Rotator Cuff Repair Using Coracoacromial Ligament Autograft for Supraspinatus Footprint Augmentation.

Failure of rotator cuff repair can be a disastrous clinical outcome. Although failure is a multifactorial issue, recent interest has piqued in understanding the biology of the insertional components of the supraspinatus and infraspinatus at the footprint. When the torn tendon is of poor quality, especially if it is diminutive or thin, rotator cuff repair augmentation should be considered to aid in long-term healing. Various allograft options have been described in the past, and more recently, xenografts and synthetics have become more commonly used. The use of autografts in the treatment of insertional footprint deficiency has great potential; however, few grafts have been described. This study describes the surgical technique for footprint augmentation in arthroscopic supraspinatus repair using harvested autologous coracoacromial ligament tissue.

Shoulder surgeon techniques and preferences in treatment of massive rotator cuff tears: current practices for rotator cuff repair and superior capsule reconstruction.

Background: Massive rotator cuff tears can be difficult to manage and consensus regarding treatment is debated. The purpose of this questionnaire study was to examine surgeon techniques and considerations for treatment of massive rotator cuff tears including how they implement superior capsule reconstruction (SCR), when indicated. Methods: A 21-item questionnaire was sent to members of the American Shoulder and Elbow Surgeons and the American Orthopedic Society for Sports Medicine. Questions covered management preferences for massive rotator cuff tears, rotator cuff repair and SCR techniques, beliefs about SCR, implant choices, use of augments, demographics, and patient management scenarios. Results: The questionnaire had 230 respondents. In rotator cuff repair of massive rotator cuff tears, preferred responses were long head biceps tendon preservation (when asymptomatic, 45.3%), routine subacromial decompression (62.1%), solid threaded anchors (71.1%), double row configuration (65.1%), and bone marrow stimulation of the footprint (55.6%). For providers that perform SCR (n = 166), preferred strategies included long head biceps tenodesis (55.4%), human dermal allograft tissue (93.2%), glenoid fixation with 3 implants (71.2%) using solid threaded anchors (42.3%), and humeral fixation with 2 solid threaded anchors medially (71.0%), and 2 solid threaded anchors laterally (46.9%). Other highly recommended strategies were side-to-side repair to the posterior rotator cuff if able (97.6%) and to use the thickest graft available (62.2%). Conclusion: Despite improved techniques and growing interest in SCR, many questions still remain. This study identifies the significant variability in repair constructs and methodology with SCR; further investigation into these variables could be analyzed to identify best practice guidelines.

Impact of COVID-19 on Recovered Athletes Returning to Competitive Play in the NBA "Bubble".

BACKGROUND: The global pandemic caused by COVID-19 has had far-reaching implications for the world of professional sports. The National Basketball Association (NBA) suspended active regular season play in 2020 after a player tested positive for SARS-CoV-2. No previous studies have examined the impact of COVID-19 on return to play in the NBA. PURPOSE/HYPOTHESIS: The purpose of this study was to examine performance measures for NBA players who had recovered from COVID-19 and returned to play in the NBA bubble. We hypothesized that these athletes would play fewer minutes and have decreased performance statistics compared with performance during the 2019-2020 regular season prior to the lockdown and with career averages. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: NBA players positive for SARS-CoV-2 who played in both the 2019-2020 regular season and the NBA bubble were identified. Data collected included player demographics and player performance statistics. RESULTS: A total of 20 players were included in the study. Players who had recovered from COVID-19 played significantly fewer minutes per game in the NBA bubble (25.8 vs 28.7; P = .04) and made fewer field goals per game (4.6 vs 5.4; P = .02) compared with the season prior to shutdown. While NBA bubble players demonstrated slight decreases in averages for points (P = .06), rebounds (P =.13), assists (P = .23), steals (P = .30), and blocks (P = .71) per game, these were not statistically significant. Aside from an increase in made free throws per game during the bubble (3.3 vs 2.8; P = .04), player performance was not significantly different from career averages. CONCLUSION: For players who tested positive for SARS-CoV-2 prior to playing in the NBA bubble, the current study demonstrated that despite playing significantly fewer minutes per game, performance was not statistically different from either their pre-COVID 2019-2020 level of play or from their career averages.

