Augmentation of triceps tendon repair with a bio-inductive collagen scaffold.

Two active, adult male patients, one with prior triceps rupture and direct repair, presented with traumatic rupture of the distal triceps tendon. MRI confirmed not only complete rupture with retraction in both, but also signal changes within the tendon, raising concern for healing potential and re-rupture. Surgical repair was performed using heavy, non-absorbable suture and suture anchors in the standard fashion, followed by augmentation with a bovine, bio-inductive collagen scaffold in order to increase tendon thickness and aid with healing capability. This technique is well described for rotator cuff repair augmentation but is a novel technique to the literature in the setting of triceps tendons repair. Both patients returned to full, preinjury activity without complication with sustained results at 3 and 3.5 years postoperatively.

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

A Case Report of Bilateral Lipoma Arborescens: An Unusual Consideration for Knee Pain.

Introduction: Lipoma arborescens (LAs) is a benign, intra-articular proliferation of fat cells in villous projections, creating a tree-like pattern on magnetic resonance imaging (MRI). The suprapatellar pouch is usually affected, and symptoms are typically gradual in nature, and patients may report painless swelling of the knee. Only ten cases of bilateral LA have been reported in the literature so far. Early recognition of this disease process and treatment may help to prevent prolonged symptoms and delays in care. Case Report: A 49-year-old female with bilateral knee pain and intermittent swelling for over 20 years presented to our clinic with complaints of bilateral knee pain and swelling. She had previous steroid injection but no relief. After MRI was obtained concerning for LA, a surgical discussion was had with the patient about arthroscopic removal. She elected to proceed with surgery and underwent arthroscopic debridement of both knees. At her follow-up at 6 months for the right knee and 2 months for the left knee, she had a significant improvement in pain and quality of life. Conclusion: LA of the knee is a rare condition, particularly bilateral, and in this patient, the diagnosis was missed for many years, and her definitive treatment was delayed. In her case, arthroscopic debridement of her bilateral LA proved to be a viable treatment option which significantly improved the patient's quality of life and function.

A Sleepwalking Patient Presenting with Concomitant ACL, PCL, and Meniscal Root Avulsion Fractures: A Case Report.

Introduction: Tibial-sided anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) avulsion fractures compose a rare subset of cruciate ligament injuries. Fixation strategies are mixed in the literature, particularly regarding the PCL, which has traditionally been addressed using an open approach. Case Report: A 41-year-old male sustained avulsion fractures of the tibial eminence involving the ACL, PCL, and posterior medial meniscal root through an unknown mechanism while sleepwalking. Surgical treatment comprised of entirely arthroscopic reduction and transtibial suture fixation. Only seven cases of combined ACL/PCL avulsion fracture have been reported and all but one utilized open fixation for at least the PCL and restricted weight-bearing postoperatively. Conclusion: This previously unreported triad of injury was successfully managed arthroscopically, negating a posterior approach to the knee. Early post-operative weight-bearing and aggressive range of motion aided in swift recovery and a favorable outcome.

Quadruple Hamstring Autograft Technique for Anterior Cruciate Ligament Reconstruction Reduces Allograft Augmentation.

Purpose: To assess the discrepancy in graft diameter between double- and quadruple-folded hamstring autografts and the need for allograft augmentation to obtain an adequate graft diameter during arthroscopic anterior cruciate ligament reconstruction. Methods: All patients undergoing anterior cruciate ligament reconstruction with hamstring autograft between 2017 and 2021 at a single institution by a single surgeon were identified. The surgeon changed from double-folded hamstring autograft to quadruple-folded hamstring autograft within the study period. Results: A total of 191 patients were identified, of whom 57 received double-folded autografts and 134 quadruple-folded autografts. Patient characteristics between cohorts were similar. Median double-folded graft size (7.5 mm; interquartile range, 7.0-8.0 mm) was significantly thinner than the quadruple-folded graft size (9 mm; interquartile range, 8.5-9.5 mm, P = .001). Quadruple-folded autograft was less likely to require an allograft augmentation than the double-folded autograft (0.7% vs 26.3%) (odds ratio 0.02; 95% confidence interval 0.00-0.16; P < .001). Conclusions: Quadruple-folded hamstring autograft provides a larger graft diameter and reduced need for allograft augmentation. Level of Evidence: Level III, retrospective comparative study.

Perceptual-Motor Efficiency and Concussion History Are Prospectively Associated With Injury Occurrences Among High School and Collegiate American Football Players.

