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Background: Patients with anterior cruciate ligament (ACL) revision report lower outcome scores on validated knee questionnaires postoperatively compared to cohorts with primary ACL reconstruction. In a previously active population, it is unclear if patient-reported outcomes (PROs) are associated with a return to activity (RTA) or vary by sports participation level (higher level vs. recreational athletes). Hypotheses: Individual RTA would be associated with improved outcomes (ie, decreased knee symptoms, pain, function) as measured using validated PROs. Recreational participants would report lower PROs compared with higher level athletes and be less likely to RTA. Study Design: Cohort study; Level of evidence, 2. Methods: There were 862 patients who underwent a revision ACL reconstruction (rACLR) and self-reported physical activity at any level preoperatively. Those who did not RTA reported no activity 2 years after revision. Baseline data included patient characteristics, surgical history and characteristics, and PROs: International Knee Documentation Committee questionnaire, Marx Activity Rating Scale, Knee injury and Osteoarthritis Outcome Score, and the Western Ontario and McMaster Universities Osteoarthritis Index. A binary indicator was used to identify patients with same/better PROs versus worse outcomes compared with baseline, quantifying the magnitude of change in each direction, respectively. Multivariable regression models were used to evaluate risk factors for not returning to activity, the association of 2-year PROs after rACLR surgery by RTA status, and whether each PRO and RTA status differed by participation level. Results: At 2 years postoperatively, approximately 15% did not RTA, with current smokers (adjusted odds ratio [aOR] = 3.3; P = .001), female patients (aOR = 2.9; P < .001), recreational participants (aOR = 2.0; P = .016), and those with a previous medial meniscal excision (aOR = 1.9; P = .013) having higher odds of not returning. In multivariate models, not returning to activity was significantly associated with having worse PROs at 2 years; however, no clinically meaningful differences in PROs at 2 years were seen between participation levels. Conclusion: Recreational-level participants were twice as likely to not RTA compared with those participating at higher levels. Within a previously active cohort, no RTA was a significant predictor of lower PROs after rACLR. However, among patients who did RTA after rACLR, approximately 20% reported lower outcome scores. Most patients with rACLR who were active at baseline improved over time; however, patients who reported worse outcomes at 2 years had a clinically meaningful decline across all PROs.

Background: Although graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome. Hypothesis: In the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up. Study Design: Cohort study; Level of evidence, 2. Methods: Patients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery. Results: A total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores ( P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized ( P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts ( P = .87) or between BTB autografts and soft tissue allografts ( P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft ( P = .010; OR, 0.56; 95% CI, 0.36-0.87). Conclusion: BTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Infection is a rare occurrence after revision anterior cruciate ligament reconstruction (rACLR). Because of the low rates of infection, it has been difficult to identify risk factors for infection in this patient population. The purpose of this study was to report the rate of infection following rACLR and assess whether infection is associated with patient- and surgeon- dependent risk factors. We reviewed two large prospective cohorts to identify patients with postoperative infections following rACLR. Age, sex, body mass index (BMI), smoking status, history of diabetes, and graft choice were recorded for each patient. The association of these factors with postoperative infection following rACLR was assessed. There were 1423 rACLR cases in the combined cohort, with 9 (0.6%) reporting post-operative infections. Allografts had a higher risk of infection than autografts (odds ratio=6.8; 95% CI: 0.9-54.5; p=0.045). Diabetes (odds ratio=28.6; 95% CI: 5.5-149.9; p=0.004) was a risk factor for infection. Patient age, sex, BMI and smoking status were not associated with risk of infection after rACLR. STATEMENT OF CLINICAL SIGNIFICANCE: While there is a low rate of infection following rACLR, use of allograft and comorbidity with diabetes are associated with a higher risk of infection following this surgery.

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health. This has been a successful intervention in patients with isolated tears and tears associated with anterior cruciate ligament (ACL) reconstruction. However, the results of meniscal repair in the setting of revision ACL reconstruction have not been documented. Purpose: To examine the prevalence and 2-year operative success rate of meniscal repairs in the revision ACL setting. Study Design: Case-control study; Level of evidence, 3. Methods: All cases of revision ACL reconstruction with concomitant meniscal repair from a multicenter group between 2006 and 2011 were selected. Two-year follow-up was obtained by phone and email to determine whether any subsequent surgery had occurred to either knee since the initial revision ACL reconstruction. If so, operative reports were obtained, whenever possible, to verify the pathologic condition and subsequent treatment. Results: In total, 218 patients (18%) from 1205 revision ACL reconstructions underwent concurrent meniscal repairs. There were 235 repairs performed: 153 medial, 48 lateral, and 17 medial and lateral. The majority of these repairs (n = 178; 76%) were performed with all-inside techniques. Two-year surgical follow-up was obtained on 90% (197/218) of the cohort. Overall, the meniscal repair failure rate was 8.6% (17/197) at 2 years. Of the 17 failures, 15 were medial (13 all-inside, 2 inside-out) and 2 were lateral (both all-inside). Four medial failures were treated in conjunction with a subsequent repeat revision ACL reconstruction. Conclusion: Meniscal repair in the revision ACL reconstruction setting does not have a high failure rate at 2-year follow-up. Failure rates for medial and lateral repairs were both

