Faculty Bibliography

Objectives: Participation rates in women's ice hockey is increasing in North America. Recent studies have demonstrated an increased prevalence of femoroacetabular impingement (FAI) in elite male ice hockey players, yet little is known about hip pathology of players in the National Women's Hockey League (NWHL). The primary purpose of this study was to determine the prevalence of radiographic FAI in women's professional ice hockey players. The secondary purpose was to analyze the relationship between the presence of radiographic cam deformity and hip ROM, clinical impingement signs and age of menarche.
Method(s): In this IRB-approved study, physical examination and demographic data were prospectively collected for 27 NWHL players. Alpha angles were measured on 45-degree Dunn views with an alpha angle >55degree defined as cam-positive. Pearson correlations were performed to analyze the relationship between alpha angle and ROM measurements, clinical impingement signs and self-reported age of menarche. Players were grouped into those with and without cam impingement and group differences were assessed using the student's t-test. Statistical significance was set at p<0.05.
Result(s): Twenty-seven athletes were included in the study. Nineteen of the 27 players (70%) had radiologic evidence of cam-type impingement with alpha angle >55 degrees; 14 players (52%) had bilateral cam deformity. The average age of menarche was 13.9+/-1.5 years. There was a significant association between age of menarche and right alpha angle (R=0.57, CI [0.16, 0.81], p=0.011), as well as age of menarche and left alpha angle (R=0.48, CI [0.03, 0.77], p=0.039). There was no statistically significant association between alpha angle and any ROM measurement. Additionally, there was no difference in the incidence of clinical impingement for players with or without an alpha angle >55degree.
Conclusion(s): This study suggests that elite female ice hockey players have a significantly higher prevalence of cam-type morphology than the general population. The clinical significance of this radiographic finding is uncertain as the majority of these deformities seem to be asymptomatic. Interestingly, the positive association between alpha angle and age of menarche lends support to the etiological hypothesis that cam lesions are a result of activityrelated stress at the proximal femoral physis. This data suggests that players with earlier menarche (and therefore earlier physeal closure) seem to be less vulnerable to the development of cam deformity of the proximal femur

BACKGROUND:There is mixed opinion regarding the optimal femoral fixation method for hamstring tendon autograft in anterior cruciate ligament (ACL) reconstruction. Currently, no study exists showing a superior method of femoral fixation, and thus the topic has remained controversial. The purpose of this study is to network meta-analyze the randomized control trials comparing cortical-button (CB), cross-pin (CP) and interference screws (IS) for femoral fixation with hamstring tendon autograft in ACL reconstruction. METHODS:The literature review was conducted in accordance with the PRISMA guidelines. Randomized control trials comparing CB, CP and IS were included. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with all statistical analysis performed using R, with a p-value <0.05 being considered statistically significant. RESULTS:There were 11 studies included comparing; 194 patients with CB to 201 patients with CP (6 studies), 48 patients with CB to 50 patients with IS (1 study), and 172 patients with CP to 162 patients with IS (5 studies). One study compared all three groups, including 48 patients with CB, 50 patients with IS, and 52 with CP. There was a mean follow-up time of 26.4 months. No statistically significant difference was found between the fixation methods when evaluating knee stability, functional outcomes, graft failures, or revision procedures. CONCLUSION/CONCLUSIONS:Using a network meta-analysis, our study found that, there was no difference in failure rate, knee stability, functional outcomes or incidence of revision procedures between CB, CP or IS femoral fixation techniques of hamstring tendon autografts in ACL reconstruction. LEVEL OF EVIDENCE/METHODS:Level I, network meta-analysis of Level I studies.

PURPOSE OF REVIEW/OBJECTIVE:Accurate isolated PCL diagnosis continues to present a challenge. This article reviews the current literature regarding clinical and radiographic evaluation of PCL injuries. RECENT FINDINGS/RESULTS:A thorough history to understand the mechanism of injury should begin any evaluation. Several clinical tests have been shown to effectively assess PCL laxity, with the posterior drawer test possessing the highest sensitivity and specificity. Any thorough exam should compare the contralateral, uninjured leg. If a PCL or multi-ligament injury is suspected, plain radiographs should be performed to avoid missing a fracture or avulsion. An MRI represents the current gold standard for diagnosing ligament injuries in the knee and should always be obtained in these cases. Due to the significant incidence of nerve injuries (25%) and vascular injuries (18%) with knee dislocations, any suspicion of neurovascular compromise necessitates further studies. A combination of a thorough clinical history and examination, followed by appropriate imaging optimizes PCL and multi-ligament injury evaluation.

