The American Journal of Sports Medicine

Background: Double-bundle ACL reconstruction popularity is increasing with the aim to reproduce native ACL anatomy and improve ACL reconstruction outcome. However, to date, only a few randomized clinical studies have been published.

Purpose: The aim of this study was to prospectively compare the clinical results of single- and double-bundle ACL reconstruction.

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

Methods: Seventy patients with a chronic unilateral ACL rupture who underwent arthroscopically assisted ACL reconstruction using a hamstring graft were randomized to receive a single- (SB) or double-bundle (DB) reconstruction. Both groups were comparable with regard to preoperative data. A double-incision surgical technique was adopted in both groups. The graft was fixed by looping the hamstring tendons around a bony (DB) or a metallic (SB) bridge on the tibial side and with interference screws reinforced with a staple on the femur. The same rehabilitation protocol was adopted. Outcome assessment was performed by a blinded, independent observer using the visual analog scale (VAS) score, the new International Knee Documentation Committee (IKDC) form, the Knee Injury and Osteoarthritis Outcome Score (KOOS), and KT-1000 arthrometer evaluation.

Results: All the patients reached a minimum follow-up of 2 years. No differences between the 2 groups were observed in terms of KOOS and IKDC subjective score. A statistically significant difference in favor of the DB group was found with the VAS ( P < .03). The objective IKDC final scores showed statistically significantly more “normal knees” in the DB group than in the SB group ( P = .03). There was 1 stability failure in the DB group and 3 in the SB group. The KT-1000 arthrometer data showed a statistically significant decrease in the average anterior tibial translation in the DB group (1.2 mm DB vs 2.1 mm SB; P < .03). The incidence of a residual pivot-shift glide was 14% in DB and 26% in SB (P = .08).

Conclusion: In the 2-year minimum follow-up, DB ACL reconstructions showed better VAS, anterior knee laxity, and final objective IKDC scores than SB. However, longer follow-up and accurate instrumented in vivo rotational stability assessment are needed.

Background: Retears of the rotator cuff are not uncommon after arthroscopic and mini-open rotator cuff repairs. In most studies, the clinical results in patients with persistent defects demonstrated significantly less pain and better function and strength compared with their preoperative state at an early follow-up.

Hypothesis: The clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up.

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

Methods: This study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L’Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound.

Results: At the 7.9 year follow-up the average scores were 95 (American Shoulder and Elbow Surgeons), 95 (L’Insalata), 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (P < .001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm2 to 467 mm2 (P < .001). Finally, the size of the defect increased in all patients, and no defects healed structurally.

Conclusion: At an average of 7.9 years, patients with recurrent defects after rotator cuff repair still had an improvement in terms of pain, function, and satisfaction. However, the rotator cuff defect significantly increased in size, and there was a progression of strength deficits. These findings suggest that patients with recurrent defects can remain asymptomatic over the long term but will predictably lose strength in the involved extremity. Furthermore, the study demonstrated that defects after rotator cuff repair increase in size but often remain asymptomatic.

Background: Although a number of reports have documented outcomes after open revision rotator cuff repair, there are few studies reporting results after arthroscopic revision.

Hypothesis: Arthroscopic repair of failed rotator cuff results in significant improvement in shoulder functional outcome and pain relief.

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

Methods: Multiple variables including demographic data, the number of prior ipsilateral shoulder surgeries, and tear size were recorded from chart review. An independent examiner then measured shoulder strength, range of motion, and shoulder functional outcome scores including American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and visual analog pain scale. Paired t tests were performed to compare preoperative and postoperative measures. Additionally, contingency table analysis was performed to identify prognostic factors for failure of repair requiring further surgery and American Shoulder and Elbow Surgeons score less than 50.

Results: Fifty-four patients (88.5%) were available for follow-up evaluation with a mean age of 54.9 ± 10.1 years (range, 22.7-82.5 years) and a mean follow-up of 31.1 ± 11.9 months. American Shoulder and Elbow Surgeons scores improved from 43.8 ± 5.7 (mean ± 95% confidence interval) before revision to 68.1 ± 7.2 at final follow-up (P = .0039). The Simple Shoulder Test improved significantly from 3.56 ± 0.8 before surgery to 7.5 ± 1.1 at most recent follow-up (P < .0001). Visual analog pain scale scores improved from 5.17 ± 0.8 to 2.75 ± 0.8 ( P = .03), and forward elevation increased from 121.0° ± 12.3° to 136° ± 11.8° postoperatively (P = .025). Greater than 1 prior shoulder surgery was associated with cases that required additional surgery (P = .031). Female gender (P = .007) and preoperative abduction less than 90° (P = .009) were associated with American Shoulder and Elbow Surgeons scores less than 50.

