Faculty Bibliography

Anterior cruciate ligament (ACL) injuries are a highly prevalent and costly injury to treat, both financially and regarding its long-term detrimental effects on those injured. Adolescent female soccer players appear to be particularly vulnerable, possibly due to various biomechanical risk factors, such as knee valgus loading and imbalanced hamstrings-quadriceps (H/Q) ratio. Many studies support the benefits of generic neuromuscular training programs in mitigating this heightened injury risk. Despite this, ACL injuries remain pervasive within this population. This review aims to highlight the current tools available to assess athletes for biomechanical risk factors at an individual level, including three-dimensional motion analysis, the Landing Error Scoring System (LESS), and the Cutting Movement Assessment Score (CMAS). Utilization of these analyses could facilitate developing and implementing more individualized training programs, thereby identifying high-risk athletes, reducing sports-related ACL injuries, and lessening the economic burden of these injuries on both the patient and the health care system.

Intra-articular injections have traditionally been performed "blind," guided only by anatomic palpation. Many may be placed inaccurately, and the use of imaging may significantly improve injection accuracy. This review analyzed the impact of ultrasound-guidance on injection accuracy and clinical efficacy in the knee and shoulder joints. Ultrasound-guided injections were significantly more accurate than blind injections in clinical studies of the knee joint (92.7% vs. 77.9%, p < 0.05). Shoulder injections into the glenohumeral and acromioclavicular joints showed modest benefit in cadaver studies, but improved accuracy has not been demonstrated in clinical studies. Insufficient data was available to show any effect in the subacromial bursa. Preliminary efficacy research shows that that ultrasound guidance may modestly improve the subjective pain relief and functional improvement provided by these injections.

BACKGROUND: The saline solution load test helps to determine if a wound extends into the knee joint. Little is known about the volume of injected intra-articular saline solution that is needed to effectively rule in or rule out a traumatic arthrotomy of the knee. The purpose of the present study was to determine the appropriate volume and needle location for the diagnosis of a traumatic knee arthrotomy and to assess the effect of associated variables, including knee circumference, body mass index, and sex. METHODS: Fifty-six consecutive patients scheduled for knee arthroscopy were enrolled. A standard inferolateral arthroscopic portal was made with a single stab incision with use of a number-11 blade. Injection sites were randomized to either a superomedial or inferomedial location. The injection of normal saline solution at a rate of 5 mL/sec through an 18-gauge needle was continued while the knee was moved through a range of motion until fluid extravasated from the iatrogenic laceration. The volume of injected fluid was recorded. RESULTS: The study group included thirty-one female patients and twenty-five male patients with a combined average age of fifty years and an average body mass index of 30.9. In order to effectively diagnose 50% of the arthrotomies, 75 mL of injected fluid was needed; the volumes that were needed in order to effectively diagnose 75%, 90%, 95%, and 99% of the arthrotomies were 110, 145, 155, and 175 mL, respectively. The mean volumes of injected fluid needed for a positive result at the inferomedial and superomedial needle locations were 64.0 and 95.2 mL, respectively; this difference was significant (p = 0.01). There was no correlation between necessary injection volume and sex, body mass index, or knee circumference. CONCLUSIONS: In order to detect 95% of 1-cm inferolateral arthrotomies of the knee with use of the saline solution load test, 155 mL must be injected. An inferomedial injection location requires significantly less fluid than a superomedial injection location does for the diagnosis of inferolateral arthrotomies of the knee

Isolated fracture of the lesser tuberosity is an unusual phenomenon in children and adolescents. These injuries are difficult to diagnose acutely and often present as chronic shoulder pain. In this study, we report on 1 case of a displaced lesser tuberosity apophysis avulsion fracture in an adolescent treated with open reduction and internal fixation, as well as a review of the literature. A 14-year-old adolescent male presented to the senior surgeon complaining of left shoulder pain and weakness 10 days after a wrestling injury. He was diagnosed with a displaced, isolated fracture of the lesser tuberosity apophysis for which he underwent open reduction and internal fixation. A combination of sutures passed through drill holes in the proximal humerus and bioabsorbable suture tacks were used to anatomically fix the lesser tuberosity fragment and subscapularis tendon. Postoperatively, he underwent a progressive physical therapy regimen. At 4 months follow-up, he had full range of motion, complete return of strength, and returned to competitive athletics. We report here on the successful surgical treatment of a fracture of the lesser tuberosity apophysis in an adolescent

