Lateral epicondylitis of the elbow: an up-to-date review of management.

Lateral epicondylitis, also known as tennis elbow, is an overuse tendinopathy of the common extensor origin of the elbow in patients involved in repetitive movement of the wrist and forearm. Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. This article reviews the recent updates on operative and non-operative management of lateral epicondylitis.

Return to Sports Following Meniscal Allograft Transplantation Is Possible but Remains Questionable: A Systematic Review.

OBJECTIVE: To evaluate the return to sports rate and time following meniscal allograft transplantation (MAT). METHODS: PubMed, Web of Science, and Embase were searched in December 2020. Eligibility criteria included clinical studies reporting the return to sport rate following MAT with ≥12-month follow-up. RESULTS: A total of 14 case series were included with 670 patients. The bone bridge technique was used for all transplantations in 5 studies, and suture fixations with bone tunnels were used for all transplantations in 5 studies. In 2 studies, bone plugs were used for medial menisci and bone bridge for lateral menisci. In 1 study, suture fixation was used for medial menisci, and bone bridge for lateral menisci. The return to sports rate ranged from 20% to 91.7%, with 2 studies reporting low return to sport rates. The return to sport time ranged between 7.6 and 16.9 months. The return to preinjury level had a rate of 7% to 100%. Return to a higher level of sports was reported in only 2 studies (28.5% to 86%). Return to a lower level of sports was reported in low proportions in most studies. In terms of patient-reported outcomes, the Lysholm knee and subjective International Knee Documentation Committee (IKDC) scores and Knee Osteoarthritis Outcome Score (KOOS) had significant improvements after MAT. The KOOS quality of life subscore did not change significantly in 1 study. The total reoperation rate after MAT ranged between 3.1% and 80%, whereas the total failure ranged between 1.1% and 30.1%. CONCLUSION: Despite that most studies reporting high return to sports rates, the current level of evidence is low, with all studies being case series. There is significant variability in the reported return to sports rate, time, and level. Therefore, high-quality comparative studies are mandated to elucidate whether MAT is associated with higher return to sports rates and levels. LEVEL OF EVIDENCE: IV, systematic review.

Anterior Cruciate Ligament Injuries in the Older Athlete.

CONTEXT: Older adults are remaining active longer and continuing during later stages of life to participate in sports and activities that involve pivoting on 1 foot. The rate of anterior cruciate ligament (ACL) tears is increasing in people older than 40 years of age, which has caused a concomitant increase in the rate of surgical reconstruction. EVIDENCE ACQUISITION: We searched the PubMed database for articles published in English between January 1980 and January 2018 using the terms anterior cruciate ligament injury, ACL injury, ACL tear, anterior cruciate ligament reconstruction, ACLR, older, older athlete, and elderly. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Nonoperative treatment with activity modification and physical therapy may be an appropriate option for nonathletes older than 40 years of age with physically low-demand lifestyles. For patients with injuries that are unresponsive to nonoperative treatment or athletes participating in physically demanding activities, ACL reconstruction can improve function and facilitate return to sports. When evaluating whether a patient is a candidate for surgery, numerous variables should be considered, such as timing, graft choice, and postoperative rehabilitation. CONCLUSION: Outcomes of ACL reconstruction in older athletes are similar to those of younger patients. To date, published evidence is inadequate to determine the long-term effects of nonoperative and operative treatment as well as the role of ACL reconstruction in the development of osteoarthritis in the older athlete.

Basic Science Research Trends in Orthopedic Surgery: An Analysis of the Top 100 Cited Articles.

BACKGROUND: Much of current clinical orthopedics traces its origin to basic science investigation of cellular and biochemical pathways, tissue engineering, and biomechanics of bone and joint physiology in animal and cadaveric models. QUESTIONS/PURPOSES: We sought to describe research trends in highly cited basic science studies in orthopedics. METHODS: By searching Web of Science, we identified the 100 most cited basic science orthopedics articles and focused on author position and degree (PhD, MD, or MD/PhD), topic, type of study, country, institution, and citation trends. RESULTS: These articles were published from 1970 to 2008 (citation range, 330 to 2111), with the majority from the USA (78). While there was no correlation between years since publication and total citations, more recent articles had higher citation rates. There were 38 unique first authors represented, with Caplan, Harris, Mankin, Noyes, and Warren as primary authors or co-authors of four articles each. Twelve journals published these 100 articles, with the majority in Journal of Bone and Joint Surgery (46) and Clinical Orthopaedics and Related Research (18). Frequent topics included biomechanics (31), healing/regeneration (21), and cellular/molecular biology (13). The Hospital for Special Surgery/Cornell University (10) published the most, followed by the Hospital for Joint Diseases/New York University (6), and University of Pittsburgh (6). No difference was observed in total citations and average citation rate by author degree. Eight articles were contributed from privately owned institutions or industry, with the rest from academic hospitals. CONCLUSION: This review may aid those seeking insight into landmark studies and future direction of basic science research in orthopedics.

Robotic-Assisted and Computer-Navigated Unicompartmental Knee Arthroplasties: A Systematic Review.

