The American Journal of Sports Medicine

Background: Randomized controlled trials after anterior cruciate ligament reconstructions with long-term follow-up including assessment of health-related quality of life are rare.

Purpose: To compare clinical outcome and health-related quality of life 8 years after anterior cruciate ligament reconstruction using 2 types of graft.

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

Methods: Long-term follow-up of 164 patients with anterior cruciate ligament injury randomized to arthroscopic reconstruction with a quadrupled semitendinosus graft or a bone–patellar tendon–bone graft was undertaken. After a mean 8 years, 153 patients were available for follow-up, including instrumented laxity, 1-legged hop test, a knee-walking test, and assessment with International Knee Documentation Committee, Lysholm, Tegner, and patellofemoral pain score. Health-related quality of life was assessed with Knee Osteoarthritis Outcome Score and Short Form–36.

Results: Patients in both graft groups retained the same stability, knee function, and health-related quality of life. The patellofemoral pain score was similar for both groups; the bone–patellar tendon–bone group had more donor site morbidity from kneeling and knee walking. In the bone–patellar tendon–bone group, 19 patients had no kneeling problems, 23 slight problems, 31 moderate problems, and 5 unable to kneel. Corresponding figures for the semitendinosus group were 25, 32, 16, and 2 (P < .001). Patients with early reconstructions (<5 months) had a lower risk for meniscal injuries (37%) than did later reconstructed (62%, P = .008). Health-related quality of life regarding physical functioning in Short Form–36 was better for the early-reconstructed patients than for the later reconstructed (92 vs 85; P = .014). Patients without medial meniscal surgery had higher Knee Osteoarthritis Outcome Scores for all subscales than did patients with medial meniscal surgery, with most significant difference for sport and recreation (63 vs 75, P = .008).

Conclusion: In the long term, the semitendinosus graft provided similar stability, knee function, and health-related quality of life but with less kneeling morbidity than did the bone–patellar tendon–bone graft.

Background: The influence of standard meniscus treatment strategies regarding osteoarthritic progress, function, and sports activity has not been estimated in a direct long-term comparison.

Hypothesis: Meniscal repair compared with partial meniscectomy (partial meniscal resection) decreases osteoarthritic changes and reduces the effect on sports activity in the long-term follow-up.

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

Methods: Eighty-one patients with an arthroscopic meniscus shape–preserving surgery after isolated traumatic medial meniscal tear (repair: n = 42; meniscectomy: n = 39) were examined clinically (Lysholm score, Tegner score) and radiologically (Fairbank score, compared with the uninjured knee); the follow-up was divided into midterm (3.4 years; n = 35) and long term (8.8 years; n = 46). Additionally, the influences of the preoperative sports activity level and age at surgery were evaluated.

Results: In the long-term follow-up, no osteoarthritic progress was detectable in 80.8% after repair compared with 40.0% after meniscectomy (P = .005) with significant benefit for the “young” subgroup (P = 0.01). The preinjury activity level was obtained in 96.2% after repair compared with 50% after meniscectomy (P = .001). The function score revealed no significant difference between these strategies (P = .114). The athletes showed a significantly reduced loss of sports activity after repair compared with the athletes after meniscectomy (P = .001).

Conclusion: Arthroscopic meniscal repair offers significantly improved results for isolated traumatic meniscal tears regarding the long-term follow-up in osteoarthritis prophylaxis and sports activity recovery compared with partial meniscectomy.

Background: The etiologic factors, time of development, and extent of the progression of postoperative osteoarthritis (OA) in traumatic shoulder instability remain controversial.

Hypothesis: Most OA seen postoperatively occurs before surgery and progresses very slowly.

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

Methods: Review of 167 joints of 163 patients undergoing the open Bankart procedure, who had no history of shoulder surgery and were younger than 45 years at follow-up, was done at a mean follow-up of 8.7 years (range, 5-20 years). The shoulders were directly examined and radiographed. A statistical analysis was performed to examine the correlation between OA development/progression and patients’ demographic characteristics and various factors, and to evaluate the correlation between these factors.

Results: Recurrence of instability occurred in 8 of 167 joints (4.8%). Preoperative computed tomography (CT) showed OA in 44 shoulders (26.3%), among which 12 shoulders (7.2%) showed OA on the preoperative radiographs. Consequently, CT-proven OA in the remaining 32 shoulders was incipient OA that was not revealed radiographically. Radiographs taken at follow-up revealed OA in 30 shoulders (18.0%), of which 24 (80%) had had OA proven by preoperative imaging. Preoperative CT-proven OA in 20 shoulders never became visible on postoperative radiographs. The severity of OA slightly increased in 14 joints (32%) during the postoperative period. The number of preoperative subluxations and the total number of preoperative dislocations/subluxations were significantly greater, and the percentages of male patients and glenoid bone defect greater than 20% of the anteroposterior diameter were higher for the 30 shoulders with postoperative OA.