Background: Anterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery. Hypotheses: Participants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates. Results: Two-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC ( P < .0001), KOOS-Symptoms ( P = .01), KOOS–Sports and Recreation ( P = .04), and KOOS–Quality of Life ( P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates. Conclusion: Participation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes than primary ACL reconstruction. The reasons remain varied and not completely understood. METHODS: Patients undergoing revision ACL reconstruction were prospectively enrolled. Data collected included baseline demographics, surgical technique and pathological condition, prescribed rehabilitation instructions, and a series of validated patient-reported outcome instruments. Patients were followed for 2 years and asked to complete a set of outcome instruments identical to those completed at baseline. Subsequent surgical procedures on the ipsilateral knee were recorded. Regression analysis was used to control for age, sex, activity level, baseline outcome scores, and the above-mentioned rehabilitation-related variables in order to assess the factors affecting clinical outcomes 2 years after revision ACL reconstruction. RESULTS: A total of 843 patients met the inclusion criteria and were successfully enrolled, and 82% (695) were followed for 2 years. Two rehabilitation-related factors were found to influence outcome. First, patients who were prescribed an ACL brace for their return to sports had a significantly better Knee injury and Osteoarthritis Outcome Score (KOOS) for sports and recreational activities at 2 years (odds ratio [OR] =1.50, 95% confidence interval [CI] = 1.07 to 2.11; p = 0.019). Second, patients prescribed an ACL brace for the postoperative rehabilitation period were 2.3 times more likely to have subsequent surgery by 2 years (OR = 2.26, 95% CI = 1.11 to 4.60; p = 0.024). The odds of a graft rerupture were not affected by any type of brace wear. CONCLUSIONS: Rehabilitation-related factors that the physician can control at the time of an ACL reconstruction have the ability to influence clinical outcomes at 2 years. Weight-bearing and motion can be initiated immediately postoperatively. Bracing during the early postoperative period is not helpful. Use of a functional brace early in the postoperative period was associated with an increased risk of a reoperation. Use of a functional brace for a return to sports improved the KOOS on the sports/recreation subscale. LEVEL OF EVIDENCE: Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background:Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.Hypothesis:Larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.Study Design:Case-control study; Level of evidence, 3.Methods:Subjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.Results:A total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had Conclusion:Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

BACKGROUND The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed as an extensive question bank with multiple health domains that could be utilized for computerized adaptive testing (CAT). In the present study, we investigated the use of the PROMIS Physical Function CAT (PROMIS PF CAT) in an otherwise healthy population scheduled to undergo surgery for meniscal injury with the hypotheses that (1) the PROMIS PF CAT would correlate strongly with patient-reported outcome instruments that measure physical function and would not correlate strongly with those that measure other health domains, (2) there would be no ceiling effects, and (3) the test burden would be significantly less than that of the traditional measures. METHODS Patients scheduled to undergo meniscal surgery completed the PROMIS PF CAT, Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale, Short Form-36 (SF-36), and EuroQol-5 Dimension (EQ-5D) questionnaires. Correlations were defined as high (≥0.7), high-moderate (0.61 to 0.69), moderate (0.4 to 0.6), moderate-weak (0.31 to 0.39), or weak (≤0.3). If ≥15% respondents to a patient-reported outcome measure obtained the highest or lowest possible score, the instrument was determined to have a significant ceiling or floor effect. RESULTS A total of 107 participants were analyzed. The PROMIS PF CAT had a high correlation with the SF-36 Physical Functioning (PF) (r = 0.82, p < 0.01) and KOOS Sport (r = 0.76, p < 0.01) scores; a high-moderate correlation with the KOOS Quality-of-Life (QOL) (r = 0.63, p < 0.01) and EQ-5D (r = 0.62, p < 0.01) instruments; and a moderate correlation with the SF-36 Pain (r = 0.60, p < 0.01), KOOS Symptoms (r = 0.57, p < 0.01), KOOS Activities of Daily Living (ADL) (r = 0.60, p < 0.01), and KOOS Pain (r = 0.60, p < 0.01) scores. The majority (89%) of the patients completed the PROMIS PF CAT after answering only 4 items. The PROMIS PF CAT had no floor or ceiling effects, with 0% of the participants achieving the lowest and highest score, respectively. CONCLUSIONS The PROMIS PF CAT correlates strongly with currently used patient-reported outcome measures of physical function and demonstrates no ceiling effects for patients with meniscal injury requiring surgery. It may be a reasonable alternative to more burdensome patient-reported outcome measures.

