Outcomes of Elbow Arthroscopic Osteocapsular Arthroplasty.

PURPOSE: To evaluate the results of elbow arthroscopic osteocapsular arthroplasty (AOA) and determine which factors influence the outcome in a large group of patients with primary osteoarthritis. METHODS: A consecutive series of 46 patients with elbow osteoarthritis underwent AOA by a single surgeon (N.G.H.) between December 2005 and January 2013. Thirty-one patients returned for a comprehensive physical examination an average of 3.4 years later. The outcomes measures included visual analog scale (VAS), Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH), and American Shoulder and Elbow Society (ASES) scores. Preoperative and postoperative continuous variables were compared and a multivariable regression analysis was performed. RESULTS: Thirty-one patients with a mean age of 48 years (range, 19-77 years) returned for final follow-up, including 27 men and 4 women. Statistically significant improvement was observed in extension deficit (24° before surgery to 12° after surgery), flexion (126° before surgery to 135° after surgery), visual analog scale (6.4 before surgery to 1.6 after surgery), and Mayo Elbow Performance Scores (57 [poor] before surgery to 88 [good] after surgery). Subjective scores included a mean postoperative Disabilities of the Arm, Shoulder, and Hand score of 13 and an American Shoulder and Elbow Society pain score of 40. No complications were noted at final follow-up. CONCLUSIONS: Elbow AOA is a safe, efficacious treatment for patients with mild to moderate osteoarthritis. Our retrospective review found significant improvement in elbow motion, pain and clinical outcomes.

Incidence and Risk Factors for Extensor Pollicis Longus Rupture in Elastic Stable Intramedullary Nailing of Pediatric Forearm Shaft Fractures.

BACKGROUND: Elastic stable intramedullary nailing (ESIN) is an effective means of fixation for unstable, pediatric forearm shaft fractures with the benefit of smaller incisions, less soft tissue manipulation, and ease of removal. This study was designed to evaluate the incidence of and risk factors for extensor pollicis longus (EPL) rupture after fixation of pediatric radial shaft fractures with ESIN. METHODS: A retrospective review of all patients younger than 19 years who had a repair of a forearm fracture with flexible intramedullary nailing between 2006 and 2011 was performed. Nineteen consecutive patients were identified from the electronic medical record. All patients were treated with a titanium elastic nailing system using a dorsal approach to the radius. The patients were followed postoperatively for at least 2 years, and all fractures healed. An extensive chart review assessing for persistent pain, EPL function, and risk factors for EPL rupture was performed. Implants were removed in all but 1 patient. RESULTS: Seventeen records were available for review. Fourteen (82%) were male, and the mean age at time of fracture was 10 years old (range, 5 to 14 y). Follow-up averaged 5.5 years (range, 2.9 to 7.8 y). The mean weight was 32.7 kg for males and 50.6 kg for females corresponding to the 61st and 60th percentile respectively of weight-for-age (range, 8th to 99.9th percentile). Hardware was removed in all but 1 case, and the median time from surgery to hardware removal was 21 weeks (range, 8 to 63). Three of the 17 patients (18%) experienced rupture of the EPL. Two were treated with additional surgery following hardware removal, and one was untreated due to patient preference. None of the 17 patients (including those with rupture) had independent risk factors for tendon rupture: inflammatory arthritis, diabetes, or prior steroid use. Time to removal, patient age, and percentile of weight-for-age did not correlate with EPL rupture. CONCLUSIONS: Although ESIN of pediatric forearm shaft fractures has gained acceptance as a treatment option, our series of 17 patients revealed an 18% rate of EPL rupture. With this small patient cohort, no patient characteristics proved to be significant risk factors for predicting tendon rupture. However, awareness should be raised for an increased risk of EPL rupture with this fixation method. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Risk factors for the development of heterotopic ossification after acetabular fracture fixation.

