All-Inside PCL Reconstruction, Double Bundle, With Internal Brace Augmentation.

PCL reconstructive techniques are constantly evolving, and further clinical studies are needed to definitively understand the potential benefits of internal brace augmentation and anatomic double-bundle PCL reconstruction. This Technical Note reports an arthroscopic all-inside anatomic double-bundle PCL reconstruction with internal brace augmentation that is effective and reproducible.

Off-Season Arthroscopic Partial Meniscectomy in National Collegiate Athletic Association Division I Football Players Has a Longer Return to Sport Time than In-Season Surgery.

Purpose: To report the outcomes of routine arthroscopic meniscectomy in National Collegiate Athletic Association (NCAA) Division I Football players. Methods: NCAA athletes who underwent arthroscopic meniscectomy over 5 years were included. Players who had incomplete data, previous knee surgery, ligamentous injury, and/or microfractures were excluded. Data collected were player position, timing of surgery, procedures performed, return to play (RTP) rate and time, and postoperative performance. Continuous variables were analyzed with Student t-tests or a one-way analysis of variance. Results: Thirty-six athletes (38 knees) who underwent arthroscopic partial meniscectomy (31 lateral, 7 medial) were included. The mean RTP time was 71 ± 39 days. The mean RTP time in athletes who underwent in-season surgery) was significantly shorter than the RTP in athletes who had off-season surgery (58 ± 41 days vs 85 ± 33 days, P < .05). The mean RTP in 29 athletes (31 knees) with lateral meniscectomy was similar to the 7 athletes (7 knees) who had medial meniscectomy (70 ± 36 vs 77 ± 56, P = .6803). The mean RTP time was similar between football players who underwent isolated lateral meniscectomy and those who had lateral meniscectomy with chondroplasty (61 ± 36 days vs 75±41 days, P = .32). Athletes played an average of 7.7 ± 4.9 games the season they returned; position category and anatomical compartment of the knee lesion had no bearing on number of games played (P = .1864 and P = .425). Conclusions: NCAA Division 1 football players who underwent arthroscopic partial meniscectomy RTP at approximately 2.5 months' postoperatively. Athletes who underwent off-season surgery had longer RTP time compared with those who underwent in-season surgery. RTP time and performance after surgery did not differ based on player position, anatomical location of the lesions, or chondroplasty at the time of meniscectomy. Level of Evidence: Level IV, therapeutic case series.

Anabolic Androgenic Steroids in Orthopaedic Surgery: Current Concepts and Clinical Applications.

Despite the well-documented effects of testosterone and its synthetic derivatives-collectively termed anabolic androgenic steroids (AASs)-on the musculoskeletal system, the therapeutic use of these agents has received limited investigation within the field of orthopaedic surgery. In the last 2 decades, preclinical and clinical research has started to identify promising applications of the short-term use of AASs in the perioperative period. There is evidence to suggest that AASs may improve postoperative recovery after anterior cruciate ligament reconstruction and total joint arthroplasty. In addition, AASs may augment the biological healing environment in specific clinical scenarios including muscle injury, fracture repair, and rotator cuff repair. Current literature fails to present strong evidence for or against the use of AASs in orthopaedics, but there is continuous research on this topic. The purpose of this study was to provide a comprehensive overview of the current status of AAS applications in orthopaedic surgery, with an emphasis on preclinical data, clinical studies, and future directions.

Supracondylar femur fracture following multiligament knee reconstruction with Internal Brace® augmentation: A case report.

This a case report of a 40-year-old male with left knee dislocation Type III and associated peroneal nerve palsy underwent delayed allograft reconstruction of his multiligament knee injury (MKI) with Internal Brace augmentation. The patient returned to work at 6 months postoperatively. He then fell and sustained a displaced supracondylar left femur fracture at the site of the internal brace augmentation of his lateral collateral ligament (LCL) reconstruction for which he underwent placement of a retrograde femoral nail. At 2 years of follow-up the patient had no evidence of knee instability. Level of evidence: V.

