Augmentation of triceps tendon repair with a bio-inductive collagen scaffold.

Two active, adult male patients, one with prior triceps rupture and direct repair, presented with traumatic rupture of the distal triceps tendon. MRI confirmed not only complete rupture with retraction in both, but also signal changes within the tendon, raising concern for healing potential and re-rupture. Surgical repair was performed using heavy, non-absorbable suture and suture anchors in the standard fashion, followed by augmentation with a bovine, bio-inductive collagen scaffold in order to increase tendon thickness and aid with healing capability. This technique is well described for rotator cuff repair augmentation but is a novel technique to the literature in the setting of triceps tendons repair. Both patients returned to full, preinjury activity without complication with sustained results at 3 and 3.5 years postoperatively.

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

A Case Report of Bilateral Lipoma Arborescens: An Unusual Consideration for Knee Pain.

Introduction: Lipoma arborescens (LAs) is a benign, intra-articular proliferation of fat cells in villous projections, creating a tree-like pattern on magnetic resonance imaging (MRI). The suprapatellar pouch is usually affected, and symptoms are typically gradual in nature, and patients may report painless swelling of the knee. Only ten cases of bilateral LA have been reported in the literature so far. Early recognition of this disease process and treatment may help to prevent prolonged symptoms and delays in care. Case Report: A 49-year-old female with bilateral knee pain and intermittent swelling for over 20 years presented to our clinic with complaints of bilateral knee pain and swelling. She had previous steroid injection but no relief. After MRI was obtained concerning for LA, a surgical discussion was had with the patient about arthroscopic removal. She elected to proceed with surgery and underwent arthroscopic debridement of both knees. At her follow-up at 6 months for the right knee and 2 months for the left knee, she had a significant improvement in pain and quality of life. Conclusion: LA of the knee is a rare condition, particularly bilateral, and in this patient, the diagnosis was missed for many years, and her definitive treatment was delayed. In her case, arthroscopic debridement of her bilateral LA proved to be a viable treatment option which significantly improved the patient's quality of life and function.

A Sleepwalking Patient Presenting with Concomitant ACL, PCL, and Meniscal Root Avulsion Fractures: A Case Report.

Introduction: Tibial-sided anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) avulsion fractures compose a rare subset of cruciate ligament injuries. Fixation strategies are mixed in the literature, particularly regarding the PCL, which has traditionally been addressed using an open approach. Case Report: A 41-year-old male sustained avulsion fractures of the tibial eminence involving the ACL, PCL, and posterior medial meniscal root through an unknown mechanism while sleepwalking. Surgical treatment comprised of entirely arthroscopic reduction and transtibial suture fixation. Only seven cases of combined ACL/PCL avulsion fracture have been reported and all but one utilized open fixation for at least the PCL and restricted weight-bearing postoperatively. Conclusion: This previously unreported triad of injury was successfully managed arthroscopically, negating a posterior approach to the knee. Early post-operative weight-bearing and aggressive range of motion aided in swift recovery and a favorable outcome.

Quadruple Hamstring Autograft Technique for Anterior Cruciate Ligament Reconstruction Reduces Allograft Augmentation.

Purpose: To assess the discrepancy in graft diameter between double- and quadruple-folded hamstring autografts and the need for allograft augmentation to obtain an adequate graft diameter during arthroscopic anterior cruciate ligament reconstruction. Methods: All patients undergoing anterior cruciate ligament reconstruction with hamstring autograft between 2017 and 2021 at a single institution by a single surgeon were identified. The surgeon changed from double-folded hamstring autograft to quadruple-folded hamstring autograft within the study period. Results: A total of 191 patients were identified, of whom 57 received double-folded autografts and 134 quadruple-folded autografts. Patient characteristics between cohorts were similar. Median double-folded graft size (7.5 mm; interquartile range, 7.0-8.0 mm) was significantly thinner than the quadruple-folded graft size (9 mm; interquartile range, 8.5-9.5 mm, P = .001). Quadruple-folded autograft was less likely to require an allograft augmentation than the double-folded autograft (0.7% vs 26.3%) (odds ratio 0.02; 95% confidence interval 0.00-0.16; P < .001). Conclusions: Quadruple-folded hamstring autograft provides a larger graft diameter and reduced need for allograft augmentation. Level of Evidence: Level III, retrospective comparative study.

Perceptual-Motor Efficiency and Concussion History Are Prospectively Associated With Injury Occurrences Among High School and Collegiate American Football Players.

