Michael G. Ciccotti

The Relationship Between Passive Joint Laxity and Functional Outcome After Anterior Cruciate Ligament Injury

Twenty patients with anterior cruciate ligament-defi cient knees were studied. Ten patients returned to all sports activities (compensators) and 10 patients were not improved with nonoperative management and re quired surgical stabilization (noncompensators). Joint laxity was measured using a KT-2000 arthrometer (manual maximum Lachman). Subjects completed a Lysholm questionnaire and Knee Outcome Score. The International Knee Documentation Committee form was also completed. Patients also rated their knee function on a scale of 1 to 100. There was no difference in level and frequency of athletic activity between the two groups before their anterior cruciate ligament inju ries as determined by the knee outcome score. The compensator group had a mean side-to-side difference of 3.25 mm at 89 N and the noncompensators had a mean difference of 3 mm preoperatively. Manual max imum tests gave side-to-side differences of 6.7 mm for the compensators and 6 mm for the noncompensators. There were no differences in laxity measures between groups. The correlation between knee outcome scores and side-to-side laxity measurements were not signif icant. Measurements of anterior laxity in anterior cru ciate ligament-deficient patients were not correlated with measures of functional outcome used in this study. Functional outcome measurements that are par tially based on joint laxity measures, such as the Inter national Knee Documentation Committee form, may artificially overestimate the disability after anterior cru ciate ligament rupture.

Lateral and Medial Epicondylitis of the Elbow.

Epicondylitis of the elbow involves pathologic alteration in the musculotendinous origins at the lateral or medial epicondyle. Although commonly referred to as “tennis elbow” when it occurs laterally and “golfers elbow” when it occurs medially, the condition may in fact be caused by a variety of sports and occupational activities. The accurate diagnosis of these entities requires a thorough understanding of the anatomic, epidemiologic, and pathophysiologic factors. Nonoperative treatment should be tried first in all patients, beginning with an initial phase of rest, ice, nonsteroidal anti-inflammatory agents, and possibly corticosteroid injection. A second phase includes coordinated rehabilitation, consisting of range-of-motion and strengthening exercises and counterforce bracing, as well as technique enhancement and equipment modification if a sport or occupation is causative. Nonoperative treatment has been deemed highly successful, yet the few prospective reports available suggest that symptoms frequently persist or recur. Operative treatment is indicated for debilitating pain that is diagnosed after the exclusion of other pathologic causes for pain and that persists in spite of a well-managed nonoperative regimen spanning a minimum of 6 months. The surgical technique involves excision of the pathologic portion of the tendon, repair of the resulting defect, and reattachment of the origin to the lateral or medial epicondyle. Surgical treatment results in a high degree of subjective relief, although objective strength deficits may persist.

Shoulder arthroscopy positioning: lateral decubitus versus beach chair.

Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. Most surgeons use the same patient position to perform all of their arthroscopic shoulder procedures, regardless of the pathology. Each position has its advantages and disadvantages. The evidence regarding the efficiency, efficacy, and risks of the lateral decubitus and the beach chair positions for shoulder arthroscopy does not show one position to be superior. This review presents a comparison of these positions with regard to setup, surgical visualization, access, and patient risk.

Differences in Femoral Notch Anatomy between Men and Women A Magnetic Resonance Imaging Study

Background Research has shown that variations in femoral intercondylar notch morphometry may be a predisposing factor for noncontact anterior cruciate ligament injury. Hypothesis There are anatomic differences in the anterior cruciate ligament and femoral notch between men and women. Study Design Descriptive anatomic study. Methods Using magnetic resonance imaging, we performed a three-dimensional analysis of the femoral intercondylar notch morphometry to look for differences in femoral notch and anterior cruciate ligament volumes between men and women. Axial plane magnetic resonance imaging scans were performed on 96 knees in 48 asymptomatic subjects. Digital measurements were taken of femoral notch area, anterior cruciate ligament area, notch width, and bicondylar width, within defined parameters of the femoral notch. The notch and anterior cruciate ligament volumes were then calculated. Analysis of variance was performed using sex, height, and weight as covariates. Results The volume of the femoral notch was found to be statistically smaller in women compared with men; this difference was primarily related to height. A similar relationship was found for anterior cruciate ligament volume. A statistically significant correlation was found between femoral notch volume and anterior cruciate ligament volume; patients with smaller notches also had smaller anterior cruciate ligaments. Conclusions Our results suggest that there is a difference in femoral notch and anterior cruciate ligament volume between men and women, which, in turn, is related to differences in height and weight.