BACKGROUND: Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated. QUESTIONS/PURPOSES: The purposes of this study were to determine specific risk factors associated with the development of severe HO and the frequency with which patients develop severe HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach. METHODS: Using an institutional orthopaedic trauma database at a regional Level I trauma center, patients undergoing open treatment of acetabular fractures during the study period (January 2000 to January 2010) were identified. A review of medical records and imaging studies was performed on 508 patients who were treated by the senior author (MR) through an isolated Kocher-Langenbeck approach. During the study period, the senior author used indomethacin for HO prophylaxis in patients who had ipsilateral femur fracture treated with antegrade reamed medullary nailing or severe local soft tissue injury; 49 (10%) of the patients he treated with the Kocher-Langenbeck approach received prophylaxis, and they were excluded from this study, leaving a total of 459 patients who met inclusion criteria. Of those, 147 (29%) were lost to followup or did not have radiographs both before and at a minimum of 6 weeks (median, 1 week; range, 0-3 weeks), leaving 312 (61% of the patients treated with the Kocher-Langenbeck approach during this time) available for this analysis. Demographic data as well as information related to cause of injury, associated periacetabular findings, other system injuries, and treatment were gathered. Final followup radiographs were assessed for the presence of ectopic bone by two of the authors (TJO, AS) using the modified Brooker classification. Logistic regression was performed to identify possible predictors of development of severe ectopic bone. RESULTS: The only predictor we identified for the development of severe HO was the need for prolonged mechanical ventilation (odds ratio, 7.1; 95% confidence interval, 2.9-17.3; p=0.001). Injury Severity Score, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and head and chest Abbreviated Injury Score>2 did not correlate with severe HO. Severe HO (Brooker Class III or IV) developed in 38 of 312 patients (12%). CONCLUSIONS: Patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population. However, future prospective studies need to be performed to verify this finding given the fact that a considerable number of patients were prophylactically treated in this study. LEVEL OF EVIDENCE: Level IV, prognosticstudy. See Guidelines for Authors for a complete description of levels of evidence.

Volar plate fixation failure for volar shearing distal radius fractures with small lunate facet fragments.

PURPOSE: To determine the percentage of AO B3 distal radius fractures that lose reduction after operative fixation and to see whether fracture morphology, patient factors, or fixation methods predict failure. We hypothesized that initial fracture displacement, amount of lunate facet available for fixation, plate position, and screw fixation would be significant risk factors for loss of reduction. METHODS: A prospective, observational review was conducted of 51 patients (52 fractures) with AO B3 (volar shearing) distal radius fractures treated operatively between January 2007 and June 2012. We reviewed a prospective distal radius registry to determine demographic data, medical comorbidities, and physical examination findings. Radiographs were evaluated for AO classification, loss of reduction, length of volar cortex available for fixation, and adequacy of stabilization of the lunate facet fragment with a volar plate. Preoperative data were compared between patients who maintained radiographic alignment and those with loss of reduction. A multivariate logistic regression analysis was completed to determine significant predictors of loss of reduction. RESULTS: Volar shearing fractures with separate scaphoid and lunate facet fragments (AO B3.3), preoperative lunate subsidence distance, and length of volar cortex available for fixation were significant predictors for loss of reduction; the latter was significant in multivariate analysis. Plate position and number of screws used to stabilize the lunate facet were not statistically different between groups. CONCLUSIONS: Patients with AO B3.3 fractures with less than 15 mm of lunate facet available for fixation, or greater than 5 mm of initial lunate subsidence, are at risk for failure even if a volar plate is properly placed. In these cases, we recommend additional fixation to maintain reduction of the small volar lunate facet fracture fragments in the form of plate extensions, pins, wires, suture, wire forms, or mini screws. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The incidence of trigger digit after carpal tunnel release in diabetic and nondiabetic patients.