Conclusion: Most postoperatively detected OA developed before surgery. The preoperative factors are profoundly involved in the development of OA. The role of surgery in favoring the OA development appears to be inconclusive. The development and progression of OA cannot be prevented by surgical intervention, but the progression of postoperative OA is extremely slow.

Background: There are no validated outcome measures consistently used in the literature to report results of ulnar collateral ligament reconstruction in overhead athletes.

Hypothesis: The Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow score (KJOC score) will correlate with other validated scores for upper extremity assessment but will be more accurate in evaluating ulnar collateral ligament reconstruction outcomes in professional baseball players.

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

Methods: Fifty-five professional baseball players who underwent ulnar collateral ligament reconstruction were asked to complete the KJOC score, the Disabilities of the Arm, Shoulder and Hand (DASH) score, and the DASH sports module. Players were separated into 3 categories—(1) playing without pain, (2) playing with pain, and (3) not playing because of pain—and compared with 123 asymptomatic throwers. Pearson (parametric) and Spearman rank (nonparametric) correlations among the 3 systems were conducted to validate the KJOC score. Means across categories were compared using a Wilcoxon rank-sum test, and a threshold score separating categories 1 and 3 was determined using receiver operator characteristic discrimination analysis.

Results: Significant correlations were found between the KJOC score and the DASH (−.693, P < .0001), and the DASH sports module (−0.804, P < .0001). Only the KJOC score was able to discriminate between categories 2 and 3, as well as category 1 and the uninjured population. In addition, the KJOC score was the most sensitive and accurate method of discriminating category 1 from category 3, with a threshold score of 81.3.

Conclusion: The results of this study validate the use of the KJOC score for evaluation of overhead athletes undergoing ulnar collateral ligament reconstruction. The KJOC score is the most sensitive score for detecting subtle changes in performance in the throwing athlete.

Background: Injuries to the posterolateral corner of the knee remain a challenging problem and have been cited frequently as a reason for failure of anterior and posterior cruciate ligament reconstructions. Although several reconstructive techniques currently exist, there are relatively few clinical outcomes data after reconstruction of the posterolateral corner.

Purpose: The study was undertaken to examine the clinical outcomes and provide objective data using arthrometry and stress radiography of a posterolateral corner reconstruction technique.

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

Methods: A retrospective cohort study of a consecutive series of patients who underwent posterolateral corner reconstruction of the knee was evaluated. The surgery featured dual femoral tunnels, a transfibular tunnel, and a free graft to reconstruct the posterolateral corner of the knee. All patients had concomitant reconstruction of one or both cruciate ligaments. Outcomes were assessed using the Short Form–12, Lysholm, and Tegner knee scores. A clinical examination, KT-2000 arthrometry measurements, single-legged hop quotient, and varus and posterior Telos stress radiographs were obtained and compared with results for the contralateral, uninjured knees.

Results: Twenty-four (83%) of 29 consecutive patients were evaluated at a mean 39 months postoperatively (range, 24-81 months). The mean Lysholm and Tegner knee scores were 83 and 6, respectively. The mean difference (± standard deviation) in total anterior-posterior side-to-side KT arthrometry measurements was 1.4 ± 1.3 mm. The varus stress radiographic mean side-to-side difference measured at 20° of flexion was 0.2 ± 1.9 mm. The mean radiographic posterior tibial displacement with a 15-kg stress at 90° of flexion was 3.2 ± 4.5 mm in patients undergoing posterior cruciate ligament reconstruction.

Conclusion: This reconstruction of the posterolateral corner of the knee with concomitant cruciate ligament reconstruction restores varus and rotational stability at a minimum of 2 years postoperatively.

Background: Currently in double-bundle anterior cruciate ligament (ACL) reconstructions, the range of knee flexion angles that surgeons use for anteromedial (AM) and posterolateral (PL) bundle graft fixation spans from 0° to 90° for both bundle grafts. Despite the recent popularity of this procedure, no consensus exists on an optimal set of AM and PL graft fixation angles.

Hypothesis: Graft fixation angles that simulate the native tensioning relationship of the AM and PL bundles will produce kinematic results similar to the intact knee, while graft fixation angles that do not simulate this relationship will under- or overconstrain the knee.

Study design: Controlled laboratory study.

