Examination of Early Functional Recovery After ACL Reconstruction: Functional Milestone Achievement and Self-Reported Function.

BACKGROUND: Few studies have documented early functional recovery after anterior cruciate ligament (ACL) reconstruction. PURPOSE: To quantify the time to early functional milestone achievement and change in function over 12 weeks after ACL reconstruction and to identify demographic characteristic predictors of the outcomes. STUDY DESIGN: Prospective, longitudinal, observational study. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 182 patients (95 females, 87 males; mean ± SD age, 28 ± 12 years; mean ± SD body mass index [BMI], 25 ± 4 kg/m2) who received primary, unilateral, ACL reconstruction were included. Testing occurred before surgery as well as 1, 2, 4, 8, and 12 weeks postsurgery. Outcomes included demographic characteristics, self-reported functional milestone achievements and responses on the Short Musculoskeletal Function Assessment (SMFA) questionnaire. Time to functional milestone achievement was calculated, and patients were categorized into "faster" or "prolonged" recovery groups based on the median value. Longitudinal change in SMFA subscale scores (daily activities and mobility) as well as demographic predictors of functional recovery group assignment and postsurgical change in SMFA subscale scores were examined. RESULTS: Median time for discontinuing narcotic pain medication was 9 days, while that for discontinuing crutches was 15 days. Time to return to work occurred at a median of 11 days, return to school at 7 days, and return to driving at 11 days. Both SMFA subscale scores significantly decreased (improved) over time, with the greatest change occurring between 1 and 4 weeks postsurgery. The demographic predictor of faster functional recovery for discontinuation of narcotic pain medication was surgery with allograft; those for return to work were higher age, male sex, decreasing BMI, and sedentary/light occupational demand; and those for return to driving were higher age, male sex, and surgery on the left side of the body. CONCLUSION: Functional recovery occurs rapidly over the first month after ACL reconstruction for most patients. Nonmodifiable demographic characteristics may influence recovery time for specific functional milestones. CLINICAL RELEVANCE: Results can be used to counsel patients on early functional recovery after ACL reconstruction.

Return to Play After Multiligament Knee Injuries in National Football League Athletes.

BACKGROUND:: Return to play (RTP) of National Football League (NFL) athletes after isolated anterior cruciate ligament (ACL) tears has been reported. However, no studies have reported on RTP of NFL athletes after multiligament knee injuries. HYPOTHESES:: NFL athletes with multiligament knee injuries have lower RTP rates and longer recoveries than athletes with isolated ACL tears. Second, athletes with ACL and medial collateral ligament (MCL) injuries will have higher RTP rates and shorter time to RTP than athletes with an ACL tear and posterolateral corner involvement. STUDY DESIGN:: Retrospective cohort study. LEVEL OF EVIDENCE:: Level 4. METHODS:: Publicly available NFL injury data were reviewed for all multiligament knee injuries incurred between 2000 and 2016 with RTP information. Athletes were excluded if RTP was limited for reasons unrelated to the injury. Extracted data included type of injury, RTP, time to RTP (days), number and percentage of games played, and performance. RESULTS:: A total of 50 NFL athletes with multiligament knee injuries met inclusion and exclusion criteria. The overall RTP rate was 64.0%. Athletes with ACL/MCL tears had an RTP rate of 70.8%, whereas athletes with ACL and posterior collateral ligament/lateral collateral ligament (PCL/LCL) tears had an RTP rate of 55.6% ( P = 0.26). Mean time to RTP for all 50 athletes was 388.71 ± 198.52 days. The mean time to RTP for athletes with ACL/MCL injuries was 305.1 ± 58.9 days, compared with 459.2 ± 245.1 days ( P = 0.004) and 609.3 ± 183.1 days ( P < 0.0001) for those with combined ACL and PCL/LCL injuries and frank knee dislocations, respectively. Athletes with ACL/MCL injuries were more likely to return to prior performance level (43.5%) than those with ACL and PCL/LCL injuries (18.5%) ( P < 0.001). CONCLUSION:: The RTP rate for athletes with multiligament knee injuries is significantly less than the RTP rate for athletes with isolated ACL tears. In addition, athletes with ACL and MCL tears have a higher RTP rate, a significantly shorter time to RTP, and a greater likelihood of returning to prior performance than athletes with ACL and PCL/LCL tears. CLINICAL RELEVANCE:: Multiligament knee injuries significantly affect the ability of a football player to return to sport. ACL and MCL tears are associated with better RTP prognosis compared with ACL and PCL/LCL tears.

