Anterior Cruciate Ligament Reconstruction Graft Preference Most Dependent on Patient Age: A Survey of United States Surgeons.

PURPOSE: The purpose of this study was to define the anterior cruciate ligament (ACL) reconstruction (ACLR) graft preference of surgeons and to explore factors associated with their predilection. METHODS: A 15-question survey regarding ACLR graft preference in various situations was completed by 514 American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America surgeons. Surgeon and practice demographics, along with various patient factors, were evaluated with bivariate and multivariable models for association with surgeon preference. Surgeons were also queried about their preference for their own ACLR. For surgeons who personally sustained an ACL, an additional 6 questions inquired about their experience. RESULTS: Surgeons reported the 5 most important factors in patient graft choice, in order: patient age, graft failure in literature and practice, pivot sport, and patient preference. Autograft patellar and quadriceps tendon were strongly preferred for younger, pivoting athletes (P < .001), among those with fellowship training (47% vs 33%, P = .006), in academic practices (52% vs 44%, P = .003), and in more sports medicine-specific practices, with a higher number of ACLRs performed per year (P < .001). Northeast, Southeast, Midwest, and Southwest surgeons had lower hamstring autograft preference (P < .001). Non-fellowship-trained surgeons preferred hamstring autograft (P = .010). Allograft was preferred for older patients (P < .001). Nonsignificant predictors included highest level of athlete for whom an ACLR had been performed, level of athlete serving as team physician, and years in practice. No factors were associated with surgeon preference for their own ACLR despite deeming these factors important for patients. ACL tears were reported by 13% of respondents, with 86% stating it influenced their decision to enter orthopaedics. CONCLUSIONS: Patient age was the most important factor in graft choice, with patellar and quadriceps tendon autograft the preferred graft for ACLR for younger, pivoting athletes. Fellowship training and practice demographics were also correlated with graft choice for patients. CLINICAL RELEVANCE: Graft preference for ACLR varies among surgeons and is associated with surgeon experience and patient characteristics, including patient age, type of sport, and patient preference.

Assessing the Resident Progenitor Cell Population and the Vascularity of the Adult Human Meniscus.

PURPOSE: To identify, characterize, and compare the resident progenitor cell populations within the red-red, red-white, and white-white (WW) zones of freshly harvested human cadaver menisci and to characterize the vascularity of human menisci using immunofluorescence and 3-dimensional (3D) imaging. METHODS: Fresh adult human menisci were harvested from healthy donors. Menisci were enzymatically digested, mononuclear cells isolated, and characterized using flow cytometry with antibodies against mesenchymal stem cell surface markers (CD105, CD90, CD44, and CD29). Cells were expanded in culture, characterized, and compared with bone marrow-derived mesenchymal stem cells. Trilineage differentiation potential of cultured cells was determined. Vasculature of menisci was mapped in 3D using a modified uDisco clearing and immunofluorescence against vascular markers CD31, lectin, and alpha smooth muscle actin. RESULTS: There were no significant differences in the clonogenicity of isolated cells between the 3 zones. Flow cytometry showed presence of CD44+CD105+CD29+CD90+ cells in all 3 zones with high prevalence in the WW zone. Progenitors from all zones were found to be potent to differentiate to mesenchymal lineages. Larger vessels in the red-red zone of meniscus were observed spanning toward red-white, sprouting to smaller arterioles and venules. CD31+ cells were identified in all zones using the 3D imaging and co-localization of additional markers of vasculature (lectin and alpha smooth muscle actin) was observed. CONCLUSIONS: The presence of resident mesenchymal progenitors was evident in all 3 meniscal zones of healthy adult donors without injury. In addition, our results demonstrate the presence of vascularization in the WW zone. CLINICAL RELEVANCE: The existence of progenitors and presence of microvasculature in the WW zone of the meniscus suggests the potential for repair and biologic augmentation strategies in that zone of the meniscus in young healthy adults. Further research is necessary to fully define the functionality of the meniscal blood supply and its implications for repair.

