Marlene DeMaio

Understanding and Preventing Noncontact Anterior Cruciate Ligament Injuries A Review of the Hunt Valley II Meeting, January 2005

The incidence of noncontact anterior cruciate ligament injuries in young to middle-aged athletes remains high. Despite early diagnosis and appropriate operative and nonoperative treatments, posttraumatic degenerative arthritis may develop. In a meeting in Atlanta, Georgia (January 2005), sponsored by the American Orthopaedic Society for Sports Medicine, a group of physicians, physical therapists, athletic trainers, biomechanists, epidemiologists, and other scientists interested in this area of research met to review current knowledge on risk factors associated with noncontact anterior cruciate ligament injuries, anterior cruciate ligament injury biomechanics, and existing anterior cruciate ligament prevention programs. This article reports on the presentations, discussions, and recommendations of this group.

Real-Time Intersession and Interrater Reliability of the Functional Movement Screen

Onate, JA, Dewey, T, Kollock, RO, Thomas, KS, Van Lunen, BL, DeMaio, M, and Ringleb, SI. Real-time intersession and interrater reliability of the functional movement screen. J Strength Cond Res 26(2): 408–415, 2012—The purpose of this study was to examine the real-time intersession and interrater reliability of the functional movement screen (FMS). The overall study consisted of 19 volunteer civilians (12 male, 7 female). The intersession reliability consisted of 12 men and 7 women, whereas 10 men and 6 women participated in the interrater reliability test session. Two raters (A and B) were involved in the interrater reliability aspect of this study. The FMS includes 7 tests: deep squat (DS), hurdle step (HS), in-line lunge (IL), shoulder mobility (SM), active straight leg raise (ASLR), trunk stability push-up (TSPU), and rotary stability (RS). Researchers analyzed the data via intraclass correlation (ICC). To determine the reliability of the intersession scoring of the FMS and the intrasession interrater scoring of the FMS a 2-way mixed effects model intraclass correlation coefficient (ICC3,1) was used for the continuous data, whereas a weighted Cohens kappa (κ) was used for the categorical data. The dependent variables were FMS total score (0–21 scale) and associated tests were DS, HS, IL, SM, ASLR, TSPU, and RS. Intersession reliability (ICC, SEM) and κ were as follows: FMS total score (0.92, 0.51), DS (κ = 0.69), HS (κ = 0.16), IL (κ = 0.69), SM (κ = 0.84), ASLR (κ = 0.69), TSPU (κ = 0.77), and RS (no covariance). Interrater reliability (ICC, SEM) and κ were as follows: FMS total score (0.98, 0.25), DS (κ = 1.0), HS (κ = 0.33), IL (κ = 0.88), SM (κ = 0.90), ASLR (κ = 0.88), TSPU (κ = 0.75), and RS (no covariance). The FMS total scores displayed high intersession and interrater reliabilities. Finally, with the exception of HS, all tasks displayed moderate to high intersession reliability and good to high interrater reliability.

Ehlers-Danlos Syndrome in Orthopaedics: Etiology, Diagnosis, and Treatment Implications

Ehlers-Danlos syndrome is a heterogeneous connective tissue condition characterized by varying degrees of skin hyperextensibility, joint hypermobility, and vascular fragility. Joint dislocations, musculoskeletal pain, atrophic scars, easy bleeding, vessel/viscera rupture, severe scoliosis, and obstetric complications may occur. These manifestations are secondary to abnormal collagen, with specific molecular defects in types I, III, and V collagen; they may also be related to tenascin-X, which has been identified in some patients. Ehlers-Danlos syndrome has been classified into 6 types, with variable degrees of joint instability, skin hyperextensibility, wound healing difficulty, and vascular fragility. Diagnosis begins with recognition of the signs and symptoms of global hypermobility and referring appropriate patients for genetic consultation. It is important to accurately identify patients with Ehlers-Danlos syndrome to initiate appropriate musculoskeletal treatment, optimize anesthetic and postoperative management, perform appropriate vascular screening, and help families address their concerns with other families and advocacy groups.

Comparison of Insertional Trauma Between Suprapatellar and Infrapatellar Portals for Tibial Nailing

The purpose of this study was to determine differences in insertional articular trauma in infrapatellar tibial portal and suprapatellar portal intramedullary tibial nail insertion techniques. A cadaveric study was performed on 10 matched pairs of fresh-frozen adult cadaver lower extremities with intact extensor mechanisms. Two study groups with 10 limbs each were created: left lower limbs were treated with a standard medial parapatellar nailing portal and right lower limbs were treated with a suprapatellar tibial nailing portal. Start points were created under fluoroscopic guidance in anteroposterior and mediolateral planes. A start wire was placed and opening reaming was performed on the specimens using instrumentation specific to the nailing portal. Specimens were then dissected by medial parapatellar arthrotomy, revealing the intra-articular condition of the knee structures. The border of the tibial entry reamer hole was measured to the anterior horns of the menisci, anterior cruciate ligament root, and intermeniscal ligament using a digital caliper accurate to 0.02 mm. The structure was considered damaged if the structure was obviously damaged on visual inspection or if a measurement was less than 1 mm. Impact to intra-articular structures was numerically lower in the suprapatellar group (2/10) compared with the infrapatellar group (4/10), but the difference was not statistically significant between the 2 groups (P=.629). The suprapatellar portal approach to the tibial start point demonstrated a lower overall incidence of damage to intra-articular structures, but no significant statistical difference existed between the 2 treatment groups.