Isolated fibular collateral ligament injuries in athletes.

Isolated injuries to the fibular collateral ligament (FCL) are rare. Although recent data suggest that operative and nonoperative treatment can both result in good functional outcomes, limited data exist on return to play for nonoperative treatment of FCL injuries and the value of magnetic resonance imaging in predicting prognosis. In this article, we present a review of the current literature and present a focused review regarding the diagnosis, treatment, and prognosis of FCL injuries, as well as the senior authors experience and a cohort of National Football League players. Magnetic resonance imaging can be useful to predict the length of disability in isolated FCL injuries, and both operative and nonoperative management of isolated FCL injuries successfully resulted in return to play in all players in several series of elite athletes; however, nonoperative management may result in faster return to play. Evaluation of potential concomitant injury is imperative in treatment of FCL injuries.

Part I: An anatomic-based tunnel in the fibular head for posterolateral corner reconstruction using magnetic resonance imaging.

PURPOSE: Currently, there are no studies that clearly define a method for the placement of the fibular tunnel between the fibular collateral ligament (FCL) and popliteofibular ligament (PFL) insertions when performing an anatomic-based posterolateral corner reconstruction. The purpose of this study was to use magnetic resonance-based anatomic landmarks to describe the orientation of a fibular tunnel between the FCL and PFL insertions. METHODS: Magnetic resonance imaging (MRI) of 105 patients with normal posterolateral corner knee anatomy was identified by a musculoskeletal radiologist, and the FCL and popliteofibular insertions were labelled. Three experienced providers independently evaluated the images. In the axial plane, the Cobb angle of a fibular tunnel from the FCL to the popliteofibular insertion was measured using the tibial tubercle as a reference. In the sagittal plane, the same tunnel was measured in reference to the lateral tibial plateau. RESULTS: In the axial plane, the average Cobb angle for an anatomic-based fibular tunnel was 48.1° ± 10.7° (ICC(2,1) = 0.76, p < 0.01) externally rotated to the tibial tubercle. In the sagittal plane, the average Cobb angle for an anatomic-based fibular tunnel was 59.8° ± 11.9° (ICC(2,1) = 0.81, p < 0.01) cranial, referenced from the lateral tibial plateau. The average length of the fibular tunnel was 2.0 ± 0.4 cm (ICC(2,1) = 0.78, p < 0.01), at the point of the fibular insertion. The distance from the midpoint of the fibular tunnel to the posterolateral wall of the fibular head was 0.8 ± 0.2 cm (ICC(2,1) = 0.63, p < 0.01). CONCLUSIONS: The results of this study suggest that MRI can be used to identify the orientation between the FCL and PFL insertions to create an anatomic-based fibular tunnel, which is 50° externally rotated from the tibial tubercle in the axial plane and placed in a cranial direction of 60° relative to the lateral joint line. The clinical relevance of this study is that this information may aid surgeons in placing a fibular tunnel connecting the FCL and PFL insertions. LEVEL OF EVIDENCE: IV.

Patient-specific instrumentation and return to activities after unicondylar knee arthroplasty.

In the past decade, there has been a major increase in the use of unicompartmental knee arthroplasty (UKA) as surgical techniques have been refined and patient selection has improved. UKAs now account for 8% to 10% of knee arthoplasty procedures. Recent studies have suggested excellent medium- and long-term results of UKA. Overall, results have shown 85% to 90% survivorship at 10 years, with 90% of patients reporting good to excellent subjective and objective outcomes. Recent studies suggest that unicompartmental arthroplasty allows a high percentage of patients to return to presurgical sport and activity participation.

Injuries in professional football: current concepts.

