Justin W. Arner

Arthroscopic Capsulolabral Reconstruction for Posterior Instability of the Shoulder

Background: There are few reports in the literature detailing the arthroscopic treatment of unidirectional posterior shoulder instability. Hypothesis: Arthroscopic capsulolabral reconstruction is effective in restoring stability and function and alleviating pain in athletes with symptomatic unidirectional posterior instability. Study Design: Cohort study; Level of evidence, 2. Methods: One hundred eighty-three athletes (200 shoulders) with unidirectional recurrent posterior shoulder instability were treated with arthroscopic posterior capsulolabral reconstruction and underwent an evaluation at a mean of 36 months postoperatively. A subset of 117 shoulders of contact athletes was compared with the entire group of 200 shoulders. Patients were evaluated prospectively with the American Shoulder and Elbow Surgeons (ASES) scoring system. Stability, strength, and range of motion were evaluated preoperatively and postoperatively with standardized subjective scales. Methods of intraoperative soft tissue fixation as well as anchorless (n = 44) and anchored (n = 156) plications were recorded for each patient. Results: At a mean of 36 months postoperatively, the mean ASES score improved from 45.9 to 85.1 (P < .001). There were also significant improvements in stability, pain, and function based on previously used scales (P < .001). The contact athletes did not demonstrate any significant differences when compared with the entire cohort for any outcome measure. With regard to the method of internal fixation, patients who underwent capsulolabral plications with suture-anchors showed significantly greater improvement in ASES scores (P < .001) and a higher rate of return to play (P < .05) when compared with patients with anchorless capsulolabral plications. Conclusion: Arthroscopic capsulolabral reconstruction is an effective, reliable treatment for symptomatic, unidirectional recurrent posterior glenohumeral instability in an athletic population. Overall, 90% of patients were able to return to sport, with 64% of patients able to return to the same level postoperatively. With the incorporation of bone suture-anchors in capsulolabral reconstruction, patients had greater improvements in ASES scores and a higher rate of return to play.

The Influence of Meniscal and Anterolateral Capsular Injury on Knee Laxity in Patients with Anterior Cruciate Ligament Injuries

Background: The role of the anterolateral capsule (ALC) as a secondary restraint to quantitative rotatory laxity of patients with an anterior cruciate ligament (ACL) injury is currently debated. Purpose/Hypothesis: The purpose was to determine the influence of concomitant ALC injuries as well as injuries to other soft tissue structures on rotatory knee laxity in patients with an ACL injury. It was hypothesized that a concomitant ALC injury would be associated with increased rotatory knee laxity as measured during a quantitative pivot-shift test. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Forty-one patients with an ACL injury (average age, 23 ± 6.9 years) were enrolled. Two blinded musculoskeletal radiologists reviewed magnetic resonance imaging (MRI) scans for the presence of ACL injuries and concomitant soft tissue injuries including the ALC, medial collateral ligament, lateral collateral ligament, posterolateral corner, medial meniscus, and lateral meniscus. A standardized pivot-shift test was performed under anesthesia, and rotatory laxity was quantified according to anterior translation of the lateral tibial compartment during the pivot-shift maneuver. The Student t test was used to analyze the data. Statistical significance was set at P < .05. Results: A complete ACL rupture was confirmed in all of the patients. MRI evidence of an ALC injury was observed in 21 (51%) of the patients. Patients with MRI evidence of an ALC injury had significantly higher rotatory knee laxity (3.6 ± 1.5 mm) compared with those without an ALC injury (2.7 ± 1.5 mm; P = .04). Lateral and medial meniscus injuries were detected in 17 (41%) and 19 (46%) patients, respectively. Patients with MRI evidence of either a medial meniscus injury or lateral meniscus injury had significantly higher rotatory knee laxity compared with patients without these injuries (medial meniscus: 3.7 ± 1.4 mm vs 2.7 ± 1.6 mm, respectively; lateral meniscus: 3.7 ± 1.7 mm vs 2.7 ± 1.3 mm, respectively) (P = .03 for both). Conclusion: MRI evidence of a concomitant injury to the ALC, medial meniscus, or lateral meniscus is associated with increased knee rotatory laxity in patients with an ACL injury. These structures may function as important secondary stabilizers in an ACL-injured knee. Careful assessment and proper treatment of injuries to these secondary stabilizers should be considered, especially in knees with a high level of the pivot shift.