Upper-extremity blood flow restriction: the proximal, distal, and contralateral effects-a randomized controlled trial.

BACKGROUND: Blood flow restriction (BFR) training with low weight is purported to induce similar physiological changes to high-weight regimens with the benefit of less tissue stress. We hypothesized that low-weight training with BFR would produce increased gains in strength and hypertrophy for muscle groups proximal, distal, and contralateral to tourniquet placement compared with low-weight training alone. METHODS: In this prospective, randomized controlled trial, healthy subjects were randomized into a 6-week low-weight training program either with or without BFR on 1 extremity. Outcome measures included limb circumference and strength. Comparisons were made between the BFR and non-BFR extremities, BFR and control groups, and non-BFR extremity and control groups. RESULTS: A total of 24 subjects (14 BFR and 10 control subjects) completed the protocol. Significantly greater gains were observed in dynamometric strength both proximal (shoulder scaption [30% greater], flexion [23%], and abduction [22%]) and distal (grip strength [13%]) to the tourniquet in the BFR limb compared with both the non-BFR extremity and the control group (P < .05). Arm and forearm circumferences significantly increased in the BFR limb compared with the non-BFR limb and control group (P = .01). The non-BFR extremity demonstrated greater grip strength than the control group (9%, P < .01). No adverse events were reported. CONCLUSION: Low-weight BFR training provided a greater increase in strength and hypertrophy in the upper-extremity proximal and distal muscle groups compared with the control group. The non-BFR extremity showed a significant increase in grip strength compared with the control group, indicating a potential systemic effect.

Posterior capsule injection of local anesthetic for post-operative pain control after ACL reconstruction: a prospective, randomized trial.

PURPOSE: Alternative modalities to optimize pain control after anterior cruciate ligament reconstruction (ACLR) are continually being explored. The purpose of this study was to compare femoral nerve block (FNB) only vs FNB with posterior capsule injection (PCI) of the knee for pain control in patients undergoing ACLR. METHODS: Patients undergoing primary ACLR were randomized to receive either FNB only or FNB with PCI. Following surgery, patient's pain was evaluated in the postoperative care unit (PACU) and at home for 4 days. Pain levels were measured via visual analog scale (VAS) and calculating opioid consumption. Outcomes of interest included postoperative pain levels and opioid consumption. RESULTS: A total of 42 patients were evaluated, with 21 patients randomized to each study arm. Outcomes showed significant pain reduction in both anterior and posterior knee VAS scores in the PACU in those that received PCI (anterior VAS: 39.6 vs 21.3 (SD = 12.9), p < 0.01; posterior VAS: 25.4 vs 15.3 (SD = 8.05), p = 0.01). Moreover, the PCI group also showed significantly less opioid consumption compared to FNB only (23.5 vs 17.4 pills, p = 0.03). There were no differences found in pain scores between groups in home VAS sores. CONCLUSIONS: These finding suggest the use of arthroscopically assisted injection of local anesthetic to the posterior capsule of the knee significantly reduces early post-operative pain and dramatically reduces the number of opoid medication taken after ACLR. LEVEL OF EVIDENCE: Prospective, randomized, control trial, Level I.

The significant effect of the medial hamstrings on dynamic knee stability.

