Faculty Bibliography

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.

Patients with gluteus minimus and medius tears that fail nonoperative management may be indicated for surgical repair; however, structural failure after gluteal tendon repair remains unacceptably high. This is likely related to the limited healing potential of tendinous tissue, which is poorly vascular and heals by formation of fibrocartilaginous scar tissue rather than histologically normal tendon. An emerging option to augment tendon healing is the use of a bioinductive implant that is designed to amplify the host healing response and induce the formation of healthy tendon tissue. Though it is rapidly being adopted for partial- and full-thickness rotator cuff tears, this implant has not yet been used in the hip. A detailed technical description and a discussion of the advantages and disadvantages of the technique are provided.

Objectives: Proper surgical planning requires accurate and reliable pre-operative patient information. The more comprehensive the data, the more the surgeon can tailor a general surgical technique to an individual patient's unique anatomy. A previous retrospective study demonstrated that three-dimensional magnetic resonance imaging more accurately characterized rotator cuff tears compared to two-dimensional images when checked against intraoperative pictures. The purpose of this study was to determine if three-dimensional MRI imaging would continue to be more accurate than two-dimensional imaging in a prospective study. Methods: Patients were prospectively included if they had a full-thickness primary rotator cuff tear on pre-operative MRI. Intra-op videos were taken from the posterior and lateral portals, with a grasper fully mobilizing the torn tendon in each view. 7 surgeons then reviewed the videos and independently characterized the shape of the tears into crescent, U-shaped tears, L-shaped tears, or massive tears. This was considered the gold-standard. Two musculoskeletal radiologists reviewed the corresponding MRI studies independently and blind to the arthroscopic findings and characterized the shape on the basis of the tear's retraction and size 2D MRI. The 3D reconstructions of each cuff tear were reviewed by each radiologist to characterize the shape. Statistical analysis included 95% confidence intervals and fleiss's kappa. Results: 37 patients were enrolled in the study. Among the 7 surgeons, agreement on cuff tear was 93% ( =.87). The accuracy for differentiating between crescent-shaped, longitudinal, and massive tears using measurements on 2D MRI was 73.4% for reader 1 and 71.2% for reader 2. The accuracy for tear shape characterization into crescent and longitudinal U- or L-shaped using 3D MRI was 92% for reader 1 and 94% for reader 2. When further characterizing the longitudinal tears as massive or not using 3D MRI, both readers had an accuracy of 83%. The overall accuracy of 3D MRI was 91%, significantly different (P=.07) from 2D MRI accuracy (70.4). Conclusion: Our study has demonstrated that 3D MR reconstructions of the rotator cuff improve the accuracy of characterizing rotator cuff tear shapes compared with current 2D MRI-based techniques. (Figure Presented)

BACKGROUND: Basketball players are at risk for foot injuries, including Jones fractures. It is unknown how this injury affects the future play and performance of athletes. HYPOTHESIS: National Basketball Association (NBA) players who sustain Jones fractures of the base of the fifth metatarsal have high rates of return to play and do not experience a decrease in performance on return to competition when compared with preinjury and with control-matched peers. STUDY DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: Level 5. METHODS: Data on 26 elite basketball players with Jones fractures over 19 NBA seasons (1994-1995 to 2012-2013) were obtained from injury reports, press releases, player profiles, and online public databases. Variables included age, body mass index (BMI), player position, experience, and surgical treatment. Individual season statistics pre- and postinjury were collected. Twenty-six controls were identified by matched player position, age, and performance statistics. RESULTS: The mean age at the time of injury was 24.8 years, mean BMI was 24.7 kg/m(2), and the mean experience prior to injury was 4.1 NBA seasons. Return to previous level of competition was achieved by 85% of athletes. There was no change in player efficiency rating (PER) when pre- and postinjury performance was compared. When compared with controls, no decline in PER measured performance was identified. CONCLUSION: The majority of NBA players sustaining a Jones fracture return to their preinjury level of competition. These elite athletes demonstrate no decrease in performance on their return to play. CLINICAL RELEVANCE: Jones fractures are well-studied injuries in terms of etiology, diagnosis, and management. However, the effect of these injuries on future performance of athletes is unknown. Using the findings of our study, orthopaedic surgeons may be better prepared to counsel and educate elite athletes who sustain a Jones fracture.

