A Closer Look at the Relationship Between Industry and Orthopaedic Sports Medicine Surgeons.

BACKGROUND: A recent study demonstrated that discrepancies exist between disclosures reported by authors publishing in The American Journal of Sports Medicine and disclosures listed in the Physician Payments Sunshine Act-initiated Open Payments database, managed by the Centers for Medicare & Medicaid Services (CMS). However, no study to date has explored the relationship between the biopharmaceutical and device industry (industry) and the membership base of the American Orthopaedic Society for Sports Medicine (AOSSM). PURPOSE: To critically examine the relationship between orthopaedic sports medicine surgeons and industry. STUDY DESIGN: Cross-sectional study. METHODS: The publicly available CMS Open Payments database website was accessed to search for sports medicine orthopaedic surgeons in the United States who were members of the AOSSM. Financial data, specifically general, research, and ownership payments for 2015, were recorded for each surgeon. The American Academy of Orthopaedic Surgeons (AAOS) disclosures of each surgeon were then obtained. Descriptive statistics and simple proportions were calculated to summarize the collected data, including years in practice and amount of payment. Median values for general payments were compared to provide a more accurate reflection of payments transferred to a "typical" sports medicine surgeon. RESULTS: A total of $58,113,561 in general payments, $3,996,051 in research payments, $72,481,814 in money invested, and $144,552,383 in interest earned from money invested were identified as being paid to 2274 surgeons (all amounts in US$). The distribution of total general payments received was skewed: 10% of surgeons received 95.4% ($55,463,183) of the total general payments. A total of 1433 surgeons had completed, up-to-date AAOS disclosures. Although 44% (635 surgeons) self-reported no financial conflict to the AAOS, the Open Payments database indicated some level of industry support to these surgeons. Unreported general payments totaled $1,393,212, or a median of $561 per surgeon (interquartile range, $10-$200,048). CONCLUSION: Although orthopaedic sports medicine surgeons received substantial payments from industry, most of the total general payments were given to a small proportion of people. The regional distribution of these payments did not differ significantly. Summary reports of data are largely skewed by outliers and should be interpreted with caution. However, a large percentage of these surgeons failed to reveal industry support of any kind in their AAOS disclosures, including meals and educational funding, demonstrating the importance of transparency and accuracy when completing financial disclosures.

3-Dimensional Printed Models May Be a Useful Tool When Planning Revision Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine whether using 3-dimensional (3D)-printed models in addition to computed tomography (CT) scans to evaluate the primary femoral and tibial tunnels before revision anterior cruciate ligament (ACL) reconstruction leads to better agreement with the surgical approach than CT alone. METHODS: Fifteen patients who underwent revision ACL reconstruction were retrospectively identified. The mean age was 24.3 years, and 73% were female. Using only CT images, 3 board-certified orthopaedists and 5 sports medicine orthopaedic fellows evaluated whether the existing tibial and femoral tunnels were acceptable for the revision surgery. Subsequently, 3D-printed models were made available in addition to the CT scan, and the same questions were asked. RESULTS: For the attending orthopaedic physicians, adding the 3D-printed models did not have a significant impact on the tibial or femoral tunnel agreement compared with the surgical approach. With the fellow physicians, however, using the 3D-printed models with tibial tunnel evaluation led to a higher agreement rate (76%) compared with CT images alone (63%) (P = .050). Furthermore, with the fellow physicians, there was a higher overall agreement when evaluating both the tibial and femoral tunnels with the addition of 3D-printed models (74%) compared with CT alone (65%) (P = .049). CONCLUSION: Our hypothesis that using 3D-printed models leads to better agreement with the surgical approach was unsupported based on the response of the board-certified orthopaedists. Based on the fellow response, it stands to reason that 3D-printed models may be a useful tool in understanding spatial orientation when planning for revision ACL surgery. LEVEL OF EVIDENCE: IV, retrospective case series.

Preoperative sonographic measurement can accurately predict quadrupled hamstring tendon graft diameter for ACL reconstruction.

