Lauren H. Redler

Platelet-Rich Plasma Therapy: A Systematic Literature Review and Evidence for Clinical Use

Abstract Platelet-rich plasma (PRP) is an autologous blood-derived product with an increased concentration of platelets in plasma, which are used to deliver supraphysiological levels of growth factors. Platelet-rich plasma has been used in many fields, including oral, maxillofacial, and plastic surgery. Its use in sports medicine has been increasing after recent evidence and media publicity suggest that it may augment the treatment of muscle strains, as well as tendon and ligament healing. Basic science and animal studies show promising results, but high-level clinical trials have yet to prove its efficacy. With increasing media coverage on the use of PRP in athletes, it is paramount that orthopedic surgeons and sports medicine physicians understand the various methods of preparation and administration, potential clinical applications, and available clinical results to best counsel patients on its advantages and disadvantages.

Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients With Transphyseal Tunnels

PURPOSE Our purpose was to evaluate the results of transphyseal anterior cruciate ligament (ACL) reconstruction with hamstring autograft in skeletally immature patients. METHODS Eighteen knees in 18 skeletally immature pubescent patients with a mean chronologic age of 14.2 years underwent transphyseal ACL reconstruction with hamstring autograft between 2002 and 2007. Concurrent meniscal surgery was performed in 9 knees. The final patient evaluation occurred at a mean of 43.4 months (range, 24.0 to 86.6 months) and included physical examination, KT-1000 arthrometry testing (MEDmetric, San Diego, CA), and functional outcome instruments, including the International Knee Documentation Committee subjective knee form, the Lysholm knee score, and the Tegner knee activity scale. RESULTS At the latest follow-up, the mean International Knee Documentation Committee subjective knee score was 92.4 ± 10, the mean Lysholm knee score was 94.3 ± 8.8, and the mean Tegner activity scale score was 8.5 ± 1.4. Lachman and pivot-shift testing were negative in all knees. No restriction in knee range of motion of 5° or greater when compared with the contralateral knee was observed in any patient. The mean manual maximum side-to-side difference with KT-1000 testing was 0.29 ± 1.07 mm, and no patients had a difference greater than 3 mm. No angular deformities were noted, and all leg-length measurements were symmetric bilaterally on clinical examination. No patients had traumatic graft disruption or underwent revision ACL reconstruction, whereas 3 patients sustained an ACL injury in the contralateral leg while participating in sports. CONCLUSIONS Transphyseal ACL reconstruction with autogenous quadrupled hamstring graft with metaphyseal fixation in skeletally immature pubescent patients yielded excellent functional outcomes in a high percentage of patients without perceived clinical growth disturbance. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Prevention and screening programs for anterior cruciate ligament injuries in young athletes: a cost-effectiveness analysis.

BACKGROUND Anterior cruciate ligament (ACL) injuries are common among young athletes. Biomechanical studies have led to the development of training programs to improve neuromuscular control and reduce ACL injury rates as well as screening tools to identify athletes at higher risk for ACL injury. The purpose of this study was to evaluate the cost-effectiveness of these training methods and screening strategies for preventing ACL injuries. METHODS A decision-analysis model was created to evaluate three strategies for a population of young athletes participating in organized sports: (1) no training or screening, (2) universal neuromuscular training, and (3) universal screening, with neuromuscular training for identified high-risk athletes only. Risk of injury, risk reduction from training, and sensitivity and specificity of screening were based on published data from clinical trials. Costs of training and screening programs were estimated on the basis of the literature. Sensitivity analyses were performed on key model parameters to evaluate their effect on base case conclusions. RESULTS Universal neuromuscular training of all athletes was the dominant strategy, with better outcomes and lower costs compared with screening. On average, the implementation of a universal training program would save

Reliability of a field-based drop vertical jump screening test for ACL injury risk assessment

100 per player per season, and would reduce the incidence of ACL injury from 3% to 1.1% per season. Screening was not cost-effective within the range of reported sensitivity and specificity values. CONCLUSIONS AND CLINICAL RELEVANCE Given its low cost and ease of implementation, neuromuscular training of all young athletes represents a cost-effective strategy for reducing costs and morbidity from ACL injuries. While continued innovations on inexpensive and accurate screening methods to identify high-risk athletes remain of interest, improving existing training protocols and implementing neuromuscular training into routine training for all young athletes is warranted.