Methods: Twelve cadaveric knees were biomechanically tested in the intact state, ACL-sectioned state, and a randomized order of 7 double-bundle ACL reconstructed states at multiple graft fixation angle combinations. For each test state, data were collected for 88 N anterior tibial loads, 10 N·m valgus torques, 5 N·m internal rotation torques, and 2 simulated pivot shift loads consisting of a 5 N·m internal rotation torque coupled with either a 10 N·m valgus torque or an 88 N anterior tibial load at 0°, 20°, 30°, 60°, and 90° of knee flexion.

Results: The AM and PL graft fixation angle combinations of 0°/0° (AM graft fixation angle/PL graft fixation angle), 60°/0°, 45°/15°, and 75°/15° restored normal laxity to the reconstructed knee in all of the biomechanical tests. The 30°/30°, 60°/60°, and 90°/90° graft fixation angle combinations significantly restricted knee laxity compared with the intact state in various biomechanical tests.

Conclusion: We found that as long as the PL bundle graft was fixed between 0° and 15°, the AM graft could be fixed up to 75° without restricting knee laxity. However, fixation of the PL graft at 30° of knee flexion and above significantly overconstrained the knee.

Clinical Relevance: This study provides a range of angles that can be used in double-bundle ACL reconstructions to restore normal knee stability without causing overconstraint.

Background: During rotator cuff repair, biceps tendon lesions are frequently encountered. However, there is still controversy about optimal treatment for these lesions.

Purpose: To compare the results of tenotomy and suture anchor tenodesis prospectively.

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

Methods: From January 2006 to June 2007, 90 patients (age, >55 years) with a rotator cuff tear and biceps tendon lesion (tear more than 30%, subluxation or dislocation, or degenerative superior labrum anterior to posterior lesion type II) were evaluated prospectively. The first 45 patients treated consecutively underwent biceps tenodesis, and the next 45 underwent biceps tenotomy. Postoperatively, patient evaluations were conducted with a focus on (1) “Popeye” deformity, (2) arm cramping pain, and (3) elbow flexion powers (measured with a hand dynamometer). Overall shoulder function was assessed with the American Shoulder and Elbow Surgeons (ASES) score and the Constant score.

Results: At final follow-up, 43 in the tenodesis and 41 in the tenotomy groups were available for evaluation. There was no difference between groups in demographic data such as age, sex, dominant arm, and the time from symptom to surgery and in preoperative ASES score, Constant score, and rotator cuff tear size. A Popeye deformity occurred in 4 (9%) in the tenodesis group and in 11 (27%) in the tenotomy group (P = .0360). Mild cramping pain was observed in 2 in the tenodesis group and 4 in the tenotomy group (P = .4274). Mean elbow flexor power ratio (vs the contralateral side) showed no difference between the 2 groups, with mean values of 0.92 ± 0.15 (tenodesis) and 0.94 ± 0.19 (tenotomy) (P = .7475). The ASES and Constant scores were improved from 38.9 ± 14.2 and 52.1 ± 21.3 to 84.7 ± 13.6 and 82.9 ± 13.5 in the tenodesis group (P < .0001) and from 35.2 ± 10.5 and 48.1 ± 21.3 to 79.6 ± 15.8 and 78.3 ± 14.1 in the tenotomy group (P < .0001), respectively.

Conclusion: Suture anchor tenodesis of the long head of the biceps tendon appears to lead to less Popeye deformity than tenotomy. No other clinical variables showed a difference between the 2 modalities.

Background: The pivot shift is a dynamic test of knee stability that involves a pathologic, multiplanar motion path elicited by a combination of axial load and valgus force during a knee flexion from an extended position.

Purpose: To assess the stabilizing effect of the medial and lateral meniscus on anterior cruciate ligament-deficient (ACL-D) knees during the pivot shift examination.

Study Design: Controlled laboratory study.

Methods: A Lachman and a mechanized pivot shift test were performed on 16 fresh-frozen cadaveric hip-to-toe lower extremity specimens. The knee was tested intact, ACL-D, and after sectioning the medial meniscus (ACL/MM-D; n = 8), lateral meniscus (ACL/LM-D; n = 8), and both (ACL/LM/MM-D; n = 16). A navigation system recorded the resultant anterior tibial translations (ATTs). For statistical analysis an analysis of variance was used; significance was set at P < .05.

Results: The ATT significantly increased in the ACL-D knee after lateral meniscectomy (ACL/LM-D; P < .05) during the pivot shift maneuver. In the lateral compartment of the knee, ATT in the ACL-D knee increased by 6 mm after lateral meniscectomy during the pivot shift (16.6 ± 6.0 vs 10.5 ± 3.5 mm, P < .01 for ACL/LM out vs ACL out). Medial meniscectomy, conversely, had no significant effect on ATT in the ACL-D knee during pivot shift examination (P > .05). With standardized Lachman examination, however, ATT significantly increased after medial but not lateral meniscectomy compared with the ACL-D knee (P < .001).