PURPOSE: Previous studies reported sonography was inferior to MRI to predict hamstring tendon graft diameter for ACL reconstruction. This study aimed to investigate the correlation between intraoperative hamstring tendon graft diameter and its preoperative measurement using different sonographic scanning protocol from previous studies. METHODS: Two cadaveric knees were utilized for validation. Sonographically guided gracilis tendon (G) and semitendinosus tendon (ST) injections were performed at myotendinous junction of sartorius using colored latex and then dissection was performed. In the clinical studies, 28 patients underwent primary ACL reconstruction were enrolled. Cross-sectional area (CSA) of G and ST were measured at myotendinous junction of Sartorius. The diameter of doubled G (2G), doubled ST (2ST) and quadrupled ST + G (4STG) were intraoperatively measured using graft sizing devices with 0.5-mm increments. RESULTS: Cadaveric dissection showed the presence of latex on the surface of G and ST at myotendinous junction of Sartorius in all specimens. In the clinical studies, CSA of G, ST, and ST + G significantly correlated with diameter of 2G (r = 0.464, p = 0.039), 2ST (r = 0.712, p < 0.001), and 4STG (r = 0.792, p < 0.001), respectively. As a result of the simple linear regression analysis, 4STG diameter could be predicted by the following formula: 4.345 + 0.210 × CSA. The differences between calculated diameter by this formula and intraoperative 4STG diameter were within ± 0.5 mm in 89.3% (25/28) of subjects. CONCLUSIONS: The diameter of 2ST and 4STG can be reliably predicted based on sonographic CSA measurement preoperatively. Sonography is a cost-effective alternate to repeat MRI to predict hamstring graft diameter preoperatively. LEVEL OF EVIDENCE: Diagnostic study; Level II.

Individualized Anterior Cruciate Ligament Graft Matching: In Vivo Comparison of Cross-sectional Areas of Hamstring, Patellar, and Quadriceps Tendon Grafts and ACL Insertion Area.

BACKGROUND: Recent literature correlated anterior cruciate ligament (ACL) reconstruction failure to smaller diameter of the harvested hamstring (HS) autograft. However, this approach may be a simplification, as relation of graft size to native ACL size is not typically assessed and oversized grafts may impart their own complications. PURPOSE: To evaluate in vivo data to determine if the commonly used autografts reliably restore native ACL size. STUDY DESIGN: Descriptive laboratory study. METHODS: Intraoperative data of the tibial insertion area and HS graft diameter were collected and retrospectively evaluated for 46 patients who underwent ACL reconstruction with HS autografts. Magnetic resonance imaging measurements of the cross-sectional area (CSA) of the possible patellar tendon (PT) and quadriceps tendon (QT) autografts were also done for each patient. The percentages of tibial insertion site area restored by the 3 possible grafts were then calculated and compared for each individual. RESULTS: The mean ACL tibial insertion area was 107.2 mm2 (60.5-155.5 mm2). The mean CSAs of PT, HS, and QT were 33.2, 55.3, and 71.4 mm2, respectively. When all grafts were evaluated, the percentage reconstruction of the insertion area varied from 16.2% to 123.1% on the tibial site and from 25.5% to 176.7% on the femoral site, differing significantly for each graft type ( P < .05). On average, 32.8% of the tibial insertion area would have been filled with PT, 53.6% by HS, and 69.5% by QT. Based on previous cadaveric studies indicating that graft size goal should be 50.2% ± 15% of the tibial insertion area, 82.7% of patients in the HS group were within this range (36.9%, QT; 30.5%, PT), while 65.2% in the PT group were below it and 60.9% in the QT group were above it. CONCLUSION: ACL insertion size and the CSAs of 3 commonly used grafts vary greatly for each patient and are not correlated with one another. Thus, if the reconstructed ACL size is determined by the harvested autograft size alone, native ACL size may not be adequately restored. PT grafts tended to undersize the native ACL, while QT might oversize it. CLINICAL RELEVANCE: These results may help surgeons in preoperative planning, as magnetic resonance imaging measurements can be helpful in determining individualized graft choice to adequately restore the native ACL.

Bone Bruise Patterns in Skeletally Immature Patients With Anterior Cruciate Ligament Injury: Shock-Absorbing Function of the Physis.