Correlation of estradiol in pregnancy and anterior cruciate ligament laxity

The purpose of this study was to determine whether a correlation existed between estradiol in pregnancy and laxity of the anterior cruciate ligament by measuring anterior tibial translation. All patients underwent measurement of anterior tibial translation using KT-1000 knee arthrometer testing and serum estradiol determination during the third trimester of pregnancy and postpartum. Forty knees were studied. The average serum estradiol levels decreased from 10,755.0 ng/L to 50.3 ng/L. There was an average decrease anterior tibial translation with a manual maximum displacement of 3.0 mm (range, 1 mm–5 mm) from the first to second examinations. Average measurement of anterior tibial translation in pregnant women showed a statistically significant increase in laxity in the third trimester of pregnancy compared with the postpartum laxity. The results of this study show that high serum estradiol levels during the third trimester of pregnancy correlate with increased anterior tibial translation and that this anterior tibial translation decreases with the return of serum estradiol to nonpregnant levels.

Revision anterior cruciate ligamentreconstruction

Abstract Anterior cruciate ligament (ACL) reconstruction has gained, wide acceptance as the treatment of choice for thefunctionally unstable ACL-deficient knee and is now performed on about a half million individuals, per year. The documented long-term good or excellent result rates for functional stability, relief of symptoms, and return to activity for intra-articular ACL reconstructions is approximately 75% to 95%. This leaves a substantial group of patients with an unsatisfactory result secondary to a variety of reasons. Review of the literature reveals that recurrent instability and graft failure are responsible for unsatisfactory results in as high as 8% of these patients. In this article, the factors responsible for graft failure and recurrent instability are discussed. In addition, the planning and difficulties that the orthopedic surgeon must address before, during, and after the procedure, are also reviewed.

A comparison of the results of anterior cruciate ligament reconstruction using bioabsorbable versus metal interference screws: a meta-analysis.

BACKGROUND Graft fixation during anterior cruciate ligament (ACL) reconstruction can be achieved with use of either bioabsorbable screws or metal screws. Although bioabsorbable screws and metal screws have similar fixation strengths, bioabsorbable screws eliminate the need for removal. In addition, postoperative imaging is easier to interpret when bioabsorbable screws are used. Bioabsorbable screws may be associated with an increased inflammatory response, an increased risk of screw breakage, incomplete screw absorption, or tunnel widening. We investigated the outcomes associated with the use of bioabsorbable screws as compared with metal screws for ACL reconstruction. Our hypothesis was that there is no significant difference in outcomes between these screw types for ACL reconstruction. METHODS We systematically searched electronic databases to identify randomized controlled trials in which bioabsorbable screws were compared with metal screws for ACL reconstruction. Therapeutic studies with a minimum twelve-month mean follow-up were considered for inclusion. Clinical outcomes (International Knee Documentation Committee [IKDC], Lysholm, Tegner activity scores), laxity testing, and reported complications were evaluated in the meta-analysis. Additionally, imaging assessment of tunnel widening was evaluated. RESULTS Eight studies matched the inclusion criteria. These studies comprised a total of 745 patients undergoing ACL reconstruction (including 378 patients managed with bioabsorbable screws and 367 patients managed with metal screws). No significant differences were identified between the two screw types with respect to IKDC, Lysholm, or Tegner activity scores or with respect to the results of laxity testing with arthrometry. The complication rates were also statistically similar in the two groups. The variability in imaging assessment of tunnel widening among the studies precluded meta-analysis. CONCLUSIONS The clinical results associated with bioabsorbable screws and metal screws are statistically similar. Laxity evaluation demonstrated no significant differences between bioabsorbable screws and metal screws. The complication rates associated with bioabsorbable screws and metal screws were also similar. The results of this meta-analysis support the hypothesis that there are no significant differences in the outcomes associated with bioabsorbable screws as compared with metal screws for ACL reconstruction. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Evaluation and Management of Hamstring Injuries

