Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study.

BACKGROUND: Meniscal and chondral damage is common in the patient undergoing revision anterior cruciate ligament (ACL) reconstruction. PURPOSE: To determine if meniscal and/or articular cartilage pathology at the time of revision ACL surgery significantly influences a patient's outcome at 6-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled between 2006 and 2011. Data collection included baseline demographics, surgical technique, pathology, treatment, and scores from 4 validated patient-reported outcome instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx Activity Rating Scale. Patients were followed up at 6 years and asked to complete the identical set of outcome instruments. Regression analysis assessed the meniscal and articular cartilage pathology risk factors for clinical outcomes 6 years after revision ACL reconstruction. RESULTS: An overall 1234 patients were enrolled (716 males, 58%; median age, 26 years). Surgeons reported the pathology at the time of revision surgery in the medial meniscus (45%), lateral meniscus (36%), medial femoral condyle (43%), lateral femoral condyle (29%), medial tibial plateau (11%), lateral tibial plateau (17%), patella (30%), and trochlea (21%). Six-year follow-up was obtained on 79% of the sample (980/1234). Meniscal pathology and articular cartilage pathology (medial femoral condyle, lateral femoral condyle, lateral tibial plateau, trochlea, and patella) were significant drivers of poorer patient-reported outcomes at 6 years (IKDC, KOOS, WOMAC, and Marx). The most consistent factors driving outcomes were having a medial meniscal excision (either before or at the time of revision surgery) and patellofemoral articular cartilage pathology. Six-year Marx activity levels were negatively affected by having either a repair/excision of the medial meniscus (odds ratio range, 1.45-1.72; P≤ .04) or grade 3-4 patellar chondrosis (odds ratio, 1.72; P = .04). Meniscal pathology occurring before the index revision surgery negatively affected scores on all KOOS subscales except for sports/recreation (P < .05). Articular cartilage pathology significantly impaired all KOOS subscale scores (P < .05). Lower baseline outcome scores, higher body mass index, being a smoker, and incurring subsequent surgery all significantly increased the odds of reporting poorer clinical outcomes at 6 years. CONCLUSION: Meniscal and chondral pathology at the time of revision ACL reconstruction has continued significant detrimental effects on patient-reported outcomes at 6 years after revision surgery.

Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting.

BACKGROUND: Lytic or malpositioned tunnels may require bone grafting during revision anterior cruciate ligament reconstruction (rACLR) surgery. Patient characteristics and effects of grafting on outcomes after rACLR are not well described. PURPOSE: To describe preoperative characteristics, intraoperative findings, and 2-year outcomes for patients with rACLR undergoing bone grafting procedures compared with patients with rACLR without grafting. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 1234 patients who underwent rACLR were prospectively enrolled between 2006 and 2011. Baseline revision and 2-year characteristics, surgical technique, pathology, treatment, and patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale [Marx]) were collected, as well as subsequent surgery information, if applicable. The chi-square and analysis of variance tests were used to compare group characteristics. RESULTS: A total of 159 patients (13%) underwent tunnel grafting-64 (5%) patients underwent 1-stage and 95 (8%) underwent 2-stage grafting. Grafting was isolated to the femur in 31 (2.5%) patients, the tibia in 40 (3%) patients, and combined in 88 patients (7%). Baseline KOOS Quality of Life (QoL) and Marx activity scores were significantly lower in the 2-stage group compared with the no bone grafting group (P≤ .001). Patients who required 2-stage grafting had more previous ACLRs (P < .001) and were less likely to have received a bone-patellar tendon-bone or a soft tissue autograft at primary ACLR procedure (P≤ .021) compared with the no bone grafting group. For current rACLR, patients undergoing either 1-stage or 2-stage bone grafting were more likely to receive a bone-patellar tendon-bone allograft (P≤ .008) and less likely to receive a soft tissue autograft (P≤ .003) compared with the no bone grafting group. At 2-year follow-up of 1052 (85%) patients, we found inferior outcomes in the 2-stage bone grafting group (IKDC score = 68; KOOS QoL score = 44; KOOS Sport/Recreation score = 65; and Marx activity score = 3) compared with the no bone grafting group (IKDC score = 77; KOOS QoL score = 63; KOOS Sport/Recreation score = 75; and Marx activity score = 7) (P≤ .01). The 1-stage bone graft group did not significantly differ compared with the no bone grafting group. CONCLUSION: Tunnel bone grafting was performed in 13% of our rACLR cohort, with 8% undergoing 2-stage surgery. Patients treated with 2-stage grafting had inferior baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting. Patients treated with 1-stage grafting had similar baseline and 2-year patient-reported outcomes and activity levels compared with patients not undergoing bone grafting.

