Editorial Commentary: Arthroscopic Subscapularis Repair: Bridging Successful Tendon Healing and Improved Patient Outcomes.

Open repair has been regarded as the gold standard for the treatment of subscapularis tendon tears. However, recent studies on newer arthroscopic techniques and published results of arthroscopic repair have shown promising results. As such, there exists a growing interest in understanding the best fixation technique to obtain successful functional and patient-reported clinical outcomes. While the literature shows superior outcomes after double-row repair for posterosuperior rotator cuff tears compared with single-row repair, the evidence is inconclusive for subscapularis tears. We believe that arthroscopic double-row transosseous equivalent repair of full-thickness subscapularis tears leads to superior clinical outcomes with higher healing rates and will become the standard of care in the future.

Administration of Aspirin as a Prophylaxis Agent Against Venous Thromboembolism Results in Lower Incidence of Periprosthetic Joint Infection.

The efficacy and safety of aspirin (ASA) for prevention of venous thromboembolism (VTE) following total joint arthroplasty (TJA) have been demonstrated. Our hypothesis was that postoperative ASA compared to warfarin lowers the incidence of periprosthetic joint infection (PJI). Between January 2006 and December 2012, 1456 patients received ASA and 1700 patients received warfarin following primary TJA as standard VTE prophylaxis. Logistic regression was utilized to identify independent risk factors of PJI. Incidence of PJI was significantly lower at 0.4% in patients receiving ASA vs. 1.5% in patients receiving warfarin (P<0.001). Warfarin and elevated BMI were independent risk factors for PJI following TJA (P<0.05). Our research suggests that the use of ASA compared to warfarin for VTE prophylaxis reduces the risk of PJI following TJA.

Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report.

CASE: A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair. CONCLUSION: With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

Retrospective Review of Radiographic Imaging of Tibial Bony Stress Injuries in Adolescent Athletes With Positive MRI Findings: A Comparative Study.

BACKGROUND: It is difficult to diagnose and grade bony stress injury (BSI) in the athletic adolescent population without advanced imaging. Radiographs are recommended as a first imaging modality, but have limited sensitivity and, even when findings are present, advanced imaging is often recommended. HYPOTHESIS: It was hypothesized that the significance of radiographs is underestimated for BSI in the adolescent with positive clinical examination and history findings. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 80 adolescent athletes with a history of shin pain underwent clinical examination by an orthopaedic surgeon. On the day of clinical examination, full-length bilateral tibial radiographs and magnetic resonance imaging (MRI) scans were obtained. MRI scans were reviewed using Fredericson grading for BSI. At the completion of the study, radiographic images were re-evaluated by 2 musculoskeletal (MSK) radiologists, blinded to MRI and clinical examination results, who reviewed the radiographs for evidence of BSI. Radiographic results were compared with clinical examination and MRI findings. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated based on comparison with MRI. RESULTS: All radiographs were originally read as normal. Of the tibia studied, 80% (127 of 160) showed evidence of BSI on MRI. None of the original radiographs demonstrated a fracture line on initial review by the orthopaedic surgeons. Retrospective review by 2 MSK radiologists identified 27% of radiographs (34 of 127) with evidence of abnormality, which correlated with clinical examination and significant findings on MRI. Review of radiographs found evidence of new bone on 0 of 28 Fredericson grade 0, 0 of 19 Fredericson grade I, 11 of 80 (13.7%) Fredericson grade II, 18 of 28 (64%) Fredericson grade III, and 5 of 5 (100%) Fredericson grade IV. Sensitivity of radiographs showed evidence of new bone on 27% (34 of 127) of initial radiographs, with presence more common with greater degree of BSI, as 23 of 33 (70%) were higher-grade injuries (III of IV) of BSI. Specificity and positive predictive value were 100%, while negative predictive value was 17%. CONCLUSION: These findings highlight the importance of initial radiographs in identifying high-grade BSI. As radiographs are readily available in most office settings of sports medicine physicians, this information can influence the management of adolescent athletic BSI without the need to delay treatment to obtain an MRI. CLINICAL RELEVANCE: Adolescent athletes with radiographic evidence of BSI should be treated in a timely and more conservative manner, given the likelihood of higher-grade BSI. In addition, clinicians knowledgeable of the radiographic findings of high-grade BSI should feel more confident that a negative initial radiograph is not likely to be a high-grade BSI and can modify their treatment plans accordingly.

