Correlation between higher lateral tibial slope and inferior long term subjective outcomes following single bundle anterior cruciate ligament reconstruction.

BACKGROUND: The impact of anatomical factors, such as the lateral tibial slope (LTS), on outcomes following anterior cruciate ligament (ACL) reconstruction is an area of growing interest. This study was led by the observation that patients with a higher LTS may have different recovery trajectories. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate the correlation between a higher LTS and long term subjective outcomes following single-bundle ACL reconstruction. STUDY DESIGN: This study was designed as a retrospective cohort study. METHODS: The study comprised 138 patients who underwent single-bundle ACL reconstruction. The LTS was measured on preoperative radiographs. Patient-reported outcome measures (PROMs) were collected, which included the Lysholm Knee Score, UCLA Activity Score, IKDC Score, and Tegner Activity Score, over a mean follow-up duration of 137 months. RESULTS: A significant negative correlation was found between LTS and all measured PROMs (p < 0.001). The established cut-off value of LTS distinguishing between "Good" and "Fair" Lysholm scores was 8.35 degrees. Female patients have statistically significant higher LTS and lower PROMs scores than male. Patients with LTS greater than or equal to 8.35 had significantly lower PROMs, indicative of poorer functional and subjective outcomes. CONCLUSION: Our findings suggest that a higher LTS is associated with inferior subjective outcomes following single-bundle ACL reconstruction in long term. The LTS cut-off value of 8.35 degrees could potentially be used as a reference in preoperative planning and patient counseling. CLINICAL RELEVANCE: Understanding the relationship between LTS and ACL reconstruction outcomes could inform surgical planning and postoperative management. These findings highlight the need to consider anatomical variances, such as LTS, when assessing patient-specific risks and recovery expectations, contributing to the advancement of personalized care in sports medicine.

Enhanced reliability and time efficiency of deep learning-based posterior tibial slope measurement over manual techniques.

PURPOSE: Multifaceted factors contribute to inferior outcomes following anterior cruciate ligament (ACL) reconstruction surgery. A particular focus is placed on the posterior tibial slope (PTS). This study introduces the integration of machine learning and artificial intelligence (AI) for efficient measurements of tibial slopes on magnetic resonance imaging images as a promising solution. This advancement aims to enhance risk stratification, diagnostic insights, intervention prognosis and surgical planning for ACL injuries. METHODS: Images and demographic information from 120 patients who underwent ACL reconstruction surgery were used for this study. An AI-driven model was developed to measure the posterior lateral tibial slope using the YOLOv8 algorithm. The accuracy of the lateral tibial slope, medial tibial slope and tibial longitudinal axis measurements was assessed, and the results reached high levels of reliability. This study employed machine learning and AI techniques to provide objective, consistent and efficient measurements of tibial slopes on MR images. RESULTS: Three distinct models were developed to derive AI-based measurements. The study results revealed a substantial correlation between the measurements obtained from the AI models and those obtained by the orthopaedic surgeon across three parameters: lateral tibial slope, medial tibial slope and tibial longitudinal axis. Specifically, the Pearson correlation coefficients were 0.673, 0.850 and 0.839, respectively. The Spearman rank correlation coefficients were 0.736, 0.861 and 0.738, respectively. Additionally, the interclass correlation coefficients were 0.63, 0.84 and 0.84, respectively. CONCLUSION: This study establishes that the deep learning-based method for measuring posterior tibial slopes strongly correlates with the evaluations of expert orthopaedic surgeons. The time efficiency and consistency of this technique suggest its utility in clinical practice, promising to enhance workflow, risk assessment and the customization of patient treatment plans. LEVEL OF EVIDENCE: Level III, cross-sectional diagnostic study.

Anatomic versus Low Tibial Tunnel in Double-Bundle Posterior Cruciate Ligament Reconstruction: Clinical and Radiologic Outcomes with a Minimum 2-Year Follow-Up.