Returning to Activity After Anterior Cruciate Ligament Revision Surgery: An Analysis of the Multicenter Anterior Cruciate Ligament Revision Study (MARS) Cohort at 2 Years Postoperative.

BACKGROUND: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). HYPOTHESES: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. RESULTS: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. CONCLUSION: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Association Between Graft Choice and 6-Year Outcomes of Revision Anterior Cruciate Ligament Reconstruction in the MARS Cohort.

BACKGROUND: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. HYPOTHESIS: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. RESULTS: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87). CONCLUSION: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Rate of infection following revision anterior cruciate ligament reconstruction and associated patient- and surgeon-dependent risk factors: Retrospective results from MOON and MARS data collected from 2002 to 2011.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon-dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting postoperative infections. Allografts had a higher risk of infection than autografts (odds ratio, 6.8; 95% CI, 0.9-54.5; p = .045). Diabetes (odds ratio, 28.6; 95% CI, 5.5-149.9; p = .004) was a risk factor for infection. Patient age, sex, BMI, and smoking status were not associated with risk of infection after rACLR.

Predictors of Patient-Reported Outcomes at 2 Years After Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Patient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients. PURPOSE/HYPOTHESIS: The purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery. RESULTS: A total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery. CONCLUSION: PROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

Physiologic Preoperative Knee Hyperextension Is a Predictor of Failure in an Anterior Cruciate Ligament Revision Cohort: A Report From the MARS Group.

BACKGROUND: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. RESULTS: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). CONCLUSION: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Surgical Predictors of Clinical Outcomes After Revision Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. HYPOTHESIS: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. CONCLUSION: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Platelet-rich plasma injection reduces pain in patients with recalcitrant epicondylitis.

Thirty patients (31 elbows) with epicondylitis unresponsive to nonsurgical treatment (including steroid injection) for >6 months received a single treatment of platelet-rich plasma injected with a peppering technique. Patients were followed using a 5-subcategory visual analog scale (VAS) for pain (0, no pain; 10, worst possible pain), modified American Shoulder and Elbow Surgeons assessment survey, and VAS for patient satisfaction (0, not at all satisfied; 10, very satisfied). Successful treatment was defined as a 25% decrease in worst pain at follow-up with no intervention after 1 year. Two patients (2 elbows) elected for surgery 1 month postinjection. Of the remaining 29 elbows followed, 28 had a 25% reduction in worst pain at ≥1 follow-up visits, for an overall success rate of 90% (28 of 31 elbows). Mean scores for worst pain at baseline, 3 months, and last follow-up (patients with at least 6 months of follow-up; 25±14 months) were 7.2±1.6 (n=30 elbows), 4.0±2.2 (n=23), and 1.1±1.7 (n=26), respectively (P<.01 or less comparing follow-up scores to baseline using each patient as his or her own control). Patient satisfaction scores improved from 5.1±2.5 at 1 month to 9.1±1.9 at last follow-up (P<.01). Only 1 patient reported no improvement after 6 months. Results suggest that a single platelet-rich plasma injection can improve pain and function scores, thus avoiding surgery.