PURPOSE: While hamstring autograft is a popular option for the general population, BTB autograft is still significantly more popular among professional athletes due to concerns of altering knee kinematics with hamstring harvest. This study seeks to quantify the contribution of the medial hamstrings to knee stability. METHODS: Valgus knee laxity, anterior tibial translation, and rotational motion were measured in eight fresh-frozen cadaveric knees after forces were applied on the tibia in each plane (coronal, sagittal, and axial). Four muscle loading conditions were tested: (1) physiologic fully loaded pes anserinus, (2) semitendinosus only loaded, (3) gracilis only loaded, and (4) unloaded pes anserinus. The protocol was then repeated with the ACL transected. RESULTS: In the ACL intact knee, the neutral position of the tibia with an unloaded pes anserinus was significantly more externally rotated (p < 0.01) and anteriorly translated (p < 0.05) at all knee flexion angles than a tibia with a physiologic loaded pes anserinus. Applying an external rotation torque significantly increased external rotation for the fully unloaded (p < 0.001), gracilis only loaded (p < 0.001), and semitendinosus only loaded (p < 0.01) conditions at all flexion angles. Applying a valgus torque resulted in a significant increase in laxity for the fully unloaded condition only at 30° of flexion (p < 0.05). Applying an anterior tibial force resulted in significant increase in anterior translation for the fully unloaded condition at all flexion angles (p < 0.01), and for the gracilis only loaded condition in 30° and 60° of flexion (p < 0.05). Similar results were seen in the ACL deficient model. CONCLUSION: The medial hamstrings are involved in rotational, translational, and varus/valgus control of the knee. Applying anterior, external rotation, and valgus forces on the hamstring deficient knee significantly increases motion in those planes. Harvesting the gracilis and semitendinosus tendons alters native knee kinematics and stability. This is clinically relevant and should be a consideration when choosing graft source for ACL reconstruction, especially in the elite athlete population.

Bioelectric Silver-Zinc Dressing Equally Effective to Chlorhexidine in Reducing Skin Bacterial Load in Healthy Volunteers.

PURPOSE: The aim of the present study was to evaluate and compare the effectiveness of the silver-zinc bioelectric dressing as compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in reducing the bacterial count on the knee. METHODS: Three groups consisting of 48 healthy volunteers were included. Age range was 23 to 54 years old and 60% of participants were male. Each subject had 1 knee serve as the test and the contralateral as the control. The test site was prepared with either 2% chlorhexidine, 4% chlorhexidine, or a silver-zinc bioelectric dressing and after 24 hours skin cultures were taken and examined for bacterial growth. RESULTS: In the 2% chlorhexidine group 23 of 48 unprepped knees had positive cultures, compared with 9 of 48 prepped knees (P = .003; risk reduction, 4.0 times). In the 4% chlorhexidine group 25 of 48 unprepped knees had positive cultures, compared with 14 of 48 prepped knees (P = .027; risk reduction, 2.6 times). In the silver-zinc bioelectric dressing group 29 of 48 unprepped knees had positive cultures, compared with 7 of 48 prepped knees (P < .001; risk reduction, 8.9 times). There was no difference in the positive skin culture rate between the 3 methods. CONCLUSIONS: Application of the silver-zinc bioelectric dressing was equally effective at reducing skin bacterial load when compared with skin preparation with 2% chlorhexidine or 4% chlorhexidine in healthy volunteers. LEVEL OF EVIDENCE: Basic Science - Microbiology. CLINICAL RELEVANCE: The findings of this study indicate that the use of a bioelectric dressing after knee surgery can match the standard of care of preparing the skin with an antiseptic before surgery.

Lack of level I evidence on how to prevent infection after elective shoulder surgery.

PURPOSE: Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery. METHODS: An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery. RESULTS: Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis. CONCLUSION: There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society. LEVEL OF EVIDENCE: IV systematic review of literature.

The biomechanical evaluation of a novel 3-strand docking technique for ulnar collateral ligament reconstruction in the elbow.