There is currently no consensus on the optimal placement of the tibial tunnel for double-bundle posterior cruciate ligament (PCL) reconstruction. The purpose of this study was to compare the clinical and radiologic outcomes of double-bundle PCL reconstruction utilizing anatomic versus low tibial tunnels. We conducted a retrospective cohort study involving patients who underwent double-bundle PCL reconstruction between Jan 2019 and Jan 2022, with a minimum follow-up of 2 years (n = 36). Based on the tibial tunnel position on postoperative computed tomography, patients were categorized into two groups: anatomic placement (group A; n = 18) and low tunnel placement (group L; n = 18). We compared the range of motion, stability test, complications, and side-to-side differences in tibial posterior translation using kneeling stress radiography between the two groups. There were no significant differences between the groups regarding clinical outcomes or complication rates. No significant differences in the posterior drawer test and side-to-side difference on kneeling stress radiography (2.5 ± 1.2 mm in group A vs. 3.7 ± 2.0 mm in group L; p = 0.346). In conclusion, the main findings of this study indicate that both anatomic tunnel and low tibial tunnel placements in double-bundle PCL reconstruction demonstrated comparable and satisfactory clinical and radiologic outcomes, with similar overall complication rates at the 2-year follow-up.

Addition of Preoperative Ultrasound-Guided Suprascapular Nerve Block and Axillary Nerve Block to Parecoxib Is More Effective in Early Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: A Prospective Randomized Controlled Study.

PURPOSE: To prospectively compare pain intensity and patient-reported outcomes (PROs) after arthroscopic rotator cuff repair (ARCR) between patients who received ultrasound-guided suprascapular nerve block (SSNB) and axillary nerve block (ANB) as well as preincisional parecoxib and patients who received preincisional parecoxib only. METHODS: Sixty-one patients receiving ARCR between March 2020 and March 2021 were prospectively enrolled. They were randomly assigned to the peripheral nerve block group (group N, n = 30) or control group (group C, n = 31). Two patients in group C were excluded because of miscommunication. All patients were administered 40 mg of parecoxib intravenously prior to induction of anesthesia. SSNB and ANB were performed after general anesthesia in group N, whereas no nerve block was performed in group C. Pain intensity was compared before surgery, as well as immediately, 24 hours, and 2 weeks after surgery. PROs, including the Oxford Shoulder Score, University of California-Los Angeles shoulder score, and Single Assessment Numeric Evaluation score, were compared before and 6 months after surgery. RESULTS: The numerical rating scale (NRS) score for resting pain was significantly lower in group N (4.9 ± 3.1 vs 7.6 ± 2.5, P < .001) immediately after surgery, but no difference was noted 24 hours after surgery. The resting pain NRS score 2 weeks after surgery was significantly lower in group N (1.4 ± 1.6 vs 2.7 ± 2.7, P = .03), but the scores for movement-evoked pain and night pain were similar. All PROs significantly improved 6 months after surgery in both groups, but there was no difference between the 2 groups. CONCLUSIONS: The addition of preoperative ultrasound-guided SSNB and ANB to parecoxib offered better resting pain control immediately and 2 weeks after ARCR, but there was no benefit for PROs 6 months after surgery. LEVEL OF EVIDENCE: Level II, prospective randomized controlled trial.

Relationship between shoulder and elbow range of motion and ultrasonographic structural abnormalities in the elbow of Taiwanese high school baseball players.

BACKGROUND: Ultrasonographic structural abnormalities are regarded as one of the risk factors of elbow injuries. Elbow injuries are commonly associated with decreased shoulder/elbow range of motion (ROM). The purpose of this study is to determine the relationship between shoulder/elbow ROM and elbow ultrasonographic structural abnormalities in Taiwan high school baseball players. METHODS: A total of 533 Taiwan high school baseball players were enrolled. Physical examinations including measurements on shoulder/elbow ROM and elbow sonographic examinations were performed and recorded by professional physicians. The analyses were conducted in three subgroups according to their defensive position because the training programs were different. All players pooled, pitchers-only, and fielders-only, due to several demographic differences among these subgroups. In all the subgroups, univariate analyses were conducted separately for participants with and those without elbow ultrasonographic structural abnormalities, and then multivariate analyses were conducted to identify factors significantly related. The odds ratios (ORs) were used to estimate the risk of elbow ultrasonographic structural abnormalities. RESULTS: Demographic data showed that pitchers had taller body height (P < 0.001) and greater elbow flexion/extension ROM (P < 0.001). When all players were pooled, significant risk factors included started playing baseball at an younger age (OR = 1.202; 95% CI = 1.064-1.357; P = 0.003), longer experience of official baseball (OR = 1.154; 95% CI = 1.038-1.283; P = 0.008), lower total shoulder rotation angle (OR = 1.007; 95% CI = 1.000-1.014; P = 0.050), and less total elbow arm angle (OR = 1.052; 95% CI = 1.017-1.088; P = 0.003) For pitchers, significant risk factors included longer experience of official baseball (OR = 1.342; 95% CI = 1.098-1.640; P = 0.004), lower total shoulder rotation angle (OR = 1.016; 95% CI = 1.004-1.027; P = 0.006), and lower total elbow arm angle (OR = 1.075; 95% CI = 1.024-1.129; P = 0.004) (Table 5). There were no significant risk factors for elbow structural abnormalities in fielders. CONCLUSION: For Taiwan high school pitchers, longer official baseball experience, decreased shoulder total rotational angle, and decreased elbow total flexion/extension angle, were related to ultrasonographic structural abnormalities in elbows.

