Endoscopic Olecranon Bursectomy in the Treatment of Recalcitrant Olecranon Bursitis: Patient Selection and Operative Technique.

Olecranon bursitis is the most common form of bursitis. While it can commonly be treated using noninvasive measures, a surgical approach is indicated for cases of recalcitrant olecranon bursitis, which fail such treatment options. Traditionally, recalcitrant olecranon bursitis has been treated with an open bursectomy. Recently, arthroscopy has been proposed as an alternative method. Contraindications for this approach are cases where the bursa is massively enlarged and contains copious amounts of gouty tophi. While a unanimous consensus regarding which surgical approach is optimal has yet to be made, the endoscopic approach could potentially reduce issues inherent to open bursectomies such as improper wound healing and recurrence. This would reduce patient discomfort and allow them to return to activity sooner. We present a technique for treating recalcitrant olecranon bursitis using endoscopic resection.

No Wound Healing Complications or Recurrences Were Seen and a High Level of Satisfaction Was Reported in Patients Who Underwent Endoscopic Olecranon Bursectomy for Recalcitrant Olecranon Bursitis.

Purpose: To determine the outcomes of endoscopic olecranon bursectomy for the treatment of recalcitrant olecranon bursitis in one surgeon's practice. Methods: A retrospective analysis was conducted on all patients who underwent an endoscopic olecranon bursectomy for the treatment of recalcitrant olecranon bursitis between January 2018 and May 2021 at one surgeon's practice. Demographic variables as well as causes for olecranon bursitis such as aseptic, septic, and gouty tophi were recorded. In addition, any complications such as infection, recurrence, wound failure, or hospitalizations were documented, with wound dehiscence, recurrence of bursitis, and return to the operating room being the primary outcome measures. During the final phone encounter before finalizing this project, patients were queried to obtain the patient-reported form of the American Shoulder and Elbow Surgeons Elbow Questionnaire, quick Disabilities of the Arm Shoulder and Hand score, and the Single Assessment Numeric Evaluation score. Results: Our study included 28 patients (23 male and 5 female) with an average age of 68 years (ranging from 33-86 years), all of whom had follow-up. The average follow-up was 24.7 months (range 3-42 months). There were 15 cases (54%) of aseptic bursitis, 13 cases (46%) of septic bursitis, and 7 cases (25%) that contained gouty tophi (5 aseptic and 2 septic). Of the 28 patients, 4 experienced complications. These all occurred within 3 months of surgery. One necessitated hospitalization and intravenous antibiotics, 2 were minor infections treated with oral antibiotics, and one was swelling treated successfully with in-office aspiration. Overall, 24 (86%) patients reported no issues at all related to the surgery. There were no instances of recurrence, wound failure, or secondary operations. Of the 20 (71.4%) patients who were reached for patient-reported form of the American Shoulder and Elbow Surgeons Elbow Questionnaire, quick Disabilities of the Arm Shoulder and Hand score, and Single Assessment Numeric Evaluation scores, all 20 patients reported no residual pain or difficulties with daily tasks. Average satisfaction with the procedure was 9.9 of 10 and, on average, patients reported that their elbow functionality was 96% with 100% representing completely normal. Conclusions: In this population, patients who underwent endoscopic olecranon bursectomy experienced no recurrences or wound-healing complications necessitating return to the operating room. In addition, patients reported high function and satisfaction after the procedure. Level of Evidence: Level IV, therapeutic case series.

Repair of Chronic Patellar Tendon Rupture with Extensor Mechanism Allograft Augmentation.

The purpose of this study was to evaluate the effectiveness of our novel chronic patellar tendon repair with allograft augmentation in an active-duty military population. From 2014 to 2018, five patients with chronic patellar tendon ruptures were treated with a primary repair of the patellar tendon augmented with Achilles tendon allograft. All patients were followed for 12 months, and their range of motion, Lysholm scores, and straight leg raise ability were assessed. Additionally, their return to active military duty was followed. All patients were managed with tendon reapproximation and Achilles allograft augmentation. Lysholm scores improved in all patients from an average of 35 to 87 postoperatively. No patients demonstrated postoperative extensor lag, and patients regained an average flexion of 130 degrees. All patients returned to active military duty. We presented a safe and effective technique to manage chronic patellar tendon ruptures that produced good outcomes. (Journal of Surgical Orthopaedic Advances 32(3):242-245, 2023).

Novel anterior coracoglenoid line utilizing magnetic resonance imaging (MRI) corresponds with critical glenoid bone loss.