Background Stromal cell-derived factor-1a (SDF-1α) and high mobility group box chromosomal protein 1 (HMGB1) are chemokines that can drive post-traumatic osteoarthritis (PTOA) induced by anterior cruciate ligament (ACL) injury. However, the influence of patient characteristics on expression of those chemokines remains unclear. Our aim was to determine the relationship between chemokine expression in synovial fluid (SF) of the ACL-deficient (ACL-D) knee and patient characteristics including time from injury, sex, and age. Methods SF samples were collected immediately prior to the first-time ACL reconstruction (ACLR) from 82 patients. Expression of SDF-1α and HMGB1 was measured with human-specific solid phase sandwich enzyme-linked immunosorbent assays. The expression levels between groups divided by time from injury, or age, or sex was compared using Student's t-test. The association of SDF-1α or HMGB1 levels with those variables was determined using regression analysis and Pearson product–moment correlation coefficient. Results Regression and correlation analysis indicated significant correlation between SDF-1α expression and time from injury in the cohort (r = − 0.266, P = 0.016, n = 82) and in females (r = − 0.386, P = 0.024, n = 34). Significant correlation was also observed between SDF-1α expression and age in the cohort (r = − 0.224, P = 0.043, n = 82) and in males (r = − 0.289, P = 0.046, n = 48). No significant correlation between HMGB1 expression and patient characteristics was detected. Conclusions SDF-1α rather than HMGB1 might serve as a protein marker for monitoring the development of PTOA in the ACL-D knee, especially in female patients.

Background: The accuracy of correction has been shown to be an important determinant in long-term outcomes of patients who were treated with a medial open-wedge high tibial osteotomy (HTO) who suffer from unicompartmental osteoarthritis (OA). Computer navigation systems have the potential to improve surgical precision. The purpose of this study was to compare radiographic outcomes between patients treated with a navigation system and those treated through conventional methods of assessing alignment intra-operatively. The null hypothesis was that the method of assessing the alignment intra-operatively would make no difference in the accuracy of correction. Methods: In this retrospective study, 107 patients with medial varus OA who were managed by open-wedge HTO were included. Of the 107 patients, 41 were treated using an intraoperative navigation system and 66 were treated using conventional methods. Pre-operative and postoperative single-leg, long-leg standing alignment films were used to determine the extent of pre-operative varus deformity and the post-surgical correction achieved compared to the predetermined target range. Results: The navigational system had eight instances of software malfunction (19.5%) intraoperatively and correction was determined using the cable method. These results were analyzed as part of the conventional group. Post-operative radiographic differences were significant between the two groups. In the navigation group, 75.8% of the patients were corrected within the target range compared to 66.2% in the conventional group. More patients were also under corrected (to the point of remaining in varus) using conventional methods compared to a navigation system. There was no statistically significant difference in the degree of correction in the sagittal plane between the two groups. Regardless of the method used for checking alignment intra-operatively, there was a statistically significant difference in post-operative weight-bearing measurements when the surgeon had intra-operative axial loading versus when they did not. Conclusion: For coronal plane corrections, the navigation system was shown to have greater success in achieving the desired correction value and in having fewer patients who were under corrected. Despite the measurement technique a surgeon chooses to assess the accuracy of correction, axial loading the extremity in order to simulate the weight-bearing film alignment postoperatively is important to maximize the accuracy of correction needed.