INTRODUCTION: Unicompartmental knee arthroplasty (UKA) effectively improves pain and function associated with isolated compartmental knee arthritis. The developments of computer-navigated and robotic-assisted UKA are among the most significant changes that have improved patient outcomes. This study aimed to systematically review the literature to identify differences between computer-navigated and robotic-assisted UKAs. MATERIALS AND METHODS: Twenty total articles were identified. Data pertaining to demographics, outcomes, and complications/failures were extracted from each study. Reoperation/revision rates, indications for reoperation/revision, type of procedure, and number of patients who underwent conversion to TKA (when available) were recorded. RESULTS: Nine studies reported 451 computer-navigated medial UKAs, with 19 (3.9%) reportedly requiring reoperation: primary revision (n=8; 42.1%), conversion to TKA (n=6), and manipulation under anesthesia (n=5). Eleven studies reported 2,311 robotic-assisted UKAs (74 lateral UKAs), with 106 (5.0%) requiring reoperation: conversion to TKA (n=46; 43.4%), primary revision (n=43), reoperations without component-removal (n=15), subchondroplasty, and partial meniscectomy/synovectomy (both n=1). Reoperation rate discrepancy between computer-navigated and robotic-assisted UKA was not statistically significant (p=0.495); age and BMI differed between both groups (p<0.0001). DISCUSSION: This study represents the first known comparison of revision rates of computer-navigated and robotic-assisted UKA, suggesting that these methods can benefit orthopaedic surgeons, especially those new to UKA or in a low-volume practice.

Resection of a Giant-Cell Tumor of the Proximal Aspect of the Radius with Osteoarticular Allograft Reconstruction: A Case Report.

CASE: Giant-cell tumors are locally aggressive osteolytic benign tumors that are characterized by multinucleated giant cells. Recurrence rates are ≤30% after curettage and <5% after resection, but reconstruction can be difficult. We describe an osteoarticular allograft reconstruction of the proximal aspect of the radius in a 23-year-old man after resection of a giant-cell tumor. CONCLUSION: Five months after surgery, the patient had satisfactory joint articulation, range of motion, and strength, with no signs of hardware or graft failure. By 17 months, there was complete osseous union. The joint remained stable at 54 months. We describe our surgical approach, which restores joint stability and minimizes recurrence.

A biomechanical analysis of tibial ACL reconstruction with graft length mismatch.

INTRODUCTION: The incidence of graft length mismatch (GLM) during anterior cruciate ligament (ACL) reconstruction is reported to be up to 13%, with a rate of 20% when using bone-patellar tendon-bone (BPTB) allografts. Multiple techniques have been described to accommodate for the longer BPTB graft. As no study has compared the biomechanical properties of these methods (with cyclic loading), we evaluated the strength of four different surgical techniques used to accommodate for GLM during ACL reconstruction. METHODS: A total of 32 fresh-frozen bovine tibiae and patellar tendons were divided into four groups based on the method of tibial graft fixation: (1) sutures tied over a post, (2) bone staples, (3) screws and washers, and (4) soft-tissue conversion with interference screw. Biomechanical testing was performed comparing the tensile properties of graft fixation techniques under cyclic loading. Ability to withstand 1500 cycles of load, the maximum tensile strength at load-to-failure, and the mode-of-failure were evaluated. RESULTS: Only group 4 had all grafts intact after 1500 loading cycles, while the other groups had one graft failure at 338 (group 1), 240 (group 2), and 309 (group 3) cycles. The highest mean load-to-failure was observed in group 3 at 762 ± 173 N, which was found to be significantly higher than the other groups. The mean loads to failure in groups 1-4 were 453 ± 86 N, 485 ± 246 N, 762 ± 173 N, and 458 ± 128 N. CONCLUSION: While there are multiple viable techniques for fixation of a BPTB graft in the case of GLM, this study demonstrated that direct screw fixation offers the strongest construct.

Total Shoulder Arthroplasty Demographics, Incidence, and Complications-A Nationwide Inpatient Sample Database Study.

INTRODUCTION: Total shoulder arthroplasty (TSA) has become a popular and successful surgery to treat advanced glenohumeral arthritis, rotator cuff arthropathy, and proximal humerus fractures. Historical data is available investigating the epidemiology of total shoulder arthroplasty with regard to patient characteristics, outcomes, and complications; however, there is a lack of studies investigating the most recent and up to date national trends related to shoulder replacement. The purpose of this study was to evaluate changes in the annual incidence, various demographics, and complications of TSA in America. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) was assessed to identify all patients who were admitted for TSA in the United States between 1998 and 2010. National trends in patient demographics, incidence, and length-of-stay (LOS) were analyzed for correlations. The impacts of contributing factors to each outcome were assessed using adjusted multivariable regression analysis. These were used to calculate odds ratios of cohort demographics and their association with complications and LOS. RESULTS: Admissions for TSA have risen (8,041 to 39,072 admissions). The majority of the cohort consisted of Caucasian men between the ages of 64 and 79 years. The incidence rate of complications has remained consistent. Female gender, age > 80 years, and higher Deyo Comorbidity scores were risk factors for higher complications. The LOS has decreased (2.96 to 2.21 days) during the study time period. Female gender, African-American race, Medicaid insurance, and higher Deyo Comorbidity scores were associated with longer stays. DISCUSSION: Our study demonstrates a rapid increase in incidence rates of TSAs within the 13-year period in the United States. An increased risk of complications was noted with older age, female gender, and increased Deyo score. CONCLUSION: Our findings may help health care providers identify ways to better manage this procedure and select patients.

