The American Journal of Sports Medicine

Background: Little is known of the long-term results of acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations.

Hypothesis: Acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations will provide good results at long-term follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: The authors evaluated a cohort of young patients who sustained first-time anterior glenohumeral dislocations and were acutely treated with arthroscopic Bankart repair using bioabsorbable tacks. Subjective outcome measures were obtained at a mean follow-up of 11.7 years (range, 9.1-13.9 years).

Results: Thirty-nine patients (40 shoulders) were available of the original cohort of 49 shoulders (82%). Two of the 9 who were lost to follow-up had revision surgery before being lost and are carried forward in the calculations of recurrent instability and revision surgery but are not included in the calculation of the functional scores. The mean Single Assessment Numeric Evaluation was 91.7, the mean Western Ontario Shoulder Instability score was 371.7, the mean subjective Rowe score was 25.3, the mean Simple Shoulder Test was 11.1, the mean American Shoulder and Elbow Society score was 90.9, the mean Short Form-36 Physical Component score was 94.4, and the mean Tegner score was 6.5. Six patients sustained recurrent dislocations for a redislocation rate of 14.3%. Nine patients (21.4%) reported experiencing subluxation events. Six patients (14.3%) underwent revision stabilization surgery.

Conclusion: At long-term follow-up, acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics in young, active patients with an acceptable rate of recurrence and reoperation.

Background: Double-row arthroscopic rotator cuff repair has become more popular, and some studies have shown better footprint coverage and improved biomechanics of the repair.

Hypothesis: Double-row rotator cuff repair leads to superior cuff integrity and early clinical results compared with single-row repair.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Forty patients were randomized to either single-row or double-row rotator cuff repair at the time of surgical intervention. Patients were followed with clinical measures (UCLA, Constant, WORC, SANE, ASES, as well as range of motion, internal rotation strength, and external rotation strength). Magnetic resonance imaging (MRI) studies were performed on each shoulder preoperatively, 6 weeks, 3 months, and 1 year after repair.

Results: Mean anteroposterior tear size by MRI was 1.8 cm. A mean of 2.25 anchors for single row (SR) and 3.2 for double row (DR) were used. There were 2 retears at 1 year in each group. There were 2 additional cases that had severe thinning in the DR repair group at 1 year. The MRI measurements of footprint coverage, tendon thickness, and tendon signal showed no significant differences between the 2 repair groups. At 1 year, there were no differences in any of the postoperative measures of motion or strength. At 1 year, mean WORC (SR, 84.8; DR, 87.9), Constant (SR, 77.8; DR, 74.4), ASES (SR, 85.9; DR, 85.5), UCLA (SR, 28.6; DR, 29.5), and SANE (SR, 90.9; DR, 89.9) scores showed no significant differences between groups.

Conclusions: No clinical or MRI differences were seen between patients repaired with a SR or DR technique.

Background: Recent studies comparing double-bundle anterior cruciate ligament reconstruction to single-bundle anterior cruciate ligament reconstruction have reported some biomechanical advantages but little or no short-term clinical benefit from the double-bundle technique. In the current healthcare environment, the potential economic implications of widespread conversion to a double-bundle anterior cruciate ligament reconstruction are an important consideration.

Purpose: To determine the economic implications of widespread use of the double-bundle technique for anterior cruciate ligament reconstruction.

Study Design: Economic analysis; Level of evidence, 2.

Methods: A cost model to assess the effect of double-bundle anterior cruciate ligament reconstruction was constructed using standard accounting methodology. The model was based on actual 2008 cost figures (in US dollars) for ligamentous allografts, fixation implants, and operating room time. Revision rate (4%) and time to revision surgery (mean, 4 years) for single-bundle anterior cruciate ligament reconstruction was based on the available literature. Assumptions about the prevalence of double-bundle versus single-bundle anterior cruciate ligament reconstruction, the number of grafts used, and the revision rate for double-bundle reconstruction were varied to assess their effect on cost.

Results: The potential additional cost for widespread conversion to the double-bundle technique for anterior cruciate ligament reconstruction ranges from $36 million to $792 million per year in the United States alone. To offset this increased cost, the double-bundle technique would have to reduce the revision rate at a minimum from 4% to 1.5% and potentially from 24.1% to 0%.

Conclusion: Double-bundle anterior cruciate ligament reconstruction has the potential of adding considerable cost to the healthcare system.

Clinical Relevance: While further research is warranted to determine if there are other benefits from this technique, widespread adoption of a double-bundle anterior cruciate ligament reconstruction does not appear to be cost-effective at this time.

Background: Chondral lesions are often documented at the time of anterior cruciate ligament reconstruction. They are usually asymptomatic. It is not known if these lesions change the outcome of current ACL treatments.