Background:Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions.Purpose/Hypothesis:The purpose of this study was to determine if the prevalence, location, and/or degree of meniscal and chondral damage noted at the time of revision ACL reconstruction predicts activity level, sports function, and osteoarthritis symptoms at 2-year follow-up. The hypothesis was that meniscal loss and high-grade chondral damage noted at the time of revision ACL reconstruction will result in lower activity levels, decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery.Study Design:Cohort study; Level of evidence, 2.Methods:Between 2006 and 2011, a total of 1205 patients who underwent revision ACL reconstruction by 83 surgeons at 52 hospitals were accumulated for study of the relationship of meniscal and articular cartilage damage to outcome. Baseline demographic and intraoperative data, including the International Knee Documentation Committee (IKDC) subjective knee evaluation, Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Marx activity score, were collected initially and at 2-year follow-up to test the hypothesis. Regression analysis was used to control for age, sex, body mass index, smoking status, activity level, baseline outcome scores, revision number, time since last ACL reconstruction, incidence of having a previous ACL reconstruction on the contralateral knee, previous and current meniscal and articular cartilage injury, graft choice, and surgeon years of experience to assess the meniscal and articular cartilage risk factors for clinical outcomes 2 years after revision ACL reconstruction.Results:At 2-year follow-up, 82% (989/1205) of the patients returned their questionnaires. It was found that previous meniscal injury and current articular cartilage damage were associated with the poorest outcomes, with prior lateral meniscectomy and current grade 3 to 4 trochlear articular cartilage changes having the worst outcome scores. Activity levels at 2 years were not affected by meniscal or articular cartilage pathologic changes.Conclusion:Prior lateral meniscectomy and current grade 3 to 4 changes of the trochlea were associated with worse outcomes in terms of decreased sports participation, more pain, more stiffness, and more functional limitation at 2 years after revision surgery, but they had no effect on activity levels.Registration:NCT00625885

Background Clinical weightbearing provocation tests, like the duck walk test, may be of value in diagnosing or screening for medial meniscal tears. However, evidence of the diagnostic accuracy of the duck walk test is lacking. Questions/purposes (1) To determine the sensitivity and specificity of the duck walk test in diagnosing medial meniscal tears. (2) To determine whether tear location, tear cause (traumatic versus degenerative), and ACL insufficiency were associated with differences in the sensitivity and specificity of the test. Methods A convenience sample of 136 patients of all ages was retrospectively analyzed by evaluating the outpatient knee clinic appointment list of one orthopaedic surgeon for patients with a broad range of knee injuries who had a prior MRI before (24%) or after (76%) physical examination and had a duck walk test stated in their patient records. Of 230 patients with MRI requested by one orthopaedic surgeon attributable to knee complaints, 136 (59%) fulfilled the inclusion criteria; 70 (52%) patients were male and 66 (49%) were female, with a mean age of 42 (± SD 14) years. The duck walk test was performed in case of suspected meniscal injury, based on mechanism of injury, general joint line pain, and/or mechanical complaints (ie, locking, giving away). The test is performed by squatting and “waddling” before rising and is positive in case of general joint line pain or painful “clicking”. Interobserver repeatability was not evaluated, but the test is well defined and leaves little room for difference in interpretation. Diagnostic accuracy measures were evaluated. Since the convenience sample in this study consisted of patients who had a duck walk test and MRI, and a positive result of the duck walk test almost certainly increased the probability that MRI would be ordered in the majority (76%) of the patients, the test properties calculated here—especially sensitivity—should be considered inflated. Results The calculated sensitivity of the duck walk test was 71% (95% CI, 59%–81%) and there was low specificity of 39% (95% CI, 27%–52%). We found no difference in sensitivity between medial (67%; 95% CI, 51%–80%) and lateral (76%; 95% CI, 50%–92%; p = 0.492) meniscal tears. With the numbers available, we compared these patients with patients without a history of trauma and with an intact ACL. We found no difference among patients with traumatic tears (79%; 95% CI, 59%–91%; p = 0.253) and in patients with ACL tears (77%; 95% CI, 46%–94%; p = 0.742). Conclusions Because of the issue of verification bias, the actual sensitivity of this test in practice is likely much lower than the calculated sensitivity we observed. In addition, the test did not seem to perform better in patients with trauma or ACL insufficiency, nor was it more effective in detecting medial than lateral tears, although the numbers on some of those comparisons were rather small. Based on these results, we conclude that used alone, the duck walk test likely has little value in practice as a screening test. However, it is conceivable that it could be used in combination with other provocative tests for screening purposes. Future studies might consider using it as a means to best identify which patients should undergo MRI for the possibility of a meniscal tear. Level of Evidence Level III, diagnostic study.

Background: The occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR. Results: Analyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as “younger” and those above as “older” (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03). Conclusion: This study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

Background: Revision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction. Hypothesis: Certain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes. Study Design: Case-control study; Level of evidence, 3. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction. Results: A total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient’s last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort. Conclusion: There are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

Background: While revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR. Purpose: To report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation. Results: Of the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged Conclusion: There was a significant reoperation rate after revision ACLR at 2 years (11%), with meniscal procedures most commonly involved. Independent risk factors for subsequent surgery on the ipsilateral knee included age

