Vehniah K. Tjong

A Qualitative Investigation of the Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction To Play or Not to Play

Background: Primary anterior cruciate ligament (ACL) reconstruction is known to have excellent outcomes, but many patients do not return to their preinjury level of sport participation. Previous studies have used subjective outcome scores to evaluate this discrepancy, but none to date has used qualitative, in-depth patient interviews. Purpose: To understand the factors influencing a patient’s decision to return to his or her preinjury level of sport after ACL reconstruction. Hypothesis: Extrinsic and intrinsic factors may affect one’s decision to return to sport after primary ACL reconstruction despite good functional knee scores. Study Design: Case series; Level of evidence, 4. Methods: An experienced interviewer conducted qualitative, semistructured interviews of 31 patients, aged 18 to 40 years, who had undergone primary ACL reconstruction surgery. All participated in sport before injury and had a minimum 2-year follow-up with no further surgeries or knee injuries. Qualitative analysis was then performed to derive codes, categories, and themes. An assessment of preinjury and current sport participation by type, level of competition, and Marx activity score, along with patient-reported knee function, was also conducted. Results: Patient interviews revealed 3 overarching themes: fear, lifestyle changes, and innate personality traits. Elements of these factors were shown to largely influence the decision to return to the preinjury sport both in those patients who had returned and those who had not returned to sport. Less common factors included the surgeon’s advice not to return, depressed mood, and persistent knee pain. Conclusion: Patients who did not return to their preinjury level of sport after primary ACL reconstruction despite having good knee function were largely influenced by fear, shifts in priority, and individual personalities. This study highlights the importance for treating physicians to recognize and address psychological factors and lifestyle changes that largely contribute to a patient’s postoperative decision to return to sport. Results from this study will allow surgeons and health care professionals to educate patients contemplating surgery and to better understand the recovery process not only from sport-related surgeries but other surgical interventions with the goal of returning to activity.

A Qualitative Investigation of Return to Sport after Arthroscopic Bankart Repair: Beyond Stability

Background: Arthroscopic shoulder stabilization is known to have excellent functional results, but many patients do not return to their preinjury level of sport, with return to play rates reported between 48% and 100% despite good outcome scores. Purpose: To understand specific subjective psychosocial factors influencing a patient’s decision to return to sport after arthroscopic shoulder stabilization. Study Design: Case series; Level of evidence, 4. Methods: Semistructured qualitative interviews were conducted with patients aged 18 to 40 years who had undergone primary arthroscopic shoulder stabilization and had a minimum 2-year follow-up. All patients participated in sport before surgery without any further revision operations or shoulder injuries. Qualitative data analysis was performed in accordance with the Strauss and Corbin theory to derive codes, categories, and themes. Preinjury and current sport participation was defined by type, level of competition, and the Brophy/Marx shoulder activity score. Patient-reported pain and shoulder function were also obtained. Results: A total of 25 patients were interviewed, revealing that fear of reinjury, shifts in priority, mood, social support, and self-motivation were found to greatly influence the decision to return to sport both in patients who had and had not returned to their preinjury level of play. Patients also described fear of sporting incompetence, self-awareness issues, recommendations from physical therapists, and degree of confidence as less common considerations affecting their return to sport. Conclusion: In spite of excellent functional outcomes, extrinsic and intrinsic factors such as competing interests, kinesiophobia, age, and internal stressors and motivators can have a major effect on a patient’s decision to return to sport after arthroscopic shoulder stabilization. The qualitative methods used in this study provide a unique patient-derived perspective into postoperative recovery and highlight the necessity to recognize and address subjective and psychosocial factors rather than objective functional outcome scores alone as contributing to a patient’s decision to return to play.

Vasectomy reversal provides long-term pain relief for men with the post-vasectomy pain syndrome.

