The Adductor Sling Technique for Pediatric Medial Patellofemoral Ligament Reconstruction Better Resists Dislocation Loads When Compared With Adductor Transfer at Time Zero in a Cadaveric Model.

Purpose: To characterize the ability of the intact medial patellofemoral ligament (MPFL) and the adductor transfer and adductor sling MPFL reconstruction techniques to resist subluxation and dislocation in a cadaveric model. Methods: Nine fresh-frozen cadaveric knees were placed on a custom testing fixture with the femur fixed parallel to the floor, the tibia placed in 20° of flexion, and the patella attached to a load cell. The patella was displaced laterally, and subluxation load (in newtons), dislocation load (in newtons), maximum failure load (in newtons), patellar displacement at failure, and mode of failure were recorded. Testing was conducted with the MPFL intact and after the adductor sling and adductor transfer reconstruction techniques. Statistical analysis was completed using 1-way repeated-measures analysis of variance with the Holm-Sidák post hoc test. Results: The subluxation load was not significantly different between groups. The native MPFL dislocation load was significantly higher than the dislocation loads of both reconstruction techniques, but no significant difference between the dislocation loads of the 2 reconstruction techniques occurred. The native MPFL failure load was significantly higher than the failure loads of both reconstruction techniques. The adductor sling failure load was significantly higher than the adductor transfer failure load. The mode of failure varied across groups. The native MPFL failed by femoral avulsion, patellar avulsion, and midsubstance tear. The main mode of failure for adductor transfer was pullout, whereas failure for the adductor sling technique most often occurred at the sutures. Most of the native MPFLs and all adductor sling reconstructions failed after dislocation. The adductor transfer reconstructions were much more variable, with failures spanning from before subluxation through dislocation. Conclusions: Our cadaveric model showed that neither the adductor transfer technique nor the adductor sling technique restored failure load to that of the native condition. There was no significant difference in the subluxation or dislocation loads between the 2 MPFL reconstructions, but the adductor sling technique resulted in a higher load to failure. The adductor transfer technique frequently failed before subluxation or dislocation when compared with the adductor sling technique and the native MPFL. Clinical Relevance: The best technique for MPFL reconstruction in patients with open physes is a topic of debate. Given the long-term consequences of MPFL injury and potential for growth plate disturbance, it is important to study MPFL reconstruction techniques thoroughly, including in the laboratory setting.

Ultrasound-Guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment.

BACKGROUND: Treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. Stages 1 to 2 reflect an inflammatory process supporting a rationale for intra-articular glenohumeral joint corticosteroid injection to treat synovial inflammation and prevent progression to capsular fibrosis. HYPOTHESIS: We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with Stage 1 or 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness. STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4. METHODS: Patients with Stage 1 or 2 idiopathic adhesive capsulitis treated with an intra-articular corticosteroid injection were included. Patients were seen by a single physician and diagnosed using history and physical examination with careful attention to measurement of glenohumeral range of motion (ROM). A total of 61 patients met inclusion criteria. ROM measurements documented in the patient charts were recorded in forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre- and postinjection. All patients were treated with an USGI of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation within 15° of the contralateral side and internal rotation within 3 spinous process levels of the contralateral side. RESULTS: A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the final study cohort. Within the Stage 1 cohort, all 11 patients met recovery criteria for forward flexion and internal rotation (100%), 10 met recovery criteria for abduction (91%), and 8 met recovery criteria for external rotation (73%). Within the Stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 met recovery criteria for abduction (60%), 36 met recovery criteria for internal rotation (72%), and 25 met recovery criteria for external rotation (50%). The difference in time to recovery in days was statistically significant in all ROM planes and was within 2 to 6 weeks for patients in Stage 1 and 7 to 10 weeks for Stage 2. CONCLUSION: USGI for early adhesive capsulitis allows patients to recover ROM more rapidly if performed early after onset of pain and stiffness. CLINICAL RELEVANCE: These results stress the importance of recognition of idiopathic adhesive capsulitis in its early stages and subsequent intervention with an intra-articular glenohumeral corticosteroid injection.