The current study compares the Patient Reported Outcomes Information System Physical Function Computer Adaptive Test (PROMIS PF CAT) to traditional knee PRO instruments in a healthy population undergoing surgery for ACL injuries with the following objectives: (1) identify and determine the strength of any correlations between the scores of PROMIS PF CAT and current knee PROs or their subscales that measure physical function; (2) evaluate PROMIS PF CAT’s test burden; and (3) determine if PROMIS PF CAT has any floor or ceiling effects in this population. Patients indicated for ACL surgery completed the Short Form-36 Physical Function (SF-36 PF), Knee Injury and Osteoarthritis Outcome Score (KOOS), Marx Knee Activity Rating Scale (Marx), the EuroQol 5-dimensions Questionnaire (EQ-5D), and PROMIS PF CAT. Correlations between PROs were defined as follows: High (≥ 0.7); high–moderate (0.61–0.69); moderate (0.4–0.6); moderate–weak (0.31–0.39); and weak (≤ 0.3). Floor or ceiling effects were considered significant if 15% or more patients reported the lowest or highest possible total score, respectively. 100 patients participated with a mean age of 26 years (range 11–57). The PROMIS PF CAT demonstrated high correlations with SF-36 PF (r = 0.82, p

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up ( P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment ( P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores ( P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC ( P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale ( P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale ( P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores ( P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft ( P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Anatomic double-bundle ACL reconstruction presents a unique technical challenge for surgeons, requiring precise placement of multiple tunnels in a relatively small area. As the necessity of anatomic reconstruction has been stressed throughout the literature, developing a method to consistently improve the accuracy and precision of tunnel placement is essential. We aimed to investigate whether computer-assisted navigation allows novice surgeons to place double-bundle ACL tunnels with a similar degree of accuracy to experienced surgeons operating without computer assistance.A novice surgeon group comprising three medical students performed double-bundle ACL reconstruction using passive computer-assisted navigation in 11 cadaver knees. Their individual results were compared to those of three experienced orthopaedic surgeons, each performing the identical procedure without the use of computer-assisted navigation in 9 cadaver knees.There were no significant differences in placement of either the AM or PL tunnels on the tibial plateau between the novice surgeons using computer-assisted navigation and the experienced surgeons. However, on the lateral femoral condyle, the novice surgeons placed the AM and PL tunnels significantly more anterior along Blumensaat's line, on average, compared to the experienced surgeons.

The J-sign is defined as lateral patellar translation over the anterolateral femur proximal to the trochlear groove during active leg extension. Dynamic magnetic resonance imaging (MRI) techniques allow for quantification of the J-sign using a variety of published indices. However, to date, clinical quantification of the J-sign has not been reliably described. The purpose of the present study is to assess the accuracy of clinically quantifying the J-sign compared with objective MRI data.All patients in this case series were indicated for Fulkerson osteotomy due to recurrent lateral patellar instability and examined preoperatively for the presence of J-sign. The J-sign was estimated by placing a finger on the lateral edge of the trochlea and estimating the lateral translation of the patella while the patient actively extended the knee from 30 degrees of flexion to maximum extension. Independent preoperative measurements were obtained by both the senior author and a resident and compared to dynamic MRI measurements read by independent investigators.Preoperative physical examination for the presence of the J-sign was conducted on 10 patients (10 knees). The average difference between clinical and MRI J-sign measurement was 4.32 mm (range 0.2 - 10.4 mm). There was no significant difference between the clinical and MRI J-sign measurements (p = 0.2579). Clinical measurements of the J-sign differed by an average of 2.2 mm between the two examiners (range 0 - 5 mm).Clinical quantification of the Jsign showed relative imprecision when compared with MRI measurements of the modified lateral patellar edge (LPE), though in several patients we did achieve accurate J-sign assessment. If further research can validate this technique as accurate and consistent using larger patient populations, it could aid in the development of surgical treatment plans for patients presenting with patellar instability, and serve as an objective assessment of alignment in the postoperative period.

To study patient outcomes after surgical correction for iatrogenic patellar instability.This retrospective study looked at 17 patients (19 knees) suffering from disabling medial patellar instability following lateral release surgery. All patients underwent lateral patellofemoral ligament (LPFL) reconstruction by a single surgeon. Assessments in all 19 cases included functional outcome scores, range of motion, and assessment for the presence of apprehension sign of the patella to determine if LPFL reconstruction surgery was successful at restoring patellofemoral stability.No patients reported any residual postoperative symptoms of patellar instability. Also no patients demonstrated medial patellar apprehension or examiner induced subluxation with the medial instability test described earlier following LPFL reconstruction. Furthermore, all patients recovered normal range of motion compared to the contralateral limb. For patients with pre and postoperative outcome scores, the mean overall knee injury and osteoarthritis outcome score increased significantly, from 34.39 preoperatively (range: 7.7-70.12) to 69.54 postoperatively (range: 26.82-91.46) at final follow-up (P0.0001).This novel technique for LPFL reconstruction is effective at restoring lateral restraint of the patellofemoral joint and improving joint functionality.