PURPOSE The post-vasectomy pain syndrome is a rare but serious and debilitating complication of vasectomy. For men with the post-vasectomy pain syndrome vasectomy reversal is a surgical option after medical management has failed. However, there is a paucity of data in the literature defining its therapeutic efficacy. In this study we better define the role and effect of vasectomy reversal in the treatment of men with the post-vasectomy pain syndrome. MATERIALS AND METHODS Three urologists in Toronto, Ontario performed 149 publically funded vasectomy reversals between January 2000 and September 2010. The electronic health records were reviewed and 23 of the 149 (15%) procedures were performed for the post-vasectomy pain syndrome. Of these men who underwent 14 vasovasostomies 13 completed a telephone conducted questionnaire (response rate 56%). Patient demographics, preoperative and postoperative pain scores, and quality of life were retrospectively assessed. RESULTS Orchialgia occurred a mean ± SD of 19 ± 42.5 months after vasectomy and the men (mean age 43.8 ± 5.2 years) experienced pain for 50.3 ± 34.9 months before vasovasostomy. After vasovasostomy improvement of pain occurred in 93% (13 of 14) and 50% were rendered pain-free with an average improvement in pain intensity scores of 65% (p <0.005). Of the men 15% (2 of 13) had a recurrence of pain to baseline but overall 79% (11 of 14) had a durable positive response. Quality of life was significantly improved after vasovasostomy (p <0.005) and 93% (13 of 14) of the patients said they would undergo the same operation again. CONCLUSIONS Vasovasostomy is an effective treatment modality for the post-vasectomy pain syndrome, and it can achieve robust and durable long-term improvement in pain intensity and quality of life.

A Qualitative Assessment of Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement

Background: Hip arthroscopy for femoroacetabular impingement (FAI) is known to produce excellent outcomes, yet some patients do not return to their preinjury level of sport participation. Much literature on return to sport has revolved around anterior cruciate ligament reconstruction and even shoulder instability, but none to date have used qualitative, semistructured patient interviews on patients with hip labral tears. Purpose: To understand the factors influencing the decision to return to sport after arthroscopic hip surgery for FAI. Study Design: Case series; Level of evidence, 4. Methods: An experienced interviewer conducted qualitative, semistructured interviews of patients aged 18 to 60 years who had arthroscopic hip surgery for FAI. All had preinjury participation in sport and a minimum 2-year follow-up with no revision surgery. Qualitative analysis was then performed to derive codes, categories, and themes. An assessment of preinjury and current sports participation by type, level of competition, and frequency along with patient-reported hip function was also obtained. In addition, current modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), Hip Outcome Score–sports-specific subscale (HOS-SSS), and a coping mechanism evaluation (Brief COPE) were also recorded. Results: A total of 23 patients were interviewed to reveal the overarching themes of internal motivation, external encouragement, and resetting expectations as the predominant factors influencing a patient’s decision to return to preinjury sport. Subjective outcome measurements (mHHS, iHOT-12, patient satisfaction) showed significant differences between patients who did and did not return to sport. Interestingly, the adaptive and maladaptive coping mechanisms matched and supported our themes in those patients who described fear and self-motivation as defining features influencing their cessation of or return to play, respectively. Conclusion: Self-motivation, aging, pain, encouragement from others, and adapting to physical limitations can largely affect a patient’s decision to return to sport after arthroscopic hip surgery for FAI. Innate coping mechanisms may also help to predict the course of and subsequently aid in a patient’s postoperative recovery.

Assessment of Intraoperative Intra-articular Morphine and Clonidine Injection in the Acute Postoperative Period After Hip Arthroscopy

Background: Previous authors have suggested that intra-articular morphine and clonidine injections after knee arthroscopy have demonstrated equivocal analgesic effect in comparison with bupivacaine while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine after hip arthroscopy. Purpose: To evaluate the efficacy of intra-articular morphine in combination with clonidine on postoperative pain and narcotic consumption after hip arthroscopy surgery for femoroacetabular impingement. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review was performed on 43 patients that underwent hip arthroscopy for femoroacetabular impingement at a single institution between September 2014 and May 2015. All patients received preoperative celecoxib and acetaminophen, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 μg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the 2 groups. Results: Patients who received intra-articular morphine and clonidine used significantly less opioid analgesic (mEq) in the postanesthesia recovery (median difference, 17 mEq [95% CI, –32 to –2 mEq]; P = .02) compared with the control group. There were no differences in time spent in recovery before hospital discharge or in visual analog pain scores recorded immediately postoperatively and at 1 hour after surgery. Conclusion: Intraoperative intra-articular injection of morphine and clonidine significantly reduced the narcotic requirement during the postsurgical recovery period after hip arthroscopy. The reduction in postsurgical opioids may decrease adverse effects, improve overall pain management, and lead to better quality of recovery and improved patient satisfaction.

The NFL’s Chop-Block Rule Change: Does It Prevent Knee Injuries in Defensive Players?