The increased lateral tibial slope may result in inferior long-term clinical outcome after DB-ACL reconstruction.

PURPOSE: To determine if there is a correlation between lateral tibial slope and long-term clinical results in patients who underwent double-bundle ACL reconstruction. METHODS: We retrospectively reviewed patients that received double-bundle ACL reconstruction at a single institution by a single surgeon from January 2011 to December 2014. All the magnetic resonance imaging were reviewed and lateral tibial slopes (LTS) were recorded by an experienced surgeon and rechecked by the other two authors of this study that specialized in orthopedic knee surgery. The relationship between PROMs measurement and lateral tibial slope were analyzed. The patients were then separated into two groups (LTS > 7.4° and < 7.4°) according to the previous study. RESULTS: A total of 119 patients were enrolled in this study. All enrolled patients were followed for at least 8 years. The PROMS result were negatively correlated with the lateral tibial slope (p values all < 0.001). The patients with high lateral tibial slope had significantly lower PROMS values (Lysholm 94.26 ± 5.61 vs 80.15 ± 8.28, p = 0.013; IKDC 82.99 ± 4.55 vs 70.09 ± 7.15, p = 0.003; Tegner 9.32 ± 0.95 vs 6.85 ± 1.99, p < 0.001). Finally, the LTS cutoff value between patients with "Good" and "Fair" Lysholm score in our study was 7.55 degrees. CONCLUSIONS: Patients with high lateral tibial slope may result in inferior long-term subjective outcomes. The using of double-bundle ACL reconstruction along cannot overcome the negative impact caused by steep lateral tibial slope. A lateral tibial slope of 7.55° may be used as a cut-off for a good clinical outcome. LEVEL OF EVIDENCE: III retrospective comparative prognostic trial.

Feasibility of predicting maximal oxygen uptake by using the efficiency factor in healthy men.

Conventionally, efficiency is indirectly estimated through a respiratory gas analyser (oxygen, carbon dioxide), which is a complex and rather costly calculation method that is difficult to perform in many situations. Therefore, the present study proposed a modified definition of efficiency, called the efficiency factor (EF) (i.e., the ratio of work to the corresponding exercise intensity), and evaluated the relation between the EF and maximal oxygen uptake ([Formula: see text]), as well as compared the prediction models established based on the EF. The heart rate (maximal heart rate: 186 ± 6 beats min-1), rating of perceived exertion (19 ± 1), and [Formula: see text] (39.0 ± 7.1 mL kg-1 min-1) of 150 healthy men (age: 20 ± 2 years; height: 175.0 ± 6.0 cm; weight: 73.6 ± 10.7 kg; body mass index [BMI]: 24.0 ± 3.0 kg m-2; percent body fat [PBF]: 17.0 ± 5.7%) were measured during the cardiopulmonary exercise test (CPET). Through multiple linear regression analysis, we established the BMI model using age and BMI as parameters. Additionally, we created the PBF modelHRR utilizing weight, PBF, and heart rate reserve (HRR) and developed PBF modelEF6 and PBF modelEF7 by incorporating EF6 from the exercise stage 6 and EF7 from the exercise stage 7 during the CPET, respectively. EF6 (r = 0.32, p = 0.001) and EF7 (r = 0.31, p = 0.002) were significantly related to [Formula: see text]. Among the models, the PBF modelEF6 showed the highest accuracy, which could explain 62.6% of the variance in the [Formula: see text] at with a standard error of estimate (SEE) of 4.39 mL kg-1 min-1 (%SEE = 11.25%, p < 0.001). These results indicated that the EF is a significant predictor of [Formula: see text], and compared to the other models, the PBF modelEF6 is the best model for estimating [Formula: see text].

Arthroscopic Lower Trapezius Tendon Transfer for a Patient with Axillary Nerve Injury and Concomitant Rotator Cuff Tear: A Case Report and Technical Notes.

