Background There is increasing interest in comparing the efficacy of single-bundle versus double-bundle anterior cruciate ligament reconstruction. Challenging this comparison, however, has been the lack of an established consensus on the success of single-bundle reconstruction. Hypothesis The current outcomes of single-bundle reconstruction can be clarified from a large unbiased body of evidence for future comparisons with double-bundle reconstructions. Study Design Systematic review. Methods A systematic review of 11 randomized, controlled trials comparing patellar tendon and hamstring tendon grafting is reported. The respective outcomes of each group were combined to assist the orthopaedic surgeon in assessing the current success of single-bundle reconstruction. The primary factors assessed were tibial subluxation and side-to-side differences in laxity. Secondary outcomes included concomitant injuries and treatments, complications, graft failure, range of motion, and radiographic evidence of degenerative changes. Results In this review of 1024 single-bundle anterior cruciate ligament reconstructions, 495 concomitant meniscal tears, 95 chondral injuries, and 2 posterior cruciate ligament tears were noted. The complication rate was 6%, and graft failure 4%. Reported pivot-shift test results were negative in 81 % of cases; reported Lachman tests were negative in 59% cases; and KT-1000 arthrometer side-to-side differences were ≤5 mm in 86% of cases. Flexion and extension deficits were reported in 9 of 11 studies through mean range of motion or deficit ranges. Radiographic changes of articular surface abnormalities were observed in 7% of the knees at follow-up investigation. Conclusion Systematic review of a significant body of unbiased outcome data on single-bundle anterior cruciate ligament reconstruction demonstrates it to be a safe, consistent surgical procedure affording reliable results. Clinical Relevance These results may be used to assist orthopaedic surgeons in evaluating the benefit and practicality of pursuing new anterior cruciate ligament reconstruction techniques over standard single-bundle anterior cruciate ligament reconstruction.

Defining the Terms Acute and Chronic in Orthopaedic Sports Injuries: A Systematic Review

Background: Although many authors report on acute injuries and chronic injuries in the orthopaedic literature, the actual terms are seldom explicitly defined. Hypothesis: Much of the literature pertaining to sports injuries that are acute or chronic does not define these terms. It is believed that definitions will provide clarity and specificity in future literature. Study Design: Systematic review. Methods: A systematic review of 116 articles was conducted to determine whether and how the terms acute and chronic were defined as they pertain to several commonly treated conditions: Achilles tendon rupture, distal biceps tendon rupture, pectoralis major tendon rupture, anterior cruciate ligament (ACL) tear, anterior shoulder instability, and acromioclavicular (AC) joint dislocation. Articles were isolated from various databases and search engines by use of keywords to identify relevant literature. Results: This study determined that the terms acute and chronic for each injury are defined, respectively, as follows: Achilles tendon rupture: <1 week, >4 weeks; distal biceps tendon rupture: <6 weeks, >12 weeks; pectoralis major tendon rupture: <6 weeks, >6 weeks; ACL tear: <6 weeks, >6 months; anterior shoulder instability: <2 weeks, >6 months; AC joint dislocation, <3 weeks, >6 weeks. Conclusion: The current literature varies greatly in defining the terms acute and chronic in common sports injuries. The vast majority of authors imply these terms, based on the method of their studies, rather than define them explicitly. Injuries involving tendons showed greater consistency among authors, thus making a definition based on consensus easier to derive. The literature on ACL and shoulder instability in particular showed great variability in defining these terms, likely representing the more complex nature of these injuries and the fact that timing of surgery in the majority of patients does not particularly affect the complexity of the surgical approach and treatment. Clinical Relevance: Defining injuries as acute or chronic is clinically relevant in many cases, particularly concerning tendon injuries, where these terms have implications regarding the anatomic pathologic changes and tissue quality, which may necessitate augmentation and alter the initial surgical plan. In cases where these terms are less pertinent to operative treatment considerations, they bring clarity to the discussion of the acuity of the injury (as it pertains to time from insult).