Background: The chop block, a football maneuver in which an offensive player blocks an opponent around the thigh while another offensive player engages the same opponent above the waist, was declared illegal by the National Football League (NFL) before the 2016-2017 season. Chop blocks have been hypothesized to be associated with medial collateral ligament and anterior cruciate ligament injury, especially in offensive/defensive linemen. Purpose: To quantify the impact that the chop-block rule change had on the incidence of knee injuries to defensive players in the NFL over 4 seasons (2014-2018). Study Design: Cohort study; Level of evidence, 3. Methods: NFL injury data for all defensive players from regular-season games played from 2014 through 2018 were collected. For this study, all knee injuries were attributed to competitive game play. Injury rates were reported as the number of injuries per 1000 athletic exposures (with 95% CIs). Results: A total of 256 games were played during the 2014-2015, 2015-2016, 2016-2017, and 2017-2018 NFL regular seasons, and all were included in this study. Among defensive players, the relative risk for a knee injury per 1000 athletic exposures was 0.84 (95% CI, 0.75-0.96) for the 2 seasons after the chop-block rule change (2016-2017 and 2017-2018) versus the 2 seasons before (2014-2015 and 2015-2016) (P = .009). Thus, the relative risk reduction was 16%. The relative risk for a defensive player to be placed on injured reserve per season was 0.90 (95% CI, 0.72-1.13) for the 2 seasons after the rule change versus the 2 seasons before (P = .39). Conclusion: The NFL’s recent ruling against in-game chop blocks may have reduced the incidence of knee injuries among defensive players.

Treatment of a Neglected Patellar Tendon Rupture with a Modified Surgical Technique: Ipsilateral Semitendinosus Autograft Reconstruction with Suture Tape Augmentation

Patellar tendon ruptures are rare, but debilitating injuries are typically seen in young active males in the third and fourth decades of life. They can occur as a single acute injury or from repetitive microtrauma weakening the tendon. Patients typically present complaining of knee pain, swelling, and an inability to perform a straight leg raise. Most conventionally, these injuries are classified as acute (less than two weeks) or chronic (greater than two weeks) based upon the timing of presentation. In patients with patellar tendon ruptures and inability to perform a straight leg raise, patellar tendon repair is most often recommended. A subset of patients with chronic patellar tendon ruptures, however, presents several months after their initial injuries. These neglected patella tendon ruptures present a particularly challenging clinical scenario in which primary repair is often difficult or not possible. This case report describes a modification to an existing surgical technique for reconstructing the patellar tendon using an ipsilateral semitendinosus tendon autograft with suture tape augmentation.

Arthroscopic Treatment of Type II Superior Labral Anterior to Posterior (SLAP) Lesions in a Younger Population: Traditional Repair versus Biceps Tenodesis with Accelerated Rehabilitation

Objectives: Biceps tenodesis is a viable surgical alternative to repair for type II SLAP lesions in an older population; however, its efficacy in a younger population is not well studied. The objective of this study was to compare clinical outcomes between arthroscopic biceps tenodesis and labral repair for type II SLAP lesions in a young active population. Methods: Patients aged 15 to 40 who underwent primary arthroscopic shoulder surgery for type II SLAP tear between 2009 and 2015 with either a suprapectoral biceps tenodesis or labral repair were included in the study. Shoulders with intraarticular chondral damage, full thickness rotator cuff tear or rotator cuff repair, labral repair outside of the superior labrum, bony subacromial decompression, and acromioclavicular joint resection were excluded. Patient-reported outcomes (PRO) pre-operatively and at a minimum of one year after surgery were evaluated using the American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand Sports/Performing Arts Module (DASH-sport), visual analog scale (VAS) for pain, and patient satisfaction. Complications and reoperation rates were also recorded. Statistical comparisons between the two groups were performed using the student t-test and chi-squared test with an alpha level of 0.05 indicating statistical significance. Results: Fifty-three patients were available for follow-up at an average of 3.2 years (range: 1.0-6.5 years). Twenty underwent biceps tenodesis and 33 underwent repair. Pre-operatively, there were no significant differences in mean ASES, DASH-sport, and VAS between biceps tenodesis and repair groups. Both groups had significant postoperative improvement in all PROs, and the average amount of change from preoperative to postoperative scores between the two groups was not significantly different for any of the PRO scores. Post-operatively, there were no significant differences in mean ASES, DASH-sport, VAS, and satisfaction between biceps tenodesis and repair groups (ASES: biceps tenodesis 87.1 vs. repair 86.9, P=0.97; DASH-sport: 17.0 vs. 19.5, P=0.75; VAS: 1.8 vs. 1.6, P=0.73; Satisfaction: 8.6 vs. 8.2, P=0.45). Rate of return to pre-injury level of play in sport/physical activity was also similar between groups (biceps tenodesis 55% vs. repair 50%, P=0.73). In the repair group, there was one minor complication involving a superficial paresthesia, and one other patient required reoperation (capsular release) after two years for persistent difficulty throwing in softball. There were no complications or reoperations in the biceps tenodesis group. Conclusion: In a young active population, biceps tenodesis may be a viable surgical alternative for type II SLAP lesions and may facilitate earlier return to activity compared to repair. Further research, particularly prospective randomized studies with longer time to follow-up, is warranted given the limitations of this preliminary study.

