Multirater agreement of the causes of anterior cruciate ligament reconstruction failure: a radiographic and video analysis of the MARS cohort.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction failure occurs in up to 10% of cases. Technical errors are considered the most common cause of graft failure despite the absence of validated studies. Limited data are available regarding the agreement among orthopaedic surgeons regarding the causes of primary ACL reconstruction failure and accuracy of graft tunnel placement. HYPOTHESIS: Experienced knee surgeons have a high level of interobserver reliability in the agreement about the causes of primary ACL reconstruction failure, anatomic graft characteristics, and tunnel placement. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: Twenty cases of revision ACL reconstruction were randomly selected from the Multicenter ACL Revision Study (MARS) database. Each case included the patient's history, standardized radiographs, and a concise 30-second arthroscopic video taken at the time of revision demonstrating the graft remnant and location of the tunnel apertures. All 20 cases were reviewed by 10 MARS surgeons not involved with the primary surgery. Each surgeon completed a 2-part questionnaire dealing with each surgeon's training and practice, as well as the placement of the femoral and tibial tunnels, condition of the primary graft, and the surgeon's opinion as to the causes of graft failure. Interrater agreement was determined for each question with the kappa coefficient and the prevalence-adjusted, bias-adjusted kappa (PABAK). RESULTS: The 10 reviewers have been in practice an average of 14 years and have performed at least 25 ACL reconstructions per year, and 9 were fellowship trained in sports medicine. There was wide variability in agreement among knee experts as to the specific causes of ACL graft failure. When participants were specifically asked about technical error as the cause for failure, interobserver agreement was only slight (PABAK = 0.26). There was fair overall agreement on ideal femoral tunnel placement (PABAK = 0.55) but only slight agreement on whether a femoral tunnel was too anterior (PABAK = 0.24) and fair agreement on whether it was too vertical (PABAK = 0.46). There was poor overall agreement for ideal tibial tunnel placement (PABAK = 0.17). CONCLUSION: This study suggests that more objective criteria are needed to accurately determine the causes of primary ACL graft failure as well as the ideal femoral and tibial tunnel placement in patients undergoing revision ACL reconstruction.

Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort.

BACKGROUND: Graft survivorship, reinjury rates, and career length are poorly understood after anterior cruciate ligament (ACL) reconstruction in the elite collegiate athlete. The purpose of this study was to examine the outcomes of ACL reconstruction in a National Collegiate Athletic Association (NCAA) Division I athlete cohort. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective chart review was performed of all Division I athletes at a single public university from 2000 to 2009 until completion of eligibility. Athletes were separated into 2 cohorts: those who underwent precollegiate ACL reconstruction (PC group) and those who underwent intracollegiate reconstruction (IC group). Graft survivorship, reoperation rates, and career length information were collected. RESULTS: Thirty-five athletes were identified with precollegiate reconstruction and 54 with intracollegiate reconstruction. The PC group had a 17.1% injury rate with the original graft, with a 20.0% rate of a contralateral ACL injury. For the IC group, the reinjury rates were 1.9% with an ACL graft, with an 11.1% rate of a contralateral ACL injury after intracollegiate ACL reconstruction. The athletes in the PC group used 78% of their total eligibility (average, 3.11 years). The athletes in the IC group used an average of 77% of their remaining NCAA eligibility; 88.3% of those in the IC group played an additional non-redshirt year after their injury. The reoperation rate for the PC group was 51.4% and was 20.4% for the IC group. CONCLUSION: Reoperation and reinjury rates are high after ACL reconstruction in the Division I athlete. Precollegiate ACL reconstruction is associated with a very high (37.1%) rate of repeat ACL reinjuries to the graft or opposite knee. The majority of athletes are able to return to play after successful reconstruction.

Athletic performance and vitamin D.

