Orthopedic Injuries in Professional Surfers: A Retrospective Study at a Single Orthopedic Center.

BACKGROUND: Literature regarding surfing injuries is scarce and most studies report a high number of minor injuries. Recent literature suggests that musculoskeletal injuries are more common than previously reported. In the mid 2000s, competitive surfing has seen an increase in aerial maneuvers, as they have become more highly rewarded by the judging panel, which may be contributing to a change in injury patterns. Our goal was to evaluate orthopedic injuries in professional surfers. HYPOTHESIS: Orthopedic injuries in professional surfers are diverse and have evolved with skill and technology. STUDY DESIGN: Retrospective observational study. LEVEL OF EVIDENCE: Level 4 Case Series. METHODS: Medical records of professional surfers from a single orthopedic center between 1991 and 2016 were reviewed. Injuries sustained while surfing and chronic injuries related to surfing were included. Site of injury, diagnosis, and treatment were recorded along with demographic data. RESULTS: In total, 163 injuries in 86 athletes were recorded. The median injury age was 28.5 years (range 12-62 years) and 92.6% of patients were male. The most frequently injured body parts were the knee (28.2%), ankle (22.1%), and shoulder (19%). Most knee injuries were of the medial collateral ligament at 49%, with 75% of ankle injuries being sprains, and in shoulder, 48% had instability, 42% had a rotator cuff tear, and 35% had a superior anterior-posterior labral tear. Lower extremity injuries primarily affected the surfers' back leg (72.5%). In all, 34.6% of all injuries required surgical intervention and involved shoulder injuries most the time. CONCLUSIONS: The most common orthopedic injuries in professional surfers involve the knee, ankle, shoulder, hip, and back. Surfers' rear extremities were preferentially injured which is the extremity responsible for power and torque. Shoulder injuries increased the probability of an operative intervention. Last, overuse injuries (femoral-acetabular impingement, rotator cuffs) occurred in the older surf population compared with more acute injuries (ankle sprains/fractures, anterior cruciate ligament tears) which is also consistent with time to surgery.

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation.

BACKGROUND: The purpose was to assess the minimum 2-year patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears. METHODS: From 2008-2014, patients who underwent revision rotator cuff repair augmented with AHDM with greater than 2 years' follow-up by a single surgeon were retrospectively reviewed. Data regarding surgical history, demographic characteristics, and medical comorbidities were collected. Outcome data included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, as well as rotator cuff healing on magnetic resonance imaging or ultrasound. Retears and subsequent surgical procedures were characterized. RESULTS: A total of 28 patients met our inclusion criteria, and 23 (82%) were available for follow-up at 2 years. The mean age was 60.1 ± 9.3 years (range, 43-79 years), with a mean follow-up period of 48 ± 23 months. All patients had at least 1 prior rotator cuff repair. Of the 23 patients, 13 (56%) underwent postoperative imaging, and 4 of these 13 (31%) had a retear. A reoperation was performed in 3 of 23 patients (13%). Among the 6 patients with both preoperative and postoperative outcome scores, we saw improvement in the ASES score from 56 to 85 (P = .03) and in the SANE score from 42 to 76 (P = .03). The full cohort's mean postoperative ASES and SANE scores were 77 and 69, respectively. CONCLUSION: AHDM allograft augmentation is a safe and effective treatment method for patients with full-thickness rotator cuff retears. Further research is needed with larger studies to confirm these findings from our small cohort of patients.

Does the Utilization of Allograft Tissue in Medial Patellofemoral Ligament Reconstruction in Pediatric and Adolescent Patients Restore Patellar Stability?