PURPOSE: To directly compare single-loaded suture anchors (SSA) with double-loaded suture anchors (DSA) to help surgeons optimize the operative technique, time, and cost of Bankart repairs. METHODS: A literature review was performed using the PubMed and SCOPUS databases. Studies that directly compared SSA and DSA for Bankart repairs, or indirectly compared them by collecting relevant data despite a different objective, were included. RESULTS: A total of two studies were included, both of which were cadaveric laboratory studies. A total of 28 shoulders were tested. Tests conducted include loading to failure and cyclic loading. One study found SSA to be biomechanically equivalent to DSA, and one found DSA to be superior. CONCLUSIONS: Based on limited cadaveric study, DSA are at least equivalent biomechanically to SSA, and may be superior. By using DSA, surgeons create repair constructs that are as strong as, or stronger than, those made with SSA, but with fewer anchors. This reduces the amount of holes drilled and implants placed in the glenoid, while also minimizing cost. CLINICAL RELEVANCE: Quantifying the benefit of additional sutures in a suture anchor can help optimize the quality of repair, time, and cost in arthroscopic shoulder repair.

PURPOSE: This study aims to study femoral tunnel lengths drilled with a flexible reamer and the distance to important lateral structures obtained by flexing the knee at various angles and by drilling the guide pins arthroscopically to resemble clinical practice. The purpose of this cadaveric study was twofold: 1. to determine whether femoral tunnel lengths of greater than 20 mm can be created with a flexible reamer system at 90 degrees of knee flexion and 2. to determine whether the lateral structures of the knee are safe with this technique. METHODS: Ten fresh cadaveric knees were utilized. The intra-osseous length can be measured with a specially de - signed flexible guide pin. Flexible pins were inserted with the knee at 70 degrees , 90 degrees , and 120 degrees of flexion. The intra-osseous length was measured with the measuring device. Each speci - men was dissected around the lateral aspect of the knee to identify the critical structures, the common peroneal nerve, and the LCL. The distance from the guide pins to the com - mon peroneal nerve and femoral attachment of the LCL were measured with a standard flexible paper ruler to the nearest millimeter. RESULTS: There is a trend for progressively increasing mean intra-osseous length associated with increased flexion of the knee. The mean intra-osseous length for 70 degrees flexion was 25.2 mm (20 mm to 32 mm), which was statistically significant when compared to mean intra-osseous lengths of 32.1 mm (22 mm to 45 mm) and 38.0 mm (34 mm to 45 mm) in the 90 degrees and 120 degrees flexion groups, respectively (p < 0.05). There were no significant differences among the groups with respect to distance to the LCL. There is a trend toward longer distances to the common peroneal nerve with increased flexion. There was a statistically significant dif - ference when comparing 120 degrees versus 70 degrees (p < 0.05). CONCLUSIONS: This study that shows that adequate femoral tunnel lengths can be safely created without knee hyperflex - ion using flexible instruments via an anteromedial portal.

PURPOSE: To evaluate the fixation integrity at time zero of a type I/III collagen patch secured to a chondral defect in the porcine knee using methods typically employed in autologous chondrocyte implantation (ACI) and matrix-assisted chondrocyte implantation. METHODS: Twenty-four porcine knee specimens underwent a medial parapatellar arthrotomy. A prefabricated template was used to create cartilage defects of 2 cm2 in the medial femoral condyle. A size-matched collagen patch was fashioned. Four methods of fixation to the chondral defect were analyzed: group 1-saline, group 2-fibrin glue around the periphery of the patch, group 3-fibrin glue applied to the base of the defect and around the periphery of the patch, group 4-6-0 vicryl suture and fibrin glue around the periphery of the patch. Collagen patch fixation was assessed at intervals of 60, 300, 600, 900, and 1,200 cycles from full extension to 90 degrees of flexion, performed manually without application of axial force. Patch fixation was evaluated by 2 independent observers using a customized scoring scale. RESULTS: Mean peripheral detachment of the patch and chondral defect uncovering remained less than 25% for all groups. Area of defect uncovering was significantly increased in group 2 compared with group 4 after 900 and 1,200 cycles (P = .0014 and P = .0025, respectively). Fibrin glue applied to the base of the defect, or suturing of the patch, reduced deformation significantly after 900 cycles. CONCLUSIONS: Suture increases the stability of fixation of a type I/III collagen patch to a chondral defect better than fibrin glue alone in the porcine knee after repetitive cycling, with respect to patch detachment and chondral defect uncovering. Application of fibrin glue to the base of the defect, or securing the patch with suture, decreases collagen patch deformation. CLINICAL RELEVANCE: In cases where minimally invasive techniques do not allow suture fixation of the collagen patch, scaffold fixation may be compromised during articular motion protocols typically used after second- and third-generation ACI procedures.