Economic and Performance Impact of Anterior Cruciate Ligament Injury in National Basketball Association Players.

BACKGROUND: Anterior cruciate ligament (ACL) tears are one of the most devastating injuries seen in the National Basketball Association (NBA). No previous studies have examined the economic impact of ACL tears in the NBA. PURPOSE/HYPOTHESIS: The purpose of this study was to examine the economic impact of ACL tears on NBA players and teams by calculating the costs of recovery (COR) and classifying players based on preinjury success level (All-Star or equivalent, starter, or reserve) and salary (in US$ million: <1.5, 1.5-4, or >4 per season). It was hypothesized that players with a lower preinjury salary or primarily a reserve role would have decreased costs, lower rates of return to play (RTP), and shorter careers. STUDY DESIGN: Descriptive epidemiology study. METHODS: We reviewed the publicly available records of NBA players treated with ACL reconstruction from 2000 to 2015. Data collected included player demographics, player salaries, statistical performance using player efficiency rating (PER), and specifics regarding time missed and RTP rate. RESULTS: A total of 35 players met the study inclusion criteria. The cumulative economic loss from ACL injuries in the NBA from 2000 to 2015 was $99 million. The average COR was $2.9 million per player. RTP rate was 91% overall, with 70% retention at 3 years. Players that made a salary of less than $1.5 million per season before the injury had a significant drop in PER (difference of -7), RTP rate of 63%, and only 37% retention at 3 years. Conversely, recovering All-Star players also had a significant drop in PER (-6.2), and no players repeated as All-Stars in the season after ACL reconstruction (0%), although they did have a 100% RTP rate and an average career length of 5.6 seasons postinjury. CONCLUSION: While the RTP rate in NBA athletes remained high, ACL reconstruction can result in decreased statistical performance and/or inability to return to prior levels of play. Players who made less than $1.5 million preinjury or played primarily in a reserve role were associated with lower RTP and retention in the NBA at 3 years.

Evaluation and Treatment of Borderline Dysplasia: Moving Beyond the Lateral Center Edge Angle.

PURPOSE OF REVIEW: The purpose of this manuscript is to 1 define the features associated with borderline acetabular dysplasia and 2 review current status of diagnostic algorithms and treatment options for borderline dysplasia. RECENT FINDINGS: Acetabular dysplasia is a common cause of hip pain secondary to insufficient coverage of the femoral head by the bony acetabulum. Historical classification of acetabular dysplasia has utilized the lateral center edge angle (LCEA); values above 25° are normal and below 20° are considered pathologic. Borderline dysplasia describes hips with LCEA between 20 and 25o; treatment of these patients is controversial. While many studies utilize LCEA in classification of borderline dysplasia, isolated reliance on measurement of lateral femoral head coverage to define severity of undercoverage will continue to mislabel morphology. Thorough assessment of the characteristics of mild acetabular undercoverage is necessary for future studies, which will allow effective comparisons of results between hip arthroscopy and periacetabular osteotomy.

Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To assess the impact of fondaparinux on venous thromboembolism (VTE) following elective lumbar spine surgery in high-risk patients. METHODS: Matched patient cohorts who did or did not receive inpatient fondaparinux starting postoperative day 2 following elective lumbar spine surgery were compared. All patients received 1 month of acetyl salicylic acid 325 mg following discharge. The primary outcome was a symptomatic DVT (deep vein thrombosis) or PE (pulmonary embolus) within 30 days of surgery. Secondary outcomes included prolonged wound drainage, epidural hematoma, and transfusion. RESULTS: A significantly higher number of DVTs were diagnosed in the group that did not receive inpatient VTE prophylaxis (3/102, 2.9%) compared with the fondaparinux group (0/275, 0%, P = .02). Increased wound drainage was seen in 18.5% of patients administered fondaparinux, compared with 25.5% of untreated patients (P = .15). Deep infections were equivalent (2.2% with fondaparinux vs 4.9% control, P = .18). No epidural hematomas were noted, and the number of transfusions after postoperative day 2 and 90-day return to operating room rates were equivalent. CONCLUSIONS: Patients receiving fondaparinux had lower rates of symptomatic DVT and PE and a favorable complication profile when compared with matched controls. The retrospective nature of this work limits the safety and efficacy claims that can be made about the use of fondaparinux to prevent VTE in elective lumbar spine surgery patients. Importantly, this work highlights the potential safety of this regimen, permitting future high-quality trials.