Conclusion: Arthroscopic revision rotator cuff repair may be a reasonable treatment option even after prior open repairs and provides both improved pain relief and shoulder function. Nonetheless, results are not completely optimal. Female patients and those who have undergone more than 1 ipsilateral shoulder surgery are at increased risk for poorer results.

Background: Computer-based assessment programs are commonly used to document baseline cognitive performance for comparison with postconcussion testing. There are currently no guidelines for how often baseline assessments should be updated, and no data documenting the test-retest stability of baseline measures over relevant time periods.

Purpose: To establish long-term test-retest reliability of baseline assessments using ImPACT, and to compare various statistical methods for establishing test-retest reliability.

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

Methods: Participants were 95 collegiate varsity athletes completing baseline cognitive testing at 2 time periods, approximately 2 years apart. No participant sustained a concussion between assessments. All athletes completed the ImPACT test battery; dependent measures were the composite scores and total symptom scale score.

Results: Intraclass correlation coefficient estimates for visual memory (.65), processing speed (.74), and reaction time (.68) composite scores reflected stability over the 2-year period, with greater variability in verbal memory (.46) and symptom scale (.43) scores. Using reliable change indices and regression-based methods, only a small percentage of participants’ scores showed “reliable” or “significant” change on the composite scores (0%-6%), or symptom scale scores (5%-10%).

Conclusion: The current results suggest that college athletes’ cognitive performance at baseline remains considerably stable over a 2-year period. These data help establish the effects of longer, clinically pragmatic testing intervals on test-retest reliability.

Clinical Implications: The current results suggest that stretching the time between baseline assessments from 1 to 2 years may have little effect on the clinical management of concussions in collegiate athletes. These results should not be generalized to collegiate football players, who were not included in this sample. Youth athletes (high school and younger) should continue to receive annually updated baseline assessments until prospective study of the stability of baseline assessments for this younger age group can be completed.

Background: The geometry of the tibial plateau has been largely ignored as a source of possible risk factors for anterior cruciate ligament injury. Discovering the anterior cruciate ligament injury risk factors associated with the tibial plateau may lead to delineation of the existing sex-based disparity in anterior cruciate ligament injuries and help develop strategies for the prevention of anterior cruciate ligament injuries regardless of gender.

Hypothesis: Individuals with a shallower medial tibial depth of concavity, while having increased posteriorly directed slope of their tibial plateau, are at increased risk of suffering an anterior cruciate ligament injury compared with those with decreased posterior slope and increased medial tibial depth. Furthermore, these relationships are different between men and women.

Study Design: Case-control study (prevalence); Level of evidence, 3.

Methods: The medial, lateral, and coronal tibial plateau slopes as well as the medial tibial depth of concavity in 55 uninjured controls (33 women and 22 men) and 49 anterior cruciate ligament—injured cases (27 women and 22 men) were measured using magnetic resonance images. First, a preliminary t test was performed to establish any existing differences between groups. Next, a logistic regression model was developed to determine the probability of anterior cruciate ligament injury in an individual based on the measured covariates.

Results: The female anterior cruciate ligament—injured cases had increased lateral tibial slope (P = .03) and shallower medial tibial depth (P = .0003) compared with the uninjured controls, while male cases had increased lateral and medial tibial slope (P = .02) and shallower medial tibial depth (P = .0004) compared with controls. The logistic regression analysis and odds ratio estimates showed that medial tibial depth is an important risk factor (odds ratio = 3.03 per 1 mm decrease in its value), followed by lateral tibial slope (odds ratio = 1.17 per 1° increase in its value) in all participants. The medial tibial slope (odds ratio = 1.18 per 1° increase in its value) was a risk factor only in men.

Conclusion: A combination of increased posterior-directed tibial plateau slope and shallow medial tibial plateau depth could be a major risk factor in anterior cruciate ligament injury susceptibility regardless of gender. Different injury risk models may be needed for men and women as other key risk factors are identified.

Background: Two previous studies have examined the association between an increased posterior tibial slope and anterior cruciate ligament (ACL) injuries as measured on plain radiographs. The study results were contradictory, with 1 reporting a statistical difference and the other showing no association.

Purpose: To determine if there is a difference in posterior tibial slope angle between patients with a history of noncontact ACL injury and a control group with no history of ACL injury. A secondary objective was to examine differences in tibial slope angle between male and female subjects within each group.

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

Methods: We identified all noncontact ACL injuries that were treated operatively at the United States Military Academy, West Point, New York, from 2004 to 2007. We digitally measured the posterior tibial slope from plain film radiographs of 140 noncontact ACL injuries, stratified them by sex, and compared them with a control cohort of 179 patients and radiographs.