Cutibacterium acnes persists despite topical clindamycin and benzoyl peroxide.

BACKGROUND: Cutibacterium (formerly Propionibacterium) acnes persists in the dermis despite standard skin antiseptic agents, prompting some surgeons to use topical antimicrobials such as benzoyl peroxide and clindamycin prior to shoulder arthroplasty surgery. However, the efficacy of these topical agents has not been established. METHODS: The upper backs of 12 volunteers were randomized into 4 treatment quadrants: topical benzoyl peroxide, topical clindamycin, combination topical benzoyl peroxide and clindamycin, and a negative control. The corresponding topical agents were applied to each site twice daily for 3 days. A 3-mm dermal punch biopsy specimen was obtained from each site and cultured for 14 days to assess for C acnes growth. Positive cultures were assessed for the hemolytic phenotype. The McNemar test was used to compare the proportion of positive cultures in each group. RESULTS: C acnes grew in 4 of 12 control sites (33.3%), 1 of 12 benzoyl peroxide sites (8.3%), 2 of 12 clindamycin sites (16.7%), and 2 of 12 combination benzoyl peroxide-clindamycin sites (16.7%). The C acnes hemolytic phenotype was present in 2 of 12 control specimens (16.7%) compared with 0 (0.0%) in the benzoyl peroxide group, 2 of 12 (16.7%) in the clindamycin group, and 2 of 12 (16.7%) in the combination benzoyl peroxide-clindamycin group. There were no statistically significant differences between treatment arms. CONCLUSION: The topical application of benzoyl peroxide and clindamycin did not eradicate C acnes in all subjects. The clinical implications of these findings are yet to be determined.

A nationwide analysis of failed irrigation and debridement for pediatric septic arthritis of the hip.

Irrigation and debridement (I&D) is the gold standard for treatment of pediatric septic arthritis of the hip. If the index surgery fails, subsequent surgery may be required to eradicate the infection, resulting in substantial increases in morbidity, healthcare costs, and psychosocial burden. The purpose of this study was to identify the incidence of failed I&D for pediatric septic arthritis of the hip, defined by the need for at least one subsequent surgical intervention, and potential risk factors for failed initial I&D. The Kids' Inpatient Database was used to extract data for pediatric patients diagnosed with septic arthritis of the hip from 1997 to 2012. Factors such as patient demographics, preoperative comorbidities, inpatient variables, and hospitals variables were assessed for associations with successful versus failed I&Ds. During the period examined, 3341 (94.3%) children were successfully treated with a single I&D, whereas 203 (5.7%) children required at least one additional surgery during the same hospitalization. Univariate analysis found anemia, coagulopathy, and electrolyte disorders to be associated with repeat surgery. Patients who required multiple surgeries had significantly longer lengths of stay (11.3 vs. 6.9 days), higher likelihood of being discharged with home health (39 vs. 25%), and higher total overall inpatient costs ($58 400 vs. $31 900). On the basis of the results of this study, the nationwide incidence of patients requiring multiple I&Ds was 5.7%. Patient preoperative comorbidities such as coagulopathy, and hospital characteristics such as government ownership and teaching status were significantly associated with failed initial I&D for septic arthritis of the hip. We believe this data can be useful in guiding future research efforts and providing clearer anticipatory guidance to patients and guardians. Level of evidence: Level III: Retrospective comparative study.

The Biomechanics of Multiligament Knee Injuries: From Trauma to Treatment.

The multiple ligament injured knee is a complex biomechanical environment. When primary stabilizers fail, secondary stabilizers have an increased role. In addition, loss of primary restraints puts undue stress on the remaining intact structures of the knee. Treatment of these injuries requires accurate diagnosis of all injured structures, and careful consideration of repairs and reconstructions that restore the synergistic stability of all ligaments in the knee.