Acute Exertional Bilateral Thigh Compartment Syndrome in a Patient with Rhabdomyolysis After Spin Class: A Case Report.

CASE: A healthy 24-year-old woman developed rhabdomyolysis and acute bilateral thigh compartment syndrome after 10 minutes of spin class. She was successfully managed with early recognition, aggressive fluid resuscitation, and prompt bilateral surgical decompressive fasciotomy. CONCLUSION: Rhabdomyolysis with acute compartment syndrome is a rare but devastating combination of conditions. A high suspicion for rhabdomyolysis and progression to acute compartment syndrome is warranted for any patient presenting with increasing pain even with a limited history of trauma or exertion. Early recognition and medical and surgical treatment are paramount to preventing permanent damage.

Bilateral Knee Dislocations Treated with Acute, Single-Stage Multiligament Reconstructions.

Bilateral knee dislocations are exceedingly rare in orthopaedics. Managing these injuries presents a difficult task given their high complication rate and guarded prognosis. We report the case of a 21-year-old male who presented to our institution with bilateral knee dislocations sustained in a motor vehicle collision. The patient subsequently underwent multiligament knee reconstruction surgeries for each knee at one and three weeks following the initial injury. At one-year follow-up, the patient has achieved a successful outcome and has returned to regular activities which include hiking and exercising at the gym.

Postoperative Rhabdomyolysis in the Bilateral Shoulder Areas After Cardiac Surgery.

Rhabdomyolysis (RML) is a disease that results from the death of muscle fibers and the release of intracellular contents into the bloodstream as a result of traumatic or non-traumatic muscle injury. Postoperative RML is a rare complication that may result from improper patient positioning, extended surgery time, or unique patient risk factors. We describe a case of a 43-year-old obese male who presented with postoperative bilateral shoulder RML after undergoing cardiothoracic surgery for aortic valve disease. To our knowledge, after a thorough review of the literature using PubMed, Medline, and Google Scholar, no previous studies have reported positioning injuries specific to obese cardiac surgical patients and their relation to RML.

Latarjet Procedure for Anterior Glenohumeral Instability: Early Postsurgical Complications for Primary Coracoid Transfer Versus Revision Coracoid Transfer After Failed Prior Stabilization.

BACKGROUND: The Latarjet procedure (coracoid transfer) is often used to successfully treat failed instability procedures. However, given the reported increased complication rates in primary Latarjet surgery, there is a heightened concern for complications in performing the Latarjet procedure as revision surgery. PURPOSE: To evaluate the early outcomes and complications of the Latarjet procedure as primary surgery compared with revision surgery. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 157 patients were included and retrospectively reviewed: 103 patients in the revision group and 54 patients in the primary group. Patients were evaluated by physical examination findings as well as by documentation of complications and reoperations extracted from their electronic medical records. RESULTS: The mean follow-up was 7.8 ± 11.0 months for the primary group and 7.0 ± 13.2 months for the revision group. There were no significant differences in overall complication rates between the primary and revision groups (16.7% vs 8.7%, respectively; P = .139). The complication rate was significantly higher in patients in the revision group who had undergone a prior open procedure compared with those who had undergone only arthroscopic procedures (30.0% vs 4.1%, respectively; P < .001). Of those patients who sustained a complication, 7 of the 9 underwent a reoperation in the primary group (13.0%), and 7 of the 9 did so in the revision group (6.8%); the risk of reoperations was not different between groups (P = .198). There were 4 patients in the primary group (7.4%) and 5 patients in the revision group (4.9%) who experienced recurrent dislocations during the follow-up period (P = .513). There was no difference in postoperative range of motion. CONCLUSION: The Latarjet procedure is a reasonable option for the treatment of failed arthroscopic instability repair with an early complication rate similar to that found in primary Latarjet surgery.