BACKGROUND: Rupture of the distal biceps brachii tendon has most commonly been repaired by anatomic reattachment of the tendon to the radial tuberosity by a single- or two-incision approach. Researchers have studied suture anchor attachment through a single incision, but the tendon-suture interface and bone quality have not previously been analyzed. HYPOTHESIS: Suture anchor repair results in stiffness and tensile strength equal to that of bone-tunnel repair for biceps tendon rupture. STUDY DESIGN: Controlled laboratory study. METHODS: Twelve matched pairs of fresh-frozen cadaveric elbow specimens were used. Suture anchor and bone-tunnel tendon repairs were performed in a randomized fashion. Each specimen was loaded to tensile failure. Load-displacement graphs were generated to calculate repair stiffness, yield strength, and ultimate strength. Computed tomography bone density measurements and additional statistical analyses were then performed after grouping the specimens by mode of failure. RESULTS: The bone-tunnel repair was found to be significantly stiffer in all cases and to have significantly greater tensile strength than the suture anchor repair in the younger, nonosteoporotic elbows. CONCLUSIONS: Suture anchor repairs were not as stiff or strong as bone-tunnel repairs. CLINICAL RELEVANCE: Biceps tendon surgery using the traditional two-incision technique yields a stronger and stiffer repair in the typical patient with this injury

This study reports the development of a novel osteochondral graft for cartilage repair. A technique of proteoglycan extraction via timed enzymatic digestion with hyaluronidase and trypsin and subsequent processing with a chloroform-methanol solution to remove cellular debris from a fresh-frozen bovine osteochondral sample is a method described to prepare a stable biological carrier of low immunogenicity. Lyophilization of the carrier followed by rehydration in a suspension of lapine chondrocytes produced a chimeric xenograft that succeeded in vivo in enhancing cartilage repair. In a pilot study, full-thickness articular cartilage defects treated with these xenografts demonstrated improved healing compared to untreated defects or defects treated with unseeded grafts at 2, 6, and 12 weeks postimplantation. The xenograft provoked a mild inflammatory response; however this did not impede the repair process. Further investigation of this novel chimeric xenograft eventually may yield a method of cartilage repair superior to current methods of treatment

The functional outcomes of 143 total knee arthroplasties performed by 1 surgeon between 1988 and 1992 were reviewed. Ninety-three procedures were carried out with sacrifice of the posterior cruciate ligament (PCL); in 50, the PCL was preserved. All cases were performed using the Kinemax prosthesis (Howmedica, Rutherford, NJ). Demographically, there were no differences between the 2 patient groups. Patients were evaluated over a mean follow-up period of 3 years (range, 2-6 years) using the 100-point Hospital for Special Surgery knee scoring system. The data revealed no difference in clinical or early radiographic outcome between PCL-sacrificing and PCL-retaining arthroplasties and support the argument that PCL sacrifice should be considered in cases in which extensive releases and complex ligamentous balancing are required

An unconstrained cadaver ankle model was designed to reevaluate the effect of ankle mortise widening and syndesmotic fixation on the load-bearing characteristics of the tibiotalar joint. Tibiotalar contact area, centroid shift, and mean contact pressure were quantified using a pressure-sensitive film technique. Six fresh-frozen below-knee amputation specimens were axially loaded with 500 N in three positions: neutral, 10 degrees of dorsiflexion, and 20 degrees of plantarflexion. The tibiotalar contact area and centroid position for each specimen in its intact state were first determined and then compared with values obtained after syndesmotic fixation, mortise widening of 2 and 4 mm, and deep deltoid ligament transection. Syndesmotic fixation significantly decreased joint contact area but did not consistently affect centroid position. However, unlike earlier studies, which used more constrained ankle fracture models, mortise widening with or without deltoid rupture was not found to significantly affect contact area, centroid position, or joint contact pressure. When statically loaded, the talus moved to its position of maximal congruence in the mortise, rather than displacing laterally along with the lateral malleolus

Two types of growth factors were used in an attempt to improve the quality of the regenerate bone in canine tibias after Ilizarov lengthening. Mechanical testing, biochemical analysis and histology did not demonstrate appreciable differences between the treated and the control limbs