The Effect of Obesity on Operative Times and 30-Day Readmissions After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To understand the effect of obesity on operative times and 30-day readmission rates after arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify all patients aged 18 years and older who underwent ACLR between 2007 and 2014. The Student t test was used for continuous variables, and the χ-square or Fisher exact test was used for categorical variables. Multivariate analysis was conducted to identify factors associated with 30-day readmission. RESULTS: We identified 9,000 patients who underwent ACLR. In the readmission analysis, the total readmission rate was 0.70%. After multivariate analysis, a body mass index (BMI) of 40 or greater was associated with a significantly increased risk of 30-day readmission (odds ratio, 3.06; 95% confidence interval, 1.09-8.57). An operative time of less than 80 minutes was associated with a decreased risk of readmission (odds ratio, 0.40, 95% confidence interval, 0.18-0.92). In the operative-time analysis, the mean operative time was 100.7 minutes. Older age was predictive of decreasing operative time, with the operative time being 32.75 minutes shorter in patients aged 65 years or older than in those younger than 25 years. After multivariate analysis, class II obesity (BMI of 35-39.9) predicted an increase of 7.11 minutes and class III obesity (BMI ≥ 40) predicted an increase of 8.70 minutes compared with normal weight (BMI of 18.5-24.9). CONCLUSIONS: Obesity is associated with longer operative times and increased 30-day readmissions after ACLR, with patients with a BMI of 40 or greater having over 3 times the risk of readmission compared with patients with a normal weight. Male sex, black race, and younger age are all also associated with increased operative times. LEVEL OF EVIDENCE: Level III, observational, retrospective cohort study.

Suture Augmentation: An Alternative to Reconstruction for Incomplete Posterior Cruciate Ligament Injuries in the Multiple Ligament-Injured Knee.

Treatment of posterior cruciate ligament injuries remains controversial, particularly in the case of partial or incomplete tears in the context of a multiple ligament-injured knee. Suture augmentation, or internal bracing, has been shown in other ligament and tendon repairs or reconstructions to provide stable biomechanics and facilitate early return to activity. In the knee, suture augmentation has previously been used for the treatment of medial collateral ligament tears and in the support of anterior cruciate ligament reconstructions. We describe our arthroscopic technique for suture augmentation of incomplete posterior cruciate ligament injuries.

Risk Factors for 30-Day Readmission Following Shoulder Arthroscopy.

PURPOSE: The purpose of this study was to evaluate a large population of shoulder arthroscopy cases in order to provide insight into the risk factors associated with readmission following this common orthopaedic procedure. METHODS: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) billing codes to identify all patients older than 18 years of age who underwent shoulder arthroscopy between 2011 and 2013. Univariate and multivariate analyses were conducted to identify factors associated with 30-day readmission. RESULTS: We identified 15,015 patients who had undergone shoulder arthroscopy, with a 30-day readmission rate of 0.98%. The most common reason for readmission was pulmonary embolism (0.09%). On multivariate analysis, operative time > 1.5 hours (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.29 to 2.50), age 40 to 65 years (OR, 3.80; 95% CI, 1.37 to 10.59), age > 65 years (OR, 3.91; 95% CI, 1.35 to 11.35), American Society of Anesthesiologists (ASA) class 3 (OR, 4.53; 95% CI, 1.90 to 10.78), ASA class 4 (OR, 7.73; 95% CI, 2.91 to 27.25), chronic obstructive pulmonary disease (COPD; OR, 2.65; 95% CI, 1.54 to 4.55), and chronic steroid use (OR, 2.96; 95% CI, 1.46 to 6.01) were identified as independent risk factors for readmission. CONCLUSIONS: Operative time > 1.5 hours, age > 40 years, ASA classes 3 or 4, COPD, and chronic steroid use are independent risk factors for readmission following elective arthroscopic shoulder surgery, although the readmission rate following these procedures is low. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Radiographic Landmarks for Identifying the Anterolateral Ligament of the Knee.