Repair of Rotator Cuff Tears in the Elderly: Does It Make Sense? A Systematic Review.

BACKGROUND: The indications and outcomes for rotator cuff repair (RCR) among patients ≥70 years old are not widely reported. Many active patients in this age range desire a joint-preserving option, and several small series reported successful clinical outcomes after RCR among patients aged ≥70 years. PURPOSE: To systematically review the literature on the outcomes of RCR among patients ≥70 years old. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The electronic databases of PubMed and Cochrane were used for the literature search. The quality of the included studies was evaluated according to the Coleman Methodology Score. Studies in English evaluating repair of full-thickness rotator cuff tears among patients aged ≥70 years were included. RESULTS: Eleven studies were reviewed, including 680 patients (694 shoulders) who were treated with arthroscopic and/or open RCR with a mean follow-up of 24.2 months (range, 12-40.8 months). Forty patients were lost to follow-up, leaving 654 shoulders with outcome data. This age group demonstrated a significant increase in clinical and functional outcomes after RCR with high satisfaction. American Shoulder and Elbow Surgeons scores showed an improvement from 44.2 (range, 35.4-56) preoperatively to 87.9 (range, 84-90.3) postoperatively, while Constant scores improved from 41.7 (range, 22.6-53.6) to 70.8 (range, 58.6-76). Postoperative imaging evaluation was performed on 513 shoulders, revealing a retear rate of 27.1% (139 shoulders). There were 45 retears after open repair and 94 after arthroscopic repair. The difference in retear rate among patients receiving arthroscopic repairs was not significantly different than open repairs (P = .831). Pain according to a visual analog scale improved from 5.5 (range, 4.6-6.4) preoperatively to 1.3 (range, 0.5-2.3) postoperatively. CONCLUSION: RCR among patients ≥70 years old shows high clinical success rates with good outcomes and overall excellent pain relief. Although patients in this age group have a high potential for retear or persistent defects on imaging studies, RCR offers a joint-preserving option with significant functional and clinical improvement for the appropriately indicated patient.

Youth Single-Sport Specialization in Professional Baseball Players.

BACKGROUND: An increasing number of youth baseball athletes are specializing in playing baseball at younger ages. PURPOSE: The purpose of our study was to describe the age and prevalence of single-sport specialization in a cohort of current professional baseball athletes. In addition, we sought to understand the trends surrounding single-sport specialization in professional baseball players raised within and outside the United States (US). STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A survey was distributed to male professional baseball athletes via individual team athletic trainers. Athletes were asked if and at what age they had chosen to specialize in playing baseball at the exclusion of other sports, and data were then collected pertaining to this decision. We analyzed the rate and age of specialization, the reasons for specialization, and the athlete's perception of injuries related to specialization. RESULTS: A total of 1673 professional baseball athletes completed the survey, representing 26 of the 30 Major League Baseball (MLB) organizations. Less than half (44.5%) of professional athletes specialized in playing a single sport during their childhood/adolescence. Those who reported specializing in their youth did so at a mean age of 14.09 ± 2.79 years. MLB players who grew up outside the US specialized at a significantly earlier age than MLB players native to the US (12.30 ± 3.07 vs 14.89 ± 2.24 years, respectively; P < .001). Additionally, MLB players raised in the US recalled a significantly higher incidence of sustaining an injury attributed to specializing in baseball than MLB athletes raised outside the US (27.7% vs 20.6%, respectively; P = .05). CONCLUSION: This study challenges the current trends toward early youth sport specialization, finding that the majority of professional baseball athletes studied did not specialize as youth and that those who did specialize did so at a mean age of 14 years. With the potential cumulative effects of pitching and overhead throwing on an athlete's arm, the trend identified in this study toward earlier specialization within baseball is concerning.

