Faculty Bibliography

PURPOSE: To evaluate whether screening radiographs as part of the initial workup of knee pain impacts clinical decision-making in a sports medicine practice. METHODS: A questionnaire was completed by the attending orthopaedic surgeon following the initial office visit for 499 consecutive patients presenting to the sports medicine centre with a chief complaint of knee pain. The questionnaire documented patient age, duration of symptoms, location of knee pain, associated mechanical symptoms, history of trauma within the past 2 weeks, positive findings on plain radiographs, whether magnetic resonance imaging was ordered, and whether plain radiographs impacted the management decisions for the patient. Patients were excluded if they had prior X-rays, history of malignancy, ongoing pregnancy, constitutional symptoms as well as those patients with prior knee surgery or intra-articular infections. Statistical analyses were then performed to determine which factors were more likely do correspond with diagnostic radiographs. RESULTS: Overall, initial screening radiographs did not change management in 72 % of the patients assessed in the office. The mean age of patients in whom radiographs did change management was 57.9 years compared to 37.1 years in those patients where plain radiograph did not change management (p < 0.0001). Plain radiographs had no impact on clinical management in 97.3 % of patients younger than 40. In patients whom radiographs did change management, radiographs were more likely to influence management if patients were over age forty, had pain for over 6 months, had medial or diffuse pain, or had mechanical symptoms. A basic cost analysis revealed that the cost of a clinically useful radiographic series in a patient under 40 years of age was $7,600, in contrast to $413 for a useful series in patients above the age of 40. CONCLUSION: Data from the current study support the hypothesis that for the younger patient population, routine radiographic imaging as a screening tool may be of little clinical benefit. Factors supporting obtaining screening radiographs include age greater than 40, knee pain for greater than 6 months, the presence of medial or diffuse knee pain, and the presence of mechanical symptoms. LEVEL OF EVIDENCE: II.

Rotator cuff tears are a common pathologic entity, and rotator cuff repairs are a frequently performed procedure. Given the high rate of structural failure of repair, biological augmentation of repairs is increasingly important. Biological augmentation primarily enhances the healing response and secondarily provides a mechanical bridge for tension free repair. Understanding biology of tendons and tendon healing aids in determining an optimal environment for repair. The basic principles of rotator cuff repair are aimed at achieving high initial fixation strength of the repair, restoring the anatomic footprint of the cuff tendon, minimizing gap formation, and maintaining mechanical stability until biologic healing occurs. Methods of augmentation come in many different forms and can be categorized by cell type and mechanism of delivery. Cell types include individual growth factors, stem cells, or a combination of both. Vehicles range from in situ delivery, such as microfracture, direct injection, or scaffold materials that are biologic or synthetic.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) has traditionally been reserved for young patients with functional instability. As the aging population continues to grow and embrace a more active lifestyle, it is important to determine if favorable outcomes of ACLR can be achieved in older adults. METHODS: Patients greater than 50 years of age undergo- ing ACLR between January 2001 and September 2006 were identified. Charts were retrospectively reviewed for clinical, pathologic, and radiographic findings. Prospective data was collected at follow-up, including Lysholm Knee Score, Tegner Activity Level Score, International Knee Documenta- tion Committee (IKDC) Subjective Knee Form Score, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Anteroposterior (AP) instability was assessed with use of a KT-2000 arthrometer (MEDmetric, San Diego, CA). RESULTS: Forty-seven patients underwent ACLR with 32 (16 males and 16 females) available at a mean follow-up of 5.0 years (range: 2.2 to 9.0 years). The mean age at the time of operation was 58.4 years (range: 51 to 65 years). At time of final follow-up, the mean side-to-side difference measured by KT-2000 was 1.2 +/- 1.3 mm (range: 0 to 4.5 mm). Mean postoperative subjective IKDC score was 80.1 (range: 33 to 100) and Lysholm score was 86.7 (range: 45 to 95). There was no change in Tegner score from pre-injury (range: 0 to 3) to postoperative (range: 0 to 3). Twelve patients (38%) underwent subsequent knee surgery. All patients were sat- isfied with the final outcome of their ACLR surgery. Only patellofemoral Outerbridge cartilage grade was associated with worse outcome. CONCLUSION: ACLR provides symptomatic relief and restoration of function for patients greater than 50 years of age. ACLR should be considered in active older patients with subjective functional instability.

AC (acromioclavicular) joint dislocations are a common injury seen by physicians. Symptoms range from minor discomfort with activity to complete disability of the extremity. Although most orthopaedic surgeons agree on how to treat either mild (type 1-2) or severe (type 4-6) injuries, there is no consensus for treatment of type 3 injuries. This article reviews the relevant literature pertaining to the anatomy of the injury, evaluation of the patient, pertinent imaging as well as the controversial management of type 3 AC joint dislocations. With improvement in surgical techniques over the past 30 years, there have been many published studies evaluating both operative and non-operative care. Surgery has shown dramatic improvement in patient-rated outcomes; however, it is not always without complications. These risks in some patients may not be worth the potential surgical benefits. In type 3 AC joint injuries each patient and pathology must be carefully analyzed to ensure that the correct treatment option is chosen.

Varus or valgus malalignment of the lower extremity can alter the load distribution across the knee and hasten the development of focal osteoarthritis. Although knee arthroplasty remains an effective option for end-stage arthritis, it is not typically recommended in the young, active patient. In the setting of painful unicompartmental cartilage injury in a mechanically malaligned limb, alignment correction by osteotomy has been shown to slow the progression of osteoarthritis and lessen pain. In this review, we will discuss the different options, indications, and techniques for osteotomies about the knee.

Distal biceps ruptures occur most commonly in middle-aged males and result from eccentric contraction of the biceps tendon. The injury typically presents with pain and a tearing sensation in the antecubital fossa with resultant weakness in flexion and supination strength. Physical exam maneuvers and diagnostic imaging aid in determining the diagnosis. Nonoperative management is reserved for elderly, low demand patients, while operative intervention is generally pursued for younger patients and can consist of nonanatomic repair to the brachialis or anatomic repair to the radial tuberosity. Anatomic repair through a one-incision or two-incision approach is commonplace, while the nonanatomic repairs are rarely performed. No clear advantage exists in operative management with a one-incision versus two-incision techniques. Chronic ruptures present a more difficult situation, and allograft augmentation is often necessary. Common complications after repair include transient nerve palsy, which often resolves, and heterotopic ossification. Despite these possible complications, most studies suggest that better patient outcomes are obtained with operative, anatomic reattachment of the distal biceps tendon.