The Pivot Shift: Current Experimental Methodology and Clinical Utility for Anterior Cruciate Ligament Rupture and Associated Injury.

PURPOSE OF REVIEW: The purpose of this manuscript is to (1) examine the history, techniques, and methodology behind quantitative pivot shift investigations to date and (2) review the current status of pivot shift research for its clinical utility for management of anterior cruciate ligament (ACL) rupture with associated injuries including the anterolateral complex (ALC). RECENT FINDINGS: The pivot shift is a useful physical exam maneuver for diagnosis of rotatory instability related to ACL tear. Recent evidence suggests that the pivot shift is multifactorial and can be seen in the presence of ACL tear with concomitant injury to secondary stabilizers or with predisposing anatomical factors. The presence of a pivot shift post-operatively is associated with poorer outcomes after ACL reconstruction. Recent clinical and biomechanical investigations can help guide clinicians in utilizing pivot shift in diagnosis and surgical planning. Further research is needed to clarify optimal management of ALC in addition to ACL injury.

Cervical Spine Fractures: Who Really Needs CT Angiography?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Compare a novel two-step algorithm for indicating a computed tomography angiography (CTA) in the setting of a cervical spine fracture with established gold standard criteria. SUMMARY OF BACKGROUND DATA: As CTA permits the rapid detection of blunt cerebrovascular injuries (BCVI), screening criteria for its use have broadened. However, more recent work warns of the potential for the overdiagnosis of BCVI, which must be considered with the adoption of broad criteria. METHODS: A novel two-step metric for indicating CTA screening was compared with the American College of Surgeons guidelines and the expanded Denver Criteria using patients who presented with cervical spine fractures to a tertiary-level 1 trauma center from January 1, 2012 to January 1, 2016. The ability for each metric to identify BCVI and posterior circulation strokes that occurred during this period was assessed. RESULTS: A total of 721 patients with cervical fractures were included, of whom 417 underwent CTAs (57.8%). Sixty-eight BCVIs and seven strokes were diagnosed in this cohort. All algorithms detected an equivalent number of BCVIs (52 with the novel metric, 54 with the ACS and Denver Criteria, P = 0.84) and strokes (7/7, 100% with the novel metric, 6/7, 85.7% with the ACS and Denver Criteria, P = 1.0). However, 63% fewer scans would have been needed with the proposed screening algorithm compared with the ACS or Denver Criteria (261/721, 36.2% of all patients with our criteria vs. 413/721, 57.3% with the ACS standard and 417/721, 57.8%) with the Denver Criteria, P < 0.0002 for each). CONCLUSION: A two-step criterion based on mechanism of injury and patient factors is a potentially useful guide for identifying patients at risk of BCVI and stroke after cervical spine fractures. Further prospective analyses are required prior to widespread clinical adoption. LEVEL OF EVIDENCE: 4.

Limb Salvage After Failed Initial Operative Management of Bimalleolar Ankle Fractures in Diabetic Neuropathy.

BACKGROUND: Ankle fractures in patients with diabetes mellitus (DM) can be difficult to manage, especially in the presence of peripheral neuropathy. In patients who fail initial operative management, attempts at limb salvage can be challenging, and no clear treatment algorithm exists. This study examined outcomes of different procedures performed for limb salvage in this population. METHODS: This study retrospectively reviewed 17 patients with DM complicated by peripheral neuropathy who sustained a bimalleolar ankle fracture and failed initial operative management. Patients were treated with revision open reduction internal fixation (ORIF) (3/17), closed reduction external fixation (CREF) (8/17), or primary ankle joint fusion (3/17 tibiotalocalcaneal fusion with hindfoot nail [TTCN] and 3/17 with tibiotalar arthrodesis using plates and screws [TTA]). Median follow-up was 20 months. RESULTS: The overall rate of limb salvage was 82.3% (14/17). All patients who went on to amputation presented with infection and were treated initially with CREF (3/3). All patients who achieved successful limb salvage ended up with a clinically fused ankle joint (14/14); 9 underwent a primary or delayed formal fusion and 5 had a clinically fused ankle joint at study conclusion after undergoing revision ORIF or CREF with adjunctive procedures. CONCLUSION: This small study suggests that in this complicated group of patients it is difficult to achieve limb salvage with an end result of a functional ankle joint. CREF can be a viable option in cases where underlying infection or poor bone quality is present. Treatment with revision ORIF frequently requires supplementary external fixator or tibiotalar Steinman pin placement for additional stability. All patients who underwent revision ORIF ended up with clinically fused ankle joints at the end of the study period. Primary fusion procedures (TTA, TTCN) were associated with a high rate of limb salvage and a decreased number of operations. LEVEL OF EVIDENCE: Level III, retrospective case series.

