[Show abstract][Hide abstract] ABSTRACT: When performing reconstruction of the ACL, the major complications that can arise include missed concomitant injuries, tunnel malposition, patellar fracture, knee stiffness, and infection. We review the complications that can occur as a result of errors made before, during, and after surgery.
Full-text · Article · Nov 2011 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Using 3-dimensional high-resolution magnetic resonance imaging (MRI), we sought to compare femoral and tibial tunnel position and resultant graft obliquity with single-bundle anterior cruciate ligament (ACL) reconstruction using transtibial (TT) or anteromedial (AM) portal femoral tunnel reaming techniques.
Thirty patients were prospectively enrolled after primary, autogenous bone-patellar tendon-bone ACL reconstruction by 2 groups of high-volume, fellowship-trained sports medicine surgeons. With the TT technique, an external starting point was used to maximize graft obliquity and femoral footprint capture. By use of high-resolution MRI and imaging analysis software, bilateral 3-dimensional knee models were created, mirrored, and superimposed. Differences between centroids for each femoral and tibial insertion, as well as corresponding ACL/graft obliquity, were evaluated with paired t tests and 2-sided Mann-Whitney nonparametric tests, with P < .05 defined as significant.
No significant differences were observed between groups in position of reconstructed femoral footprints. However, on the tibial side, AM centroids averaged 0.8 ± 1.9 mm anterior to native ACL centroids, whereas the TT group centered 5.23 ± 2.4 mm posterior to native ACL centroids (P < .001). Sagittal obliquity was closely restored with the AM technique (mean, 52.2° v. 53.5° for native ACL) but was significantly more vertical (mean, 66.9°) (P = .0001) for the TT group.
In this clinical series, AM portal femoral tunnel reaming more accurately restored native ACL anatomy than the TT technique. Although both techniques can capture the native femoral footprint with similar accuracy, the TT technique requires significantly greater posterior placement of the tibial tunnel, resulting in decreased sagittal graft obliquity. When a tibial tunnel is drilled without the need to accommodate subsequent femoral tunnel reaming, more accurate tibial tunnel position and resultant sagittal graft obliquity are achieved.
Level III, retrospective comparative study.
No preview · Article · Sep 2011 · Arthroscopy The Journal of Arthroscopic and Related Surgery
[Show abstract][Hide abstract] ABSTRACT: Young, active, skeletally mature patients have higher failure rates after various surgical procedures, including stabilization for shoulder instability and primary ACL reconstruction. It is unclear whether young, active, skeletally mature patients share similarly high failure rates after revision ACL reconstruction.
We therefore determined whether revision ACL reconstruction restores knee stability and allows young (younger than 18 years), active, skeletally mature patients to return to preinjury activity levels.
We retrospectively identified 36 patients who had an initial ACL reconstruction between the ages of 12 and 17 years (mean, 15.4 years) and subsequent revision between the ages of 13 and 18 years (mean, 16.9 years); of these, 2-year followup was available for 21 (75%). Mechanisms of primary graft failure included traumatic rerupture (23 noncontact, seven contact), persistent instability (five), and infection (one). One patient had open physes at the time of revision. All revisions were single-stage transosseous reconstructions. The minimum followup was 24 months (mean, 36 months; range, 24-63 months).
At last followup, 19 of 21 patients had a negative or IA Lachman and 20 of 21 had a negative pivot shift. Mean International Knee Documentation Committee subjective score was 89 (range, 64-99). Eleven of the 21 patients returned to the same or higher activity/sport level as before their original injury. Two patients reported subjective knee instability, with two having repeat revision reconstruction for failure.
Single-stage transosseous revision ACL reconstruction in young, active, skeletally mature patients restores knee stability but returns only 52% of patients to their prior level of activity or sport.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Full-text · Article · Jul 2011 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: The management of patellar instability has advanced with an improved understanding of the critical role of the medial patellofemoral ligament (MPFL), along with the development of novel techniques for ligament reconstruction. The docking technique for MPFL reconstruction offers several technical advantages, including anatomically accurate reconstruction, ease of confirmation of graft isometry, and simplicity of graft tensioning and fixation. Biomechanically, the femoral fixation provides a combined interference screw and suture anchor construct. Imbrication of the vastus medialis obliquus (VMO) and medial retinaculum contributes additional dynamic support to the medial soft-tissue reconstruction. The docking technique offers a simplified and accurate approach to MPFL reconstruction, with consistently favorable postoperative results in the management of patellar instability.