Treatment of Distal Fibular Malunion with Corrective Osteotomy: Yablon Revisited.

Yablon originally described that late posttraumatic degenerative ankle arthritis was due to ongoing tibio-talar joint incongruity, and more importantly that anatomic reduction of the lateral malleolus was key to anatomic reduction of the ankle joint, as the talus "faithfully followed that of the lateral malleolus." Ankle fractures involving the lateral malleolus, left unreduced, can lead to malunion and posttraumatic degenerative arthritis. Treatment of this often includes a fibular osteotomy to restore length and rotation. We revisit Yablon's original principles and present a review of the literature pertaining to techniques and outcomes of lateral malleolus malunions treated with distal fibular osteotomies as well as a case report highlighting the challenges and considerations when facing this problem.

The Evolution of Treated Versus Untreated Femoroacetabular Impingement in a Professional Hockey Player with a 10-Year Follow-up: A Case Report.

CASE: We describe the diagnosis, treatment, rehabilitation, and 10-year outcome of a National Hockey League (NHL) player who was treated successfully with hip arthroscopy for symptomatic femoroacetabular impingement (FAI) of the right hip. At the 10-year follow-up, the patient presented with contralateral hip symptoms consistent with FAI and radiographic progression of degenerative changes that were not present at the initial presentation. CONCLUSION: Untreated FAI may result in the progression of degenerative changes in the hip.

Fibular Collateral Ligament/ Posterolateral Corner Injury: When to Repair, Reconstruct, or Both.

The posterolateral corner (PLC) of the knee was regarded as the "dark side" of the knee because of limited understanding of its anatomy and biomechanics and because of poor outcomes after injuries to PLC structures. These injuries rarely occur in isolation, with 28% reported as isolated PLC injuries. Nonoperative treatment of these injuries has led to persistent instability, development of early osteoarthritis, and poor outcomes. Several techniques for reconstruction of the PLC have been described, and all are reported to improve outcomes. Biomechanically validated anatomic reconstructions are preferred because they restore native knee kinematics and improve clinical outcomes without over-constraining the knee.

Variations in Blood Supply From Proximal to Distal in the Ulnar Collateral Ligament of the Elbow: A Qualitative Descriptive Cadaveric Study.

BACKGROUND: The vascular supply of the ulnar collateral ligament (UCL) is unknown. Previous studies reported varying success in return-to-play rates after nonoperative management of partial UCL tears and suggested a varying healing capacity as possibly related to the location of the UCL injury. PURPOSE: To analyze the macroscopic vascular anatomy of the UCL of the elbow. STUDY DESIGN: Descriptive laboratory study. METHODS: Eighteen fresh-frozen male cadaveric elbows from 9 donors were sharply dissected 15 cm proximal to the medial epicondyle. Sixty milliliters of India ink was injected through the brachial artery of each elbow. Arms were then frozen at -10°C, radial side down, in 15° to 20° of elbow flexion. A band saw was used to section the frozen elbows into 5-mm coronal or sagittal sections. Sections were cleared for visualization with the modified Spalteholz technique. Images of the specimens were taken, and qualitative description of UCL vascularity was undertaken. RESULTS: The authors consistently found a dense blood supply to the proximal UCL, while the distal UCL was hypovascular. They also observed a possible osseous contribution to the proximal UCL from the medial epicondyle in addition to an artery from the flexor/pronator musculature that consistently appeared to provide vascularity to the proximal UCL. The degree of vascular penetration from proximal to distal in the UCL ranged from 39% to 68% of the overall UCL length, with a 49% mean length of vascular penetration of the UCL. CONCLUSION: This study found a difference in the vascular supply of the UCL. The proximal UCL was well vascularized, while the distal UCL was hypovascular. This difference in vascular supply may be a factor in the differential healing capacities of the UCL based on the location of injury. CLINICAL RELEVANCE: An improved understanding of the macroscopic vascular supply of the UCL may aid in the clinical management of partial UCL tears and suggests an indication for these treatments with respect to location of UCL injuries.