Conclusion: Although the medial meniscus functions as a critical secondary stabilizer to anteriorly directed forces on the tibia during a Lachman examination, the lateral meniscus appears to be a more important restraint to anterior tibial translation during combined valgus and rotatory loads applied during a pivoting maneuver.

Clinical Relevance: This model may have implications in the evaluation of surgical reconstruction procedures in complex knee injuries.

Background: During the past decade, the use of biodegradable implants in anterior cruciate ligament surgery has increased.

Hypothesis: Poly-L-lactide acid (PLLA) interference screws would render the same clinical results but greater tunnel enlargement than metal screws 8 years after anterior cruciate ligament reconstruction using hamstring tendon (semitendinosus/gracilis) autografts.

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

Methods: A randomized series of 77 patients, all with a unilateral anterior cruciate ligament rupture, were divided into 2 groups (PLLA and metal). In both groups, hamstring tendon autografts were used with interference screw fixation at both ends and the patients were examined with standard radiographs, Tegner activity level, Lysholm knee score, single-legged hop test, early C-reactive protein response, and KT-1000 arthrometer knee laxity measurements.

Results: The preoperative assessments in both groups were similar in terms of gender, clinical tests, and the time from injury to surgery. The patients returned for a radiographic and clinical examination a mean of 96 months (range, 78-120 months) after the index operation. The PLLA group displayed significantly larger bone tunnels on the radiographs than the metal group on the femoral side (mean, 11.4 mm [range, 0-17.8 mm] vs 8.0 mm [range, 0-16.3 mm]; P < .005) but not on the tibial side (mean, 10.7 mm [range, 7.8-14.1 mm] vs 10.5 mm [range, 0-20.3 mm]; difference not significant). At follow-up, no significant differences were found between the PLLA and metal groups in terms of knee laxity measurements (median, 1.0 mm [range, –2.0-4.0 mm] vs 1.0 mm [range, –3.0-6.5 mm]), Tegner activity level (median, 7 [range,3-9] vs 6 [range, 2-9]), or the Lysholm knee score (median, 90 points [range, 51-100] vs 89 points [range, 53-100]). The C-reactive protein values did not differ significantly between the 2 groups except for an increase in the PLLA group compared with the metal group at day 1 postoperatively—23 mg/L (range, <6-55) vs 9 mg/L (range, <6-55) (P < .001).

Conclusion: There were significantly larger radiographically visible bone tunnels on the femoral side but not on the tibial side in the PLLA group compared with the metal group 8 years after anterior cruciate ligament reconstruction using hamstring tendon autografts. This finding did not correlate with inferior clinical results. Because of the results in the present study, the authors have discontinued the use of PLLA interference screws.

Background: Left-handed individuals make up about 10% of the general population, yet left-handers comprise approximately 30% of the pitching staffs in Major League and Division I college baseball. Despite speculation regarding differences between right- and left-handed pitchers, distinction between right- and left-handed pitching mechanics has not been documented in the literature at any level of play.

Hypothesis: Left-hand–dominant pitchers display similar pitching mechanics and upper extremity joint loads when compared to their right-hand–dominant counterparts.

Study Design: Controlled laboratory study.

Methods: Three-dimensional, high-speed (240-Hz) video data were collected on fastballs from 84 collegiate baseball pitchers. Kinematic parameters related to pitching mechanics and resultant kinetics on the throwing shoulder and elbow were calculated. The 28 left-handed pitchers in the database were matched with 28 right-handed pitchers for age, height, mass, and ball velocity, and paired t tests were used to compare the kinematic and kinetic parameters.

Results: Six parameters were found to have statistically significant differences between left- and right-handed pitchers. Passive nonthrowing shoulder external rotation (right, 113° ± 9°; left, 124° ± 8°), elbow flexion at stride-foot contact (right, 79° ± 16°; left, 94° ± 20°), and shoulder abduction during acceleration (right, 72° ± 11°; left, 105° ± 8°) were greater in left-handed pitchers than right-handed pitchers. Shoulder abduction at stride-foot contact (right, 115° ± 13°; left, 73° ± 10°), shoulder horizontal abduction at stride-foot contact (right, 25° ± 12°; left, 15° ± 12°), and peak horizontal adduction angular velocity (right, 707 ± 185 deg/s; left, 551 ± 160 deg/s) were less for the left-handed pitchers.

Conclusion: Biomechanical differences between left- and right-handed pitchers have been demonstrated in a collegiate population.