Long-term results of ulnar collateral ligament reconstruction in throwing athletes based on a hybrid technique.

BACKGROUND: Tearing or attenuation of the ulnar collateral ligament (UCL) of the elbow is a common injury in the throwing athlete. Several techniques for reconstruction of the attenuated or torn UCL have been developed. HYPOTHESIS: Ulnar collateral ligament reconstruction based on a hybrid technique, with an ulnar osseous tunnel and suture anchor fixation on the humerus, allows throwing athletes to return to prior activity level and has a low complication rate. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review was performed of the UCL reconstructions performed in 34 throwing athletes, as based on a hybrid technique, over a 6-year period. All elbows were reconstructed with a tendon graft fixed through an osseous tunnel placed at the sublime tubercle and with 2 suture anchors placed into a bony trough at the humeral origin of the native ligament. RESULTS: Average postoperative follow-up was 6.9 years (range, 4.2 to 8.7 years). The average age was 20.2 years, with symptoms present for an average of 22.4 weeks before clinic presentation. Each athlete had pain with valgus stress or milking maneuver in addition to a documented tear of the UCL on magnetic resonance imaging. All experienced pain on the medial aspect of the elbow while throwing. Only 1 patient had new onset of temporary ulnar nerve paresthesia, for a complication rate of 2%. Of 34 athletes, 29 (85%) had an excellent result, defined as the ability to return to play at or above preinjury level. Of the 5 patients who did not return to preinjury level, only 2 were unable to do so secondary to pain. CONCLUSION: Ulnar collateral ligament reconstruction based on a hybrid fixation technique results in a low complication rate and allows full recovery to preinjury level of performance in the majority (85%) of patients.

A minimally disruptive surgical technique for the treatment of osteitis pubis in athletes.

BACKGROUND: MULTIPLE SURGICAL PROCEDURES EXIST FOR THE TREATMENT OF OSTEITIS PUBIS: curettage of the symphysis joint, wedge resection, complete resection of the joint, placement of extraperitoneal retropubic synthetic mesh, and arthrodesis of the joint. However, a paucity of literature has reported long-term successful outcomes with the aforementioned approaches. Patients treated operatively have reported recalcitrant pain resulting from iatrogenic instability. The article presents the results of a conservative operative technique that avoids disruption of adjacent ligaments. HYPOTHESIS: Preserving the adjacent ligamentous structures will allow competitive athletes to return to competition and activities of daily living free of iatrogenic pelvic instability and pain. STUDY DESIGN: Case series. METHODS: Four competitive athletes (2 professional and 2 collegiate football players) diagnosed with osteitis pubis were treated conservatively for a minimum of 6 months. Patients underwent surgical intervention upon failure to respond to nonoperative management. The degenerative tissue was resected, allowing only bleeding cancellous bone to remain while preserving the adjacent ligaments. An arthroscope was used to assist in curettage, allowing the debridement to be performed through a small incision in the anterior capsule. RESULTS: The symptoms of all 4 patients resolved, and they returned to competitive athletics. This ligament-sparing technique provided a solid, stable repair and pain relief. CONCLUSION: This surgical technique preserves the adjacent ligamentous structures and allows competitive athletes to return to competition and activities of daily living free of pain and void of pelvic instability. CLINICAL RELEVANCE: This technique is a surgical treatment option for athletes with osteitis pubis who fail conservative treatment.

Pectoralis major tears: correlation of magnetic resonance imaging and treatment strategies.

