Faculty Bibliography

BACKGROUND: Injury to subchondral bone is associated with knee pain and osteoarthritis (OA). A percutaneous calcium phosphate injection is a novel approach in which subchondral bone marrow edema lesions are percutaneously injected with calcium phosphate. In theory, calcium phosphate provides structural support while it is gradually replaced by bone. However, little clinical evidence supports the efficacy of percutaneous calcium phosphate injections. QUESTIONS/PURPOSES: We asked: (1) Does percutaneous calcium phosphate injection improve validated patient-reported outcome measures? (2) What proportion of patients experience failure of treatment (defined as a low score on the Tegner Lysholm Knee Scoring Scale)? (3) Is there a relationship between outcome and age, sex, BMI, and preoperative grade of OA? METHODS: Between September 2012 and January 2014, we treated 33 patients with percutaneous calcium phosphate injections. Twenty-five satisfied our study inclusion criteria; of those, three patients were lost to followup and 22 (88%; 13 men, nine women) with a median age of 53.5 years (range, 38-70 years) were available for retrospective chart review and telephone evaluation at a minimum of 6 months (median, 12 months; range, 6-24 months). Our general indications for this procedure were the presence of subchondral bone marrow edema lesions observed on MR images involving weightbearing regions of the knee associated with localized pain on weightbearing and palpation and failure to respond to conservative therapy (> 3 months). Patients with pain secondary to extensive nondegenerative meniscal tears with a flipped displaced component at the level of bone marrow edema lesions, or with mechanical axis deviation greater than 8 degrees were excluded. All patients had Grades III or IV chondral lesions (modified Outerbridge grading system for chondromalacia) overlying MRI-identified subchondral bone marrow edema lesions. Percutaneous calcium phosphate injection was performed on the medial tibial condyle (15 patients), the medial femoral condyle (five patients), and the lateral femoral condyle (two patients). Concomitant partial meniscectomy was performed in 18 patients. Preoperative and postoperative scores from the Knee Injury and Arthritis Outcome Score (KOOS) and the Tegner Lysholm Knee Scoring Scale were analyzed. RESULTS: For patients available for followup, the outcome scores improved after treatment. The KOOS improved from a mean of 39.5 +/- 21.8 to 71.3 +/- 23 (95% CI, 18.6-45.2; p < 0.001) and the Tegner and Lysholm score from 48 +/- 15.1 to 77.5 +/- 20.6 (95% CI, 18.8-40.2; p < 0.001). However, seven of the 22 patients had poor clinical outcomes as assessed by the Tegner Lysholm Knee Scoring Scale, whereas three had fair results, five had good results, and seven had excellent results. The postoperative Tegner Lysholm score was inversely related to the preoperative Kellgren-Lawrence OA grade (R2 = 0.292; F (1.20) = 9.645; p = 0.006). We found no relationship between outcome scores and age, sex, or BMI. CONCLUSIONS: In a study that would have been expected to present a best-case analysis (short-term followup, loss to followup of patients with potentially unsatisfactory results, and use of invasive cotreatments including arthroscopic debridements), we found that percutaneous calcium phosphate injection in patients with symptomatic bone marrow edema lesions of the knee and advanced OA yielded poor results in a concerning proportion of our patients. Based on these results, we advise against the use of percutaneous calcium phosphate injections for patients with advanced osteoarthritic changes. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Objectives: The purpose of the present study was to determine when patients recover the ability to safely operate the brakes of an automobile following a right knee anterior cruciate ligament reconstruction (ACLR). Methods: A prospective case series of 27 patients who underwent a right knee ACLR, nine with a bone patellar tendon-bone (BPTB) autograft, nine patients who had hamstring (HS) tendon autograft and nine patients who had tibialis anterior (TA) tendon allograft for their reconstructions were tested in a validated computerized driving simulator. At 7-10 days, three weeks, and six weeks post operatively, patients were evaluated with respect to their brake reaction time (BRT), brake travel time (BTT), and total braking time (TBT). Each cohort was then compared with thirty healthy volunteers with similar demographics to establish normative mean values. Results: At 7-10 days post-operatively, all patients had statistically significant differences compared to controls for BRT, BTT, and TBT, regardless of the graft used for the reconstruction. By three weeks postoperatively, those reconstructed with TA allografts demonstrated a return to normal braking parameters with no statistically significant differences compared to controls between BRT, BTT, and TBT, whereas those with BPTB and HS autografts continued to have significant delays in their BTT and TBT with BPTB (p = 0.007, p = 0.009) and HS (p = 0.016, p = 0.015), respectively. By six weeks post-operatively, braking parameters for patients receiving an ACL reconstruction with a hamstring autograft returned to normal values while those treated with a BPTB autograft continued to demonstrate impairment in brake travel time and total braking time compared to controls; however, their brake reaction time had recovered to normative values. Conclusion: Patients who underwent a right knee ACL reconstruction with a TA allograft regained normal braking times by three weeks post-operatively and continued to improve through the six week postoperative time point. In contrast, those treated with a BPTB or HS autograft demonstrated impaired ability to operate motor vehicle brakes three weeks following surgery. While at six weeks, the braking ability of patients treated with hamstring autografts normalized, those receiving a BPTB autograft continued to demonstrate limitations in their brake travel time and total braking time. Patients should be counseled appropriately when discussing reconstruction options and when it is safe to resume driving

