Robert A. Arciero

Persistent disability associated with ankle sprains: a prospective examination of an athletic population.

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17–24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.

Risk factors associated with noncontact injury of the anterior cruciate ligament: a prospective four-year evaluation of 859 West Point cadets.

Background: The causes of noncontact anterior cruciate ligament injury remain an enigma. Purpose: To prospectively evaluate risk factors for noncontact anterior cruciate ligament injuries in a large population of young athletic people. Study Design: Prospective cohort study. Methods: In 1995, 1198 new United States Military Academy cadets underwent detailed testing and many parameters were documented. During their 4-year tenure, all anterior cruciate ligament injuries that occurred were identified. Statistical analyses were used to identify the factors that may have predisposed the cadets to noncontact anterior cruciate ligament injuries. Results: Among the 895 cadets who completed the entire 4-year study, there were 24 noncontact anterior cruciate ligament tears (16 in men, 8 in women). Significant risk factors included small femoral notch width, generalized joint laxity, and, in women, higher than normal body mass index and KT-2000 arthrometer values that were 1 standard deviation or more above the mean. The presence of more than one of these risk factors greatly increased the relative risk of injury. All female cadets who had some combination of risk factors sustained noncontact anterior cruciate ligament injuries, indicating that some combinations of factors are especially perilous to the female knee. Conclusion: Several risk factors may predispose young athletes to noncontact anterior cruciate ligament injury.

Arthroscopic Bankart Repair Versus Nonoperative Treatment for Acute, Initial Anterior Shoulder Dislocations

A prospective study evaluating nonoperative treatment versus arthroscopic Bankart suture repair for acute, ini tial dislocation of the shoulder was undertaken in young athletes. All patients met the following criteria: 1) sus tained an acute first-time traumatic anterior dislocation, 2) no history of impingement or occult subluxation, 3) the dislocation required a manual reduction, and 4) no concomitant neurologic injury. Thirty-six athletes (average age, 20 years) met the criteria for inclusion. Group I patients were immobilized for 1 month followed by rehabilitation; they were allowed full activity at 4 months. Group II patients underwent arthroscopic Bankart repair followed by the same protocol as Group I. Group I consisted of 15 athletes. Twelve patients (80%) developed recurrent instability; 7 of the 12 have required open Bankart repair for recurrent instability. Group I consisted of 21 patients; 18 patients (86%) had no recurrent instability at last followup (average, 32 months; range, 15 to 45) (P = 0.001). One patient in Group II has required a subsequent open Bankart repair to treat symptomatic recurrence (P = 0.005). In this study, arthroscopic Bankart repair significantly reduced the recurrence rate in young athletes who sustained an acute, initial anterior dislocation of the shoulder.

Pathologic Changes Associated with Shoulder Dislocations Arthroscopic and Physical Examination Findings in First-Time, Traumatic Anterior Dislocations

This prospective observational study was performed on young patients, less than 24 years old, with first- time, traumatic anterior shoulder dislocations. These patients were offered either arthroscopic or nonopera tive treatment. Fifty-three patients chose nonoperative treatment. Sixty-three patients elected to have arthro scopic procedures. The average patient age was 19.6 years. There were 59 men and 4 women. All proce dures were performed within 10 days of dislocation. All 63 patients had hemarthrosis. Sixty-one of 63 (97%) patients treated surgically had complete detachment of the capsuloligamentous complex from the glenoid rim and neck (Perthes-Bankart lesion), with no gross evi dence of intracapsular injury. Of the other two patients, one had an avulsion of the inferior glenohumeral liga ment from the neck of the humerus, and one had an interstitial capsular tear adjacent to the intact glenoid labrum. Fifty-seven patients had Hill-Sachs lesions; none were large. There were six superior labral ante rior posterior lesions, two with detachment of the bi ceps tendon. There were no rotator cuff tears. Of the 53 nonoperatively treated patients, 48 (90%) have de veloped recurrent instability. In this population, the capsulolabral avulsion appeared to be the primary gross pathologic lesion after a first-time dislocation. These findings, associated with the 90% nonoperative recurrence rate, suggest a strong association between recurrent instability and the Perthes-Bankart lesion in this population.

