Michael J. Tranovich

Practice Patterns for Combined Anterior Cruciate Ligament and Meniscal Surgery in the United States

Purpose The purpose of the study was to compare frequency of meniscal repair to partial meniscectomy in patients undergoing anterior cruciate ligament reconstruction using the American Board of Orthopaedic Surgeons (ABOS) database. Hypotheses (1) Practice patterns are similar with respect to geographic region. (2) Surgeons with fellowship training perform more meniscal repairs compared with general orthopaedic practitioners. (3) Younger patients are more likely to be treated with meniscal repair at the time of anterior cruciate ligament reconstruction. (4) The frequency of meniscal repair in conjunction with anterior cruciate ligament reconstruction has increased over time. Study Design Cross-sectional study; Level of evidence, 3. Methods Information was extracted from the ABOS database from 2002 orthopaedic surgeons who sat for the part II examination from 2003 to 2007. The database was queried for all patients who underwent anterior cruciate ligament reconstruction (Current Procedural Terminology [CPT] code 29888) without or with meniscectomy (CPT 29881) or meniscal repair (CPT 29882). Factors affecting meniscal surgery that were investigated included patient age, geographic region of practice, fellowship training, and declared subspecialty of the surgeon. Results On average there were 52 000 cases per year registered in the ABOS database, approximately 1700 of whom underwent anterior cruciate ligament reconstruction. Meniscal repair was most frequently performed in the Southwest region (18.6%, P < .001) and least frequently in the Northwest region (11.3%, P < .001). Combined anterior cruciate ligament reconstruction and meniscal repair was performed significantly more often by fellowship-trained surgeons (17%) than by surgeons with other fellowship training (12%) or no fellowship training (12%, P < .001) and in patients younger than age 25 years (19%) compared with those age 40 years and older (8%, P < .001). Meniscal repair was performed in 13.9% of anterior cruciate ligament reconstructions in 2003 and in 16.4% of anterior cruciate ligament reconstructions in 2007 (P > .05). Conclusion Combined anterior cruciate ligament reconstruction with meniscal repair was more frequent for younger patients and by surgeons with sports fellowship training. Concomitant meniscal repair is performed by fellowship-trained surgeons in this study in only 18% of anterior cruciate ligament reconstructions.

Does the lateral intercondylar ridge disappear in ACL deficient patients

The aim of this study was to determine whether there is a difference in the presence of the lateral intercondylar ridge and the lateral bifurcate ridge between patients with sub-acute and chronic ACL injuries. We hypothesized that the ridges would be present less often with chronic ACL deficiency. Twenty-five patients with a chronic ACL injury were matched for age and gender to 25 patients with a sub-acute ACL injury. The lateral intercondylar ridge and lateral bifurcate ridge were scored as either present, absent, or indeterminate due to insufficient visualization by three blinded observers. The kappa for the three observers was .61 for the lateral intercondylar ridge and .58 for the lateral bifurcate ridge. The lateral intercondylar ridge was present in 88% of the sub-acute patients and 88% of the chronic patients. The lateral bifurcate ridge was present in 48% of the sub-acute and 48% of the chronic patients. This matched-pairs case–control study was unable to show a difference in the presence of the femoral bony ridges between patients with acute and chronic ACL injuries. The authors would suggest looking for the ridges as a landmark of the native ACL insertion site during ACL reconstruction in both acute and chronic ACL injuries.