BACKGROUND AND HYPOTHESIS: The original 2-strand docking technique for elbow ulnar collateral ligament reconstruction has recently been modified to use a 3-strand graft. To date, no biomechanical study has compared the 2 techniques. We hypothesized that the 3-strand docking technique would restore valgus laxity to its native state, with comparable load-to-failure characteristics to the 2-strand docking technique. MATERIALS AND METHODS: Sixteen fresh cadaveric elbows were matched to the corresponding contralateral side from the same individual to create 8 matched pairs and were then randomized to undergo ulnar collateral ligament reconstruction using either the 2- or 3-strand technique. Valgus laxity and rotation measurements were quantified using a MicroScribe 3DLX digitizer at various flexion angles for the native state, transected state, and 1 of the 2 tested reconstructed ligaments. Each reconstruction was then tested to failure. RESULTS: Valgus laxity for the intact state at elbow flexion angles of 30°, 60°, 90°, and 120° was 7° ± 2°, 7° ± 2°, 6° ± 1°, and 5° ± 2°, respectively. These values were similar to those of both reconstruction techniques. On load-to-failure testing, there was no significant difference in any parameter recorded. Yield torques for the 3- and 2-strand reconstructions were 13.4 ± 4.80 N/m and 11.8 ± 4.76 N/m, respectively (P = .486). The ultimate torques were 15.7 ± 6.10 N/m and 14.4 ± 5.58 N/m for the 3- and 2-strand techniques, respectively (P = .582). CONCLUSION: The 3-strand docking technique was able to restore valgus laxity to the native state, with similar load-to-failure characteristics to the 2-strand docking technique.

Identifying Hidden Zones of the Far Posterior Cartilage of the Femoral Condyles Not Visible During Knee Arthroscopy.

OBJECTIVE: The purpose of this study was to compare standard knee arthroscopic and MRI findings and measurements for visualization of the femoral condyle articular cartilage. The hypothesis was that certain posterior cartilage defects identified with MRI may not be accessible with routine arthroscopy. MATERIALS AND METHODS: Six cadaveric knees were examined by routine arthroscopy through standard inferomedial and inferolateral portals. Suture anchors were inserted into the femoral condyles at 30°, 60°, 90°, and 120° of flexion as markers of the cartilage surface at the most posterior aspect of the condyle that could be accessed at each degree of flexion. Each specimen was then examined with 3-T MRI and gross dissection. Measurements were obtained and compared. RESULTS: During arthroscopy at 90° of knee flexion, only 5.83 mm of the medial femoral condyle and 6.83 mm of the lateral femoral condyle were visualized posterior to the anchor placed at 90° of flexion. These arthroscopic measurements were statistically significant underestimates of the actual amount of cartilage identified posterior to the 90° anchor at gross dissection (medial condyle, 44.20 mm; lateral condyle, 37.50 mm) and MRI (medial, 41.33 mm; lateral, 38.87 mm). This indicates that 85.9% of the medial and 81.8% of the lateral posterior articular cartilage of the femoral condyle seen at MRI were not visualized during arthroscopy. CONCLUSION: More than 80% of the articular cartilage proximal to the menisci seen at MRI is not visible during routine arthroscopy. This far posterior articular cartilage should be called the hidden zone.

A biomechanical cadaveric study comparing superior capsule reconstruction using fascia lata allograft with human dermal allograft for irreparable rotator cuff tear.

BACKGROUND: Biomechanical and clinical success of the superior capsule reconstruction (SCR) using fascia lata (FL) grafts has been reported. In the United States, human dermal (HD) allograft has been used successfully for SCRs; however, the biomechanical characteristics have not been reported. METHODS: Eight cadaveric shoulders were tested in 5 conditions: (1) intact; (2) irreparable supraspinatus tear; (3) SCR using FL allograft with anterior and posterior suturing; (4) SCR using HD allograft with anterior and posterior suturing; and (5) SCR using HD allograft with posterior suturing. Rotational range of motion, superior translation, glenohumeral joint force, and subacromial contact were measured at 0°, 30°, and 60° of glenohumeral abduction in the scapular plane. Graft dimensions before and after testing were also recorded. Biomechanical parameters were compared using a repeated-measures analysis of variance with Tukey post hoc test, and graft dimensions were compared using a Student t-test (P < .05). RESULTS: Irreparable supraspinatus tear significantly increased superior translation, superior glenohumeral joint force, and subacromial contact pressure, which were completely restored with the SCR FL allografts. Both SCR HD allograft repairs partially restored superior translation and completely restored subacromial contact and superior glenohumeral joint force. The HD allografts significantly elongated by 15% during testing, whereas the FL allograft lengths were unchanged. CONCLUSIONS: Single-layered HD SCR allografts partially restored superior glenohumeral stability, whereas FL allograft SCR completely restored the superior glenohumeral stability. This may be due to the greater flexibility of the HD allograft, and the SCR procedure used was developed on the basis of FL grafts.