Results: Subjects in the noncontact ACL group had significantly greater slope angles (9.39° ± 2.58°) than did control subjects (8.50° ± 2.67°) (P = .003). The trend toward greater tibial slope angles in the noncontact ACL group was also observed when each sex was examined independently; however, the difference was only statistically significant for the female subjects between the injury and control groups (9.8° ± 2.6° vs 8.20° ± 2.4°) (P = .002).

Conclusion: Despite the identification of an increased posterior tibial slope as a possible risk factor for women, more research that combines the multifactorial nature of an ACL injury must be performed.

Background: Despite improvement in treatment for articular cartilage lesions, prolonged recovery still precludes early return to competitive sports. The challenge of postoperative rehabilitation is to optimize return to preinjury activities without jeopardizing the graft.

Hypothesis: Intensive rehabilitation after second-generation arthroscopic autologous cartilage implantation (Hyalograft C) facilitates graft maturation and safely allows for early return to competition without jeopardizing clinical outcome at longer follow-up.

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

Methods: The outcome of 31 competitive male athletes with International Cartilage Repair Society grade III-IV cartilaginous lesions of the medial or lateral femoral condyle or trochlea were evaluated at 1-, 2-, and 5-year follow-up. The athletic cohort was compared with a similar control cohort of 34 nonathletic patients who were treated with autologous chondrocyte implantation. The athletic cohort followed a 4-phase intensive rehabilitation protocol. Eleven of the patients in this cohort were also treated with an isokinetic exercise program and on-field rehabilitation. The patients in the control cohort completed only phase 1 of rehabilitation.

Results: When comparing the 2 groups, a greater improvement in the group of athletes was achieved at 5-year follow-up (P = .037) in the self-assessment of quality of life and International Knee Documentation Committee subjective evaluation at 12 months and at 5 years of follow-up (P = .001 and P = .002, respectively). When analyzing the return to sports activity, 80.6% of the athletes returned to their previous activity level in 12.4 ± 1.6 months; athletes treated with the on-field rehabilitation and isokinetic exercise program had faster recovery and an even earlier return to competition (10.6 ± 2.0 months).

Conclusion: For optimal results, autologous chondrocyte implantation rehabilitation should not only follow but also facilitate the process of graft maturation. Intensive rehabilitation may safely allow a faster return to competition and also influence positively the clinical outcome at medium-term follow-up.

Background: Intact articular cartilage tissue is used clinically in the form of osteochondral allografts and experimentally as explants in modeling the physiologic behavior of chondrocytes in their native extracellular matrix. Long-term maintenance of allograft tissue is challenging.

Hypothesis: By carefully modulating the preservation environment, it may be possible to preserve osteochondral allograft tissue over the long term while maintaining its original mechanical and biochemical properties.

Study Design: Controlled laboratory study.

Methods: In this study, juvenile bovine, mature bovine, and canine cartilage explants were cultured in chemically defined media with or without supplementation of dexamethasone for up to 4 weeks.

Results: The mechanical properties and biochemical content of juvenile bovine explants cultured in the presence of dexamethasone were significantly enhanced after 2 weeks in culture and remained stable with sustained cell viability thereafter. In contrast, the mechanical properties and biochemical content of juvenile bovine explants cultured in the absence of the dexamethasone significantly decreased after 2 weeks of culture. The mechanical and biochemical content of mature bovine and canine explants were not significantly affected by the presence of dexamethasone and maintained initial (day 0) mechanical and biochemical properties throughout the entire culture period with or without supplementation of dexamethasone.

Conclusion: These results suggest that juvenile and mature cartilage explants respond differently to dexamethasone. The functional properties of juvenile cartilage explants can be maintained in vitro through the addition of dexamethasone to culture media. Functional properties of mature cartilage can be preserved for at least 4 weeks in culture regardless of the presence of dexamethasone.

Clinical Relevance: Biochemical and biomechanical properties of osteochondral allograft tissue may be enhanced by the addition of dexamethasone to culture media. These findings may translate to longer shelf life of preserved osteochondral allograft transplantation tissue and increased clinical availability of grafts.

Background: Isolated high-grade tears of the lateral collateral ligament (LCL) of the knee are rare, as most injuries are part of a broader pattern of damage to the posterolateral corner. Limited data exist in the literature about the ideal management of isolated LCL injuries, especially in elite-level athletes.

Hypothesis: Operative and nonoperative treatment of MRI-documented isolated grade III LCL injury can produce equal results in terms of return to play in the National Football League (NFL).

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

Methods: The NFL Injury Surveillance System was used to identify all players with lateral ligament injuries of the knee from 1994 to 2004. In addition, the medical staffs of all NFL clubs were surveyed about injuries during the same period. Nine players with MRI-documented isolated grade III LCL injuries were identified through this process. The medical staff for each respective player then completed a data questionnaire. Statistics were analyzed using 1-way analysis of variance.

