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OBJECTIVE. MRI has proven to be a helpful tool in the detection and description of pathologic changes of the rotator cuff, biceps tendon, and glenoid labrum and has thus become a mainstay in the evaluation of patients with shoulder pain. This review seeks to illustrate some of the more subtle abnormalities that can be detected on shoulder MRI and to highlight some normal anatomic variants that may mimic pathologic processes, concentrating on structures at the anterior superior aspect of the shoulder. CONCLUSION. Shoulder MRI can provide a very accurate evaluation of shoulder pathologic processes and can assist in elucidating abnormalities that can be difficult to diagnose clinically. Awareness of the known anatomic variants and the sometimes subtle potential pain generators at the anterior superior aspect of the shoulder will allow a more accurate interpretation and can therefore increase the diagnostic yield of shoulder MRI.

To evaluate whether decreased hamstring autograft size and decreased patient age are predictors of early graft revision.Of 338 consecutive patients undergoing primary anterior cruciate ligament (ACL) reconstruction with hamstring autograft, 256 (75.7%) were evaluated. Graft size and patient age, gender, and body mass index at the time of ACL reconstruction were recorded, along with whether subsequent ACL revision was performed.The 256 patients comprised 136 male and 120 female patients and ranged in age from 11 to 52 years (mean, 25.0 years). The mean follow-up was 14 months (range, 6 to 47 months). Revision ACL reconstruction was performed in 18 of 256 patients (7.0%) at a mean of 12 months after surgery (range, 3 to 31 months). Revision was performed in 1 of 58 patients (1.7%) with grafts greater than 8 mm in diameter, 9 of 139 patients (6.5%) with 7.5- or 8-mm-diameter grafts, and 8 of 59 patients (13.6%) with grafts 7 mm or less in diameter (P = .027). There was 1 revision performed in the 137 patients aged 20 years or older (0.7%), but 17 revisions were performed in the 119 patients aged under 20 years (14.3%) (P.0001). Most revisions (16 of 18) were noted to occur in patients aged under 20 years with grafts 8 mm in diameter or less, and the revision rate in this population was 16.4% (16 of 97 patients). Age less than 20 years at reconstruction (odds ratio [OR], 18.97; 95% confidence interval [CI], 2.43 to 147.06; P = .005), decreased graft size (OR, 2.20; 95% CI, 1.00 to 4.85; P = .05), and increased follow-up time (OR, 1.07; 95% CI, 1.02 to 1.12) were associated with increased risk of revision.Decreased hamstring autograft size and decreased patient age are predictors of early graft revision. Use of hamstring autografts 8 mm in diameter or less in patients aged under 20 years is associated with higher revision rates.Level III, retrospective comparative study.

Background Variants of the origin of the long head of the biceps have been described intraoperatively. It is unclear whether these variants contribute to shoulder pathology. Our purpose was to describe an anatomic variation of the origin of the long head of the biceps and associated clinical presentations of 2 subjects and to review existing reports of other variants. Methods We present the history and physical examination, imaging, and arthroscopic findings of 2 cases of an abnormal variant of the origin of the long head of the biceps. Results In 2 subjects, the long head of the biceps was noted to have a Y-shaped origin with 1 limb coming from the rotator cable and the other limb taking origin medial to the superior glenoid tubercle. A 42-year-old male weightlifter presented with distal clavicle osteolysis confirmed by diagnostic injection and had resolution of symptoms after a distal clavicle excision. A 38-year-old female retired military officer presented with subcoracoid impingement confirmed by magnetic resonance imaging findings and a diagnostic injection and did well after subcoracoid decompression. In neither case did the biceps tendon appear diseased or related to shoulder pathology. Conclusions In rare cases, the long head of the biceps takes origin from the rotator cable and has a second origin medial to the supraglenoid tubercle. This variant does not appear to contribute to shoulder pathology because standard treatment of concomitant diagnoses resulted in resolution of symptoms.

Multidirectional shoulder instability is defined as symptomatic instability in two or more directions. Instability occurs when static and dynamic shoulder stabilizers become incompetent due to congenital or acquired means. Nonspecific activity-related pain and decreased athletic performance are common presenting complaints. Clinical suspicion for instability is essential for timely diagnosis. Several examination techniques can be used to identify increased glenohumeral translation. It is critical to distinguish increased laxity from instability. Initial management begins with therapeutic rehabilitation. If surgical management is required, capsular plication has been used successfully. Advanced arthroscopic techniques offer several advantages over traditional open approaches and may have similar outcomes. The role of rotator interval capsular plication is controversial, but it may be used to augment capsular plication in patients with specific patterns of instability. Despite encouraging results, outcomes remain inferior to those associated with traumatic unidirectional instability.

To describe a type of meniscus flap tear resembling a bucket-handle tear, named a “hemi-bucket-handle” tear; to compare its imaging features with those of a typical bucket-handle tear; and to discuss the potential therapeutic implications of distinguishing these two types of tears. Five knee MR examinations were encountered with a type of meniscus tear consisting of a flap of tissue from the undersurface of the meniscus displaced toward the intercondylar notch. A retrospective analysis of 100 MR examinations prospectively interpreted as having bucket-handle type tears yielded 10 additional cases with this type of tear. Cases of hemi-bucket-handle tears were reviewed for tear location and orientation, appearance of the superior articular surface of the meniscus, presence and location of displaced meniscal tissue, and presence of several classic signs of bucket-handle tears. A total of 15/15 tears involved the medial meniscus, had tissue displaced toward the notch, and were mainly horizontal in orientation. The superior surface was intact in 11/15 (73.3%). In 1/15 (6.7%) there was an absent-bow-tie sign; 6/15 (40%) had a double-PCL sign; 14/15 (93.3%) had a double-anterior horn sign. We describe a type of undersurface flap tear, named a hemi-bucket-handle tear, which resembles a bucket-handle tear. Surgeons at our institution feel this tear would likely not heal if repaired given its predominantly horizontal orientation, and additionally speculate the tear could be overlooked at arthroscopy. Thus, we feel it is important to distinguish this type of tear from the typical bucket-handle tear.

