Moira M. McCarthy

The Moving Patellar Apprehension Test for Lateral Patellar Instability

Background Physical examination maneuvers for patellar instability are often inaccurate. Hypothesis The “moving patellar apprehension test” is a sensitive and specific physical examination technique for the diagnosis of patellar instability. Study Design Cohort study (diagnosis); Level of evidence, 3. Methods The moving patellar apprehension test was performed in an office setting preoperatively and compared with the ability to dislocate the patella when examined under anesthesia in 51 patients. The examination begins with the knee held in full extension and the patella is manually translated laterally with the thumb. The knee is then flexed to 90° and then brought back to full extension while the lateral force on the patella is maintained. For the second half of the test, the knee is started in full extension, brought to 90° of flexion, and then back to full extension while the index finger is used to translate the patella medially. For a positive test in part 1, the patient orally expresses apprehension and may activate his or her quadriceps in response to apprehension. In part 2, the patient experiences no apprehension and allows free flexion and extension of the knee. Results When compared with the ability to dislocate the patella under anesthesia, the moving patellar apprehension test was found to have a sensitivity of 100%, a specificity of 88.4%, a positive predictive value of 89.2%, a negative predictive value of 100%, and an accuracy of 94.1%. Conclusion The moving patellar apprehension test is an accurate physical examination technique that, when performed and interpreted correctly, is highly sensitive and specific for patellar instability.

Injury Profile in Elite Female Basketball Athletes at the Women’s National Basketball Association Combine

Background: Anterior cruciate ligament (ACL) and meniscus injuries are common in female athletes participating in cutting and pivoting sports such as basketball. The epidemiological characteristics of injury in athletes seen at the Women’s National Basketball Association (WNBA) combine and the effect of ACL reconstruction and meniscus surgery on longevity in the WNBA are unknown. Purpose: To evaluate the details and spectrum of injuries in athletes entering the WNBA combine and to assess the potential effect of specific injuries on the round drafted into the WNBA and career length. Study Design: Descriptive epidemiology study. Methods: Demographic data and the documented collegiate injury profile were reviewed from the WNBA database for all players entering the WNBA combine in 2000-2008. The study included injury data on 506 athletes. Complete demographic data were available for 496 players. Results: Of the athletes taking part in the combine, 45.2% were guards, 33.7% were forwards, and 21.1% were centers. Ankle sprain (47.8% of players), hand injury (20.8%), patellar tendinitis (17.0%), ACL injury (15.0%), meniscus injury (10.5%), stress fracture (7.3%), and concussion (7.1%) were the most common injuries reported. Seventy-three athletes (14.4%) reported ACL reconstruction before entering the WNBA combine, and meniscus surgery was the next most common surgery (n = 50 players; 9.9%). There were no differences in ACL or meniscus surgery when analyzed by player position or round drafted. History of ACL or meniscus surgery did not affect career length in the WNBA. Excluding ACL and meniscus surgery, other reported surgical procedures were knee arthroscopic surgery (11.7%), ankle reconstruction (2.6%), and shoulder stabilization (2.0%). Conclusion: The ankle is the most common site of injury and ACL reconstruction is the most common surgery in elite female athletes participating in the WNBA combine. A history of injury or surgery did not affect the round drafted or career length.

Increased Lateral Tibial Slope Is a Risk Factor for Pediatric Anterior Cruciate Ligament Injury: An MRI-Based Case-Control Study of 152 Patients