Reliability and Validity of 3 Methods of Assessing Orthopedic Resident Skill in Shoulder Surgery.

OBJECTIVE: Traditional measures for evaluating resident surgical technical skills (e.g., case logs) assess operative volume but not level of surgical proficiency. Our goal was to compare the reliability and validity of 3 tools for measuring surgical skill among orthopedic residents when performing 3 open surgical approaches to the shoulder. METHODS: A total of 23 residents at different stages of their surgical training were tested for technical skill pertaining to 3 shoulder surgical approaches using the following measures: Objective Structured Assessment of Technical Skills (OSATS) checklists, the Global Rating Scale (GRS), and a final pass/fail assessment determined by 3 upper extremity surgeons. Adverse events were recorded. The Cronbach α coefficient was used to assess reliability of the OSATS checklists and GRS scores. Interrater reliability was calculated with intraclass correlation coefficients. Correlations among OSATS checklist scores, GRS scores, and pass/fail assessment were calculated with Spearman ρ. Validity of OSATS checklists was determined using analysis of variance with postgraduate year (PGY) as a between-subjects factor. Significance was set at p < 0.05 for all tests. RESULTS: Criterion validity was shown between the OSATS checklists and GRS for the 3 open shoulder approaches. Checklist scores showed superior interrater reliability compared with GRS and subjective pass/fail measurements. GRS scores were positively correlated across training years. The incidence of adverse events was significantly higher among PGY-1 and PGY-2 residents compared with more experienced residents. CONCLUSION: OSATS checklists are a valid and reliable assessment of technical skills across 3 surgical shoulder approaches. However, checklist scores do not measure quality of technique. Documenting adverse events is necessary to assess quality of technique and ultimate pass/fail status. Multiple methods of assessing surgical skill should be considered when evaluating orthopedic resident surgical performance.

Factors Affecting Perceptions of Open, Mini-Open, and Arthroscopic Rotator Cuff Repair Techniques Among Medical Professionals.

Although no long-term difference between arthroscopic and mini-open rotator cuff repairs has been documented, use of arthroscopic repair has exploded. We conducted a study to determine which repair technique medical professionals preferred for their own surgery and to analyze the perceptions shaping those opinions. A survey was emailed to selected professionals at our institution: attendings, residents, and allied health professionals; 84 (41, 20, and 23, respectively) responded. Irrespective of specialty or career length, almost half (39, 46%) preferred deferring the repair choice to their surgeon; the other 45 preferred arthroscopic (22, 26%), mini-open (19, 23%), open (2, 2%), or no (2, 2%) repair. Most agreed repairs were safe and fast but had no opinion about cost-effectiveness or which technique provided the best outcome. Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs promoted quick healing, good cosmetic results, and patient satisfaction compared with open repair, but these repairs were also perceived as significantly (P < .05) harder to learn and more challenging than open repair. It is important for medical professionals to recognize these biases, especially given that many defer to the judgment of their medical peers.

The Top 100 Cited Articles in Clinical Orthopedic Sports Medicine.

Orthopedic sports medicine continues to evolve, owing much of its clinical management and practice to rigorous academic research. In this review, we identify and describe the top 100 cited articles in clinical sports medicine and recognize the authors and institutions driving the research. We collected articles (excluding basic science, animal, and cadaveric studies) from the 25 highest-impact sports medicine journals and analyzed them by number of citations, journal, publication date, institution, country, topic, and author. Mean number of citations was 408 (range, 229-1629). The articles were published in 7 journals, most in the 1980s to 2000s, and represented 15 countries. Thirty topics were addressed, with a heavy emphasis on anterior cruciate ligament injury and reconstruction, knee rating systems, rotator cuff reconstruction, and chondrocyte transplantation. The 3 most cited articles, by Insall and colleagues, Constant and Murley, and Tegner and Lysholm, addressed a knee, a shoulder, and another knee rating system, respectively. Several authors contributed multiple articles. The Hospital for Special Surgery and the University of Bern contributed the most articles (5 each). This study provides a comprehensive list of the past century's major academic contributions to sports medicine. Residents and fellows may use this list to guide their scholarly investigations.

Techniques for suture anchor removal in shoulder surgery.

Although suture anchor complications after arthroscopic shoulder surgery are uncommon, they can be devastating, such as articular cartilage or bone loss secondary to a dislodged or prominent suture anchor. Proper insertion of the anchor is the most important factor in the prevention of this complication, but if a complication occurs, prompt recognition and treatment are important to prevent damage to the shoulder. The goals were to (1) discuss strategies for preventing or dealing with dislodged or prominent suture anchors and (2) introduce techniques for removal of these implants.