Muscle injuries are the most common injuries in sports, with hamstring injuries accounting for 29% of all injuries in athletes. These injuries lead to prolonged impairment and have a reinjury risk of 12% to 31%. They range from mild muscle damage without loss of structural integrity to complete muscle tearing with fiber disruption. Novel MRI scores are increasingly being used and allow a more precise prediction of return to sport. In this article, the authors review the history, mechanisms of injury, and classification systems for hamstring injuries as well as present the latest evidence related to the management of hamstring injuries, including intramuscular and both proximal and distal insertional injuries. Indications for surgical treatment of certain proximal and distal avulsions, biological augmentation to the nonoperative treatment of midsubstance injuries, and advances in risk reduction and injury prevention are discussed.

Return to Play After Type II Superior Labral Anterior-Posterior Lesion Repairs in Athletes: A Systematic Review

BackgroundSuperior labral anterior-posterior (SLAP) lesions are a common cause of pain and disability in athletes. Individual studies have suggested low patient satisfaction with SLAP repairs in throwing athletes in particular and it is unclear how frequently athletes return to their previous level of competetion.Questions/purposesWe systematically reviewed the literature to determine (1) patient satisfaction and (2) return to play at previous level of competition among throwing athletes compared to all athletes who underwent repair of Type II SLAP tears using various types of fixation.MethodsWe searched databases for English-language articles in peer-reviewed journals from 1950 to 2010 reporting Type II SLAP repairs with 2-year followup for our systematic review. A total of 506 patients with Type II SLAP tears were reviewed from 14 studies; of these, 327 had SLAP lesions repaired by anchor, 169 by tacks, and 10 by staples. Of the 506 patients, 198 were overhead athletes with a pooled subset of 81 identified baseball players.ResultsFor the entire patient population, 83% had “good-to-excellent” patient satisfaction and 73% returned to their previous level of play whereas only 63% of overhead athletes returned to their previous level of play. Anchor repair in overhead athletes resulted in a higher percentage of “good-to-excellent” patient satisfaction (88% versus 74%) and a slightly higher return to play rate (63% versus 57%) compared with tack repair.ConclusionsRepair of Type II SLAP tears leads to a return to previous level of play in most patients. Overhead athletes appear to have a lower rate of return to level of previous of play. Anchor fixation appears to be the most favorable fixation in both subjective scores and return to previous level of play.

Stress Sonography of the Ulnar Collateral Ligament of the Elbow in Professional Baseball Pitchers A 10-Year Study

Background: An injury to the ulnar collateral ligament (UCL) of the elbow is potentially career threatening for elite baseball pitchers. Stress ultrasound (US) of the elbow allows for evaluation of both the UCL and the ulnohumeral joint space at rest and with stress. Hypothesis: Stress US can identify morphological and functional UCL changes and may predict the risk of a UCL injury in elite pitchers. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 368 asymptomatic professional baseball pitchers underwent preseason stress US of their dominant and nondominant elbows over a 10-year period (2002-2012). Stress US examinations were performed in 30° of flexion at rest and with 150 N of valgus stress by a single musculoskeletal radiologist. Ligament thickness, ulnohumeral joint space width, and ligament abnormalities (hypoechoic foci and calcifications) were documented. Results: There were 736 stress US studies. The mean UCL thickness in the dominant elbow (6.15 mm) was significantly greater than that in the nondominant elbow (4.82 mm) (P < .0001). The mean stressed ulnohumeral joint space width in the dominant elbow (4.56 mm) was significantly greater than that in the nondominant elbow (3.72 mm) (P < .02). In the dominant arm, hypoechoic foci and calcifications were both significantly more prevalent (28.0% vs 3.5% and 24.9% vs 1.6%, respectively; P < .001). In the 12 players who incurred a UCL injury, there were nonsignificant (P > .05) increases in baseline ligament thickness, ulnohumeral joint space gapping with stress, and incidence of hypoechoic foci and calcifications. More than 1 stress US examination was performed in 131 players, with a mean increase of 0.78 mm in joint space gapping with subsequent evaluations. Conclusion: Stress US indicates that the UCL in the dominant elbow of elite pitchers is thicker, is more likely to have hypoechoic foci and/or calcifications, and has increased laxity with valgus stress over time.