Professional football is one of the most popular sports in the United States. There is a common constellation of injuries that are seen frequently. Much attention has been focused on concussions and their long-term outcomes in this population. Other common causes of morbidity include cervical spine injuries, knee injuries including anterior cruciate ligament and other ligamentous injuries, ankle sprains, and medical issues including cardiac and sickle trait. Several recent studies have focused on hip impingement and hamstring injuries, among others, as sources of missed playing time as well. This review describes some of the frequently seen injuries and medical issues in professional football players. Proper management of both medical disease and on-field injuries can reduce morbidity and may lead to faster return to play and reduced risk of future injury.

Ischial apophyseal avulsions: proximal hamstring repair with bony fragment excision.

BACKGROUND: Avulsion injury of the hamstring muscles from their origin on the ischium is an uncommon injury. In persons aged 14 to 25 years, such an avulsion may include detachment of an epiphyseal fragment at the growth plate of the ischial apophysis. The literature suggests that surgery is not necessary unless there is a large displacement of the fragment. The objective of this report is to present evidence that treatment planning should be based on symptoms, regardless of displacement. METHODS: Between July 1998 and July 2002, 3 consecutive patients with avulsion of the immature ischial apophysis were evaluated by the senior author. In each case the bony fragment was excised and the hamstrings were reattached to the ischium with suture anchors. All patients were assessed postoperatively by biodex strength testing. RESULTS: The average age of the patients was 15 years and the average time to repair was 7 months from the time of injury. The average retraction was 3.7 cm. The average follow-up period was 78 months. The average strength was 86% and the average power was 100% compared with the contralateral side at the final follow-up. In all 3 cases pain was relieved, and with adequate rehabilitation normal strength was regained and the subjects returned to sport. There was one complication involving an activity-related peroneal nerve palsy. This was treated by neurolysis with good functional return. CONCLUSIONS: The 3 cases presented here suggest that treatment should be planned on the basis of pain and disability rather than pathology, and that surgical treatment can effectively address a chronic condition. Each case requires an individualized treatment plan and should include a consideration of the patient's functional goals.

Increasing alpha angle is predictive of athletic-related "hip" and "groin" pain in collegiate National Football League prospects.

PURPOSE: The first purpose was to evaluate radiographic pathomorphology/abnormalities in a cohort of high-level collegiate football players screened with hip radiographs. The second purpose was to define the radiographic predictors of athletic-related "hip" and "groin" symptoms in this cohort of high-level athletes. METHODS: The study population included all male collegiate football players undergoing evaluation and hip radiography at the National Football League (NFL) Scouting Combine in 2009 and 2010. All radiographs were evaluated with a detailed evaluation for hip pathomorphology. Symptoms were recorded as symptomatic or asymptomatic with respect to athletic-related groin/hip pain for comparative purposes. RESULTS: There were 125 players (239 hips) who had hip radiographs and were included in the final cohort. Ninety percent of players (87% of hips) in this cohort had at least 1 finding consistent with cam-type and/or pincer-type femoroacetabular impingement (FAI). There were 75 hips in the symptomatic group and 164 hips in the asymptomatic group. Although the symptomatic group had a greater prevalence of cam-type FAI (P = .009), combined-type FAI (P < .001), and osteitis pubis (P = .014), increasing alpha angle (larger cam deformities) was the only independent predictor of athletic-related groin pain (P = .01). There was no correlation, however, between FAI and body mass index (P = .659), player position (P = .166), or whether a player was drafted by an NFL team (P = .430). CONCLUSIONS: Radiographic signs of FAI were frequently seen in collegiate NFL prospects who were screened with hip radiographs. Although patients with radiographic evidence of osteitis pubis, cam- and combined-type FAI, and larger cam deformities showed a statistically higher prevalence of symptoms, increasing alpha angle (larger cam deformity) was the only independent predictor of athletic-related hip/groin pain. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Correlating MRI findings with disability in syndesmotic sprains of NFL players.