Achieving anatomical graft placement remains a concern in Anterior Cruciate Ligament (ACL) reconstruction. The purpose of this study was to quantify the effect of femoral graft placement on the ability of ACL reconstruction to restore normal knee kinematics under in vivo loading conditions. Two different groups of patients were studied: one in which the femoral tunnel was placed near the anterior and proximal border of the ACL (anteroproximal group, n=12) and another where the femoral tunnel was placed near the center of the ACL (anatomic group, n=10) MR imaging and biplanar fluoroscopy were used to measure in vivo kinematics in these patients during a quasi-static lunge. Patients with anteroproximal graft placement had up to 3.4mm more anterior tibial translation, 1.1mm more medial tibial translation and 3.7° more internal tibial rotation compared to the contralateral side. Patients with anatomic graft placement had motion that more closely replicated that of the intact knee, with anterior tibial translation within 0.8mm, medial tibial translation within 0.5mm, and internal tibial rotation within 1°. Grafts placed anteroproximally on the femur likely provide insufficient restraint to these motions due to a more vertical orientation. Anatomical femoral placement of the graft is more likely to reproduce normal ACL orientation, resulting in a more stable knee. Therefore, achieving anatomical graft placement on the femur is crucial to restoring normal knee function and may decrease the rates of joint degeneration after ACL reconstruction.

The dissemination of evidence-based information into medical practice is essential to provide patients with optimal care and realize society's substantial investments in medical research. Effective information delivery and treatment utilization may lead to improvements in patient outcome, reductions in cost, and an overall lower burden on the health-care system. This study examines the dissemination of medical evidence following a first-time anterior shoulder dislocation (FTASD) and assesses the impact of potential dissemination strategies.The state of evidence dissemination into clinical practice for FTASD was evaluated with use of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. The treatment pathway for patients with FTASDs was mapped and evaluated using data that were collected through an orthopaedic shoulder-specialist survey and with review of a claims database.A total of 1,755 patients with an FTASD were identified through a national claims database; 50% of patients followed up with a care provider within 30 days after an emergency department (ED) or urgent care visit. Based on shoulder-specialist survey data, physician estimates of the risk of redislocation within a 2-year window aligned with medical evidence 59% of the time. Only 29% of patients obtained information for FTASD that aligns with high-level medical evidence.There are gaps and deficiencies in the dissemination and application of evidence in the treatment of FTASDs. Specifically, patients have limited exposure to health-care encounters where appropriate information related to low rates of follow-up following ED or urgent care visits may be communicated. Evaluating the current state of practice and identifying areas of improvement for the dissemination of evidence regarding FTASDs can be achieved through application of the RE-AIM framework. Greater consideration and resourcing of dissemination and implementation strategies may improve the dissemination and the impact of existing medical evidence.

Injury to the posteromedial corner (PMC) of the knee differs anatomically and biomechanically from isolated injury to the medial collateral ligament. Newer anatomic and biomechanical studies are refining the field’s understanding of the medial side of the knee, as well as its role in multiple ligament injuries. Valgus instability places additional strain on a reconstructed anterior or posterior cruciate ligament, which can contribute to late graft failure. Injuries to the PMC may not heal without surgical repair or reconstruction, particularly when part of a multiple-ligament injury. Identification of PMC injury before cruciate reconstruction is important so that appropriate repair or reconstruction of the PMC and medial collateral ligament can be undertaken at the same time. This article reviews the relevant literature on the PMC, discusses reasons for selective operative management, and illustrates reconstructive strategies for PMC injuries occurring as part of a medial-sided or multiligament injury to the knee.

The medial collateral ligament complex is a primary stabilizer that combines static and dynamic resistance to direct valgus stress while contributing significant restraints to rotatory motion and anterior-posterior translation. Varying opinions exist among investigators regarding injury classification and treatment algorithms. Whereas most agree that the majority of isolated medial collateral ligament complex injuries can be treated nonoperatively, isolated injuries with chronic instability and multiligament injuries may require operative intervention. Substantial confounding factors are present within published reports, making comparative analyses and systematic review challenging. This review focuses on the anatomy and biomechanics of the medial structures of the knee; it discusses the clinical evaluation of complex injuries; and it reviews nonoperative and operative treatment methods.

Multiple-ligament knee injuries are increasingly recognized and require a multidisciplinary approach to treatment. Emergency department evaluation should focus on life- and limb-threatening issues with a high degree of suspicion for associated neurovascular injuries. The initial management should focus on emergent reduction with treatment priority given to vascular injuries. The management of ligamentous injuries should be undertaken after the treatment of vascular and bony injuries. After appropriate physical examination and imaging studies, an experienced surgeon will direct the surgical repair or reconstruction of the damaged ligaments. Our philosophy for surgical treatment of the knee with multiple-ligament injuries emphasizes the anatomic repair or reconstruction of each torn ligament and that ligament healing and stability take priority over knee range of motion. Indeed, in these complex injuries, stiffness is easier to address than recurrent instability.

Background: Revision anterior cruciate ligament (ACL) reconstruction can be potentially devastating for a patient. As such, it is important to identify prognostic factors that place patients at an increased risk for graft failure. There are no data on the effects of patellar tendinopathy on failure of ACL reconstruction when using a bone–patellar tendon–bone (BPTB) autograft. Purpose/Hypothesis: The purpose of this study was to investigate the association of patellar tendinopathy with the risk of graft failure in primary ACL reconstruction when using a BPTB autograft. The hypothesis was that patellar tendinopathy would result in higher rates of graft failure when using a BPTB autograft for primary ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: All patients undergoing ACL reconstruction at a single institution from 2005 to 2015 were examined. A total of 168 patients undergoing primary ACL reconstruction with a BPTB autograft were identified. Patients’ magnetic resonance imaging scans were reviewed for the presence and grade of patellar tendinopathy by 2 musculoskeletal fellowship–trained radiologists; both were blinded to the aim of the study, patient demographics, surgical details, and outcomes. Patients were divided into 2 groups: failure (defined as presence of symptomatic laxity or graft insufficiency) and success of the ACL graft. Statistical analyses were run to examine the association of patellar tendinopathy with failure of ACL reconstruction using a BPTB autograft. Results: At a mean follow-up of 18 months, there were 7 (4.2%) patients with graft failure. Moderate or severe patellar tendinopathy was associated with ACL graft failure ( P = .011). Age, sex, and side of reconstruction were not associated with the risk of graft failure, although the majority of patients who failed were younger than 20 years. The use of patellar tendons with moderate to severe tendinopathy was associated with a relative risk of ruptures of 6.1 (95% CI, 1.37-27.34) as compared with autograft tendons without tendinopathy. Conclusion: Moderate or severe patellar tendinopathy significantly increases the risk of graft failure when using a BPTB autograft for primary ACL reconstruction. Patellar tendinopathy should be considered when determining the optimal graft choice for patients undergoing primary ACL reconstruction with autograft tendons.