An Analysis of Extensor Carpi Ulnaris Groove Morphology and Tendon Instability.

BACKGROUND: The extensor carpi ulnaris (ECU) tendon has a distinct subsheath at the distal ulna. Symptomatic tears of this subsheath and subluxation of the ECU tendon often require reconstruction. We sought to determine the anatomical constraints of the ECU subsheath. METHODS: The ECU subsheath was exposed on 12 fresh-frozen upper extremities. The tip of the ulnar styloid, the distal ulnar joint surface, and the proximal extent of the distal radio-ulnar joint were identified and dimensions measured. Subluxation of the tendon was then assessed with and without an intact subsheath in 9 specimens. The travel of the tendon was measured in pronation through supination and flexion before and after sectioning of the subsheath. RESULTS: The ECU subsheath is 8.9 mm (standard deviation [SD] = 0.8 mm) wide proximally and 9.0 mm (SD = 1.2 mm) distally. The distal ulnar insertion is 0.5 mm (SD = 0.8 mm) proximal to the tip of the styloid, and stretches 10.2 mm (SD = 2.7 mm) proximally. From maximum pronation to maximum supination and flexion, the ECU tendon traveled 3.32 mm (SD = 4.24) medially when the subsheath was intact and 5.42 mm (SD = 5.0 mm) after sectioning. The maximum depth of the ulnar groove was 2.5 mm (1.59-3.56 mm). There was no significant association between changes in ECU subluxation and the depth of the ECU groove (Spearman's rho = 0.25). CONCLUSION: The ECU subsheath is roughly 1 cm square stretching proximally from the ulnar styloid. ECU groove depth is not a significant independent predictor of tendon subluxation.

Does Ligamentous Laxity Protect Against Chondral and Osteochondral Injuries in Patients With Patellofemoral Instability?

Background: Many patients undergoing medial patellofemoral ligament (MPFL) reconstruction for patellofemoral instability have chondral or osteochondral injuries requiring treatment. Hypothesis: In patients undergoing MPFL reconstruction for patellofemoral instability, those with ligamentous laxity (LAX) would be less likely to have chondral or osteochondral defects requiring surgical intervention compared with those with no laxity (NLX). Study Design: Cohort study; Level of evidence, 2. Methods: Included were 171 patients with patellofemoral instability (32 men, 139 women; mean age, 22 years [range, 11-57 years]) who underwent MPFL reconstruction between 2005 and 2015. Patients with a Beighton-Horan score ≥5 were considered LAX (n = 96), while patients with scores <5 were considered NLX (n = 75). Preoperative magnetic resonance images were evaluated to determine the presence, size, and location of chondral or osteochondral injury as well as the grade according to the Outerbridge classification. Documented anatomic measurements included tibial tubercle-trochlear groove (TT-TG) distance, Caton-Deschamps Index (CDI) for patellar height, and the Dejour classification for trochlear dysplasia. Results: Of the 171 patients, 58 (34%) required a surgical intervention for a chondral or osteochondral defect: chondroplasty (29/58; 50%), particulated juvenile cartilage implantation (18/58; 31%), microfracture (16/58; 28%), osteochondral fracture fixation (2/58; 3.4%), and osteochondral allograft (2/58; 3.4%). While there was no statistical difference in the proportion of patellar chondral or osteochondral injuries between patients with NLX (58%) versus LAX (67%) (P = .271), there was a significantly higher rate of patellar grade 3 or 4 injuries in the NLX (74%) versus LAX (45%) group (P = .004). Similarly, there was no difference in femoral chondral or osteochondral injury rates between groups (P = .132); however, femoral grade 3 or 4 injuries were significantly higher in the NLX (67%) versus the LAX (13%) group (P = .050). After adjusting for age, sex, radiographic parameters (TT-TG distance and CDI), and trochlear morphology, patients with LAX were 75% less likely to have had a grade 3 or 4 patellar cartilage injury compared with patients with NLX (P = .006). Conclusion: For patients who sustained patellar or femoral chondral or osteochondral injuries, compared with their counterparts with NLX, patients with LAX were less likely to have severe (grade 3 or 4) injuries requiring surgical intervention.