A Biomechanical Evaluation of an Anatomical Coracoclavicular Ligament Reconstruction

Background Despite numerous surgical techniques described, there have been few studies evaluating the biomechanical performance of acromioclavicular joint reconstructions. Purpose To compare a newly developed anatomical coracoclavicular ligament reconstruction with a modified Weaver-Dunn procedure and a recently described arthroscopic method using ultrastrong nonabsorbable suture material. Study Design Controlled laboratory study. Methods Forty-two fresh-frozen cadaveric shoulders (72.8 ± 13.4 years) were randomly assigned to 3 groups: arthroscopic reconstruction, anatomical coracoclavicular reconstruction, and a modified Weaver-Dunn procedure. Bone mineral density was obtained on all specimens. Specimens were tested to 70 N in 3 directions, anterior, posterior, and superior, comparing the intact to the reconstructed states. Superior cyclic loading at 70 N for 3000 cycles was then performed at a rate of 1 Hz, followed by a load to failure test (120 mm/min) to simulate physiologic states at the acromioclavicular joint. Results In comparison to the intact state, the modified Weaver-Dunn procedure had significantly (P <. 05) greater laxity than the anatomical coracoclavicular reconstruction or the arthroscopic reconstruction. There were no significant differences in bone mineral density (g/cm2), load to failure, superior migration over 3000 cycles, or superior displacement. The anatomical coracoclavicular reconstruction had significantly less (P <. 05) anterior and posterior translation than the modified Weaver-Dunn procedure. The arthroscopic reconstruction yielded significantly less anterior displacement (P <. 05) than the modified Weaver-Dunn procedure. Conclusion The anatomical coracoclavicular reconstruction has less anterior and posterior translation and more closely approximates the intact state, restoring function of the acromioclavicular and coracoclavicular ligaments. Clinical Relevance A more anatomical reconstruction using a free tendon graft of both the trapezoid and conoid ligaments may provide a stronger, permanent biologic solution for dislocation of the acromioclavicular joint. This reconstruction may minimize recurrent subluxation and residual pain and permit earlier rehabilitation.

Arthroscopic Single-Row Versus Double-Row Suture Anchor Rotator Cuff Repair

Background Recurrent defects after open and arthroscopic rotator cuff repair are common. Double-row repair techniques may improve initial fixation and quality of rotator cuff repair. Purpose To evaluate the load to failure, cyclic displacement, and anatomical footprint of 4 arthroscopic rotator cuff repair techniques. Hypothesis Double-row suture anchor repair would have superior structural properties and would create a larger footprint compared to single-row repair. Study Design Controlled laboratory study. Methods Twenty fresh-frozen cadaveric shoulders were randomly assigned to 4 arthroscopic repair techniques. The repair was performed as either a single-row technique or 1 of 3 double-row techniques: diamond, mattress double anchor, or modified mattress double anchor. Angle of loading, anchor type, bone mineral density, anchor distribution, angle of anchor insertion, arthroscopic technique, and suture type and size were all controlled. Footprint length and width were quantified before and after repair. Displacement with cyclic loading and load to failure were determined. Results There were no differences in load to failure and displacement with cyclic loading between the single-row repair and each double-row repair. All repair groups demonstrated load to failure greater than 250 N. A significantly greater supraspinatus footprint width was seen with double-row techniques compared to single-row repair. Conclusions The single-row repair technique was similar to the double-row techniques in load to failure, cyclic displacement, and gap formation. The double-row anchor repairs consistently restored a larger footprint than did the single-row method. Clinical Relevance The arthroscopic techniques studied have strong structural properties that approached the reported performance of open repair techniques. Double-row techniques provide a larger footprint width; although not addressed by this study, such a factor may improve the biological quality of repair.

Evaluation and Treatment of Acromioclavicular Joint Injuries

Acromioclavicular joint injuries and, more specifically, separations are commonplace both in general practice and during athletic participation. This article reviews the traditional classification as well as the clinical evaluation of patients with acute and chronic acromioclavicular joint separations. It also highlights many recent advances, principally in the anatomy and biomechanics of the acromioclavicular joint ligamentous complex. The concept of increases in superior translation as well as disturbances in horizontal translation with injuries to this joint and ligaments are discussed. This information, coupled with the unpredictable longterm results with the Weaver-Dunn procedure and its modifications, have prompted many recent biomechanical studies evaluating potential improvements in the surgical management of acute and chronic injuries. The authors present these recent works investigating cyclic loading and ultimate failure of traditional reconstructions, augmentations, use of free graft, and the more recent anatomic reconstruction of the conoid and trapezoid ligaments. The clinical results (largely retrospective), including acromioclavicular joint repair, reconstruction and augmentation with the coracoclavicular ligament, supplemental sutures, and the use of free autogenous grafts, are summarized. Finally, complications and the concept of the failed distal clavicle resection and reconstruction are addressed. The intent is to provide a current, in-depth treatise on all aspects of acromioclavicular joint complex injuries to include anatomy, biomechanics, benchmark studies on instability and reconstruction, clinical and radiographic evaluation, and to present the most recent clinical research on surgical outcomes.