Return to Play and Recurrent Instability After In-Season Anterior Shoulder Instability A Prospective Multicenter Study

Background: There is no consensus on the optimal treatment of in-season athletes with anterior shoulder instability, and limited data are available to guide return to play. Purpose: To examine the likelihood of return to sport and the recurrence of instability after an in-season anterior shoulder instability event based on the type of instability (subluxation vs dislocation). Additionally, injury factors and patient-reported outcome scores administered at the time of injury were evaluated to assess the predictability of eventual successful return to sport and time to return to sport during the competitive season. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Over 2 academic years, 45 contact intercollegiate athletes were prospectively enrolled in a multicenter observational study to assess return to play after in-season anterior glenohumeral instability. Baseline data collection included shoulder injury characteristics and shoulder-specific patient-reported outcome scores at the time of injury. All athletes underwent an accelerated rehabilitation program without shoulder immobilization and were followed during their competitive season to assess the success of return to play and recurrent instability. Results: Thirty-three of 45 (73%) athletes returned to sport for either all or part of the season after a median 5 days lost from competition (interquartile range, 13). Twelve athletes (27%) successfully completed the season without recurrence. Twenty-one athletes (64%) returned to in-season play and had subsequent recurrent instability including 11 recurrent dislocations and 10 recurrent subluxations. Of the 33 athletes returning to in-season sport after an instability event, 67% (22/33) completed the season. Athletes with a subluxation were 5.3 times more likely (odds ratio [OR], 5.32; 95% CI, 1.00-28.07; P = .049) to return to sport during the same season when compared with those with dislocations. Logistic regression analysis suggests that the Western Ontario Shoulder Instability Index (OR, 1.05; 95% CI, 1.00-1.09; P = .037) and Simple Shoulder Test (OR, 1.03; 95% CI, 1.00-1.05; P = .044) administered after the initial instability event are predictive of the ability to return to play. Time loss from sport after a shoulder instability event was most strongly and inversely correlated with the Simple Shoulder Test (P = .007) at the time of initial injury. Conclusion: In the largest prospective study evaluating shoulder instability in in-season contact athletes, 27% of athletes returned to play and completed the season without subsequent instability. While the majority of athletes who return to sport complete the season, recurrent instability events are common regardless of whether the initial injury was a subluxation or dislocation.

Management of mid-season traumatic anterior shoulder instability in athletes.

&NA; Shoulder dislocation and subluxation injuries are common in young athletes and most frequently occur during the competitive season. Controversy exists regarding optimal treatment of an athlete with an in‐season shoulder dislocation, and limited data are available to guide treatment. Rehabilitation may facilitate return to sport within 3 weeks, but return is complicated by a moderate risk of recurrence. Bracing may reduce the risk of recurrence, but it restricts motion and may not be tolerated in patients who must complete certain sport‐specific tasks such as throwing. Surgical management of shoulder dislocation or subluxation with arthroscopic or open Bankart repair reduces the rate of recurrence; however, the athlete is unable to participate in sport for the remainder of the competitive season. When selecting a management option, the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport‐ and position‐specific demands, duration of treatment, and the athletes motivation.

Trochlear Contact Pressures After Straight Anteriorization of the Tibial Tuberosity

Background Anteromedialization of the tibial tuberosity has been shown to decrease mean total contact pressures of the lateral trochlea and to shift contact pressures to the medial trochlea. Hypothesis Modifying the anteromedialization osteotomy to a straight anteriorization osteotomy of the tibial tuberosity can decrease trochlear contact pressures without a resultant medial shift of forces to the medial trochlear contact area. Study Design Controlled laboratory study. Methods Ten cadavers were tested before and after straight anteriorization tibial tuberosity osteotomy by loading the extensor mechanism with 89.1 and 178.2 N at 0°, 30°, 60°, and 90° of flexion following a validated patellofemoral joint loading protocol. Contact pressures were measured with electroresistive pressure sensors placed directly on the trochlea. Results The mean trochlear contact pressures after osteotomy decreased significantly (P < .05) for loads of 89.1 and 178.2 N at both 30° (23% and 20%, respectively) and 60° (18.7% and 31.9%, respectively) of knee flexion. The peak contact pressures decreased significantly (P < .05) for loads of 89.1 and 178.2 N at 30° (24.3% and 27.0%, respectively) and 60° (31.9% and 24.5%, respectively) and for loads of 89.1 N at 90° (13.4%) of knee flexion. Conclusion The authors demonstrated significantly decreased trochlear contact forces after straight anteriorization osteotomy of the tibial tuberosity, without a significant resultant medial shift of the center of force. Clinical Relevance Straight anteriorization of the tibial tuberosity may be a useful adjunct for patients with medial articular defects of the patellar or trochlea in whom anteromedialization would be otherwise contraindicated.