A Historical Review of Common Bone Graft Materials in Foot and Ankle Surgery

Foot and ankle fusion is an important treatment for arthritis and deformities of the ankle and hindfoot. The literature has shown that there are improvements in fusion rates with the addition of bone graft and bone graft substitutes. Today autografts, specifically the iliac crest bone graft (ICBG), continue to be the gold standard despite significant donor site morbidity and nonunion rates, persisting around 10%. To address these drawbacks, bone graft substitutes have been developed. This article includes a historical review of the use, outcomes, and safety of autografts, allografts, and bone graft substitutes, such as ceramics, demineralized bone matrix, and platelet-derived growth factor.

The Effects of Anterior Cruciate Ligament Deficiency on the Meniscus and Articular Cartilage A Novel Dynamic In Vitro Pilot Study

Background: Anterior cruciate ligament (ACL) injury increases the risk of meniscus and articular cartilage damage, but the causes are not well understood. Previous in vitro studies were static, required extensive knee dissection, and likely altered meniscal and cartilage contact due to the insertion of pressure sensing devices. Hypothesis: ACL deficiency will lead to increased translation of the lateral meniscus and increased deformation of the medial meniscus as well as alter cartilage contact location, strain, and area. Study Design: Descriptive laboratory study. Methods: With minimally invasive techniques, six 1.0-mm tantalum beads were implanted into the medial and lateral menisci of 6 fresh-frozen cadaveric knees. Dynamic stereo x-rays (DSXs) were obtained during dynamic knee flexion (from 15° to 60°, simulating a standing squat) with a 46-kg load in intact and ACL-deficient states. Knee kinematics, meniscal movement and deformation, and cartilage contact were compared by novel imaging coregistration. Results: During dynamic knee flexion from 15° to 60°, the tibia translated 2.6 mm (P = .05) more anteriorly, with 2.3° more internal rotation (P = .04) with ACL deficiency. The medial and lateral menisci, respectively, translated posteriorly an additional 0.7 mm (P = .05) and 1.0 mm (P = .03). Medial and lateral compartment cartilage contact location moved posteriorly (2.0 mm [P = .05] and 2.0 mm [P = .04], respectively). Conclusion: The lateral meniscus showed greater translation with ACL deficiency compared with the medial meniscus, which may explain the greater incidences of acute lateral meniscus tears and chronic medial meniscus tears. Furthermore, cartilage contact location moved further posteriorly than that of the meniscus in both compartments, possibly imparting more meniscal stresses that may lead to early degeneration. This new, minimally invasive, dynamic in vitro model allows the study of meniscus function and cartilage contact and can be applied to evaluate different pathologies and surgical techniques. Clinical Relevance: This novel model illustrates that ACL injury may lead to significant meniscus and cartilage abnormalities acutely, and these parameters are dynamically measurable while maintaining native anatomy.

Improvement of Segmental Lordosis in Transforaminal Lumbar Interbody Fusion: A Comparison of Two Techniques

Study Design Retrospective review. Objective The purpose of this study was to determine the radiographic impact of a transforaminal lumbar interbody fusion (TLIF) versus a cantilever TLIF technique on segmental lordosis, segmental coronal alignment, and disk height. Methods A retrospective review was done of all patients undergoing TLIF procedures from 2006 to 2011 by three spine surgeons. Traditional TLIF versus cantilever TLIF results were compared, and radiographic outcomes were assessed. Results One hundred one patients were included in the study. Patients undergoing the cantilever TLIF procedure had a significantly greater change in segmental lordosis and disk height compared with those who underwent the traditional procedure (p > 0.0001). Conclusions The cantilever TLIF technique can lead to greater change in segmental lordosis based upon radiographic outcomes.

Is There a Difference in Graft Motion for Bone-Tendon-Bone and Hamstring Autograft ACL Reconstruction at 6 Weeks and 1 Year?