PURPOSE: To identify the radiographic position of the origin and insertion of the anterolateral ligament (ALL) of the knee on a lateral radiograph. METHODS: Twelve unpaired, fresh-frozen cadaveric knees were dissected to expose the ALL. The origin and insertion of the ALL on each cadaver were then tagged using 2-mm radiopaque beads. True lateral fluoroscopic views of the knee were then obtained, and the distance from known radiographic landmarks was recorded by 2 reviewers. RESULTS: The origin of the ALL was found at a distance that is 37.0 ± 9.2% of the total anterior-posterior length of the femoral condyle from the posterior edge as measured along Blumensaat's line. The insertion was located at a distance that is 56.1 ± 6.9% of the total length of the tibial plateau from the posterior edge. The origin of the ALL is 5 mm posterior to a line from the posterior femoral cortex and 9 mm distal to a line along Blumensaat's line. The insertion is 4 mm anterior to the 50% mark of the anterior-posterior width of the tibia, 14 mm distal to the articular surface. CONCLUSIONS: The origin and insertion of the ALL can be accurately identified using intraoperative fluoroscopy. CLINICAL RELEVANCE: Determining radiographic parameters for the ALL will assist in developing accurate surgical techniques for ALL reconstruction.

Optimal femoral tunnel positioning in posterior cruciate ligament reconstruction using outside-in drilling.

PURPOSE: The goal of our study was to determine the precise femoral drill guide placement during reconstruction of the anterolateral bundle (ALB) of the posterior cruciate ligament (PCL) femoral footprint that would produce a minimum tunnel length of 25 mm, a maximum graft/femoral tunnel angle of 50°, and a minimum distance of 10 mm between the femoral socket and the subchondral bone of the weight-bearing surface of the medial femoral condyle. METHODS: Using computer navigation, we used synthetic replicas of human femora to create a series of virtual femoral sockets. We then measured the bone tunnel length, angle of the femoral socket relative to the PCL footprint, and distance from the subchondral bone of the weight-bearing surface of the medial femoral condyle to the femoral socket at a series of guide pin sleeve positions. We positioned the guide pin using the following angle combinations: -20°, -10°, 0°, 10°, 20°, 30°, 40°, 50°, and 60° to a line perpendicular to the femoral axis in the coronal plane and -15°, 0°, 15°, 30°, 45°, and 60° to a line parallel to the transepicondylar axis in the axial plane. Using linear regression models, we determined the precise drill guide placement angles that would produce the optimal tunnel length, graft/femoral tunnel angle, and distance to the subchondral bone margin. RESULTS: The results were consistent between small, medium, and large femora. We found that the optimal drilling angles for anatomic reconstruction of the femoral footprint of the ALB of the PCL were 0° to a line perpendicular to the femoral axis in the coronal plane and 15° to a line parallel to the transepicondylar axis in the horizontal or axial plane. CONCLUSIONS: During outside-in drilling for PCL reconstruction, holding the guide pin sleeve at a position 0° to a line perpendicular to the femoral axis in the coronal plane and 15° to a line parallel to the transepicondylar axis in the horizontal or axial plane results in optimal bone tunnel length, graft/tunnel angle, and distance between the femoral socket and the subchondral bone of the weight-bearing surface of the medial femoral condyle. CLINICAL RELEVANCE: We describe a precise femoral tunnel drill guide placement during outside-in PCL reconstruction that ensures an optimal femoral socket with a minimum bone tunnel length of 25 mm, maximum graft/femoral tunnel angle of 50°, and minimum distance of 10 mm between the subchondral bone of the weight-bearing surface of the medial femoral condyle and the femoral socket.

Combined Glenoid and Humeral Head Reconstruction with Allografts: A Report of Two Cases and the Midterm Outcomes.