BACKGROUND: Syndesmotic sprains may be a significant source of missed playing time, especially in football players. Advanced imaging is frequently used to confirm the clinical diagnosis. Our purpose was to evaluate the prognostic ability of MRI in predicting time of disability. METHODS: Training room records from 1993 to 2007 for three National Football League teams were reviewed. Forty-three players were diagnosed with syndesmotic ankle injuries and underwent radiographs and magnetic resonance imaging. A blinded musculoskeletal radiologist interpreted all images. Players with fractures were excluded. RESULTS: Thirty-six professional football players were included in the final analysis. Twenty-three players had a positive squeeze test which was correlated with increased missed practices (p = 0.012) and increased missed games (p ≤ 0.01). The average number of games missed was 3.3 (range, 0 to 20) and the average number of practices missed was 16.7 (range, 0 to 114). Four players had isolated injury to the anterior tibio-fibular ligament (AITFL) (MRI Grade I). Five players had injury to the AITFL and interosseous ligament (MRI Grade II). Twenty-four players sustained injury to the AITFL, interosseous ligament, and posterior inferior tibio-fibular ligament (MRI Grade III). Three players had Grade III injuries with additional injury to the deltoid ligament (MRI Grade IV). Increasing grade of injury was positively correlated with increased number of missed games (p = 0.033) and missed practices (p = 0.002). CONCLUSION: MRI can be useful to help delineate the injury pattern and associated injuries, and may be useful in predicting time of disability using a grading system. Positive squeeze test can also be useful to determine prognosis.

Autograft versus allograft: an economic cost comparison of anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to compare the costs associated with anterior cruciate ligament (ACL) reconstruction with either bone-patellar tendon-bone (BPTB) autograft or BPTB allograft. METHODS: Surgical costs are reported, including supply costs, based on invoice costs per item used per procedure, and personnel costs calculated as cost per minute. All operations were performed at an ambulatory surgery center between March 2005 and March 2006. A total of 160 patients underwent primary ACL reconstruction with either BPTB autograft (n = 106) or BPTB allograft (n = 54). Procedure cost data were retrieved from a financial management database and divided into various categories for comparison of the 2 groups. Payment data were provided by the surgery center's billing office. RESULTS: The total mean cost per case was $4,147 ± $943 in the allograft group compared with $3,154 ± $704 in the autograft group; this was statistically significant (P < .001). The mean operating room time was 12 minutes greater in autograft cases (P = .006). Supply costs comprised a mean of 58.7% of total expenses in the autograft group and 72.2% in the allograft group. CONCLUSIONS: Allograft reconstruction of the ACL was significantly more expensive than autograft reconstruction. LEVEL OF EVIDENCE: Level II, economic analysis.

Anterior cruciate ligament allograft surgery: underreporting of graft source, graft processing, and donor age.

BACKGROUND: There has been much controversy regarding the effects of sterilization techniques and graft history on the structural integrity of allograft ligaments used in reconstruction of the anterior cruciate ligament. The purpose of this review was to comprehensively examine anterior cruciate ligament allograft studies published in the last decade to evaluate the extent to which tissue source, tissue processing techniques, and donor age are reported. METHODS: The authors reviewed 202 articles published from 1999 through November 2009, of which 68 retrospective, prospective, biomechanical, and histology studies evaluating 4689 allografts were included. RESULTS: The majority of studies do not accurately report key elements of graft history including tissue bank, processing or sterilization technique, or donor age. Underreporting was particularly prominent in clinical studies as compared with basic science studies. Limited reporting of allograft processing, allograft source, and donor age raises serious questions regarding the generalizability of published studies of allograft tissue for anterior cruciate ligament reconstruction. Conclusion/ CLINICAL RELEVANCE: Orthopaedic surgeons who use allograft tissue must understand the tissue treatments being used (ie, preservation methods, chemical and sterilization processes) to best inform their patients regarding the risks, benefits, and long-term outcomes when such tissues are used. A complete understanding of the implanted tissue, as well as surgeon and recipient demographics, is necessary to ensure appropriate and predictable long-term outcomes.

Exercise in pregnancy.