Background: Relative to dislocations, glenohumeral subluxation events have received little attention in the literature, despite a high incidence in young athletes. The pathoanatomy of first-time, traumatic, anterior subluxation events has not been defined, to our knowledge. Methods: As part of a prospective evaluation of all cases of shoulder instability sustained during one academic year in a closed cohort of military academy cadets, a total of thirty-eight first-time, traumatic, anterior glenohumeral subluxation events were documented. Clinical subluxation events were defined as incomplete instability events that did not require a manual reduction maneuver. Twenty-seven of those events were evaluated with plain radiographs and magnetic resonance imaging within two weeks after the injury and constitute the cohort studied. Magnetic resonance imaging studies were independently evaluated by a musculoskeletal radiologist blinded to the clinical history. Arthroscopic findings were available for the fourteen patients who underwent arthroscopic surgery. Results: Of the twenty-seven patients who sustained a first-time, traumatic, anterior subluxation, twenty-two were male and five were female, and their mean age was twenty years. Plain radiographs revealed three osseous Bankart lesions and two Hill-Sachs lesions. Magnetic resonance imaging revealed a Bankart lesion in twenty-six of the twenty-seven patients and a Hill-Sachs lesion in twenty-five of the twenty-seven patients. Of the fourteen patients who underwent surgery, thirteen had a Bankart lesion noted during the procedure. Of the thirteen patients who chose nonoperative management, four experienced recurrent instability. Two of the thirteen patients left the academy for nonmedical reasons and were lost to follow-up. The remaining seven patients continued on active-duty service and had not sought care for a recurrent instability event at the time of writing. Conclusions: First-time, traumatic, anterior subluxation events result in a high rate of labral and Hill-Sachs lesions. These findings suggest that clinical subluxation events encompass a broad spectrum of incomplete events, including complete separations of the articular surfaces with spontaneous reduction. A high index of suspicion for this injury in young athletes is warranted, and magnetic resonance imaging may reveal a high rate of pathologic changes, suggesting that a complete, transient luxation of the glenohumeral joint has occurred.

We provide a review of the recent literature of management of posterior instability of the shoulder. Clarification in defining this problem and an overview of the ever-expanding anatomical injuries associated with increased posterior translation of the humerus are discussed. Particular attention is paid to the caspulolabral ligamentous complex and the rotator interval because these anatomical regions have provided the focus for several recent investigations into both the role played by particular anatomical constraints to shoulder motion and the techniques for manipulation of these constraints to treat these injuries. Several clinical papers have been published recently reporting the results of surgical management of posterior instability, reflecting the trend towards arthroscopic surgery and anatomical reconstruction of these injuries and the associated improvement in outcomes.

BackgroundControversy remains over the most appropriate graft for anterior cruciate ligament reconstruction.HypothesisThere is no significant difference in outcomes after 4-strand hamstring and patellar tendon autograft anterior cruciate ligament reconstructions using similar fixation techniques.Study DesignRandomized controlled trial; Level of evidence, 1.MethodsBetween August 2000 and May 2003, 64 Keller Army Hospital patients with complete anterior cruciate ligament tears were randomized to hamstring (n = 32) or patellar tendon (n = 32) autograft anterior cruciate ligament reconstruction. Operative graft fixation and rehabilitative techniques were the same for both groups. Follow-up assessments included the Single Assessment Numeric Evaluation score, Lysholm score, International Knee Documentation Committee score, and Knee Injury and Osteoarthritis Outcome Score. Postoperative radiographs were analyzed for tunnel location and orientation.ResultsEleven women and 53 men were randomized. Eighty-three percent of the patients (53 of 64) had follow-up of greater than 2 years, or to the point of graft rupture or removal (average follow-up, 36 months). Four hamstring grafts (12.5%) and three patellar tendon grafts (9.4%) ( P = .71) ruptured. One deep infection in a hamstring graft patient necessitated graft removal. Forty-five of the 56 patients with intact grafts had greater than 2-year follow-up. Patients with patellar tendon grafts had greater Tegner activity scores ( P = .04). Single Assessment Numeric Evaluation scores were 88.5 (95% confidence interval: 83.1, 93.8) and 90.1 (95% confidence interval: 85.2, 96.1) for the hamstring and patellar tendon groups, respectively ( P = .53). Lysholm scores were 90.3 (95% confidence interval: 84.4, 96.1) and 90.4 (95% confidence interval: 84.5, 96.3) for the hamstring and patellar tendon groups, respectively ( P = .97). There were no significant differences in knee laxity, kneeling pain, isokinetic peak torque, International Knee Documentation Committee score, or Knee Injury and Osteoarthritis Outcome Scores. Postoperative graft rupture correlated with more horizontal tibial tunnel orientation.ConclusionHamstring and patellar tendon autografts provide similar objective, subjective, and functional outcomes when assessed at least 2 years after anterior cruciate ligament reconstruction.

BackgroundLittle is known of the long-term results of acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations.HypothesisAcute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations will provide good results at long-term follow-up.Study DesignCase series; Level of evidence, 4.MethodsThe authors evaluated a cohort of young patients who sustained first-time anterior glenohumeral dislocations and were acutely treated with arthroscopic Bankart repair using bioabsorbable tacks. Subjective outcome measures were obtained at a mean follow-up of 11.7 years (range, 9.1-13.9 years).ResultsThirty-nine patients (40 shoulders) were available of the original cohort of 49 shoulders (82%). Two of the 9 who were lost to follow-up had revision surgery before being lost and are carried forward in the calculations of recurrent instability and revision surgery but are not included in the calculation of the functional scores. The mean Single Assessment Numeric Evaluation was 91.7, the mean Western Ontario Shoulder Instability score was 371.7, the mean subjective Rowe score was 25.3, the mean Simple Shoulder Test was 11.1, the mean American Shoulder and Elbow Society score was 90.9, the mean Short Form-36 Physical Component score was 94.4, and the mean Tegner score was 6.5. Six patients sustained recurrent dislocations for a redislocation rate of 14.3%. Nine patients (21.4%) reported experiencing subluxation events. Six patients (14.3%) underwent revision stabilization surgery.ConclusionAt long-term follow-up, acute arthroscopic Bankart repair for first-time traumatic anterior glenohumeral dislocations resulted in excellent subjective function and return to athletics in young, active patients with an acceptable rate of recurrence and reoperation.