BACKGROUND: After a sport-related concussion (SRC), the risk for lower extremity injury is approximately 2 times greater, and the risk for another SRC may be as much as 3 to 5 times greater. PURPOSE: To assess the predictive validity of screening methods for identification of individual athletes who possess an elevated risk of SRC. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Metrics derived from a smartphone flanker test software application and self-ratings of both musculoskeletal function and overall wellness were acquired from American high school and college football players before study participation. Occurrences of core or lower extremity injury (CLEI) and SRC were documented for all practice sessions and games for 1 season. Receiver operating characteristic and logistic regression analyses were used to identify variables that provided the greatest predictive accuracy for CLEI or SRC occurrence. RESULTS: Overall, there were 87 high school and 74 American college football players included in this study. At least 1 CLEI was sustained by 45% (39/87) of high school players and 55% (41/74) of college players. Predictors of CLEI included the flanker test conflict effect ≥69 milliseconds (odds ratio [OR], 2.12; 90% CI, 1.24-3.62) and a self-reported lifetime history of SRC (OR, 1.70; 90% CI, 0.90-3.23). Of players with neither risk factor, only 38% (29/77) sustained CLEI compared with 61% (51/84) of players with 1 or both of the risk factors (OR, 2.56; 90% CI, 1.50-4.36). SRC was sustained by 7 high school players and 3 college players. Predictors of SRC included the Overall Wellness Index score ≤78 (OR, 9.83; 90% CI, 3.17-30.50), number of postconcussion symptoms ≥4 (OR, 8.35; 90% CI, 2.71-25.72), the Sport Fitness Index score ≤78 (OR, 5.16; 90% CI, 1.70-15.65), history of SRC (OR, 4.03; 90% CI, 1.35-12.03), and the flanker test inverse efficiency ratio ≥1.7 (OR, 3.19; 90% CI, 1.08-9.47). CONCLUSION: Survey responses and smartphone flanker test metrics predicted greater injury incidence among individual football players classified as high-risk compared with that for players with a low-risk profile.

Revision Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament injuries continue to occur despite efforts to educate pitchers, coaches, and families at the amateur and professional levels about pitch counts, mechanics, and injury prevention. Although the data on the incidence of ulnar collateral ligament reconstructions are inconclusive, an increase in these reconstructions may mean a corresponding increase in the number of reconstruction failures and revision reconstruction surgeries. Less is known about the outcomes of revision ulnar collateral ligament reconstruction; not unexpectedly, early results are not as promising as those observed with primary reconstruction. In response, interest in revision techniques, rehabilitation, and outcomes of revision ulnar collateral ligament reconstruction surgeries has grown.

Viable Stem Cells Are in the Injury Effusion Fluid and Arthroscopic Byproducts From Knee Cruciate Ligament Surgery: An In Vivo Analysis.

PURPOSE: To examine the number of viable stem cells contained in the postinjury effusion fluid and the waste byproducts of arthroscopic cruciate ligament surgery. METHODS: This study included patients older than 18 years of age with acute (<5 weeks old) cruciate ligament injuries requiring arthroscopic surgery. The postinjury effusion fluid (effusion fluid), fat pad and cruciate ligament stump debridement tissue (byproduct tissue), and arthroscopic fluid collected during fat pad and/or stump debridement (byproduct fluid) were collected at the time of surgery from 30 individuals. Specimens were analyzed, investigating cell viability, nucleated cell counts, cell concentrations, colony-forming unit assays, and flow cytometry. Samples from the first 20 individuals were collected in small specimen containers, and samples from the last 10 individuals were collected in larger specimen containers. RESULTS: Cells of the injury effusion exhibited the greatest viability (86.4 ± 1.31%) when compared with the small volume harvest byproduct tissue (50.2 ± 2.5%, P = .0001), small volume harvest byproduct fluid (48.8 ± 1.88%, P = .0001), large volume harvest byproduct tissue (70.1 ± 5.6%, P = .0001), and large volume harvest byproduct fluid (60.3 ± 3.41%, P = .0001). The culture analysis of fibroblast colony-forming units found on average 1916 ± 281 progenitor cells in the effusion fluid, 2488 ± 778 progenitor cells in the byproduct tissue, and 2357 ± 339 progenitor cells in the byproduct fluid. Flow cytometry confirmed the presence of immature cells and the presence of cells with markers typically expressed by known stem cell populations. CONCLUSIONS: Viable stem cells are mobilized to the postinjury effusion at the time of cruciate ligament injury and can be found in the byproduct waste of cruciate ligament surgery. CLINICAL RELEVANCE: The methodology around effusion fluid and byproduct tissue capture during cruciate ligament surgery should be investigated further. Cell amounts available from these tissues with current technologies are not sufficient for immediate evidence-based clinical application.

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.

Ulnar collateral ligament injuries in the throwing athlete.

Repetitive valgus forces on the throwing elbow place significant stress on that joint. This stress can cause structural damage and injury to the ulnar collateral ligament. Many acute injuries of the throwing elbow are caused by repetitive chronic wear. Although much work has been done on injury prevention in youth who are pitchers, overuse injury in throwing sports constitutes an epidemic. Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition.