Matthew D. Milewski

Complications Related to Anatomic Reconstruction of the Coracoclavicular Ligaments

Background: Anatomic reconstruction of the coracoclavicular (CC) ligaments has become a popular surgical treatment for high-grade acromioclavicular (AC) dislocations, but little has been reported about complications related to these newer surgical techniques. Purpose: We sought to review the complications related to several new techniques for the anatomic reconstruction of the CC ligaments for the treatment of AC separations. Study Design: Case series; Level of evidence, 4. Methods: We conducted a retrospective review of the operative treatment of AC separation utilizing anatomic reconstruction of the CC ligaments by reviewing the case logs of 3 fellowship-trained orthopaedic surgeons at a single academic sports medicine center for the past 5 years using appropriate current procedural terminology codes. The medical records and postoperative radiographs were assessed for complications. Results: Twenty-seven cases of anatomic reconstruction of the CC ligaments were reviewed. All patients had an autograft or allograft ligament reconstruction utilizing either a coracoid tunnel (10 cases) or a loop around the coracoid base (17 cases). Eight complications (80%) were noted in the coracoid tunnel group including 2 coracoid fractures (20%), 5 patients with some loss of reduction (more than 5-mm increased CC interval displacement on subsequent postoperative radiographs) (50%), and 1 patient with an intraoperative failure of the coracoid button fixation (10%). Six patients developed complications in the coracoid loop group (35%) including 3 clavicle fractures (18% within group, 11% overall), 1 patient with loss of reduction (6%), 1 patient with loss of reduction and an infection (6% within group, 4% overall), and 1 patient with adhesive capsulitis postoperatively (6% within group, 4% overall). Conclusion: Newer techniques for the anatomic reconstruction of the CC ligaments may have steep learning curves associated with complications such as coracoid and clavicle fractures. Loss of reduction continues to be associated with the operative treatment of high-grade AC separations. Further refinement of surgical technique and experience with the operative treatment of AC separation is warranted.

Anatomic Femoral Tunnel Drilling in Anterior Cruciate Ligament Reconstruction Use of an Accessory Medial Portal Versus Traditional Transtibial Drilling

Background: During anatomic anterior cruciate ligament (ACL) reconstruction, we have found that the femoral footprint can best be visualized from the anteromedial portal. Independent femoral tunnel drilling can then be performed through an accessory medial portal, medial and inferior to the standard anteromedial portal. Purpose: To compare the accuracy of independent femoral tunnel placement relative to the ACL footprint using an accessory medial portal versus tunnel placement with a traditional transtibial technique. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaveric knees were randomized such that within each pair, one knee underwent arthroscopic transtibial (TT) drilling, and the other underwent drilling through an accessory medial portal (AM). All knees underwent computed tomography (CT) both preoperatively and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Computed tomography was performed with a dual-energy scanner. Commercially available third-party software was used to fuse the preoperative and postoperative CT scans, allowing anatomic comparison of the ACL footprint to the drilled tunnel. The ACL footprint was marked in consensus by an orthopaedic surgeon and a musculoskeletal radiologist and then compared with the tunnel aperture after drilling. The percentage of tunnel aperture contained within the native footprint as well as the distance from the center of the tunnel aperture to the center of the footprint was measured. Results: The AM technique placed 97.7% ± 5% of the tunnel within the native femoral footprint, significantly more than 61.2% ± 24% for the TT technique (P = .001). The AM technique placed the center of the femoral tunnel 3.6 ± 1.2 mm from the center of the native footprint, significantly closer than 6.0 ± 1.9 mm for the TT technique (P = .003). Conclusion: This study demonstrates that use of an accessory medial portal will facilitate more accurate placement of the femoral tunnel in the native ACL femoral footprint. Clinical Relevance: More accurate placement of the femoral tunnel in the native ACL femoral footprint should improve the ability to achieve more anatomic positioning of the ACL graft.

Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent Athletes

Background: Much attention has been given to the relationship between various training factors and athletic injuries, but no study has examined the impact of sleep deprivation on injury rates in young athletes. Information about sleep practices was gathered as part of a study designed to correlate various training practices with the risk of injury in adolescent athletes. Methods: Informed consent for participation in an online survey of training practices and a review of injury records was obtained from 160 student athletes at a combined middle/high school (grades 7 to 12) and from their parents. Online surveys were completed by 112 adolescent athletes (70% completion rate), including 54 male and 58 female athletes with a mean age of 15 years (SD=1.5; range, 12 to 18 y). The students’ responses were then correlated with data obtained from a retrospective review of injury records maintained by the school’s athletic department. Results: Multivariate analysis showed that hours of sleep per night and the grade in school were the best independent predictors of injury. Athletes who slept on average <8 hours per night were 1.7 times (95% confidence interval, 1.0-3.0; P=0.04) more likely to have had an injury compared with athletes who slept for ≥8 hours. For each additional grade in school, the athletes were 1.4 times more likely to have had an injury (95% confidence interval, 1.2-1.6; P<0.001). Conclusion: Sleep deprivation and increasing grade in school appear to be associated with injuries in an adolescent athletic population. Encouraging young athletes to get optimal amounts of sleep may help protect them against athletic injuries. Level of Evidence: Level III.

Preliminary results of a novel single-stage cartilage restoration technique: Particulated juvenile articular cartilage allograft for chondral defects of the patella

PURPOSE To evaluate outcomes and magnetic resonance imaging (MRI) findings after use of particulated juvenile cartilage for the treatment of focal Outerbridge grade 4 articular cartilage defects of the patella. METHODS From 2007 to 2011, 16 patients (2 bilateral) underwent a novel single-stage articular cartilage restoration procedure using particulated juvenile articular cartilage allograft. We enrolled 15 knees (13 patients) in this study. The mean age at surgery was 26.4 ± 9.1 years, and the mean postoperative follow-up was 28.8 ± 10.2 months. A musculoskeletal radiologist evaluated each knee with postoperative MRI for the International Cartilage Repair Society cartilage repair assessment score, graft hypertrophy, bony changes around the graft, and percent fill of the defect. All patients also completed the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee Subjective Knee Evaluation, and Kujala clinical outcome survey (scale, 0 to 100), as well as the Tegner activity scale and visual analog pain scale (scale, 0 to 10). RESULTS The mean International Cartilage Repair Society cartilage repair assessment score on MRI was 8.0 ± 2.8, a nearly normal assessment. Of 15 knees, 11 (73%) were found to have normal or nearly normal cartilage repair. Three patients had mild graft hypertrophy whereas 2 had gross graft hypertrophy, 2 of whom required arthroscopic debridement because of symptoms. The mean fill of the defect at follow-up was 89% ± 19.6%, with 12 of 15 knees (80%) showing at least 90% defect coverage. The mean clinical outcome score at follow-up was 73.3 ± 17.6 for the International Knee Documentation Committee evaluation, and the mean scores for each subdomain of the Knee Injury and Osteoarthritis Outcome Score were as follows: 84.2 ± 14.2 for pain, 85.0 ± 12.3 for symptoms and stiffness, 88.9 ± 12.9 for activities of daily living, 62.0 ± 25.1 for sports and recreation, and 60.8 ± 28.6 for quality of life. The median score for the Kujala survey was 79 (range, 55 to 99). The median score on the Tegner activity scale was 5 (range, 3 to 9), and the mean score on the visual analog scale was 1.9 ± 1.4, indicating minimal pain. CONCLUSIONS Preliminary results suggest that cartilage restoration using particulated juvenile articular cartilage allograft offers a viable option for patients with focal grade 4 articular cartilage defects of the patella.