Particulated Juvenile Articular Cartilage and Matrix-Induced Autologous Chondrocyte Implantation Are Cost-Effective for Patellar Chondral Lesions.

PURPOSE: To compare the cost-effectiveness of nonoperative management, particulated juvenile allograft cartilage (PJAC), and matrix-induced autologous chondrocyte implantation (MACI) in the management of patellar chondral lesions. METHODS: A Markov model was used to evaluate the cost-effectiveness of three strategies for symptomatic patellar chondral lesions: 1) nonoperative management, 2) PJAC, and 3) MACI. Model inputs (transition probabilities, utilities, and costs) were derived from literature review and an institutional cohort of 67 patients treated with PJAC for patellar chondral defects (mean age 26 years, mean lesion size 2.7 cm2). Societal and payer perspectives over a 15-year time horizon were evaluated. The principal outcome measure was the incremental cost-effectiveness ratio (ICER) using a $100,000/quality-adjusted life year (QALY) willingness-to-pay threshold. Sensitivity analyses were performed to assess the robustness of the model and the relative effects of variable estimates on base case conclusions. RESULTS: From a societal perspective, nonoperative management, PJAC, and MACI cost $4,140, $52,683, and $83,073 and were associated with 5.28, 7.22, and 6.92 QALYs gained, respectively. PJAC and MACI were cost-effective relative to nonoperative management (ICERs $25,010/QALY and $48,344/QALY, respectively). PJAC dominated MACI in the base case analysis by being cheaper and more effective, but this was sensitive to the estimated effectiveness of both strategies. PJAC remained cost-effective if PJAC and MACI were considered equally effective. CONCLUSIONS: In the management of symptomatic patellar cartilage defects, PJAC and MACI were both cost-effective compared to nonoperative management. Because of the need for one surgery instead of two, and less costly graft material, PJAC was cheaper than MACI. Consequently, when PJAC and MACI were considered equally effective, PJAC was more cost-effective than MACI. Sensitivity analyses accounting for the lack of robust long-term data for PJAC or MACI demonstrated that the cost-effectiveness of PJAC versus MACI depended heavily on the relative probabilities of yielding similar clinical results. LEVEL OF EVIDENCE: III, economic and decision analysis.

Combined MPFL Reconstruction with Tibial Tubercle Osteotomy and Repair of Patellar Cartilage Defect with Particulated Juvenile Articular Cartilage.