Reported Concussion Rates for Three Division I Football Programs An Evaluation of the New NCAA Concussion Policy

Background: There has been increased interest in the number of concussions occurring in college football over the past year. In April 2010, the National Collegiate Athletic Association (NCAA) published new guidelines for the diagnosis and treatment of concussions in student athletes. Purpose: To determine the number of concussions that occurred on 3 collegiate Division I military academy football teams prior to and following recent changes in the NCAA concussion management policy. Study Design: Descriptive epidemiology study. Methods: Injury reports were reviewed from 3 Division I military academy football teams. The number of concussions that occurred over the 2009-2010 and 2010-2011 seasons, including those sustained in practice and game situations, was determined for each team. Incidence rates were compared using the exact binomial method. Results: The combined concussion incidence rate doubled from 0.57 per 1000 athlete exposures in the 2009-2010 season to 1.16 per 1000 athlete exposures in the 2010-2011 season (incidence rate ratio, 2.04; 95% CI, 1.2-3.55; P = 0.01). The combined numbers of concussions for the 2009-2010 and 2010-2011 seasons were 23 (40,481 exposures) and 42 (36,228), respectively. Conclusion: The combined incidence rate of concussions for the 2010-2011 season doubled from the previous season after the implementation of new NCAA policies on concussion management. While the institution of a more formalized concussion plan on the part of medical staff is one possible factor, another may have been the increased recognition and reporting on the part of players and coaches after the rule change.

Risk of Anterior Cruciate Ligament Injury in Athletes on Synthetic Playing Surfaces: A Systematic Review

Background: The effect of synthetic playing surfaces on the risk of injury in athletes is frequently debated in the orthopaedic literature. Biomechanical studies have identified increased frictional force at the shoe-surface interface, theoretically increasing the risk of injury relative to natural grass. This increase in frictional force is potentially relevant for the risk of anterior cruciate ligament (ACL) rupture, where noncontact mechanisms are frequent. However, clinical studies examining this issue have shown mixed results. Hypothesis/Purpose: The purpose of this study was to systematically review the available literature on risk of ACL rupture on natural grass versus artificial turf. We hypothesized that the risk of ACL rupture on synthetic playing surfaces would not be higher than that of natural grass playing surfaces. Study Design: Systematic review. Methods: A systematic keyword search was performed of OVID, EMBASE, the Cochrane Library of Systematic Reviews, and the PROSPERO International Prospective Register of Systematic Reviews. Candidate articles were included if they reported the risk ratio of ACL rupture on natural grass versus synthetic playing surfaces, were of level 3 evidence or better, and included only ACL injuries sustained during organized athletic events. Exclusion criteria included a study with non-field-related sports and the use of historical cohorts for calculating risk ratios. Results: A total of 10 studies with 963 ACL injuries met criteria for inclusion, all of which reported on soccer and football cohorts. Among these, 4 studies (753 ACL injuries) found an increased risk of ACL injury on artificial playing surfaces. All 4 of these articles were conducted using American football cohorts, and they included both earlier-generation surfaces (AstroTurf) and modern, 3rd-generation surfaces. Only 1 study in football players found a reduced risk of ACL injury on synthetic playing surfaces. No soccer cohort found an increased risk of ACL injury on synthetic surfaces. Conclusion: High-quality studies support an increased rate of ACL injury on synthetic playing surfaces in football, but there is no apparent increased risk in soccer. Further study is needed to clarify the reason for this apparent discrepancy.