Results: Four players underwent direct surgical repair of their injuries; they missed an average of 14.5 weeks of play and did not return within the same season. Five players were managed nonoperatively and missed an average of 2.0 weeks (P = .0001). Four of the 5 players in the nonoperative group returned within the same season at an average of 10 days; 1 missed the rest of the season. All 9 players were able to return to play the following season, and played for an average total of 2.8 (operative) and 4.4 (nonoperative) additional seasons (P = .253).

Conclusion: Nonoperative management of MRI-documented isolated grade III lateral collateral ligament injuries in NFL athletes results in more rapid return to play without subjecting the player to the risks of surgery, while achieving an equal likelihood of return to play at the professional level.

Background: In the past 20 years, there has been an increase in the incidence of upper extremity tendinous injuries, especially in sports including strong physical activity, such as in weight lifting, as well as with the concurrent use of anabolic steroids. Today, there are more than 200 cases describing rupture of the pectoralis major muscle in athletes.

Hypothesis: Surgical treatment will have a better outcome than nonsurgical treatment in total rupture of the pectoralis major muscle in athletes.

Study Design: Cohort study; Level of evidence, 2.

Methods: Twenty athletes with pectoralis major muscle (PMM) rupture were studied; 10 had surgical treatment, and the other 10 were treated nonoperatively. The mean age was 32.27 years (range, 27-47 years); all of them were men. The average follow-up was 36 months (range, 48-72 months). Injuries were diagnosed by history, physical examination, and subsidiary tests. Functional evaluation and isokinetic evaluation were performed on all 20 patients.

Results: The clinical evaluation revealed 70% (n = 7) excellent, 20% good (n = 2), and 10% poor (n = 1) outcomes for the cases treated with surgery and 20% good (n = 2), 50% fair (n = 5), and 40% poor (n = 4) outcomes for the cases treated nonsurgically. The isokinetic evaluation at 60-deg/s speed showed a decrease in strength of 53.8% in the nonsurgical group and 13.7% for the surgical group.

Conclusion: Total PMM rupture in athletes showed a better functional result after surgical treatment than after nonsurgical treatment.

Background: Hip injuries are common among professional hockey players in the National Hockey League (NHL).

Hypothesis: Professional hockey players will return to a high level of function and ice hockey after arthroscopic labral repair and treatment of femoroacetabular impingement.

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

Methods: Twenty-eight professional hockey players (NHL) were unable to perform at the professional level due to unremitting and debilitating hip pain. Players underwent arthroscopic labral repair and were treated for femoroacetabular impingement from March 2005 to December 2007. Players who had bilateral hip symptoms were excluded. Athletes completed the Modified Harris Hip Score preoperatively and postoperatively and also completed a patient satisfaction questionnaire postoperatively. Return to sport was defined as the player resuming skating for training or participation in the sport of ice hockey.

Results: The average age at the time of surgery was 27 years (range, 18-37). There were 11 left hips and 17 right hips. Player positions included 9 defensemen, 12 offensive players, and 7 goaltenders. All players had labral lesions that required repair. In addition, all patients had evidence of femoroacetabular impingement at the time of surgery. The average time to return to skating/hockey drills was 3.4 months. The average time to follow-up was 24 months (range, 12-42). The Modified Harris Hip Score improved from 70 (range, 57-100) preoperatively to an average of 95 (range, 74-100) at follow-up. The median patient satisfaction was 10 (range, 5-10). Two players had reinjury and required additional hip arthroscopy.

Conclusion: Treatment of femoroacetabular impingement and labral lesions in professional hockey players resulted in successful outcomes, with high patient satisfaction and prompt return to sport.

Background: Osteochondral autografts and allografts require mechanical force for proper graft placement into the defect site; however, impaction compromises the tissue. This study aimed to determine the effect of impaction force and number of hits to seat the graft on cartilage integrity.

Hypothesis: Under constant impulse conditions, higher impaction load magnitudes are more detrimental to cell viability, matrix integrity, and collagen network organization and will result in proteoglycan loss and nitric oxide release.

Study Design: Controlled laboratory study.

Methods: Osteochondral explants, harvested from fresh bovine trochleae, were exposed to a series of consistent impact loads delivered by a pneumatically driven device. Each plug received the same overall impulse of 7 Ns, reflecting the mean of 23 clinically inserted plugs. Impaction loads of 37.5 N, 75 N, 150 N, and 300 N were matched with 74, 37, 21, and 11 hits, respectively. After impaction, the plugs were harvested, and cartilage was analyzed for cell viability, histology by safranin-O and picrosirius red staining, and release of sulfated glycosaminoglycans (GAGs) and nitric oxide. Data were compared with nonimpacted controls.