Comparison of Diabetic Charcot Patients With and Without Foot Wounds.

BACKGROUND: The primary aim of this study was to evaluate the outcomes of a series of patients with Charcot neuroarthropathy (CN) who were evaluated in a tertiary care setting. We hypothesized that those patients with CN who presented with a Charcot-related foot wound would have lower rates of successful limb salvage than patients who presented without a wound. METHODS: Two hundred forty-five patients (280 feet) were identified with diabetic CN during the time period from January 1, 2005, to June 1, 2015. This consecutive cohort of patients was treated by a single surgeon and had a mean age of 57.9 ± 10.0 years. Our CN patients were divided into 2 groups for the purpose of our analysis. Our study group included those patients who presented to our clinic with a Charcot-related foot wound. Our control group was composed of CN patients who presented without a Charcot-related foot wound. RESULTS: Overall, 78 feet (27.9%) were successfully treated nonoperatively and 202 feet (72.1%) required some type of surgery. Of the 202 feet that received surgery, 22 (10.9%) were not felt to be suitable for reconstruction and underwent a definitive transtibial amputation without an attempt at reconstruction. An additional 18 patients underwent soft tissue surgery, which included drainage of infection, posterior muscle group lengthening, or soft tissue reconstructive flap surgery. The remaining 162 feet underwent osseous surgery, which included ostectomies for osteomyelitis, exostectomies, osteotomies, and arthrodesis. Eighteen of the 180 limbs (10.0%) that underwent soft tissue or osseous reconstruction ultimately required a transtibial amputation, resulting in a successful limb salvage rate of 90.0%. Thirty-five amputations were performed in 164 feet (21.3%) with Charcot-related foot wounds compared with 5 amputations in 116 feet (4.5%) without Charcot-related foot wounds (OR 6.02, 95% CI 2.28-15.91, P < .0001). CONCLUSION: The presence of a Charcot-related foot wound at presentation increased the likelihood of a major lower extremity amputation by a factor of 6. Other risk factors that were associated with major amputation in patients included active infection at presentation, nonunion/instability after reconstruction, and a postoperative wound problem. The overall rate of successful limb salvage in patients deemed reconstructive candidates was 90%. LEVEL OF CLINICAL EVIDENCE: Level III, retrospective, case-control study.

Comparison of transfer sites for flexor digitorum longus in a cadaveric adult acquired flatfoot model.

Posterior tibialis tendon (PTT) dysfunction (PTTD) is associated with adult acquired flatfoot deformity. PTTD is commonly treated with a flexor digitorum longus (FDL) tendon transfer (FDLTT) to the navicular (NAV), medial cuneiform (CUN), or distal residuum of the degraded PTT (rPTT). We assessed the kinetic and kinematic outcomes of these three attachment sites using cadaveric gait simulation. Three transfer locations (NAV, CUN, rPTT) were tested on seven prepared flatfoot models using a robotic gait simulator (RGS). The FDLTT procedures were simulated by pulling on the PTT with biomechanically realistic FDL forces (rPTT) or by pulling on the transected FDL tendon after fixation to the navicular or medial cuneiform (NAV and CUN, respectively). Plantar pressure and foot bone motion were quantified. Peak plantar pressure significantly decreased from the flatfoot condition at the first metatarsal (NAV) and hallux (CUN). No difference was found in the medial-lateral center of pressure. Kinematic findings showed minimal differences between flatfoot and FDLTT specimens. The three locations demonstrated only minimal differences from the flatfoot condition, with the NAV and CUN procedures resulting in decreased medial pressures. Functionally, all three surgical procedures performed similarly.