BACKGROUND: Controversy exists in the diagnosis and treatment of pectoralis major tear patterns. HYPOTHESIS: Magnetic resonance imaging is useful in determining the grade and the location of pectoralis major tears and in guiding toward an appropriate treatment plan. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 1998 and December 2002, 27 patients were treated for pectoralis major tears. All patients were evaluated by history and physical examination. A clinical impression was formed regarding the location and grade of injury, and a treatment plan was established. All patients underwent magnetic resonance imaging, and images were reviewed by an orthopaedic surgeon and a board-certified musculoskeletal radiologist, resulting in a final treatment plan. The mean follow-up was 12 months. All patients were evaluated by questionnaire and clinical examination to assess pain, function, deformity, and overall satisfaction. RESULTS: In 19 of 27 patients, the clinical impression and magnetic resonance imaging agreed regarding the location and the grade of the injury. A total of 19 patients underwent surgical repair, and 8 patients were treated nonoperatively. The magnetic resonance imaging result changed the treatment plan in 3 patients from operative to nonoperative. CONCLUSION: The clinical impression appeared to overestimate the severity, the location, and the grade of the injury. Magnetic resonance imaging provided a more accurate assessment and, in conjunction with the clinical examination, helped to identify those patients who would benefit most from surgical repair.

Rotator cuff repair in spinal cord injury patients.

Previous studies on the treatment of rotator cuff tears in wheelchair-bound patients have concentrated on nonsurgical management. We conducted a retrospective review to determine the effectiveness of surgical repair of rotator cuff tears in spinal cord-injured patients. Five male patients with rotator cuff tears confirmed by physical examination and magnetic resonance imaging underwent rotator cuff repair. Two of eight shoulders were revisions. The patients were evaluated postoperatively with the American Shoulder and Elbow Surgeons Scoring System. These results were compared with preoperative functional assessment. Patients were given a subjective questionnaire to assess their overall experience. Postoperative range of motion improved in 6 of 8 shoulders. Strength was increased in 6 of 8 shoulders. Patients reported satisfaction with the results in 7 of 8 shoulders, and all 5 patients would recommend the procedure to other spinal cord injury patients. At recent follow-up, 7 of 8 shoulders returned to their preinjury level of function. Surgery for spinal cord injury patients with rotator cuff tears can improve their functional capability and autonomy while reducing their pain. Compliance with the demanding postoperative rehabilitation is essential; therefore proper patient selection is crucial for optimal results.

Intra-articular anterior cruciate ligament reconstruction using patellar tendon allograft in the skeletally immature patient.

PURPOSE: Tears of the anterior cruciate ligament (ACL) are becoming more prevalent in the skeletally immature patient. We report our results with intra-articular transphyseal ACL reconstruction in this patient population. TYPE OF STUDY: Retrospective analysis. METHODS: Ten skeletally immature athletes underwent transphyseal intra-articular ACL reconstruction using patellar tendon allograft. The patients ranged from 9 to 15 years of age. Clinical outcomes were measured using the Lysholm and International Knee Documentation Committee scoring systems, follow-up radiographs, clinical examination, and KT-1000 testing. RESULTS: Mean follow-up was 40 months. The average Lysholm score was 95, and 9 of 10 patients reported normal or nearly normal knee function. There was no clinical or objective evidence of instability, limb-length discrepancy, or early physeal arrest. Nine of 10 patients returned to their preinjury level of athletics. CONCLUSIONS: Skeletally immature athletes with symptomatic complete ACL tears who do not want to modify their athletic activity may benefit from intra-articular ACL reconstruction using patellar tendon allografts. Special attention to bone plug and interference screw placement will reduce the risk of early physeal arrest.

Arthroscopic posterior cruciate ligament repair.

PURPOSE: We present our technique of arthroscopic repair for femoral avulsion soft-tissue tears of the posterior cruciate ligament (PCL) and its results. TYPE OF STUDY: Case series, retrospective review. METHODS: We performed 13 arthroscopic repairs of the PCL and reviewed them retrospectively. Follow-up was available for 11 (85%) patients. Nonabsorbable monofilament sutures were placed through the loose fibers of the ligament and tied over a bone bridge. Patients were evaluated using magnetic resonance imaging, comparative stress views, and according to the scoring systems of Lysholm and Gillquist and the International Knee Documentation Committee (IKDC). RESULTS: Mean follow-up was 51.4 months. IKDC scores revealed 4 (36.4%) patients with normal knee function, and 7 (63.6%) with nearly normal function. Average Lysholm and Gillquist score was 95.4 (90 to 100). All athletes returned to the same or a higher level of competition. CONCLUSIONS: Arthroscopic repair of the PCL in patients with a femoral avulsion is effective in reducing postoperative instability and improving functional outcome.