No preview · Article · Jun 2010 · Operative Techniques in Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: Various patellar stabilization techniques exist and are best used when they address the specific underlying pathology, which is often multifactorial. Each technique has unique potential complications that must be prevented or, recognized early and managed. Soft tissue proximal realignment procedures, including (1) lateral release, (2) arthroscopic or open medial imbrication, and (3) repair or reconstruction of the medial patellofemoral ligament, can alter kinematics and stress patterns, over-constraining or even further destabilizing the patellofemoral articulation. The creation of drill holes in the patella for ligament reconstruction can risk damage to the articular cartilage or even patellar fracture. Similarly, distal realignment via tibial tubercle osteotomy risks possible nonunion, neurovascular injury, and fracture of the tibia. In all instances, preoperative articular cartilage injury should be recognized and further loading these areas from surgical stabilization technique should be avoided or at least minimized. Individual patellofemoral stabilization procedures and their specific complications are reviewed here in detail.
No preview · Article · Jun 2010 · Operative Techniques in Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: Elbow ulnar collateral ligament (UCL) reconstruction has become the standard of care for the throwing athlete with a symptomatic ruptured or insufficient ligament and the desire to resume competitive play. Since Jobe's initial description of UCL reconstruction, the technique has evolved. A novel modification was the "docking" technique developed by Altchek. Subsequently, the docking technique as originally described was slightly modified. Arthroscopy is no longer routinely performed, and in some cases, a 3-strand graft is used.
We treated 21 overhand athletes with clinical and radiographic evidence of UCL insufficiency with ligament reconstruction using a modified version of the docking technique using a 3-strand graft. There were 5 professional, 11 college, and 5 high school baseball players in the reconstructed group. Athletes were evaluated postoperatively by use of the Conway Scale.
Of the 21 patients who underwent the modified docking technique with a three-strand graft, 19 (90%) had excellent results. There were 2 good results and no complications.
UCL reconstruction can successfully treat athletes with UCL insufficiency. Several different reconstruction techniques have been described. By use of the docking and modified docking techniques, good to excellent results can be achieved in the majority of cases with a low complication rate.
No preview · Article · Mar 2010 · Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]
[Show abstract][Hide abstract] ABSTRACT: Men's intercollegiate lacrosse is played at a fast pace and with significant force. Glove protection is required. However, the thumb is at risk because of contact with opponents' sticks, the ball, other players, and the ground or artificial surface.
To characterize patterns of hand injuries in men's intercollegiate lacrosse and to compare them with those in similar intercollegiate stick-handling sports that require gloves.
Descriptive epidemiology study.
The National Collegiate Athletic Association (NCAA) Injury Surveillance System was utilized to evaluate thumb injuries in intercollegiate stick-handling sports (men's lacrosse, women's lacrosse, and men's ice hockey) during 16 intercollegiate seasons. Injuries were defined as events requiring an athlete to seek medical treatment and miss competition. Data were collected for injuries to the thumb, phalanges, and hand. Descriptive statistics were performed to calculate rates of injury per 1000 athlete-exposures and the relative exposure of the thumb with respect to total hand injuries. chi(2) testing with the Yates correction for continuity was performed to determine differences in proportions of injury among the 3 sports studied.
During 16 intercollegiate seasons, there were 692 thumb, finger, and hand injuries in 3 038 255 athlete-exposures. Total thumb injuries were significantly higher in men's lacrosse, accounting for 59.4% of total hand injuries, when compared with women's lacrosse (42%) and men's ice hockey (35.8%) (P <.001). Thumb fractures and contusions were each also found to be significantly more prevalent (P <.001) when compared with women's lacrosse and men's ice hockey.
Men's intercollegiate lacrosse requires the use of gloves; nonetheless, injury rates of the thumb are significantly elevated in this sport compared with other gloved, stick-handling sports. Recommendations include the development of gloves with improved thumb protection.
No preview · Article · Mar 2010 · The American Journal of Sports Medicine
[Show abstract][Hide abstract] ABSTRACT: Treating ACL injuries in prepubescent patients requires balancing the risk of chondral and meniscal injuries associated with delaying treatment against the risk of growth disturbance from early surgical reconstruction. Multiple physeal respecting techniques have been described to address this vulnerable population; however, none restore the native ACL attachments while keeping the graft and fixation entirely in the epiphysis.