Perceptions of Orthopaedic Sports Medicine Surgeons About Medical Cannabidiol Use: A Survey Study.

INTRODUCTION: Multiple studies exist identifying cannabidiol (CBD) as an effective part of an orthopaedic patient's pain regimen; however, there is a paucity of studies elucidating orthopaedic surgeons' perception of the use and prescription of CBD in the medical setting. This study surveys orthopaedic sports medicine surgeons about their previous education on and current perceptions and usage of CBD in their medical practice. METHODS: Between April 2023 and July 2023, orthopaedic sports medicine surgeons from across the country were surveyed. This survey was designed in hopes of identifying physician perceptions and current use of CBD as well as their previous education and training on its use. RESULTS: Overall, 75 orthopaedic surgeons responded. More than three-fourths of responders had not received formal education on medical CBD use, nor did they have partners or colleagues who used CBD in their practice. More than half of all surgeons believed that there is a stigma associated with CBD use. A higher proportion of surgeons from CBD legal states recommended CBD to help patients control their pain (53.7% vs. 37.5%). Less than 15% of responders believed that CBD can adversely affect surgical outcomes. Finally, four-fifths of all responders believed that CBD is easy to legally access and affordable to buy by patients who desire it. DISCUSSION: The relative novelty of CBD inclusion in medicine has led to a lack of early education and overall experience with its use among orthopaedic sports medicine surgeons. Still, surgeons believe that CBD is a safe and effective option to control pain. As surgeons continue to gain more familiarity and trust with CBD's medical uses over time, it has the potential to be a mainstay in orthopaedic multimodal pain regimens.

Current Concepts in the Business of Orthopaedics.

Practice management within orthopaedic surgery demands a multifaceted skillset including clinical expertise, technical proficiency, and business acumen, yet the latter is rarely taught during orthopaedic training. As the healthcare system evolves in the United States, surgeons continue to face challenges such as decreasing reimbursements, increased regulatory burdens, and potential for practice acquisition. To remain competitive and provide exceptional care for patients, orthopaedic surgeons must cultivate a business-minded approach. This article highlights the growing significance of the business of orthopaedics and offers guidance on ambulatory surgical center ownership models, effective management of ancillary services, the effect of private equity in orthopaedic practice, real estate investment opportunities in medical office buildings, and the importance of brand recognition. By understanding these concepts, orthopaedic surgeons can exercise greater control over their practice's finances while providing quality care for their patients.

Glenohumeral contact pressure in a simulated active compression test using cadaveric shoulders.

BACKGROUND: The active compression test has been described to detect superior labrum anterior and posterior (SLAP) lesions. Some have speculated that contact between the lesser tuberosity and the superior glenoid in the testing position causes a positive test. This study evaluated the location of peak glenohumeral contact pressures during a simulated active compression test in a cadaveric model with and without SLAP lesions. MATERIALS AND METHODS: Six specimens were tested. A pressure sensor was used to record glenohumeral contact, and a motion analysis system was used to measure humeral head translation. Contact pressures and translations were measured during serial deltoid and biceps loads. These were repeated for small and large SLAP lesions. RESULTS: There was a notable shift in the location of peak contact pressure from the anterior-inferior glenoid to the anterior-superior glenoid with increasing deltoid load. Deltoid loading translated the humeral head posteriorly relative to the glenoid. Conversely, biceps loads countered the pull of the deltoid only when the biceps load was greater than the deltoid load. The SLAP tears did not significantly alter the degree of humeral head translation or location of the contact pressures. CONCLUSIONS: In the active compression test, the posterior capsule is taut and the anterior capsule is lax, which permits the deltoid to translate the humeral head posteriorly. This shift in the peak contact pressure to the superior glenoid may elicit a positive active compression test. LEVEL OF EVIDENCE: Basic Science Study, Biomechanics, Cadaver Model.