Results: Impacted plugs had significantly lower cell viability than nonimpacted plugs. A dose-response relationship in loss of cell viability with respect to load magnitude was seen immediately and after 4 days but lost after 8 days. Histological analysis revealed intact cartilage surface in all samples (loaded or control), with loaded samples showing alterations in birefringence. While the sulfated GAG release was similar across varying impaction loads, release of nitric oxide increased with increasing impaction magnitudes and time.

Conclusion: Impaction loading parameters have a direct effect on the time course of the viability of the cartilage in the graft tissue.

Clinical Relevance: Optimal loading parameters for surgical impaction of osteochondral grafts are those with lower load magnitudes and a greater number of hits to ensure proper fit.

Background: Glenohumeral internal rotation deficit (GIRD) and posterior shoulder tightness have been linked to internal impingement.

Purpose: To determine if improvements in GIRD and/or decreased posterior shoulder tightness are associated with a resolution of symptoms.

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

Methods: Passive internal rotation and external rotation (ER) range of motion (ROM) at 90° of shoulder abduction and posterior shoulder tightness (cross-chest adduction in side lying) were assessed in 22 patients with internal impingement (11 men, 11 women; age 41 ± 13 years). Treatment involved stretching and mobilization of the posterior shoulder. The Simple Shoulder Test (SST) was administered on initial evaluation and discharge. Changes in GIRD, ER ROM, and posterior shoulder tightness were compared between patients with complete resolution of symptoms versus patients with residual symptoms using independent t tests.

Results: Patients had significant GIRD (35°), loss of ER ROM (23°), and posterior shoulder tightness (35°) on initial evaluation (all P < .01). Physical therapy (7 ± 2 weeks; range, 3-12 weeks) improved GIRD (26° ± 14°; P < .01), ER ROM loss (14° ± 20°), and posterior shoulder tightness (27° ±19°). The SST improved from 5 ± 3 to 11 ± 1 (P < .01). A greater improvement in posterior shoulder tightness was seen in patients with complete resolution of symptoms (n = 12) compared with patients with residual symptoms (35° vs 18°; P < .05). Improvements in GIRD and ER ROM loss were not different between groups (GIRD, 25° vs 28°, P = .57; ER ROM, 14° vs 15°, P = .84).

Conclusion: Resolution of symptoms after physical therapy treatment for internal impingement was related to correction of posterior shoulder tightness but not correction of GIRD.

Background: Posterior ankle impingement syndrome (PAIS) was first described in ballet dancers but is increasingly being diagnosed in other sports. Operative treatment may be indicated when nonoperative measures have failed. Traditionally, operative treatment has involved an open approach; more recently, posterior ankle arthroscopy has been employed.

Purpose: This study was conducted to describe the factors that influence return to play in professional athletes after posterior ankle arthroscopy for posterior ankle impingement syndrome.

Study Design: Case series; Level of evidence 4.

Methods: A consecutive series of 28 elite professional soccer players who had clinically and radiologically diagnosed posterior ankle impingement syndrome that failed to respond to nonoperative treatment underwent posterior ankle arthroscopy for bony or soft tissue posterior ankle impingement syndrome over 5 years.

Results: Of the 28 players, 27 were available for follow-up. Five had a diagnosis of soft tissue impingement and underwent debridement with flexor hallucis longus release, 13 had a symptomatic os trigonum that was excised arthroscopically, and 9 had removal of a bony avulsion fragment from the posterior ankle ligament complex. The mean length of time to return to training postoperatively was 34 days and return to playing was 41 days (range, 29-72 days). The duration of symptoms before surgery and excision of bony impingement were significantly correlated with the time to return to training and playing. There were no major complications and no reoperations at an average of 23 months of follow-up (range, 15-49 months).

Conclusion: Posterior ankle arthroscopy is safe and effective in the treatment of posterior ankle impingement syndrome in the elite soccer player, with return to training expected at an average of 5 weeks.

Background: Medial tibial stress syndrome (MTSS) is a pain syndrome along the tibial origin of the tibialis posterior or soleus muscle. Extracorporeal shock wave therapy (SWT) is effective in numerous types of insertional pain syndromes.

Hypothesis: Shock wave therapy is an effective treatment for chronic MTSS.

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

Methods: Forty-seven consecutive subjects with chronic recalcitrant MTSS underwent a standardized home training program, and received repetitive low-energy radial SWT (2000 shocks; 2.5 bars of pressure, which is equal to 0.1 mJ/mm2; total energy flux density, 200 mJ/mm2; no local anesthesia) (treatment group). Forty-seven subjects with chronic recalcitrant MTSS were not treated with SWT, but underwent a standardized home training program only (control group). Evaluation was by change in numeric rating scale. Degree of recovery was measured on a 6-point Likert scale (subjects with a rating of completely recovered or much improved were rated as treatment success).