Introduction: Concomitant nerve injuries with musculoskeletal injuries present a challenging problem. The goals of nerve reconstruction for the shoulder include shoulder abduction and external rotation. When patients fail to achieve acceptable shoulder external rotation and shoulder abduction, tendon transfers such as trapezius transfer offer a reliable option in the subsequent stage. Case Presentation: A 32-year-old male presented with weak external rotation in his left shoulder, after previous axillary nerve reconstruction. He received the ipsilateral lower trapezius transfer with the aim of improving the external rotation. Discussion: The lower trapezius restores a better joint reaction force in both the compressive-distractive and anterior-posterior balancing and provides a centering force through the restoration of the anterior-posterior force couple. Conclusion: We believe that the ipsilateral lower trapezius transfer to the infraspinatus is a good outcome and is effective in improving overall shoulder stability and the shoulder external rotation moment arm or at least maintaining in neutral position with the arm fully adducted in patients with post axillary nerve injuries post unsatisfactory nerve reconstruction to increase the quality of life and activities of daily living.

Using Single Peroneal Longus Tendon Graft for Segmental Meniscus Transplantation and Revision Anterior Cruciate Ligament Combined Anterolateral Reconstruction.

This case report describes a new approach to segmental meniscal reconstruction using a peroneal longus autograft in a patient with recurrent traumatic medial meniscus tear and anterior cruciate ligament reconstruction (ACLR) failure. While allograft meniscal transplantation is the preferred method for treating meniscal deficiency, its high cost and various legal regulations have limited its widespread use. Autologous tendon grafts have been proposed as a substitute for allograft meniscus transplantation, but their initial results were poor, leading to little progress in this area. However, recent animal experiments and clinical studies have demonstrated promising results in using autologous tendon grafts for meniscal transplantation, including improvements in pain and quality of life for patients. Further research is needed to evaluate the effectiveness of segmental meniscal reconstruction using autologous tendon grafts, but it could potentially lead to more accessible and cost-effective treatment options for patients with meniscal deficiency.

Arthroscopic-assisted reduction and internal fixation for complex tibial plateau fracture: radiographic and clinical outcomes with 2- to 15-year follow-up.

BACKGROUND: To investigate the radiologic and prognostic outcomes after using arthroscopic-assisted reduction and internal fixation (ARIF) in complex tibial plateau fractures with mid- to long-term follow-up. METHODS: This retrospective study reviewed complex tibial plateau fractures that underwent ARIF from 1999 to 2019. Radiologic outcomes, including tibial plateau angle (TPA), posterior slope angle (PSA), Kellgren-Lawrence classification and Rasmussen radiologic assessment, were measured and evaluated. The prognosis and complications were assessed by the Rasmussen clinical assessment with a minimum follow-up of 2 years. RESULTS: Ninety-two consecutive patients (mean age: 46.9 years) with a mean follow-up of 74.8 months (24-180) were included in our series. Using AO classification, there were 20 type C1 fractures, 21 type C2 fractures, and 51 type C3 fractures. All the fractures achieved solid union. TPA was maintained well on average at the last follow-up and showed no significant difference compared to postoperatively (p = 0.208). In the sagittal plane, the mean PSA increased from 9.3 ± 2.9° to 9.6 ± 3.1° (p = 0.092). A statistically significant increase in PSA was also noted in the C3 group (p = 0.044). Superficial or deep infection was noted in 4 cases (4.3%), and total knee arthroplasty (TKA) was performed in 2 cases (2.2%) due to grade 4 osteoarthritis (OA). Ninety (97.8%) and 89 (96.7%) patients had good or excellent results in the Rasmussen radiologic assessment and Rasmussen clinical assessment, respectively. CONCLUSIONS: The complex tibial plateau fracture could be treated successfully using arthroscopy-assisted reduction and internal fixation. Most patients achieve excellent and good clinical outcomes with low complication rates. In our experience, a higher incidence of increased slope was noted, especially in type C3 fractures. Reduction of the posterior fragment should be done cautiously during the operation. LEVELS OF EVIDENCE: Level III.

Reconstruction of High-Grade Trochlea Dysplasia in a Young Female with Recurrent Patella Dislocation: A Case Report.