We describe a technique of all-epiphyseal ACL reconstruction for use in prepubescent skeletally immature patients. Intraoperative CT scanning with three-dimensional (3-D) reconstruction was used to confirm the precise localization of the all-epiphyseal femoral and tibial tunnels. The femoral tunnel is drilled entirely in the epiphysis of the lateral femoral condyle. The tibial tunnel is drilled from inside-out to the level of the tibial physis using a retrograde drill. Fixation of the soft tissue graft is achieved with a retrograde interference screw in the tibia and an interference screw in the femur.
Case examples are presented for three boys aged 10-12, Tanner Stage 1 development, with a minimum followup of 1 year.
All three patients had stable knees based on Lachman and KT-1000 testing and no evidence of growth disturbance. All had full ROM and symmetric strength for knee flexion and extension. All patients returned to their sports activities using a custom ACL brace.
Although longer-term followup will be necessary, this technique provides for an anatomic all-epiphyseal-based ACL reconstruction using intraoperative 3-D imaging to minimize the risk of growth disturbance.
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Preview · Article · Feb 2010 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Protective gloves are worn for stick-handling sports, including ice hockey, men's lacrosse, and women's lacrosse, but are not mandated for women's field hockey. The purpose of this study is to evaluate whether collegiate field hockey players are at increased risk for significant hand injuries compared with stick-handling athletes who wear protective gloves.
In this descriptive, epidemiological study, data were gathered from the NCAA Injury Surveillance System reported over a 16-yr period pertaining to 1036 hand and phalangeal injuries occurring in 3,752,547 exposures in stick-handling athletes (field hockey, ice hockey, men's lacrosse, and women's lacrosse). An exposure was defined as an athlete's participation in an individual practice or game. Data were analyzed for total injuries, fractures, ligamentous injuries, contusions, and lacerations and calculated as rates per 1000 exposures. Rates were compared among the four stick-handling sports.
Odds ratios (OR) of hand injuries, hand fractures, phalangeal injuries, and phalangeal fractures were significantly higher in the ungloved (field hockey) athletes than in the gloved athletes (P < 0.01). The odds of a hand injury (OR = 2.12), hand fracture (OR = 1.93), phalangeal injury (OR = 4.19), or phalangeal fracture (OR = 4.04) occurring in ungloved players were significantly higher than for gloved players.
Of participants in four stick-handling sports, collegiate field hockey players have significantly higher odds of sustaining hand or phalangeal injuries. Wearing gloves is a protective measure common in ice hockey and men's and women's lacrosse. However, it is not the current practice in field hockey. We recommend the use of protective gloves in collegiate field hockey practice and competition.
No preview · Article · Dec 2008 · Medicine and science in sports and exercise
[Show abstract][Hide abstract] ABSTRACT: Open exposure of the posterolateral corner of the knee is challenged by limitations of posterolateral ligamentous tissues and posterior neurovascular structures. We have used a modification of a lateral femoral epicondyle osteotomy, described historically for surgical management of posterolateral rotatory instability, as an approach to the posterolateral intraarticular structures. The historic technique for ligamentous reconstruction has been abandoned because its nonanatomic fixation does not restore ligamentous isometry. In this report, osteotomy of a bone block from the lateral femoral epicondyle is used to access the joint space. The lateral collateral ligament is reflected distally and posteriorly through traction on the block. Once the intraarticular disorder has been addressed, the lateral femoral epicondyle is secured in its native, anatomic position, thereby restoring isometry and normal joint mechanics after surgery. This technique has been used successfully to address posterolateral articular disorders on femoral and tibial sides. Postoperative magnetic resonance imaging verified restoration of lateral collateral ligament anatomy. Physical examination at 0° and 30° knee flexion showed clinical stability at all postoperative evaluations through 6 and 10 months followup. Using this technique, intraarticular disorders at the posterolateral corner may be addressed in an open manner with anatomic reduction and preserved postoperative function of the lateral collateral ligament.
Level of Evidence: Level V, expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.
Full-text · Article · Aug 2008 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: Methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as a serious skin infection in the athletic population. Literature in reference to football players has been sparse. We sought to better elucidate circumstances surrounding such infections in collegiate football players.
Data from three Division-I collegiate football programs were consolidated and analyzed. Variables included presence of MRSA infection, timing of occurrence, body location involved, lesion morphology, need for surgical treatment, and antibiotic route. Data were analyzed statistically to evaluate player position, body location, and timing of occurrences.
