Faculty Bibliography

PURPOSE: Traditionally, biceps tenotomy has been recommended for obese, older, and less active patient populations, while tenodesis is preferred in younger, thinner, and more active individuals. In an effort to better understand the impact obesity has on the surgical management of long head of the biceps tendinopathy, the current study analyzed the effect body mass index had on surgical outcomes following open subpectoralis major biceps tenodesis. METHODS: Patients who underwent biceps tenodesis between June 2006 and December 2013 were identified from our institution's surgical database. They were then contacted to assess their functional outcomes using validated outcome measures. Comparisons were made between the outcomes seen in obese patients (BMI >/= 30) and non-obese patients (BMI < 30) with subgroup analyses looking at gender, age, and length of follow-up. RESULTS: One hundred and twenty-two patients completed a follow-up assessment with a mean follow-up of 29.3 months. The non-obese cohort was composed of 84 patients with a mean BMI of 25.8. The obese cohort was composed of 38 patients with a mean BMI of 33.4. No significant difference was noted to be present with respect to postoperative outcome measures. Regression analysis with BMI as an independent variable demonstrated poor correlation with outcome measures. CONCLUSIONS: The results of the current study support open subpectoralis biceps tenodesis as an acceptable option for the treatment of LHB pathology irrespective of the treated patient's body mass index. Both obese and non-obese patients demonstrated low postoperative DASH scores and high Oxford Shoulder scores.

PURPOSE: To investigate the biomechanical properties of the load shifting following opening-wedge distal femoral varus osteotomies (DFVOs) and determine the osteotomy correction needed to unload the lateral compartment. METHODS: Five human cadaveric knees were tested with a load of 500 N of axial compression. Medial and lateral tibiofemoral compartment contact area and pressure were assessed utilizing a modified F-scan pressure-sensitive sensor. The knees were tested in their baseline anatomic alignment, 10 degrees valgus malalignment and following corrective DFVOs of 5 degrees , 10 degrees and 15 degrees . The load shifting effect of the various DFVO correction angles was analysed using a one-way ANOVA to determine the correction angle necessary to unload the lateral compartment. RESULTS: Gradually shifting the loading vector medially with increasing DFVO angles resulted in a decrease in the mean contact area and mean contact pressures in the lateral compartment with progressive increases in the medial compartment. The largest reduction in lateral compartment pressure and contact area was seen with the 15 degrees osteotomy with a 25 % decrease in mean contact pressure and 20 % decrease in mean maximum contact pressure and mean contact area when compared to the 10 degrees valgus-malaligned knee. For the 10 degrees valgus knee, a 15 degrees correction resulted in near-normal contact pressures and areas compared with the knee in normal anatomic alignment. CONCLUSION: Progressive unloading of the lateral tibiofemoral compartment occurred with increasing DFVO correction angles. Clinically, when performing a DFVO for valgus malalignment, surgeons should consider overcorrecting the osteotomy by 5 degrees to restore near-normal contact pressures and contact areas in the lateral compartment rather than the traditional teaching of correcting to neutral alignment.

With the increasing incidence of anterior cruciate ligament (ACL) reconstruction in women and younger patients, the optimal graft choice in the young female patient has become the subject of much debate. This study aimed to evaluate patient-reported outcomes, objective knee stability, complication rates, and the incidence of failure after ACL reconstruction using bone-patellar tendon-bone (BPTB) autograft compared with hamstring (HS) autograft in young female patients. Female patients who underwent primary ACL reconstruction with BPTB or HS autograft between ages 15 and 25 years were identified. Medical records were reviewed for postoperative complications and subsequent procedures on the operative knee. Patients were evaluated with functional surveys, physical examination including Lachman and pivot-shift tests, and arthrometric testing with a KT-1000 arthrometer. There were 37 patients in the BPTB group and 28 patients in the HS group. For patients who did not undergo revision, significant differences were not found in visual analog score (p = 0.94), Lysholm score (p = 0.81), Kujala score (p = 0.85), or Tegner level (p = 0.81). No difference was detected in the rate of return to a level of activity at or above the same level prior to injury (p = 0.31). Significantly more patients in the BPTB group were graded 1a Lachman and negative pivot shift compared with the HS group (p < 0.001). There was a significant difference in mean side-to-side manual maximum arthrometric testing (p < 0.001). There were significantly fewer subsequent procedures and a lower rate of graft failures in the BPTB group. We detected no difference in subjective functional outcomes following ACL reconstruction. However, a higher failure rate in the HS reconstructions and greater laxity by arthrometric testing may indicate increased objective stability with the use of BPTB autograft in the young female patient population. The level of evidence for this article is (level III, retrospective cohort).