The patellofemoral joint involves a combination of bony structures and soft tissues to maintain stability. Patella instability is a disabling condition, and the cause is multifactorial. The main risk factors include patella alta, trochlea dysplasia, excessive tibial tuberosity to trochlea grove (TT-TG) distance, and excessive lateral patella tilt. In this case report, we highlight the thinking process of diagnosis and method for selecting the optimal treatment in accordance with the guidelines by Dejour et al. when we are presented with a patient with patella instability. A 20-year-old Asian woman without underlying medical conditions, presented with recurrent (>3 episodes) right patella dislocation for 7 years. Investigations revealed a type D trochlea dysplasia, increased TT-TG distance, and excessive lateral tilt angle. She underwent trochlea sulcus deepening, sulcus lateralization and lateral facet elevation, lateral retinacular release, and medial quadriceps tendon-femoral ligament (MQTFL) reconstruction. Due to the complexity behind the anatomy and biomechanics of patella instability, an easy-to-follow treatment algorithm is essential for the treating surgeon to provide effective and efficient treatment. MQTFL reconstruction is recommended for recurrent patella dislocation due to satisfactory clinical and patient reported outcomes and a reduced risk of iatrogenic patella fracture. Controversies for surgical indication in lateral retinacular release, and whether the sulcus angle is an accurate parameter for diagnosis of trochlea dysplasia, remain, and further research is required.

Effect of the Brief Instructional Video Intervention on the Quality of Cardiopulmonary Resuscitation.

Background: Chest compressions are the basis of cardiopulmonary resuscitation (CPR), and high-quality chest compressions can improve survival rate in patients with out-of-hospital cardiac arrest. Although many efforts have been made to improve the quality of CPR in inexperienced adults, the results are still not high, especially during emergencies. The primary purpose of this study is to investigate whether a brief instructional chest compression-only CPR video could improve chest compression quality in inexperienced adults. Methods: One hundred adults with no CPR experience (age: 20.28 ± 2.28 years; women: 50, men: 50) participated in this study. Participants completed body composition and handgrip strength measurements, and performed two CPR quality tests on the Laerdal® Little Anne QCPR Manikin, namely without video-CPR (WV-CPR) and video-CPR (V-CPR). The WV-CPR quality test was performed first. After 2 minutes of continuous chest compression, the participants rested for 10 seconds and repeated 3 cycles (phase 1, phase 2, and phase 3). After resting for more than 72 hours, V-CPR quality test was conducted. During the V-CPR with video intervention, the participants also continued to compress the chest for 2 minutes, and then rested for 10 seconds, repeating 3 cycles. Results: In phase 1, compared with WV-CPR, the V-CPR has a significant increase (p < 0.001) in chest compression fraction (CCF) (56.31 ± 33.22% vs. 41.82 ± 32.30%) and percent of correct compression rate (PCCR) (96.17 ± 8.45% vs. 26.31 ± 37.55%). In addition, the V-CPR has significantly lower (p < 0.001) chest compression rate (CCR) (110.85 ± 2.40 cpm vs. 128.86 ± 24.52 cpm) and rating of perceived exertion (RPE) (11.89 ± 2.25 vs. 12.87 ± 2.25). For phases 2 through 3, V-CPR and WV-CPR achieved significant differences in CCF, CCD, CCR, PCCR, and RPE (p < 0.01). There were significant differences (p < 0.05) in CCF, CCD, chest compression rebound rate, and RPE among the different administration stages of both WV-CPR and V-CPR. Conclusions: The results of this study revealed that a brief instructional chest compression-only CPR video could improve chest compression quality for inexperienced adults by reducing fatigue and CCR, and increasing CCF and PCCR.

Combined 3-Dimensional CT and Multidirectional CT Arthrography for Femoroacetabular Impingement and Hip Lesions: A Cross-sectional Study Comparing Imaging and Hip Arthroscopic Surgery Findings.