BACKGROUND: The purpose of this study was to see if 3-dimensional (3D) magnetic resonance imaging (MRI) could improve our understanding of rotator cuff tendon tear shapes. We believed that 3D MRI would be more accurate than two-dimensional (2D) MRI for classifying tear shapes. METHODS: We performed a retrospective review of MRI studies of patients with arthroscopically proven full-thickness rotator cuff tears. Two orthopedic surgeons reviewed the information for each case, including scope images, and characterized the shape of the cuff tear into crescent, longitudinal, U- or L-shaped longitudinal, and massive type. Two musculoskeletal radiologists reviewed the corresponding MRI studies independently and blind to the arthroscopic findings and characterized the shape on the basis of the tear's retraction and size using 2D MRI. The 3D reconstructions of each cuff tear were reviewed by each radiologist to characterize the shape. Statistical analysis included 95% confidence intervals and intraclass correlation coefficients. RESULTS: The study reviewed 34 patients. The accuracy for differentiating between crescent-shaped, longitudinal, and massive tears using measurements on 2D MRI was 70.6% for reader 1 and 67.6% for reader 2. The accuracy for tear shape characterization into crescent and longitudinal U- or L-shaped using 3D MRI was 97.1% for reader 1 and 82.4% for reader 2. When further characterizing the longitudinal tears as massive or not using 3D MRI, both readers had an accuracy of 76.9% (10 of 13). The overall accuracy of 3D MRI was 82.4% (56 of 68), significantly different (P = .021) from 2D MRI accuracy (64.7%). CONCLUSION: Our study has demonstrated that 3D MR reconstructions of the rotator cuff improve the accuracy of characterizing rotator cuff tear shapes compared with current 2D MRI-based techniques.

Purpose: iBalance high tibial osteotomy, (iHTO, Arthrex Inc, Naples, Florida), is a recently introduced surgical procedure for correction of knee varus malalignment. iHTO, utilizing a polyetheretherketone (PEEK) implant and osteoinductive compounds (OIC), presents challenging post operative radiographs which can easily be misinterpreted as infection. Our purpose is to report, based on review of 24 cases, the previously undescribed to the best of our knowledge, radiographic features of iHTO and its complications. Materials and Methods: Retrospective query of our digital database was performed to identify iHTO cases. The clinical and postsurgical images in all cases with > 1-month follow up imaging were reviewed with attention to 1. Correction of varus malalignment, 2. Healing at the osteotomy site, 3. Changes in the OIC, and 4. Complications. Results: There were 24 iHTOs in 23 patients (17 men, 6 women, ages 21-59, mean 44, median 46), imaged 1 to 29 months post-surgery, with angle of correction, when available, ranging from 5 to 14degree. Immediate post-surgical correction of varus malalignment was seen in 100 % of patients. 100 % depicted oval radiolucencies, at bone PEEK interface simulating erosions and infection. Four, often overlapping, signs of healing were noted: 1. Blurring of bony margins at the osteotomy site, noted within 2 weeks post surgery, 2. Blurring of sharp interface between OIC and host bone, 3. Anterior, posterior and less commonly medial bridging callus, 4. Resorption of OIC, noted as early as 4 months. Complications, seen in 7 cases (29 %), included genu varum recurrence (n = 2), painful exuberant bone formation, (n = 1), and propagation of the osteotomy through the lateral tibial cortex (n = 4). In patients with >6 months follow-up, nonunion and possible infection was seen in 1 patient. 2 patients required total knee arthroplasty due to iHTO failure. Conclusion: iBalance HTO typically depicts oval radiolucencies at the PEEK bone interface not to be mistaken for infection. Familiarity with this features, as well as with other signs of healing, should aid the radiologist in accurate interpretation of post operative films of iHTO patients

Osseous injuries affecting the posterosuperolateral aspect ofthe humeral head, also known as the Hill-Sachs lesion, arecommon and can pose a difficult problem for the operatingsurgeon. Hill-Sachs lesions can lead to recurrent shoulderinstability if not identified and addressed. This review willfocus on osseous defects of the humeral head and addressthe pathoanatomy, diagnosis, indications, and surgicaltechniques for the treatment of these lesions.