Results: One month, 4 months, and 15 months from baseline, success rates for the control and treatment groups according to the Likert scale were 13% and 30% (P < .001), 30% and 64% (P < .001), and 37% and 76% (P < .001), respectively. One month, 4 months, and 15 months from baseline, the mean numeric rating scale for the control and treatment groups were 7.3 and 5.8 (P < .001), 6.9 and 3.8 (P < .001), and 5.3 and 2.7 (P < .001), respectively. At 15 months from baseline, 40 of the 47 subjects in the treatment group had been able to return to their preferred sport at their preinjury level, as had 22 of the 47 control subjects.

Conclusion: Radial SWT as applied was an effective treatment for MTSS.

Background: High use of medication and nutritional supplements has been reported in several sports.

Purpose: To document the use of prescribed medication and nutritional supplements in female and male junior, youth, and adult track and field athletes depending on their sports discipline.

Study Design: Descriptive epidemiology study.

Methods: Analysis of 3 887 doping control forms undertaken during 12 International Association of Athletics Federations World Championships and 1 out-of-competitions season in track and field.

Results: There were 6 523 nutritional supplements (1.7 per athlete) and 3 237 medications (0.8 per athlete) reported. Nonsteroidal anti-inflammatory drugs (NSAIDs; 0.27 per athlete, n = 884), respiratory drugs (0.21 per athlete, n = 682), and alternative analgesics (0.13, n = 423) were used most frequently. Medication use increased with age (0.33 to 0.87 per athlete) and decreased with increasing duration of the event (from sprints to endurance events; 1.0 to 0.63 per athlete). African and Asian track and field athletes reported using significantly fewer supplements (0.85 vs 1.93 per athlete) and medications (0.41 vs 0.96 per athlete) than athletes from other continents. The final ranking in the championships was unrelated to the quantity of reported medications or supplements taken. Compared with middle-distance and long-distance runners, athletes in power and sprint disciplines reported using more NSAIDs, creatine, and amino acids, and fewer antimicrobial agents.

Conclusion: The use of NSAIDs in track and field is less than that reported for team-sport events. However, nutritional supplements are used more than twice as often as they are in soccer and other multisport events; this inadvertently increases the risk of positive results of doping tests.

Clinical Relevance: It is essential that an evidence-based approach to the prescribing of medication and nutritional supplements is adopted to protect the athletes’ health and prevent them from testing positive in doping controls.

Background: Previously published reports present a variety of nonoperative and operative treatments for a persistent olecranon physis. However, the radiographic indication for the operative treatment is not clear.

Hypothesis: Our radiographic classification of persistent olecranon physis is helpful in formulating treatment decisions. Study Design: Cohort study; Level of evidence, 3.

Methods: Sixteen male baseball players with persistent olecranon physis were retrospectively evaluated. The mean age at first presentation was 14.7 years (range, 12-17 years). The lesion was classified into 2 stages based on radiographic appearance. Stage I demonstrated widening of the olecranon epiphyseal plate when compared with the contralateral elbow on the lateral view. Sclerotic change indicated stage II. All patients underwent nonoperative treatment for at least 3 months. Follow-up radiographs were taken at 1-month intervals. Operative treatment was provided to the patients whose condition had failed to improve after nonoperative treatment.

Results: Of the 16 patients, 12 had stage I lesions and 4 had stage II lesions. Nonoperative management produced healing in 91.7% of patients with stage I lesions and none of the patients with stage II lesions.

Conclusion: Our radiographic classification of persistent olecranon physis is useful for treatment decision making. In addition, our results demonstrated that sclerotic change is a high predictive indicator of the need for operative treatment.

Background: Recently, there is increasing interest in different arthroscopic biceps tenodesis techniques. However, little data have been published about the biomechanical properties of soft tissue tenodesis.

Purpose: This study was undertaken to evaluate the biomechanical properties of 2 different arthroscopic biceps tenodeses: the percutaneous intra-articular transtendon (PITT) technique and the suture-anchor technique.

Study Design: Controlled laboratory study.

Methods: Fifteen fresh-frozen cadaveric specimens were randomly allocated to the 2 different biceps tenodesis techniques. The humerus with biceps tenodesis was mounted on a materials testing machine to perform a load to failure test. The structural properties including ultimate load (N) and stiffness (N/mm) were derived from the load-displacement curve. The mode of failure was also recorded. Ultimate load and stiffness were compared with the parametric Student t test.

Results: Both repairs showed typical load-displacement curves followed by a constant increase in load and displacement until failure occurred. Suture-anchor and PITT techniques had ultimate loads of 175.4 ± 40.4 N and 142.7 ± 30.9 N ( P = .10) and stiffness of 15.9 ± 8.4 N/mm and 13.3 ± 3 N/mm (P = .36), respectively, with no significant differences between them. All of the surgical constructs failed in the tendon site by pulling out with the sutures through the substance of the tendon.