Background: There is limited research investigating the diagnostic strength of 3-dimensional computed tomography (3D-CT) and multidirectional CT arthrography (CTA) for femoroacetabular impingement (FAI) and related hip lesions. Purpose: To evaluate the diagnostic strength of combined 3D-CT and CTA in patients with FAI and related hip lesions by comparing it with hip arthroscopic surgery findings. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: This study included patients who were suspected of having FAI and related hip lesions and who underwent a combination of 3D-CT and CTA and subsequent hip arthroscopic surgery between December 2013 and December 2017. The CT and intraoperative arthroscopic findings were recorded and compared. The sensitivity, specificity, and accuracy of 3D-CT for FAI and those of CTA for related hip lesions were calculated. Results: A total of 114 patients with 114 hips were included in our study. There were 101 patients with positive findings and 13 patients with negative findings for FAI (including cam, pincer, and combined morphology) according to 3D-CT. The sensitivity, specificity, and accuracy of 3D-CT for FAI were 91.58%, 57.14%, and 89.47%, respectively. The sensitivity, specificity, and accuracy of CTA for labral tears were 94.64%, 100.00%, and 94.73%, respectively. For acetabular cartilage defects, the sensitivity, specificity, and accuracy of CTA were 60.71%, 91.37%, and 76.31%, respectively. For femoral cartilage defects, the sensitivity, specificity, and accuracy of CTA were 82.22%, 76.81%, and 78.94%, respectively. Conclusion: The study results indicated that 3D-CT was able to provide excellent accuracy for FAI compared with hip arthroscopic surgery findings. In addition, multidirectional CTA demonstrated promising diagnostic strength for hip lesions such as labral tears and chondral defects.

Comparison of hook plate alone, hook plate augmented with suture anchor, and arthroscopically-assisted tightrope fixation in the treatment of patients with acute type v acromioclavicular joint dislocations.

INTRODUCTION: The best treatment for Rockwood type V acromioclavicular (AC) joint dislocation is unknown. HYPOTHESIS: Hook plate augmented with suture anchor (HA) may have different clinical and radiological results than hook plate alone (H), and arthroscopically assisted TightRope (TR) techniques in treating acute type V AC joint dislocations. MATERIAL AND METHODS: This retrospective study included 71 patients with acute type V AC joint dislocations between December 2010 and August 2018. Patients were categorized into three groups: H group (n=22), HA group (n=23) and TR group (n=26). We measured the coracoclavicular distance (CCD) differences and CCD ratio compared to uninjured side pre-operatively, immediately post-operatively, at 3-month and 2-year after operation. Clinical outcomes were assessed as well at the same time points. Loss of correction was determined by the CCD difference and ratio between surgical and uninjured sides. RESULTS: The mean age and follow-up period were 41.8±24.7 years and 30.2±4.3 months, respectively. No significant differences were found in the demographic data between the three groups. The HA group presented a trend of less overcorrection but without significance compared with the H group at immediately post-operation, 3-month, and 2-year follow-up. (CCD difference: -2.4mm vs. -3.7mm, -1.6mm vs. -1.8, and 0.2mm vs -1.9mm, CCD ratio: 67.7% vs. 40.9%, 79.3% vs. 70.1%, and 100.6% vs. 86.5%, respectively). The HA group also had significantly less loss of correction compared with the TR group at 3-month and 2-year after the operation (CCD difference: -1.6mm vs. 1.6mm, 0.2mm vs. 2.4mm; CCD ratio: 79.3% vs. 122.2%, 100.6% vs. 136.1%, all p<0.05). All three methods achieved significant improvement in function and pain without inter-group differences. No coracoid-related or tunnel complications occurred. DISCUSSION: The hook plate alone, and hook plate with suture anchor augmentation techniques provided less residual vertical instability compared to TightRope fixation at 2-year follow-up. The patient-reported functional outcomes were promising and comparable among the three groups. LEVEL OF EVIDENCE: III, Retrospective comparative therapeutic trial.

Recurrent Shoulder Instability after Arthroscopic Bankart Repair in an Elite Baseball Pitcher-A Case Report.

A 16-year-old right-handed male pitcher had a first-time right anterior shoulder dislocation during a baseball game. X-ray and MRI revealed no apparent glenoid bone loss or Hill-Sachs lesion, but an anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesion with mild posterolateral decompression of the humerus head. His instability severity index score (ISIS score) was 5 with an on-track lesion. He had an arthroscopic Bankart repair using two all-suture anchors and returned to pitching 6 months after the index surgery. However, he had an unstable sensation after 50 pitches during a game one year postoperatively. This time, he presented with a significant Hill-Sachs lesion and a recurrent APLSA lesion. His ISIS score was 6 with an on-tract lesion. During the arthroscopic examination, the previous suture was stable, while anterior capsuloligament tissues were dislodged from sutures, and a Hill-Sachs lesion was observed. This time, a revision arthroscopic Bankart repair and Remplissage procedure were done on him with four double-loaded soft tissue anchors. Pitchers often develop more external rotation in their throwing arm because of a repetitive stretch of the anterior shoulder capsule and ligaments during pitching. The decrease in external rotation after surgery may limit the pitching speed of the pitcher, making a return to play (RTP) more difficult. There is still a paucity of best evidence to revise a failed arthroscopic Bankart repair in the dominant arm of a pitcher. Arthroscopic Bankart repair and Remplissage procedure have gained increasing popularity because they can provide a stable shoulder without harvesting the coracoid. The Latarjet procedure provides a high RTP rate; however, we did not perform it in the revision surgery and decided to revise the Bankart lesion again on its own with a Remplissage procedure, even with his ISIS score being 6 before the revision surgery. A salvage Latarjet procedure is left as a bailout procedure.

