Marilyn Pink’s research while affiliated with Loma Linda University and other places

Background There is no consensus on the optimal surgical technique for recurrent patellofemoral instability. Despite many different surgical procedures discussed in the literature, there are few studies with long-term outcomes. Hypothesis/Purpose The purpose of this study was to compare subjective and objective preoperative data from patients with recurrent patellar instability and normal alignment to midterm and long-term outcomes after an arthroscopically assisted medial reefing technique. The hypothesis was that the previously reported successful outcomes at 60 months would be well maintained over time. Study Design Case series; Level of evidence, 4. Methods A total of 19 patients (20 knees) with recurrent patellar instability and normal bony anatomy underwent arthroscopically assisted medial reefing without lateral release. They were evaluated preoperatively and then at midterm (average, 63 months) and long-term (average, 142 months) follow-ups. Patients underwent a history assessment, physical examination, and radiographic evaluation. Outcomes evaluated included Lysholm and Tegner scores, subjective data, and examination and radiographic findings. Operative reports were reviewed for the presence of chondral lesions. Comparative statistics were utilized ( P < .05). Results All patients were satisfied with their surgery results and would undergo the procedure again. There was 1 recurrent subluxation and no recurrent dislocations. Subjective symptom scores demonstrated significant improvement from preoperative to midterm and long-term follow-ups for pain, instability, and swelling. Both Lysholm and Tegner scores improved significantly from preoperative to midterm and long-term follow-ups. At long-term follow-up, 70% of the patients reported excellent or good results, 5 patients reported fair results, and 1 patient reported a poor result. However, Tegner activity scores decreased significantly from midterm to long-term follow-ups. Significant improvement from preoperative to midterm and long-term follow-ups was demonstrated in physical examination findings including decreases in patellar apprehension and patellar quadrant glide; however, there was no significant difference in retropatellar pain or range of motion. For radiographic measurements, the lateral patellofemoral angle was significantly improved from preoperative to midterm and long-term follow-ups. At long-term radiographic analysis, 5 knees (25%) had narrowing of the patellofemoral joint space, 10 knees (50%) revealed patellofemoral osteophytes, and 7 knees (35%) demonstrated a medial ossicle. The presence of preoperative chondral lesions resulted in significantly lower Lysholm and Tegner scores and increased findings of osteoarthritis at long-term follow-up. Conclusion Arthroscopically assisted medial reefing, without lateral release, is an effective long-term treatment for patients with recurrent patellar instability and normal bony anatomy.

Background: It has been suggested that patellofemoral contact pressures and contact forces may be altered secondary to an opening wedge high tibial osteotomy, yet few data are available that quantify the effect of varying degrees of medial opening wedge osteotomy on the patellofemoral joint contact characteristics. Hypothesis: Opening wedge medial proximal tibial osteotomy will increase patellofemoral contact force and pressure. Study design: Controlled laboratory study. Methods: Nine human cadaver knees were used. Pressure-sensitive film was placed in the suprapatellar pouch, leaving the patellar tendon and medial and lateral retinacula intact. The quadriceps tendon was attached to a materials testing machine along the axis of the femur, whereby a pulley mechanism generated 950 N of force. Patellofemoral contact characteristics were measured with pressure-sensitive film at 30°, 60°, 90°, and 120° of flexion for the native knee and after subsequent 10-mm and 15-mm medial opening wedge proximal tibial osteotomies. The film was analyzed with imaging software. Results: There was a statistically significant increase (P < .05) in mean contact pressure at 30° and 120° between the 10-mm osteotomy and native knee and across all flexion angles between the 15-mm osteotomy and native knee. Furthermore, a significant difference was seen in peak pressures when native knees were compared with 10-mm and 15-mm opening wedge osteotomies at all flexion angles. Conclusion: There was a significant increase in patellofemoral pressures at varying degrees of knee flexion after medial opening wedge proximal tibial osteotomies of only 10 mm; a larger osteotomy resulted in a greater increase. Clinical relevance: When performing a medial opening wedge proximal tibial osteotomy, the surgeon should consider the negative effects of increased patellofemoral peak pressure.