Conclusion: The suture-anchor and PITT techniques exhibited satisfactory initial strength with no statistical difference between the 2 groups. These findings, along with the consistent pullout of the suture through the tendon during failure, suggest that the most important factor for initial strength is not the attachment site but the quality of the biceps tendon.

Clinical Relevance: The quality of the tendon should be taken into account when deciding the surgical technique and the rehabilitation program. The PITT technique has the benefit of avoiding hardware complications and cost.

Background: Lateral ulnar collateral ligament (LUCL) reconstruction using a tendon graft is a well-accepted procedure used in the treatment of posterolateral rotatory instability. However, unlike most other ligament reconstructions, anatomical guidelines for the isometric points for tunnel placement of LUCL reconstruction have not been defined.

Purpose: To determine if isometric points exist for tunnel placement for LUCL reconstruction and, if so, to determine their anatomical guidelines.

Study Design: Controlled laboratory study.

Methods: A series of 1.8-mm drill holes was placed in potential ligament reconstruction origin and insertion sites in 13 normal cadaveric elbows along the supinator crest of the ulna and in the lateral epicondyle of the humerus. The prepared specimens were mounted in a plastic test frame with electromagnetic sensors inserted into the drill holes. The distance between each potential pair of insertion sites was measured throughout the arc of elbow motion to determine the most isometric combinations of humeral and ulnar insertion sites.

Results: We could not locate truly isometric points for tunnel placement for LUCL reconstruction. For LUCL reconstruction, the position of most isometric tunnel placement was on the supinator crest 16 to 20 mm distal to the proximal margin of the radial head for the proximal wall of the ulnar tunnel, and between the 3:00 and 4:30 o’clock positions on the lateral epicondyle for the posterior/distal wall of the humeral tunnel.

Conclusion: Similar to the native LUCL, there is no truly isometric location for LUCL tendon graft reconstruction tunnels. Also similar to the native LUCL, the distance between the optimal tunnel position decreases in elbow extension and often increases in elbow flexion.

Clinical Relevance: The most isometric position for LUCL reconstruction tunnel placement was defined using anatomical references.

Background: Further knee surgery after proximal tibial osteotomies has been reported to have a more difficult surgical exposure due to decreased patellar height after the osteotomy. Although a decrease in patellar height has been reported for closing-wedge proximal tibial osteotomies, it has not been widely verified among opening-wedge procedures.

Hypothesis: A significant decrease in patellar height would result after opening-wedge proximal tibial osteotomies and a postoperative change in tibial slope would also result, depending on the medial tibial plate position, which would affect patellar height. Study Design: Case series; Level of evidence, 4.

Methods: Patients (n = 129) who underwent opening-wedge proximal tibial osteotomies (n = 130) were prospectively followed. Patellar height was calculated for preoperative lateral knee radiographs, and postoperatively at 2 weeks and 3 and 6 months. The Insall-Salvati, Blackburne-Peel, and Caton-Deschamps indices and a modified Miura and Kawamura index were used to calculate patellar height. Posterior tibial slope was also calculated for preoperative and 6-month postoperative knees.

Results: Coronal plane alignment changed significantly, from 24.6% to 55.2% of the tibial weightbearing axis. The overall decrease in patellar height for all patients was significant from preoperative assessment to the 2-week postoperative assessment and to both 3-month and 6-month follow-up with all 4 methods. The Insall-Salvati index decreased from 1.03 preoperatively to 0.99 at 2 weeks postoperatively, 0.97 at 3 months, and 0.95 at 6 months postoperatively. The Blackburne-Peel index decreased from 0.90 preoperatively to 0.75, 0.77, and 0.76, respectively, at each postoperative interval. The Caton-Deschamps index decreased from 0.98 preoperatively to 0.87, 0.86, and 0.84 at each postoperative measurement. The Miura-Kawamura index changed from 0.76 preoperatively to 0.61, 0.63, and 0.60 for each postoperative assessment. The average tibial slope significantly increased from 9.0° to 11.9° overall for all patients. In comparing the plate position, the tibial slope significantly increased from 8.8° preoperatively to 13.1° at 6 months postoperatively for anteromedially positioned plates and from 9.3° to 10.3° for posteromedially positioned plates.

Conclusion: Opening-wedge proximal tibial osteotomies decrease patellar height within the first 3 postoperative months. Shortening of the patellar tendon may affect future surgeries and needs to be evaluated in preoperative assessment. Moreover, a significant increase in tibial slope occurred, which may affect patellar height and future ligament reconstructions.

Background: Postfixation loosening within the Krackow stitch—tendon construct may be associated with gap formation in patellar tendon repair.

Hypothesis: Pretensioning the Krackow stitch—tendon construct decreases postfixation gap formation in transpatellar patellar tendon repair.

Study Design: Controlled laboratory study.