Arthroscopic In Situ Biceps Tenodesis Using a Double Loop-and-Tack Knotless Suture Anchor.

The long head biceps tendon is a common culprit of anterior shoulder pain and dysfunction that can be surgically treated with tenotomy or tenodesis. Many techniques exist for tenodesis. This article submits an arthroscopic technique using two loop-and-tack sutures and a knotless suture anchor to tenodese the long head biceps tendon in the proximal bicipital groove in situ. The advantage of this technique is that it maintains the biceps in its native position by performing tenodesis before tenotomy. Most other techniques attempt to restore native position of the biceps through approximation. The transverse humeral ligament is also released to decompress the bicipital groove. This technique can be used to treat isolated biceps pathology or combined with rotator cuff and labral procedures.

Physician Trainees' Perception of Cannabidiol Use in Medicine: A Survey Study.

PURPOSE: Given the ongoing national opiate crisis, physicians have been challenged with mitigating the risk of opiate dependence in their patients. With current physician efforts to mitigate the risks of treating pain with opioid prescriptions, this study evaluates medical students' and residents' understanding and perceptions regarding cannabidiol (CBD) in current medical care and their future medical practice. METHODS: Orthopedic residents from all American programs and medical students from 50 medical schools, regardless of training year or future specialty plans, were eligible to participate in this survey-based study administered from December 2022 to March 2023. The surveys ask questions about demographic information, what education they receive on CBD utilization in medicine, thoughts on CBD effectiveness in pain control, and future plans on utilizing CBD. RESULTS: A total of 55 residents (1.4%) and 53 medical students (5.1%) responded. Trainees in CBD-legal states were more likely to work with physicians who use CBD in their practice. Most trainees, regardless of location, believe CBD use has a stigma attached to it. Many responders were concerned about the role of CBD in pain control. Finally, most trainees believed that CBD is easy to access if desired and is affordable to purchase. CONCLUSION: The trajectory of CBD use in the United States indicates that the therapeutic benefits of CBD will be targeted, and future physicians are not always provided adequate educational opportunities to learn about its potential medical uses. Continued training as well as interactions with patients may help decrease the stigma surrounding medical CBD use and help solidify its therapeutic use in pain control.

Return to Sport After Arthroscopic Capsular Repair in Elite Baseball Players.

Background: Chronic attritional midsubstance capsular tears arising from repetitive throwing stress are a rare but important source of pain and dysfunction in elite baseball players; however, little is known regarding outcomes after arthroscopic capsular repair. Purpose: To evaluate the patient-reported outcomes and return-to-sport (RTS) rates after arthroscopic capsular repair in elite baseball players. Study Design: Case series; Level of evidence, 4. Methods: We identified 11 elite-level baseball players who were treated with arthroscopic repair for a midsubstance glenohumeral capsular tear by a single surgeon with a uniform approach and a standardized postoperative protocol between 2012 and 2019. All players had at least 2 years of follow-up data. Demographic data and concomitant surgical procedures were recorded. Preoperative and postoperative Kerlan-Jobe Orthopaedic Clinic (KJOC) scores and Single Assessment Numeric Evaluation (SANE) scores were collected in a subset of the cohort, and statistical comparisons were made. A telephone survey was conducted to determine the patients' RTS level and outcome scores. Statistical comparisons between preoperative and postoperative outcomes scores were made using t tests. Results: Eight major league players, 1 minor league player, and 2 collegiate players were included. There were 9 pitchers, 1 catcher, and 1 outfielder. All patients had debridement of the posterosuperior labrum and rotator cuff. Two pitchers underwent a rotator cuff repair, and 1 outfielder underwent a posterior labral repair. The mean age at the time of surgery was 26.9 years (range, 20-34 years), with a mean follow-up of 3.5 years (range, 2.6-5.9 years). There were significant preoperative versus postoperative improvements in the mean KJOC (20.6 vs 89.8; P = .0002) and SANE (28.3 vs 86.7; P = .001) scores. All patients reported a high degree of satisfaction. At a mean of 16.3 months (range, 6.5-25.4 months), 10 of 11 (90.1%) players met the Conway-Jobe good or excellent criteria for RTS. Conclusion: Arthroscopic capsular repair provided significant improvements in functional outcomes in elite baseball players, high levels of patient satisfaction, and high levels of RTS.