OBJECTIVE: Glenoid bone loss is estimated using a best-fit circle method and requires software tools that may not be available. Our hypothesis is that a vertical reference line drawn parallel to the long axis of the glenoid and passing through the inflection point of the coracoid and glenoid will represent a demarcation line of approximately 20% of the glenoid. Our aim is to establish a more efficient method to estimate a surgical threshold for glenoid insufficiency. METHODS: Fifty patients with normal glenoid anatomy were randomly chosen from an orthopedic surgeon's database. Two orthopedic surgeons utilized T1-weighted sagittal MRIs and the coracoglenoid line technique to determine the percentage of bony glenoid anterior to vertical line. Two musculoskeletal radiologists measured the same 50 glenoids using the circle technique. Differences were determined using dependent t test. Reliability was compared using interclass correlation coefficient and Kappa. Validity was compared using Pearson correlation coefficient. RESULTS: Mean surface area of the glenoid anterior to the vertical line was on average 21.69% ± 3.12%. Surface area of the glenoid using the circle method was on average 20.86% ± 2.29%. Inter-rater reliability of the circle method was 0.553 (fair). Inter-rater reliability of the vertical line technique was 0.83 (excellent). There was a linear relationship between circle and vertical line measurements, r = 0.704 (moderate to high). CONCLUSION: The coracoglenoid line appears to represent a line of demarcation of approximately 21% of glenoid bone anterior to the coracoglenoid line. Our technique was found to be reliable, valid, and accurate.

Return to Play After Platelet-Rich Plasma Injection for Elbow UCL Injury: Outcomes Based on Injury Severity.

BACKGROUND: Ulnar collateral ligament (UCL) injuries of the elbow are uncommon in the general population but prevalent in the athletic community, particularly among baseball players. Platelet-rich plasma (PRP) injection therapy has become a popular nonoperative adjuvant treatment for such injuries to help reduce recovery time and avoid surgery. PURPOSE/HYPOTHESIS: To analyze patient outcomes by injury severity and identify injury types that responded most favorably and unfavorably to PRP treatment. It was hypothesized that PRP therapy would prove to be most beneficial in the treatment of lower-grade, partial UCL tears and less effective in the treatment of more severe, complete UCL tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A cohort of 50 patients with UCL injuries in their dominant elbow, diagnosed by MRI (magnetic resonance imaging) arthrogram, underwent PRP therapy in conjunction with an established rehabilitation program. UCL injuries were classified by MRI as low-grade partial tear (Type I), high-grade partial tear (Type II), complete tear (Type III), or tear in more than 1 location (Type IV). RESULTS: In total, 24 of 39 (61.5%) Type I and II tears, 3 of 3 (100%) Type III tears, and 1 of 8 (12.5%) patients with Type IV tears responded to UCL PRP injection therapy and were able to return to play without surgery. Ten patients required subsequent UCL PRP injections, of which 3 (30%) were able to return to sport without surgery. CONCLUSION: PRP treatment for Types I and II UCL tears shows great promise when combined with physical therapy and a rehabilitation program. Type III UCL tears demonstrated a high rate of success, although with low cohort numbers. Type IV UCL tears did not appear to respond well to PRP injection therapy and often required surgical intervention or cessation of sport. Therefore, PRP treatment does not appear to be appropriate for patients with complete Type IV UCL tears but may enhance recovery and improve outcomes in throwing athletes with Types I, II, and III UCL injuries.

Relative Age Effect: Beyond the Youth Phenomenon.

Introduction. The relative age effect (RAE) refers to performance advantage of youth born in the first quarter of the birth year when auditioning for select, age-restricted sports. This advantage conferred to the older athlete is a result of being more physically and emotionally mature, therefore, assumed to be a more advanced player. We hypothesize an RAE exists in Olympic athletes, and this extends across selected categories of athletes (by gender), such as team versus individual sports, winter versus summer athletes, and sports using a ball versus those not using a ball. Methods. We extended the exploration of an RAE beyond specific sports by examining the birth quarter of more than 44 000 Olympic athlete's birthdates, born between 1964-1996. The data were summarized by birth quarter (January 1 to March 31, etc) and presented as percentages and 95% confidence intervals. Results. The fractions of births in the first versus the fourth quarter were significantly different ( P < .001) from each other for the summer and winter Olympians, ball and nonball sports, and team as well as individual sports. Conclusions. The general presence of an RAE in Olympic athletes exists regardless of global classification.

Relative age effect: beyond the youth phenomenon.