BACKGROUND: After a sport-related concussion (SRC), the risk for lower extremity injury is approximately 2 times greater, and the risk for another SRC may be as much as 3 to 5 times greater. PURPOSE: To assess the predictive validity of screening methods for identification of individual athletes who possess an elevated risk of SRC. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Metrics derived from a smartphone flanker test software application and self-ratings of both musculoskeletal function and overall wellness were acquired from American high school and college football players before study participation. Occurrences of core or lower extremity injury (CLEI) and SRC were documented for all practice sessions and games for 1 season. Receiver operating characteristic and logistic regression analyses were used to identify variables that provided the greatest predictive accuracy for CLEI or SRC occurrence. RESULTS: Overall, there were 87 high school and 74 American college football players included in this study. At least 1 CLEI was sustained by 45% (39/87) of high school players and 55% (41/74) of college players. Predictors of CLEI included the flanker test conflict effect ≥69 milliseconds (odds ratio [OR], 2.12; 90% CI, 1.24-3.62) and a self-reported lifetime history of SRC (OR, 1.70; 90% CI, 0.90-3.23). Of players with neither risk factor, only 38% (29/77) sustained CLEI compared with 61% (51/84) of players with 1 or both of the risk factors (OR, 2.56; 90% CI, 1.50-4.36). SRC was sustained by 7 high school players and 3 college players. Predictors of SRC included the Overall Wellness Index score ≤78 (OR, 9.83; 90% CI, 3.17-30.50), number of postconcussion symptoms ≥4 (OR, 8.35; 90% CI, 2.71-25.72), the Sport Fitness Index score ≤78 (OR, 5.16; 90% CI, 1.70-15.65), history of SRC (OR, 4.03; 90% CI, 1.35-12.03), and the flanker test inverse efficiency ratio ≥1.7 (OR, 3.19; 90% CI, 1.08-9.47). CONCLUSION: Survey responses and smartphone flanker test metrics predicted greater injury incidence among individual football players classified as high-risk compared with that for players with a low-risk profile.

Blumensaat Line as a Prediction of Native Anterior Cruciate Ligament Length.

BACKGROUND: Graft-tunnel mismatch (GTM) is a condition in which the anterior cruciate ligament (ACL) graft is either too long or too short. GTM is particularly problematic when bone-patellar tendon-bone grafts are used because of a potential compromise in fixation of the bone plug on the tibia. HYPOTHESIS: The Blumensaat line (BL), a radiographic landmark representing the roof of the intercondylar fossa, will accurately approximate the native ACL (nACL) length and may aid in the prevention of GTM. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 130 patients (66 males, 64 females) underwent direct measurement of the nACL during knee arthroscopy. The lengths of the nACL and patellar ligament (PL) were measured intraoperatively, and BL length was measured on lateral knee radiographs. The nACL length was compared with PL and BL lengths to calculate the absolute difference (AD). Mean AD was calculated and used to determine mean percentage difference (MPD). Pearson correlation coefficients (CC) between BL, PL, and nACL length were calculated, along with inter- and intraobserver reliability coefficients for the measurement of BL. RESULTS: For male patients, the mean length of the nACL was 32.5 mm, BL was 30.4 mm, and PL was 49.2 mm. The AD between the BL and nACL was 2.4 ± 1.3 mm, MPD was 2.6% ± 1.9%, and CC was 0.88. The CC between the PL and nACL was 0.08. For female patients, the mean length of the nACL was 30.2 mm, BL was 27.5 mm, and PL was 44.4 mm. The AD between the BL and nACL was 2.7 ± 1.7 mm, MPD was 4.5% ± 2.4%, and CC was 0.93. The CC between the PL and nACL was 0.1. The inter- and intraobserver reliability coefficients for the measurement of BL were 0.86 and 0.83, respectively. CONCLUSION: A strong correlation was found between BL and nACL with a high inter- and intraobserver reliability. This correlation provides a simple and reliable method to closely approximate nACL length before reconstruction and may aid in the prevention of graft-tunnel mismatch.

Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To assess the current literature regarding the relationship between the shoulder and the spine with regard to (1) overlapping pain pathways; (2) differentiating history, exam findings, and diagnostic findings; (3) concomitant pathology and optimal treatments; and (4) cervical spine-based etiology for shoulder problems. METHODS: A systematic literature search was performed according to the guidelines set forth by the Cochrane Collaboration. Studies were included if they examined the clinical, anatomical, or physiological overlap between the shoulder and cervical spine. Two reviewers screened and selected full texts for inclusion according to the objectives of the study. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores. RESULTS: Out of 477 references screened, 76 articles were included for review and grouped into 4 main sections (overlapping pain pathways, differentiating exam findings, concomitant/masquerading pathology, and cervical spine-based etiology of shoulder pathology). There is evidence to suggest cervical spine pathology may cause shoulder pain and that shoulder pathology may cause neck pain. Specific examination tests used to differentiate shoulder and spine pathology are critical as imaging studies may be misleading. Diagnostic injections can be useful to confirm sources of pain as well as predicting the success of surgery in both the shoulder and the spine. There is limited evidence to suggest alterations in the relationship between the spine and the scapula may predispose to shoulder impingement or rotator cuff tears. Moreover, cervical neurological lesions may predispose patients to developing rotator cuff tears. The decision to proceed with shoulder or spine surgery first should be delineated with careful examination and the use of shoulder and spine diagnostic injections. CONCLUSION: Shoulder and spine pathology commonly overlap. Knowledge of anatomy, pain referral patterns, shoulder kinematics, and examination techniques are invaluable to the clinician in making an appropriate diagnosis and guiding treatment. In this review, we present an algorithm for the identification and treatment of shoulder and cervical spine pathology.

Treatment of Ipsilateral Femoral Neck and Shaft Fractures With Cannulated Screws and Antegrade Reconstruction Nail.

Ipsilateral femoral neck and shaft fractures are challenging injuries, and there are different fixation options but no consensus on a superior construct. Our preferred method is cannulated screw fixation of the femoral neck and antegrade reconstruction nailing of the shaft. Compressive fixation of the femoral neck fracture with cancellous lag screws followed by reconstruction nail placement provides compressive fixation and fixed angle support of the neck fracture while allowing for more optimal treatment of femoral shaft fractures at or above the isthmus. The purpose of this submission is to describe the surgical decision-making, surgical technique, and all surgically related complications of this technique.

Reamer-Irrigator-Aspirator Multiuse Application in the Treatment of Chronic Osteomyelitis.

INTRODUCTION: The treatment of chronic intramedullary infection of the long bones relies on microbe-specific antibiotics in conjunction with surgical removal of infected necrotic material. We discuss the use of reamer-irrigator-aspirator(RIA) for debridement of the intramedullary canal instead of conventional reaming techniques. This is the first case report to explore the use of RIA for osteomyelitis. CASE REPORT: We discuss the use of the RIA in treatment of a 26-year-old female presenting with chronic osteomyelitis of the left distal femoral shaft. She had normalization of infection laboratories at 6 weeks and complete resolution of symptoms at 3 months and was released at 6 months. CONCLUSION: Recent exploration of the RIA system's (Synthes®, Inc. West Chester, Philadelphia) multipurpose applications has indicated use in long bone debridement. While further exploration and high-quality studies are needed to make robust claims of efficacy, we believe that the use of RIA in the context of chronic osteomyelitis is a superior alternative to conventional reaming techniques.

Revision Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament injuries continue to occur despite efforts to educate pitchers, coaches, and families at the amateur and professional levels about pitch counts, mechanics, and injury prevention. Although the data on the incidence of ulnar collateral ligament reconstructions are inconclusive, an increase in these reconstructions may mean a corresponding increase in the number of reconstruction failures and revision reconstruction surgeries. Less is known about the outcomes of revision ulnar collateral ligament reconstruction; not unexpectedly, early results are not as promising as those observed with primary reconstruction. In response, interest in revision techniques, rehabilitation, and outcomes of revision ulnar collateral ligament reconstruction surgeries has grown.

A Case Report: Bilateral Patella Stress Fractures in a Collegiate Gymnast.

INTRODUCTION: The overuse and repetitive loading of a bone cause a stress fracture, commonly occurring in the weight-bearing structures of the lower extremities of athletes, but rarely the patella. Patella stress fractures are an extremely rare occurrence. Müller first described a patella stress fracture in 1943; however, we could find <15 reported cases in literature since that time. Thus, some uncertainty exists as to the proper treatment of this very rare condition. CASE REPORT: A female collegiate gymnast presented with 2-months of anterior knee pain, and initial radiographs revealed a non-displaced patella stress fracture. An magnetic resonance imaging (MRI)was obtained which confirmed the diagnosis and ruled out any patellar tendon or intra-articular pathology. The patient was treated with immobilization, vitamin supplementation, and low-intensity pulsed ultrasound therapy. At 3 months, the patient had complete healing of her fracture and returned to full competition in her sport. After approximately 1year of returning to sport, she unfortunately developed a patella stress fracture in her contralateral knee confirmed by radiographs and MRI. She received the same conservative management plan as before, and at 3 months, she was pain free and returned to full competition in her sport. She is now 3 years from injury on the right knee and 2 years from injury on the left knee and continues to compete at the Division I collegiate level without pain. CONCLUSION: This case report illustrates how patella stress fractures may be successfully treated conservatively, even when presenting with a radiographic fracture line. This varies from other forms of stress fractures where surgical fixation is recommended once radiographic fracture line is noted. This is likely due to the abundant blood supply in the region, which allows for healing.