The Prevalence of Symptomatic Deep Venous Thrombosis and Pulmonary Embolism After Anterior Cruciate Ligament Reconstruction

Background: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. The incidence and risk factors of venous thromboembolism (VTE) after ACL reconstruction remain unclear. Purpose: To define the incidence of VTE after ACL reconstruction and identify associated risk factors in a large cohort of patients. Study Design: Descriptive epidemiological study. Methods: All patients aged ≥18 years who underwent ACL reconstruction between 2005 and 2011 were identified from the Department of Defense Medical Data Repository. The prevalence of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE), within 3 months of ACL reconstruction was queried. Univariate analyses were performed to define odds ratios (ORs) for demographic, medication use, and procedural-related risk factors. Results: A total of 87 VTE events (0.53% [95% CI, 0.42%-0.65%]) occurred after 16,558 ACL reconstructions performed on 15,767 patients. DVT was documented after 55 procedures and PE after 35 procedures. Three patients were documented to have both DVT and PE within the study period. The odds of VTE increased in patients aged ≥35 years (OR, 1.96 [95% CI, 1.27-3.04]; P = .003). Nicotine history increased the odds of DVT (OR, 1.99 [95% CI, 1.15-3.43]; P = .014). Concomitant high tibial osteotomy (HTO) increased the odds of PE (OR, 18.31 [95% CI, 2.4-139.6]; P = .005), whereas concomitant posterior cruciate ligament (PCL) reconstruction increased the odds of both VTE (OR, 3.43 [95% CI, 1.07-11.2]; P = .38) and DVT (OR, 5.57 [95% CI, 1.71-18.14]; P = .004). Nonsteroidal drug use was associated with decreased odds for VTE and DVT (OR, 0.44 [95% CI, 0.28-0.70]; P < .001 and OR, 0.38 [95% CI, 0.22-0.69]; P < .001, respectively). Anticoagulants were associated with increased odds for VTE, DVT, and PE (OR, 98.32 [95% CI, 61.63-156.86]; P < .001; OR, 111.93 [95% CI, 63.95-195.92]; P < .001; and OR, 47.84 [95% CI, 22.55-101.52]; P < .001, respectively). No detectible difference in odds was found for sex, body mass index, or aspirin or cyclooxygenase-2 inhibitor use. Conclusion: The incidence of VTE after ACL reconstruction in this large population was low. Increased odds of VTE was identified in patients aged ≥35 years with a history of nicotine use, anticoagulant use, concomitant HTO, or concomitant PCL reconstruction. Controlled studies are necessary to determine the efficacy of chemoprophylaxis and to develop evidence-based clinical practice guidelines to minimize VTE after ACL reconstruction.

Patellar tendon repair with suture anchors using a combined suture technique of a Krackow-Bunnell weave.

Suture repair of the ruptured patellar tendon is the treatment of choice for patients requiring operative management. This standard technique includes fixation through transosseous tunnels in the patella. The use of suture anchor fixation has several advantages over the standard approach, including less dissection, decreased surgical time, more accurate suture placement, and a low-profile construct. Additionally, the pullout strength of suture anchors warrants consideration of this technique in these repairs. This article describes using suture anchors for repair of the acute ruptured patellar tendon with a combination of Krackow and Bunnell sutures.

Effects of training on physical performance wearing personal protective equipment

We evaluated the effects of wearing a weighted vest during 6 weeks of military-style training. Forty-three subjects were randomly assigned to a control group or a vest group (carrying 4-5 kg for 2 weeks, and 8-10 kg for 4 weeks), with 37 completing the study (17 vest, 20 control). Both groups performed stair climbing in addition to standard Marine Corps training for 1 hour, four times per week. Pre- and post-tests were performed while wearing military personal protective equipment, with the exception of the Marine Physical Readiness Test (PRT). Both groups significantly improved PRT scores (8.4% 3-mile run, 28-38% calisthenics) and an agility drill (4.4%). Significant improvements in uphill treadmill performance (6.8% vest, 3.0% control) and maximal oxygen consumption (10.7% vest, 6.8% control) were approximately twice as much in the vest versus control group, although these differences did not reach significance (p = 0.16 and 0.13, respectively).

