Michael C. Ciccotti

The Prevalence of Articular Cartilage Changes in the Knee Joint in Patients Undergoing Arthroscopy for Meniscal Pathology

PURPOSE The purposes of this study were to evaluate the prevalence of articular cartilage changes in the knee joint and to analyze predictive factors for these changes in patients undergoing arthroscopy for meniscal pathology. METHODS Between March 2005 and June 2009, 1,010 patients underwent arthroscopic meniscectomy or meniscal repair by the senior author. During surgery, a precise diagram was used to carefully note the presence, location, size, and Outerbridge grade of changes to the articular surfaces of the knee joint. The prevalence of articular cartilage changes was calculated for 6 age groups: younger than 20 years, 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, and 60 years or older. Demographic data including gender, ethnicity, smoking status, and body mass index (BMI) were acquired from patient charts. RESULTS Overall, 48% of patients showed changes to the medial compartment, 25% to the lateral compartment, and 45% to the patellofemoral compartment. Eighty-five percent of patients aged 50 to 59 years and 86% of patients aged 60 years or older showed articular cartilage changes to at least 1 knee compartment. In contrast, only 13% of patients aged younger than 20 years and 32% of patients aged 20 to 29 years showed changes to at least 1 compartment. A significant relation was found between age and the development of articular cartilage changes in each of the 3 compartments (P < .0001). BMI was also significantly related to articular cartilage changes in the medial and patellofemoral compartments (P < .0001) but not the lateral compartment (P = .08). CONCLUSIONS This study shows a high prevalence of articular cartilage damage as defined by the Outerbridge classification in patients undergoing arthroscopic surgery for meniscal pathology. Risk factors that correlate with articular cartilage damage include increasing age, elevated BMI, medial compartment pathology, and knee contractures. LEVEL OF EVIDENCE Level IV, therapeutic case series.

Stress Ultrasound Evaluation of Medial Elbow Instability in a Cadaveric Model

Background: An injury of the ulnar collateral ligament (UCL) is potentially career threatening for elite overhead-throwing athletes. Stress ultrasonography (SUS) allows for a rapid, cost-effective, and noninvasive evaluation of the UCL and elbow joint both at rest and with applied stress. Purpose/Hypothesis: To determine the amount of cadaveric elbow valgus gapping with sequential sectioning of medial elbow structures as measured by SUS. It was hypothesized that the greatest increase in ulnohumeral joint gapping would be noted with release of the anterior bundle of the UCL. Study Design: Descriptive laboratory study. Methods: Twelve cadaveric elbows were divided into 2 groups and dissected in reverse sequences under the direct supervision of an experienced orthopaedic surgeon. Baseline ultrasound and SUS with applied valgus loads were performed by an experienced radiologist. A valgus load was applied at each sectioning interval using a standardized device. Ulnohumeral joint gapping in millimeters was measured by SUS for each step as the width of the medial joint from the trochlea to the sublime tubercle. The mean increases in joint gapping (Δ) between each step were calculated to quantify the additional gapping achieved with release of each sequential stabilizer. Results: Release of the anterior band of the anterior bundle resulted in a mean Δ of 2.0 mm (95% CI, 1.1-2.8 mm). Release of the posterior band of the anterior bundle resulted in a mean Δ of 1.4 mm (95% CI, 0.6-2.2 mm). Release of the entire anterior bundle caused a mean increase in ulnohumeral valgus joint gapping of 3.4 mm (95% CI, 2.4-4.3 mm). Release of the remaining individual structures each resulted in a mean increase in valgus joint gapping of ≤0.8 mm. Conclusion: The results of the current cadaveric study suggest that different amounts of gapping are seen on SUS with sectioning of the medial elbow stabilizers. The hypothesis was confirmed with release of the anterior bundle of the UCL resulting in the greatest increase in joint gapping as measured by SUS. Clinical Relevance: This study illustrates that SUS can identify the contributions of each anatomic portion of the UCL and the flexor-pronator mass to ulnohumeral joint stability in a cadaveric model.