Influence of Rotator Cuff Tear Size and Repair Technique on the Creation and Management of Dog Ear Deformities in a Transosseous-Equivalent Rotator Cuff Repair Model

Abstract Objectives: There is an epidemic of anterior cruciate ligament (ACL) injuries in youth athletes. Poor neuromuscular control is an easily modifiable risk factor for ACL injury, and can be screened for by observing dynamic knee valgus on landing in a drop vertical jump test. This study aims to validate a simple, clinically useful population-based screening test to identify at-risk athletes prior to participation in organized sports. We hypothesized that both physicians and allied health professionals would be accurate in subjectively assessing injury risk in real-time field and office conditions without motion analysis data and would be in agreement with each other. Methods: We evaluated the inter-rater reliability of risk assessment by various observer groups, including physicians and allied health professionals, commonly involved in the care of youth athletes. Fifteen athletes age 11–17 were filmed performing a drop vertical jump test. These videos were viewed by 242 observers including orthopaedic surgeons, orthopaedic residents/fellows, coaches, athletic trainers (ATCs), and physical therapists (PTs), with the observer asked to subjectively estimate the risk level of each jumper. Objective injury risk was calculated using normalized knee separation distance (measured using Dartfish, Alpharetta, GA), based on previously published studies. Risk assessments by observers were compared to each other to determine inter-rater reliability, and to the objectively calculated risk level to determine sensitivity and specificity. Seventy one observers repeated the test at a minimum of 6 weeks later to determine intra-rater reliability. Results: Between groups, the inter-rater reliability was high, κ = 0.92 (95% CI 0.829–0.969, p < 0.05), indicating that no single group gave better (or worse) assessments, including comparisons between physicians and allied health professionals. With a screening cutoff isolated to subjects identified by observers as “high risk”, the sensitivity was 63.06% and specificity 82.81%. Reducing the screening cutoff to also include jumpers identified as “medium risk” increased sensitivity to 95.04% and decreased the specificity to 46.07%. Intra-rater reliability was moderate, κ = 0.55 (95% CI 0.49–0.61, p < 0.05), indicating that individual observers made reproducible risk assessments. Conclusions: This study supports the use of a simple, field-based observational drop vertical jump screening test to identify athletes at risk for ACL injury. Our study shows good inter- and intra-rater reliability and high sensitivity and suggests that screening can be performed without significant training by physicians as well as allied health professionals, including: coaches, athletic trainers and physical therapists. Identification of these high-risk athletes may play a role in enrollment in appropriate preventative neuromuscular training programs, which have been shown to decrease the incidence of ACL injuries in this population.