Medial patellofemoral ligament (MPFL) reconstruction with tibial tubercle osteotomy (TTO) and particulated juvenile articular cartilage (PJAC) grafting can be performed in combination for the treatment of recurrent patellar instability with associated patellar cartilaginous defects. Description: Preoperative planning is an essential component for this procedure. Measurement of the tibial tubercle to trochlear groove (TT-TG) distance and the Caton-Deschamps index (CDI) allows for determination of the degree of medial and anterior translation and helps to identify whether distalization is necessary. The procedure begins with a thorough examination under anesthesia to determine range of motion, patellar tracking, translation, and tilt. A diagnostic arthroscopy is performed, at which time patellar tracking is again assessed and the patellar and trochlear cartilage are evaluated. A medial parapatellar incision is made, and the layer between the capsule and retinaculum is identified. This layer will serve as the location for the MPFL graft passage. The medial patella is decorticated to prepare for graft fixation. The patella is then everted, and the cartilaginous defect is prepared and sized. The PJAC graft is prepared on the back table based on these measurements. The MPFL graft is then anchored to the decorticated medial patella. Attention is then turned to performing the TTO. The patellar tendon is isolated and protected. The osteotomy shingle is created with a combination of sagittal saw and osteotomes, followed by shingle translation and fixation. Attention is then turned to performing the MPFL graft fixation on the femur. An incision is made, the area of the sulcus between the medial epicondyle and adductor tubercle is identified, and a pin is placed. Graft isometry is assessed, pin placement is confirmed, and a socket is created. After thorough irrigation, the patella is then everted and the PJAC graft is implanted and set with fibrin glue. Finally, the MPFL graft is passed through the previously identified layer and docked into the medial femur at its isometric point. Alternatives: Nonoperative treatment of first-time patellar instability can often include physical therapy, bracing, and activity modification. However, recurrence rates can be high, especially in a subset of high-risk patients with characteristics such as age of <25 years, trochlear dysplasia, patella alta, and coronal plane malalignment. For patients with recurrent patellar instability, a well-executed MPFL reconstruction restores stability while the TTO serves to unload the lateral and/or inferior patellar cartilage and correct osseous malalignment. Additional techniques, such as a distal femoral osteotomy and trochleoplasty, have been suggested to address patellar tracking and trochlear dysplasia. For patients who have sustained cartilaginous injury from their previous dislocations, PJAC can be utilized to restore the patellofemoral cartilage. Alternative operative treatments of cartilaginous defects include matrix-induced autologous chondrocyte implantation (MACI), mosaicplasty, osteochondral allograft, microfracture, and-in later stages of disease-patellofemoral arthroplasty. Rationale: The MPFL is an important medial stabilizer in the knee, with high rates of injury in patients who have experienced patellar instability. When an MPFL reconstruction is combined with a TTO, it can stabilize the patella while simultaneously correcting osseous malalignment and unloading the patellofemoral joint. Additionally, use of PJAC is advantageous for patients with patellar chondral defects because it is a single-stage technique, has low technical difficulty, and can be customized to accommodate large lesions. Expected Outcomes: MPFL in combination with TTO and PJAC provides patellar stabilization and overall improvements in pain and function, with low rates of recurrent instability. A recent study by Franciozi et al. showed significant improvement in functional outcome scores at a minimum of 2 years with no recurrent subluxations or dislocations1. Another study by Krych et al. showed an 83% rate of return to sport in patients who underwent MPFL reconstruction combined with TTO2. With respect to PJAC grafts, a study by Grawe et al. assessed the maturation of PJAC implanted into patellar chondral defects, demonstrating that the matured grafts paralleled the characteristics of the surrounding native cartilage. In addition, the authors reported that 73% of patients who completed follow-up magnetic resonance imaging at 2 years postoperatively had good defect fill, defined as >66%3. Important Tips: A lateral release may be necessary if the patella is unable to be everted parallel with the table. Typically, 80% of patients with instability do not need a lateral release, whereas 80% of patients with malalignment and isolated patellar osteoarthritis do need a release.MPFL graft isometry should be assessed by manually placing the patella in the center of the trochlea and flexing the knee to roughly 70°. The graft should slacken in subsequent deeper flexion and should never tighten.When customizing the TTO to obtain the necessary anatomic alignment, the surgeon can achieve additional medialization by dropping their hand to create a flatter cut, while additional anteriorization can be created with a steeper cut.Once the cartilage defect has been prepared and measured, a mold can be created to allow for concomitant PJAC preparation on the back table earlier in the procedure. Acronyms and Abbreviations: TT-TG = tibial tubercle to trochlear groove distanceMPFL = medial patellofemoral ligamentTTO = tibial tubercle osteotomyPJAC = particulated juvenile articular cartilageMACI = matrix-induced autologous chondrocyte implantationOR = operating roomIV = intravenousK-wires = Kirschner wiresCPM = continuous passive motionMRI = magnetic resonance imagingOA = osteoarthritisASA = acetylsalicylic acid (aspirin)DVT = deep vein thrombosisPPX = prophylaxisNWB = non-weight-bearingFWB = full weight-bearingPOD = postoperative day.

Evaluation and management of patellar instability.