Background: Increased posterior tibial slope is associated with increased risk of anterior cruciate ligament (ACL) injury in adults. A similar association has not been rigorously examined in children and adolescents. Purpose: To determine whether alterations in posterior tibial slope are associated with ACL tears in pediatric and adolescent patients and to quantify changes in tibial slope by age. Study Design: Case-control study; Level of evidence, 3. Methods: Magnetic resonance imaging (MRI) studies of the knee were reviewed by 3 raters blinded to each other in a 1:1 sample of cases and age- and sex-matched controls. A total of 76 skeletally immature ACL-injured knees were compared with 76 knees without ACL injury; the mean age of the study population was 14.8 ± 1.3 years. The posterior slope of the articular surface of the medial tibial plateau and lateral tibial plateau was measured by use of a method similar to that used in previous studies in adult populations. The current study technique differed in that the slope was measured on the cartilage surface, not the subchondral bone. Comparisons between knees were made with t tests, and Spearman correlation analysis was used to assess changes in tibial slope with advancing age. Results: Increased slope of the lateral tibial plateau (LTS) was significantly increased in ACL-injured patients compared with controls (5.7° ± 2.4° vs 3.4° ± 1.7°; P < .001). There was no statistically significant difference in the slope of the medial tibial plateau (MTS) in the ACL-injured and control knees (5.4° ± 2.2° vs 5.1° ± 2.3°; P = .42). There was no difference in LTS between male and female patients (4.46° vs 4.58°; P = .75). Receiver operating characteristic (ROC) analysis of the LTS revealed that a posterior tibial slope cutoff of >4° resulted in a sensitivity of 76% and a specificity of 75% for predicting ACL tears in this cohort. Spearman correlation analysis revealed that MTS and LTS decreased, or flattened, by 0.31° (P = .028, correlation coefficient r = −0.18) and 0.37° (P = .009, correlation coefficient r = −0.21) per year, respectively, as adolescents age. Conclusion: The LTS was significantly associated with an increased risk of ACL injury in pediatric and adolescent patients. The MTS was not associated with risk of injury. Posterior slope was found to decrease, or flatten, with age. A cutoff of >4° for the posterior slope of the lateral compartment is 76% sensitive and 75% specific for predicting ACL injury in this cohort. The LTS did not influence the incidence of ACL injury differently between sexes.

Contact Stress and Kinematic Analysis of All-Epiphyseal and Over-the-Top Pediatric Reconstruction Techniques for the Anterior Cruciate Ligament

Background: Adult anterior cruciate ligament (ACL) reconstruction techniques may be inappropriate to treat skeletally immature patients because of the risk of physeal complications. “Physeal-sparing” reconstruction techniques exist, but their ability to restore knee stability and contact mechanics is not well understood. Purpose: (1) To assess the ability of the all-epiphyseal (AE) and over-the-top (OT) reconstruction techniques to restore knee kinematics, (2) to assess whether these reconstruction techniques decrease the high posterior contact stresses seen with ACL deficiency, and (3) to determine whether the AE or OT technique produces abnormal tibiofemoral contact stresses. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen human cadaveric knees were tested using a robotic manipulator. Tibiofemoral motions were recorded with the ACL intact, after sectioning the ACL, and after both reconstructions in each of the 10 specimens. The AE technique consisted of tunnels exclusively within the epiphysis and was fixed with suspensory cortical fixation devices. The OT procedure consisted of a central and vertical tibial tunnel with an over-the-top femoral position and was fixed with staples and posts on both ends. Anterior stability was assessed with 134-N anterior force at 0°, 15°, 30°, 60°, and 90° of knee flexion. Rotational stability was assessed with combined 8 N·m and 4 N·m of abduction and internal rotation, respectively, at 5°, 15°, and 30° of knee flexion. Results: Both reconstruction techniques off-loaded the posterior aspect of the tibial plateau compared with the ACL-deficient knee in response to both anterior loads and combined moments as demonstrated by reduced contact stresses in this region at all flexion angles. Compared with the ACL-intact condition, both the AE and OT procedures had increased posteromedial contact stresses in response to anterior load at some flexion angles, and the OT technique had increased peripheral posterolateral contact stresses at 15° in response to combined moments. Neither reconstruction technique completely restored the midjoint contact stresses. Both techniques restored anterior stability at flexion angles ≤30°; however, neither restored anterior stability at 60° and 90° of flexion. Both reconstruction techniques restored coupled anterior translation under combined moments. Additionally, the AE procedure overconstrained internal rotation in response to combined moments by 12% at 15° of flexion. Conclusion: Both reconstruction techniques provide anterior and rotational stability and decrease posterior joint contact stresses compared with the ACL-deficient knee. However, neither restored the contact mechanics and kinematics of the ACL-intact knee. Clinical Relevance: Because the AE reconstruction technique has clinical advantages over the OT procedure, the results support this technique as a potential candidate for use in the skeletally immature athlete.

Does the Quality, Accuracy, and Readability of Information about Lateral Epicondylitis on the Internet Vary with the Search Term Used?