Hypothesis: Untreated deep cartilage lesions incidentally found during anterior cruciate ligament reconstruction do not affect clinical and radiological results.

Study Design: Case control study; Level of evidence, 3.

Methods: From 1991 to 1995, 586 anterior cruciate ligament reconstructions were performed; 51 of these were in patients with a concomitant single focal chondral lesion of Outerbridge grade 3 or 4. The mean defect size was 2.1 cm2 (range, 0.5-4.0 cm2). The control group (anterior cruciate ligament injury only) was matched for sex, age, and operation time. Outcomes were reported at 10- and 15-year follow-up using International Knee Documentation Committee criteria, Lysholm score, and Tegner activity scale.

Results: Forty-two patients were evaluated at 10-year follow-up and 36 at 15-year follow-up. At 10-year follow-up according to Lysholm, Tegner, and International Knee Documentation Committee objective scores, no statistical differences were noted between the groups. The mean total International Knee Documentation Committee subjective score was significantly lower in the defect group than in the control group (mean, 79.6 points vs 83.7; P = .031). At 15 years, there were no statistical differences according to Lysholm, Tegner, and either objective or subjective International Knee Documentation Committee scores.

Conclusion: Deep cartilage lesions found during anterior cruciate ligament reconstruction, left with no treatment, do not appear to affect clinical outcome at 10- and 15-year follow-up.

Background: It has been suggested that transtibial posterior cruciate ligament reconstruction may be compromised by graft abrasion at the “killer turn,” where the graft emerges from the tibia. In 1998, one of the authors suggested that beginning the tibial tunnel anterolaterally rather than anteromedially would reduce the killer turn and possibly improve the results of posterior cruciate ligament reconstruction.

Purpose: This article is intended to present the clinical results of single-bundle transtibial posterior cruciate ligament reconstruction, comparing cases in which the tibial tunnel was begun anteromedially with cases in which the tunnel was begun anterolaterally.

Study Design: Cohort study; Level of evidence, 3.

Methods: The authors retrospectively studied 23 patients (group I) using the anteromedial tibial tunnel technique from April 1998 to August 2003 and 37 patients (group II) using the anterolateral tibial tunnel technique from February 1998 to August 2003. The average follow-up period was 58.6 months in group I and 56.9 months in group II. The minimum follow-up period was 24 months in each group. All revision cases and patients with general laxity were excluded.

Results: The mean side-to-side difference of posterior tibial translation by Telos stress radiography was 3.98 ± 1.27 mm (range, 1.80-7.80 mm) in group I and 2.87 ± 1.25 mm (range, 1.43-6.82 mm) in group II, which was a statistically significant difference (P < .01). The final mean Lysholm knee score was 88.6 ± 7.10 points (range, 77-98 points) in group I and 88.4 ± 6.44 points (range, 78-98 points) in group II, which was not a statistically significant difference (P = .4358). According to the final International Knee Documentation Committee (IKDC) evaluation in group I, 30.4% (7 of 23) were normal (A), 60.9% (14 of 23) were nearly normal (B), and 8.7% (2 of 23) were abnormal (C). In group II, 24.3% (9 of 37) were normal (A), 73.0% (27 of 37) were nearly normal (B), and 2.7% (1 of 37) were abnormal (C) ( P = .467). With respect to the mean side-to-side difference of range of motion, there was no statistically significant difference (P = .1697). The mean was 4.7° ± 2.38° (range, 2°-10°) in group I and 4.0° ± 1.73° (range, 0°-8°) in group II.

Conclusion: The anterolateral tibial tunnel technique is preferred to the anteromedial technique in terms of the objective results; however, clinical results as judged by Lysholm and IKDC scores are not significantly correlated to these results.

Background: New devices for graft fixation in anterior cruciate ligament reconstruction are released to clinical use without clinical follow-up data.

Hypothesis: There is similar clinical outcome after either cross-pin or absorbable interference screw fixation in anterior cruciate ligament reconstruction with hamstring tendons.

Study Design: Randomized controlled clinical trial; Level of evidence, 1.

Methods: A total of 120 patients were randomized into 4 different groups (30 each) for anterior cruciate ligament reconstruction with hamstring tendons: femoral Rigidfix cross-pin and Intrafix tibial expansion sheath with a tapered expansion screw; Rigidfix femoral and BioScrew interference screw tibial fixation, BioScrew femoral and Intrafix tibial fixation; or BioScrew fixation into both tunnels. The evaluation methods were clinical examination, knee scores, and instrumented laxity measurements.