PURPOSE: To determine whether patients with diabetes mellitus (DM) are at greater risk for developing postoperative trigger digits (TD) after carpal tunnel release (CTR) compared with patients without diabetes. METHODS: A retrospective review of our electronic medical records identified all patients who had undergone CTR by a single hand fellowship-trained surgeon from September 2007 through May 2012. For patients with DM, additional information regarding method of disease control and hemoglobin A1c (HbA1c) level was recorded. We recorded HbA1c levels 3 months before and 3 months after CTR. The location and time to development of postoperative, new-onset TD were recorded for each case. Statistical testing included chi-square or Student t test and multivariate logistic regression analysis. RESULTS: Of the 1,217 CTRs, 214 had DM. Of the 1,003 CTRs in cases without DM, 3% developed TD within 6 months of CTR and 4% within 1 year of CTR, compared with 8% and 10%, respectively, for diabetic cases. A multivariate regression analysis revealed DM as a significant risk factor for developing TD after CTR at 6 and 12 months. We found no significant association between HbA1c level at the time of CTR and the likelihood of developing TD. CONCLUSIONS: The incidence of TD after CTR was higher in the diabetic population compared with a nondiabetic cohort. The presence of DM rather than its severity was the most important factor for developing TD. Preoperative counseling for patients with DM undergoing CTR may alert them to the possibility of developing TD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Magnetic resonance imaging after endoscopic carpal tunnel release.

PURPOSE: To determine with magnetic resonance imaging (MRI) the morphologic changes in the carpal tunnel and median nerve 3 months after endoscopic carpal tunnel release (ECTR). METHODS: We enrolled patients who had complete resolution of numbness and pain by 6 weeks after ECTR. Patients who met these inclusion criteria received an MRI at 3 months after surgery. Images were analyzed to determine whether median nerve morphology changes and discrete gap or separation of the flexor retinaculum could be appreciated on MRI. RESULTS: There were 17 patients screened and 15 met the inclusion criteria. Three-month MRI in all patients demonstrated changes in the flexor retinaculum over the median nerve. In all 15 patients, a distinct gap or separation in the fibers of the flexor retinaculum overlying the median nerve could not be appreciated. Median nerve width-to-height ratios at the level of the pisiform and at the hook of the hamate were 2.4 and 2.1, respectively. Median nerve cross-sectional area was 14.1 at the pisiform and 13.3 at the hook of the hamate. CONCLUSIONS: MRI of patients 3 months after successful ECTR does not demonstrate a discrete gap or separation in the flexor retinaculum overlying the median nerve but may be useful for evaluating median nerve morphology. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Reverse total shoulder arthroplasty in obese patients.

PURPOSE: To determine function and complications after reverse total shoulder arthroplasty (RTSA) in obese patients compared with a control group of nonobese patients. METHODS: Between 2005 and 2011, we performed 76 RTSAs in 17 obese, 36 overweight, and 23 normal weight patients, based on World Health Organization body mass index classification. We reviewed the charts for age, sex, body mass index, date of surgery, type of implant, type of incision, length of stay, comorbidities, surgical time, blood loss, American Society of Anesthesiologists score, shoulder motion, scapular notching, and postoperative complications. Complications and outcomes were analyzed and compared between groups. RESULTS: Reverse total shoulder arthroplasty in obese patients was associated with significant improvement in range of motion. Complication rate was significantly greater in the obese group (35%), compared with 4% in the normal weight group. We found no significant differences between scapular notching, surgical time, length of hospitalization, humeral component loosening, postoperative abduction, forward flexion, internal and external rotation, pain relief, or instability between groups. CONCLUSIONS: Our results show that obese patients have significant improvement in motion after RTSA but are at an increased risk for complication. Obesity is not a contraindication to RTSA, but obese patients need to understand fully the increased risk of complication with RTSA. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Clinical outcomes of endoscopic carpal tunnel release in patients 65 and over.