The outcome is unknown for 2 common bracing treatments utilized for patients with lateral epicondylitis. The purpose of this study was to compare the clinical outcomes of a wrist splint with that of a counterforce forearm strap for the management of acute lateral epicondylitis. Forty-two patients (44 elbows) received either a wrist extension splint (Group I-24 elbows) or a counterforce forearm strap (Group II-20 elbows). Measures on the Mayo Elbow Performance (MEP) and American Shoulder and Elbow Society (ASES) Elbow Assessment Form were collected prior to treatment and at 6 weeks. A total score was derived, utilizing the ASES Elbow Assessment, as was a score utilizing the standard scoring system for the MEP. Group I's score derived from the ASES form improved 16 points and Group II's score improved 13 points. Group I's score on the MEP improved 13 points and Group II's score improved 12 points. There was no significant difference measured between the Groups with the ASES (P = .60) nor MEP (P = .63) scores. However, within the ASES derived score, pain relief was significantly better with the extension splint group (P = .027). No other variables were statistically significantly different. Significant pain relief with the wrist extension splint may be due to improved immobilization of the wrist extensor muscles in a resting position. The wrist extension splint allows a greater degree of pain relief than does the forearm strap brace for patients with lateral epicondylitis.

Most surgical reconstructions of the separated acromioclavicular joint do not address the injured ligaments and capsule of the acromioclavicular joint. This study was undertaken to compare the biomechanical characteristics of a modified Weaver-Dunn reconstruction and an intramedullary acromioclavicular joint reconstruction that uses a free-tissue graft for reconstruction of both the coracoclavicular and acromioclavicular ligaments. Controlled laboratory study. Each pair of 6 matched pairs of cadaveric shoulders was randomly selected for a modified Weaver-Dunn reconstruction on 1 side and the contralateral side was used for free-tissue graft reconstruction of the coracoclavicular and acromioclavicular ligamentous complexes. Anterior-posterior and superior-inferior acromioclavicular joint translation (in millimeters) was measured with acromioclavicular joint compressions of 10, 20, and 30 N, and with translational loads of 10 and 15 N both before and after acromioclavicular joint reconstruction. Load-to-failure testing was then performed for each construct. Repeated-measures analysis of variance (translational testing) and Wilcoxon signed rank test (load-to-failure testing), both with P = .05, were used for statistical analysis. Mean anterior-posterior and superior-inferior translation of the intramedullary acromioclavicular joint reconstruction was significantly less than that of the modified Weaver-Dunn under all loading conditions (P < .001 and P = .001, respectively), but was not significantly different from that of the intact state (P = .656 and P = .173, respectively). Although the mean ultimate and yield loads and linear stiffness for the intramedullary acromioclavicular reconstruction were greater than that of the modified Weaver-Dunn reconstruction, this did not reach statistical significance (P = .625, P = .625, and P = .625, respectively). Acromioclavicular joint reconstruction with free-tissue graft for both the coracoclavicular and acromioclavicular ligamentous complexes demonstrates initial stability significantly better than a modified Weaver-Dunn and similar to that of intact specimens. This acromioclavicular joint reconstruction provides the surgeon with a relatively nondestructive option.

We hypothesized that both the AC joint capsule and CC ligaments are biomechanically robust structures in the anterior-posterior (AP) and superior-inferior (SI) planes with low loads, and that these ligaments provide essential function in AC joint stability. Anterior-posterior (AP) and superior-inferior (SI) AC joint translations were quantified in 6 cadaver matched pairs with AC joint compressions of 10N, 20N and 30N, and with translational loads of 10N and 15N. Either the AC joint capsule or CC ligaments were transected, and measurements were then repeated. Biomechanical characteristics of the remaining AC joint capsule or CC ligaments were compared. There were significant increases in AP translation with the cut AC joint capsule, and significant increases in SI translation with the cut CC ligaments (P < 0.0001). Compression significantly decreased translation (P < 0.0001). Our study is supported by, and further develops, recent studies and anatomical knowledge. It offers two interpreted pieces of information for the sports medicine physician to consider for reconstruction of the AC joint. First, resection of the distal clavicle may have a detrimental effect. Second, repair of the AC joint capsule, in addition to the customarily repaired CC ligaments, appears to have a beneficial effect. The AC joint capsule is a robust anatomical structure that contributes significantly to the AC joint stability, especially in the AP plane. Compression increases stability. Basic science study.