Results: Ten patients were completely lost to follow-up and 3 revisions were done before the 2-year follow-up, leaving 107 of 120 (89%) patients for analysis. No statistically significant differences between the groups were seen 2 years postoperatively, and all but 2 patients in the Rigidfix/Intrafix and Rigidfix/BioScrew groups, respectively, were classified into International Knee Documentation Committee A or B categories. A revision reconstruction was performed before the 2-year follow-up in 2 cases after a high-energy injury caused a rerupture (1 in Rigidfix/Intrafix and 1 in BioScrew/BioScrew groups). In addition, there were 4 nontraumatic failures revised before the 2-year follow-up (2 in Rigidfix/Intrafix and 1 each in Rigidfix/BioScrew and BioScrew/BioScrew).

Conclusion: There were no statistically or clinically relevant differences in the results 2 years postoperatively, and all 4 techniques improved patient performance.

Background: This study was undertaken to prospectively analyze, at a mean 11-year follow-up, the clinical and radiographic outcomes in patients undergoing the authors’ intra-articular anterior cruciate ligament reconstructive procedure with extraarticular augmentation, and to compare these data with those at 5-year follow-up.

Purpose: The clinical and radiographic outcomes in patients undergoing anterior cruciate ligament reconstruction were analyzed at a mean 11-year follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: The authors studied 54 of 60 consecutive high-level sports patients who underwent their anterior cruciate ligament reconstruction technique between 1993 and 1995. The surgical technique uses the hamstring tendons with intact tibial insertions for intra-articular double-stranded reconstruction plus an extra-articular plasty (augmentation) performed with the remnant part of the tendons. Clinical and radiographic evaluations were performed.

Results: After 11 years, the International Knee Documentation Committee score demonstrated good or excellent results (A and B) in 90.7% of patients. Ligament arthrometry using the KT-2000 arthrometer demonstrated that only 2 patients had >5 mm manual maximum side-to-side difference in laxity. The mean Tegner activity score was 4.5, while the mean Lysholm score was 97.3 and the mean subjective score was 90.0%. Radiographic evaluation demonstrated progressive joint narrowing only for the 20 patients having concomitant medial meniscal surgery.

Conclusion: The original technique demonstrates highly satisfactory results. Factors negatively affecting the outcomes are meniscectomy and laxity. In this series, anterior cruciate ligament reconstruction with lateral plasty shows maintenance of knee stability at long-term follow-up. Knee osteoarthritis after anterior cruciate ligament reconstruction with extra-articular tenodesis does not appear to be greater than after anterior cruciate ligament reconstructions without extra-articular augmentation as reported in historical controls.

Background: Recurrent instability after surgical stabilization of the shoulder is uncommon. Although results of open revision stabilization procedures have been reported, only 3 studies have evaluated the outcome of arthroscopic revision surgery.

Purpose: To analyze results of arthroscopic revision anterior shoulder reconstruction at the authors’ institution.

Study Design: Case series; Level of evidence, 4.

Methods: Chart review identified 18 shoulders that had arthroscopic revision anterior shoulder reconstruction at the Southern California Orthopedic Institute between November 4, 1997, and May 14, 2002. Anterior reconstruction of the shoulder was performed using suture anchors and nonabsorbable sutures. In most patients, posterior capsular plication was also performed; in 1 patient, closure of the rotator interval was performed. Sixteen shoulders in 15 patients were examined and 1 patient who required revision surgery was interviewed at a mean of 38 months (range, 24-67 months) after arthroscopic revision anterior shoulder reconstruction. The patient population consisted of 13 men and 3 women whose age at surgery was between 17 and 55 years (mean, 30 years; SD, 11.9 years). Patient satisfaction, the Simple Shoulder Test, and the Rowe scale were used to measure outcome.

Results: Prior surgeries included 10 arthroscopic procedures in 9 shoulders and 10 open procedures in 8 shoulders. In this study group, 1 patient dislocated his shoulder 4 months after arthroscopic revision anterior shoulder reconstruction during an altercation and subsequently underwent a Bristow procedure. Of the remaining cases, none of the 16 shoulders had recurrence of dislocation or subluxation; all 15 patients were satisfied with their revision surgeries. Among this group, the Simple Shoulder Test responses improved from 8.3 yes responses to 11.3 after arthroscopic revision anterior shoulder reconstruction (P < .05). Using the Rowe scale, there were 9 excellent, 4 good, and 3 fair results. Mean Rowe score at follow-up was 83.8 (range, 55-100; SD, 14.7) for these 16 shoulders.

Conclusion: In this series, 94% of shoulders were stable after arthroscopic revision anterior shoulder reconstruction, and there were a high number of good and excellent outcomes. Results suggest arthroscopic revision anterior shoulder reconstruction using suture anchors is a viable treatment alternative for patients with failed anterior shoulder reconstructions.

Background: Although the exact mechanism of action has yet to be elucidated, recent animal studies have demonstrated chondroprotective and anti-inflammatory properties of hyaluronic acid viscosupplementation.