Clinical Relevance: The results of the current study indicate that left-handed pitchers may be at increased risk for certain shoulder injuries compared with their right-handed counterparts. Information has been provided for athletes, coaches, and sports medicine providers to further improve preventive and rehabilitative protocols for college pitchers. The results of the study also suggest that different normative data sets may need to be developed for left- and right-handed pitchers, independently of one another.

Background: Although the literature has extensively discussed impingement after anterior cruciate ligament (ACL) reconstruction, the definition of impingement is vague, and impingement pressure has not been well investigated as a function of tunnel position.

Purpose: To determine the amount of impingement pressure between the ACL and posterior cruciate ligament (PCL) and between the ACL and notch roof in the native ACL, the single-bundle ACL reconstruction with different tunnel placements, and the anatomical double-bundle ACL reconstruction.

Study design: Controlled laboratory study.

Methods: Fifteen fresh-frozen nonpaired human cadaver knees were used. In each knee, different femoral and tibial tunnels were created, which allowed different graft placements. A single graft was placed in 3 positions: tibial anteromedial (AM) to femoral AM (anatomical), tibial posterolateral (PL) to femoral high AM (nonanatomical/mismatch), and tibial AM to femoral high AM. Double grafts were placed in an anatomical fashion (AM to AM and PL to PL). In each case, pressure-measuring films were inserted between the ACL and roof, the ACL and PCL, and the AM and PL bundles (for double-bundle group only). Knees were then moved with 40 N of force and from full flexion to full extension, and the pressure pattern on the film was analyzed.

Results: Compared with other groups, only the AM–high AM group showed significantly higher roof impingement pressure (P < .05). There was no significant difference in PCL impingement pressure between the intact ACL group and any of the reconstructed groups. No impingement pressure was observed between the grafts in the anatomical double-bundle ACL reconstruction.

Conclusion: This study evaluated the effect of different tunnel placements on the impingement pressure after ACL reconstruction. Anatomical single- or double-bundle ACL reconstruction and nonanatomical tibial PL–femoral high AM ACL reconstruction do not cause roof, PCL, and interbundle impingement.

Clinical relevance: Surgeons can perform the anatomical double-bundle ACL, anatomical single-bundle, and nonanatomical tibial PL–femoral high AM reconstructions as impingement-free reconstructions.

Background: Double-bundle anterior cruciate ligament (ACL) reconstruction is a technically demanding procedure; it requires drilling 2 tibial and 2 femoral tunnels. Tunnel communication, whether intraoperative or postoperative, is a serious complication: It jeopardizes knee stability and graft function.

Hypothesis: During double-bundle ACL reconstruction, special aimers would be helpful to avoid intraoperative bone bridge fracture. The bone bridge between the bone tunnels would maintain its structural integrity, and no tunnel communication would be observed postoperatively because of tunnel widening.

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

Methods: This prospective study included 32 patients undergoing double-bundle ACL reconstruction. A multidetector computed tomography study was performed at a mean of 17 months postoperatively. The thickness of the bone bridge between the bone tunnels was measured in the femoral and tibial sides on an axial and sagittal plane, respectively, at 3 locations: the level of the joint line, the midportion of the bone bridge, and the base of the bone bridge. The bone density of the bone bridge was measured in Hounsfield units in the same locations. Bone density of the anterior tibial cortex and lateral femoral condyle was measured for comparisons.

Results: Tunnel communication occurred intraoperatively in 1 patient on the tibial side at the level of the joint line. In the rest of the patients, a well-defined triangular bone bridge was present between the 2 tunnels in the femoral and tibial sides. The thickness at the apex of the bone bridge was 2.0 and 2.2 mm for the femur and tibia, respectively. In addition, the density of the bone bridge at its apex was similar to that of cortical bone.

Conclusion: This study demonstrated that double-bundle ACL reconstruction, as used with anatomic aimers, produces a low rate of tunnel convergence. The bone bridge remains intact postoperatively, although it is thin at the level of the joint line.

Background: Taping has been used to treat patellofemoral pain syndrome for more than 20 years, but its effectiveness is still controversial.

Purpose: This study was undertaken to investigate the effect and predictors of effectiveness of taping in the treatment of patellofemoral pain syndrome.

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

Methods: A total of 118 consecutive patients with patellofemoral pain syndrome were recruited; 100 of them completed this study. Patient sex, age, body mass index, Q angle, lateral patellar displacement, and lateral patellofemoral angle were recorded/measured. One therapist applied adhesive tape to each patient by the McConnell method. Patients scored their pain level on a 100-mm visual analog scale during stepping down from an 8-in platform, before and after taping. The change of score was evaluated by paired t test. Patients with a visual analog scale score decrease of 20 mm or more after taping were considered responsive, and the others were considered nonresponsive. The influences of the aforementioned factors, plus pretaping visual analog scale score, on the effectiveness of taping were analyzed by multivariate logistic regression.