Of the 491 collegiate football players, 33 (6.7%) were diagnosed with MRSA infections. Cutaneous manifestations included abscess (70%), cellulitis (16%), folliculitis, impetigo, and necrotizing fasciitis. Of the infections, 90% underwent surgical drainage, whereas 27% received intravenous antibiotics. Extremity infections (n = 30) greatly exceeded truncal infections (n = 7); the most common locations were the elbow (n = 11), knee (n = 6), leg (n = 4), and forearm (n = 4). There was no difference in occurrence by player position. Infections occurred predominantly in the first third of the season (P < 0.001, chi-square test) and significantly decreased as the season progressed.
MRSA infections involving football players are becoming more common. This study documents player positions involved, timing of occurrence in the season, location and type of infections, and required treatment. Exposed extremities may predispose to infection due to risk for minor trauma and direct contact with bacteria. As infection risk seems to be independent of position, all players should observe protective measures. Although most infections occur earlier in the season, physicians should remain alert for infection occurrences throughout the season.
No preview · Article · Aug 2008 · Medicine and science in sports and exercise
[Show abstract][Hide abstract] ABSTRACT: Traumatic arteriovenous fistulae are rare injuries in the pediatric population. Most are caused by penetrating injuries or are post-surgical in nature. Fistulae resulting from non-penetrating injuries are often missed early in the course of physical examination. This occurs due to the absence of clinical signs of arterial or venous injury, despite the close proximity of the affected vessels to point of injury. Likewise, signs and symptoms of post-surgical vascular injury may be difficult to discern from normal postoperative discomfort. The astute clinician must be on alert for unusual presentations of vascular injury to intervene in an expeditious manner. This article presents a series of vascular complications following either blunt injury or surgical management of the lower extremity in children who presented to our facility between November 2004 and December 2005.
[Show abstract][Hide abstract] ABSTRACT: Internal fixation of a traumatic osteochondral defect presents a challenge in terms of obtaining anatomic reduction, fixation, and adequate compression for healing. Fixation with countersunk intraarticular screws, Herbert screws, bioabsorbable screws and pins, mini-cancellous screws, and glue tissue adhesive have been reported with varying results. We present an alternative fixation method used in two patients for femoral condylar defects that achieved anatomic reduction with compression via a cruciate-shaped suture bridge construct tied down over a bony bridge. This fixation method allowed early passive range of motion and permitted high-quality MRI for followup of fracture healing and articular cartilage integrity. Arthroscopic examination of one of two patients at 6 months followup showed the gross appearance of a healed, anatomically reduced fracture. With 1 year followup for one patient and 2 years for the other, the patients have resumed activity as tolerated with full, painless range of motion at the knee. Longer-term outcomes are unknown. However, the suture bridge is an alternative means of fixation with encouraging early results for treatment of traumatic osteochondral fragments in the knee.
Level of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Full-text · Article · Jul 2008 · Clinical Orthopaedics and Related Research
[Show abstract][Hide abstract] ABSTRACT: The conventional method of inserting pedicle screws (ie, plain radiography, standard 2D fluoroscopy, direct palpation) was found to be less accurate with cortical violation ranging from 10 to 50%. Small and variable anatomy of the cervical and thoracic spine poses a particular challenge, and it can lead to a devastating neurovascular complication. With recent advances in imaging technologies, such as computed tomography-based image guidance and isocentric C-arm fluoroscopy, surgeons are now able to visualize hidden pedicles and reduce screw misplacement. Using these various navigation systems, the rate of pedicle screw perforation can be decreased to less than 10% and potentially eliminate clinically significant complications and revision surgeries.
No preview · Article · Jun 2007 · Seminars in Spine Surgery
[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to compare the relative incidence of thumb injuries in men's lacrosse with similar intercollegiate stick-handling sports. In this descriptive, epidemiological study, NCAA Injury Surveillance System data was gathered pertaining to hand injuries in gloved, stick-handling sports (men's ice hockey, men's lacrosse, and women's lacrosse). Data analysis was performed to determine the relative exposure of the thumb with respect to total hand injuries. During 16 intercollegiate seasons, there were 692 thumb, finger, and hand injuries in 3,038,255 athletic exposures. Total thumb injuries were significantly increased in men's lacrosse, accounting for 59.4% of total hand injuries when compared to women's lacrosse (42%) and ice hockey (35.8%) (p<0.001). Thumb fractures and contusions were each also found to be significantly increased (p<0.001) when compared to women's lacrosse and ice hockey. Injury rates of the thumb are significantly elevated in men's intercollegiate lacrosse. Recommendations include development of gloves with improved thumb protection.