BackgroundConcern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis.MethodsWe used three different search terms (“tennis elbow,” “lateral epicondylitis,” and “elbow pain”) in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website’s readability using the Flesch–Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons.ResultsThe mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms “tennis elbow” and “lateral epicondylitis” compared to “elbow pain” (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information.ConclusionsReliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.

Patellofemoral pain: an update on diagnostic and treatment options

Patellofemoral pain is a frequent and often challenging clinical problem. It affects females more than males and includes many different pathologic entities that result in pain in the anterior aspect of the knee. Diagnosis of the specific cause of pain can be difficult and requires assessment of lower extremity strength, alignment, and range of motion, as well as specific patella alignment, tracking, and mobility. The treatment for patellofemoral pain is usually conservative with anti-inflammatory medications, activity modification, and a specific physical therapy program focusing on strengthening and flexibility. Infrequently, surgical treatment may be indicated after a non-operative program fails. The outcomes of surgical management may include debridement, lateral release, and realignment of the extensor mechanism to unload the patellofemoral articulation are favorable.

The Mature Athlete Aging Tendon and Ligament

Context: Aging changes the biology, healing capacity, and biomechanical function of tendons and ligaments and results in common clinical pathologies that present to orthopedic surgeons, primary care physicians, physical therapists, and athletic trainers. A better understanding of the age-related changes in these connective tissues will allow better patient care. Evidence Acquisition: The PubMed database was searched in December 2012 for English-language articles pertaining to age-related changes in tendons and ligaments. Level of Evidence: Level 5. Results: The mature athlete faces challenges associated with age-dependent changes in the rotator cuff, Achilles tendon, lateral humeral epicondylar tendons, quadriceps tendon, and patellar tendon. The anterior cruciate ligament and the medial collateral ligament are the most studied intra-articular and extra-articular ligaments, and both are associated with age-dependent changes. Conclusion: Tendons and ligaments are highly arranged connective tissue structures that maintain joint motion and joint stability. These structures are subject to vascular and compositional changes with increasing age that alter their mechanotransduction, biology, healing capacity, and biomechanical function. Emerging research into the etiology of age-dependent changes will provide further information to help combat the age-related clinical complications associated with the injuries that occur to tendons and ligaments.

All-Inside, All-Epiphyseal Autograft Reconstruction of the Anterior Cruciate Ligament in the Skeletally Immature Athlete

Introduction We present an all-inside, all-epiphyseal anterior cruciate ligament (ACL) reconstruction technique with use of a hamstring autograft for skeletally immature athletes. Step 1 Identify Subcutaneous Landmarks Identify and mark subcutaneous landmarks to aid with anatomic orientation throughout the operation and to assist with socket placement. Step 2 Harvest the Hamstring Graft Harvest a hamstring autograft to create a four-strand autograft in the standard fashion or, if you prefer, perform a posterior hamstring harvest. Step 3 Prepare the Graft Prepare a four-strand hamstring autograft using suspensory cortical fixation devices-a reverse-tensioning button (ACL TightRope RT; Arthrex, Naples, Florida) on the femoral side and an attachable button system (ACL TightRope ABS, Arthrex) on the tibial side. Step 4 Prepare the Femoral and Tibial Sockets Create blind-ended intra-articular sockets in the femur and tibia using the center-center footprint positions while avoiding the physeal plates. Step 5 Pass and Secure the Graft Pass the hamstring autograft through the anteromedial portal and dock it in the femoral and tibial sockets; engage the cortical button on the femur, dock the graft, and then perform final fixation on the tibial side. Step 6 Postoperative Rehabilitation The patients age and maturity level dictate the progression of rehabilitation, and parents and caregivers are encouraged to regularly participate in the childs rehabilitation regimen. Results Research is ongoing to evaluate the clinical and radiographic outcomes following ACL reconstruction in skeletally immature athletes with use of this technique19. What to Watch For IndicationsContraindicationsPitfalls & Challenges.