BackgroundOver 30 years ago, Feagin and Curl reported on the diagnosis and treatment of “isolated” injuries of the anterior cruciate ligament (ACL). The purpose of this study was to evaluate the long-term results of the patients initially diagnosed with tears of the ACL, with special emphasis on those treated with primary repair.HypothesisLong-term results are unsatisfactory for open evaluation and treatment of ACL injuries with or without primary repair.Study DesignCase series; Level of evidence, 4.MethodsFollow-up was available on 34 of the original 57 patients (60%) who had ACL tears on evaluation by arthrotomy. The average age at the index procedure was 20 years, and average follow-up was 32 (range, 29-36) years. Twenty-five of the 26 complete ACL tears were treated with primary repair. None of the 8 partial tears was repaired. Evaluations included the subjective and symptom ratings of the International Knee Documentation Committee (IKDC) evaluation form, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner activity scale, and SANE rating.ResultsFor the IKDC subjective score, 18 of 34 patients rated their knees as normal or nearly normal. The Lysholm scores averaged 70.1 (range, 20-100). The average SANE rating at 5 years was 74.8 (range, 49-110), and the current SANE rating averaged 68.9 (range, 10-100). The overall KOOS rating averaged 68.6 (range, 26.4-100). The Tegner activity score was 3.7. There was little difference between patients with unrepaired partial tears and those who had primary repairs.ConclusionAt more than 30-year follow-up, patients have decreased activity levels and an equal mix of acceptable and unacceptable outcomes. We were unable to identify any predictive factors that correlated with the results; however, subsequent meniscal surgery did correlate with poor results. The results at greater than 30 years reinforce the 5-year results that showed unsatisfactory results after the open evaluation and treatment of ACL injuries with or without repair.

Background The literature provides little information detailing the incidence of traumatic shoulder instability in young, healthy athletes. Hypothesis Shoulder instability is common in young athletes. Study Design Descriptive epidemiologic study. Methods We prospectively captured all traumatic shoulder instability events at the United States Military Academy between September 1, 2004, and May 31, 2005. Throughout this period, all new traumatic shoulder instability events were evaluated with physical examination, plain radiographs, and magnetic resonance imaging. Instability events were classified according to direction, chronicity, and type (subluxation or dislocation). Subject demographics, mechanism of injury, and sport were evaluated. Results Among 4141 students, 117 experienced new traumatic shoulder instability events during the study period; 11 experienced multiple events. The mean age of these 117 subjects was 20.0 years; 101 students were men (86.3%), and 16 were women (13.7%). The 1-year incidence proportion was 2.8%. The male incidence proportion was 2.9% and the female incidence proportion was 2.5%. Eighteen events were dislocations (15.4%), and 99 were subluxations (84.6%). Of the 99 subluxations, 45 (45.5%) were primary events, while 54 (54.5%) were recurrent. Of the 18 dislocations, 12 (66.7%) were primary events, while 6 (33.3%) were recurrent. The majority of the 117 events were anterior in nature (80.3%), while 12 (10.3%) were posterior, and 11 (9.4%) were multidirectional. Forty-four percent (43.6%) of the instability events experienced were as a result of contact injuries, while 41.0% were a result of noncontact injuries, including 9 subluxations caused by missed punches during boxing; information was unavailable for the remaining 15%. Conclusion Glenohumeral instability is a common injury in this population, with subluxations comprising 85% of instability events.

The purpose was to evaluate which meniscal repair technique for radial tears of the midbody of the lateral meniscus demonstrates the best biomechanical properties. An electronic literature search was conducted using PubMed, EMBASE, CINAHL, and ScienceDirect databases. Biomechanical studies investigating the repair characteristics of radial tears in the midbody of the lateral meniscus were included. After appropriate screening, a total of 54 studies were reviewed in detail (full text), and 6 met inclusion criteria. The most common cause of exclusion was the investigation of longitudinal tears. Only two studies could be meta-analyzed. Stiffness was significantly higher for all-inside compared with inside-out repair techniques ( p = 0.0009). No significant differences were observed between both suture methods for load to failure ( p = 0.45). However, both studies used different all-inside devices and suture constructs. No clear conclusions can be drawn from the comparison of both types of repairs for displacement, site of failure, or contact pressure changes. Overall, there are no conclusive data to suggest that inside-out or outside-in suture repair has better load to failure or stiffness, less displacement, or different site of failure compared with all-inside repair. According to biomechanical data, it is under surgeon's preference to elect one repair technique over the other.

Background: Most of the literature on shoulder instability focuses on patients experiencing anterior glenohumeral dislocation, with little known about the treatment of anterior subluxation events. Purpose: To determine the outcomes of surgical stabilization of patients with anterior glenohumeral subluxations and to compare open and arthroscopic approaches. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: We prospectively enrolled patients with anterior glenohumeral subluxations undergoing surgical stabilization. Patients were offered randomization between open and arthroscopic stabilization. Inclusion criteria included patients with anterior glenohumeral subluxations undergoing Bankart repair, while exclusions included the presence of glenoid or humeral bone loss, multidirectional instability, capsular tear/humeral avulsion of the glenohumeral ligament lesion, and rotator cuff tear requiring repair. Patients were randomized to an open Bankart repair through a subscapularis takedown or an arthroscopic Bankart repair, both using the same bioabsorbable suture anchors, and they were followed for a minimum of 2 years. Outcomes were evaluated with the Single Assessment Numeric Evaluation (SANE), Western Ontario Shoulder Instability Index (WOSI), American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), Rowe, and Tegner activity scores. Results: A total of 26 patients were enrolled, with 7 being lost to follow-up. Complete follow-up data were available on 19 subjects (74%): 10 in the open group and 9 in the arthroscopic group. There were no significant differences noted between the randomized groups, with a 2-year WOSI score of 320 in the open subjects and 330 in the arthroscopic subjects, and similar findings in the other scoring scales. There were no cases of dislocation following surgery. There were 3 patients with recurrent instability (subluxations only) in each group at a mean of 17 months, for an overall recurrent subluxation rate of 31%. These subjects with recurrence had lower outcome scores (WOSI, 532; SANE, 88.4). The outcomes of the 9 subjects with ≤3 subluxation events were superior to those of the 10 subjects with >3 events prior to stabilization. The patients with ≤3 events had a WOSI score of 143, compared with 470 ( P = .042), and an ASES mean score of 98.8, compared with 87.1 ( P = .048). Four of the 6 patients with recurrent subluxations had sustained >3 subluxations prior to stabilization. Conclusion: Overall, patients with Bankart lesions resulting from an anterior glenohumeral subluxation event had excellent outcomes with surgical stabilization. The overall recurrence in the 19 subjects with at least 2-year follow-up was 6 cases (31%), with no instances of dislocation in this young, active cohort. There was no significant benefit to open or arthroscopic stabilization, and we did find that stabilization of subluxation patients with ≤3 events resulted in superior outcomes compared with chronic recurrent subluxation patients with >3 events. We recommend early surgical stabilization of young athletes with Bankart lesions that result from anterior subluxation events.