Hypothesis: Intra-articular hyaluronic acid after microfracture improves the quality of the repair leading to a more hyaline-like repair tissue with better defect fill and adjacent area integration.

Study Design: Controlled laboratory study.

Methods: Full-thickness cartilage defects were created in the weightbearing area of the medial femoral condyle in 36 female New Zealand White rabbits. The defects were then treated with surgical microfracture. Eighteen rabbits formed the 3-month cohort and the other 18 formed the 6-month cohort. Within each cohort, 6 rabbits were randomly assigned to receive 3 weekly injections of hyaluronic acid (group A), 5 weekly injections (group B), or control injections of normal saline (group C). At 3 and 6 months postmicrofracture, the animals were sacrificed and the operative knee harvested. Repair tissue was assessed blinded— both grossly, using a modified component of the International Cartilage Repair Society (ICRS) Cartilage Repair Assessment scoring scale, and histologically, using the modified O’Driscoll histological cartilage scoring system. Comparisons were made with respect to gross and histologic findings between treatment groups at each time point. Effects of each treatment type were also evaluated longitudinally by comparing the 3-month results with the 6-month results. Statistical analysis was performed using unpaired Student t tests with significance defined as P < .05.

Results: At 3 months, gross and histologic evaluation of the repair tissue demonstrated that the 3-injection group had significantly better fill of the defects and more normal appearing, hyaline-like tissue than controls (a mean ICRS score of 1.92 vs 1.26; P < .05 and a mean modified O’Driscoll score of 10.3 vs 7.6; P < .02). Specimens treated with 5 weekly injections were not significantly improved compared with controls. At 6 months, the mean gross appearance and histologic scores between the 3 specimen cohorts were not significantly different. However, examination of the entire operative knee demonstrated a significantly greater extent of degenerative changes (synovial inflammation and osteophyte formation) in the control group than in both hyaluronic acid treatment groups (P < .05).

Conclusion: Supplementing the microfracture technique with 3 weekly injections of intra-articular hyaluronic acid had a positive effect on the repair tissue that formed within the chondral defect at the early follow-up time point. This improvement was not found for the 3-injection group at 6 months or for the 5-injection group at either time point. Additionally, hyaluronic acid supplementation had a possible chondroprotective and anti-inflammatory effect, limiting the development of degenerative changes within the knee joint.

Clinical Relevance: The adjunctive use of hyaluronic acid appears to hold promise in the treatment of chondral injuries and warrants further investigation.

Background: Tendon disorders are common problems in sports and are known to be difficult to treat. Only limited information is available concerning treatment of proximal hamstring tendinopathy. To the authors’ knowledge, no histopathologic findings of proximal hamstring tendinosis have been published.

Hypothesis: Surgery (semimembranosus tenotomy and exploration of the sciatic nerve) is an effective treatment for proximal hamstring tendinopathy.

Study Design: Case series; Level of evidence, 4.

Methods: A total of 103 cases of proximal hamstring tendinopathy in athletes (58 men, 32 women; 13 bilateral operations) with surgical treatment were included. The cases were retrospectively analyzed, and a 4-category rating system was used to evaluate the overall result. At the follow-up, the patients were asked about possible symptoms and their return to sports. Biopsy samples from 15 of the operated tendons were taken and analyzed by a pathologist.

Results: The average follow-up was 49 months (range, 12-156 months). The result was evaluated to be excellent in 62 cases, good in 30, fair in 5, and poor in 6. After surgery, 80 of the 90 patients were able to return to the same level of sporting activity as before the onset of the symptoms. This took a mean of 5 months (range, 2-12 months). Typical morphologic findings of tendinosis were found in all biopsy specimens.

Conclusion: Given the good functional outcome and low complication rate, the authors present surgical treatment as a valuable option in proximal hamstring tendinopathy if conservative treatment fails.

Background: In patients with unicompartmental medial knee arthritis, medial opening wedge high tibial osteotomy is used to shift the mechanical weightbearing line laterally to reduce pain and improve function. There have been concerns that opening wedge high tibial osteotomy is associated with a reduction of patellar height and increase in the sagittal posterior tibial slope, both of which can adversely affect the final result.

Hypothesis: A more distal oblique osteotomy at the level of insertion of the patellar tendon should decrease these effects when compared with a horizontal osteotomy made proximal to the patellar tendon insertion.

Study Design: Cohort study; Level of evidence, 3.

Methods: Review of 22 horizontal and 19 oblique high tibial osteotomies with a mean follow-up of 4.2 ± 1.8 years (mean ± SD) was performed. Anatomic tibiofemoral angle, mechanical weightbearing line, medial coronal tibial plateau angle, patellar height (Blackburne and Peel ratio), and sagittal tibial slope were measured.