Contribution of Body Mass Index Stratification for the Prediction of Maximal Oxygen Uptake.

The purpose of this study was to investigate whether modeling within separate body mass index (BMI) stratifications improves the accuracy of maximal oxygen uptake (VO2max) prediction compared to a model developed regardless of adults' BMIs. A total of 250 Taiwanese adults (total group, TOG) aged 22-64 years participated in this study, and were stratified into a normal group (NOG: 135), an overweight group (OVG: 69), and an obesity group (OBG: 46), according to the BMI classification recommended by the Taiwan Ministry of Health and Welfare. VO2max was directly measured on an electromagnetic bicycle ergometer. Using the participant's heart rate in the 3-min incremental step-in-place test and demographic parameters, VO2max prediction models established for four groups were TOG model, NOG model, OVG model, and OBG model, respectively. Compared with the TOG model, the OVG and OBG models had higher coefficients of determination and lower standard error of estimates (SEEs), or %SEEs. The validities of the NOG (r = 0.780), OVG (r = 0.776), and OBG (r = 0.791) models for BMI subgroups increased by 1.79%, 4.64%, and 8.22% respectively, and the reliabilities (NOG model: ICC = 0.755; OVG model: ICC = 0.765; OBG model: ICC = 0.779) increased by 3.18%, 3.27%, and 9.63%, respectively. These results suggested using separate models established in BMI stratifications can effectively improve the prediction of VO2max.

Pneumothorax, an Uncommon but Devastating Complication following Shoulder Arthroscopy: Case Reports.

Shoulder arthroscopy is a mature and widely used treatment to deal with various shoulder disorders. It enables faster recovery and decreases postoperative complications. However, some complications related to shoulder arthroscopy cannot be neglected because they could be life threatening. We presented three cases of various clinical manifestations of pneumothorax after shoulder arthroscopy. The first case was a 65-year-old female who underwent arthroscopic rotator cuff repair under general anesthesia and interscalene nerve block in the beach-chair position. The second case was a 58-year-old male undergoing arthroscopic rotator cuff repair and reduction in glenoid fracture under general anesthesia in the lateral decubitus position. The third case was a 62-year-old man receiving arthroscopic rotator cuff repair under general anesthesia in the lateral decubitus position. Each case's operation time was 90, 240, and 270 min. The pressure of the irrigation pumping system was 30, 50, and 70 mmHg, respectively. The second and third cases did not undergo interscalene nerve block. Although the incidence of pneumothorax following shoulder surgery and interscalene nerve block was only 0.2%, it is one of the most life-threatening complications following shoulder arthroscopy. In these cases, multifactorial factors, including patient positioning, interscalene nerve block, long surgical time, size of rotator cuff tears, and the pressure of the irrigation and suction system, can be attributed to the occurrence of pneumothorax. It is crucial to fully comprehend the diagnosis and management of pneumothorax to reduce the risk for patients receiving shoulder arthroscopy.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer With Autologous Semitendinosus Tendon and Long Head of Biceps Superior Capsule Reconstruction for Massive Irreparable Posterosuperior Rotator Cuff Tears.

We present a surgical technique combining arthroscopic-assisted lower trapezius tendon (LTT) transfer with autologous semitendinosus tendon and long head of biceps tendon (LHBT) superior capsule reconstruction (SCR) for massive irreparable posterosuperior rotator cuff tears. The patients are placed in the beach-chair position with the ipsilateral lower leg prepared simultaneously. After both tendons are harvested, 1 limb of a semitendinosus graft is fixed with the LTT via a Krakow suture. The LHBT is then fixed by an anchor 5 to 8 mm posterior to the bicipital groove and tenotomized distally. The transverse humeral ligament is released afterward to provide better visualization. A Beath pin is introduced from anterolateral portal, aiming at the bicipital groove, and drilled posteriorly until it exits at the infraspinatus footprint. Next, 4.5- and 8-mm cannulated drills are used sequentially to create a humeral tunnel. A shuttle suture passed through infraspinatus fascia in the back brings the EndoButton and looped semitendinosus graft from posterior to anterior of the humerus, until the EndoButton flips and is fixed inside the bicipital groove. The shoulder is placed in 45° abduction and 30° external rotation. The free limb of semitendinosus tendon is then sutured with LTT with the desired tension.

