Mark C. Drakos

Effect of graft selection on the incidence of postoperative infection in anterior cruciate ligament reconstruction.

Background Knee joint infection is a potentially devastating complication of anterior cruciate ligament (ACL) reconstruction. There is a theoretical increased risk of infection with the use of allograft material. Hypothesis An allograft ACL reconstruction predisposes patients to a higher risk of bacterial infection. Study Design Cohort Study; Level of evidence, 3. Methods All primary ACL reconstructions performed at our institution between January 2002 and December 2006 were reviewed; 3126 total procedures were identified. A retrospective medical record review was performed to determine the incidence of infection, offending organism, time after surgery until presentation, infection treatment, and graft salvage as an outcome of graft choice. Results Of the 3126 ACL reconstructions, 1777 autografts and 1349 allografts were performed. Eighteen infections were identified (0.58%). Infections occurred in 6 of the 1349 allografts (0.44%), 7 of the 1430 bone-patellar tendon-bone (BPTB) autografts (0.49%), and 5 of the 347 hamstring autografts (1.44%). Five grafts were removed because of graft incompetence or loosening: 3 hamstring tendon, 1 BPTB, and 1 allograft. The most common organism isolated was Staphylococcus aureus. Hamstring tendon autograft had an increased incidence of infection compared with both BPTB autograft and allograft (P < .05), with a trend toward a more common need for graft removal (P = .09). Allograft reconstructions were equally likely to have graft salvage as autograft reconstructions. Conclusion Hamstring tendon autografts have a higher incidence of infection than BPTB autografts or allografts. The use of allograft material in ACL reconstructions does not increase the risk of infection or the need for graft removal with infection.

Injury in the National Basketball Association: A 17-Year Overview

Background: Injury patterns in elite athletes over long periods continue to evolve. The goal of this study was to review of the injuries and medical conditions afflicting athletes competing in the National Basketball Association (NBA) over a 17-year period. Design: Descriptive epidemiological study. Methods: Injuries and player demographic information were reported by each team’s athletic trainer. Criteria for reportable injuries were those that resulted in (1) physician referral, (2) a practice or game being missed, or (3) emergency care. The demographics, frequency of injury, time lost, and game exposures were tabulated, and game-related injury rates and 95% confidence intervals were calculated. Results: A total of 1094 players appeared in the database 3843 times (3.3 ± 2.6 seasons). Lateral ankle sprains were the most frequent orthopaedic injury (n, 1658; 13.2%), followed by patellofemoral inflammation (n, 1493; 11.9%), lumbar strains (n, 999; 7.9%), and hamstring strains (n, 413; 3.3%). The most games missed were related to patellofemoral inflammation (n, 10 370; 17.5%), lateral ankle sprains (n, 5223; 8.8%), knee sprains (n, 4369; 7.4%), and lumbar strains (n, 3933; 6.6%). No correlations were found between injury rate and player demographics, including age, height, weight, and NBA experience. Conclusion: Professional athletes in the NBA experience a high rate of game-related injuries. Patellofemoral inflammation is the most significant problem in terms of days lost in competition, whereas ankle sprains are the most common injury. True ligamentous injuries of the knee were surprisingly rare. Importantly, player demographics were not correlated with injury rates. Further investigation is necessary regarding the consequences and sport-specific treatment of various injuries in NBA players. Clinical Relevance: Knowledge of these injury patterns can help to guide treatments and provide more accurate guidelines for an athlete to return to play.

Internal Impingement of the Shoulder in the Overhead Athlete

Internal impingement of the shoulder refers to a constellation of pathologic conditions, including, but not limited to, articular-sided rotator cuff tears, labral tears, biceps tendinitis, anterior instability, internal rotation deficit, and scapular dysfunction. Physiologic adaptations to throwing include increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all of which may predispose an individual to internal impingement. Nonoperative treatment should always be attempted first, with a focus on increasing the range of motion and improving scapular function. When an operative intervention is chosen, it is important to address microinstability in order to have a good outcome and prevent failure.