Patellar instability is a common clinical problem that primarily affects the adolescent and young adult population. The demographic and anatomic risk factors that predispose patients to patellar instability are multifactorial and include young age, female sex, trochlear dysplasia, elevated tibial tubercle to trochlear groove distance (TT-TG), patella alta, femoral and tibial malalignment, ligamentous laxity, and lack of neuromuscular control. There have been substantial efforts to predict which patients who sustain a first-time dislocation will go on to incur additional dislocations. This is particularly important because with each dislocation event, there is a significant risk of injury to the patellofemoral joint including both medial patellofemoral ligament (MPFL) stretch or rupture and damage to the cartilage which can range from simple fissures to full-thickness cartilage defects and osteochondral fractures. Prediction models have demonstrated that amongst first time dislocators, young patients with trochlear dysplasia are at the highest risk for redislocation. The current standard of care for treatment of first-time dislocators without a loose body or osteochondral fracture is nonoperative management. However, recently there has been a focus on implementing a risk-stratified approach to the surgical indications for a first-time dislocator as the high-risk population might be better treated with early surgical stabilization to prevent or reduce their risk of recurrent dislocation and its associated morbidity. Likewise, for patients with recurrent dislocations, it remains to be determined whether an isolated MPFL reconstruction is sufficient for high-risk patients with several poor prognostic risk factors or if bony realignment procedures should be implemented concurrently.

Ankle Injuries in Dancers.

The term dance encompasses a broad range of different styles; much of the orthopaedic literature has focused on ballet dancers. Injury is common in dancers at all levels, and many serious dancers sustain multiple injuries as they progress through their career. Foot and ankle injuries are among the most common injuries experienced by dancers. These injuries include those that are specific to dancers because of the unique physical maneuvers required to effectively perform, but they can also include common injuries that may require relatively different treatment because of the physical demands of the dancer. Os trigonum syndrome and flexor hallucis longus tenosynovitis generally fall into the former category as they are injuries that are more prevalent in dancers due to the extreme plantarflexion involved in dancing, especially ballet, and the relative demand placed on the toe flexors, most notably the flexor hallucis longus. On the other hand, anterior ankle impingement occurs both in dancers and in the general public. In many cases, a team approach to treatment with knowledgeable physical therapists can obviate the need for surgical treatment. If surgical treatment proves necessary, good results can be achieved with sound surgical technique and a well thought-out rehabilitation program.

Treatment of Adhesive Capsulitis of the Shoulder.

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

Determining glenoid component version after total shoulder arthroplasty.

BACKGROUND: Glenoid component loosening after total shoulder arthroplasty (TSA) may occur if retroversion is not corrected to <10°. However, accurately measuring postoperative glenoid component version has been difficult without postoperative computed tomography (CT), adding cost and radiation exposure outside of the standard radiographic follow-up. We present a new method to assess glenoid component version after TSA using only routine preoperative CT and postoperative radiographs (x-rays). METHODS: Preoperative glenoid version was measured using established methods with an axillary x-ray, 2-dimensional CT, and Glenosys software (Imascap, Plouzané, France). Postoperative glenoid component version and inclination were measured for 61 TSA patients using Mimics software (Materialise, Leuven, Belgium) with preoperative CT and postoperative x-rays. Four patients also had postoperative CTs. Glenoid implantation and imaging were performed on 14 cadavers, allowing validation of results against the gold standard postoperative CT glenoid retroversion measurement. RESULTS: Compared with the gold standard, retroversion and inclination measurement error was 2° ± 1° and 2° ± 1°, respectively. Average postoperative version correction was 6° ± 7°, with 35 of 61 patients (57%) corrected to <10° of retroversion. Correlation between preoperative version measurement methods was good to very good, except on the axillary x-ray. Patients not corrected to <10° of retroversion had significantly higher preoperative retroversion (14° ± 6°) than those corrected to <10° (6° ± 7°; P < .00001). CONCLUSIONS: Glenoid component retroversion after TSA can be accurately measured with a method using only routine preoperative CT and postoperative x-rays, validated to within 1.9° of the gold standard postoperative CT measurement. Future studies using this method may correlate glenoid retroversion correction with glenoid component longevity to help optimize shoulder arthroplasty outcomes.