Posterior cruciate ligament (PCL) reconstruction using the transtibial drilling or arthroscopic tibial-inlay technique has a risk of injury to the popliteal neurovascular bundle because a pin is drilled anterior to posterior. Intraoperative fluoroscopy is used to decrease the risk of neurovascular injury. In addition, graft passage in the transtibial technique may be problematic because of a sharp turn when placing the graft into the tibial tunnel, which may damage graft fibers. In the surgical technique described in this report, the posteromedial portal is used for visualization and the posterolateral portal is used for debridement of the PCL tibial footprint and the synovial fold closest to the PCL. A curved guide is placed from the posterolateral portal to the tibial footprint, and a flexible pin is drilled across the tibia. The tibial tunnel is then created using a flexible reamer under direct visualization up to the desired length, and a graft can be positioned in the tibial tunnel through the posterolateral portal. This technique has the potential advantages of decreasing the risk of injury to the popliteal neurovascular bundle (use of anteriorly directed, inside-out drilling), avoiding a sharp turn during graft passage, and allowing accurate and anatomic tibial tunnel placement without intraoperative fluoroscopy.

Medial-sided knee injuries are very common, the medial collateral ligament being the most commonly injured ligament of the knee. Injuries to the medial side of the knee can occur in isolation or concomitant with other knee ligament injuries. Isolated grade I and II injuries have been typically treated nonoperatively with excellent results. Isolated grade III injuries, however, are less common and more controversial. Although some recent literature has shown acceptable results with nonoperative treatment of isolated grade III injuries, most authors recommend surgical treatment. A variety of operative techniques have been described, including repair, augmentation, and reconstruction, all with favorable outcomes. Choice of treatment method should be based on injury pattern with the goal of regaining valgus and anteromedial rotatory stability of the knee.

Background The purpose of this study was to conduct a systematic review of the literature to evaluate the characteristics of injury and treatment outcomes of rotator cuff tears in young patients. Methods A systematic electronic search was performed for clinical studies evaluating rotator cuff tears in patients younger than 40 years with special emphasis on reporting of injury characteristics and treatment outcomes with a minimum 1-year follow-up. Results Twelve studies (involving 336 patients) met inclusion criteria. The mean age of the patients was 28 years (range, 16-40 years), with a mean follow-up of 39 months. There were 2 distinct subgroups. The majority of studies (7 of 10) showed that patients typically had a full-thickness tear with an acute traumatic etiology. However, within the subgroup of elite throwers, 5 of 6 studies demonstrated a majority of tears that were partial thickness stemming from chronic overuse. Rotator cuff repair improved pain and strength in almost all studies reporting on these parameters. Eighty-seven percent of patients reported they were satisfied. However, all studies examining elite throwers showed significant difficulty in returning to play (25%-97%). Conclusions In young patients with rotator cuff tears, there are 2 primary groups. (1) A majority group with rotator cuff tears of traumatic origin responded well to both arthroscopic and open rotator cuff repair in terms of pain relief and self-reported outcomes postoperatively. These patients reported high levels of satisfaction and return to preinjury level of play. (2) A unique subpopulation composed of elite throwers had improved outcomes but suboptimal return to play.

The incidence of noncontact anterior cruciate ligament injuries in young to middle-aged athletes remains high. Despite early diagnosis and appropriate operative and nonoperative treatments, posttraumatic degenerative arthritis may develop. In a meeting in Atlanta, Georgia (January 2005), sponsored by the American Orthopaedic Society for Sports Medicine, a group of physicians, physical therapists, athletic trainers, biomechanists, epidemiologists, and other scientists interested in this area of research met to review current knowledge on risk factors associated with noncontact anterior cruciate ligament injuries, anterior cruciate ligament injury biomechanics, and existing anterior cruciate ligament prevention programs. This article reports on the presentations, discussions, and recommendations of this group.

BackgroundSymptomatic, traumatic posterior shoulder instability is often the result of a posteriorly directed blow to an adducted, internally rotated, and forward-flexed upper extremity. Operative repair has been shown to provide favorable results. Current arthroscopic techniques with suture anchors and the ability to plicate the capsule using a nonabsorbable suture may provide favorable outcomes with reduced morbidity.PurposeTo evaluate the results of operative shoulder stabilization in patients with traumatic posterior shoulder instability.Study DesignCase series; Level of evidence, 4.MethodsA consecutive series of patients who underwent arthroscopic or open posterior stabilization for traumatic posterior shoulder instability were evaluated using subjective assessments, physical examinations, the Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and the Western Ontario Shoulder Instability Index.ResultsBetween May 1996 and February 2002, 31 shoulders (30 patients) underwent posterior stabilization (19 arthroscopically, 12 open). There were 29 men and 1 woman (mean age, 23 years). Preoperatively, all patients had a distinct traumatic cause for the instability. On physical examination, all patients had posterior apprehension and increased (2+, 3+) posterior load-shift testing. Preoperative radiographs and/or magnetic resonance imaging revealed posterior rim calcification or reverse Bankart lesions in 29 cases (94%). At arthroscopy, posterior labral injuries, reverse Bankart lesions, or humeral head defects were identified. Follow-up averaged 40 months, and the mean duration between injury and surgery was 21 months. The mean Single Assessment Numeric Evaluation, Rowe score, Simple Shoulder Test, and Western Ontario Shoulder Instability Index scores, respectively, for the entire group were 89, 87, 11, and 346; for the open group, they were 81, 80, 10.5, and 594; for the arthroscopic group, they were 92, 92, 11.4, and 190. The Western Ontario Shoulder Instability Index (P ConclusionIn the case of traumatic posterior shoulder subluxation, posterior lesions of the labrum (“reverse Bankart”), articular edge, and capsule are observed. Surgical treatment addressing these lesions led to satisfactory results for both the open and arthroscopic treated groups. In this study, an arthroscopic technique utilizing suture anchor repair with capsular placation provided the most favorable outcomes.