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is one of several surgical procedures used to treat patellofemoral instability. Use of allograft tissue can preserve autogenous tissue and may be preferable in patients with connective tissue disorders or ligamentous laxity. Although there are successful reports in adults, it is unclear if the use of allograft tissue in MPFL reconstruction can restore patellofemoral stability in children and adolescents. QUESTIONS/PURPOSES: (1) Does allograft tissue in MPFL reconstruction in pediatric and adolescent patients restore patellar stability? (2) What complications were associated with allograft MPFL reconstructions in children and adolescents? METHODS: Between June 2012 and August 2015, one surgeon (NKP) performed 26 MPFL reconstructions in 23 patients with gracilis allograft for traumatic patellar instability. Of those, 25 (96%) were available for followup more than 1 year later (mean, 24 months; range, 12-44 months). During this time, the surgeon suggested reconstruction to patients who had recurrent dislocation or subluxation after 6 weeks of bracing, physical therapy, and activity modification if they were noted to have a torn or attenuated MPFL on MRI. During that period, this was the only surgical technique the surgeon used to treat traumatic patellar instability. Patients undergoing concurrent bony procedures were ineligible for inclusion. The mean age of the patients in the series was 16.0 (± 2) years. Age, sex, skeletal maturity, presence of trochlear dysplasia, and additional arthroscopic procedures at the time of reconstruction were collected. Postoperative notes and imaging were reviewed for presence of complications defined as recurrent dislocation, recurrent subluxations, fractures, infection, or arthrofibrosis. These complications were identified by chart review by the senior surgeon (NKP) and study personnel (EH) not involved in clinical care of the patients or by patient-reported complications. Recurrent subluxation or dislocation was patient-reported at the time of the clinic visit or followup phone/email contact. Fractures were defined as any cortical disruption in the femur or patella that required treatment (change in postoperative protocol), infection requiring treatment (antibiotics and/or return to the operating room), or arthrofibrosis (stiffness that necessitated a change in the postoperative protocol or manipulation under anesthesia). RESULTS: Ninety-two percent (23 of 25) of patients reported no further instability episodes after MPFL reconstruction. Sixteen percent (four of 25) of patients had complications: two repeat episodes of patellar instability, one patella fracture, and one symptomatic hardware requiring interference screw removal. No patients developed arthrofibrosis or infection. CONCLUSIONS: In this small case series, we found that MPFL reconstruction using allograft tissue in children and adolescents resulted in a low risk of recurrent instability, perhaps comparable to what has been published by others who have used autograft tissue. Longer followup is needed, because in some orthopaedic applications, allograft ligaments have been observed to attenuate over time. Future studies might compare these techniques using patient-reported outcomes scores as well as use a control group of patients with autograft tissue. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Comparison of Surface Area across the Allograft-Host Junction Site Using Conventional and Navigated Osteotomy Technique.

Bulk allograft reconstruction plays an important role in limb-salvage surgery; however, non-union has been reported in up to 27% of cases. The purpose of this study is to quantify average surface contact areas across simulated intraoperative osteotomies using both free-hand and computer-assisted navigation techniques. Pressure-sensitive paper was positioned between two cut ends of a validated composite sawbone and compression was applied using an eight-hole large fragment dynamic compression plate. Thirty-two samples were analyzed for surface area contact to determine osteotomy congruity. Mean contact area using the free-hand osteotomy technique was equal to 0.21 square inches. Compared with a control of 0.69 square inches, average contact area was found to be 30.5% of optimal surface contact. Mean contact area using computer-assisted navigation was equal to 0.33 square inches. Compared with a control of 0.76 square inches, average contact area was found to be 43.7% of optimal surface contact. Limited contact achieved using standard techniques may play a role in the high rate of observed non-union, and an increase in contact area using computer-assisted navigation may improve rates of bone healing. The development of an oncology software package and navigation hardware may serve an important role in decreasing non-union rates in limb salvage surgery.

Fixation methods and implants in shoulder stabilization: A historical perspective.

BACKGROUND: Treatment for shoulder instability has changed significantly over the past decade from open procedures to arthroscopic procedures using a variety of different fixation methods and implants. The development of these implants has been highly influenced by the numerous complications that have arisen using early designs. METHODS: A review of the literature was performed to describe the history of shoulder stabilization. CONCLUSION: As biomedical technology improves, we should continue to see changes to implant design and manufacturing. Having an understanding of the history and evolution of these implants will provide us with context in which to guide future implant design and clinical use. This review article provides a comprehensive overview of the evolution of early shoulder stabilization techniques and implants to the modern implants being used today.

Does duration of symptoms affect clinical outcome after hip arthroscopy for labral tears? Analysis of prospectively collected outcomes with minimum 2-year follow-up.