PURPOSE: To examine outcomes of endoscopic carpal tunnel release (ECTR) in patients 65 and older. We hypothesized that this population could expect relief of pain, night pain/numbness, and numbness. METHODS: A retrospective review was conducted of all patients 65 years of age and over who had ECTR for nerve conduction study-confirmed carpal tunnel syndrome (CTS) from October 2007 to July 2010. The charts were reviewed for demographic data, symptoms and physical findings, patient satisfaction, and 3 patient-reported outcome scores. Preoperative and postoperative results for pain, night pain/numbness, and numbness were compared. Logistic regression analysis was used to assess whether age influenced symptom resolution. Boston carpal tunnel, Short Form-36 and Disabilities of the Arm, Shoulder, and Hand scores were compared between patients with mild, moderate, or severe CTS. RESULTS: A total of 78 patients had ECTR. Their ages ranged from 65 to 93 years (mean, 73 y). Before surgery 69% of patients had constant numbness. Night pain/numbness was present in 65 patients before surgery, and 61 had complete resolution. All 70 patients who presented with pain reported complete relief by the 6-month follow-up. Following ECTR, the average Boston carpal tunnel symptom severity, functional status, and Disabilities of the Arm, Shoulder, and Hand scores were 1.5,1.5, and 13, respectively. At final evaluation, 79% of patients were very satisfied or satisfied with their outcome. A significant number of patients were found to have improvement in pain, night pain/numbness, and numbness following ECTR. CONCLUSIONS: This study has demonstrated relief of symptoms in a statistically significant number of patients following ECTR. We found that preoperative CTS severity, based on nerve conduction study result, did not significantly correlate with patient outcome following ECTR. Advanced symptoms at presentation do not preclude symptom resolution and should not be a contraindication to ECTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Median Nerve and Carpal Tunnel Morphology Before and After Endoscopic Carpal Tunnel Release: A 6-Year Follow-up Study.

BACKGROUND: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR). METHODS: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point. RESULTS: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years. CONCLUSIONS: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

Anomalous extensor tendons to the long finger: a cadaveric study of incidence.

PURPOSE: To evaluate the incidence and anatomic insertion sites of extensor medii proprius and extensor indicis medii communis tendons to the long finger in cadaveric dissection and to describe the insertion of the extensor medii proprius. METHODS: Thirty randomly selected adult cadavers, 44 upper extremities, were examined for the presence or absence of an anomalous extensor tendon to the long finger. If present, tendon origin and insertion sites were documented, and the width of the tendon was evaluated. RESULTS: The extensor medii proprius was observed in 4 of 44 extremities, an incidence of 9%. The extensor indicis medii communis was observed in 7 of 44 extremities, an incidence of 16%. Tendon widths for both the extensor medii proprius and extensor indicis medii communis specimens ranged from 1.5 to 3.0 mm. CONCLUSIONS: The incidence of an anomalous slip of tendon to the long finger might be higher than previously reported, with a combined incidence of 25% in this cadaveric study. This anomalous slip can be a resource for surgical reconstruction. CLINICAL RELEVANCE: The presence of anomalous tendinous slips to the long finger can be easily overlooked. Understanding the anatomical relationships, incidence, and donor tendon availability of these anomalous tendons might aid with surgical planning.

Anomalous tendon to the middle finger for sagittal band reconstruction: report of 2 cases.

Multiple techniques with good outcomes have been described for sagittal band reconstruction. We describe 2 cases of sagittal band reconstruction using an anomalous slip of the extensor tendon to the middle finger. This anomalous slip can be a resource for surgical reconstruction that can add stability to primary sagittal band repair.

Predicting the outcome of revision carpal tunnel release.

PURPOSE: To test the hypothesis that the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms would serve as a good predictor of the outcome of later carpal tunnel release (CTR). METHODS: We conducted a retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome over a 2-year period at our institution. A total of 28 wrists in 23 patients met inclusion criteria. We evaluated patients to determine whether preoperative factors or the result of injection predicted the outcome of revision CTR. We used a multivariate logistic regression analysis to predict surgical success when multiple preoperative findings were considered. RESULTS: Of the 23 wrists that had relief from injection, 20 had symptom improvement with surgery. Although they did not reach statistical significance, the sensitivity and positive predictive value for injection alone predicted outcome of revision CTR in 87%. No patient characteristic or physical examination finding predicted successful revision CTR. Multivariate logistic regression analysis combining preoperative injection results with physical examination findings (numbness and/or motor weakness in median nerve distribution, positive Durkin test, and positive Phalen test) provided a sensitivity of 100% and a specificity of 80%. CONCLUSIONS: In a small group of patients with recurrent carpal tunnel syndrome, cortisone injection into the carpal tunnel was not, by itself, a statistically significant predictor of successful revision surgery. However, relief from injection as a diagnostic test for predicting successful revision CTR was found to have both a high sensitivity and a positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish surgical success with revision CTR. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Single compared to double-bundle PCL reconstruction using allograft tissue.