Background: Bone–patellar tendon–bone (BTB) grafts are generally believed to heal more quickly than soft tissue grafts after anterior cruciate ligament (ACL) reconstruction, but little is known about the time course of healing or motion of the grafts within the bone tunnels. Hypothesis: Graft-tunnel motion will be greater in hamstring (HS) grafts compared with BTB grafts and will be less at 1 year than at 6 weeks. Study Design: Controlled laboratory study. Methods: Twelve patients underwent anatomic single-bundle ACL reconstruction using HS or BTB autografts (6 per group) with six 0.8-mm tantalum beads embedded in each graft. Dynamic stereo x-ray images were collected at 6 weeks and 1 year during treadmill walking and stair descent and at 1 year during treadmill running. Tibiofemoral kinematics and bead positions were evaluated. Graft-tunnel motion was based on bead range of motion during the loading response phase (first 10%) of the gait cycle. Results: During treadmill walking, there was no difference in femoral tunnel or tibial tunnel motion between BTB or HS grafts at 6 weeks (BTB vs HS: 2.00 ± 1.05 vs 1.25 ± 0.67 mm [femoral tunnel]; 1.20 ± 0.63 vs 1.27 ± 0.71 mm [tibial tunnel]), or 1 year (BTB vs HS: 1.62 ± 0.76 vs 1.08 ± 0.26 mm [femoral tunnel]; 1.58 ± 0.75 vs 1.68 ± 0.53 mm [tibial tunnel]). During stair descent, there was no difference in femoral or tibial tunnel motion between BTB and HS grafts at 6 weeks or 1 year. With running, there was no difference between graft types at 1 year. For all results, P values were > .05. Knee kinematics were consistent with the literature. Conclusion: During walking and stair descent, ACL reconstruction using suspensory fixation yielded no difference between graft types in femoral or tibial tunnel motion at 6 weeks or 1 year. All subjects were asymptomatic with knee kinematics similar to that of the literature. The significance of persistent, small (1 to 3 mm) movements at 1 year for healing or graft performance is unknown. Clinical Relevance: These study results may have significant implications for graft choice, rehabilitation strategies, and timing for return to sports.

In Throwers With Posterior Instability, Rotator Cuff Tears Are Common but Do Not Affect Surgical Outcomes

In a previous study, compared with throwing athletes with superior labral anterior posterior (SLAP) tears, those with concomitant SLAP tears and rotator cuff tears (RCTs) had significantly poorer outcome scores and return to play. Posterior shoulder instability also occurs in throwing athletes, but no studies currently exist regarding outcomes of these patients with concomitant RCTs. The authors hypothesized that throwing athletes treated with arthroscopic capsulolabral repair for posterior shoulder instability with coexistent rotator cuff pathology would have poorer outcome scores and return to play. Fifty-six consecutive throwing athletes with unidirectional posterior shoulder instability underwent arthroscopic capsulolabral repair. Preoperative and postoperative patient-centered outcomes of pain, stability, function, range of motion, strength, and American Shoulder and Elbow Surgeons Shoulder (ASES) scores, as well as return to play, were evaluated. Patients with and without rotator cuff pathology were compared. Forty-three percent (24/56) of throwing athletes had rotator cuff pathology in addition to posterior capsulolabral pathology. All RCTs were débrided. At a mean of 3 years, there were no differences in preoperative and postoperative patient-centered outcomes between those with and without RCTs. Return-to-play rates showed no between-group differences; 92% (22/24) of athletes with concomitant RCTs returned to sport (P = .414), and 67% (16/24) returned to the same level (P = .430). Arthroscopic capsulolabral reconstruction is successful in throwing athletes with RCTs treated with arthroscopic débridement. Unlike the previous study evaluating throwers outcomes after surgical treatment for concomitant SLAP tears and RCTs, the authors found no difference in patient-reported outcome measures or return to play for throwing athletes with concomitant posterior shoulder instability and RCTs. In throwing athletes with concomitant posterior instability and RCTs, arthroscopic posterior capsulolabral repair with rotator cuff débridement is successful.