Methods: Patellar tendon rupture was simulated in 8 pairs of cadaveric knees. Standard manual traction was used in all specimens to remove Krackow stitch slack. In the experimental group, specimens were pretensioned with a simulated active concentric quadriceps contraction with cycling of the knee 10 times from 90° to 5° of flexion. All specimens were then cycled at 0.25 Hz from 90° to 5° for 1000 cycles until failure, which was defined as 3 or 5 mm of gap formation.

Results: A 3-mm gap occurred at 1 cycle (mean, 3.5 mm) and 35 cycles (4.0 mm) in the control and experimental groups, respectively. Gapping of 5 mm occurred at 35 (5.9 mm) and 100 cycles (5.0 mm) in the control and experimental specimens, respectively. Gap formation was smaller in the experimental group through 100 cycles ( P < .05).

Conclusion: Gapping was lower with pretensioning in the early cycling stages. However, significant gapping occurred in both groups with repetitive concentric active loading ranging from 90° to 5° of flexion.

Clinical Relevance: Tightening of the Krackow stitch as done in this study does not result in a clinically important decrease in gapping. This observation may be generalizable to other applications of the Krackow stitch.

Background: Growing awareness of the biomechanical contribution of the medial patellofemoral ligament has led to an upsurge in the publication of techniques and trials dealing with reconstructive techniques, warranting a review that includes the most recent evidence.

Study Design: Systematic review.

Methods: The authors undertook a systematic electronic search and rigorous screening process to find and identify published evidence describing the outcomes of medial patellofemoral ligament reconstruction.

Results: Fourteen trials were included for analysis. Although they showed generally excellent outcomes for medial patellofemoral ligament reconstruction modalities, there were several recurring weaknesses. Most were small case series, many had limited follow-up, and a majority employed other adjunctive techniques besides medial patellofemoral ligament reconstruction, making it difficult to distinguish the determining factors in their outcomes.

Conclusion: There is limited but growing evidence that a medial patellofemoral ligament—based surgical approach to patellofemoral instability leads to excellent functional outcomes.

Background: Despite the large number of anterior cruciate ligament reconstructions performed each year, there remains a significant controversy regarding the effect of the graft source on the functional outcome of patients.

Hypothesis: There is no difference in outcomes of autograft versus allograft anterior cruciate ligament reconstructions.

Study Design: Systematic review.

Methods: The authors systematically identified prospective studies (Oxford level of evidence I or II only) that included autograft patients, allograft patients, or both. Objective outcomes that were reported were meta-analyzed; this included pivot-shift results, KT-1000 arthrometer results, International Knee Documentation Committee (IKDC) scores, Lysholm Scores, graft failures, and postoperative complications. Two statistical analyses were performed. First a primary statistical analysis was performed comparing pooled autograft data (bone—patellar—tendon bone and hamstrings combined) and pooled allograft data (bone—patellar—tendon bone and hamstrings combined). To have a more comprehensive understanding of the differences between each specific graft source, a secondary analysis was performed without pooling the data; this directly compared the 4 types of graft sources that were studied.

Results: Over 400 scientific manuscripts were initially reviewed; 31 manuscripts fulfilled all of the search criteria. There were very few statistically significant differences between autograft and allograft tissue. The KT-1000 arthrometer laxity testing revealed a mean of 1.4 ± 0.2 mm (weighted mean ± standard error of the mean) for the allograft group compared with 1.8 ± 0.1 mm for the autograft group (t = 2.40; P < .02). However, this difference was only for the mean score; there was no statistical significance when considering KT-1000 arthrometer measurements of greater than 3 or 5 mm. The percentage of patients receiving a final IKDC score of ‘‘A’’ (normal knee) was statistically significant for allograft tissue (43.9% ± 5.5%) versus autograft tissue (28.2% ± 1.0%) reconstructions. There was no statistically significant difference between the percentages of IKDC scores of A or B for patients receiving pooled allograft (82.9% ± 4.2%) versus pooled autograft (87.2% ± 0.9%) anterior cruciate ligament reconstruction (t = 1.01; P > .1). The graft failure rate was 4.7 ± 0.5 per 100 for autograft reconstructions and 8.2 ± 2.1 per 100 allograft reconstructions; although this may represent a trend, it is not statistically significant (t = 1.49; P > .1). The complication rate was slightly higher for autograft reconstructions at 3.5 ± 0.4 complications per 100 autograft reconstructions compared with 2.4 ± 1.1 complications per 100 allograft reconstructions, but not significant (t = 1.41; P > .1).

Conclusion: After a comprehensive examination and statistical analysis of the modern literature, the authors could not identify an individual graft source that was clearly superior to the other graft sources. This led them to believe that, with currently available data, the graft source has a minimal effect on the outcome of patients undergoing anterior cruciate ligament reconstruction.