Results: The overall mean visual analog scale score decreased significantly after taping (from 49.0 to 29.3 mm; P < .001). There were 66 patients in the responsive group and 34 in nonresponsive group. Among the factors, body mass index, lateral patellofemoral angle, and Q angle were significant predictors of effectiveness. The responsive group had significantly smaller mean lateral patellofemoral angle, larger mean Q angle, and larger mean pretaping visual analog scale score than the nonresponsive group.

Conclusion: Taping was an effective treatment for patellofemoral pain syndrome, but was less effective in patients with higher body mass index, larger lateral patellofemoral angle, and smaller Q angle.

Background: Quantifying changes in meniscal volume in vivo before and after partial meniscectomy (PM) could help elucidate the mechanisms involved in osteoarthritis development after meniscal injury and its surgical treatment.

Purpose/Hypothesis: To determine whether quantitative magnetic resonance imaging (qMRI) can detect the immediate reduction in meniscal volume created by PM, while ruling out changes in unresected structures. We hypothesized that qMRI would be reliable for determining meniscal volume within the repeated images of unresected menisci. Additionally, we expected no significant difference in volume between the uninjured menisci of the injured knees and the same menisci of the uninjured knees.

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

Methods: Ten subjects with meniscal tears were evaluated with 3-T MRI before and after arthroscopic PM. Manual segmentation was used to create models of the menisci and to determine the preoperative and postoperative meniscal volumes for each subject. The responsiveness and reliability of qMRI for determining meniscal volume in vivo were evaluated using these measurements. We expected a decrease in volume of the resected menisci, but not in the uninjured menisci, after surgery.

Results: The mean preoperative volume of the injured menisci was significantly greater than the mean postoperative volume (2896 ± 277 vs 2480 ± 277 mm³; P = .000). There was no significant difference between the mean preoperative and postoperative volumes of the uninjured menisci (2687 ± 256 vs 2694 ± 256 mm³; P = 1.000).

Conclusion: Manual segmentation demonstrated a significant reduction in the volume of the surgically resected menisci after PM, but no significant change in the volume of unresected meniscal tissue, indicating that the manual segmentation method is responsive.

Clinical Relevance: This approach offers a novel, reliable method to study the relationship between the volume of meniscal tissue removed during PM and subsequent patient outcomes during long-term clinical studies.

Background: The structural properties of the individual components of the superficial medial collateral ligament (MCL), deep MCL, and posterior oblique ligament (POL) have not been studied in isolation. To define the necessary strength requirements for an anatomical medial knee reconstruction, knowledge of these structural properties is necessary.

Hypothesis: The components of the superficial MCL, POL, and deep MCL have significantly different structural properties.

Study Design: Controlled laboratory study.

Methods: This study used 20 fresh-frozen nonpaired cadaveric knee specimens with a mean age of 54 years (range, 27 to 68 years). These knees provided 8 samples for each tested medial knee structure, which was individually isolated and loaded to failure at 20 mm per minute. Specifically tested were the superficial MCL with intact femoral and detached proximal tibial attachments, the superficial MCL with intact femoral and detached distal tibial attachments, the central arm of the POL, and the isolated deep MCL. Load was recorded as a function of displacement. Stiffness of the ligament at failure was calculated from these measurements.

Results: The mean load at failure for the superficial MCL with the intact femoral and distal tibial attachments was 557 N. Mean load at failure was 88 N for the intact femoral and proximal tibial divisions of the superficial MCL, 256 N for the POL, and 101 N for the deep MCL. Stiffness of the ligaments just before failure was 63, 17, 38, and 27 N/mm, in the same order as above.

Conclusion: The proximal and distal tibial divisions of the superficial MCL, POL, and deep MCL produced loads of clinical importance.

Clinical Relevance: Knowledge of the structural properties of these attachment sites will assist in reconstruction graft choices, fixation method choices, and overall operative treatment of medial knee injury.

Background: Multiple studies have described in general the injuries associated with mountain biking, and detailed accounts of spine injuries sustained in hockey, gymnastics, skiing, snowboarding, rugby, and paragliding have previously been published. However, no large-scale detailed assessment of mountain biking associated spinal fractures and spinal cord injuries has previously been published.

Purpose: This study was undertaken to describe the patient demographics, injuries, mechanisms, treatments, outcomes, and resource requirements associated with spine injuries sustained while mountain biking.

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

Methods: Patients who were injured while mountain biking, and who were seen at a provincial spine referral center between 1995 and 2007 inclusive, with spinal cord injuries and/or spine fracture were included. A chart review was performed to obtain demographic data, and details of the injury, treatment, outcome, and resource requirements.