The MacIntosh Procedure

Historically known as the first surgical technique to address the pivot shift phenomenon following anterior cruciate ligament rupture, the MacIntosh procedure, also known as the extra-articular lateral tenodesis, has evolved over time since its original description. The following chapter outlines the birth of the MacIntosh I and its progression to the MacIntosh II, the most common form currently described and employed in practice. A discussion of current literature is presented to investigate its use as an adjunct for rotational stability in the setting of an ACL reconstruction. Although preliminary data suggests that this procedure may provide rotational stability for the ACL-deficient knee, there are no long-term studies to support its efficacy or affect on post-reconstruction osteoarthritis of the knee.

A case series of pectoralis major injuries on one collegiate football team

Introduction Pectoralis major muscle (PMM) ruptures are an uncommon shoulder injury, but are often reported in football players (1,4,9,13,14,22). Injury to the PMM can result in pain, weakness, and deformity of the upper extremity (31). PMM ruptures are significant injuries for collision athletes because this muscle functions to stabilize the shoulder joint and also rotate, flex, and adduct the arm (9,16). The injury pattern of PMM ruptures reported in the literature is likely due to the muscle’s unique anatomy (30,31). The PMM has two origins, the clavicular and sternal head, which join to insert at the lateral lip of the bicipital groove of the humerus (16). The superior muscle fibers that originate from the clavicular head insert more anteriorly and distal than the inferior segment fibers. The inferior segment fibers originate from the sternal head, and rotate 180to insert more posteriorly and proximal on the humerus (24,31). The inferior segment of the PMM tendon is predisposed to rupture first (13,31). Most commonly, the musculotendinous junction of the PMM is torn from indirect trauma due to eccentric overload (9,16). Excessive eccentric overload leading to PMM rupture has been associated with bench pressing when the arm is extended and externally rotated (31). The rigorous strength training required to play collegiate varsity football potentially puts players at risk to suffer PMM ruptures (31). In addition, football players also are subject to eccentric overload when attempting to block a charging opponent, usually with 90flexion of the elbow and elbows locked (19). The resulting collision directs a posterior force on the player’s upper extremity which is translated into an eccentric force on the PMM (4,9,13,16,31). Over the last decade, the number of individuals suffering from pectoralis major tears has increased; two recent studies attributed this phenomena to an increase in the number of individuals participating in high impact sports like football (3,14). Each year, at the NFL Combine, football players compete in a bench press competition (21). The popularity of bench pressing may be a contributing factor to the rising number of pectoralis major tears within the athletic population (4). A recent case control study reviewed all pectoralis major injuries in NFL players from 2000 to 2010 (31). Tarity et al. (31) found the incidence of grade III pectoralis major tears in NFL athletes over a 10-yr period to be 0.004 per year (about 1 NFL athlete each year), and the average days lost to injury was 111 d. The results of Tarity et al. show that pectoralis major tears are an uncommon, but significant injury for NFL athletes. During the years 2014 to 2015, five members of the varsity football team involved in this study suffered pectoralis major injuries. The incidence rate of pectoralis major injury on this team during 2014 to 2015 was 0.025, almost 10 times the incidence rate reported by Tarity et al. of pectoralis major tears in NFL athletes. There is a gap in current literature on the incidence rate of PMM injuries in varsity collegiate football players (31). An incidence rate of 0.025 for pectoralis major injuries on a single football team over 2 yr has never been recorded before and thus warrants further investigation. This study will investigate factors that may have attributed to an excessive number of pectoralis major injuries on a single football team.