Avulsion fracture of the ulnar sublime tubercle in overhead throwing athletes.

BACKGROUND: Injuries to the ulnar collateral ligament are relatively common in throwing athletes and result from either acute traumatic or repeated valgus stress to the elbow. Avulsion fracture of the sublime tubercle of the ulna is a rarely reported site of ulnar collateral ligament injury. PURPOSE: We retrospectively reviewed our cases of ulnar collateral ligament injuries to study avulsion fractures of the sublime tubercle of the ulna. STUDY DESIGN: Case series. METHODS: Data, including radiographs and magnetic resonance imaging scans, were obtained by review of hospital and office records and by follow-up examination. Of 33 consecutive patients treated for ulnar collateral ligament injuries, 8 had avulsion fractures of the sublime tubercle of the ulna. All eight were male baseball players with dominant arm involvement, an average age of 16.9 years, and an average follow-up of 23.6 months. RESULTS: Six of eight patients had failure of nonoperative treatment and required surgical repair. Two of the six underwent ulnar collateral ligament reconstruction and four had direct repair of the sublime tubercle avulsion with bioabsorbable suture anchors. At last follow-up, all eight had returned to their preinjury level of activity. No patient had residual medial elbow pain or laxity. CONCLUSIONS: Diagnosis of sublime tubercle avulsion fracture is made with history, physical examination, and radiographic studies. Magnetic resonance imaging can help identify an avulsion fracture not visible radiographically and can help determine whether direct repair or reconstruction is needed.

Arthroscopic technique for the knee in morbidly obese patients.

Patients with morbid obesity present an additional surgical difficulty for routine knee arthroscopy. Accurate portal placement in these patients is of utmost importance in order to achieve adequate access to the surgical pathology. To facilitate portal placement, we changed our standard surgical technique, establishing operative portals under direct arthroscopic visualization. We present our technique in this article as an option in the approach to treating these patients.

Analysis of arthroscopically assisted ankle arthrodesis.

PURPOSE: Evaluation of an arthroscopically assisted ankle arthrodesis technique for clinical and radiographic union, function, and patient satisfaction. TYPE OF STUDY: Retrospective analysis and review of the literature. METHODS: Twenty-one patients with a mean age of 52.7 years who underwent arthroscopic ankle arthrodesis were examined at an average follow-up time of 34 months. The mean duration of symptoms was 4.4 years. The most common diagnosis for patients who underwent arthrodesis was post-traumatic arthritis (19 of 21) with 1 patient having a diagnosis of avascular necrosis of the talus and the other patient having rheumatoid arthritis. All patients described severe mechanical pain as the most important reason for undergoing the procedure. RESULTS: Fusion occurred in 20 of 21 patients. The average time to clinical and radiographic union was 8.9 weeks. Nine patients were graded as excellent; no pain, limp, or occupational restriction, and a stable fusion. Eleven were graded as good; mild pain, occasional limp, or occupational restriction with a stable fusion. One was graded as poor; failed union and pain. The failure had extensive avascular necrosis involving approximately 50% of the talus as a preoperative diagnosis. CONCLUSIONS: The advantages of the arthroscopic technique include a high fusion rate, decreased time to fusion, and decreased cost. There are considerable advantages to the arthroscopic technique in appropriately selected patients with no or mild angular deformity and no avascular necrosis greater than 30% of the talus. There is a substantial reduction in time to fusion in the arthroscopic procedure compared with published reports on open procedures for ankle arthrodesis. While this procedure is not indicated in all instances, selected patients with disabling ankle arthrosis may be more appropriately treated with an arthroscopic arthrodesis than by open surgery.