CASE: We present two cases of anterior glenohumeral instability in which both the humeral head and the glenoid were reconstructed concurrently with use of allografts; we discuss the midterm outcomes at four and one-half and five years of follow-up, respectively. CONCLUSION: In our experience, concomitant glenoid and humeral head allograft reconstruction for anterior glenohumeral instability with severe combined humeral head and glenoid pathology yielded good midterm clinical, functional, and radiographic outcomes. This treatment approach may be a viable option for young and active patients presenting with severe combined glenoid and humeral pathology and warrants additional investigation.

Surgical excision of a symptomatic congenital coracoclavicular joint.

The coracoclavicular joint is a rare anatomic variant that consists of an articulation between the conoid tubercle of the clavicle and the superior surface of the coracoid process of the scapula. The coracoclavicular joint is most often asymptomatic and is found incidentally. A symptomatic coracoclavicular joint is exceedingly rare, with only 17 cases reported from 1915 to 2009. Symptoms may include limited range of motion, paresthesia, and brachialgia with radiation to the ipsilateral extremity. In the case of symptomatic coracoclavicular joints for which treatment data are reported, the response to conservative management with rest, analgesics, and physical therapy has been poor. Operative management resulted in complete resolution of symptoms in most patients and symptomatic improvement in the rest. This article reports the case of a 63-year-old man who presented with chronic left anterior shoulder pain exacerbated by forward flexion and overhead activities. Radiographs and computed tomography scan of the affected shoulder showed a bony articulation between the clavicle and the coracoid process of the scapula. The patient did not achieve long-term relief through conservative measures and corticosteroid injections, so the joint was surgically excised by an open procedure. Intraoperative findings were significant for a fully formed synovial joint with a capsule articulating between the clavicle and the coracoid process. After resection, the patient had minimal residual pain, improved range of motion, and symptomatic improvement with activity. The current case provides further data that the coracoclavicular joint can be the cause of significant shoulder pain and can be treated successfully with total resection of the joint if symptoms do not improve with conservative non-operative measures.

Serum interleukin-6 as a marker of periprosthetic shoulder infection.

BACKGROUND: Infection after shoulder arthroplasty can be a devastating complication, and subacute and chronic low-grade infections have proven difficult to diagnose. Serum marker analyses commonly used to diagnose periprosthetic infection are often inconclusive. The purpose of this study was to evaluate the effectiveness of serum interleukin-6 (IL-6) as a marker of periprosthetic shoulder infection. METHODS: A prospective cohort study of thirty-four patients who had previously undergone shoulder arthroplasty and required revision surgery was conducted. The serum levels of IL-6 and C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and the white blood-cell count (WBC) were measured. The definitive diagnosis of an infection was determined by growth of bacteria on culture of intraoperative specimens. Two-sample Wilcoxon rank-sum (Mann-Whitney) tests were used to determine the presence of a significant difference in the ESR and WBC between patients with and those without infection, while the Fisher exact test was used to assess differences in IL-6 and CRP levels between those groups. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of each marker were also calculated. RESULTS: There was no significant difference in the IL-6 level, WBC, ESR, or CRP level between patients with and those without infection. With a normal serum IL-6 level defined as <10 pg/mL, this test had a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 0.14, 0.95, 0.67, 0.61, and 0.62, respectively. CONCLUSIONS: IL-6 analysis may have utility as a confirmatory test but is not an effective screening tool for periprosthetic shoulder infection. This finding is in contrast to the observation, in previous studies, that IL-6 is more sensitive than traditional serum markers for periprosthetic infection.

Tension band plating of a nonunion anterior tibial stress fracture in an athlete.

The authors present a rare technique of tension band plating of the anterior tibia in the setting of a nonunion stress fracture. Surgical management with an intramedullary nail is a viable and proven option for treating such injuries. However, in treating elite athletes, legitimate concerns exist regarding the surgical disruption of the extensor mechanism and the risk of anterior knee pain associated with intramedullary nail use. The described surgical technique demonstrates the use of tension band plating as an effective treatment of delayed union and nonunion anterior tibial stress fractures in athletes without the potential risks of intramedullary nail insertion.

Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a modified technique using arthroscopy.

Latissimus dorsi transfer is a well-established method for the treatment of posterosuperior massive irreparable rotator cuff tears. We propose using an arthroscopically assisted technique that avoids insult to the deltoid. With the patient in the lateral decubitus position, an L-shaped incision is made along the anterior belly of the latissimus muscle and then along the posterior axillary line. The latissimus and teres major are identified and separated. The tendon insertion of the latissimus is isolated, and a FiberWire traction suture (Arthrex, Naples, FL) is placed, facilitating dissection of the muscle to the thoracodorsal neurovascular pedicle and subsequent mobilization. The interval deep to the deltoid and superficial to the teres minor is developed into a subdeltoid tunnel for arthroscopic tendon transfer. The latissimus tendon is then transferred and stabilized arthroscopically to the lateral aspect of the infraspinatus and supraspinatus footprints by multiple suture anchors.

Biologic resurfacing of the glenoid with meniscal allograft: long-term results with minimum 2-year follow-up.

BACKGROUND: There is a lack of consensus in treating glenohumeral arthritis in younger patients. Hemiarthroplasty has historically been favored because of complications associated with total shoulder arthroplasty. Biologic resurfacing of the glenoid has been investigated as a potential treatment that would decrease glenoid erosion and pain, the major complications of hemiarthroplasty. MATERIALS AND METHODS: We report on 19 shoulders treated with meniscal allograft glenoid resurfacing and shoulder hemiarthroplasty. All patients were followed up for a minimum of 2 years postoperatively (mean, 4.25 years) with Disabilities of the Arm, Shoulder and Hand (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) scores. In addition, we compared the outcomes related to preoperative concentric versus eccentric glenoid wear. RESULTS: At final follow-up, the mean score for the DASH questionnaire was 28; SST, 8; and VAS, 3.5. Whereas the eccentric wear group (DASH score, 19.4; SST score, 9.1; VAS score, 2.5) exhibited better shoulder function and pain scores compared with the concentric wear group (DASH score, 37.6; SST score, 8.4; VAS score, 4.1), the difference was not statistically significant (P = .098, P = .647, and P = .198, respectively). There were 6 complications (32%), all resulting in repeat surgery. Three patients underwent total shoulder arthroplasty and one shoulder had revision hemiarthroplasty, whereas synovectomy was performed in another shoulder. The sixth patient underwent lysis of adhesions and capsular release. DISCUSSION: With long-term follow-up, we have observed that biologic resurfacing of the glenoid with meniscal allograft exhibits inconsistent results and high complication rates. Strong consideration should be given to performing total shoulder arthroplasty in patients in whom all conservative treatment options have failed.

Intra-articular scapular fractures: Outcomes after internal fixation.

BACKGROUND: Although operative treatment may offer an appropriate management option for displaced glenoid fractures, there is sparse research assessing post-operative functional outcomes. This study assessed functional outcomes of patients after undergoing open reduction and internal fixation of displaced glenoid fractures. METHODS: Fifteen patients were treated with open reduction and internal fixation for displaced intra-articular fractures between 2005 and 2010. The indication for operative fixation was intra-articular displacement >4 mm. Post-operative functional outcomes were assessed via retrospective chart review. Evaluation included review of pre-operative imaging for fracture type, review of post-operative plain radiographs for fracture healing, Disabilities of the Arm Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeon Assessment (ASES) scores at last follow-up. RESULTS: At a mean follow-up of 49 months (24-87 months) all patients had radiographic healing. The mean DASH score was 10 (range 0.83-29.17). Mean ASES score was 90 (range 41.7-100). No patients had evidence of hardware failure or infection. CONCLUSIONS: Open reduction and internal fixation of displaced intra-articular glenoid fractures results in stable fixation and is associated with good functional outcome. LEVEL OF EVIDENCE: Level IV. Case series.