Factors that influence the intra-articular rupture pattern of the ACL graft following single-bundle reconstruction

PurposesThe number of revision anterior cruciate ligament (ACL) surgeries performed annually continues to rise. The purpose of this study was to determine the most common rupture pattern in ACL revision cases after previous single-bundle reconstruction. The second aim was to determine the relationship between rupture pattern and patient-specific factors (age, gender, time between the initial ACL reconstruction and re-injury, and etiology/mechanism of failure) and surgical factors (graft type, tunnel angle).MethodsThis was a cohort study of 60 patients that underwent revision ACL surgery after previous single-bundle ACL reconstruction. Three sports medicine–trained orthopedic surgeons reviewed the arthroscopic videos and determined the rupture pattern of the grafts. The rupture pattern was then correlated to the above-mentioned factors.ResultsThe inter-observer agreement had a kappa of 0.7. The most common rupture pattern after previous single-bundle ACL reconstruction is elongation of the graft. This is different from the native ACL, which displays more proximal ruptures. With the use of autograft tissue and after a longer period of time, the rupture pattern in revision surgery is more similar to that of the native ACL.ConclusionThe most common rupture pattern after previous single-bundle reconstruction was elongation of the graft. Factors that influenced the rupture pattern were months between ACL reconstruction and re-injury and graft type.Level of evidenceCohort study, Level IV.

The Role of Mobility as a Protective Factor of Cognitive Functioning in Aging Adults A Review

Context: Over 33 chronic disease states and health disorders, including obesity and type 2 diabetes, are grouped into what is known as sedentary death syndrome. All these conditions are positively affected by 30 minutes of brisk exercise daily. In addition, only 30% of aging is based on genetics, with 70% on lifestyle. Therefore, a large majority of aging is controlled by individual health behaviors. Exercise is a powerful tool for healthy aging of the body and the mind. Courses of short- and long-term exercise provide benefits to musculoskeletal and cardiovascular health and can prevent age-related brain structural and functional losses. This review examines the evidence in support of mobility as an inexpensive and effective protective factor in maintaining brain health and preventing cognitive decline in aging adults. Evidence Acquisition: A PubMed search was performed for articles in English from 1990 to 2012. Reference lists were also reviewed and relevant articles obtained. Level of Evidence: Level 4. Results: Evidence suggests that maintaining a high level of cardiopulmonary fitness and mobility exhibits protective effects on structural changes that occur with aging in areas of the brain associated with memory, attention, and task completion. Chronic exercise is also associated with preservation of overall cognitive functioning and prevention of dementia. Conclusion: In combination with other preventative measures, physical mobility can assist in preventing or slowing cognitive decline in aging adults.

Chronic exercise preserves brain function in masters athletes when compared to sedentary counterparts

Abstract Objective: Exercise is beneficial for both the body and the mind, and it has been associated with protective neurocognitive effects, such as increased levels of brain-derived neurotrophic factor and neurogenesis. These effects are linked to the attenuation of age-related mental decline and the preservation of mental capacities in older, physically active adults. This study evaluated whether masters athletes, a highly active population, have better cognitive function compared to age-matched non-athletes based on the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) tool. Methods: Masters athletes and sedentary controls were recruited and screened for eligibility. All subjects were excluded if they had preexisting neurological diseases, psychiatric disorders, substance abuse disorders, learning disorders, and/or a history of traumatic brain injury, and in addition, control subjects were excluded if they performed >1 h/week of aerobic exercise. All participants completed a health and activity survey which includes the SF-12 and the ImPACT neurocognitive test which measures verbal and visual memory as well as reaction time. Differences between masters athletes and the control population were determined by ImPACT score composites. Results: 51 pairs of athletes and non-athletes were analyzed. Athletes had significantly higher verbal memory scores (85.9 ± 7.7 vs 79.9 ± 13.9, p = 0.01) and faster reaction times (0.71 ± 0.12 vs 0.76 ± 0.15 s, p = 0.04) on the ImPACT test. Athletes also scored significantly higher on the physical components summary score of the SF-12 (55.0 ± 3.3 vs 51.8 ± 6.7, p = 0.004). Conclusion: Masters athletes performed better on verbal memory and reaction time test, as well as on physical function as evaluated by the SF-12, compared to non-athlete controls. Chronic physical activity may preserve neurocognitive processes and increase physical health, which are protective factors for the negative effects of the aging process.