Biomechanical Comparison of 3 Novel Repair Techniques for Radial Tears of the Medial Meniscus: The 2-Tunnel Transtibial Technique, a "Hybrid" Horizontal and Vertical Mattress Suture Configuration, and a Combined "Hybrid Tunnel" Technique.

BACKGROUND: Historically, radial meniscal tears were treated with partial or near-total meniscectomy, which usually resulted in poor outcomes. Radial meniscal tears function similar to a total meniscectomy and are challenging to treat. Repair of radial meniscal tears should be performed to prevent joint deterioration and the need for salvage procedures in the future. PURPOSE/HYPOTHESIS: The purpose was to compare 3 repair techniques for radial tears of the medial meniscus: the 2-tunnel, hybrid, and hybrid tunnel techniques. It was hypothesized that there would be no differences among the 3 groups in regard to gapping and ultimate failure strength. STUDY DESIGN: Controlled laboratory study. METHODS: Thirty human male cadaver knees (10 matched pairs, n = 20; 10 unpaired, n = 10) were used to compare the 2-tunnel, hybrid, and hybrid tunnel repairs. A complete radial tear was made at the midbody of the medial meniscus. Repairs were performed according to the described techniques. Specimens were potted and mounted on a universal material testing machine where each specimen was cyclically loaded for 1000 cycles before experiencing a pull to failure. Gap distances at the tear site, ultimate failure load, and failure location were measured and recorded. RESULTS: After 1000 cycles of cyclic loading, there were no significant differences in displacement among the 2-tunnel repair (3.0 ± 1.7 mm), hybrid repair (3.0 ± 0.9 mm), and hybrid tunnel repair (2.3 ± 1.0 mm; P = .4042). On pull-to-failure testing, there were also no significant differences in ultimate failure strength among the 2-tunnel repair (259 ± 103 N), hybrid repair (349 ± 149 N), and hybrid tunnel repair (365 ± 146 N; P = .26). However, the addition of vertical mattress sutures to act as a "rip stop" significantly reduced the likelihood of the sutures pulling through the meniscus during pull-to-failure testing for the hybrid and hybrid tunnel repairs (4 of 16, 25%) as compared with the 2-tunnel repair (7 of 9, 78%; P = .017). CONCLUSION: The results showed equivalent biomechanical testing with regard to gap distance and pull-to-failure strength among the 3 repairs. The addition of the vertical mattress sutures to act as a rip stop was effective in preventing meniscal cutout through the meniscus. CLINICAL RELEVANCE: Effective healing of radial meniscal tears after repair is paramount to prevent joint deterioration and symptom development. Each tested repair showed a biomechanically equivalent and stable construct to use to repair radial meniscal tears. The authors recommend that rip stop vertical mattress sutures be used, especially in poor-quality meniscal tissue, to prevent suture cutout.

Repair of a Proximal Hamstring Rupture in a 14-Year-Old Patient: A Case Report.

Proximal hamstring tendon ruptures are rare in children and adolescents. The typical pediatric hamstring injury pattern involves an apophyseal avulsion fracture. We present the case of a 14-year-old male with a widely displaced ischial avulsion fracture and a bony fragment that was too small to allow for bony fixation. The patient presented with left-buttock pain and ecchymosis, as well as tenderness at the ischial tuberosity, following an injury sustained while running 2 weeks prior. Imaging demonstrated an avulsion of the proximal hamstrings with a 4-mm bony fragment, too small to allow for repair. The patient underwent primary repair using two 3-mm suture anchors. The bony fragment was not excised but incorporated into the repair. Although most proximal hamstring injuries in children and adolescents are treated non-operatively, operative treatment may confer a small but clinically important difference in rates of healing and return to play in adolescent athletes. This case demonstrates successful treatment of a proximal hamstring rupture with suture anchor fixation, which may be considered for pediatric and adolescent displaced avulsion fractures when the bony fragment is too small to allow for bony fixation.