A 21-year-old West Point cadet presented to our institution with a history of chronic left lateral ankle instability. The initial injury occurred 5 years earlier. Physical examination results and stress radiographs were consistent with lateral instability. The patient underwent an ankle arthroscopy and lateral ankle ligament reconstruction. Arthroscopic findings included moderate synovitis, grade II anterolateral chondrosis, and an anterior talar osteophyte. The patient had an uneventful postoperative course and returned to activity. Eleven months after surgery he presented with increased left ankle pain. On physical examination he had a stable ankle, but radiographs revealed marked loss of ankle joint space. Significant diffuse fraying and thinning of the articular cartilage noted on repeat arthroscopy were consistent with chondrolysis.

BackgroundBracing after anterior cruciate ligament reconstruction is expensive and is not proven to prevent injuries or influence outcomes.PurposeTo determine whether postoperative functional knee bracing influences outcomes.Study DesignProspective, randomized, multicenter clinical trial.MethodsOne hundred volunteers from the 3 US service academies with acute anterior cruciate ligament tears were randomized into braced or nonbraced groups. Only those subjects with anterior cruciate ligament tears treated surgically within the first 8 weeks of injury were included. Patients with chondral injuries, significant meniscal tears, or multiple knee ligament injuries were excluded. Surgical procedures and the postoperative physical therapy protocols were identical for both groups. The braced group was instructed to wear an off-the-shelf functional knee brace for all cutting, pivoting, or jumping activities for the first year after surgery.ResultsNinety-five subjects were available with a minimum 2-year follow-up. There were no statistically significant differences between groups in knee stability, functional testing with the single-legged hop test, International Knee Documentation Committee scores, Lysholm scores, knee range of motion, or isokinetic strength testing. Two braced subjects had reinjuries, and 3 nonbraced subjects had reinjuries.ConclusionsIn this young, active population, postoperative bracing does not appear to change the clinical outcomes after anterior cruciate ligament reconstruction.

The purpose of this paper is to introduce the Sports Ankle Rating System and provide the initial validation for its use. As its name implies, this outcomes measurement system is intended for use in assessing the functional outcomes of athletes with ankle injuries. This unique system consists of three distinct instruments: the Quality of Life Measure, the Clinical Rating Score, and the Single Assessment Numeric Evaluation. We began the validation process of the Sports Ankle Rating System with subjects who had sustained lateral ankle sprains because this is the most common injury in sports. The results of this study indicate that the Sports Ankle Rating System is: effective at assessing the impact that an ankle sprain has on an athlete's functional and psychosocial status responsive to changes in an athlete's ankle-related health status, and valid and reliable as tested.

Shoulder instability can present as symptomatic and asymptomatic laxity, dislocation, and subluxation. There are several mechanisms that contribute to anterior shoulder instability including both soft tissue injuries and bony injuries. These injuries include Bankart lesions, humeral avulsions of the glenohumeral ligament (HAGL), glenoid labral articular defect (GLAD), and anterior labral periosteal sleeve avulsion (ALPSA), Hill–Sachs lesions, bony Bankarts, and tuberosity fractures. Diagnosis is paramount to determining timely treatment to prevent further injuries and recurrent instability. To successfully treat anterior shoulder instability, surgeons should address the labrum, chondral surfaces, and bony fractures and defects. This chapter includes key points to guide clinicians in diagnosis and management of the more common causes of anterior instability.

Objectives: Alterations in joint mechanics contribute to the onset and progression of cartilage degeneration. While shoulder kinematics have been investigated through range-of-motion activity with minimal loads, less is known about shoulder function during weight-bearing exercise, specifically in terms of cartilage deformation. This study used magnetic resonance (MR) imaging and three-dimensional (3D) modeling of the glenohumeral joint to measure cartilage thickness before and after upper-extremity exercise. A series of 30 standard pushups were hypothesized to produce measurable strain in the glenohumeral cartilage. Methods: A total of 8 healthy subjects (5 male, 3 female; age 22-28 years) without history of shoulder injury or treatments were recruited for this IRB-approved study. Subjects were instructed to perform a series of 30 pushups with hands shoulder width apart, spine in neutral, legs extended, and elbows bent parallel to the sagittal plane. Before and after exercise, axial MR imaging was taken of the subject’s dominant shoulder (3.0 T; Siemens TruFISP). To establish baseline cartilage thicknesses, subjects avoided strenuous upper-extremity activity for 24 hours prior to testing and rested 45 minutes immediately before pre-exercise imaging. Pre- and post-exercise MR images were imported into solid modeling software. From manual segmentation of glenohumeral cartilage and subchondral bone, 3D cartilage thickness maps were generated for the glenoid and humerus, before and after exercise (cartilage thickness = nearest distance between points on cartilage surface and underlying bone). After spatial registration of pre- and post-exercise models, cartilage strain (thickness change post-exercise, divided by pre-exercise thickness) was measured at 18 locations on the humeral head and 9 on the glenoid, averaging all strain measurements within 2 mm of the sampled location. Strain across the entire glenoid or humeral surface was calculated by averaging sampled measurements. Student’s t-tests were used to compare pre- and post-exercise cartilage thicknesses. One-way ANOVA and Bonferroni post-hoc tests were used to determine differences in cartilage strain by region (pResults: Pre-exercise cartilage thickness averaged 1.33 ± 0.06 mm at the glenoid and 0.99 ± 0.06 mm at the humerus (Fig. 1). The humeral and glenoid cartilage thicknesses significantly decreased to 1.13 ± 0.08 mm and 0.81 ± 0.04 mm after exercise, respectively, resulting in an average glenoid cartilage strain of 15 ± 3% and average humeral cartilage strain of 17% ± 3%. Glenoid strain in the anterior region (19% ± 1%) was significantly greater than that of the central and posterior regions (15% ± 2%, 12% ± 2%, pConclusion: This study demonstrates that a common intensive upper-extremity exercise induces significant changes in glenohumeral cartilage thickness. Specifically, the anterior glenoid cartilage was observed to experience the highest strains. This strain distribution data can serve as benchmarks of healthy shoulder function in future studies of joint disease and cartilage degeneration.