Currently, a significant proportion of effort on cartilage tissue research is devoted to establishing the most effective method of inducing cartilage repair. However, the studies themselves lack uniform documentation and comparisons are difficult to make. If valuable therapeutic information is to be gained from future studies, it is important that an accurate system exists for assessing focal cartilage defects to allow comparison between studies and/or investigators.

Tibial tubercle-trochlear groove (TT-TG) distance is currently used at our institution to determine tibial tubercle medialization required in Fulkerson osteotomies. If the correlation between a modified lateral patellar edge (LPE) and the transfer distance was found to be stronger than its correlation with TT-TG, it would suggest that the best measurement to use is actually modified LPE.The electronic medical records of 32 patients who underwent Fulkerson osteotomy procedures with femoral nerve stimulation were reviewed and measured. For each patient, modified LPE was measured on quadriceps active hyperextension MRI, and TT-TG was measured on passive extension MRI. Correlation between both TT-TG and LPE and tibial tubercle transfer distance was then determined and analysed.The correlation between TT-TG and actual intra-operative tibial tubercle transfer distance in Fulkerson osteotomy procedures with intra-operative femoral nerve stimulation was found to be weak at 0.436 (p0.05). The correlation between modified LPE and actual intra-operative tibial tubercle transfer distance was found to be strong at 0.697 (p0.001).The correlation between modified LPE and actual intra-operative tibial tubercle transfer distance was stronger than the correlation between TT-TG and tibial tubercle transfer distance. This suggests that the modified LPE may actually be a better preoperative determinant than the currently-utilized TT-TG of the transfer distance required during Fulkerson osteotomy procedures.Level II, diagnostic study.

To describe the prevalence of symptoms of depression among competitive collegiate student athletes and examine the factors associated with symptoms of depression among this population.A baseline survey of a prospective cohort study.The survey was administered at the preseason team meetings.The sample included 257 collegiate student athletes (167 males and 90 females) who participated in Division I National Collegiate Athletic Association (NCAA)-sponsored sports during the 2005-2006 academic year.Symptoms of depression were measured by the Center for Epidemiological Studies Depression Scale (CESD). Anxiety was measured by the State-Trait Anxiety Inventory (STAI). The Generalized Estimating Equations (GEE) was used to assess the factors associated with symptoms of depression.Twenty-one percent of participants reported experiencing symptoms of depression. Athletes who were female, freshmen, or with self-reported pain were associated with significantly increased odds of experiencing symptoms of depression after adjusting for sports and other covariates. In particular, female athletes had 1.32 greater odds (95% CI, 1.01 to 1.73) of experiencing symptoms of depression compared to male student athletes. Freshmen had 3.27 greater odds (95% CI, 1.63 to 6.59) of experiencing symptoms of depression than their more senior counterparts. Student athletes who reported symptoms of depression were associated with higher scores of State-Anxiety and Trait-Anxiety, respectively (P0.0001).Our findings provide empirical data for the future study on mental health among collegiate athletes. Further studies on why female and freshmen athletes are at increased risk of experiencing symptoms of depression are also warranted.

Background In 1998, the National Collegiate Athletic Association legislated a decrease in the number of scrimmages and full-contact practices allowed during the spring season. Hypothesis A significantly increased risk of injury faced by the same player during the spring versus fall practice sessions does exist, but the National Collegiate Athletic Association regulations will not have the intended effect of reducing injury rates to equal or below those of the fall practice sessions. Study Design Retrospectively analyzed, descriptive study of prospectively collected injury surveillance data followed by a prospective, controlled, repeated-measures study after the rule change. Methods Phase 1: the Big Ten Conference Sports Injury Surveillance System database was reviewed from spring 1992 through fall 1997 for all reportable injuries. Phase 2: a prospective investigation was instituted from spring 1998 through fall 2000. This protocol was modified to also document updated individual player position descriptions and string as well as exposures for the old fall and spring practice categories (scrimmages, full contact, and limited contact) and the new spring practice designations (full pads with and without tackling, helmets only, spring game, and other scrimmages). Results Phase 1: There were 3950 fall injuries and 1007 spring injuries, with 469 of the 1007 attributable to the “spring risk factor.” There was a statistically significant increase in injury rate in the spring (19.8) versus fall (10.6). Scrimmages (incidence density ratio = 2.4) and limited-contact practices (incidence density ratio = 2.5) showed more than twice the fall injury rate. Phase 2: There were 1502 fall injuries and 648 spring injuries, with 192 attributable to the spring risk factor. There was a 3-fold increase in injury rate in the spring (incidence density ratio = 3.2). Although the noncontact, helmets-only practices produced the lowest injury rates, the nonspring game scrimmages and the limited-contact practices defined as “practice with pads but without tackling” displayed the highest injury rates. In both spring and fall, nonplayers exhibited the highest injury rates for all string groups. Conclusions There was and still is a statistically significant increase in spring practice injury risk. The 1998 rule change resulted in an even greater increase in spring practice injury risk. If the goal is to minimize the number of spring practice injuries, it will be best accomplished by limiting the number of scrimmages and limited-contact sessions.