Results: A total of 102 men and 5 women were identified for inclusion. The mean age at injury was 32.7 years (95% confidence interval 30.6, 35.0). Seventy-nine patients (73.8%) sustained cervical injuries, while the remainder sustained thoracic or lumbar injuries. Forty-three patients (40.2%) sustained a spinal cord injury. Of those with cord injuries, 18 (41.9%) were American Spinal Injury Association (ASIA) A, 5 (11.6%) were ASIA B, 10 (23.3%) ASIA C, and 10 (23.3%) ASIA D. Sixty-seven patients (62.6%) required surgical treatment. The mean length of stay in an acute hospital bed was 16.9 days (95% confidence interval 13.1, 30.0). Thirty-three patients (30.8%) required intensive care unit attention, and 31 patients (29.0%) required inpatient rehabilitation. Of the 43 patients (40.2%) seen with spinal cord injuries, 14 (32.5%) improved by 1 ASIA category, and 1 (2.3%) improved by 2 ASIA categories. Two patients remained ventilator-dependent at discharge.

Conclusion: Spine fractures and spinal cord injuries caused by mountain biking accidents typically affect young, male, recreational riders. The medical, personal, and societal costs of these injuries are high. Injury prevention should remain a primary goal, and further research is necessary to explore the utility of educational programs, and the effect of helmets and other protective gear on spine injuries sustained while mountain biking.

Background: The surgical results have been reported as poor for advanced osteochondral lesions of the ankle with large subchondral lesions including subchondral cyst.

Hypothesis: Transplanting an autologous cancellous bone plug from the pelvis to the lesions retrogradely may bring good clinical results for the treatment of advanced osteochondral lesions with large subchondral lesions including subchondral cyst of the ankle.

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

Methods: Twenty-five osteochondral lesion patients who had large subchondral lesions of the ankle (diameter ≥10 mm on magnetic resonance imaging) met the criteria of this study. Fourteen of those patients were treated with arthroscopic antegrade drilling (group AD), and the other 11 patients were treated with arthroscopic retrograde cancellous bone plug transplantation from the iliac crest (group RC). The clinical results in conjunction with the American Orthopaedic Foot and Ankle Society (AOFAS) scores, diameters of the subchondral lesions on magnetic resonance imaging, and the regenerative cartilage in second-look arthroscopy using International Cartilage Repair Society (ICRS) visual repair assessment score were evaluated.

Results: The mean AOFAS score at 2 years after surgery was 82.2 ± 7.2 in group AD and 95.8 ± 4.6 in group RC (P < .0001). Diameter of the subchondral lesion was almost unchanged in 11 cases (78.5%) in group AD, compared with disappearance in 7 cases (73.8%) and decreased lesion size in 4 cases (36.4%) in group RC. The mean ICRS score at second-look arthroscopy was 5.1 ± 1.9 in group AD and 10.5 ± 0.8 in group RC (P = .0001).

Conclusion: The authors recommend arthroscopic retrograde autologous cancellous bone plug transplantation from the iliac crest as a surgical procedure for the treatment of advanced osteochondral lesions with large subchondral lesions of the ankle.

Background: Chronic exertional compartment syndrome is an entity that typically fails nonoperative management and requires operative treatment with fasciotomies for return to activity. Fasciotomies performed through single or multiple incisions may fail to totally release the fascia of the afflicted compartment(s) and may result in injury to neurovascular structures that cannot be visualized.

Purpose: The authors report results of endoscopic compartment release with the assistance of a balloon dissector in the treatment of chronic exertional compartment syndrome.

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

Methods: The clinical outcomes of 14 cases of chronic exertional compartment syndrome in 9 patients treated with endoscopic release were assessed with a retrospective chart review and the results of mailed questionnaires.

Results: Fourteen legs in 9 patients (4 male and 5 female; average age, 24 years) were treated with endoscopic compartment release for chronic exertional compartment syndrome. Eight of 9 patients were able to resume preoperative activities, including collegiate athletics in 5 cases and recreational sport in 3 cases. No neurovascular injuries occurred. Complications were isolated to postoperative hematomas that resolved in 2 patients. Seven patients completed questionnaires an average of 3.75 years after surgery. There were no recurrences of symptoms.

Conclusion: Endoscopic compartment release is a cosmetic, safe, and effective means of treating chronic exertional compartment syndrome.

Background: Noncontact anterior cruciate ligament injuries are among the most common injuries in sports medicine, and identification of risk factors for noncontact injury is an area of active research.

Hypothesis: Evaluation of the femoral notch along the path of the anterior cruciate ligament may elucidate anatomical risk factors previously unseen on conventional images.