INTRODUCTION: Initially described in a sports context in ice hockey in 1985, the relative age effect (RAE) refers to the performance advantages of youth born in the first quarter of the birth year when trying-out for select, age-restricted sports. The competitive advantage bestowed to the relatively older athlete in their age band is the result of the older athlete being more physically and emotionally mature. These more mature players will likely go on to be exposed to better coaching, competition, teammates and facilities in their respective sport. OBJECTIVES: Our study sought to characterise the ubiquity of this effect by examining the birth distribution of some of the world's most elite athletes, Olympians. METHODS: We extended the exploration of the RAE beyond specific sports by examining the birth quarter of over 44 000 Olympic athlete's birthdates, born between 1964 and 1996. Our hypothesis was that the RAE would be prominent in both Olympic athletes as a whole and in selected subcategories of athletes. RESULTS AND CONCLUSION: The fractions of births in the first versus the fourth quarter were significantly different (p<0.001) from each other for the summer and winter Olympians, ball and non-ball sports, and team as well as individual sports. This significant difference was not gender specific. We found the general existence of the RAE in Olympic athletes regardless of global classification. Our findings suggest that coaching staff should be cognisant of the RAE when working with young athletes and should take relative age into consideration when evaluating a burgeoning athlete's abilities.

Blumensaat Line as a Prediction of Native Anterior Cruciate Ligament Length.

BACKGROUND: Graft-tunnel mismatch (GTM) is a condition in which the anterior cruciate ligament (ACL) graft is either too long or too short. GTM is particularly problematic when bone-patellar tendon-bone grafts are used because of a potential compromise in fixation of the bone plug on the tibia. HYPOTHESIS: The Blumensaat line (BL), a radiographic landmark representing the roof of the intercondylar fossa, will accurately approximate the native ACL (nACL) length and may aid in the prevention of GTM. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 130 patients (66 males, 64 females) underwent direct measurement of the nACL during knee arthroscopy. The lengths of the nACL and patellar ligament (PL) were measured intraoperatively, and BL length was measured on lateral knee radiographs. The nACL length was compared with PL and BL lengths to calculate the absolute difference (AD). Mean AD was calculated and used to determine mean percentage difference (MPD). Pearson correlation coefficients (CC) between BL, PL, and nACL length were calculated, along with inter- and intraobserver reliability coefficients for the measurement of BL. RESULTS: For male patients, the mean length of the nACL was 32.5 mm, BL was 30.4 mm, and PL was 49.2 mm. The AD between the BL and nACL was 2.4 ± 1.3 mm, MPD was 2.6% ± 1.9%, and CC was 0.88. The CC between the PL and nACL was 0.08. For female patients, the mean length of the nACL was 30.2 mm, BL was 27.5 mm, and PL was 44.4 mm. The AD between the BL and nACL was 2.7 ± 1.7 mm, MPD was 4.5% ± 2.4%, and CC was 0.93. The CC between the PL and nACL was 0.1. The inter- and intraobserver reliability coefficients for the measurement of BL were 0.86 and 0.83, respectively. CONCLUSION: A strong correlation was found between BL and nACL with a high inter- and intraobserver reliability. This correlation provides a simple and reliable method to closely approximate nACL length before reconstruction and may aid in the prevention of graft-tunnel mismatch.

Minimizing Graft-Tunnel Mismatch in Allograft Anterior Cruciate Ligament Reconstruction Using Blumensaat's Line: A Cadaveric Study.

PURPOSE: To evaluate the accuracy of Blumensaat's line (BL) in predicting the tendinous graft length and tibial tunnel length (TTL) in an independent-tunnel anterior cruciate ligament reconstruction (ACLR) using a bone-patellar tendon-bone (BTB) allograft. METHODS: Eighteen ACLRs were performed on cadaveric specimens using an anteromedial portal technique. All knees had no previous surgeries or deformities. Lateral knee radiographs of each specimen were taken prior to the ACLR, and BL was measured. Length-specific allografts for the tendinous portion of the grafts were then ordered by adding 20 mm to the length of BL. The TTL was predicted by subtracting BL and femoral tunnel length (FTL) from the overall graft length. Graft-tunnel mismatch (GTM) was recorded for each specimen. Statistical analysis compared overall results with the gold standard (0 mm) of GTM. RESULTS: The average lateral femoral condyle width measured in line with the femoral tunnel was 33 ± 3.43 mm. The average FTL was 25 ± 0.54 mm. The average intra-articular distance (IAD) between femoral and tibial tunnel apertures was 31 ± 3.65 mm. The average TTL was 35 ± 2.21 mm. The difference between the predicted TTL and the actual TTL was not statistically significant (P = .3). The mean GTM was -0.9 ± 3.15 mm. There was no statistically significant difference between the BL method and the gold standard (P = .45). The mean percent difference between BL and the IAD was 5.2%. CONCLUSIONS: The BL method can accurately predict the desired length for the tendinous portion of a BTB allograft as well as the TTL, thereby potentially minimizing GTM during arthroscopic BTB allograft ACLR. Patient-specific allografts can be ordered preoperatively based on BL. CLINICAL RELEVANCE: This method provides the surgeon a way to avoid GTM preoperatively by ordering patient-specific grafts prior to performing an independent-tunnel BTB allograft ACLR.