Most patients expect an improvement of walking ability and an increase in activity levels after TKA. Unfortunately, few studies report qualitative and quantitative activity improvements after TKA.The aims of this study were (1) to evaluate quantity and quality of physical activity before and after TKA with an accelerometer, and to compare activity level with that of an age-matched control group without lower-extremity disorders. (2) Improvement in measured steps per day after TKA and the ability to meet physical activity guidelines were evaluated. (3) The influence of patient-specific and implant parameters were assessed.An accelerometer was used to measure activity in 97 patients who were assessed before TKA and 1 year after TKA. The measurements included the total number of steps, moderate to vigorous activity defined as at least 100 steps per minute, and time spent lying, sitting/standing, or walking. We then calculated the proportion of patients who met the 10,000 steps per day guideline recommendation and determined factors that predicted failure to meet that goal. Thirty-nine age-matched control subjects without lower-extremity disorders were selected and underwent the same assessments using the accelerometer for comparison with patients 1 year after TKA.Measured steps per day improved from a mean of 5278 (SD, 2999) preoperatively to 6473 (SD, 3654) postoperatively (effect size, 1.23; 95% CI, 1.10-1.35; p 0.001). Moderate to vigorous steps per day improved from a mean of 1150 (SD, 982) to 1935 (SD, 1728; p 0.001). Times spent in lying, sitting, or standing position or during walking did not change after TKA. For all measured parameters, activity of the patients after TKA was considerably less than that of the age-matched control subjects, who walked a mean of 13,375 (SD, 4614) steps per day (p 0.001), performed a mean of 6562 (SD, 3401) vigorous steps per day (p 0.001), and spent a mean of 2.9 hours (SD, 1.1) per day walking (p 0.001). Only 16 patients (16.5%) met physical activity guidelines after TKA. BMI (p = 0.017), sex (p = 0.027), and comorbidities (American Society of Anesthesiologists Grade, p = 0.042) were independent factors associated with steps per day after TKA.One year after TKA, patients had increased walking and moderate to vigorous steps. However, only 16.5% achieved the guideline recommendations for walking activity. BMI, sex, and comorbidities are patient factors that are associated with activity after TKA. Even with improvements in walking, activity level after TKA remains less than that seen for age-matched control subjects. Surgeons should be aware of this when counseling patients undergoing TKA.Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Background: Hamstring strains are a recognized cause of disability for athletes in many sports, but no study exists that reports the incidence and circumstances surrounding these injuries in professional baseball. Hypothesis: Professional baseball players have a high incidence of hamstring strains, and these injuries are influenced by multiple factors including history of hamstring injury, time period within the season, and activity of base running. Study Design: Descriptive epidemiologic study. Methods: For the 2011 season, injury data were prospectively collected for every Major League Baseball (MLB) major and minor league team and recorded in the MLB’s Injury Surveillance System. Data collected for this study included date of injury, activity in which the player was engaged at the time of injury, and time loss. Injury rates were reported in injuries per athlete-exposure (A-E). Athlete-exposures were defined as the average number of players on a team who were participating in a game multiplied by the number of games. Results: In the major leagues, 50 hamstring strains were reported for an injury rate (IR) of 0.7 per 1000 A-Es and averaged 24 days missed. In the minor leagues, 218 hamstring strains were reported for an IR of 0.7 per 1000 A-Es and averaged 27 days missed. Base running, specifically running to first base, was the top activity for sustaining a hamstring strain in both major and minor leagues, associated with almost two-thirds of hamstring strains. Approximately two-thirds of these injuries in both the major and minor leagues resulted in more than 7 days of time loss. Approximately 25% of these injuries kept the player out for 1 month or longer. History of a previous hamstring strain in the prior year, 2010, was found in 20% of the major league players and 8% of the minor league players. In the major leagues, the month of May had a statistically significant higher frequency of hamstring injuries than any other month in the season ( P = .0153). Conclusion: Hamstring strains are a considerable cause of disability in professional baseball and are affected by history of hamstring strain, seasonal timing, and running to first base.