A Prospective, Randomized Evaluation of Arthroscopic Stabilization Versus Nonoperative Treatment in Patients with Acute, Traumatic, First-Time Shoulder Dislocations

Background Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. Hypothesis Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. Study Design Prospective, randomized clinical trial. Methods Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. Results Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. Conclusions Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.

Comparison of the Single Assessment Numeric Evaluation Method and Two Shoulder Rating Scales Outcomes Measures After Shoulder Surgery

The purpose of this study was to determine the correlation between the Single Assessment Numeric Evaluation method and the Rowe and American Shoulder and Elbow Surgeons scores. Between April 1993 and December 1996, 209 follow-up examinations were performed on 163 United States Military Academy cadets after shoulder surgery. These 209 examinations were divided into five follow-up categories: 3 months, 6 months, 1 year, 2 years, and greater than 2 years. The Rowe and American Shoulder and Elbow Surgeons scores from each subjects follow-up questionnaire were correlated with his or her Single Assessment Numeric Evaluation rating, which is determined by the subjects written response to the following question: “How would you rate your shoulder today as a percentage of normal (0% to 100% scale with 100% being normal)?” Correlation coefficients between the Single Assessment Numeric Evaluation and the two scores were 0.51 to 0.79 for the Rowe score and 0.46 to 0.69 for the American Shoulder Elbow Surgeons score. The results of this study indicate that the Single Assessment Numeric Evaluation correlates well with these two scores after shoulder surgery. This study suggests that this new evaluation method provides clinicians with a mechanism to gather outcomes data with little demand on their time and resources.

Anatomy of the Clavicle and Coracoid Process for Reconstruction of the Coracoclavicular Ligaments

Background Recently acromioclavicular joint reconstruction techniques have focused on anatomic restoration of the coracoclavicular (CC) ligaments. Such techniques involve creating bone tunnels in the distal clavicle and coracoid. Purpose To define the anatomy of the human clavicle and coracoid process of the scapula, in order to guide surgeons in reconstructing the CC ligaments. Study Design Descriptive laboratory study. Methods One hundred twenty (60 paired) cadaveric clavicles and corresponding scapulae (mean age ± and standard deviation, 48.3 ± 16.6 years) devoid of soft tissue were analyzed (dry osteology). Differences related to race and sex were recorded. Nineteen fresh-frozen cadaveric clavicles with intact CC ligaments were measured as well (fresh anatomic). Results The mean clavicle length was 149 ± 9.1 mm. In the dry osteology group, the distance from the lateral edge of the clavicle to the medial edge of the conoid tuberosity in male and female specimens was 47.2 ± 4.6 mm and 42.8 ± 5.6 mm, respectively (P = .006). The distance to the center of the trapezoid tuberosity was 25.4 ± 3.7 mm in males and 22.9 ± 3.7 mm in females (P = .04). The ratio of the distance to the medial edge of the conoid tuberosity divided by clavicle length was 0.31 in males and females. This ratio for the trapezoid was 0.17 in both sexes. The mean coracoid length was 45.2 ± 4.1 mm. The mean width and height of the coracoid process were 24.9 ± 2.5 mm and 11.9 ± 1.8 mm, respectively. No interracial differences in measurements were observed. In the fresh anatomic samples, the ratio of the distance to the conoid center to clavicle length was 0.24. This ratio for the trapezoid was 0.17. Conclusions While absolute differences in the origin of the CC ligaments exist between men and women, the ratio of these origins to total clavicle length is constant. Clinical Relevance Clavicle length can be obtained intraoperatively. These findings allow the surgeon to predict the origin of the conoid and trapezoid ligaments accurately and to correctly create bone tunnels to reconstruct the anatomy of the CC complex.