Deltopectoral Approach for Arthroplasty After Early Failed Proximal Humerus Fixation Via Deltoid Split Heals Uneventfully: A Case Report.

CASE: A 57-year-old male carpenter sustained a 2-part displaced proximal humerus fracture of his nondominant arm with varus angulation after a fall down the stairs. Fifteen days postinjury, the patient underwent direct reduction and surgical fixation with an intramedullary cage implant via a deltoid split approach. Nine days postsurgery, the patient presented to the emergency department after another fall with failed fixation. Two weeks after index surgery, he was revised to a reverse total shoulder arthroplasty via a deltopectoral approach and healed both incisions uneventfully. CONCLUSION: A deltopectoral approach performed acutely after a deltoid split approach for fracture can heal uneventfully.

A comparison of the Functional Movement ScreenTM and the Landing Error Scoring System: A cohort study.

The Functional Movement Screen (FMSTM) is a nonspecific movement pattern assessment while the Landing Error Scoring System (LESS) is a screen for movement patterns associated with lower extremity injury. The purpose of this study was to determine if the LESS and FMSTM are correlated or if they can be used as complementary assessments of preseason injury risk for anterior cruciate ligament injury. METHODS: FMSTM and LESS were used to conduct a cohort study of 126 male National Collegiate Athletic Association Division IA football players. One hundred and eleven players met the criteria for inclusion during data review. At risk and not at risk LESS scores of players and FMSTM exercise score status were compared using Welch's t-test. Associations between FMSTM composites and LESS scores were evaluated using linear regression. RESULTS: The average LESS score was 5.51±1.34, and the average composite FMSTM score was 11.77±2.13 (max=15). A poor FMSTM squat score (≤1 or asymmetry present) was associated with a higher LESS score (P<0.001). No other FMSTM individual exercise score was associated with an at-risk LESS score (P>0.05). Composite FMSTM score was loosely associated with the LESS score (R-squared=0.0677, P=0.006). Prior history of an ACL injury and player position were not associated with LESS score on multivariate regression (P>0.05). CONCLUSIONS: The LESS and FMSTM are not well correlated and may serve as complementary assessments for preseason injury risk. LEVEL OF EVIDENCE: Level III.

Age Influences Biomechanical Changes After Participation in an Anterior Cruciate Ligament Injury Prevention Program.

BACKGROUND: The prevalence of anterior cruciate ligament (ACL) injuries increases during maturation and peaks during late adolescence. Previous studies suggested an age-related association between participation in injury prevention programs and reduction of ACL injury. However, few studies have investigated differences in biomechanical changes after injury prevention programs between preadolescent and adolescent athletes. Purpose/Hypothesis: The purpose was to investigate the influence of age on the effects of the FIFA Medical and Research Centre (F-MARC) 11+ injury prevention warm-up program on differences in biomechanical risk factors for ACL injury between preadolescent and adolescent female soccer players. It was hypothesized that the ACL injury risk factors of knee valgus angle and moment would be greater at baseline but would improve more after training for preadolescent athletes than adolescent athletes. It was further hypothesized that flexor-extensor muscle co-contraction would increase after training for both preadolescent and adolescent athletes. STUDY DESIGN: Controlled laboratory study. METHODS: Institutional Review Board-approved written consent was obtained for 51 preadolescent female athletes aged 10 to 12 years (intervention: n = 28, 11.8 ± 0.8 years; control: n = 23, 11.2 ± 0.6 years) and 43 adolescent female athletes aged 14 to 18 years (intervention: n = 22, 15.9 ± 0.9 years; control: n = 21, 15.7 ± 1.1 years). The intervention groups participated in 15 in-season sessions of the F-MARC 11+ program 2 times per week. Pre- and postseason motion capture data were collected during 4 tasks: preplanned cutting, unanticipated cutting, double-legged jump, and single-legged jump. Lower extremity joint angles and moments were estimated through biomechanical modeling. Knee flexor-extensor muscle co-contraction was estimated from surface electromyography. RESULTS: At baseline, preadolescent athletes displayed greater initial contact and peak knee valgus angles during all activities when compared with the adolescent athletes, but knee valgus moment was not significantly different between age groups. After intervention training, preadolescent athletes improved and decreased their initial contact knee valgus angle (-1.24° ± 0.36°; P = .036) as well as their peak knee valgus moment (-0.57 ± 0.27 percentage body weight × height; P = .033) during the double-legged jump task, as compared with adolescent athletes in the intervention. Compared with adolescent athletes, preadolescent athletes displayed higher weight acceptance flexor-extensor muscle co-contraction at baseline during all activities ( P < .05). After intervention training, preadolescent athletes displayed an increase in precontact flexor-extensor muscle co-contraction during preplanned cutting as compared with adolescent intervention athletes (0.07 ± 0.02 vs -0.30 ± 0.27, respectively; P = .002). CONCLUSION: The F-MARC 11+ program may be more effective at improving some risk factors for ACL injury among preadolescent female athletes than adolescent athletes, notably by reducing knee valgus angle and moment during a double-legged jump landing. CLINICAL RELEVANCE: ACL prevention programs may be more effective if administered early in an athlete's career, as younger athletes may be more likely to adapt new biomechanical movement patterns.