Results: In both groups, the weightbearing line was equally shifted toward the center of the plateau. In the horizontal group, the Blackburne and Peel ratio decreased from 0.85 ± 0.16 to 0.67 ± 0.12, and the sagittal tibial slope was increased from 7.7° ± 4.6° to 10.7° ± 3.8° (P < .001). In comparison, the oblique group did not show any significant postoperative changes for these 2 parameters. In the oblique group, 2 patients sustained loss of correction and early failure when the osteotomy remained below the metaphyseal flare on the lateral cortex.

Conclusion: The oblique osteotomy group showed more normalized postoperative sagittal tibial slope and patellar height. Caution should be exercised not to osteotomize too distally.

Background: Tears of the gluteus medius tendon at the greater trochanter have been termed “rotator cuff tears of the hip.” Previous reports have described the open repair of these lesions.

Hypothesis: Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term.

Study Design: Case series; Level of evidence, 4.

Methods: Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys.

Results: At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal.

Conclusion: With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

Background: Although a tibial inlay technique for posterior cruciate ligament reconstruction is advantageous, metallic screw fixation of the bone block is required. This may pose problems for future surgery (eg, osteotomies, total knee replacement).

Hypothesis: There is no significant difference in the biomechanical integrity of bone block fixation using stainless steel versus bioabsorbable screw fixation of the tibial inlay graft in posterior cruciate ligament reconstruction.

Study Design: Controlled laboratory study.

Methods: Fourteen human cadaveric knees were randomized to receive either stainless steel or bioabsorbable screw fixation of a bone—patellar tendon—bone graft. Cyclic tensile testing of each construct was performed, followed by a load-to-failure test. Digital video digitization was used to optically determine tendon graft deformation.

Results: Cyclic creep deformation showed no significant difference between the 2 groups ( P = .8). The failure load (stainless steel, 461 ± 231 N; bioabsorbable, 638 ± 492 N; P = .7) and linear stiffness (stainless steel, 116 ± 22 N/mm, bioabsorbable, 106 ± 44 N/mm; P = .6) also showed no significant difference between the 2 groups. Optically measured graft deformation was not significant for distal (P = .7) and midsubstance (P = .8) regions, while proximal deformation was significantly higher for bioabsorbable fixation (P = .02). All samples failed at the tibial insertion site with the tibial bone block fracturing at the screws.

Conclusion: Bioabsorbable screw fixation using a tibial inlay technique does not compromise the strength and stiffness characteristics afforded by metallic fixation. From a biomechanical perspective, bioabsorbable screws are a viable alternative to metal in the context of tibial inlay reconstruction.

Clinical Relevance: Use of bioabsorbable fixation can potentially eliminate future hardware problems after posterior cruciate ligament reconstruction using a tibial inlay technique.

Background: Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up.

Hypothesis: Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate “normal” knee function at long-term follow-up.

Study Design: Case series; Level of evidence, 4.

Methods: Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm 2 (mean, 3.5 cm2). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score.

Results: Arthroscopy for screw removal revealed stable healing in 92% (11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years’ follow-up (range, 3.8-15.8 years), 83% (10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67-100), other symptoms (mean, 81.8; range, 61-96), function in activities of daily living (mean, 93.1; range, 72-100), and sports and recreation function (mean, 74.0; range, 40-100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31-88) was significantly lower (P = .003).

Conclusion: Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.

Background: Recent advances in tennis teaching techniques have been applied in nonprofessional tennis players to develop a more effective play. Hits with enormous amount of top-spin and lower technical and physical training are responsible for most wrist injuries in nonprofessional tennis players.

Hypothesis: The use of different grips (Eastern, Western, semi-Western) determines the pattern of wrist injuries in nonprofessional tennis players.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Between January 2006 and August 2007, we evaluated 370 nonprofessional division III and IV tennis players. The screening consisted of a questionnaire appropriately prepared to investigate wrist injuries. Medical records of players who reported a wrist injury were reviewed. Body mass index, years of practice, weekly hours of training, racket weight, grip (Eastern, Western and semi-Western), kind of strings, injury type, time out of competition, and therapy (medical or surgical) were recorded. Statistical analysis was performed to assess the association of different wrist injuries with these variables.

Results: A total of 320 players reported no injuries in their activity; 50 (13%) reported injuries to the wrist. Medical records of these players were reviewed, and 30 extensor carpi ulnaris lesions, 3 lesions of the extensor tendons, 5 injuries to the flexor carpi radialis, 6 de Quervain diseases, 5 triangular fibrocartilage lesions, and 1 intersection syndrome were found. Ulnar-sided injuries were more frequently associated with Western or semi-Western grips while radial-sided injuries were associated with Eastern grip (χ2 = 20.7; P < .001). Average time out of competition was 69 days; 4 players underwent surgery; the others received medical and rehabilitative therapy. No differences were observed regarding body mass index, years of practice, weekly hours of training, racket weight, and strings.