Biomechanical tensile strength analysis for medial patellofemoral ligament reconstruction.

BACKGROUND: Medial patellofemoral ligament (MPFL) reconstruction is a surgery for acute and chronic dislocating patella. Several surgical techniques have been described. No biomechanical study has compared suture anchors, interference screws, and suspensory cortical fixation for MPFL reconstruction using human gracilis allograft. METHODS: Twelve human cadaver knees were used for the analysis of five MPFL reconstruction techniques on the femur (F) and patella (P): suspensory cortical (SC), interference screw (IS) and suture anchor (SA) fixation (SC-F/SC-P, SC-F/IS-P, SC-F/SA-P, IS-F/SC-P, IS-F/IS-P). Each method was examined six times, each using a new human gracilis allograft. The force necessary for 50% patellar displacement and 100% patellar displacement were recorded for each method. Additionally, we examined the peak force to fixation failure for all methods. Patella dislocation or loss of fixation was considered failure. RESULTS: SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P required force to failure greater than that of the native MPFL. The SC-F/IS-P required the largest force to failure. The SC-F/SA-P fixation technique required significantly less force to failure (P<0.05) than the native MPFL and significantly less force to failure (P<0.05) than all four other fixation techniques. All methods of fixation employing an interference screw failed secondary to graft pullout at the interference screw-bone interface. Methods employing suture anchors and two suspensory cortical fixations failed at the graft-suture anastomosis. CONCLUSION: SC-F/SC-P, IS-F/SC-P, and SC-F/IS-P fixations were found to be stronger than the native MPFL, with the strongest being SC-F/IS-P.

Viable Stem Cells Are in the Injury Effusion Fluid and Arthroscopic Byproducts From Knee Cruciate Ligament Surgery: An In Vivo Analysis.

PURPOSE: To examine the number of viable stem cells contained in the postinjury effusion fluid and the waste byproducts of arthroscopic cruciate ligament surgery. METHODS: This study included patients older than 18 years of age with acute (<5 weeks old) cruciate ligament injuries requiring arthroscopic surgery. The postinjury effusion fluid (effusion fluid), fat pad and cruciate ligament stump debridement tissue (byproduct tissue), and arthroscopic fluid collected during fat pad and/or stump debridement (byproduct fluid) were collected at the time of surgery from 30 individuals. Specimens were analyzed, investigating cell viability, nucleated cell counts, cell concentrations, colony-forming unit assays, and flow cytometry. Samples from the first 20 individuals were collected in small specimen containers, and samples from the last 10 individuals were collected in larger specimen containers. RESULTS: Cells of the injury effusion exhibited the greatest viability (86.4 ± 1.31%) when compared with the small volume harvest byproduct tissue (50.2 ± 2.5%, P = .0001), small volume harvest byproduct fluid (48.8 ± 1.88%, P = .0001), large volume harvest byproduct tissue (70.1 ± 5.6%, P = .0001), and large volume harvest byproduct fluid (60.3 ± 3.41%, P = .0001). The culture analysis of fibroblast colony-forming units found on average 1916 ± 281 progenitor cells in the effusion fluid, 2488 ± 778 progenitor cells in the byproduct tissue, and 2357 ± 339 progenitor cells in the byproduct fluid. Flow cytometry confirmed the presence of immature cells and the presence of cells with markers typically expressed by known stem cell populations. CONCLUSIONS: Viable stem cells are mobilized to the postinjury effusion at the time of cruciate ligament injury and can be found in the byproduct waste of cruciate ligament surgery. CLINICAL RELEVANCE: The methodology around effusion fluid and byproduct tissue capture during cruciate ligament surgery should be investigated further. Cell amounts available from these tissues with current technologies are not sufficient for immediate evidence-based clinical application.

Magnetic resonance imaging-based classification for ulnar collateral ligament injuries of the elbow.