Long-Term Outcomes in Anterior Cruciate Ligament Reconstruction: A Systematic Review of Patellar Tendon Versus Hamstring Autografts:

Background: Much controversy still exists surrounding graft choice in anterior cruciate ligament (ACL) reconstruction. Over the past decade, an increase in comparative studies with longer follow-up has enhanced our understanding of current graft options and outcomes. Purpose: To describe the long-term comparative outcomes of ACL reconstruction with autograft bone–patellar tendon–bone (BPTB) versus autograft hamstring (HS) ACL reconstruction with regard to clinical and radiographic outcomes. Study Design: Systematic review; Level of evidence, 2. Methods: A search of the PubMed, MEDLINE, Cochrane, and Scopus databases was performed to identify studies in the English language with outcome data comparing ACL reconstruction utilizing autograft BPTB and autograft HS; only studies with a minimum 5-year follow-up were included. Outcome data included failure and complications, manual and instrumented laxity, patient-reported outcomes, and radiographic risk of osteoarthritis. Results: Twelve studies with a total of 953 patients met the inclusion criteria. Of these studies, 8 were level 1 evidence and 2 were level 2. Mean follow-up was 8.96 years (range, 5-15.3 years). No differences in graft failure or manual or instrumented laxity were seen in any studies. Lower clinical outcomes scores and greater motion loss were seen in BPTB patients in 1 and 2 studies, respectively. Two of 4 studies reporting on anterior knee pain, and 3 of 7 that recorded kneeling pain found it more frequently among BPTB patients. One study found significantly increased reoperation rates in HS patients, while another found a similar result in BPTB, and 1 study reported a significant increase in contralateral ACL tears in BPTB patients. Three of 5 studies reporting on radiographic evidence of osteoarthritis noted significantly increased rates in BPTB patients. Conclusion: This systematic review comparing long-term outcomes after ACL reconstruction with either autograft BPTB or autograft HS suggests no significant differences in manual/instrumented laxity and graft failures between graft types. An increase in long-term anterior knee pain, kneeling pain, and higher rates of osteoarthritis were noted with BPTB graft use.

Outcomes of Arthroscopic Repair of Panlabral Tears of the Glenohumeral Joint

Background: Combined lesions of the glenoid labrum involving tears of the anterior, posterior, and superior labrum have been infrequently reported in the literature. Purpose: To evaluate the clinical outcomes of arthroscopic repair of these lesions in a general population using validated scoring instruments, presence of complications, and need for revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Fifty-eight patients who had arthroscopic labral repair of tears involving the anterior, posterior, and superior labrum (defined as a panlabral repair) were identified at our institution by retrospective review. All patients underwent arthroscopic labral repair with suture anchor fixation by a uniform approach and with a standardized postoperative protocol. Forty-four patients had a minimum 16-month postoperative follow-up. Outcomes were assessed postoperatively by the American Shoulder and Elbow Surgeons (ASES) score and the Penn Shoulder score. Complications were also documented, including need for revision surgery. Results: The mean age at the time of surgery was 32 years (range, 15-55 years) in the 44 patients. Presenting shoulder complaints included pain alone (40%), instability alone (14%), or pain and instability (45%). Mean number of anchors per repair was 7.9 (range, 5-12). Mean follow-up was 42 months (range, 16-78 months). Mean ± standard deviation ASES score at final follow-up was 90.1 ± 17.7 (range, 22-100), and mean Penn Shoulder score was 90.2 ± 15.3 (range, 38-100). Three of the 4 patients with outcome scores of 70 or less at final follow-up had undergone prior surgery. Thirteen postoperative complications (30%) occurred, with 3 (7%) requiring a second surgery. Five patients (11%) had an instability event following panlabral repair, but only 1 of these patients (2%) required revision surgery for a recurrent labral tear. Conclusion: Combined tears of the anterior, posterior, and superior glenoid labrum represent a small but significant portion of labral injuries. Arthroscopic repair of these injuries can be performed with good postoperative outcomes and a low rate of recurrent labral injury.

Open Treatment of Medial Epicondylitis

Although limited literature exists on medial epicondylitis of the elbow, this disorder is an injury affecting many professionals and athletes at every level, especially throwing athletes. Care must be taken in diagnosing medial epicondylitis to distinguish it from other possible pathologies of the medial elbow, which may exist concurrently. The large majority of patients diagnosed with medial epicondylitis will respond to a well-structured, nonsurgical program. However, patients with persistent or recurring symptoms can be treated surgically, which yields high patient satisfaction and ultimately a reliable return to preinjury levels of activity.

Anatomic Anterior Cruciate Ligament Reconstruction via Independent Tunnel Drilling: A Systematic Review of Randomized Controlled Trials Comparing Patellar Tendon and Hamstring Autografts