Conclusion: In nonprofessional tennis players with wrist injuries, different grips of the racket are related to the anatomical site of the lesion: Eastern grip with radial-side injuries and Western or semi-Western with ulnar-side injuries. Knowledge of this relationship may influence training, prevention, diagnosis, and therapy of wrist problems in nonprofessional tennis players.

Background: The National Football League holds an annual combine where individual teams evaluate college football players likely to be drafted for physical skills, review players’ medical history and imaging studies, and perform a physical examination.

Purpose: The purpose of this study was to test the effect of specific diagnoses and surgical procedures on the likelihood of playing and length of career in the league by position.

Study Design: Cohort study; Level of evidence, 3.

Methods: A database for all players reviewed at the annual National Football League Combine by the medical staff of 1 National Football League team from 1987 to 2000 was created, including each player’s orthopaedic rating, diagnoses, surgical procedures, number of games played, and number of seasons played in the National Football League. Athletes were grouped by position as follows: offensive backfield, offensive receiver, offensive line, quarterback, tight end, defensive line, defensive secondary, linebacker, and kicker. The percentage of athletes who played in the National Football League was calculated by position for each specific diagnosis and surgery.

Results: The effect of injury on the likelihood of playing in the league varied by position. Anterior cruciate ligament injury significantly lowered the likelihood of playing in the league for defensive linemen (P = .03) and linebackers (P = .04). Meniscal injury significantly reduced the probability of playing ( P < .05) and length of career (P = .002) for athletes in the defensive secondary. Shoulder instability had a significant effect on playing in the league for offensive (P = .03) and defensive linemen (P = .02), and shortened the length of career for defensive linemen (P = .016). Spondylolisthesis did not significantly reduce the chance of playing in the league for any position, while a history of spondylolysis had a significant effect for running backs (P = .01). Miscellaneous injuries (eg. acromioclavicular joint, knee medial collateral ligament, carpal fractures) had isolated position-specific effects.

Conclusion: The significant injuries and diagnoses appear congruent with the position-specific demands placed on the athletes. This information is useful to physicians and athletic trainers caring for college football athletes as well as those assessing these athletes at the National Football League Combine.

Background: To the authors’ knowledge, no previous published study has focused on management and outcome of repeat revision of anterior cruciate ligament reconstruction in terms of functional result and meniscus and articular cartilage status.

Hypothesis: Repeat revision of anterior cruciate ligament reconstruction improves knee stability, but with inferior results for functional outcome compared with primary anterior cruciate ligament reconstruction. Meniscal tears and subsequent articular cartilage degeneration are more prevalent with successive revisions due to recurrent laxity.

Study Design: Case series; Level of evidence, 4.

Materials and Methods: Between February 2003 and November 2006, a consecutive series of 10 patients with an average age at 30 years (range, 17-48) were operated on for a repeat revision of anterior cruciate ligament reconstruction (2 revisions after a primary reconstruction) with arthroscopic procedures. A clinical and a radiographic evaluation were performed to assess anterior cruciate ligament reconstruction failures, outcome of revisions, and causes of failures. Meniscal tears and articular cartilage lesions were analyzed.

Results: The average follow-up of the second revision was 38 months (range, 12-61). At latest follow-up, final International Knee Documentation Committee assessment was excellent or good in 7 cases. Postoperatively, only 2 patients recovered to the same sports activity level they had before their first anterior cruciate ligament reconstruction. Four had a lower level, and 4 discontinued sports activity. The postoperative average side-to-side KT-1000 arthrometer maximum manual difference was 1.3 ± 1.9 mm. Nine patients had meniscal tears and 7 had articular cartilage lesions. Meniscal tears, meniscectomies, and articular cartilage degeneration increased after the second revision (P = .016, P = .0098, and P = .0197, respectively). Severe articular cartilage degeneration (International Cartilage Repair Society grade III and IV lesions) was found in patients with bad functional outcome (final International Knee Documentation Committee assessment C or D) (P = .0472). Incidence of articular cartilage degeneration was found to be more prevalent in cases of meniscal tears and partial meniscectomy at the same tibiofemoral compartment (P = .0157). Index anterior cruciate ligament reconstruction and first revision failures were caused by recurrent trauma (60% and 70%, respectively) or a surgical technical error with tunnel malpositioning (40% and 10%, respectively).

Conclusion: Outcome of repeat revision of anterior cruciate ligament reconstruction was excellent or good in 70% of the cases, although decreased after the second revision, in relation to the occurrence of meniscal tears and articular cartilage lesions. Meniscal and articular cartilage lesions were more frequent and more severe with recurrent laxity. The cause of failures was mainly recurrent trauma, followed by surgical technical errors.