Serotonin Reuptake Inhibitors and Bleeding Risks in Major Orthopedic Procedures

BACKGROUND Risk of abnormal bleeding in surgery patients prescribed serotonin reuptake inhibitors (SRIs) is unclear. Considering the quantity of literature on abnormal gastrointestinal (GI) bleeding with SRIs, relatively little exists on SRI bleeding risks in surgical procedures. We investigated whether SRIs increase the risk of surgical bleeding in patients undergoing knee and hip total joint replacement. METHODS RA retrospective case-control study was conducted among subjects undergoing primary total hip and knee replacement surgeries from January 2005 to March 2011 at a single institution. The experimental group was defined by utilization of SRIs at the time of surgery (the independent variable). The control group was matched for age, sex, ethnicity, and type of surgery (hip or knee). Any case with preoperative hematocrit <30, platelets <100,000; abnormal prothrombin time, partial-prothrombin time, and international normalized ratio (INR), primary bleeding disorder, medical conditions, or medications associated with increased bleeding was excluded. All cases were randomly selected. RESULTS RA total of 194 subjects (hip 104, knee 90) were included. Statistical analysis was performed on the SRI group (n = 71) and the control, non-SRI group (n = 123). No difference was found between the groups in estimated blood loss, hemoglobin, hematocrit, platelets, PT, PTT, and INR from preoperative to postoperative day 1, 2, and 3. Furthermore, no subjects in either group required blood transfusions. CONCLUSION SRIs were not associated with increased risk of bleeding in primary knee or hip replacement surgeries in this study. The hypothesis that SRIs increase the risk of bleeding based on presumptions about their action on platelet aggregation is uncertain and warrants further study.

Predictors of Revision Surgery After Anterior Cruciate Ligament Reconstruction

Background: Arthroscopically assisted anterior cruciate ligament (ACL) reconstruction is a common orthopaedic procedure. Graft failure after reconstruction remains a devastating complication, often requiring revision surgery and less aggressive or modified rehabilitation. Worse functional and patient-reported outcomes are reported compared with primary reconstruction. Moreover, both rates and risk factors for revision are variable and inconsistent within the literature. Purpose: To determine the rate of revision surgery after ACL reconstruction in a large cohort of patients, to assess the influence of patient characteristics on the odds of revision, and to compare revision rates between active-duty military members and non–active-duty beneficiaries. Study Design: Descriptive epidemiology study. Methods: Using administrative data from the Military Health System, a retrospective study was designed to characterize the rate of ACL revision surgery among patients treated within a military facility. All patients ≥18 years at the time of ACL reconstruction were identified using the American Medical Association Current Procedural Terminology (CPT) for ACL reconstruction (CPT code 29888) over 7 years (2005-2011). Revision ACL reconstructions were identified as having ≥2 ACL reconstruction procedure codes on the ipsilateral knee at least 90 days apart. Univariate analysis was performed to calculate odds ratios (ORs) for demographic, perioperative medication use, and concomitant procedure–related risk factors. A multivariate logistic regression model determined risk covariates in the active-duty cohort. Results: The study population consisted of 17,164 ACL reconstructions performed among 16,336 patients, of whom 83.3% were male with a mean ± SD age of 28.9 ± 7.6 years for the nonrevision group, and was predominantly active duty (89.2%). Patients undergoing ACL reconstruction on both knees only contributed their index knee for analyses. There were 587 patients who underwent revision surgery, corresponding to an overall revision rate of 3.6%. The median time from the index surgery to revision surgery was 500 days (interquartile range, 102-2406 days). Revision rates were higher in the active-duty cohort as compared with non–active-duty beneficiaries (3.8% vs 1.8%, respectively; OR, 2.14; 95% CI, 1.49-3.07). Based on multivariate logistic regression in the active-duty cohort, age ≥35 years (OR, 0.44; 95% CI, 0.33-0.58) and concomitant meniscal repair (OR, 0.69; 95% CI, 0.53-0.91) were found to be protective with regard to the odds of revision surgery. Perioperative medication use of nonsteroidal anti-inflammatory drugs (NSAIDs) (OR, 1.33; 95% CI, 1.12-1.58; number needed to harm [NNH], 100) and COX-2 inhibitors (OR, 1.31; 95% CI, 1.04-1.66; NNH, 333) was associated with increased odds of revision surgery. No significant findings were detected among sex, race, nicotine use, body mass index, or other concomitant procedures of interest. Conclusion: In this large cohort study, the rate of revision ACL reconstruction was 3.6%, which is consistent with the existing literature. Increased odds of revision surgery among active-duty personnel were associated with the perioperative use of NSAIDs and COX-2 inhibitors. Age ≥35 years and concomitant meniscal repair were found to be protective against ACL revision.

A Novel Technique for Ligamentous Reconstruction of the Sternoclavicular Joint

SUMMARY The technique presented is a departure from previous attempts to standardize the treatment of sternoclavicular dislocations. It offers stability without requiring extra dissection around vital intrathoracic structures and greatly decreases the risk of migration of the implant used for fixation.