Lyme Arthritis in Children Presenting with Joint Effusions

BACKGROUND The present study was designed to evaluate the prevalence of Lyme arthritis in children who had a joint aspiration at a tertiary care childrens hospital in an endemic area and to identify clinical factors useful to differentiate Lyme arthritis from septic arthritis at the time of the initial presentation. METHODS The records of all children with an age of eighteen years or less who were managed with aspiration for joint effusions at our institution from 1992 to 2009 were reviewed. Data collection included a review of aspirates; an analysis of cell count, culture results, and hematological inflammatory markers; and a review of surgical intervention. RESULTS A total of 506 joint aspirations were analyzed. One hundred and fifteen aspirations were excluded. In the remaining group of 391 patients, 123 (31%) were subsequently diagnosed with Lyme arthritis. Fifty-one patients had culture-positive septic arthritis. The two cohorts were significantly different in terms of the presence of a fever of >101.5°F (>40.6°C) at the time of presentation, the refusal to bear weight, the peripheral white blood-cell count, and joint fluid cell count. The erythrocyte sedimentation rate and the C-reactive protein level were not significantly different between the two cohorts. Multivariate analysis demonstrated that refusal to bear weight was the strongest predictor of the diagnosis of septic arthritis over Lyme arthritis. CONCLUSIONS For any child presenting with a joint effusion in a Lyme-endemic area of the Northeastern United States, the likely prevalence of Lyme arthritis is 31% overall and 45% in the presence of knee effusion. Children with joint effusions resulting from Lyme disease are more likely to have knee involvement, a lower peripheral white blood-cell count, and a lower joint fluid cell count, and they are less likely to have fever or complete refusal to bear weight, when compared with children with septic arthritis.

Distinguishing Lyme From Septic Knee Monoarthritis in Lyme Disease–Endemic Areas

OBJECTIVE: Because Lyme and septic arthritis may present similarly, we sought to identify children with knee monoarthritis at low risk for septic arthritis who may not require arthrocentesis. METHODS: We performed a retrospective study of children with knee monoarthritis presenting to 1 of 2 pediatric centers, both located in Lyme disease–endemic areas. Septic arthritis was defined by a positive result on synovial fluid culture or synovial fluid pleocytosis with a positive blood culture result. Lyme arthritis was defined as a positive Lyme serologic result or physician-documented erythema migrans rash. All other children were considered to have other inflammatory arthritis. A clinical prediction model was derived by using recursive partitioning to identify children at low risk for septic arthritis, and the model was then externally validated. RESULTS: We identified 673 patients with knee monoarthritis; 19 (3%) had septic arthritis, 341 (51%) had Lyme arthritis, and 313 (46%) had other inflammatory arthritis. The following predictors of knee septic arthritis were identified: peripheral blood absolute neutrophil count ≥10 × 103 cells per mm3 and an erythrocyte sedimentation rate ≥40 mm/hour. In the validation population, no child with a absolute neutrophil count <10 × 103 cells per mm3 and an erythrocyte sedimentation rate <40 mm/hour had septic arthritis (sensitivity: 6 of 6 [100%], 95% confidence interval [CI]: 54–100; specificity: 87 of 160 [54%], 95% CI: 46–62). Overall, none of the 19 children with septic arthritis were classified as low risk (10%, 95% CI: 0–17). CONCLUSIONS: Laboratory criteria can be used to identify children with knee monoarthritis at low risk for septic arthritis who may not require diagnostic arthrocentesis.

Anterior Cruciate Ligament Reconstruction in the Young Athlete: A Treatment Algorithm for the Skeletally Immature

Injury to the anterior cruciate ligament (ACL) in the skeletally immature was once considered rare, and it was widely held that tibial spine avulsions rather than ligament ruptures occur in this young population. The incidence of ACL rupture in skeletally immature individuals sustaining a knee injury has historically been reported as 1% to 3.4%. In young athletes presenting with hemarthrosis, however, the incidence of CL rupture has been reported to be between 26% and 65%. As imaging and clinical awareness of injuries in young athletes has improved, the diagnosis and reported incidence of ACL injury has increased. The rate of ACL injury in patients with open physes has recently been shown to approach the rate of tibial spine fractures and traumatic ACL disruption has also been described in children as young as 4 years of age.

Anatomic Femoral Tunnels in Posterior Cruciate Ligament Reconstruction Inside-Out Versus Outside-In Drilling