A greater number of women are choosing to exercise in pregnancy as the recommendations by the American College of Obstetrics and Gynecology (ACOG) and other organizations have changed in recent years. Exercise during pregnancy can be beneficial to the health of the fetus and mother. Physicians should be aware of the contraindications to exercise, the warning signs to terminate exercise, and the latest recommendations by the ACOG. In the absence of contraindications, the authors believe that physicians should help to develop a reasonable exercise protocol for women based upon their previous activity levels. It is incumbent upon physicians to be aware of the unique physiologic factors present during pregnancy that may predispose women to injuries. Treatment of injuries sustained during pregnancy must balance the risks to both the mother and fetus.

Descriptive epidemiology of collegiate women's basketball injuries: National Collegiate Athletic Association Injury Surveillance System, 1988-1989 through 2003-2004.

OBJECTIVE: To review 16 years of National Collegiate Athletic Association (NCAA) injury surveillance data for women's basketball and to identify potential areas for injury prevention initiatives. BACKGROUND: The number of colleges participating in women's college basketball has grown over the past 25 years. The Injury Surveillance System (ISS) has enabled the NCAA to collect and report injury trends over an extended period of time. This has allowed certified athletic trainers and coaches to be more informed regarding injuries and to adjust training regimens to reduce the risk of injury. It also has encouraged administrators to make rule changes that attempt to reduce the risk of injury. MAIN RESULTS: From 1988-1989 through 2003-2004, 12.4% of schools across Divisions I, II, and III that sponsor varsity women's basketball programs participated in annual ISS data collection. Game and practice injury rates exhibited significant decreases over the study period. The rate of injury in a game situation was almost 2 times higher than in a practice (7.68 versus 3.99 injuries per 1000 athlete-exposures, rate ratio = 1.9, 95% confidence interval = 1.9, 2.0). Preseason-practice injury rates were more than twice as high as regular-season practice injury rates (6.75 versus 2.84 injuries per 1000 athlete-exposures, rate ratio = 2.4, 95% confidence interval = 2.2, 2.4). More than 60% of all game and practice injuries were to the lower extremity, with the most common game injuries being ankle ligament sprains, knee injuries (internal derangements and patellar conditions), and concussions. In practices, ankle ligament sprains, knee injuries (internal derangements and patellar conditions), upper leg muscle-tendon strains, and concussions were the most common injuries. RECOMMENDATIONS: Appropriate preseason conditioning and an emphasis on proper training may reduce the risk of injury and can optimize performance. As both player size and the speed of the women's game continue to increase, basketball's evolution from a finesse sport to a high-risk contact sport also will continue. The rates of concussions and other high-energy trauma injuries likely will increase. The NCAA ISS is an excellent tool for identifying new risk factors that may affect injury rates and for developing consistent injury definitions in order to improve the research and provide a source of clinically relevant data.

Acetabular labral tears with underlying chondromalacia: a possible association with high-level running.

PURPOSE: The use of hip arthroscopy has helped delineate intra-articular pathology and has enabled clinicians to further elucidate the factors responsible for injuries, such as running. The subtle development of degenerative changes may be a result of repetitive impact loading associated with this sport. This study presents a population of runners with common pathologic acetabular changes. TYPE OF STUDY: Case series. METHODS: Eight high-level runners with an average age of 36 years (range, 19 to 45 years) were seen for complaints of increasing hip pain with running without any history of macrotrauma. All of the patients had either run several marathons (4), were triathletes (1), Olympic middle distance runners (1), or had run more than 10 miles per week for longer than 5 years (2). Plain radiographic analysis revealed no degenerative changes and an average center-edge (CE) angle of 36.7 degrees (range, 28 degrees to 44 degrees). RESULTS: All patients underwent hip arthroscopy with labral debridement. In 6 patients (75%), a chondral injury of the acetabular cartilage underlying the labral tear was noted. In addition, 3 patients had ligamentum teres disruptions. CONCLUSIONS: It is possible that the development of these tears is the result of subtle instability, which may be exacerbated by running, eventually leading to labral tearing and possible ligamentum teres disruption. While perhaps concurrently, subtle acetabular dysplasia may play a role. Although this study does not confirm an association between running and the development of labral tears or chondral lesions in the hip, it certainly questions whether there is an injury pattern common to this population, a "runner's hip." LEVEL OF EVIDENCE: Level IV.