Neil K. Bakshi

Does Repair of a Hill-Sachs Defect Increase Stability at the Glenohumeral Joint?

Background: The effect of osteoallograft repair of a Hill-Sachs lesion and the effect of allograft fit on glenohumeral translations in response to applied force are poorly understood. Purpose: To compare the impact of a 25% Hill-Sachs lesion, a perfect osteoallograft repair (PAR) of a 25% Hill-Sachs lesion, and an “imperfect” osteoallograft repair (IAR) of a 25% Hill-Sachs lesion on glenohumeral translations in response to a compressive load and either an anterior or posterior load in 3 clinically relevant arm positions. Study Design: Controlled laboratory study. Methods: A robotic/universal force-moment sensor testing system was used to apply joint compression (22 N) and an anterior or posterior load (44 N) to cadaveric shoulders (n = 9) with the skin and deltoid removed (intact) at 3 glenohumeral joint positions (abduction/external rotation): 0°/0°, 30°/30°, and 60°/60°. The 25% bony defect state, PAR state, and IAR state were created and the loading protocol was performed. Translational motion was measured in each position for each shoulder state. A nonparametric repeated-measures Friedman test with a Wilcoxon signed-rank post hoc test was performed to compare the biomechanical parameters (P < .05). Results: Compared with the defect shoulder, the PAR shoulder had significantly less anterior translation with an anterior load in the 0°/0° (15.3 ± 8.2 vs 16.6 ± 9.0 mm, P = .008) and 30°/30° (13.6 ± 7.1 vs 14.2 ± 7.0 mm, P = .021) positions. Compared with IAR, the PAR shoulder had significantly less anterior translation with an anterior load in the 0°/0° (15.3 ± 8.2 vs 16.6 ± 9.0 mm, P = .008) and 30°/30° (13.6 ± 7.1 vs 14.4 ± 7.1 mm, P = .011) positions, and the defect shoulder had significantly less anterior translation with an anterior load in the 30°/30° (14.2 ± 7.0 vs 14.4 ± 7.0 mm, P = .038) position. Conclusion: PAR resulted in the least translational motion at the glenohumeral joint. The defect shoulder had significantly less translational motion at the joint compared with the IAR. An IAR resulted in the most translational motion at the glenohumeral joint. This demonstrates the biomechanical importance of performing an osteoallograft repair in which the allograft closely matches the Hill-Sachs defect and fully restores the preinjury state of the humeral head. Clinical Relevance: This study demonstrates the importance of performing an osteoallograft repair of a Hill-Sachs defect that closely matches the preinjury state and restores normal humeral head anatomy.

Return to Play After Multiligament Knee Injuries in National Football League Athletes

Background: Return to play (RTP) of National Football League (NFL) athletes after isolated anterior cruciate ligament (ACL) tears has been reported. However, no studies have reported on RTP of NFL athletes after multiligament knee injuries. Hypotheses: NFL athletes with multiligament knee injuries have lower RTP rates and longer recoveries than athletes with isolated ACL tears. Second, athletes with ACL and medial collateral ligament (MCL) injuries will have higher RTP rates and shorter time to RTP than athletes with an ACL tear and posterolateral corner involvement. Study Design: Retrospective cohort study. Level of Evidence: Level 4. Methods: Publicly available NFL injury data were reviewed for all multiligament knee injuries incurred between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited for reasons unrelated to the injury. Extracted data included type of injury, RTP, time to RTP (days), number and percentage of games played, and performance. Results: A total of 50 NFL athletes with multiligament knee injuries met inclusion and exclusion criteria. The overall RTP rate was 64.0%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, whereas athletes with ACL and posterior collateral ligament/lateral collateral ligament (PCL/LCL) tears had an RTP rate of 55.6% (P = 0.26). Mean time to RTP for all 50 athletes was 388.71 ± 198.52 days. The mean time to RTP for athletes with ACL/MCL injuries was 305.1 ± 58.9 days, compared with 459.2 ± 245.1 days (P = 0.004) and 609.3 ± 183.1 days (P < 0.0001) for those with combined ACL and PCL/LCL injuries and frank knee dislocations, respectively. Athletes with ACL/MCL injuries were more likely to return to prior performance level (43.5%) than those with ACL and PCL/LCL injuries (18.5%) (P < 0.001). Conclusion: The RTP rate for athletes with multiligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a greater likelihood of returning to prior performance than athletes with ACL and PCL/LCL tears. Clinical Relevance: Multiligament knee injuries significantly affect the ability of a football player to return to sport. ACL and MCL tears are associated with better RTP prognosis compared with ACL and PCL/LCL tears.