Objectives: The purpose of this study was to determine if patellar tendon (PT) thickness measured on pre-operative magnetic resonance imaging (MRI) is a risk factor for failure after anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BTB) autograft.
Method(s): 18 patients [age (mean 96 Normal 0 false false false EN-US X-NONE X-NONE /*Style Definitions*/ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent: mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; mso-bidi-font-size:12.0pt; font-family:Helvetica;} +/- standard deviation) 21.5 +/- 4.99years] that underwent an ACLR with BTB autograft and returned for revision ACLR between July 2005-January 2017 at our institution were included in the study. Failures were age-, sex-, height-, and weight-matched to 36 control (age 21.5 +/- 4.99years) BTB-ACLR patients that have not required revision at a minimum of 2-years follow-up. Demographic data and mechanism of injury were recorded from patients' medical records. PT thickness was measured at 3 points (5mm lateral to the center, center, and 5mm medial to the center) each at the level of the inferior pole of the patella (IPP), midpoint (MP), and insertion to tibial tubercle (ITT) on pre-operative axial-cut MRI.
Result(s): All ACLR failures occurred after a non-contact pivot-shift type injury. Mean time between primary ACLR and revision was 2.4 +/- 2.4 years and mean follow-up time was 3.1 +/- 0.9 years in the control group. Patients with a failed ACLR had significantly thicker PTs at the IPP (lateral: 4.66 +/- 1.47 vs 3.96 +/- 0.66mm; central: 5.39 +/- 1.49 vs 4.51 +/- 1.04mm; medial: 5.51 +/- 1.52 vs 4.59 +/- 1.05mm) and MP (lateral: 4.50 +/- 0.83 vs 4.12 +/- 0.54mm; central: 4.83 +/- 0.80 vs 4.43 +/- 0.59mm; medial: 4.57 +/- 0.88 vs 4.13 +/- 0.59mm). There were no significant differences in PT thickness at the ITT. PT width tended to be larger in the failure cohort but this was not statistically significant (IPP: 32.2 +/- 4.6 vs 29.8 +/- 4.3mm; MP: 31.3 +/- 4.9 vs 29.5 +/- 3.8mm; ITT: 27.7 +/- 3.7 vs 26.2 +/- 2.9mm).
Conclusion(s): Contrary to conventional wisdom, we found that BTB autograft ACLR failures had significantly thicker patellar tendons at the inferior pole of the patella and midpoint. Further studies are need to investigate possible causes for this inverse correlation, such as poor histological tendon quality or mechanical impingement due to increased tendon size

Knee pain in young, active patients with meniscus-deficient knees and articular cartilage damage can present a challenge to treatment. Meniscal allograft transplantation (MAT) has shown good clinical results as treatment for meniscus deficiency; however, worse outcomes have been observed in patients with significant chondral damage. The development of chondral restorative techniques such as osteochondral allograft transplantation (OCA) has expanded the population of patients who may benefit from MAT. We present a case of proximal tibial osteochondral and lateral meniscal allograft transplant. This review includes a sample of patient examinations and imaging, followed by a detailed technical description of the case. The technique article concludes with a discussion on the niche combined MAT-OCA procedures occupy in the patient treatment realm.

BACKGROUND: Lack of insurance has been shown to lead to delays in seeking care as well as fewer preventive medicine visits and poorer overall health status. PURPOSE: To investigate the effects of insurance status on the timing and treatment of patients with bucket-handle meniscus tears. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Charts from 2004 to 2013 were retrospectively reviewed for patients diagnosed with bucket-handle meniscus tears. Patients were divided into 2 groups: insured or underinsured. The insured group included patients with commercial insurance or Medicare. The underinsured group included patients with Medicaid or Charity Care. Time intervals were categorized as <6 weeks or >/=6 weeks. RESULTS: A total of 52 patients were included in this study: 15 (29%) insured and 37 (71%) underinsured. Underinsured patients experienced delays in initial presentation to an orthopaedic surgeon (P = .004), time from magnetic resonance imaging to surgery (P = .01), and time from injury to surgery (P = .007). Repair rates were 40% and 38% (P > .999) for the insured and underinsured, respectively. Repair rates for <6 weeks from injury to surgery were 75% for insured (P = .007) and 100% for underinsured patients (P = .001). Repair rates for >/=6 weeks from injury to surgery were 0% for insured and 30% for underinsured patients. Overall, patients with an injury-to-surgery time of <6 weeks had a significantly higher repair rate (87%) than those managed >6 weeks (19%) (P < .001). CONCLUSION: Underinsured patients experience significant delays in time to presentation and overall time to surgery. However, the overall repair rate between the insured and underinsured is similar. Regardless of insurance status, patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks. CLINICAL RELEVANCE: Patients undergoing arthroscopy within 6 weeks of injury have a significantly higher repair rate than those after 6 weeks.