Outcome of Grade I and II Hamstring Injuries in Intercollegiate Athletes: A Novel Rehabilitation Protocol

Background: Hamstring muscle strains represent a common and disabling athletic injury with variable recurrence rates and prolonged recovery times. Objectives: To present the outcomes of a novel rehabilitation protocol for the treatment of proximal hamstring strains in an intercollegiate sporting population and to determine any significant differences in the rate of reinjury and time to return to sport based on patient and injury characteristics. Study Design: Retrospective case series. Methods: A retrospective review was performed of 48 consecutive hamstring strains in intercollegiate athletes. The rehabilitation protocol consisted of early mobilization, with flexible progression through supervised drills. Athletes were allowed to return to sport after return of symmetrical strength and range of motion with no pain during sprinting. Primary outcomes included time to return to sport and reinjury rates. Results: All patients returned to their sports, and 3 sustained repeat hamstring strains (6.2% reinjury rate) after a minimum follow-up of 6 months. The average number of days missed from sport was 11.9 (range, 5-23 days). There was no statistically significant difference for time to return to sport between first-time and recurrent injuries and between first- and second-degree injuries (P > 0.05). Conclusions: Grade I and II hamstring strains may be aggressively treated with a protocol of brief immobilization followed by early initiation of running and isokinetic exercises—with an average expected return to sport of approximately 2 weeks and with a relatively low reinjury rate regardless of injury grade (I or II), injury characteristics (including first-time and recurrent injuries), or athlete characteristics.

Incidence Rate and Results of the Surgical Treatment of Pectoralis Major Tendon Ruptures in Active-Duty Military Personnel

Background: Pectoralis major tendon ruptures are commonly described as rare injuries affecting men between 20 and 40 years of age, with generally excellent results after surgical repair. However, this perception is based on a relatively small number of case series and prospective studies in the orthopaedic literature. Purpose: To determine the incidence of pectoralis major tendon ruptures in the active-duty military population and the demographic risk factors for a rupture and to describe the outcomes of surgical treatment. Study Design: Case control study; Level of evidence, 3. Methods: We utilized the Military Health System Data Repository (MDR) to identify all active-duty military personnel surgically treated for a pectoralis major tendon rupture between January 2012 and December 2014. Electronic medical records were searched for patients’ demographic information, injury characteristics, and postoperative complications and outcomes. Risk factors for a rupture were calculated using Poisson regression, based on population counts obtained from the MDR. Risk factors for a postoperative complication, the need for revision surgery, and the inability to continue with active duty were determined using univariate analysis and multivariate logistic regression. Results: A total of 291 patients met inclusion criteria. The mean patient age was 30.5 years, all patients were male, and the median follow-up period was 18 months. The incidence of injuries was 60 per 100,000 person-years over the study period. Risk factors for a rupture included service in the Army, junior officer or junior enlisted rank, and age between 25 and 34 years. White race and surgery occurring >6 weeks after injury were significant risk factors for a postoperative complication. Among the 214 patients with a minimum of 12 months’ clinical follow-up, 95.3% were able to return to military duty. Junior officer/enlisted status was a significant risk factor for failure to return to military duty. Conclusion: Among military personnel, Army soldiers and junior officer/enlisted rank were at highest risk of pectoralis major tendon ruptures, and junior personnel were at highest risk of being unable to return to duty after surgical treatment. Although increasing time from injury to surgery was not a risk factor for treatment failure or inability to return to duty, it did significantly increase the risk of a postoperative complication.

Tibial stress fractures in an active duty population: long-term outcomes.

Tibial stress fractures are a common overuse injury among military recruits. The purpose of this study was to determine what, if any, long-term effects that tibial stress fractures have on military personnel with respect to physical activity level, completion of military training, recurrence of symptoms, and active duty service. Twenty-six military recruits included in a previous tibial stress fracture study were contacted 10 years after initial injury and asked a series of questions related to any long-term consequences of their tibial stress fracture. Of the 13 patients available for contact, no patients reported any necessary limited duty while on active duty, and no patient reported being separated or discharged from the military as a result of stress fracture. Tibial stress fractures in military recruits are most often an isolated injury and do not affect ability to complete military training or reflect a long-term need for decreased physical activity.