An Anomalous Accessory Pectoralis Major Muscle A Case Report

Background: Redundancies in the rotator cuff tissue, commonly referred to as “dog ear” deformities, are frequently encountered during rotator cuff repair. Knowledge of how these deformities are created and their impact on rotator cuff footprint restoration is limited. Purpose: The goals of this study were to assess the impact of tear size and repair method on the creation and management of dog ear deformities in a human cadaveric model. Study Design: Controlled laboratory study. Methods: Crescent-shaped tears were systematically created in the supraspinatus tendon of 7 cadaveric shoulders with increasing medial to lateral widths (0.5, 1.0, and 1.5 cm). Repair of the 1.5-cm tear was performed on each shoulder with 3 methods in a randomized order: suture bridge, double-row repair with 2-mm fiber tape, and fiber tape with peripheral No. 2 nonabsorbable looped sutures. Resulting dog ear deformities were injected with an acrylic resin mixture, digitized 3-dimensionally (3D), and photographed perpendicular to the footprint with calibration. The volume, height, and width of the rotator cuff tissue not in contact with the greater tuberosity footprint were calculated using the volume injected, 3D reconstructions, and calibrated photographs. Comparisons were made between tear size, dog ear measurement technique, and repair method utilizing 2-way analysis of variance and Student-Newman-Keuls multiple-comparison tests. Results: Utilizing 3D digitized and injection-derived volumes and dimensions, anterior dog ear volume, height, and width were significantly smaller for rotator cuff repair with peripheral looped sutures compared with a suture bridge (P < .05) or double-row repair with 2-mm fiber tape alone (P < .05). Similarly, posterior height and width were significantly smaller for repair with looped peripheral sutures compared with a suture bridge (P < .05). Dog ear volumes and heights trended larger for the 1.5-cm tear, but this was not statistically significant. Conclusion: When combined with a standard transosseous-equivalent repair technique, peripheral No. 2 nonabsorbable looped sutures significantly decreased the volume, height, and width of dog ear deformities, better restoring the anatomic footprint of the rotator cuff. Clinical Relevance: Dog ear deformities are commonly encountered during rotator cuff repair. Knowledge of a repair technique that reliably decreases their size, and thus increases contact at the anatomic footprint of the rotator cuff, will aid sports medicine surgeons in the management of these deformities.

Combined Reconstruction of the Medial Patellofemoral Ligament (MPFL) and Medial Quadriceps Tendon - Femoral Ligament (MQTFL) for Patellar Instability in Children and Adolescents: Surgical Technique and Outcomes

Anomalous muscles in the chest wall and axillary region have been reported in several cadaveric studies.z Various names have been given to these muscles based on their origin and insertion and include chondroepitrochlearis, chondrofascialis, pectoralis quadratus, sternalis, and the axillary arch of Langer. To our knowledge, this is the first case report of an accessory pectoralis major muscle in an adult patient that caused painful activity-related symptoms and required surgical excision. To date, 3 cases have been reported in the orthopaedic literature involving a chondroepitrochlearis muscle in an infant and a teenager in whom it was restricting abduction and in a young adult in whom it was causing ulnar neuropathy. The purpose of this case is to report the symptoms, physical examination, imaging studies, and surgical approach and outcome of a patient with a unique accessory pectoralis major musculotendinous complex and to review the pertinent literature.

Rehabilitation variability following medial patellofemoral ligament reconstruction

Objectives: A variety of surgical options exist to treat the challenging problem of recurrent patellar instability in skeletally immature patients. The current study describes a combined reconstruction technique involving both the medial patellofemoral ligament (MPFL) and the medial quadriceps tendon - femoral ligament (MQTFL) and reports patient outcomes of a single-surgeon series. Methods: All patients studied underwent combined MPFL and MQTFL reconstruction for patellar instability. Demographic data, pre- and post-operative radiographic data were collected. Reconstruction was performed using gracilis allograft. The graft midportion was fixed to the MPFL insertion on the femur via suture anchor. One arm of the graft (MPFL) was tunneled under medial retinaculum to the medial border of the patella and fixed there via suture anchor, while the other (MQTFL) arm was tunneled, delivered under the VMO and brought through the medial distal quadriceps tendon and sutured in place. Subjective outcome scores (Kujala, Pedi-IKDC, Lysholm) were collected via questionnaires mailed to patients more than one year from surgery. Results: A total of 25 patients (27 knees), including 15 females and 10 males with an average age of 15.0 ± 2.2 years (range 10.3-18.9), underwent combined MPFL and MQTFL reconstruction. 6/25 (24%) had undergone prior ipsilateral patellofemoral surgery for instability. 5/25 (20%) underwent simultaneous guided growth via hemiepiphysiodesis for valgus deformity at the time of combined reconstruction. Preoperative imaging showed a mean TT-TG of 17.2 ± 3.8, Caton-Deschamps Index (CDI) of 1.13 ± 0.16, and trochlear dysplasia Dejour A/B (22/26 (85%)) or Dejour C/D (4/26 (15%)). A total of 18 patients (19 knees, 72%) returned outcomes questionnaires at a mean 2.0 ± 0.5 years after surgery. Mean Kujala, Pedi-IKDC, and Lysholm scores were 85.9 ± 13.9, 81.5 ± 15.2, and 84.3 ± 13.5, respectively. 2/25 patients (8%) later required a revision procedure (tibial tubercle osteotomy) for recurrent patellar instability, and another patient reported persistent instability not requiring revision. 10/13 patients (77%) were able to return to sports at a mean of 5.8 +/- 3.9 months (range 2-15). Conclusion: The current study describes a novel anatomically-validated surgical technique involving the simultaneous reconstruction of both the MPFL and MQTFL in a pediatric patient population. Follow-up data presented demonstrates overall positive results in treating this challenging problem in a young patient population.