Objectives: The purpose of the current study is to investigate the functional strength outcomes of late distal biceps reconstruction using allograft tissue. Methods: Patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2013 were identified. Charts were retrospectively reviewed for post-operative complications, gross flexion and supination strength, and range of motion (ROM). Isokinetic strength and endurance in elbow flexion and forearm supination were measured in both arms. Tests were conducted using a dynamometer at 60o per second for isokinetic strength and 240o per second for endurance. Isometric strength testing was also measured for elbow flexion and forearm supination. Paired t tests were used for statistical analysis. Results: Ten patients with a mean age of 48 years (range 42 - 61 years) were included in the study. Distal biceps reconstruction was performed using an Achilles tendon allograft in 9 patients and a combination of tibialis anterior allograft and gracilis allograft in 1 patient. Of the reconstructions, 50% involved the dominant arm. Full ROM was observed in all patients at the time of their final follow up assessment. The mean followup for dynamometer strength testing was 34 months (range 13-81 months). No statistical differences were noted between data obtained from operative and contralateral extremities. The average peak torque of the operative limb (38.5+/- 5.9 Nm) was 91.7% of that of the contralateral limb (41.8+/-4.9 Nm) in flexion and 93.4% (operative, 5.7+/-1.3 Nm; contralateral, 6.1+/- 1.0 Nm) in supination. No significant differences were found in fatigue index between operative or contralateral limbs for flexion (operative, 34.1+/-17.1%; contralateral, 30.8+/-17.1%; p = 0.29) or supination (operative, 38.2+/-16.5%; contralateral, 42.1+/-11.9%; p = 0.65). The only complication observed was a transient PIN palsy in one patient which resolved by 3 months post-operatively. All patients reported postoperative cosmetic deformity but found their gross appearance acceptable. Conclusion: Late reconstruction for chronic distal biceps rupture using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. Dynamometer testing shows near normal return of strength and endurance of both elbow flexion and supination following the procedure

Ice hockey is a fast paced sport with unique injury potential. There are no studies in the literature that examine the shoulder strength and range of motion in this population. Players on a single professional ice hockey team underwent a comprehensive examination of shoulder motion and strength. Shoulder motion and strength between right and left extremities were compared within athletes. Comparisons were made between right and left handed players, players that shoot right versus left handed, and by position. Within individual athletes, there was no difference in motion or strength between right and left shoulders. There was no difference in motion or strength between the dominant and non-dominant shoulder and players that shoot right versus left handed. Defensemen had a statistically significant increase in external rotation with the arm at the side for the left shoulder (66 degrees versus 55 degrees , p = 0.02) and a trend towards increased external rotation with the arm at the side for the right shoulder (65 degrees versus 56 degrees , p = 0.07). In professional ice hockey players, there is no difference in shoulder motion and strength between the right and left upper extremity. Ice hockey defensemen may have more external rotation with the arm at the side than forward.

PURPOSE: To explore the feasibility of T1rho mapping of menisci at 3T in discriminating between patients with acute anterior cruciate ligament (ACL) injury and healthy controls. MATERIALS AND METHODS: Thirty-three subjects were included in the study and subdivided into two subgroups: 16 healthy controls (4 females, 12 males; mean age = 34.4 +/- 10.2 years, age range 24-63 years), 17 patients with ACL injury (3 females, 14 males; mean age = 29.8 +/- 10.8 years, age range 18-61 years). T1rho images from all subjects were acquired on a 3T MR scanner using a spin-lock-based 3D GRE sequence and computed for T1rho mapping. Clinical proton density (PD)-weighted fast spin echo (FSE) images in the sagittal (without fat saturation), axial, and coronal (fat-saturated) planes were also acquired for cartilage assessment using Whole-Organ MR Imaging Score (WORMS) grading. Mixed model two-way analysis of variance (ANOVA) was performed to determine whether there were any significant differences among subregional, compartmental, and whole structure T1rho values of meniscus between healthy controls and ACL-injured patients. RESULTS: Lateral posterior (29 +/- 8 msec) and medial central (25 +/- 7 msec) meniscus subregions in healthy controls had significantly lower T1rho values (P < 0.05) than the corresponding meniscus subregions in ACL-injured patients. Significantly lower meniscus T1rho values (P < 0.05) were also identified in lateral compartment in healthy controls (26 +/- 6 msec) than that of ACL-injured patients (33 +/- 4 msec). Subjects' total WORMS between healthy controls and ACL-injured patients had significant differences (P < 0.05). CONCLUSIONS: These preliminary results indicate that T1rho mapping is possibly feasible in detecting meniscus degeneration and may be useful in distinguishing ACL-injured patients. J. Magn. Reson. Imaging 2014. (c) 2014 Wiley Periodicals, Inc.

BACKGROUND: The purpose of this study was to evaluate the effect of sling immobilization on driving performance with use of a driving simulator. METHODS: This is a prospective trial with a cohort of 21 healthy volunteers comparing their driving ability with and without sling immobilization on their dominant (driving) extremity. Multiple variables, including number of collisions, off-road excursions, and centerline crossings, were measured with a validated driving simulator. Trials were separated by 2 weeks to control for "adaptations" to the simulator. Statistical significance was found in collisions between sling and no-sling tests. RESULTS: The total number of collisions for trial 1 (no sling) was 36 (mean, 1.7 +/- 1.2) compared with 73 (3.7 +/- 1.6) (P < .01) for trial 2 (sling immobilization). Approximately 70% of participants with upper extremity immobilization were involved in >/=3 collisions; approximately 70% of no-sling participants were involved in