Medial Patellofemoral Ligament Repair Versus Reconstruction for Recurrent Patellar Instability: Two-Year Results of an Algorithm-Based Approach.

BACKGROUND: Patellar instability remains a challenging problem for both the patient and surgeon. Medial patellofemoral ligament (MPFL) repair has historically had poor results, and due to this, there is currently a trend toward reconstruction. PURPOSE/HYPOTHESIS: This study was undertaken to investigate experience with repair versus reconstruction of the MPFL using a multifactorial treatment algorithm approach. Our hypothesis was that there will be no significant difference in outcome scores between patients in the MPFL repair and reconstruction groups. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 24 patients with recurrent (≥2) lateral patellar dislocations were included. All had failed nonoperative treatment for more than 6 months, and all were observed for a minimum of 2 years. First, magnetic resonance imaging (MRI) was used to find the location of the MPFL tear. A tilt test was used to determine whether a lateral retinacular lengthening was required to allow the patella to have neutral tilt. If the MRI showed a tibial tubercle-trochlear groove (TT-TG) distance greater than 20 mm, a tibial tubercle osteotomy (TTO) was recommended. An MPFL reconstruction was performed if the entire ligament was inadequately visualized on MRI or if it was torn from both insertion sites. Failure was defined as recurrent lateral patellar instability after surgery. As a secondary outcome measure, Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm score, and Tegner score were calculated. RESULTS: All patients were evaluated with a mean follow-up of 51 months (range, 25-79 months). Sixteen patients initially underwent MPFL repair, 8 underwent reconstruction, and 3 also underwent TTO. MPFL reconstructions were performed in all patients who underwent TTO. One MPFL repair was to the anatomic femoral origin and 15 were to the patellar insertion corresponding to the site of tearing on MRI. A lateral retinacular lengthening was performed in 21 patients. There was 1 failure in the repair group (6%) and none in the reconstruction group. However, the patient who failed had a TT-TG distance of 26 mm but refused a TTO. She subsequently underwent revision with a TTO and MPFL reconstruction and did not have any further instability events. There were no significant differences between groups for any of the secondary outcome scores. CONCLUSION: Using an algorithm-based approach, MPFL repair or reconstruction may lead to clinically acceptable results at 2-year follow-up.

The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review.