PURPOSE To collect the highest level of evidence comparing anatomic anterior cruciate ligament (ACL) reconstruction via independent tunnel drilling using bone-patellar tendon-bone (BTB) and hamstring tendon (HT) autografts in terms of clinical outcome and failure rate. METHODS We performed a systematic review of clinical trials that randomized patients to ACL reconstruction with either BTB or HT autografts with a minimum 2-year follow-up. Only trials using independent tunnel drilling, including outside-in and anteromedial portal techniques, for both autografts were eligible for inclusion, whereas all transtibial studies were excluded. Study design, demographics, surgical technique, rehabilitation protocol, and clinical outcomes were compiled. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Quality assessment was performed using the Coleman Methodological Scale (CMS). RESULTS Six published studies reporting on 5 randomized controlled trials (RCTs) met the inclusion criteria. No study reported a difference in rerupture rate between BTB and HT. BTB-reconstructed knees experienced a greater incidence of anterior knee pain or crepitus in 2/7 trials and radiographic evidence of degenerative change in 3/7 trials. HT-reconstructed knees had increased instrumented laxity in 2/7 trials and less knee flexion strength postoperatively. CONCLUSIONS This study collects all available Level I and II evidence for anatomic ACL reconstruction using BTB and HT grafts. According to the data presented in these studies, clinical outcome scores and failure rates showed no differences for anatomic reconstruction using either autograft. However, in some studies, BTB-reconstructed knees experienced a greater incidence of anterior knee pain and radiographic evidence of degenerative change, and in others, HT-reconstructed knees had increased laxity and less knee flexion strength. In our opinion, both BTB and HT autografts remain valid options for ACL reconstruction when using anatomic drilling techniques, providing a stable knee with reliable return to activity. LEVEL OF EVIDENCE Level II, systematic review of Level I and II studies.

Elbow Injuries in Professional Baseball: Epidemiological Findings From the Major League Baseball Injury Surveillance System:

Background: Elbow injuries cause significant disability for the throwing athlete. Scant data are available on the distribution and characteristics of these injuries in elite baseball players. No study exists that focuses solely on the epidemiological characteristics of elbow injuries in professional baseball players using a comprehensive injury surveillance system. Hypothesis: Professional baseball players have a high occurrence of elbow injuries influenced by factors including length of time playing, time period within the annual baseball season, and specific position played. Study Design: Descriptive epidemiological study. Methods: Data on elbow injuries occurring during the 2011-2014 seasons were collected from Major League Baseball’s Health Injury and Tracking System, a comprehensive injury surveillance system. Each specific type of elbow injury was evaluated with respect to overall injury rate, years as a professional player, mechanism of injury, treatment, average time lost, and return to play. Results: During the study period, 3185 elbow injuries (n = 430 Major League; n = 2755 Minor League) occurred. The mean number of days missed and percentage requiring surgery were similar between Major and Minor League players. Overall, 20.0% (650/3185) of the injuries required surgical treatment. Pitchers were the most likely to incur an elbow injury (40.0% of injured athletes were pitchers), were the most likely to require surgery (34.2% of injured pitchers required surgery), and had the greatest mean number of days missed when treated nonsurgically (33.2 days). Medial injuries composed 42.1% (1342/3185) of all elbow injuries. Of all elbow surgeries performed during the study period, the highest percentage involved ligaments (372/650; 57.2%). Conclusion: Elbow injuries are a considerable source of disability in professional baseball players. Pitchers are most likely to incur these injuries, are most likely to require surgery, and have the highest mean number of days missed when treated nonsurgically. The most common injuries involve the medial elbow, with ligament injuries most often requiring surgery. This study represents the only investigation to date using a comprehensive injury surveillance system to examine elbow injuries in professional baseball players. It provides a basis for injury prevention and treatment recommendations, establishes the most thorough framework for determining elbow injury risk, and focuses continued research on elbow injury prevention in the elite baseball player.

Early Single-Sport Specialization: A Survey of 3090 High School, Collegiate, and Professional Athletes:

Background: Youth participation in organized sports in the United States is rising, with many athletes focusing on a single sport at an increasingly younger age. Purpose: To retrospectively compare single-sport specialization in current high school (HS), collegiate, and professional athletes with regard to the rate and age of specialization, the number of months per year of single-sport training, and the athlete’s perception of injury related to specialization. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A survey was distributed to HS, collegiate, and professional athletes prior to their yearly preparticipation physical examination. Athletes were asked whether they had chosen to specialize in only 1 sport, and data were then collected pertaining to this decision. Results: A total of 3090 athletes completed the survey (503 HS, 856 collegiate, and 1731 professional athletes). A significantly greater percentage of current collegiate athletes specialized to play a single sport during their childhood/adolescence (45.2% of HS athletes, 67.7% of collegiate athletes, and 46.0% of professional athletes; P < .001). The age of single-sport specialization differed between groups and occurred at a mean age of 12.7 ± 2.4 (HS), 14.8 ± 2.5 (collegiate), and 14.1 ± 2.8 years (professional) (P < .001). Current HS (39.9%) and collegiate athletes (42.1%) recalled a statistically greater incidence of sport-related injury than current professional athletes (25.4%) (P < .001). The majority (61.7%) of professional athletes indicated that they believed specialization helps the athlete play at a higher level, compared with 79.7% of HS and 80.6% of collegiate athletes (P < .001). Notably, only 22.3% of professional athletes said they would want their own child to specialize to play only 1 sport during childhood/adolescence. Conclusion: This study provides a foundation for understanding current trends in single-sport specialization in all athletic levels. Current HS athletes specialized, on average, 2 years earlier than current collegiate and professional athletes surveyed. These data challenge the notion that success at an elite level requires athletes to specialize in 1 sport at a very young age.