Femoroacetabular Impingement in Professional Basketball Players: Return to Play, Career Length, and Performance After Hip Arthroscopy.

BACKGROUND: Previous studies have demonstrated that hip arthroscopy is an effective treatment for symptomatic femoroacetabular impingement (FAI) in professional athletes across a variety of sports. However, the return-to-play rates and postoperative performance of elite basketball players after hip arthroscopy are currently unknown. PURPOSE: To determine return-to-play rates and postoperative performance among professional basketball athletes after hip arthroscopy. STUDY DESIGN: Case series; Level of evidence, 3. METHODS: Eighteen professional basketball players underwent hip arthroscopy (24 hips) for symptomatic FAI between 2001 and 2016 by a single surgeon. Return to play was defined as competing in a single professional game of equal level after surgery. Data were retrospectively obtained for each player from basketball-reference.com , ESPN.com , eurobasket.com, and individual team websites. Matched controls were selected from the websites to compare performances. RESULTS: The mean age at the time of surgery was 25.6 years, and the mean body mass index was 24.4 kg/m2. All players returned to their previous levels of competition, with a mean number of 4 seasons played after surgery (median, 3; range, 1-12). The mean ± SD time between the date of surgery and return to a professional game was 7.1 ± 4.4 months. There was no change in player efficiency rating when pre- and postinjury performance were compared. When compared with controls, players undergoing surgery also had no significant decline in player efficiency rating. CONCLUSION: Elite basketball athletes who undergo hip arthroscopy for the treatment of FAI return to their presurgical levels of competition at a high rate. These athletes demonstrate no significant overall decrease in performance upon their return to play.

Proximal Tibiofibular Reconstruction in Adolescent Patients.

Instability of the proximal tibiofibular joint (PTFJ) can present as frank dislocations, vague symptoms of lateral knee pain, discomfort during activity, or symptoms related to irritation of the common peroneal nerve. An accurate preoperative diagnosis is imperative and should include a trial of taping of the PTFJ for a 4- to 6-week time frame before surgical reconstruction is indicated. In the adolescent population, surgical planning can be complicated by the presence of open physes; therefore, caution must be taken to avoid drilling through or placing screw fixation across the physes. Potential complications include growth arrest and limb length discrepancy. Therefore, the purpose of this Technical Note is to describe the surgical technique for addressing PTFJ instability in adolescent patients.

Surgical Repair of Dynamic Snapping Biceps Femoris Tendon.

A snapping biceps tendon is an infrequently seen and commonly misdiagnosed pathology, leaving patients with persistent symptoms that can be debilitating. Patients will present with a visible, audible, and/or painful snap over the lateral aspect of their knee when performing squats, sitting in low seats, or participating in activities with deep knee flexion. A thorough knowledge of the anatomy is essential for surgical treatment of this pathology, which is caused by a detachment of the direct arms of the long and short heads of the biceps femoris off the fibular styloid. This Technical Note provides a diagnostic approach, postoperative management, and details of a surgical technique to treat a snapping biceps tendon with an anatomic repair of the long and short head attachments of the biceps femoris to the posterolateral fibular styloid.

Correlation of MRI to Arthroscopy in the Elbow: Thrower's Elbow and Ulnar Collateral Ligament Injury.

One cannot overstate the importance of a thorough history and physical examination, supplemented with directed imaging, to help pinpoint the exact cause of the athlete's elbow pain. Although plain radiographs should not be overlooked, advanced imaging plays a critical role in diagnosis and management of pathology in the thrower's elbow, including computed tomography, magnetic resonance imaging, and stress ultrasound. By judiciously combining these elements, the clinician can appropriately manage these injuries in order to successfully return the athlete to their preinjury level of play.