This study compares the results of arthroscopic transtibial tunnel single-bundle and double-bundle posterior cruciate ligament (PCL) reconstructions using allograft tissue in PCL-based multiple ligament injured knees. Ninety consecutive PCL reconstructions are evaluated: 45 single-bundle and 45 double-bundle reconstructions. All PCL reconstructions were performed using the arthroscopically assisted transtibial tunnel PCL reconstruction technique using fresh frozen allograft tissue from the same tissue bank. Achilles tendon allograft was used for the anterolateral bundle; tibialis anterior allograft was used for the posteromedial bundle. The knees were evaluated postoperatively, comparing the single-bundle results to the double-bundle results, with KT-1000 arthrometer (Medmetric Corporation, San Diego, CA) testing, three different knee ligament rating scales, and Telos stress radiography (Austin Associates, Fallston, MD). Both the single-bundle and the double-bundle PCL reconstruction surgical techniques using allograft tissue provide successful results in the PCL-based multiple ligament injured knee when evaluated with stress radiography, arthrometer measurements, and knee ligament rating scales.

Closed reduction and treatment of 2 volar thumb metacarpophalangeal dislocations: report of 2 cases.

Volar dislocation of the metacarpophalangeal joint of the thumb may be irreducible by closed means. We describe 2 patients with volar dislocation of the thumb metacarpophalangeal joint treated with closed reduction and casting.

Results of endoscopic carpal tunnel release relative to surgeon experience with the Agee technique.

PURPOSE: To establish the rate of iatrogenic injury after endoscopic carpal tunnel release (ECTR) for a surgeon in the first 2 years of practice; to report the rate of conversion from ECTR to open carpal tunnel release (OCTR), the reason for conversion, and any increase in morbidity found in patients converted to OCTR; and to determine whether the conversion rate decreased with increasing surgeon experience. METHODS: We conducted a retrospective review of patients undergoing ECTR by a single surgeon in the first 2 years of practice. Data collected or calculated included symptom relief, rate of conversion to OCTR, reason for conversion, and neurovascular complications. For patients converted to OCTR, we assessed satisfaction and function using the Disabilities of the Arm, Shoulder, and Hand questionnaire. We compared these results for 1 to 6 months, 7 to 12 months, and 12 to 24 months to determine whether a learning curve was present. RESULTS: A total of 278 patients (358 procedures) underwent ECTR. Of these, 12 patients required conversion to OCTR during the index procedure over a 2-year period. In the first 6 months of practice, 8 of 71 ECTRs were converted to OCTR compared to 1 of 72 in the second 6 months. This was a statistically significant decrease (p = .017). In year 2, 3 of 215 patients were converted to OCTR. Average Disabilities of the Arm, Shoulder, and Hand score for patients converted from ECTR to OCTR was 9. No patients required repeat surgery for recurrence of carpal tunnel symptoms. We observed no major neurovascular complications. CONCLUSIONS: A learning curve for ECTR was present. Rates of conversion significantly diminished with increased surgeon and anesthesia experience. Patients requiring conversion showed no variation in Disabilities of the Arm, Shoulder, and Hand scores from established values after OCTR. Patients may be at a higher risk of conversion to OCTR during the learning curve time period; nevertheless, we found no increased morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Incidence of scapholunate ligament dissociation in patients with aspiration-confirmed gout.