BACKGROUND: Bone bruises are frequently found on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury and have been related to the force associated with the trauma. Yet, little is known about the bone bruise distribution pattern of skeletally immature (SI) patients, as the presence of an open physis may play a role in energy dissipation given its unique structure. PURPOSE: To describe and compare the location and distribution of tibial and femoral bone bruises, observed on MRI, between 2 groups of ACL-injured knees: the first group with an open physis and the second with a closed physis. Additionally, based on the bone bruise distribution pattern, the secondary aim of the study was to propose a new classification of bone bruise in SI patients. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A retrospective review was conducted to identify all cases of primary ACL tears in patients ≤16 years old, with MRI within 6 weeks of injury between January 2012 and December 2016. Overall, 106 patients were identified: 53 with open physis (skeletally immature [SI] group) and 53 with closed physis as control (skeletally mature [SM] group). MRI scans were reviewed to assess for the presence and location of bone bruises. Longitudinal bone bruise distribution was described as epiphyseal and metaphyseal in both femur and tibia. The proposed classification for tibia and femur has 2 parts: the location of the bone bruise in the (I) lateral, (II) medial, or (III) medial and lateral parts of the bone; and if the bone bruise (a) does not or (b) does cross the physis. For the tibia, if the bone bruise is also present in the central portion, a letter C is added. RESULTS: The SI group had significantly fewer bone bruises cross the physis and extend into the metaphysis than did the SM group for both the tibia (25% vs 85%, respectively; P < .0001) and the femur (4% vs 42%; P < .0001). The most common patterns observed in the SI group were type IIICa in the tibia (medial/lateral and central, not extending into the metaphysis: 42%) and type Ia in the femur (lateral, not extending into the metaphysis: 59%). CONCLUSION: The data from this study shows that patients with an open physis at the occurrence of an acute ACL rupture have unique bone bruise patterns as compared with those with a closed physis. In the SI patients, the bone bruise pattern is significantly less frequently observed in the tibial and femoral metaphysis.

Laparoscopic Treatment of Pubic Symphysis Instability With Anchors and Tape Suture.

Patients with pubic symphysis instability who had failed nonoperative treatments may benefit from surgical repair. This disease process is rare, most commonly seen in postpartum women and athletes, and its surgical treatment is invasive and nonphysiological. Currently described surgical interventions, although limited, include plating, which provides an overly rigid construct with the risk of failure and possibly poor long-term outcomes particularly in athletes, and treatments such as curettage, more commonly used in the treatment of osteitis pubis. An emerging option is minimally invasive laparoscopic fixation using knotless anchors with a tape suture in a crisscross configuration. This possibly allows more physiological movement of the pubic symphysis in a less invasive manner. A detailed technical description and discussion of the technique are provided.

The iliotibial band and anterolateral capsule have a combined attachment to the Segond fracture.

The purpose of this report was to describe the injury mechanism, surgical findings, and outcomes in a 21-year-old professional female football player who presented with a complete anterior cruciate ligament (ACL) rupture and Segond fracture. Interview and video analysis were performed to elicit the injury mechanism. Clinical examination and imaging revealed a complete ACL tear, Segond fracture, lateral meniscus tear, MCL sprain, and posterolateral corner sprain. Examination under anaesthesia revealed Grade 2 pivot shift and varus/valgus instability. Surgical examination revealed attachment of the posterior fibres of the iliotibial band and the lateral capsule to the Segond fragment. The fracture was reduced with suture fixation, and an anatomic ACL reconstruction was performed. Follow-up demonstrated rotatory and anterior tibial translation stability, and imaging at 7 months post-operatively revealed no movement and continued osseous integration of the Segond fragment. Level of evidence V.

A Layered Anatomic Description of the Anterolateral Complex of the Knee.

Variability in anatomic terminology, dissection protocols, and use of embalmed as opposed to fresh frozen specimens has led to the controversy surrounding the "anterolateral ligament of the knee." Conceptually the complex anatomy of the anterolateral knee is made up of the superficial, middle, deep, and capsulo-osseous layers of the iliotibial band. The anterolateral capsule is deep to these tissues and is directly attached to the lateral meniscus. These structures collectively form the anterolateral complex of the knee. The anterolateral complex in conjunction with the anterior cruciate ligament function to prevent anterolateral rotatory instability of the knee.

The Anterolateral Complex of the Knee.

BACKGROUND: Significant controversy exists regarding the anterolateral structures of the knee. PURPOSE: To determine the layer-by-layer anatomic structure of the anterolateral complex of the knee. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty fresh-frozen cadaveric knees (age range, 38-56 years) underwent a layer-by-layer dissection to systematically expose and identify the various structures of the anterolateral complex. Quantitative measurements were performed, and each layer was documented with high-resolution digital imaging. RESULTS: The anterolateral complex of the knee consisted of different distinct layers, with the superficial and deep iliotibial band (ITB) representing layer 1. The superficial ITB had a distinct connection to the distal femoral metaphysis and femoral condyle (Kaplan fibers), and the deep layers of the ITB were identified originating at the level of the Kaplan fibers proximally. This functional unit, consisting of the superficial and deep ITB, was reinforced by the capsulo-osseous layer of the ITB, which was continuous with the fascia of the lateral gastrocnemius and biceps femoris muscles. These 3 components of the ITB became confluent distally, and the insertion spanned from the Gerdy tubercle anteriorly to the lateral tibia posteriorly on a small tubercle (lateral tibial tuberosity). Layer 3 consisted of the anterolateral capsule, in which 35% (7/20) of specimens had a discreet mid-third capsular ligament. CONCLUSION: The anterolateral complex consists of the superficial and deep ITB, the capsulo-osseous layer of the ITB, and the anterolateral capsule. The anterolateral complex is defined by the part of the ITB between the Kaplan fibers proximally and its tibial insertion, which forms a functional unit. A discrete anterolateral ligament was not observed; however, the anterolateral ligament described in recent studies likely refers to the capsulo-osseous layer or the mid-third capsular ligament. CLINICAL RELEVANCE: The anterolateral knee structures form a complex functional unit. Surgeons should use caution when attempting to restore this intricate structure with extra-articular procedures designed to re-create a single discreet ligament.