PURPOSE: There is a wide array of device modalities available for post-operative treatment following arthroscopic knee surgery; however, it remains unclear which types and duration of modality are the most effective. This systematic review aimed to investigate the efficacy of device modalities used following arthroscopic knee surgery. METHODS: A systematic search of the literature was performed on: PubMed; Scopus; MEDLINE; EMBASE; PEDro; SportDiscus; and CINAHL databases (1995-2015) for clinical trials using device modalities following arthroscopic knee surgery: cryotherapy, continuous passive motion (CPM), neuromuscular electrical stimulation (NMES), surface electromyographic (sEMG) biofeedback and shockwave therapy (ESWT). Only level 1 and 2 studies were included and the methodological quality of studies was evaluated using Physiotherapy Evidence Database (PEDro) scores. Outcome measures included: muscle strength, range of motion, swelling, blood loss, pain relief, narcotic use, knee function evaluation and scores, patient satisfaction and length of hospital stay. RESULTS: Twenty-five studies were included in this systematic review, nineteen of which found a significant difference in outcomes. For alleviating pain and decreasing narcotic consumption following arthroscopic knee surgery, cryocompression devices are more effective than traditional icing alone, though not more than compression alone. CPM does not affect post-operative outcomes. sEMG biofeedback and NMES improve quadriceps strength and overall knee functional outcomes following knee surgery. There is limited evidence regarding the effects of ESWT. CONCLUSION: Cryotherapy, NMES and sEMG are recommended for inclusion into rehabilitation protocols following arthroscopic knee surgery to assist with pain relief, recovery of muscle strength and knee function, which are all essential to accelerate recovery. CPM is not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion, and additional studies are required to investigate the effects of ESWT. LEVEL OF EVIDENCE: II.

Incidence and Epidemiology of Foot and Ankle Injuries in Elite Collegiate Athletes.

BACKGROUND: Foot and ankle injuries are increasing in competitive professional and collegiate athletics. Many of these injuries result in considerable missed time from sports and often require surgical intervention. To develop and implement effective practice participation strategies, return-to-play protocols, and injury prevention programs, an understanding of injury trends and epidemiology is vital. PURPOSE: This study aimed to evaluate the incidence of foot and ankle injuries in elite athletes participating in 37 sports at a single National Collegiate Athletics Association (NCAA) Division 1 institution. STUDY DESIGN: Descriptive epidemiological study. METHODS: We evaluated the injury records of all varsity sports at a single NCAA Division 1 athletics program, including 1076 athletes participating in 37 sports. Detailed injury data were prospectively collected in a secure electronic database over a 2-year period. We reviewed the database for all foot/ankle injuries. Inclusion criteria were any foot/ankle injury that was sustained during an NCAA-sanctioned event and subsequently received medical treatment. Independent variables included athlete and injury demographics, missed days, physician visits, imaging results, and whether the injury required surgery. Injury incidence, relative frequency distributions, and sample proportions were dependent metrics for this investigation. RESULTS: During the study period, a total of 3861 total musculoskeletal injuries were recorded. There were 1035 foot/ankle injuries (27%). Of all foot/ankle injuries, 21% (218 of 1035) caused the athlete to miss at least 1 day of participation, with an average of 12.3 days of time loss from sport. Furthermore, 27% of athletes with foot/ankle injuries were referred for office evaluation by a physician, and 84% of these required radiologic imaging. The overall injury incidence rate was 3.80 per 1000 athlete-exposures (AEs). The 4 sports with the highest incidence rate (>75th percentile) were women's gymnastics, women's cross-country, women's soccer, and men's cross country. The most frequently occurring foot/ankle injuries were ankle ligament injuries, tendinopathies or fasciopathies, and bone stress injuries. CONCLUSION: The prevalence of foot/ankle injury in a large NCAA Division 1 athletics program was 27% of total musculoskeletal injuries over a 2-year period, with 21% of these injuries resulting in missed time. There were significantly higher foot and ankle injury incidence rates and more missed time in female athletes and women's sports.

Biomechanical Effects of an Injury Prevention Program in Preadolescent Female Soccer Athletes.