Purpose: To retrospectively correlate the MR imaging, arthroscopic and histopathologic appearance of resected long of biceps tendon samples following biceps tenodesis. Materials and Methods: Following IRB approval, a retrospective review of 63 cases between 2013 and 2016 was performed in patients who had undergone preoperative shoulder MRI, arthroscopy and long head of the biceps tenotomy and tenodesis followed by histopathologic inspection of the excised sample. Independently, two blinded radiologists reviewed the MRI appearance of the biceps tendon. Biceps tendon split tearing, subluxation and dislocation were described separately. A blinded shoulder orthopedist and a pathologist with bone and soft tissue specialization reviewed all operative imaging and pathologic slides respectively. Statistical analysis including inter-rater agreement was performed to assess concordance in the degree of agreement among pathologist, surgeon and radiologist. Results: Of the 63 samples of biceps tissue analyzed 59 demonstrated a histopathological abnormality pertaining to the tendon or tenosynovium. Four samples were reported as histopathologically normal.13/59 (22%) of samples with histopathological abnormality demonstrated normal appearance on MR imaging. Of these, the most common reported pathology finding was mild fibrosis and/or myxoid degeneration. Histopatholgical abnormalities of the tendon positively correlating with MRI and arthoscopic findings included intra-tendinous granulation tissue, severe myxoid degeneration and fibrocartilage tendinous tissue. Conclusion: A significant number of patients with histopathological evidence of tendinosis including mild fibrosis and myxoid degeneration demonstrate no abnormality on MRI

PURPOSE: To assess screw divergence when inserting an interference screw for a bone-patellar tendon-bone graft using an outside-in technique with a retrograde drill to create the femoral tunnel. METHODS: Ten cadaver specimens underwent anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft, with 23-mm-deep tunnels created by a retrograde drill outside-in technique. Drilling angles were based on a previous study that established the optimal angles to recreate the anterior cruciate ligament footprint. To ensure that screw insertion angles matched the angle of socket drilling, a marking pen was used to transpose 2 lines on the skin of the anterior knee corresponding to the drill in both the coronal and axial planes with the knee held at 90 degrees of flexion. The femoral-sided bone plug was affixed with a 7 x 23 mm interference screw through an anteromedial portal. Computed tomography scans were used to calculate coronal and sagittal screw-tunnel divergence. RESULTS: The median screw divergence in the coronal plane was 2.79 degrees , with a range of 1.1 degrees to 17.2 degrees . Of 10 specimens, 8 had no divergence (0 degrees to 5 degrees ), 0 screws were between 5 degrees and 10 degrees , 1 screw was between 10 degrees and 15 degrees , and 1 screw was between 15 degrees and 20 degrees . The 95% confidence interval was 3.73 degrees to 11.69 degrees . No screws had >/=20 degrees of divergence. In the sagittal plane, the median screw divergence was 5.68 degrees , with a range of 1.2 degrees to 18.7 degrees . Five specimens had no divergence (0 degrees to 5 degrees ), 3 screws were between 5 degrees and 10 degrees , 0 screws were between 10 degrees and 15 degrees , and 2 screws were between 15 degrees and 20 degrees of divergence. The 95% confidence interval was 3.73 degrees to 11.69 degrees . No screws had >/=20 degrees of divergence. CONCLUSIONS: The results of this study showed that 80% of screws diverted less than 5 degrees in the coronal plane. In the sagittal plane, only 50% of screws were found to have divergence of 5 degrees or less. No screw in either plane had divergence of greater than or equal to 20 degrees . CLINICAL RELEVANCE: When using a retrograde drill, a skin marking technique is a useful aid in placing interference screws with acceptable angles of divergence when using an inside-out technique.

PURPOSE: To determine when patients recover the ability to safely operate the brakes of an automobile after a right-knee anterior cruciate ligament reconstruction (ACLR). METHODS: A computerized driving simulator was used to determine braking ability after an isolated right-knee ACLR. Thirty healthy volunteers were tested at 1 visit to determine normal mean values, and 27 treatment subjects were tested at 1 week, 3 weeks, and 6 weeks after ACLR. Nine study subjects were treated with a patella tendon (BPTB) autograft, 9 were treated with a hamstring (HS) autograft, and 9 were treated with a tibialis anterior (TA) allograft. The driving simulator collected data on brake reaction time (BRT), brake travel time (BTT), and total brake time (TBT) at each visit. RESULTS: The control group generated a BRT of 725 milliseconds, BTT of 2.87 seconds, and TBT of 3.59 seconds. At week 1, all treatment patients had significant differences compared with controls for BRT, BTT, and TBT, except the BTT of the HS group. At week 3, all measures for the allograft group and the BRT for both autograft groups were no longer significantly different compared with controls, but significant differences were found for TBT in the HS and BPTB groups (P = .03, P = .01). At week 6, BRT, BTT, and TBT were no longer significantly different for either the HS group or BPTB group. CONCLUSIONS: Patients who underwent a right-knee ACLR with a TA allograft regained normal braking times by week 3 postoperatively. In contrast, those treated with a BPTB or HS autograft demonstrated significantly delayed braking times at 3 weeks but returned to normal braking ability by week 6. Those treated with an autograft had an earlier return of normalized BRT than BTT. LEVEL OF EVIDENCE: Level III, case-control series.