The Effect of the Shoe-Surface Interface in the Development of Anterior Cruciate Ligament Strain

The shoe-surface interface has been implicated as a possible risk factor for anterior cruciate ligament (ACL) injuries. The purpose of this study is to develop a biomechanical, cadaveric model to evaluate the effect of various shoe-surface interfaces on ACL strain. There will be a significant difference in ACL strain between different shoe-surface combinations when a standardized rotational moment (a simulated cutting movement) is applied to an axially loaded lower extremity. The study design was a controlled laboratory study. Eight fresh-frozen cadaveric lower extremities were thawed and the femurs were potted with the knee in 30 deg of flexion. Each specimen was placed in a custom-made testing apparatus, which allowed axial loading and tibial rotation but prevented femoral rotation. For each specimen, a 500 N axial load and a 1.5 Nm internal rotation moment were placed for four different shoe-surface combinations: group I (AstroTurf-turf shoes), group II (modern playing turf-turf shoes), group III (modern playing turf-cleats), and group IV (natural grass-cleats). Maximum strain, initial axial force and moment, and maximum axial force and moment were calculated by a strain gauge and a six component force plate. The preliminary trials confirmed a linear relationship between strain and both the moment and the axial force for our testing configuration. In the experimental trials, the average maximum strain was 3.90, 3.19, 3.14, and 2.16 for groups I-IV, respectively. Group IV had significantly less maximum strain (p<0.05) than each of the other groups. This model can reproducibly create a detectable strain in the anteromedial bundle of the ACL in response to a given axial load and internal rotation moment. Within the elastic range of the stress-strain curve, the natural grass and cleat combination produced less strain in the ACL than the other combinations. The favorable biomechanical properties of the cleat-grass interface may result in fewer noncontact ACL injuries.

Biomechanical Analysis of Brostrom Versus Brostrom-Gould Lateral Ankle Instability Repairs:

Background: The traditional Brostrom repair and the modified Brostrom-Gould repair are 2 historically reliable procedures used to address lateral ankle instability. The purpose of this study was to evaluate the biomechanical stability conferred by the Brostrom repair as compared to the Brostrom-Gould modification in an unstable cadaveric ankle model. Methods: A total of 10 cadaveric specimens were placed in a Telos ankle stress apparatus in an anterior-posterior position and then in a lateral position, while a 170 N load was applied to simulate anterior drawer (AD) and talar tilt (TT) tests, respectively. In both circumstances, the ankle was held in 15 degrees of plantarflexion, neutral, and 15 degrees of dorsiflexion, while the movement of the sensors was measured using a video motion analysis system. Measurement of the translation between the talus and tibia in the AD test and the angle between the tibia and talus in the TT test were calculated for specimens in the (1) intact, (2) sectioned (division of the ATFL and CFL), (3) Brostrom repair and (4) Gould modification states. Results: When compared to both the repaired states and the intact states, the sectioned state demonstrated increased inversion and translation at all ankle positions during TT and AD testing. Furthermore, no significant differences were found between the intact state and either of the repaired states. Finally, no difference in the biomechanical stability could be identified between the traditional Brostrom repair and the modified Brostrom-Gould procedure. Conclusions: Our findings indicate that there is no significant biomechanical difference in initial ankle stability conferred by augmenting the traditional Brostrom repair with the Gould modification in this time-zero cadaveric model. Clinical Relevance: These data suggest that the additional reinforcement of an ankle’s lateral ligament complex repair of the ankle with the inferior extensor retinaculum may be marginal at the time of surgery.