BACKGROUND: Magnetic resonance imaging (MRI) arthrography has been considered the gold standard for imaging ulnar collateral ligament (UCL) injuries. No classification system has been described for UCL tears to help discuss and guide treatment options. We propose that an MRI-based UCL classification system would correlate with valgus laxity and help predict surgical management. METHODS: The MRIs from 240 patients who underwent UCL reconstruction were reviewed and classified according to a system based on severity and location of the UCL injury. Bilateral elbow valgus stress radiographs were used to compare the amount of valgus laxity associated with each grade of UCL injury. Additional data from the imaging review included intraligamentous calcifications, T-sign presence, and a newly described "vacuum sign." RESULTS: The amount of valgus stress opening increased with the classification severity as follows: type I, 0.13 mm; type II, 0.20 mm; type III, 0.63 mm; and type IV, 0.76 mm. CONCLUSIONS: We propose a new classification for UCL injuries based on MRI findings that helps predict valgus laxity, improve communication, and guide treatment for UCL pathology in throwing athletes.

How much valgus instability can be expected with ulnar collateral ligament (UCL) injuries? A review of 273 baseball players with UCL injuries.

BACKGROUND: The dynamic stress radiograph of the elbow was designed to help the clinician better define valgus laxity and instability in the throwing athlete. However, no large study has quantified the amount of laxity in athletes with ulnar collateral ligament (UCL) injuries. We hypothesized that valgus stress radiographs in patients with UCL injuries will demonstrate a significantly greater amount of valgus stress opening of the dominant elbows compared with the nondominant elbow. METHODS: Bilateral elbow static and stress radiographs that were taken as part of our standard preoperative workup were retrospectively reviewed in 273 baseball players who had undergone UCL reconstruction. The valgus stress radiograph protocol used a Telos stress device (SE 2000) to provide 15 daN of stress in a standardized fashion. RESULTS: The thrower's elbow with a UCL injury opened 0.4 mm more than the uninjured side. Those with complete tears (N = 76), determined by magnetic resonance imaging findings, opened 0.6 mm on average, which was significantly more than in those with partial tears (N = 150), which opened an average of 0.1 mm. CONCLUSION: Stress radiography of the dominant elbow in baseball players with UCL injuries showed it to have 0.4 mm greater opening compared with the nondominant arm. Larger average openings (0.6 mm) can be expected with full-thickness UCL tears compared with partial-thickness tears (0.1 mm). This suggests that large openings on stress radiography may not be a critical component for predicting who will require surgical reconstruction for UCL injuries but may be more useful in differentiating complete from partial tears.

Ulnar collateral ligament injuries in the throwing athlete.

Repetitive valgus forces on the throwing elbow place significant stress on that joint. This stress can cause structural damage and injury to the ulnar collateral ligament. Many acute injuries of the throwing elbow are caused by repetitive chronic wear. Although much work has been done on injury prevention in youth who are pitchers, overuse injury in throwing sports constitutes an epidemic. Failing nonsurgical management, ulnar collateral ligament reconstruction is a viable option to return the throwing athlete to competition.

Suprascapular nerve entrapment due to a stenotic foramen: a variant of the suprascapular notch.

Suprascapular nerve (SSN) entrapment is an uncommon cause of posterior shoulder pain. Entrapment can be relieved arthroscopically in some cases.

Patellar contact pressure changes with anteromedialization of tibial tubercle, lateral release, and new technique for elevating quadriceps tendon: a biomechanical study.

Anteromedialization of the tibial tubercle has been shown to unload contact pressure in the distal and lateral region. No study has evaluated pressures after anteriorization of the quadriceps tendon as a way to decrease contact pressures at the patella. In this controlled laboratory study, six cadaveric knees were tested by placing Fuji pressure film to measure patellar contact area, pressure, and force at 0°, 30°, 60°, and 90° in the intact state and after anteromedialization of the tibial tubercle, lateral release, and anteriorization of the quadriceps tendon. The addition of anteriorizing the quadriceps tendon decreased patellar contact area and force in the distal and lateral patella more than anteromedialization of the tibial tubercle and lateral release alone, though not in the proximal aspects of the patella as hypothesized.

Treatment of a symptomatic forearm muscle herniation with a mesh graft.

Symptomatic muscle herniations are an unusual cause of upper extremity pain in the athlete that is rarely reported in the literature. Out of 18 reported cases of upper extremity herniations, only 3 were caused by strenuous exertion. This article describes a successful repair of a 21-year-old rock climber's ventral forearm herniation with polypropylene mesh.