Single Versus Double-Bundle PCL Reconstruction: Scientific Rationale and Clinical Evidence.

PURPOSE OF REVIEW: The goal of this paper is to review the biomechanical and clinical rationale for single-bundle versus double-bundle posterior cruciate ligament (PCL) reconstruction. The primary question is whether there has been demonstrated any clear biomechanical or clinical superiority of a double-bundle reconstruction over a single-bundle reconstruction. RECENT FINDINGS: There is some recent evidence demonstrating biomechanical superiority of double-bundle versus single-bundle reconstruction; however, this is not definitive. Clinical superiority has not been clearly demonstrated as of yet. The primary question which served as the basis of this review remains unanswered. There is recent biomechanical data to suggest a potential benefit of double-bundle versus single-bundle reconstruction, but not all studies are in agreement. Furthermore, the possible biomechanical advantages have not yet been borne out in clinical studies. At this point, we cannot clearly recommend one technique versus another and the decision should be left to the treating surgeon.

Report of the 2017 Arthroscopy Association of North America Traveling Fellowship-A Fellowship Odyssey.

It was an honor to be selected to participate in the 2017 Arthroscopy Association of North America Advanced Arthroscopy Traveling Fellowship. This year's group included Michael J. Alaia, M.D., Assistant Professor and Associate Sports Medicine Fellowship Director at NYU Hospital for Joint Diseases; Nathan K. Endres, M.D., Associate Professor at the University of Vermont; LCDR Patrick W. Joyner, M.D., Assistant Professor at Naval Medical Center Portsmouth, and Head Physician East Coast Navy Seals; and LTC Christopher J. Tucker, M.D., Assistant Professor at the Uniformed Services University and Chief of Sports Service at Fort Belvoir Community Hospital. This year, we were honored to have a true pioneer in sports medicine and arthroscopic surgery, Dr. Jack M. Bert, Past President of Arthroscopy Association of North America and Adjunct Clinical Professor at the University of Minnesota, serve as our Godfather.

Biomechanical tensile strength analysis for medial patellofemoral ligament reconstruction.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is a surgery for acute and chronic dislocating patella. Several surgical techniques have been described. No biomechanical study has compared suture anchors, interference screws, and suspensory cortical fixation for MPFL reconstruction using human gracilis allograft. METHODS: Twelve human cadaver knees were used for the analysis of five MPFL reconstruction techniques on the femur (F) and patella (P): suspensory cortical (SC), interference screw (IS) and suture anchor (SA) fixation (SC-F/SC-P, SC-F/IS-P, SC-F/SA-P, IS-F/SC-P, IS-F/IS-P). Each method was examined six times, each using a new human gracilis allograft. The force necessary for 50% patellar displacement and 100% patellar displacement were recorded for each method. Additionally, we examined the peak force to fixation failure for all methods. Patella dislocation or loss of fixation was considered failure. RESULTS: SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P required force to failure greater than that of the native MPFL. The SC-F/IS-P required the largest force to failure. The SC-F/SA-P fixation technique required significantly less force to failure (P<0.05) than the native MPFL and significantly less force to failure (P<0.05) than all four other fixation techniques. All methods of fixation employing an interference screw failed secondary to graft pullout at the interference screw-bone interface. Methods employing suture anchors and two suspensory cortical fixations failed at the graft-suture anastomosis. CONCLUSION: SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P fixations were found to be stronger than the native MPFL, with the strongest being SC-F/IS-P.

Magnetic resonance imaging-based classification for ulnar collateral ligament injuries of the elbow.

BACKGROUND: Magnetic resonance imaging (MRI) arthrography has been considered the gold standard for imaging ulnar collateral ligament (UCL) injuries. No classification system has been described for UCL tears to help discuss and guide treatment options. We propose that an MRI-based UCL classification system would correlate with valgus laxity and help predict surgical management. METHODS: The MRIs from 240 patients who underwent UCL reconstruction were reviewed and classified according to a system based on severity and location of the UCL injury. Bilateral elbow valgus stress radiographs were used to compare the amount of valgus laxity associated with each grade of UCL injury. Additional data from the imaging review included intraligamentous calcifications, T-sign presence, and a newly described "vacuum sign." RESULTS: The amount of valgus stress opening increased with the classification severity as follows: type I, 0.13 mm; type II, 0.20 mm; type III, 0.63 mm; and type IV, 0.76 mm. CONCLUSIONS: We propose a new classification for UCL injuries based on MRI findings that helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes.