Background: Accelerated rehabilitation has been advocated after Achilles tendon repair, but it produces significant forces at the repair site.

Hypothesis: Stresses applied to the repaired Achilles tendon simulating postoperative forces may exceed the strength of some repairs.

Study Design: Controlled laboratory study.

Methods: Fifteen Achilles tendons were incised 4 cm proximal to the calcaneal insertion, then were repaired using either a percutaneous, 4-strand Krackow, or an epitendinous augmented 4-strand Krackow technique. Tendons were cyclically loaded to 1000 cycles each at 100, 190, and 369 N. The number of cycles to initial gapping, 5-mm gapping, and total failure were compared using Mann-Whitney U tests with adjustments for multiple comparisons.

Results: Gap resistance was significantly greater for augmented Krackow repairs (2208 cycles to initial gapping) versus nonaugmented repairs (502 cycles, P = .024) and for nonaugmented Krackow repairs versus percutaneous repairs (5 cycles, P = .024). All percutaneous repairs failed during the 100-N cycling (102 ± 135 cycles). All nonaugmented Krackow repairs failed during the 190-N cycles (total cycles to failure: 1268 ± 345). All augmented Krackow repairs were intact (no gapping) after the 190-N cycles. Four failed during 369-N cycling (total cycles to failure, 2017 ± 11), and 1 remained intact for 3000 cycles.

Conclusion: Epitendinous cross-stitch weave augmentation of Achilles tendon repairs significantly increased repair strength and gap resistance.

Clinical Relevance: Epitendinous cross-stitch weave augmentation of Achilles tendon repairs may better allow for early stretching and ambulation after Achilles tendon repair.

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.

Background: Serious injuries due to breakdancing have been presented only as singular case reports to date. So far, there have been no comprehensive studies about injuries in this sport.

Hypothesis: Professional breakdancing might lead to a higher incidence of injuries than amateur training. Wearing safety equipment is correlated with a decreased incidence of injuries and pain.

Study Design: Descriptive epidemiology study.

Methods: The retrospective study surveyed 40 breakdance professionals and 104 amateurs by questionnaire.

Results: There were 1665 injuries and 206 overuse syndromes found in 380 588 hours of training, leading to a loss of 10 970.6 training days. Professionals reported significantly (P < .001) more injuries and overuse syndromes with significantly more injuries of the wrist (P < .001), knee (P < .001), hip/thigh (P = .003), ankle/foot (P = .013), and elbow ( P = .033). No significant differences were found in the time lost per injury and the time lost per overuse syndrome. Pain occurred most frequently in the region of the wrist, spine, shoulder, and ankle. A negative correlation between protective gear and injuries or frequency of pain could not be shown.

Conclusion: Breakdancing must be considered as a potentially high-risk dancing sport. Even with severe injuries, dancers interrupt training only for limited periods of time.

Clinical Relevance: Breakdance injuries and overuse should not be underestimated. Physicians should be aware of the common risks in this highly acrobatic kind of dancing.

Background: Osteochondral lesions are a common sports-related injury for which osteochondral grafting, including mosaicplasty, is an established treatment. Computer navigation has been gaining popularity in orthopaedic surgery to improve accuracy and precision.

Hypothesis: Navigation improves angle and depth matching during harvest and placement of osteochondral grafts compared with conventional freehand open technique.

Study Design: Controlled laboratory study.

Methods: Three cadaveric knees were used. Reference markers were attached to the femur, tibia, and donor/recipient site guides. Fifteen osteochondral grafts were harvested and inserted into recipient sites with computer navigation, and 15 similar grafts were inserted freehand. The angles of graft removal and placement as well as surface congruity (graft depth) were calculated for each surgical group.

Results: The mean harvesting angle at the donor site using navigation was 4° (standard deviation, 2.3°; range, 1°-9°) versus 12° (standard deviation, 5.5°; range, 5°-24°) using freehand technique (P < .0001). The recipient plug removal angle using the navigated technique was 3.3° (standard deviation, 2.1°; range, 0°-9°) versus 10.7° (standard deviation, 4.9°; range, 2°-17°) in freehand (P < .0001). The mean navigated recipient plug placement angle was 3.6° (standard deviation, 2.0°; range, 1°-9°) versus 10.6° (standard deviation, 4.4°; range, 3°-17°) with freehand technique (P = .0001). The mean height of plug protrusion under navigation was 0.3 mm (standard deviation, 0.2 mm; range, 0-0.6 mm) versus 0.5 mm (standard deviation, 0.3 mm; range, 0.2-1.1 mm) using a freehand technique (P = .0034).