Significant demographic and geographic differences exist in the reporting of superior labrum from anterior to posterior tear literature: a systematic review

Importance Superior labrum from anterior to posterior (SLAP) pathology can result in significant pain and functional limitation for a wide variety of patients. Although many different options have been described for the diagnosis and treatment of SLAP pathology, there is little high-quality evidence to support a given diagnosis/treatment method. Objective The aim of this study was to review the global demographics and trends of SLAP literature, diagnosis, management and consistency of reported outcomes Evidence review We performed a systematic search for studies addressing SLAP pathology published over the last 10 years. Extracted data included sample size, study location, intervention, outcome measures reported, sex distribution and level of evidence. Management was compared between geographic areas. Findings We identified 363 studies reporting on SLAP management over the past decade that met our inclusion and exclusion criteria. The majority of studies originated from North America (50.4%), followed by Asia (22.3%) and Europe (20.9%) with most studies describing results of operative intervention originating from the USA (58.5%). We found the majority of literature related to SLAP pathology was case series level data (44.0%) consisting of sample sizes of less than 40 patients (50.1%). The majority of studies presented clinical outcome scores with the ASES score being the most commonly reported (28.3%). The most common complications reported were pain (32.6%) and stiffness (30.4%) following surgical intervention. Conclusions Current literature related to the management of SLAP pathology demonstrates a predominance of North American studies with low levels of evidence consisting of small sample sizes and variably reported clinical outcome scores. Future research should focus on multicentre, randomised studies to clarify current controversies in the surgical versus non-operative management of SLAP pathology. Relevance Significant demographic and geographic differences exist in the diagnosis and treatment of SLAP. Level of evidence Level IV, systematic review of level I–IV studies.

A Clinical Comparison of Linear- and Surface Area–Based Methods of Measuring Glenoid Bone Loss:

Background: The purpose of this study was to determine whether linear-based measurement significantly overestimates glenoid bone loss in comparison with surface area–based measurement in patients with recurrent anterior shoulder instability and glenoid bone loss. Hypothesis: Linear-based measurement will significantly overestimate glenoid bone loss in comparison with surface area–based measurement in patients with anterior shoulder instability and glenoid bone loss. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Thirty patients with anterior shoulder instability underwent preoperative bilateral shoulder computed tomography (CT) scans. Three-dimensional CT (3D-CT) reconstruction with humeral head subtraction was performed to obtain an en face view of the 3D-CT glenoid. Glenoid bone loss was measured with the surface area and linear methods of measurement. Statistical analysis was performed with a paired 2-tailed t test. Results: Twenty-eight patients (5 female and 23 male; mean age, 25.1 years; age range, 15-58 years) were included in the study; 17 patients underwent a glenoid augmentation procedure, and 11 underwent arthroscopic Bankart repair. The mean percentage glenoid bone loss calculated with the surface area and linear methods was 12.8% ± 8.0% and 17.5% ± 9.7% (P < .0001), respectively. For the 17 patients who underwent glenoid augmentation, mean percentage bone loss with the surface area and linear methods was 16.6% ± 7.9% and 23.0% ± 8.0% (P < .0001), respectively. Conclusion: Linear measurement of glenoid bone loss significantly overestimates bone loss compared with surface area measurement in patients with anterior glenoid bony defects. These results indicate that these different methods cannot be used interchangeably and cannot be used with the same critical thresholds for glenoid bone loss.

Return to Play After Multi-Ligament Knee Injuries in National Football League (NFL) Athletes

Objectives: Return to play (RTP) of NFL athletes following isolated ACL tears has been reported in the literature. However, there have been no studies reporting on RTP of NFL athletes following multi-ligament knee injuries. The authors hypothesize that NFL athletes with multi-ligament knee injuries will have lower RTP rates and longer time to RTP compared to athletes with isolated ACL tears, as reported in the literature. We also hypothesize that athletes with ACL and MCL injuries will have higher RTP rates and shorter time to RTP compared to athletes with an ACL tear and a PCL and/or LCL tear(s). Methods: NFL injury surveillance data was reviewed for all multi-ligament knee injuries between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited due to reasons unrelated to the injury such as suspension, unrelated injury, or personal matters. Extracted data included injury, RTP, time to return to play (months), number of games played, percent of possible games played, and performance. Results: 51 NFL athletes were found to have multi-ligament knee injuries between 2000 and 2016 that met inclusion and exclusion criteria. 47.1% (24/51) of athletes had ACL and MCL tears. 52.9% (27/51) of athletes had ACL and PCL and/or LCL tears. Of the players with ACL and PCL/LCL tears, there were 8 frank knee dislocations. The overall return to play rate following multi-ligament knee injuries was 62.7%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, while the athletes with ACL and PCL/LCL tears had an RTP rate of 55.6% (p=.26). Athletes with frank knee dislocations had a 50% RTP rate. Mean time to RTP for all 51 athletes was 11.9 ± 3.52 months. The mean time to RTP for athletes with ACL/MCL injuries was 10.4±1.6 months compared with 13.7±4.3 for those with combined ACL and PCL/LCL injuries, and for frank dislocations was 20 ±6.1 (p<.001). Athletes with ACL/MCL injuries were more likely to return to prior performance levels 46% vs 18% compared to those with ACL and PCL/LCL injuries (p < .001). Conclusion: This study is the first to provide important prognostic information for NFL players sustaining multi-ligament knee injuries. The RTP rate for athletes with multi-ligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a higher likelihood of returning to prior performance than athletes with combined ACL and PCL/LCL tears.