College football players sustain an average of 3 subconcussive blows to the head per game. Concussions correlate with decreases in standardized neurocognitive test scores. It is not known whether repetitive, subconcussive microtrauma associated with participation in a full season of collision sport affects neurocognitive test scores. No difference exists between preseason, midseason, and postseason Standardized Assessment of Concussion (SAC) and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores when collegiate football players sustain subconcussive microtrauma from forceful, repetitive contact activity. Case series; Level of evidence, 4. Fifty-eight members of a Division III collegiate football team who had no known concussion during the season voluntarily completed the SAC and ImPACT instruments preseason, midseason, and postseason. A repeated measures analysis of variance was used to compare the scores at the 3 time intervals (P < .05). No statistically significant decreases were found in overall SAC or ImPACT scores or in any of the domains or composites of the tests (P < .05) when preseason, midseason, and postseason scores were evaluated. ImPACT and SAC neurocognitive test scores are not significantly altered by a season of repetitive contact in collegiate football athletes who have not sustained a concussion. A diminution in SAC or ImPACT scores in concert with clinical symptoms and findings should be interpreted as evidence of a postconcussive event.

Patellofemoral instability in patients with normal alignment has been effectively treated with medial reefing procedures and a lateral release. Recent research suggests that a lateral release may not be necessary in patients without excessive patellar tilt. Arthroscopically assisted medial reefing without lateral release is as effective as techniques with a lateral release reported in the literature. Case series; Level of evidence, 4. Twenty-four patients (25 knees) were observed for an average of 60 months. Preoperatively, patients underwent a history, physical examination, and radiographic evaluation. At follow-up, a physical examination and radiographic evaluation were repeated. Preoperative and postoperative Lysholm and Tegner scores were calculated. A subjective questionnaire was also completed. Comparative statistics were used for the preoperative and postoperative scores (P < .05). Ninety-six percent (24/25) were satisfied with their results, and all patients would have the same procedure performed again. Subjective symptom scores improved significantly. Lysholm knee scores improved from an average of 54 to 91 (P < .001). Tegner activity level improved from an average of 3.3 to 6.2 (P < .001). Significant improvement was seen in patellar mobility, apprehension, and patellofemoral tenderness with compression. Range of motion, muscle atrophy, and tilt did not change significantly. Congruence angles improved from 4.4 degrees to -2.5 degrees (P = .009), lateral patellofemoral angles improved from 5.5 degrees to 8.7 degrees (P = .011), and lateral patellar displacement improved from 2.0 to 0.2 mm (P < .044). There were no recurrent dislocations or subluxations. Arthroscopically assisted medial reefing, without lateral release, is an effective treatment for patients with recurrent patellofemoral instability and normal alignment.

Inappropriately sized tennis racket grip is often cited in the popular media as a risk factor for overuse injuries about the forearm and elbow. Currently, a hand measurement technique developed by Nirschl is commonly used by tennis racket manufacturing companies as the method for determining a player's "recommended" grip size. Quarter-inch changes from that recommended by Nirschl in tennis racket grip size will have no significant effect on forearm muscle firing patterns. Controlled laboratory study. Sixteen asymptomatic Division I and II collegiate tennis players performed single-handed backhand ground strokes with rackets of 3 different grip sizes (recommended measurement, undersized (1/4) in, and oversized (1/4) in). Fine-wire electromyography was used to measure muscle activity in extensor carpi radialis longus and brevis, extensor digitorum communis, flexor carpi radialis, and pronator teres. Repeated-measure analysis of variance was used for within-group comparisons, comparing different grips in specified phases for backhand ground strokes (P <or= .05). There were no significant differences in muscle activity between small, recommended, or big grips in any muscle tested. Based on these findings, tennis racket grip size (1/4) in above or below Nirschl's recommended measurement does not significantly affect forearm muscle firing patterns. Alterations in tennis racket grip size within (1/4) in of Nirschl's recommended sizing do not have a significant effect on forearm muscle activity and therefore may not represent a significant risk factor for upper extremity cumulative trauma, such as lateral epicondylitis.