Limited research exists on the possible association between duration of symptoms and clinical outcomes following hip arthroscopy for labral tears. The purpose of this study was to evaluate whether duration of symptoms affected clinical and patient-reported outcome (PRO) scores following hip arthroscopy for labral tears. From 2008 to 2011, data were collected prospectively on all patients undergoing primary hip arthroscopy for labral tears. Workers' compensation cases, dysplasia cases and patients with previous ipsilateral hip surgeries were excluded. A total of 738 patients were identified with a minimum of 2-year follow-up, and clinical and PRO data were available for 680 patients. Uni- and multivariate analyses were performed to determine the relationship between duration of symptoms along with other variables and PROs. Overall, patients experienced significant improvements in all clinical and PRO scores. Results of univariate analysis revealed that all PROs were negatively associated with increasing Log10 months of symptoms as were pain and satisfaction scores. During multivariate analyses, increasing Log10 months of symptoms, age, body mass index and trauma were all negatively associated with PROs (P < 0.05). Our study demonstrates that clinical and PRO scores were negatively associated with increasing duration of symptoms prior to hip arthroscopy for treatment of labral tears. Although this implies that delay in treatment may adversely affect outcome, conservative treatment remains the gold standard first line of treatment. Surgeons should incorporate this information into their treatment algorithm to maximize patient outcomes following treatment for labral tears. Level of evidence: Level IV, prospective case series.

The Pedicles Are Not the Densest Regions of the Lumbar Vertebrae: Implications for Bone Quality Assessment and Surgical Treatment Strategy.

STUDY DESIGN: Cadaver study. OBJECTIVE: To determine the bone density of lumbar vertebral anatomic subregions. Bone mineral density (BMD) is a major factor in osseous fixation construct strength. The standard region for implant fixation of the spine is the pedicle; however, other regions may be more viable options with higher bone quality. METHODS: Using computed tomography images, the spine was digitally isolated by applying a filter for adult bone. The spine model was separated into 5 lumbar vertebrae, followed by segmentation of each vertebra into 7 regions and determination of average Hounsfield units (HU). HU was converted to BMD with calibration phantoms of known BMD. RESULTS: Overall mean BMD in vertebral regions ranged from 172 to 393 mg/cm3 with the highest and lowest BMD in the lamina and vertebral body, respectively. Vertebral regions formed 3 distinct groups (P < .03). The vertebral body and transverse processes represent one group with significantly lower BMD than other regions. Spinous process, pedicles, and superior articular processes represent a second group with moderate BMD. Finally, inferior articular process (IAP) and lamina represent a third group with significantly higher BMD than other regions. CONCLUSIONS: Standard lumbar fusion currently uses the vertebral body and pedicles as primary locations for fixation despite their relatively low BMD. Utilization of posterior elements, especially the lamina and IAP, may be advantageous as a supplement to modern constructs or the primary site for fixation, possibly mitigating construct failures due to loosening or pullout.

Development of a surgical skills curriculum for the training and assessment of manual skills in orthopedic surgical residents.

OBJECTIVE: To develop and conduct a pilot study of a curriculum of 4 surrogate bone training modules to assess and track progress in basic orthopedic manual skills outside the operating room. DESIGN: Four training modules were developed with faculty and resident input. The modules include (1) cortical drilling, (2) drill trajectory, (3) oscillating saw, and (4) pedicle probing. Orthopedic resident's performance was evaluated. Validity and reliability results were calculated using standard analysis of variance and multivariate regression analysis accounting for postgraduate year (PGY) level, number of attempts, and specific outcome target results specific to the simulation module. SETTING: St. Mary's Medical Center in San Francisco, CA. PARTICIPANTS: These modules were tested on 15 orthopedic surgery residents ranging from PGY 1 to PGY 5 experience. RESULTS: The cortical drilling module had a mean success rate of 56% ± 5%. There was a statistically significant difference in performance according to the diameter of the drill used from 33% ± 7% with large diameter to 70% ± 6% with small diameter. The drill trajectory module had a success rate of 85% ± 3% with a trend toward improvement across PGY level. The oscillating saw module had a mean success rate of 25% ± 5% (trajectory) and 84% ± 6% (depth). We observed a significant improvement in trajectory performance during the second attempt. The pedicle probing module had a success rate of 46% ± 10%. CONCLUSION: The results of this pilot study on a small number of residents are promising. The modules were inexpensive and easy to administer. Conclusions of statistical significance include (1) residents who could easily detect changes in surrogate bone thickness with a smaller diameter drill than with a larger diameter drill and (2) residents who significantly improved saw trajectory with an additional attempt at the module.