Subscapularis tendon loading during activities of daily living

BACKGROUND The purpose of this study was to determine the relative amount of load that is transmitted through the superior portion of the subscapularis during activities of daily living as compared with the load that is transmitted through the middle and inferior portions in a normal shoulder and in a shoulder with a supraspinatus tear. METHODS By use of the Newcastle shoulder model, the subscapularis was modeled with 3 lines of action encircling the humeral head. The load was measured in the entire subscapularis, and the percentage of this load in each of the 3 tendinous bands was calculated. Subsequently, a supraspinatus tear was simulated, and the forces generated by the subscapularis and glenohumeral joint contact forces were measured. RESULTS The maximum force produced by the entire subscapularis muscle for the various activities ranged from 3 to 43 N. Load sharing between the 3 subscapularis bands showed that the superior band bore the largest percentage of the total load of the muscle (95% ± 2%). The load in the subscapularis, particularly in the superior band, increased significantly when a supraspinatus tear was simulated (P < .0001). CONCLUSION The superior band of the subscapularis tendon bears the highest percentage of load compared with the middle or inferior band. The load in the subscapularis increased significantly in the presence of a simulated supraspinatus tear. Because a disproportionate amount of force is transmitted through the superior subscapularis, more clinical research is warranted to determine whether tears in this region should be routinely repaired.

Return to Play and Clinical Outcomes after All-Inside, Anterior Cruciate Ligament Reconstruction in Skeletally Immature Athletes

Objectives: Anterior cruciate ligament (ACL) injuries in skeletally immature athletes are on the rise because of increased participation and level of competition within sports, sports specialization and societal factors. Conservative treatment of these injuries has a poor natural history due to recurrent instability with meniscal and articular cartilage damage. The purpose of this study was to evaluate the results of an all-inside, physeal-sparing ACL reconstruction in skeletally immature athletes, with a focus on return to play. Methods: Forty-two skeletally immature athletes (mean chronologic age 12.7 yrs, [range 10-15]) were prospectively evaluated following an all-inside ACL reconstruction utilizing hamstring autograft. The mean bone age (Greulich and Pyle method) was 13.5 years. There were 10 females and 32 males. Twenty-six patients had an all-epiphyseal (AE) ACL reconstruction and 16 patients had a partial transphyseal (PTP) ACL reconstruction, which spared the femoral physis but crossed the tibial physis. The PTP option was reserved for patients with minimal proximal tibial growth remaining. Fourteen athletes were involved in recreational sport and 28 participated competitively. Lacrosse (36%) and Soccer (32%) were the two most common sports associated with ACL injury in our cohort. All athletes were evaluated with a physical examination, KT-1000 arthrometry, isokinetic testing, validated outcome scores including the International Knee Documentation Committee score (IKDC), the Lysholm score and Marx activity rating scale. Standing radiographs and SPGR MRI analysis was performed at 6, 12 and 24 months post-op depending upon skeletal age. A ‘Return to Play’ performance analysis was also performed where symmetry, alignment control and the ability to decelerate were assessed during progressively challenging movement patterns encountered in sport. Results: At a mean follow-up of 16.7 months (range 12-24), the mean IKDC score was 92.9 ± 7.2, the mean Lysholm score was 97.7 ± 4.6 and the mean Marx activity rating scale score was 12.4 ± 3.5. Lachman and pivot shift testing was negative in all patients. The mean side-to-side difference in the KT-1000 arthrometry was 0.9 ± 0.7 mm, with the maximum difference in the cohort being 2 mm. Isokinetic testing showed a mean deficit of 4.1% in extension torque and 9.2% in flexion torque at a repetition speed of 180 degrees per second. No angular deformities, significant leg length discrepancy or physeal disturbances were observed on postoperative radiographs or MRI. One athlete had a traumatic graft disruption at 12 months and underwent revision ACL reconstruction and one athlete sustained a contralateral ACL rupture at 11 months. The mean time for return to unrestricted competitive activity after successful completion of the ‘Return to Play’ analysis was 12.5 +/- 1.3 months from the time of surgery. Conclusion: An all-inside, physeal-sparing ACL reconstruction technique using hamstring autograft demonstrates excellent subjective and objective clinical outcomes in skeletally immature athletes without growth disturbance. ‘Return to Play’ assessment is an important tool to guide the young athlete and her or his family regarding resumption of competitive sports. In our experience, athletes were on average released for full return to sport after 1 year from ACL reconstruction.