Stress fractures of the foot and ankle in athletes.

CONTEXT: Stress fractures of the foot and ankle are a common problem encountered by athletes of all levels and ages. These injuries can be difficult to diagnose and may be initially evaluated by all levels of medical personnel. Clinical suspicion should be raised with certain history and physical examination findings. EVIDENCE ACQUISITION: Scientific and review articles were searched through PubMed (1930-2012) with search terms including stress fractures and 1 of the following: foot ankle, medial malleolus, lateral malleolus, calcaneus, talus, metatarsal, cuboid, cuneiform, sesamoid, or athlete. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Stress fractures of the foot and ankle can be divided into low and high risk based upon their propensity to heal without complication. A wide variety of nonoperative strategies are employed based on the duration of symptoms, type of fracture, and patient factors, such as activity type, desire to return to sport, and compliance. Operative management has proven superior in several high-risk types of stress fractures. Evidence on pharmacotherapy and physiologic therapy such as bone stimulators is evolving. CONCLUSION: A high index of suspicion for stress fractures is appropriate in many high-risk groups of athletes with lower extremity pain. Proper and timely work-up and treatment is successful in returning these athletes to sport in many cases. Low-risk stress fracture generally requires only activity modification while high-risk stress fracture necessitates more aggressive intervention. The specific treatment of these injuries varies with the location of the stress fracture and the goals of the patient.

How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players with UCL injuries.

BACKGROUND: The dynamic stress radiograph of the elbow was designed to help the clinician better define valgus laxity and instability in the throwing athlete. However, no large study has quantified the amount of laxity in athletes with ulnar collateral ligament (UCL) injuries. We hypothesized that valgus stress radiographs in patients with UCL injuries will demonstrate a significantly greater amount of valgus stress opening of the dominant elbows compared with the nondominant elbow. METHODS: Bilateral elbow static and stress radiographs that were taken as part of our standard preoperative workup were retrospectively reviewed in 273 baseball players who had undergone UCL reconstruction. The valgus stress radiograph protocol used a Telos stress device (SE 2000) to provide 15 daN of stress in a standardized fashion. RESULTS: The thrower's elbow with a UCL injury opened 0.4 mm more than the uninjured side. Those with complete tears (N = 76), determined by magnetic resonance imaging findings, opened 0.6 mm on average, which was significantly more than in those with partial tears (N = 150), which opened an average of 0.1 mm. CONCLUSION: Stress radiography of the dominant elbow in baseball players with UCL injuries showed it to have 0.4 mm greater opening compared with the nondominant arm. Larger average openings (0.6 mm) can be expected with full-thickness UCL tears compared with partial-thickness tears (0.1 mm). This suggests that large openings on stress radiography may not be a critical component for predicting who will require surgical reconstruction for UCL injuries but may be more useful in differentiating complete from partial tears.

Functional outcome after percutaneous tendo-Achilles lengthening.

BACKGROUND: Percutaneous tendo-Achilles lengthening (PTAL) is a common procedure performed as an adjunct to other procedures that are used to treat a variety of foot and ankle disorders. Despite the widespread use of PTAL, the only literature to substantiate its efficacy comes from the treatment of forefoot ulceration in diabetics. The complications of the procedure include pain along the Achilles tendon, difficulty using stairs, weakness with toe-off, inadvertent complete tenotomy, and cosmetic appearance. We sought to investigate the functional outcomes specific to PTAL when performed in tandem with triple arthrodesis and subtalar fusion. MATERIALS AND METHODS: A retrospective review of 107 patients who underwent 117 procedures was performed. Outcomes were assessed by telephone interview using a standard questionnaire. The most common procedure in the study population was triple arthrodesis (91%). RESULTS: Fifty-eight percent of the patients reported moderate improvement in motion postoperatively, but 80% reported some degree of persistent stiffness. Despite 38% of patients reporting postoperative weakness, 66% and 61% stated that ascending and descending stairs, respectively, was easier. CONCLUSION: Overall, 81% of the study population had a positive opinion regarding their surgery. In this heterogeneous population, we showed modest improvement in Achilles tendon-related outcomes when PTAL was performed in tandem with other surgeries.