A Review of Femoroacetabular Impingement and Hip Arthroscopy in the Athlete

Abstract Femoroacetabular impingement (FAI) is increasingly recognized as a pathological condition of the hip in athletes. Although it is not always symptomatic, the bone structure leading to FAI and its associated pathology can result in significant pain and performance decline in athletes. Recognition of athletes with symptomatic FAI is of the utmost importance, as prompt treatment is necessary in order to maintain desired sports activity levels and preserve joint function. This review explores the recent evidence on the evaluation, recognition, and treatment of femoroacetabular impingement, and discusses conservative management, postoperative rehabilitation, and treatment in the pediatric and master athlete populations.

Unicompartmental arthritis in the aging athlete: osteotomy and beyond

The vitality of the aging athlete is largely dependent on continued mobility and pain-free motion. The early onset of osteoarthritis often has devastating consequences for these athletes and if left untreated, mobility declines and eventually prevents sporting activities all together. Recent advances in operative treatment for unicompartmental arthritis of the knee aim to delay the need for total joint arthroplasty by preserving or restoring the form and function of the knee to allow for continued sport participation. This review focuses on the recent literature of several surgical treatment options for unicompartmental disease including cartilage procedures, osteotomy, and unicompartmental arthroplasty.

Significant Chondrocyte Viability Is Present in Acetabular Chondral Flaps Associated With Femoroacetabular Impingement

Background: Patients presenting with cam deformity of the femoral head and neck sustain repeated trauma to the articular cartilage of the superior acetabulum, with chondral delamination injuries found during hip arthroscopy. Two previous studies reveal conflicting chondrocyte viability data in these traumatic cartilage injuries. The full-thickness nature of flaps may suggest that chondrocytes residing in the cartilage flap matrix in the joint environment would remain viable despite shear trauma. Hypothesis/Purpose: The purpose of this study is to determine the in vivo tissue viability of acetabular chondral flaps in patients with femoroacetabular impingement (FAI) when samples are analyzed immediately after biopsy. We hypothesize that the majority of the tissue in acetabular chondral flaps is viable in the joint microenvironment. Study Design: Descriptive laboratory study. Methods: Partially detached cartilage flaps from 10 patients undergoing arthroscopic hip surgery for FAI were biopsied in a minimally traumatic manner before chondroplasty and microfracture. Samples were placed in cold Hank’s Balanced Salt Solution without phenol red solution and immediately transported on ice to our laboratory. The edge of the samples was trimmed and further cut into 3 separate, 1-mm-thick sections. Sections were stained using a live/dead staining kit. Images were obtained with confocal microscopy, and the percentage of live cells was quantified. Results: Patients averaged 36 ± 11 years (range, 18-48 years), and 2 patients were female. The mean body mass index was 28.9 ± 5.6 kg/m2. The total proportion of live cells from all sections analyzed was 85.8%. The proportion of live cells per patient was 87% ± 10%. Conclusion: We determined that acetabular chondral flaps are approximately 87% live cells when analyzed immediately after biopsy, with 6 of 10 patients having greater than 90% live cells. These data point to the importance of laboratory techniques in making viability judgments in biologic systems. Clinical Relevance: Full-thickness cartilage loss is a difficult problem for all active people but particularly in the young population in whom joint preservation is key. We describe the viability of chondrocytes present in full-thickness acetabular-based chondral flaps encountered during hip arthroscopy. Identification of greater than 85% chondrocyte viability supports a foundation for evaluation and creation of novel clinical innovations for repair and replacement techniques using the flap as donor tissue, as alternatives to chondroplasty and microfracture.

Bone-patellar Tendon-bone Autograft vs Hamstring Autograft Anterior Cruciate Ligament Reconstruction in the Young Athlete: A Retrospective Matched Analysis with 2 to 10 year Follow-up (SS-41)

Purpose The aim of this study was to examine clinical and patient-reported outcomes as well as return to sport in athletes younger than 25 following ACL reconstruction with either bone-patellar tendon-bone (BTB) or hamstring (HS) autografts using a matched-pairs case–control experimental design.