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.

BACKGROUND: The active compression test has been described to detect superior labrum anterior and posterior (SLAP) lesions. Some have speculated that contact between the lesser tuberosity and the superior glenoid in the testing position causes a positive test. This study evaluated the location of peak glenohumeral contact pressures during a simulated active compression test in a cadaveric model with and without SLAP lesions. MATERIALS AND METHODS: Six specimens were tested. A pressure sensor was used to record glenohumeral contact, and a motion analysis system was used to measure humeral head translation. Contact pressures and translations were measured during serial deltoid and biceps loads. These were repeated for small and large SLAP lesions. RESULTS: There was a notable shift in the location of peak contact pressure from the anterior-inferior glenoid to the anterior-superior glenoid with increasing deltoid load. Deltoid loading translated the humeral head posteriorly relative to the glenoid. Conversely, biceps loads countered the pull of the deltoid only when the biceps load was greater than the deltoid load. The SLAP tears did not significantly alter the degree of humeral head translation or location of the contact pressures. CONCLUSIONS: In the active compression test, the posterior capsule is taut and the anterior capsule is lax, which permits the deltoid to translate the humeral head posteriorly. This shift in the peak contact pressure to the superior glenoid may elicit a positive active compression test.

BACKGROUND: Arthroscopically assisted anterior cruciate ligament reconstruction using a bioabsorbable tibial fixation screw is occasionally complicated by pretibial cyst formation. The few case reports describing pretibial cyst formation noted several graft types and fixation techniques, making it difficult to establish one etiology. Some literature suggests cysts form from communication between the joint and pretibial area leading to extravasation of joint fluid, maturing into a cyst. We propose the development of cysts after PLLA screw use may be related to a foreign body reaction. QUESTIONS/PURPOSES: We propose this foreign body reaction (1) relates to the biochemical breakdown of bioabsorbable materials; and (2) differs from cystic formations resulting from joint communication. METHODS: We retrospectively reviewed seven patients who developed pretibial cysts at least 2 years after original primary ACL reconstruction surgery. MRI was used to visualize the extent of cystic formation. Cysts were treated by debridement with specimens sent for histologic analysis. Cyst appearance had a 3-year incidence of 5%. RESULTS: No cyst had an infectious etiology. In all cases, the tibial screw outline was present on MRI, although intraoperatively, the screw was substantially decomposed. Grafts were well incorporated and none of the knees demonstrated anterior laxity. Histologically, cyst material contained fragments of PLLA surrounded by foamy histiocytes, suggesting a foreign body reaction. No cysts recurred. CONCLUSIONS: Tibial cysts occur in a subset of patients undergoing ACL reconstruction using a bioabsorbable PLLA interference screw. We suspect they arise from a foreign body response to the screw breakdown. Removal is well tolerated. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

BACKGROUND: Techniques for reconstruction of the dislocated acromioclavicular (AC) joint abound. Most, however, do not address the injured AC ligaments and capsule. Evidence exists supporting the horizontal stabilizing effect of these ligaments on the AC joint. A novel AC and coracoclavicular (CC) reconstruction technique with an intramedullary free-tissue graft secured by suture buttons is low-profile, technically straightforward, and reproducible. HYPOTHESIS: A novel intramedullary AC reconstruction will strengthen an isolated free-tissue reconstruction of the CC ligaments. STUDY DESIGN: Controlled laboratory study. METHODS: Six cadaveric matched pair shoulders were tested with a custom testing system. Anterior-posterior and superior-inferior AC joint displacements (mm) were measured with AC joint compressions of 10 N, 20 N, and 30 N, and with translational loads of 10 N and 15 N. The same measurements were made after performing either a free-tissue tendon allograft CC reconstruction, or a free-tissue graft reconstruction of the CC and AC ligamentous complexes in the corresponding contralateral matched shoulder. The AC ligamentous complex was reconstructed with an intramedullary free-tissue graft secured by suture buttons. Load-to-failure testing was then performed on each construct. A paired t test was used for statistical analysis (P < .05). RESULTS: Mean anterior-posterior translation of the reconstruction of the CC and AC ligamentous complexes was 50% or less than that of the CC reconstruction in all loading conditions (P < .05). Mean superior-inferior translation did not differ among the groups. Overall load-to-failure testing did not differ between groups. CONCLUSION: Intramedullary AC complex reconstruction utilizing free-tissue graft for reconstruction of both the CC and AC ligaments demonstrates significantly greater initial horizontal stability than a free tissue isolated CC reconstruction and is similar to intact specimens. CLINICAL RELEVANCE: This novel intramedullary AC ligament reconstruction may be considered when seeking to improve horizontal stability in an anatomical CC ligament reconstruction.