Biomechanical characteristics of a new looping stitch versus the classic Krackow stitch for distal biceps fixation.

Background: The purpose of this study was to quantify the biomechanical characteristics of a new looping stitch, developed with the concepts of a looping, locking stitch that decreases needle penetrations of the tendon, and compare it to a classic Krackow stitch for distal biceps suture-tendon fixation. Methods: The Krackow stitch with No. 2 braided suture and the looping stitch with a No. 2 braided suture loop attached to a 25-mm-length by 1.3-mm-width polyblend suture tape were compared. The Looping stitch was performed with single strand locking loops and wrapping suture around the tendon, resulting in half the needle penetrations through the graft compared to the Krackow stitch. Ten matched pairs of human distal biceps tendons were used. One side of each pair was randomly assigned to either the Krackow or the looping stitch, and the contralateral side was used for the other stitch. For biomechanical testing, each construct was preloaded to 5 N for 60 seconds, followed by cyclic loading to 20 N, 40 N, and 60 N for 10 cycles each, and then loaded to failure. The deformation of the suture-tendon construct, stiffness, yield load, and ultimate load were quantified. Comparisons between the Krackow and looping stitches were performed with a paired t-test using P < .05 as statistically significant. Results: The Krackow stitch and looping stitch had no significant difference in stiffness, peak deformation, or nonrecoverable deformation after 10 cycles of loading to 20 N, 40 N, and 60 N. There was no difference between the Krackow stitch and looping stitch in load applied to displacement of 1 mm, 2 mm, and 3 mm. The ultimate load showed that the looping stitch was significantly stronger compared to the Krackow stitch (Krackow stitch: 223.7 ± 50.3 N; looping stitch: 312.7 ± 53.8 N) (P = .002). The failure modes were either suture breakage or tendon cut through. For the Krakow stitch, there was 1 suture breakage and 9 tendons cut through. For the looping stitch, there were five suture breakages, and five tendons cut through. Conclusions: With fewer needle penetrations, incorporation of 100% of the tendon diameter, and a higher ultimate load to failure compared to the Krackow stitch, the Looping stitch may be a viable option to reduce deformation, failure, and cut-out of the suture-tendon construct.

Biomechanical Characterization of a New Locking Loop Stitch for Graft Fixation versus Krackow Stitch.