PURPOSE: Activated vitamin D (calcitriol) is a pluripotent pleiotropic secosteroid hormone. As a steroid hormone, which regulates more than 1000 vitamin D-responsive human genes, calcitriol may influence athletic performance. Recent research indicates that intracellular calcitriol levels in numerous human tissues, including nerve and muscle tissue, are increased when inputs of its substrate, the prehormone vitamin D, are increased. METHODS: We reviewed the world's literature for evidence that vitamin D affects physical and athletic performance. RESULTS: Numerous studies, particularly in the German literature in the 1950s, show vitamin D-producing ultraviolet light improves athletic performance. Furthermore, a consistent literature indicates physical and athletic performance is seasonal; it peaks when 25-hydroxy-vitamin D [25(OH)D] levels peak, declines as they decline, and reaches its nadir when 25(OH)D levels are at their lowest. Vitamin D also increases the size and number of Type II (fast twitch) muscle fibers. Most cross-sectional studies show that 25(OH)D levels are directly associated with musculoskeletal performance in older individuals. Most randomized controlled trials, again mostly in older individuals, show that vitamin D improves physical performance. CONCLUSIONS: Vitamin D may improve athletic performance in vitamin D-deficient athletes. Peak athletic performance may occur when 25(OH)D levels approach those obtained by natural, full-body, summer sun exposure, which is at least 50 ng x mL(-1). Such 25(OH)D levels may also protect the athlete from several acute and chronic medical conditions.

Effects of wearing foot orthosis with medial arch support on the fifth metatarsal loading and ankle inversion angle in selected basketball tasks.

STUDY DESIGN: Preintervention and post-intervention, repeated-measures experimental design. OBJECTIVES: The objective was to investigate the effects of foot orthoses with medial arch support on ankle inversion angle and plantar forces and pressures on the fifth metatarsal during landing for a basketball lay-up and during the stance phase of a shuttle run. BACKGROUND: Proximal fractures of the fifth metatarsal, specifically the Jones fracture, are common in sports. Wearing foot orthoses with medial arch support could increase the ankle inversion angle and the plantar forces and pressure on the fifth metatarsal that may increase the risk for fifth metatarsal fracture, METHODS AND MEASURES: Three-dimensional (3-D) videographic, force plate, and in-shoe plantar force and pressure data were collected during landing after a basketball lay-up and during the stance phase of a shuttle run with and without foot orthoses with medial arch support for 14 male subjects. Two-way ANOVAs with repeated measures were performed to compare ankle inversion angle, maximum forces, and pressure on the fifth metatarsal head and base between conditions and between tasks. RESULTS: The maximum ankle inversion angle and maximum plantar force and pressure on the base of the fifth metatarsal during both tasks as well as the maximum plantar force and pressure on the head of the fifth metatarsal during the stance of the shuttle run were significantly increased (P< or =026) when wearing foot orthoses. No significant differences were found in the maximum vertical ground reaction forces between foot orthotic conditions. CONCLUSION: Generic use of off-the-shelf foot orthoses with medial arch support causes increased plantar forces and pressures on the fifth metatarsal and may increase the risk for proximal fracture of the fifth metatarsal. Future studies are needed to investigate this risk, acknowledging that the differences noted in our study were small in magnitude and the foot type was not measured.

Intramedullary screw fixation of Jones fractures. Analysis of failure.

Treatment failures after screw fixation of Jones fractures are reported to be infrequent. Between 1993 and 1999, 15 patients (mean age, 21.7 years) underwent cannulated screw fixation of a Jones fracture at our institution. There were six treatment failures: four refractures and two symptomatic nonunions. The mean time to full activity was 6.8 weeks for the patients with failure compared with 9 weeks for patients who did not have complications. Although all patients were asymptomatic and radiographically progressing to union before return to full activity, only one of six patients with failures had complete radiographic union, compared with six of seven patients with no complications. There was a higher proportion of elite athletes (division I or professional level) among the failure group (83%) compared with those without complications (11%). There were no significant differences in age, sex, screw diameter, use of bone graft, or age of fracture between patients with failures and those without complications. Return to full activity, especially among elite athletes, before complete radiographic union was predictive of failure. Even though intramedullary screw fixation offers advantages over nonoperative treatment, a significant risk of postoperative complications exists.