Proximity of Arthroscopic Ankle Stabilization Procedures to Surrounding Structures: An Anatomic Study

PURPOSE To examine the anatomy of the lateral ankle after arthroscopic repair of the lateral ligament complex (anterior talofibular ligament [ATFL] and calcaneofibular ligament [CFL]) with regard to structures at risk. METHODS Ten lower extremity cadaveric specimens were obtained and were screened for gross anatomic defects and pre-existing ankle laxity. The ATFL and CFL were sectioned from the fibula by an open technique. Standard anterolateral and anteromedial arthroscopy portals were made. An additional portal was created 2 cm distal to the anterolateral portal. The articular surface of the fibula was identified, and the ATFL and CFL were freed from the superficial and deeper tissues. Suture anchors were placed in the fibula at the ATFL and CFL origins and were used to repair the origin of the lateral collateral structures. The distance from the suture knot to several local anatomic structures was measured. Measurements were taken by 2 separate observers, and the results were averaged. RESULTS Several anatomic structures lie in close proximity to the ATFL and CFL sutures. The ATFL sutures entrapped 9 of 55 structures, and no anatomic structures were inadvertently entrapped by the CFL sutures. The proximity of the peroneus tertius and the extensor tendons to the ATFL makes them at highest risk of entrapment, but the proximity of the intermediate branch of the superficial peroneal nerve (when present) is a risk with significant morbidity. CONCLUSIONS Our results indicate that the peroneus tertius and extensor tendons have the highest risk for entrapment and show the smallest mean distances from the anchor knot to the identified structure. Careful attention to these structures, as well as the superficial peroneal nerve, is mandatory to prevent entrapment of tendons and nerves when one is attempting arthroscopic lateral ankle ligament reconstruction. CLINICAL RELEVANCE Defining the anatomic location and proximity of the intervening structures adjacent to the lateral ligament complex of the ankle may help clarify the anatomic safe zone through which arthroscopic repair of the lateral ligament complex can be safely performed.

A Review of Synthetic Playing Surfaces, the Shoe-Surface Interface, and Lower Extremity Injuries in Athletes

Abstract The evolution of synthetic playing surfaces began in the 1960s and has had an impact on field use, shoe-surface dynamics, and the incidence of sports-related injuries. Modern third-generation turfs are being installed in recreational facilities and professional stadiums worldwide. Currently, > two-thirds of National Football League teams,> 100 National Collegiate Athletic Association Division I football teams, and > 1000 high schools in the United States have installed synthetic playing surfaces. Those in favor of such playing surfaces note their unique combination of versatility and durability; they can be used in both ideal and inclement weather conditions. However, the more widespread installation and use of these surfaces have raised questions and concerns regarding the impact of artificial turf on the type and severity of sports-related injuries. There appears to be no question that the shoe-surface interface has a significant impact on such injuries. Independent variables such as weather conditions, contact versus noncontact sport, shoe design, and field wear complicate many of the results reported in the literature, thereby preventing an accurate assessment of the true risk(s) associated with certain shoe-surface combinations. Historically, studies suggest that artificial turf is associated with a higher incidence of injury. Furthermore, reliable biomechanical data suggest that both the torque and strain experienced by lower extremity joints generated by artificial surfaces may be more than those generated by natural grass fields. Recent data from the National Football League support this theory and suggest that elite athletes may sustain more injuries, even when playing on the newer artificial surfaces. By contrast, some reports based on data collected from lower-level athletes suggest that artificial turf may protect against injury. This review discusses the history of artificial surfaces, the biomechanics of the shoe-surface interface, and some common turf-related lower extremity injuries.

Return to Sports and Physical Activities After Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients

Background: Research regarding outcomes in sports and physical activities after primary partial arthrodesis for Lisfranc injuries has been sparse. The purposes of this study were to assess various sports and physical activities in young patients following primary partial arthrodesis for Lisfranc injuries and to compare these with clinical outcomes. Methods: Patients who underwent primary partial arthrodesis for a Lisfranc injury were identified by a retrospective registry review. Thirty-eight of 46 eligible patients (83%) responded for follow-up at a mean of 5.2 (range, 1.0 to 9.3) years with a mean age at surgery of 31.8 (range, 16.8 to 50.3) years. Physical activity participation was assessed with a new sports-specific, patient-administered questionnaire. Clinical outcomes were assessed with the Foot and Ankle Outcome Score (FAOS). Results: Patients participated in 29 different and 155 total physical activities preoperatively, and 27 different and 145 total physical activities postoperatively. Preoperatively, 47.1% were high impact, and postoperatively, 44.8% were high impact. The most common activities were walking, bicycling, running, and weightlifting. Compared to preoperatively, difficulty was the same in 66% and increased in 34% of physical activities. Participation levels were improved in 11%, the same in 64%, and impaired in 25% of physical activities. Patients spent on average 4.2 (range, 0.0 to 19.8) hours per week exercising postoperatively. In regard to return to physical activity, 97% of respondents were satisfied with their operative outcome. Mean postoperative FAOS subscores were significantly worse for patients who had increased physical activity difficulty. Conclusion: Most patients were able to return to their previous physical activities following primary partial arthrodesis for a Lisfranc injury, many of which were high-impact. However, the decreased participation or increase in difficulty of some activities suggests that some patients experienced postoperative limitations in exercise. Future studies could compare sports outcomes between primary partial arthrodesis and open reduction internal fixation for Lisfranc injuries. Level of Evidence: Level IV, retrospective case series.

Synthetic Playing Surfaces and Athlete Health

&NA; Synthetic playing surfaces have evolved considerably since their introduction in the 1960s. Today, third‐generation turf is routinely installed in professional, collegiate, and community settings. Proponents of artificial surfaces tout their versatility and durability in a variety of climates. However, the health and injury ramifications have yet to be clearly defined. Musculoskeletal injury is largely affected by the shoe‐playing surface interface. However, conclusive statements cannot be made regarding the risk of certain shoe‐playing surface combinations because of the variety of additional factors, such as weather conditions, shoe wear, and field wear. Historically, clinical studies have indicated that higher injury rates occur on artificial turf than on natural surfaces. This conclusion is backed by robust biomechanical data that suggest that torque and strain may be greater on artificial surfaces than on natural grass. Recent data on professional athletes suggest that elite athletes may sustain injuries at increased rates on the newer surfaces. However, these surfaces remain attractive to athletes and administrators alike because of their durability, relative ease of maintenance, and multiuse potential.

Syndesmosis and lateral ankle sprains in the National Football League.

Syndesmosis sprains in the National Football League (NFL) can be a persistent source of disability, especially compared with lateral ankle injuries. This study evaluated syndesmosis and lateral ankle sprains in NFL players to allow for better identification and management of these injuries. Syndesmosis and lateral ankle sprains from a single NFL team database were reviewed over a 15-year period, and 32 NFL team physicians completed a questionnaire detailing their management approach. A comparative analysis was performed analyzing several variables, including diagnosis, treatment methods, and time lost from sports participation. Thirty-six syndesmosis and 53 lateral ankle sprains occurred in the cohort of NFL players. The injury mechanism typically resulted from direct impact in the syndesmosis and torsion in the lateral ankle sprain group (P=.034). All players were managed nonoperatively. The mean time lost from participation was 15.4 days in the syndesmosis and 6.5 days in the lateral ankle sprain groups (P⩽.001). National Football League team physicians varied treatment for syndesmosis sprains depending on the category of diastasis but recommended nonoperative management for lateral ankle sprains. Syndesmosis sprains in the NFL can be a source of significant disability compared with lateral ankle sprains. Successful return to play with nonoperative management is frequently achieved for syndesmosis and lateral ankle sprains depending on injury severity. With modern treatment algorithms for syndesmosis sprains, more aggressive nonoperative treatment is advocated. Although the current study shows that syndesmosis injuries require longer rehabilitation periods when compared with lateral ankle sprains, the time lost from participation may not be as prolonged as previously reported.