Background: The purpose of this study was to quantify and compare the biomechanical characteristics of a new locking loop stitch (LLS), developed utilizing the concepts of both running locking stitch and needleless stitch, to the traditional Krackow stitch. Methods: The Krackow stitch with No.2 braided suture and the LLS with 1.3-mm augmented polyblend suture tape were compared biomechanically. The LLS was performed with single strand locking loops and wrapping suture around the tendon, resulting in half the needle penetrations through the graft compared to the Krackow stitch. Twenty bovine extensor tendons were divided randomly into two groups. The tendons were prepared to match equal thickness and cross-sectional area. Each suture-tendon was stitched and preloaded to 5 N for 60 seconds, cyclically loaded to 20 N, 40 N, and 60 N for 10 cycles each, and then loaded to failure. The deformation of the suture-tendon construct, stiffness, yield load, and ultimate load were measured. Results: The LLS had significantly less deformation of the suture-tendon construct at 100 N, 200 N, 300 N, and at ultimate load compared to the Krackow stitch (Krackow stitch and LLS at 100 N: 1.3 ± 0.1 mm and 1.0 ± 0.2 mm, p < 0.001; 200 N: 3.0 ± 0.3 mm and 1.9 ± 0.2 mm, p < 0.001; 300 N: 5.1 ± 0.6 mm and 2.9 ± 0.4 mm, p < 0.001; ultimate load: 12.8 ± 2.8 mm and 5.0 ± 1.2 mm, p < 0.001). The LLS had significantly greater stiffness (Krackow stitch and LLS: 97.5 ± 6.9 N/mm and 117.2 ± 13.9 N/mm, p < 0.001) and yield load (Krackow stitch and LLS: 66.2 ± 15.9 N and 237.9 ± 93.6 N, p < 0.001) compared to the Krackow stitch. There was no significant difference in ultimate load (Krackow stitch: 450.2 ± 49.4 N; LLS: 472.6 ± 59.8 N; p = 0.290). Conclusions: The LLS had significantly smaller deformation of the suture-tendon construct compared to the Krackow stitch. The LLS may be a viable surgical alternative to the Krackow stitch for graft fixation when secure fixation is necessary.

A watertight construct in arthroscopic rotator cuff repair.

BACKGROUND: It is unknown which type of rotator cuff repair technique best isolates the healing zone interface from the synovial fluid environment. The purpose of this study was to determine the leakage area and pattern onto the rotator cuff footprint after 3 different rotator cuff repairs. MATERIALS AND METHODS: Six fresh frozen cadaveric glenohumeral joints in each of 3 groups were injected with gelatin to a pressure of 103 mm Hg (∼2 psi) after 1 of 3 different rotator cuff repairs of a supraspinatus tear: (1) single-row repair (SR), (2) knotless transosseous equivalent repair (KTE), and (3) traditional transosseous equivalent repair (TTE), which uses medial tied knots. Specimens were cycled in external rotation and abduction and were cooled to allow the gelatin to solidify. The supraspinatus was dissected off the footprint and photographs were taken. Scion Image (Frederick, MD, USA) was used to quantify the area. RESULTS: The average area of leakage was 1.09 cm(2) for the SR and 1.15 cm(2) for the KTE. The TTE did not demonstrate any leakage. The pattern of leakage for the KTE was medial and central on the footprint, whereas the SR demonstrated leakage up to the tied knots. The difference in the area of leakage in the SR and KTE compared with the TTE was statistically significant. There was no difference in area of leakage between the SR and KTE. CONCLUSION: A transosseous equivalent repair technique best prevents leakage onto the rotator cuff footprint compared with single-row and knotless repairs.

Understanding Batter's Shoulder: Diagnosis, Treatment, and Outcomes.

PURPOSE OF REVIEW: Though most of the attention in recent literature on baseball injuries has been paid to throwers, one often overlooked aspect of the game is the effect of the batter's swing on the shoulder. It is well known that the batter's lead shoulder can experience significant translational forces during the player's swing, and that these are increased following a missed swing. The purpose of this paper is to review the background and pathophysiology as well as clinical presentation and treatment of players with Batter's shoulder. RECENT FINDINGS: Recent studies demonstrate that while nonoperative treatment of Batter's shoulder is still a viable first line of treatment, favorable outcomes have been reported with arthroscopic posterior labral repair for high level athletes. Batter's injury can cause significant pain and dysfunction in baseball hitters, especially during the follow through phase of swing. While conservative care can be attempted early, outcomes following arthroscopic posterior labral repair are favorable with a high rate of return to play.