Trends in Management and Complications of Anterior Cruciate Ligament Injuries in Pediatric Patients: A Survey of the Prism Society

ABSTRACT Background: Medial patellofemoral ligament (MPFL) reconstruction is an increasingly utilized surgical option for recurrent patellar instability. Recent studies have highlighted the potential benefits of accelerated functional rehabilitation; however, no validated MPFL rehabilitation guidelines currently exist. Objective: To assess the variability of MPFL reconstruction rehabilitation protocols published online by academic orthopaedic programs. Methods: Online MPFL rehabilitation protocols from U.S. teaching orthopaedic programs were reviewed. A comprehensive scoring rubric was developed to assess each protocol for both the presence of various rehabilitation components and the timing of their introduction. Results: Thirty-one protocols (20%) were identified from 155 U.S. academic orthopaedic programs. Thirty protocols (97%) recommended immediate postoperative knee bracing. Twenty protocols (65%) allowed for weight-bearing as tolerated using crutches immediately postoperatively, whereas seven protocols (23%) recommended partial weight-bearing and four protocols (13%) recommended toe-touch weight-bearing. For those protocols advising partial and toe-touch weight-bearing, advancement to full weight-bearing was achieved at averages of 4.7 (range, 3–8) weeks and 6.3 (range, 6–7) weeks, respectively. There was considerable variation in range of motion (ROM) goals; however, most protocols (97%) recommended achieving 90 degrees of knee flexion at an average of 1.4 (range, 0–6) weeks. Significant diversity was found in the inclusion and timing of strengthening, stretching, proprioception, and basic cardiovascular exercises. Twenty-five protocols (81%) recommended return to training after completing specific athletic criteria. Conclusions: A minority of U.S. teaching orthopaedic institutions publish MPFL reconstruction rehabilitation protocols online. Furthermore, there is a high degree of variability in both the composition and timing of rehabilitation modalities across these protocols.

Complications of Patellofemoral Surgeries: Prevention and Management Strategies

Background:Anterior cruciate ligament (ACL) injuries have been recognized and treated with increasing frequency in children and adolescents. ACL reconstruction (ACLR) in skeletally immature patients has unique considerations and there is a large practice variation in the management of these injuries. The purpose of this study was to survey the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding their experience with the management and complications of pediatric ACL injuries. Methods:A 15-question survey was distributed to 71 orthopaedic members of the Pediatric Research in Sports Medicine study group. Results:Regarding treatment of an 8-year-old child with a complete ACL tear, 53% of respondents recommended iliotibial band reconstruction, 33% recommended all-epiphyseal reconstruction, and only 3% would treat nonoperatively in a brace. In adolescent patients with 2 years of growth remaining, 47% of respondents recommended a physeal “respecting” technique, 31% recommended a physeal-sparing technique, and 19% would perform an adult-style ACLR. There were 29 new cases of growth arrest reported. Conclusions:This study demonstrates that there have been major changes in the trends in pediatric ACLR over the past 15 years, and the most treatment variability is found among adolescent patients with about 2 years of growth remaining. The study also demonstrates that while the overall incidence of growth disturbance after ACLR remains low, new cases of growth disturbance continue to be identified. Level of Evidence:Level V—survey of expert opinion and experience.