Correlation of Mri to Arthroscopy in the Elbow: Thrower’s Elbow and Ulnar Collateral Ligament Injury

One cannot overstate the importance of a thorough history and physical examination, supplemented with directed imaging, to help pinpoint the exact cause of the athlete’s elbow pain. Although plain radiographs should not be overlooked, advanced imaging plays a critical role in diagnosis and management of pathology in the thrower’s elbow, including computed tomography, magnetic resonance imaging, and stress ultrasound. By judiciously combining these elements, the clinician can appropriately manage these injuries in order to successfully return the athlete to their preinjury level of play.

Single Sport Specialization in Youth Sports: A Survey of 3,090 High School, Collegiate, and Professional Athletes

Objectives: Youth participation in organized sports in the United States is rising, with many athletes focusing on a single sport at an increasingly younger age. There is considerable debate regarding the rationale, optimal timing, injury risk, and the psychosocial health of a young athlete specializing early in a single sport. The purpose of our study was to compare youth single sport specialization in high school (HS), collegiate, and professional athletes with respect to the age of specialization, the number of months per year of single sport training, and injury attributed by the athlete to specialization. Methods: A survey was distributed to HS, collegiate and professional athletes prior to their yearly pre-participation physical exam. Demographic information, details of current sport commitment, and future athletic plans were collected. Athletes were asked if they had chosen to specialize in only one sport during their childhood/adolescence, and data was then collected pertaining to when, how, and why this decision was made. Continuous data was analyzed using one-way ANOVA analysis and categorical variables were compared using chi-square analysis. Results: A total of 3,090 athletes d the survey (503 HS, 856 collegiate, and 1,731 professional athletes). 46.3% of HS athletes, 67.7% of collegiate athletes, and 45.9% of professional athletes specialized to play a single sport during their childhood/adolescence (p< 0.00001). Single sport specialization in these groups occurred at a younger age in the HS athletes (12.7 ± 2.4 years old), compared to the college (14.8 ± 2.5 years old) and professional athletes (14.06 ± 2.8 years old) (p<0.001). At the age of specialization, collegiate athletes spent more months per year training for their sport (10.03 ± 2.64 months), compared to HS (8.5 ± 3.4 months) and professional athletes (8.3 ± 3.5 months) (p<0.0001). A lower percentage of professional athletes believed that specialization helped them to play at a higher level (61.7%) compared to HS (79.7%) and collegiate athletes (80.6%) (p<0.0001). Current HS (39.9%) and collegiate athletes (42.1%) recalled a statistically higher incidence of sport-related injury than current professional athletes (25.4%) (p<0.0001). Notably, only 22.33% of professional athletes said they would want their own child to specialize to play only one sport during childhood/adolescence. Conclusion: In our study, 46.3% of current high school athletes specialized to play only one sport. Additionally, high school athletes specialized, approximately two years earlier than collegiate and professional athletes surveyed This trend towards earlier sport specialization is concerning without evidence that early specialization provides any advantage for athletic advancement with potential predisposition towards higher injury risk. Summary of Youth Single Sport Specialization Survey Results High School Collegiate Professional p-value # Surveys 503 856 1731 # sports represented 23 17 2 Age (years) 15.34 ± 1.43 19.56± 1.31 23.55 ± 8.56 <0.001 What age did you begin playing in competitive sports? 7.48 ± 3.05 7.62 ± 3.23 6.02± 2.23 <0.001 Did you quit sports to focus on one sport? Y (45.17%) Y (67.66%) Y(45.95%) <0.001 If yes, at what age did you quit other sports? 12.69± 2.37 14.79± 2.45 14.74 ± 2.40 <0.001 Did you ever sustained injury that you attributed to specializing to one sport? Y( 39.02%) Y(42.27%) Y25.36%) <0.001 Do you think specializing to play one sport helps the athlete play at a higher level? Y(79.71%) Y(80.63%) Y(61.69%) <0.001 Do you want your children to specialize to play only one sport during their childhood/adolescence? Y(30.59%) Y(27.36%) Y(22.33%) <0.001