BACKGROUND: Anterior cruciate ligament (ACL) injuries are common, and children as young as 10 years of age exhibit movement patterns associated with an ACL injury risk. Prevention programs have been shown to reduce injury rates, but the mechanisms behind these programs are largely unknown. Few studies have investigated biomechanical changes after injury prevention programs in children. Purpose/Hypothesis: To investigate the effects of the F-MARC 11+ injury prevention warm-up program on changes to biomechanical risk factors for an ACL injury in preadolescent female soccer players. We hypothesized that the primary ACL injury risk factor of peak knee valgus moment would improve after training. In addition, we explored other kinematic and kinetic variables associated with ACL injuries. STUDY DESIGN: Controlled laboratory study. METHODS: A total of 51 female athletes aged 10 to 12 years were recruited from soccer clubs and were placed into an intervention group (n = 28; mean [±SD] age, 11.8 ± 0.8 years) and a control group (n = 23; mean age, 11.2 ± 0.6 years). The intervention group participated in 15 in-season sessions of the F-MARC 11+ program (2 times/wk). Pre- and postseason motion capture data were collected during preplanned cutting, unanticipated cutting, double-leg jump, and single-leg jump tasks. Lower extremity joint angles and moments were estimated using OpenSim, a biomechanical modeling system. RESULTS: Athletes in the intervention group reduced their peak knee valgus moment compared with the control group during the double-leg jump (mean [±standard error of the mean] pre- to posttest change, -0.57 ± 0.27 %BW×HT vs 0.25 ± 0.25 %BW×HT, respectively; P = .034). No significant differences in the change in peak knee valgus moment were found between the groups for any other activity; however, the intervention group displayed a significant pre- to posttest increase in peak knee valgus moment during unanticipated cutting ( P = .044). Additional analyses revealed an improvement in peak ankle eversion moment after training during preplanned cutting ( P = .015), unanticipated cutting ( P = .004), and the double-leg jump ( P = .016) compared with the control group. Other secondary risk factors did not significantly improve after training, although the peak knee valgus angle improved in the control group compared with the intervention group during unanticipated cutting ( P = .018). CONCLUSION: The F-MARC 11+ program may be effective in improving some risk factors for an ACL injury during a double-leg jump in preadolescent athletes, most notably by reducing peak knee valgus moment. CLINICAL RELEVANCE: This study provides motivation for enhancing injury prevention programs to produce improvement in other ACL risk factors, particularly during cutting and single-leg tasks.

The effect of foot landing position on biomechanical risk factors associated with anterior cruciate ligament injury.

BACKGROUND: Identification of biomechanical risk factors associated with anterior cruciate ligament (ACL) injury can facilitate injury prevention. The purpose of this study is to investigate the effects of three foot landing positions, "toe-in", "toe-out" and "neutral", on biomechanical risk factors for ACL injury in males and females. The authors hypothesize that 1) relative to neutral, the toe-in position increases the biomechanical risk factors for ACL injury, 2) the toe-out position decreases these biomechanical risk factors, and 3) compared to males, females demonstrate greater changes in lower extremity biomechanics with changes in foot landing position. METHODS: Motion capture data on ten male and ten female volunteers aged 20-30 years (26.4 ± 2.50) were collected during double-leg jump landing activities. Subjects were asked to land on force plates and target one of three pre-templated foot landing positions: 0° ("neutral"), 30° internal rotation ("toe-in"), and 30° external rotation ("toe-out") along the axis of the anatomical sagittal plane. A mixed-effects ANOVA and pairwise Tukey post-hoc comparison were used to detect differences in kinematic and kinetic variables associated with biomechanical risk factors of ACL injury between the three foot landing positions. RESULTS: Relative to neutral, landing in the toe-in position increased peak hip adduction, knee internal rotation angles and moments (p < 0.01), and peak knee abduction angle (p < 0.001). Landing in the toe-in position also decreased peak hip flexion angle (p < 0.001) and knee flexion angle (p = 0.023). Landing in the toe-out position decreased peak hip adduction, knee abduction, and knee internal rotation angles (all p < 0.001). Male sex was associated with a smaller increase in hip adduction moment (p = 0.043) and knee internal rotation moment (p = 0.032) with toe-in landing position compared with female sex. CONCLUSIONS: Toe-in landing position exacerbates biomechanical risk factors associated with ACL injury, while toe-out landing position decreases these factors.