PURPOSE: To determine the incidence of scapholunate (SL) dissociation in patients with aspiration-confirmed gout of the wrist and aspiration-confirmed gout in any joint excluding the wrist. METHODS: Geisinger Medical Center uses the EPIC electronic medical record system, which maintains International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology coding information for every patient encounter in our hospital system. We queried this electronic medical record system from 1998 to 2008 using the International Classification of Diseases, 9th Revision, Clinical Modification codes for gout as well as Current Procedural Terminology codes for aspiration of a minor, intermediate, or major joint. We then evaluated medical records of patients meeting criteria for the presence of wrist x-rays. We examined x-rays for SL interval, SL angle, and capitolunate angle and determined the incidence of SL dissociation in all patients with a diagnosis of gout confirmed by joint aspiration. RESULTS: We reviewed a total of 1,105 cases; 159 patients met inclusion criteria. Of 159 patients, 20 had aspiration-confirmed gout in the wrist. We determined incidence using 2 definitions: (1) one or more positive radiographic criteria for SL dissociation, and (2) two or more positive radiographic criteria. The incidence of SL dissociation in wrists with aspiration-confirmed gout was 60% by definition 1 and 25% by definition 2. The average SL interval was 2.95 mm. The remaining 139 patients had aspiration-confirmed gout in joints other than the wrist. A total of 69 patients had 1 or more positive criteria for SL dissociation, whereas 18 had 2 or more positive criteria, making the incidence of SL dissociation 49.6% and 12.9%, respectively. The average scapholunate interval was 2.28 mm. The incidence of SL dissociation in patients with aspiration-confirmed gout in any joint was 50.9% and 14.5%, based on the above definitions. CONCLUSIONS: This study establishes the incidence of SL dissociation in patients with gouty arthropathy of the wrist as 60% and 25%, respectively, based on the above definitions. In addition, our study suggests that, as a result of the systemic nature of gout, a patient with aspiration-confirmed gout at a joint remote from the wrist might have subclinical effects in the wrist, leading to SL dissociation over time. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Current concepts review: the posterior cruciate ligament.

Injuries to the posterior cruciate ligament (PCL) and methods of treatment of the injured PCL have historically been surrounded by controversy in the orthopedic community. The infrequent occurrence of PCL injuries and PCL-based, multiple ligament knee injuries has led to limitations in clinical studies and a subsequent lag in basic science and clinical research compared with that for other ligamentous injuries. In recent years, new studies have elucidated the biomechanical function and complex anatomy of the PCL leading to an increased interest in research, understanding, and treatment of these complex injuries. In addition to improved understanding of knee ligament structure and biomechanics, technical advancements in allograft tissue, surgical instrumentation, and graft tensioning and fixation methods and improved surgical techniques and postoperative rehabilitation methods have enhanced the results in PCL reconstruction and PCL-based, multiple ligament knee surgical outcomes.

Arthroscopic double-bundle posterior cruciate ligament reconstruction surgical technique.

The keys to successful posterior cruciate ligament (PCL) reconstruction are to identify and treat all pathology, use strong graft material, accurately place tunnels in anatomic insertion sites, minimize graft bending, use a mechanical graft tensioning device, use primary and back-up graft fixation, and use the appropriate postoperative rehabilitation program. Adherence to these technical principles results in successful single-bundle and double-bundle arthroscopic transtibial tunnel PCL reconstruction based on stress radiography, arthrometer, knee ligament rating scales, and patient satisfaction measurements.

Examining Grit-like Qualities in National Football League Quarterbacks.

In order to excel in the National Football League (NFL) it would seem reasonable to assume an athlete has grit which consists of the constructs of consistency of interest and perseverance of effort. Grit-like qualities such as endurance, urgency and intensity, self-confidence, need for encouragement, and self-criticality may be of particular value for the athlete playing the Quarterback (QB) position. The purpose of the study was to assess the 5 grit-like constructs of endurance, urgency and intensity, self-confidence, need for encouragement, and self-criticality among NFL QBs. The Flippen ProfileTM assessment was administered to 29 NFL QBs and the 5 grit-like constructs were recorded. Each of the 5 grit-like constructs were scored on a scale of 0-100, where high scores were considered desirable for endurance, urgency and intensity, and self-confidence, while lower scores were considered as desirable for need for encouragement, and self-criticality. The scores for each of the 5 grit-like constructs were then partitioned by three categories of QB years played: 1-2 (n=8), 3-7 (n=13), and ≥8 (n=8) years. Four key findings emerged following the analysis: the NFL QBs scored favorably on all of the 5 grit-like constructs independent of years played, QBs with ≥8 years' experience scored the most favorably for endurance and the need for encouragement, QBs with 1-2 years' experience scored the most favorably for self-criticality. These results may provide coaches and athletes aspiring to play QB in the NFL with benchmarks regarding the 5 grit-like constructs that are associated with successful NFL QBs.