Anisometry of Medial Patellofemoral Ligament Reconstruction in the Setting of Increased Tibial Tubercle-Trochlear Groove Distance and Patella Alta.

PURPOSE: To assess the impact elevated tibial tubercle-trochlear groove (TT-TG) distance and patella height, as measured by the Caton-Deschamps Index (CDI), have on the isometry of a reconstructed medial patellofemoral ligament (MPFL). METHODS: Nine fresh-frozen cadaveric knees were placed on a custom testing fixture, with a fixed femur and a mobile tibia. A suture fixed to the MPFL origin on the patella and free to move at the Schöttle point on the femur represented a reconstructed MPFL. A local coordinate system was established, and retroreflective markers attached to the suture quantified MPFL length changes by use of a 3-dimensional motion capture system. The tubercle was transferred to create TT-TG distances of 20 mm and 25 mm and CDIs of 1.2 and 1.4 (patella alta). Recordings of the MPFL suture length change as the knee was brought through a range of motion were made using all combinations of tubercle anatomy in a randomized order for each specimen. A generalized estimating equation modeling technique was used to analyze and control for the clustered nature of the data. RESULTS: Knees with native tibial tubercle anatomy showed MPFL isometry through 20° to 70° range of motion. Tibial tubercle lateralization (increased TT-TG distance) significantly altered MPFL isometry with a TT-TG distance of 20 mm (P < .0001). Patella alta significantly altered MPFL isometry with a CDI of 1.2 (P = .0182). The interaction of tibial tubercle lateralization combined with patella alta significantly increased the amount of anisometry seen in the reconstructed MPFL (P < .001). CONCLUSIONS: Increased tibial tubercle lateralization and patella alta produce anisometry in an MPFL reconstruction using currently recommended landmarks, leading to potentially increased graft tension and potential failure. CLINICAL RELEVANCE: Tibial tubercle transfer should be considered when performing an MPFL reconstruction for recurrent patellofemoral instability in the setting of significant patella alta and an elevated TT-TG distance-especially when both are present-because an isolated MPFL reconstruction will be prone to failure given the anisometry shown in this study.

Reliability of a field-based drop vertical jump screening test for ACL injury risk assessment.

OBJECTIVES: There is an epidemic of anterior cruciate ligament (ACL) injuries in youth athletes. Poor neuromuscular control is an easily modifiable risk factor for ACL injury, and can be screened for by observing dynamic knee valgus on landing in a drop vertical jump test. This study aims to validate a simple, clinically useful population-based screening test to identify at-risk athletes prior to participation in organized sports. We hypothesized that both physicians and allied health professionals would be accurate in subjectively assessing injury risk in real-time field and office conditions without motion analysis data and would be in agreement with each other. METHODS: We evaluated the inter-rater reliability of risk assessment by various observer groups, including physicians and allied health professionals, commonly involved in the care of youth athletes. Fifteen athletes age 11-17 were filmed performing a drop vertical jump test. These videos were viewed by 242 observers including orthopaedic surgeons, orthopaedic residents/fellows, coaches, athletic trainers (ATCs), and physical therapists (PTs), with the observer asked to subjectively estimate the risk level of each jumper. Objective injury risk was calculated using normalized knee separation distance (measured using Dartfish, Alpharetta, GA), based on previously published studies. Risk assessments by observers were compared to each other to determine inter-rater reliability, and to the objectively calculated risk level to determine sensitivity and specificity. Seventy one observers repeated the test at a minimum of 6 weeks later to determine intra-rater reliability. RESULTS: Between groups, the inter-rater reliability was high, κ = 0.92 (95% CI 0.829-0.969, p < 0.05), indicating that no single group gave better (or worse) assessments, including comparisons between physicians and allied health professionals. With a screening cutoff isolated to subjects identified by observers as "high risk", the sensitivity was 63.06% and specificity 82.81%. Reducing the screening cutoff to also include jumpers identified as "medium risk" increased sensitivity to 95.04% and decreased the specificity to 46.07%. Intra-rater reliability was moderate, κ = 0.55 (95% CI 0.49-0.61, p < 0.05), indicating that individual observers made reproducible risk assessments. CONCLUSIONS: This study supports the use of a simple, field-based observational drop vertical jump screening test to identify athletes at risk for ACL injury. Our study shows good inter- and intra-rater reliability and high sensitivity and suggests that screening can be performed without significant training by physicians as well as allied health professionals, including: coaches, athletic trainers and physical therapists. Identification of these high-risk athletes may play a role in enrollment in appropriate preventative neuromuscular training programs, which have been shown to decrease the incidence of ACL injuries in this population.