Background:Isolated chondral fractures of the knee are a rare and challenging problem, typically occurring with an acute traumatic event such as dislocation of the patella or ligamentous injury. Historically, repair of unstable chondral fragments without osseous attachment has not been recommended due to concerns about the limited healing potential of cartilage.Purpose:To describe a technique for fixation of large isolated chondral fractures of the knee and present 3 cases where large chondral fragments without osseous attachment were fixed successfully with chondral darts and biologic adhesive.Study Design:Case series; Level of evidence, 4.Methods:The senior author reviewed his case logs for all patients on whom he performed open reduction and internal fixation on large isolated cartilage fragments without osseous attachment. Three were extracted from his review. The clinical and radiographic outcomes were retrospectively reviewed.Results:Successful results and complete healing was obtained in all 3 patients. This procedure can be done in the setting of concurrent injury, such as anterior cruciate ligament tear, using single- or multistaged chondral repair and ligament reconstruction techniques.Conclusion:Isolated chondral fragment repair techniques provide the orthopaedic surgeon an additional option for treating these challenging injuries. Primary fixation can be accomplished for what have been historically considered “unsalvageable” fragments.

From March 1992 to November 1998, 57 patients sustained 58 acute, initial, traumatic anterior shoulder dislocations at the United States Military Academy. Six patients selected nonoperative treatment. Three patients underwent primary open repair after diagnostic arthroscopy revealed no Bankart lesion amenable to repair with the bioabsorbable tissue tack. The remaining 48 patients with 49 anterior dislocations were treated with arthroscopic primary repair. There were 45 men and 3 women with an average age of 20 years (range, 17 to 23) and an average follow-up of 37 months (range, 24 to 60). The average Rowe score was 92 (range, 30 to 100). The average single assessment numeric evaluation patient rating was 95.5% (range, 50% to 100%). The average Short Form-36 score (physical function) for the stable shoulders was 99 (range, 95 to 100). Forty-three shoulders remained stable (88%). There were six failures (12%). Factors associated with failure included a history of bilateral shoulder instability, a 2+ sulcus sign, and poor capsulolabral tissue at the time of repair. All patients with stable shoulders returned to their preinjury levels of athletic activity. With follow-up of 5 years, we have observed significantly better results compared with nonoperative treatment in young, active adults at the United States Military Academy.

The purpose of this study was to evaluate the incidence of recurrent instability in a group of young athletes who underwent open shoulder stabilization with a modified Bankart repair and anterior capsulorrhaphy. Recurrent dislocation was defined as an instability episode resulting in complete dislocation requiring manual reduction. Recurrent subluxation was defined as the subjective history of the shoulder “slipping or popping out” or pain and apprehension that caused cessation of athletics for at least 1 day. Sixty-six patients (64 men and 2 women) were included in the study. A collision sport precipitated instability in 53 patients and a contact sport in 13. The average follow-up was 47 months (range, 24 to 72). The average American Shoulder and Elbow Surgeons score was 95 points (range, 71 to 100). The average Rowe score was 80 points (range, 40 to 100). Two patients had experienced recurrent dislocation after surgery (3%). Eight patients (12%) had rare (fewer than three) episodes of postsurgical subluxation. Five patients (8%) had multiple recurrent subluxations after surgery. Postsurgical recurrent instability was significantly associated with preoperative episodes of subluxation. However, all patients with rare subluxation had an excellent functional result.

Injury to the lateral ligaments of the ankle is one of the most common sports-related injuries. Although these injures generally resolve with non-operative treatment reconstruction of the lateral ligaments of the ankle is occasionally necessary. We report the surgical technique and result of reconstruction of the anterior talo-fibular ligament using a semi-tendinosis free graft in 26 patients with an average follow-up of 24 months. 81% of patients reported complete resolution or substantial improvement in instability, swelling and sharp pain. Episodes of functional instability persisted in five patients post operatively. No significant differences were noted between the operated and contra-lateral non-operated ankle in range of motion or uniaxial balance assessment.Kin-Com testing of hamstring strength showed no differences between sides. Short term results suggest that this ligament reconstruction provides good results without sacrifice of peroneal function and has minimal donor site morbidity.

Most patella dislocations are treated nonoperatively. Surgery is indicated in cases with osteochondral defects, fractures, or loose bodies. We reviewed 13 consecutive patients who underwent surgical treatment of patella dislocations between 2001 and 2006. At surgery, all patients had MPFL tears and underwent repair at the site of injury. Five osteochondral lesion required open reduction and internal fixation. Six patients underwent loose body removal while 4 required lateral retinacular release. The outcome for twelve patients was excellent. Eleven patients remain on active duty in the military without restrictions. Surgical treatment should be considered for acute patella dislocations for the following indications: loose body, osteochondral fracture, or gross patellofemoral instability.

The purpose of this study was to determine the correlation between the Single Assessment Numeric Evaluation method and the Rowe and American Shoulder and Elbow Surgeons scores. Between April 1993 and December 1996, 209 follow-up examinations were performed on 163 United States Military Academy cadets after shoulder surgery. These 209 examinations were divided into five follow-up categories: 3 months, 6 months, 1 year, 2 years, and greater than 2 years. The Rowe and American Shoulder and Elbow Surgeons scores from each subject's follow-up questionnaire were correlated with his or her Single Assessment Numeric Evaluation rating, which is determined by the subject's written response to the following question: “How would you rate your shoulder today as a percentage of normal (0% to 100% scale with 100% being normal)?” Correlation coefficients between the Single Assessment Numeric Evaluation and the two scores were 0.51 to 0.79 for the Rowe score and 0.46 to 0.69 for the American Shoulder Elbow Surgeons score. The results of this study indicate that the Single Assessment Numeric Evaluation correlates well with these two scores after shoulder surgery. This study suggests that this new evaluation method provides clinicians with a mechanism to gather outcomes data with little demand on their time and resources.

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17–24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.

Background: Ankle injuries account for 30 to 60% of all parachuting injuries. This study was designed to determine if outside-the-boot ankle braces could reduce ankle sprains during Army paratrooper training. Methods: The randomized trial involved 777 volunteers from the U.S. Army Airborne School, Fort Benning, Ga. Of this group, 745 completed all study requirements (369 brace-wearers and 376 non-brace-wearers). Each volunteer made five parachute jumps, for a total of 3,674 jumps. Results: The incidence of inversion ankle sprains was 1.9% in non-brace-wearers and 0.3% in brace-wearers (risk ratio, 6.9; p = 0.04). Other injuries appeared unaffected by the brace. Overall, 5.3% of the non-brace group and 4.6% of the brace group experienced at least one injury. The risk ratio for injured individuals was 1.2:1 (non-brace to brace groups; p = 0.65). Conclusion: Inversion ankle sprains during parachute training can be significantly reduced by using an outside-the-boot ankle brace, with no increase in risk for other injuries.