Background: During posterior cruciate ligament (PCL) reconstruction, the placement and orientation of the femoral tunnel is critical to postoperative PCL function. Purpose: To compare the ability of outside-in (OI) versus inside-out (IO) femoral tunnel drilling in placing the femoral tunnel aperture within the anatomic femoral footprint of the PCL, and to evaluate the orientation of the tunnels within the medial femoral condyle. Study Design: Controlled laboratory study. Methods: Ten matched pairs of cadaver knees were randomized such that within each pair, 1 knee underwent arthroscopic OI drilling and the other underwent IO drilling. All knees underwent computed tomography (CT) both pre- and postoperatively with a technique optimized for ligament evaluation (80 keV with maximum mAs). Commercially available third-party software was used to fuse the pre- and postoperative CT scans, allowing comparison of the PCL footprint to the drilled tunnel. The percentage of tunnel aperture contained within the native footprint, as well as the distance from the center of the tunnel aperture to the center of the footprint, were measured. In addition, the orientation of the tunnels in the coronal and axial planes was evaluated. Results: The OI technique placed 70.4% ± 23.7% of the tunnel within the native femoral footprint compared with 79.8% ± 16.7% for the IO technique (P = .32). The OI technique placed the center of the femoral tunnel 4.9 ± 2.2 mm from the center of the native footprint compared to 5.3 ± 2.0 mm for the IO technique (P = .65). The femoral tunnel angle in the coronal plane was 21.0° ± 9.9° for the OI technique and 37.0° ± 10.3° for the IO technique (P = .002). The tunnel angle in the axial plane was 27.3° ± 4.8° for the OI technique and 39.1° ± 11.5° for the IO technique (P = .01). Conclusion: This study demonstrates no difference in the ability of the OI and IO techniques to place the femoral tunnel within the PCL femoral footprint during PCL reconstruction. With the technique parameters used in this study, the IO technique created femoral tunnels with a more vertical and anterior orientation than the OI technique. Clinical Relevance: Either technique can be used to place the femoral tunnel within the anatomic footprint. Consideration should be given to tunnel orientation following each technique, and what effect it has on graft bending angles, as these characteristics may affect graft strain and, ultimately, graft failure. In this regard, the IO technique likely produces gentler graft bending angles.

Lyme Disease and the Orthopaedic Implications of Lyme Arthritis

&NA; Lyme disease is the most common tick‐borne disease in the United States and Europe. Increased awareness of the clinical manifestations of the disease is needed to improve detection and treatment. In the acute and late stages, Lyme disease may be difficult to distinguish from other disease processes. The epidemiology and pathophysiology of Lyme disease are directly related to the Borrelia burgdorferi spirochete and its effects on the integumentary, neurologic, cardiac, and musculoskeletal systems. Lyme arthritis is a common clinical manifestation of Lyme disease and should be considered in the evaluation of patients with monoarticular or pauciarticular joint complaints in a geographic area in which Lyme disease is endemic. Management of Lyme arthritis involves eradication of the spirochete with antibiotics. Generally, the prognosis is excellent. Arthroscopic synovectomy is reserved for refractory cases that do not respond to antibiotics.

Synovial fluid findings in children with knee monoarthritis in lyme disease endemic areas.

Background Although Lyme and septic arthritis of the knee may have similar clinical presentations, septic arthritis requires prompt identification and treatment to avoid joint destruction. We sought to determine whether synovial fluid cell counts alone can discriminate between Lyme, septic, and other inflammatory arthritis. Methods We conducted a retrospective cohort study of children aged 1 to 18 years with knee monoarthritis who presented to 1 of 2 pediatric emergency departments located in Lyme endemic areas. We included children who had both a synovial fluid culture and an evaluation for Lyme disease. Septic arthritis was defined as a positive synovial fluid culture or synovial fluid pleocytosis (white blood cell [WBC] ≥40,000 cells/&mgr;L) with a positive blood culture. Lyme arthritis was defined as positive Lyme serology without a positive bacterial culture. All other children were considered to have other inflammatory arthritis. We compared the synovial fluid counts by arthritis type. Results We identified 384 children with knee monoarthritis, of whom 19 (5%) had septic arthritis, 257 (67%) had Lyme arthritis and 108 (28%) had other inflammatory arthritis. Children with other inflammatory arthritis had lower synovial WBC and absolute neutrophil count, as well as percent neutrophils, than those with either Lyme or septic arthritis. There were no significant differences in the synovial fluid WBC, absolute neutrophil count, and percent neutrophils for children with Lyme and septic arthritis. Conclusions In Lyme endemic areas, synovial fluid results alone do not differentiate septic from Lyme arthritis. Therefore, other clinical or laboratory indicators are needed to direct the care of patients with knee monoarthritis.