The Segond Fracture Is an Avulsion of the Anterolateral Complex.

BACKGROUND: The Segond fracture was classically described as an avulsion fracture of the anterolateral capsule of the knee. Recently, some authors have attributed its pathogenesis to the "anterolateral ligament" (ALL). Biomechanical studies that have attempted to reproduce this fracture in vitro have reported conflicting findings. PURPOSE: To determine the anatomic characteristics of the Segond fracture on plain radiographs and magnetic resonance imaging (MRI), to compare this location with the location of the ALL described in prior radiographic and anatomic publications, and to determine the fracture's attachments to the soft tissue anterolateral structures of the knee. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 36 anterior cruciate ligament-injured patients with Segond fractures (33 male, 3 female; mean age, 23.2 ± 8.4 years) were enrolled. MRI scans were reviewed to determine the anatomic characteristics of the Segond fracture, including the following: proximal-distal (PD) length, anterior-posterior (AP) width, medial-lateral (ML) width, PD distance to the lateral tibial plateau, AP distance to the Gerdy tubercle (GT), and AP distance from the GT to the posterior aspect of the fibular head. The attachment of the anterolateral structures to the Segond fragment was then categorized as the iliotibial band (ITB) or anterolateral capsule. Interrater reliability of the measurements was determined by calculating the Spearman rank correlation coefficient. MEDLINE, Web of Science, and the Cochrane Library were searched from inception to May 2016 for the following keywords: (1) "Segond fracture," (2) "anterolateral ligament," (3) "knee avulsion," (4) "lateral tibia avulsion," and (5) "tibial plateau avulsion." All studies describing the anatomic location of the Segond fracture and the ALL were included in the systematic review. RESULTS: On plain radiographs, the mean distance of the midpoint of the fracture to the lateral tibial plateau was 4.6 ± 2.2 mm. The avulsed fracture had a mean PD length of 9.2 ± 2.5 mm and a mean ML width of 2.4 ± 1.4 mm. On MRI, the mean distance of the proximal fracture to the tibial plateau was 3.4 ± 1.6 mm. The mean PD length was 8.7 ± 2.2 mm, while the mean AP width was 11.1 ± 2.2 mm. The mean distance between the GT and the center of the fracture was 26.9 ± 3.3 mm, while the mean distance between the GT and the posterior fibular head was 53.9 ± 4.4 mm. The mean distance of the midpoint of the fracture to the tibial plateau was 7.8 ± 2.7 mm, while the center of the fracture was 49.9% of the distance between the GT and the posterior aspect of the fibular head. Analysis of soft tissue structures attached to the fragment revealed that the ITB attached in 34 of 36 patients and the capsule attached in 34 of 36 patients. One patient had only the capsule attached, another had only the ITB attached, and the last showed neither clearly attached. A literature review of 20 included studies revealed no difference between the previously described Segond fracture location and the tibial insertion of the ALL. CONCLUSION: The results of this study confirmed that while the Segond fracture occurs at the location of the tibial insertion of the ALL, as reported in the literature, MRI was unable to identify any distinct ligamentous attachment. MRI analysis revealed that soft tissue attachments to the Segond fracture were the posterior fibers of the ITB and the lateral capsule in 94% of patients.

Anatomic and Histological Investigation of the Anterolateral Capsular Complex in the Fetal Knee.