Midterm Outcomes After Revision Posterior Cruciate Ligament Reconstruction With a Single-Bundle Transtibial Autograft.

Background: There is a lack of consensus regarding the optimal technique for revision posterior cruciate ligament (PCL) reconstruction. Purpose: To evaluate midterm outcomes after revision PCL reconstruction using a single-bundle transtibial autograft. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 17 patients who underwent revision PCL reconstruction performed in our medical center by a single surgeon from 2003 to 2016. The cohort included 12 male and 5 female patients with a mean age of 31.3 years (range, 17-48 years). All of the patients underwent single-bundle transtibial reconstruction using the same surgical technique and were reviewed at a minimum of 4 years postoperatively. Preoperative and postoperative posterior stress radiography was performed. The preoperative tibial slope and tibiofemoral angle were also measured. Preoperative and postoperative functional outcomes were evaluated using the International Knee Documentation Committee (IKDC) subjective and objective scores as well as the Lysholm score. Results: The most common factor that contributed to the failure of primary surgery was misplaced tunnels, especially on the femoral side. There were 2 patients who had grade 2 laxity preoperatively, and 15 patients had grade 3 laxity preoperatively. At the latest follow-up, all 17 patients had grade 1 laxity. On posterior stress radiography, posterior displacement improved from 10.8 ± 2.1 mm preoperatively to 2.9 ± 1.1 mm at the latest follow-up (P < .001). The IKDC subjective score improved from 34.9 ± 6.8 preoperatively to 75.3 ± 15.7 postoperatively (P < .001), and the Lysholm score improved from 38.1 ± 10.0 preoperatively to 88.5 ± 7.6 postoperatively (P < .001). All patients reached the minimal clinically important difference (MCID) for the Lysholm score, and 94% reached the MCID for the IKDC subjective score, with 65% reaching the Patient Acceptable Symptom State. Conclusion: According to the findings of this study, arthroscopic revision PCL reconstruction with a single-bundle transtibial autograft offered satisfactory outcomes at midterm follow-up.

Outcomes of Anterior Cruciate Ligament Reconstruction in Patients Older Than 50 Years and Younger Than 30 Years.

Background: Few studies have compared the outcomes of anterior cruciate ligament (ACL) reconstruction between older patients and younger patients. Purpose: To evaluate the clinical and functional outcomes of ACL reconstruction with autologous hamstring tendon in patients >50 years and <30 years. It was hypothesized that the outcomes would be comparable between these age groups. Study Design: Cohort study; Level of evidence, 3. Methods: Patients >50 years (older group) or <30 years (younger group) who underwent ACL reconstruction surgery with autologous hamstring tendon between 2012 and 2015 at the authors' hospital were retrospectively enrolled in this study. All patients had a minimum of 2 years of follow-up. Intraoperative findings, including cartilage and meniscal injury, were recorded, and clinical and functional outcomes were evaluated using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores. We used the paired-samples t test for statistical analysis between the 2 age groups. Results: A total of 67 patients and 459 patients were included in the older and younger groups, respectively. Both groups achieved significant preoperative to postoperative improvement in IKDC (older group, from 41.4 to 88.9; younger group, from 49 to 91.2), Lysholm (older group, from 49.8 to 86.1; younger group, from 50.2 to 91.8), and Tegner (older group, from 2.7 to 4.4; younger group, from 4.6 to 6.9) (P < .05 for all) scores. The change in Tegner score from preinjury to postoperatively was not statistically significant in the older group (from 4.5 to 4.4; P = .471), although it was significant in the younger group (from 7.5 to 6.9; P < .05). No between-group differences were noted in preoperative or postoperative IKDC or Lysholm scores. Both age groups reached a high rate of return to sports activity, and no major complications or ACL retears were noted in either group. Conclusion: Comparable results after ACL reconstruction were achieved in patients >50 years compared with patients <30 years, with a high rate of return to sports activity and a low rate of complications at the 2-year follow-up. The younger group returned to a higher Tegner score, while the older group did not.