The traditional orthopaedic principle of restoration of anatomy has experienced a renaissance within the field of extra-articular knee reconstruction in recent years. Knee surgeons have moved again toward more anatomical ligament restoration, while continuing to develop extra-articular augmentation procedures to protect these anatomical reconstructions. Interesting recent developments in the field of extra-articular knee reconstruction include advances in the anatomical management of patellofemoral instability, posterolateral corner injury, medial collateral ligament injury and paediatric anterior cruciate ligament injury, and in the understanding of allograft and platelet-rich plasma use. Extra-articular knee reconstruction has evolved to a state where surgeons have seen improved results when advances in biological and antomical understanding are applied to surgical techniques. This chapter outlines a number of the recent advances that have improved knee surgery outcomes.

Sixty ankle arthroscopies were performed on patients with chronic soft-tissue impingement of the ankle after an ankle sprain between January 1989 and January 1994. Preoperative examination findings featured tenderness localized to the anterolateral aspect of the ankle, no instability, and, with the exception of 2 patients, normal radiographs. A preoperative bone scan was performed on 34 patients and was positive in each case but was not specific. Arthroscopy was performed an average of 23 months after injury. Results were determined by using a new ankle rating score. Hypertrophic synovium, synovitis, or fibrous adhesions were arthroscopically visualized and resected in all cases. The average follow-up was 27 months (range, 6 to 64 months). Thirty-one patients underwent complete evaluation and 29 were evaluated over the telephone. There were 51 excellent, 7 good, 1 fair, and 1 poor results. The diagnosis of chronic soft-tissue impingement of the ankle can be made from an appropriate history, thorough physical examination, and plain radiographs. Ankle arthroscopy with resection of impinging hypertrophic synovium or fibrous bands occurring after an ankle sprain was effective in alleviating pain in athletes.

The dynamic muscle stabilizers of the shoulder are critical to high performance in the overhead athlete. Previous evaluations of shoulder strength have focused on the concentric strength of the rotator cuff. Functionally, the rotator cuff muscles interact in an eccentric/concentric fashion. This is the first study to evaluate the end range eccentric antagonist/concentric agonist ratios of the shoulder rotators. Seventy-five asymptomatic college-level males were tested through a range of 20 degrees of lateral rotation to 90 degrees of medial rotation using the Kin-Com computer-assisted, hydraulic-resisted, isokinetic dynamometer at a speed of 90 degrees/sec. The end range (60-90 degrees) ratios for the medial rotators functioning eccentrically and lateral rotators functioning concentrically were 2.39:1 and 2.15:1 for the dominant and nondominant shoulders, respectively. End range (10 degrees of lateral rotation-20 degrees of medial rotation) ratios for lateral rotators functioning eccentrically and medial rotators functioning concentrically were 1.08:1 and 1.05:1 for the dominant and nondominant shoulders, respectively. The application of this functional assessment of strength testing results may provide important information in the evaluation of the injured shoulder in the overhead athlete, for prescreening, and to gauge return to sports after injury or surgery.

The complex relationship between increased range of motion and decreased stability subjects the shoulder to more episodes of subluxation and dislocation than other joints in the body. Traumatic anterior glenohumeral dislocation remains a common problem not only in young athletes but also for older individuals after a fall. The most common mechanism of injury remains shoulder abduction with forced external rotation. The shoulder is a complex joint composed of static and dynamic stabilizers. During an episode of shoulder abduction and forced external rotation, the humeral head places significant stress on the anterior-inferior labrum. At the time of dislocation, the humeral head experiences axial loading, external rotation, and anterior translation. The pathoanatomy of the traumatic anterior dislocation in young patients is typically the Bankart lesion (also known as the Perthes-Bankart lesion), where the anterior-inferior capsulolabral complex is forcefully pulled from the glenoid during the dislocation.

Altered joint motion has been thought to be a contributing factor in the long-term development of osteoarthritis after ACL reconstruction. While many studies have quantified knee kinematics after ACL injury and reconstruction, there is limited in vivo data characterizing the effects of altered knee motion on cartilage thickness distributions. Thus, the objective of this study was to compare cartilage thickness distributions in two groups of patients with ACL reconstruction: one group in which subjects received a non-anatomic reconstruction that resulted in abnormal joint motion and another group in which subjects received an anatomically placed graft that more closely restored normal knee motion. Ten patients with anatomic graft placement (mean follow-up: 20 months) and 12 patients with non-anatomic graft placement (mean follow-up: 18 months) were scanned using high-resolution MR imaging. These images were used to generate 3D mesh models of both knees of each patient. The operative and contralateral knee models were registered to each other and a grid sampling system was used to make site-specific comparisons of cartilage thickness. Patients in the non-anatomic graft placement group demonstrated a significant decrease in cartilage thickness along the medial intercondylar notch in the operative knee relative to the intact knee (8%). In the anatomic graft placement group, no significant changes were observed. These findings suggest that restoring normal knee motion after ACL injury may help to slow the progression of degeneration. Therefore, graft placement may have important implications on the development of osteoarthritis after ACL reconstruction.

Decision making in health care has evolved substantially over the last century. Up until the late 1970s, medical decision making was predominantly intuitive and anecdotal. It was based on trial and error and involved high levels of problem solving. The 1980s gave way to empirical medicine, which was evidence based probabilistic, and involved pattern recognition and less problem solving. Although this represented a major advance in the quality of medical decision making, limitations existed. The advantages of the gold standard of the randomized controlled clinical trial (RCT) are well-known and this technique is irreplaceable in its ability to answer critical clinical questions. However, the RCT does have drawbacks. RCTs are expensive and can only capture a snapshot in time. As treatments change and new technologies emerge, new expensive clinical trials must be undertaken to reevaluate them. Furthermore, in order to best evaluate a single intervention, other factors must be controlled. In addition, the study population may not match that of another organization or provider. Although evidence-based medicine has provided powerful data for clinicians, effectively and efficiently tailoring it to the individual has not yet evolved. We are now in a period of transition from this evidence-based era to one dominated by the personalization and customization of care. It will be fueled by policy decisions to shift financial responsibility to the patient, creating a powerful and sophisticated consumer, unlike any patient we have known before. The challenge will be to apply medical evidence and personal preferences to medical decisions and deliver it efficiently in the increasingly busy clinical setting. In this article, we provide a robust review of the concepts of customized care and some of techniques to deliver it. We will illustrate this through a personalized decision model for the treatment decision after a first-time anterior shoulder dislocation.