Arthroscopic Anterior Ankle Decompression Is Successful in National Football League Players

Anterior ankle impingement is a frequent cause of pain and disability in athletes with impingement of soft-tissue or osseous structures along the anterior margin of the tibiotalar joint during dorsiflexion. In this study, we hypothesized that arthroscopic decompression of anterior ankle impingement would result in significant, reliable, and durable improvement in pain and range of motion (ROM), and would allow National Football League (NFL) players to return to their preoperative level of play. We reviewed 29 arthroscopic ankle débridements performed by a single surgeon. Each NFL player underwent arthroscopic débridement of pathologic soft tissue and of tibial and talar osteophytes in the anterior ankle. Preoperative and postoperative visual analog scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scores, and ankle ROM were compared; time to return to play (RTP), events missed secondary to surgery, and complications were recorded. All athletes returned to the same level of NFL play at a mean (SD) of 8.4 (4.1) weeks after surgery and continued playing for a mean (SD) of 3.43 (2.57) years after surgery. Mean (SD) VAS pain scores decreased significantly (P < .001), to 0.38 (0.89) from 4.21 (1.52). Mean (SD) active ankle dorsiflexion increased significantly (P < .001), to 18.86° (2.62°) from 8.28° (4.14°). Mean (SD) AOFAS hindfoot scores increased significantly (P < .001), to 97.45 (4.72) from 70.62 (10.39). Degree of arthritis (r = 0.305) and age (r = 0.106) were poorly correlated to time to RTP. In all cases, arthroscopic débridement of anterior ankle impingement resulted in RTP at the same level at a mean of 2 months after surgery. There were significant improvements in VAS pain scores, AOFAS hindfoot scores, and ROM. Arthroscopic débridement of anterior ankle impingement relieves pain, restores ROM and function, and results in reliable RTP in professional football players.

Incidence and Risk Factors for Failure of Arthroscopic Posterior Capsulolabral Reconstruction

Objectives: Risk factors and outcomes of revision arthroscopic posterior capsulolabral repair is not well defined. It is hypothesized that athletes who require revision arthroscopic posterior unidirectional capsulolabral repair will have poorer outcomes and return to play with risk factors including younger age, injury size, bone loss, anchor number, and anchor type. Methods: A review of 161 shoulders who underwent arthroscopic posterior capsulolabral repair using modern techniques at minimum 2 year follow up was completed. In addition to surgical data, ASES, stability, ROM, strength, and pain scores were compared pre- and post-operatively as well as return to sport. Those who required revision surgery were identified and compared to those not undergoing revision. Results: Twenty shoulders required revision surgery (12.4%) at 5.3 year follow-up. Significant risk factors included female gender (p = 0.001), dominant shoulder (p = 0.005), and concomitant rotator cuff injury (p = 0.029). Patients with 3 or fewer anchors were more likely to require revision (OR = 3.48). There was no difference after normalization to tear size and location (p > 0.05). Return to sport at the same level was significantly lower if revision surgery was required (15.4% vs. 64.3%) (p = 0.004). All patients had significant improvements in ASES, pain, ROM, and strength after the original surgery, however, those who required revision surgery had less improvement (p < 0.05). Stability improved significantly in non-revision athletes (p < 0.001), but did not in revision patients (p = 0.662). Conclusion: Athletes required revision arthroscopic posterior capsulolabral repair at an incidence of 12.4% and had poorer outcome scores and return to play with risk factors being dominant shoulder surgery, female gender, concomitant rotator cuff injury, and the use of 3 or fewer anchors. This data is essential for patient selection, optimal treatment techniques, and patient education as posterior shoulder instability failure requiring revision has not previously been evaluated. Risk Factors for Revision Surgery Risk factor p value odds ratio Dominant shoulder 0.005 9.9 Female gender 0.001 4.47 Total anchor number* 0.005 3.48 Rotator cuff injury 0.029 4.07 *Normalized anchor number was not significant

Ethical Issues in Return to Play: How to Deal with Parents and Coaches

Return-to-play decisions for any group of athletes can be challenging and subject to multiple competing interests. These decisions can be even more complex when they involve not just players and coaches but also the parents. Parental involvement in youth athletic participation is important, but over-involvement or the wrong types of parental intervention can hinder the athlete’s experience. It is also important to realize that the athlete’s health is paramount, despite economic and social pressures otherwise. While parents, coaches, teammates, and even team physicians may benefit from early return to play, the athlete shoulders nearly all the risks should premature return to play result in detrimental health effects. For these reasons, sports medicine professionals must ignore competing interests and focus only on the patient’s best interest. The keys to successful return to play in these settings are to initiate clear communication with all involved parties early in the process, to implement objective return-to-play guidelines and assessment criteria, to maintain strict ethical standards, to reinforce the priority on the patient’s health, and to make sure that the player, parents, and coach buy in to these principles as well.