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

Methods: Twenty-seven patients with noncontact anterior cruciate ligament injuries were matched to healthy individuals for height, weight, age, and sex in this case-control study. Sagittal magnetic resonance images of the contralateral knee of the injured patients and randomized knees of the healthy controls were digitally transformed for viewing along the plane of the anterior cruciate ligament and evaluated for abnormalities of femoral notch outlet shape. Femoral notch shape was also evaluated by computer-generated surface models of the knee.

Results: A bone ridge was observed on the medial side of the anterior notch outlet, and increasing ridge thickness was strongly associated with noncontact anterior cruciate ligament injury (3.87 ± 2.17 mm in injured and 2.16 ±1.80 mm in controls; P = .0014). Anterior and posterior femoral notch outlet stenosis were both significantly associated with noncontact anterior cruciate ligament injury (P = .0008 and .02, respectively), although anterior outlet stenosis became nonsignificant when stratified by the presence of an anteromedial bone ridge. Finally, images directed through the femoral notch with the knee at 45° of flexion provided an unobstructed view for ridge detection that may be utilized in plain radiography.

Conclusion: The presence and thickness of an anteromedial bone ridge in the femoral notch has been identified as a potential risk factor for noncontact anterior cruciate ligament injury. A biomechanical injury model involving the femoral notch ridge in anterior cruciate ligament tears is proposed in which the anterior cruciate ligament may be tented and stretched over the anteromedial notch ridge during knee valgus and internal tibial rotation; alternatively, the anterior cruciate ligament may be impinged at the lateral anterior outlet wall during knee valgus and external tibial rotation. Further investigation to determine the origin of the bone ridges and the validity of the proposed injury model is recommended.

Background: No biomechanical study has been performed analyzing the merits of reconstructing the popliteofibular ligament (PFL) through a tibial tunnel with an anatomic reconstruction of the posterolateral knee.

Hypothesis: There is no difference in an anatomic posterolateral knee reconstruction with or without a PFL reconstruction placed through a tibial tunnel in restoring knee motion to the intact, uninjured state, and the knee is not overconstrained with this reconstruction.

Study Design: Controlled laboratory study.

Methods: Eight paired knees were tested in the intact state and then sectioned to simulate a grade III posterolateral knee injury. The reconstruction for the first paired knee reconstructed the PFL (through a tibial tunnel), popliteus tendon, and fibular collateral ligament (group 1); the matched knee reconstruction involved only the popliteus tendon and fibular collateral ligament (group 2).

Results: Reconstructions for group 1 knees restored knee motion to the intact state for all tested conditions at all knee flexion angles with no overconstraint of the knee. Without reconstructing the PFL (group 2), small but significant increases in motion were found for varus translation at 0° (3.0°), 20° (3.1°), and 60° (3.8°) of knee flexion compared with the intact state. At 60° and 90° of flexion, the reconstruction for group 2 had small but significant increases in internal rotation compared with the intact state (1.3° and 1.8°, respectively).

Conclusion: Inclusion of the PFL through a tibial tunnel as part of an anatomic posterolateral knee reconstruction restores knee stability back to the intact state and does not overconstrain the knee. Furthermore, inclusion of the PFL through a tibial tunnel restored normal internal rotation.

Clinical Relevance: The PFL should be included in anatomic reconstructions of grade III posterolateral knee injuries with placement through a tibial tunnel to best restore the intact, preinjury knee motion state and, most notably, normal internal rotation without evidence of overconstraint of the knee.

Injuries to the pectoralis major muscle are relatively infrequent but result in pain, weakness, and deformity of the upper extremity. The usual injury mechanism is during eccentric shortening of the pectoralis major under heavy load, such as when performing a bench press exercise. The ability to detect and treat a pectoralis major rupture is important for both the clinician and the patient and is aided with knowledge of the anatomy, the clinical findings, and results of nonoperative and operative care. It is important to understand the physical demands and desires of the patient as well as to understand the outcomes of both nonoperative and operative care to make an informed decision regarding optimal treatment. This article highlights the importance of the clinical examination in identifying the injury, examines various surgical techniques to repair the rupture, and reports on potential complication and reinjury rates.

Although suture anchor complications after arthroscopic shoulder surgery are uncommon, they can be devastating, such as articular cartilage or bone loss secondary to a dislodged or prominent suture anchor. Proper insertion of the anchor is the most important factor in the prevention of this complication, but if a complication occurs, prompt recognition and treatment are important to prevent damage to the shoulder. The goals were to (1) discuss strategies for preventing or dealing with dislodged or prominent suture anchors and (2) introduce techniques for removal of these implants.