Conclusion: Significantly greater accuracy and precision were observed in harvesting and placement of the osteochondral grafts in the navigated procedures. Clinical studies are needed to establish a benefit in vivo.

Clinical Relevance: Improvement in the osteochondral harvest and placement is desirable to optimize clinical outcomes. Navigation shows great potential to improve both harvest and placement precision and accuracy, thus optimizing ultimate surface congruity.

Background: Knee instability after anterior cruciate ligament reconstruction rarely manifests with activities of daily living, but it may occur in high-level sports performance, resulting in secondary injuries. Faced with these circumstances, sports orthopaedists have continued to improve on the results obtained with surgical techniques for treating knee joint injuries.

Hypothesis: Transverse tibial fixation with bioabsorbable cross pins is a valid technique for anterior cruciate ligament reconstruction with both the patellar tendon (bone—patellar tendon—bone) and semitendinosus and gracilis tendon.

Study Design: Cohort study; Level of evidence, 3.

Methods: The study population was 120 patients operated on by the same surgeon and subdivided into 4 subgroups of 30 subjects each. Patients were chosen and assigned to each group consecutively. Patients in group 1 (bone—patellar tendon—bone) were implanted with bioabsorbable interference screws, group 2 (bone—patellar tendon—bone) received 2 bioabsorbable cross pins, group 3 (semitendinosus and gracilis tendon) received a bioabsorbable interference screw, and group 4 (semitendinosus and gracilis tendon) received 2 bioabsorbable cross pins. Patients were assessed at 5-year follow-up for International Knee Documentation Committee Knee Ligament Standard Evaluation Form, Lysholm Knee Scoring Scale, Lysholm-Tegner Activity Scale, and KT-1000 arthrometer testing.

Results: The results at 5 years after anterior cruciate ligament reconstruction were similar across all 4 groups. No significant differences have been observed between groups.

Conclusion: The results suggest that transverse tibial fixation with bioabsorbable cross pins is a safe and reliable procedure, yielding clinical results that are comparable with those of the more widely used bioabsorbable interference screws.

Background: Anterior cruciate ligament injury is prevalent in activities involving large and rapid landing impact loads.

Hypothesis: Inhibition of anterior tibial translation/axial tibial rotation forestalls the ligament from failing at the range of peak compressive load that can induce ligament failure when both factors are unrestrained.

Study Design: Controlled laboratory study.

Methods: Sixteen porcine knee specimens were mounted onto a material testing system at 70° of flexion and were divided into 4 test groups: impact compression without restraint (IC), anterior tibial translation restraint (ICA), axial tibial rotation restraint (ICR), and combination of both restraints (ICC). Compression was successively repeated with increasing actuator displacement until ligament failure or visible bone fracture was observed. During compression, rotational and translational joint data were obtained using a motion capture system.

Results: The IC group underwent ligament failure via femoral avulsion; the peak compressive force during failure ranged from 1.4 to 4.0 kN. The ICA, ICR, and ICC test groups developed visible bone fracture with the ligament intact; the peak compressive force during fracture ranged from 2.2 to 6.9 kN. Posterior femoral displacement and axial tibial rotation for the ICA and ICR groups, respectively, were significantly lower relative to the IC group (P < .05). Both factors were substantially reduced in the ICC group, but peak compressive force was higher compared with the IC group (P < .05).

Conclusion: Substantial inhibition of these factors in an impact setup, which can induce ligament failure with the factors unrestrained, was able to prevent failure.

Clinical Relevance: Adequate inhibition of anterior tibial translation and axial tibial rotation by knee bracing during injurious impact is necessary for effective ligament protection.

Background: Primary and secondary lesions of the tendon of the long head of the biceps brachii are common, with no clear consensus about their optimal management.

Hypothesis: There is no difference in outcomes of tenotomy and tenodesis for lesions of the tendon of the long head of the biceps brachii.

Study Design: We performed a comprehensive quantitative review of the published English-language literature comparing the outcomes of tenotony and tenodesis for lesions of the tendon of the long head of the biceps brachii.

Methods: All relevant articles in peer-reviewed journals were retrieved, and each article was scored using the Coleman Methodology Score, a highly repeatable methodology score, by 2 independent reviewers.

Results: Scores were predominantly low for quality of the studies, with patient number and validated outcome measures being the weakest areas.

Conclusion: There is a lack of quality evidence to advocate one technique over the other. We emphasize the need for appropriately powered, well-conducted, randomized, controlled trials comparing the outcomes of these 2 procedures. There is little difference in the outcome of tenotomy compared with tenodesis. Tenotomy is easy and quick, with less need for postoperative rehabilitation. We therefore suggest that biceps tenotomy be the preferred method.

Clinical Relevance: Biceps pathologic lesions are common. There is no evidence base for their most appropriate management.