Bone scan index: a quantitative treatment response biomarker for castration-resistant metastatic prostate cancer.

PURPOSE: There is currently no imaging biomarker for metastatic prostate cancer. The bone scan index (BSI) is a promising candidate, being a reproducible, quantitative expression of tumor burden seen on bone scintigraphy. Prior studies have shown the prognostic value of a baseline BSI. This study tested whether treatment-related changes in BSI are prognostic for survival and compared BSI to prostate-specific antigen (PSA) as an outcome measure. PATIENTS AND METHODS: We retrospectively examined serial bone scans from patients with castration-resistant metastatic prostate cancer (CRMPC) enrolled in four clinical trials. We calculated BSI at baseline and at 3 and 6 months on treatment and performed univariate and bivariate analyses of PSA, BSI, and survival. RESULTS: Eighty-eight patients were scanned, 81 of whom have died. In the univariate analysis, the log percent change in BSI from baseline to 3 and 6 months on treatment prognosticated for survival (hazard ratio [HR], 2.44; P = .0089 and HR, 2.54; P < .001, respectively). A doubling in BSI resulted in a 1.9-fold increase in risk of death. Log percent change in PSA at 6 months on treatment was also associated with survival (HR, 1.298; P = .013). In the bivariate analysis, change in BSI while adjusting for PSA was prognostic at 3 and 6 months on treatment (HR, 2.368; P = .012 and HR, 2.226; P = .002, respectively), but while adjusting for BSI, PSA was not prognostic. CONCLUSION: These data furnish early evidence that on-treatment changes in BSI are a response indicator and support further exploration of bone scintigraphy as an imaging biomarker in CRMPC.

Proton stereotactic radiosurgery for the treatment of benign meningiomas.

PURPOSE: Given the excellent prognosis for patients with benign meningiomas, treatment strategies to minimize late effects are important. One strategy is proton radiation therapy (RT), which allows less integral dose to normal tissue and greater homogeneity than photon RT. Here, we report the first series of proton stereotactic radiosurgery (SRS) used for the treatment of meningiomas. METHODS AND MATERIALS: We identified 50 patients with 51 histologically proven or image-defined, presumed-benign meningiomas treated at our institution between 1996 and 2007. Tumors of <4 cm in diameter and located≥2 mm from the optic apparatus were eligible for treatment. Indications included primary treatment (n=32), residual tumor following surgery (n=8), and recurrent tumor following surgery (n=10). The median dose delivered was 13 Gray radiobiologic equivalent (Gy[RBE]) (range, 10.0-15.5 Gy[RBE]) prescribed to the 90% isodose line. RESULTS: Median follow-up was 32 months (range, 6-133 months). Magnetic resonance imaging at the most recent follow-up or time of progression revealed 33 meningiomas with stable sizes, 13 meningiomas with decreased size, and 5 meningiomas with increased size. The 3-year actuarial tumor control rate was 94% (95% confidence interval, 77%-98%). Symptoms were improved in 47% (16/34) of patients, unchanged in 44% (15/34) of patients, and worse in 9% (3/34) of patients. The rate of potential permanent adverse effects after SRS was 5.9% (3/51 patients). CONCLUSIONS: Proton SRS is an effective therapy for small benign meningiomas, with a potentially lower rate of long-term treatment-related morbidity. Longer follow-up is needed to assess durability of tumor control and late effects.