BACKGROUND: There is currently disagreement with regard to the presence of a distinct ligament in the anterolateral capsular complex of the knee and its role in the pivot-shift mechanism and rotatory laxity of the knee. PURPOSE: To investigate the anatomic and histological properties of the anterolateral capsular complex of the fetal knee to determine whether there exists a distinct ligamentous structure running from the lateral femoral epicondyle inserting into the anterolateral tibia. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty-one unpaired, fresh fetal lower limbs, gestational age 18 to 22 weeks, were used for anatomic investigation. Two experienced orthopaedic surgeons performed the anatomic dissection using loupes (magnification ×3.5). Attention was focused on the anterolateral and lateral structures of the knee. After the skin and superficial fascia were removed, the iliotibial band was carefully separated from underlying structures. The anterolateral capsule was then examined under internal and external rotation and varus-valgus manual loading and at different knee flexion angles for the presence of any ligamentous structures. Eight additional unpaired, fetal lower limbs, gestational age 11 to 23 weeks, were used for histological analysis. RESULTS: This study was not able to prove the presence of a distinct capsular or extracapsular ligamentous structure in the anterolateral capsular complex area. The presence of the fibular collateral ligament, a distal attachment of the biceps femoris, the entire lateral capsule, the iliotibial band, and the popliteus tendon in the anterolateral and lateral area of the knee was confirmed in all the samples. Histological analysis of the anterolateral capsule revealed a loose, hypocellular connective tissue with less organized collagen fibers compared with ligament and tendinous structures. CONCLUSION: The main finding of this study was that the presence of a distinct ligamentous structure in the anterolateral complex is not supported from a developmental point of view, while all other anatomic structures were present. CLINICAL RELEVANCE: The inability to prove the existence of a distinct ligamentous structure, called the anterolateral ligament, in the anterolateral knee capsule may indicate that the other components of the anterolateral complex, such as the lateral capsule, the iliotibial band, and its capsule-osseous layer, are more important for knee rotatory stability.

The anterolateral complex of the knee: a pictorial essay.

Injuries to the anterolateral complex of the knee can result in increased rotatory knee instability. However, to diagnose and treat patients with persistent instability properly, surgeons need to understand the multifactorial genesis as well as the complex anatomy of the anterolateral aspect of the knee in its entirety. While recent research focused primarily on one structure (anterolateral ligament-ALL), the purpose of this pictorial essay is to provide a detailed layer-by-layer description of the anterolateral complex of the knee, consisting of the iliotibial band with its superficial, middle, deep, and capsulo-osseous layer as well as the anterolateral joint capsule. This may help surgeons to not only understand the anatomy of this particular part of the knee, but may also provide guidance when performing extra-articular procedures in patients with rotatory knee instability. Level of evidence V.

Area of the tibial insertion site of the anterior cruciate ligament as a predictor for graft size.

PURPOSE: To determine the distribution of different sizes of the area of the tibial insertion site among the population and to evaluate whether preoperative MRI measurements correlate with intraoperative findings to enable preoperative planning of the required graft size to cover the tibial insertion site sufficiently. The hypothesis was that the area of the tibial insertion site varies among individuals and that there is good agreement between MRI and intraoperative measurements. METHODS: Intraoperative measurements of the tibial insertion site were taken on 117 patients. Three measurements were taken in each plane building a grid to cover the tibial insertion site as closely as possible. The mean of the three measurements in each plane was used for determination of the area. Two orthopaedic surgeons, who were blinded to the intraoperative measurements, took magnetic resonance imaging (MRI) measurements of the area of the tibial insertion site at two different time points. RESULTS: The intraoperative measured mean area was 123.8 ± 21.5 mm2. The mean area was 132.8 ± 15.7 mm2 (rater 1) and 136.7 ± 15.4 mm2 (rater 2) when determined using MRI. The size of the area was approximately normally distributed. Inter-rater (0.89; 95 % CI 0.84, 0.92; p < 0.001) and intrarater reliability (rater 1: 0.97; 95 % CI 0.95, 0.98; p < 0.001; rater 2: 0.95; 95 % CI 0.92, 0.96; p < 0.001) demonstrated excellent test-retest reliability. There was good agreement between MRI and intraoperative measurement of tibial insertion site area (ICCs rater 1: 0.80; 95 % CI 0.71, 0.87; p < 0.001; rater 2: 0.87; 95 % CI 0.81, 0.91; p < 0.001). CONCLUSION: The tibial insertion site varies in size and shape. Preoperative determination of the area using MRI is repeatable and enables planning of graft choice and size to optimally cover the tibial insertion site. LEVEL OF EVIDENCE: III.

Gross, Arthroscopic, and Radiographic Anatomies of the Anterior Cruciate Ligament: Foundations for Anterior Cruciate Ligament Surgery.

The anterior cruciate ligament (ACL) is one of the more studied structures in the knee joint. It is not a tubular structure, but is much narrower in its midsubstance and broader at its ends, producing an hourglass shape. The ACL is composed of 2 functional bundles, the anteromedial and posterolateral bundles, that are named for their location of insertion on the anterior surface of the tibial plateau. Although the relative contribution in terms of total cross-sectional area of the ACL has been noted to be equal in regards to each bundle, dynamically these bundles demonstrate different properties for knee function.