Background: There are relatively few published epidemiological studies that have correlated pitching-related risk factors with increased pitching-related arm problems as well as injuries. Hypothesis: High pitching volume and limited recovery will lead to arm fatigue, thus placing young pitchers at a greater risk for elbow and shoulder problems and, subsequently, an increased risk for arm injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A national survey was conducted among 754 youth pitchers (ages 9 to 18 years) who had pitched in organized baseball leagues during the 12 months before the survey. Self-reported risk-prone pitching activities were identified and compared with recommendations by the American Sports Medicine Institute. Relationships between self-reported pitching activities, shoulder and elbow problems, and injuries were assessed using multivariable logistic regression. Results: Of the 754 participating pitchers, 43.4% pitched on consecutive days, 30.7% pitched on multiple teams with overlapping seasons, and 19.0% pitched multiple games a day during the 12 months before the study. Pitchers who engaged in these activities had increased risk of pitching-related arm pain (odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.14-5.60; OR = 1.85, 95% CI = 1.02-3.38; OR = 1.89, 95% CI = 1.03-3.49, respectively). Nearly 70% of the sample reported throwing curveballs, which was associated with 1.66 (95% CI = 1.09-2.53) greater odds of experiencing arm pain while throwing. Pitching-related arm tiredness and arm pain were associated with increased risk of pitching-related injuries. Specifically, those who often pitched with arm tiredness and arm pain had 7.88 (95% CI = 3.88-15.99) and 7.50 (95% CI = 3.47-16.21) greater odds of pitching-related injury, respectively. However, pitching on a travel baseball club, playing baseball exclusively, or playing catcher were not associated with arm problems. Conclusion: The results of this study, along with those of others, reinforce the importance of avoiding risk-prone pitching activities to prevent pitching-related injuries among youth pitchers.

The effect of long-term exercise on canine knees was studied to determine whether an increased level of lifelong weightbearing exercise causes degeneration, or changes that may lead to degeneration, of articular cartilage. Eleven dogs were exercised on a treadmill at 3 km/hr for 75 minutes 5 days a week for 527 weeks while carrying jackets weighing 130% of their body weight. Ten control dogs were allowed unrestricted activity in cages for the 550 weeks. At the completion of the study all knee joints were inspected for evidence of joint injury and degeneration. Articular cartilage sur faces from the medial tibial plateau were examined by light microscopy, the cartilage thickness was meas ured, and the intrinsic material properties were deter mined by mechanical testing. No joints had ligament or meniscal injuries, cartilage erosions, or osteophytes. Light microscopy did not demonstrate cartilage fibrilla tion or differences in safranin O staining of the tibial articular cartilages between the two groups. Further more, the tibial articular cartilage thickness and me chanical properties did not differ between the two groups. These results show that a lifetime of regular weightbearing exercise in dogs with normal joints did not cause alterations in the structure and mechanical properties of articular cartilage that might lead to joint degeneration.

The tibial tubercle-trochlear groove measurement (TT-TG), which measures the lateral offset of the tibial tubercle relative to the trochlear groove of the femur, has been utilized as an intraoperative tool to help establish maximum patellofemoral congruency in patients who suffer from patellar instability. We have previously published our approach of establishing how far to transfer the tibial tubercle using intraoperative femoral nerve stimulation in order to achieve congruency from 0-30° of flexion. The technique and clinical outcomes have previously been published in this journal and elsewhere. Here we describe the use of the TT-TG distance to determine how far to transfer the tibial tubercle to achieve our goals and have found that it varies according to the clinical exam features.We intended to determine the effectiveness of using the preoperatively established TT-TG to predict the degree of intraoperative me- dialization of the tibial tubercle to achieve our goal of establishing dynamic congruency of the patella in the trochlear groove when using the previously described femoral nerve stimulation method of estimating dynamic tracking of the patella.From the study group of patients used in other publications, we examined 20 knees in 18 patients who had a history of recurrent lateral dislocations and underwent a Fulkerson tibial tubercle transfer. Each knee was dynamically assessed preoperatively by obtaining an MRI at 30° of flexion and complete hyperextension while voluntarily contracting their quadriceps. These were then compared to the intraoperative transfer of the tibial tubercle required to achieve maximum congruency when the femoral nerve was stimulated. We then looked at the preoperative TT-TG measurement to determine its role in predicting what was required at achieving congruency in the context of the quad active MRI findings.Thirteen knees preoperatively demonstrated a positive J-sign defined as the patella subluxated greater than or equal to 5 mm lateral in full extension compared to 30° of flexion. In these patients, the TT-TG was accurate if the distance medialized was 1:1 with the measured TT-TG. In 7 out of the 20 knees, the patella demonstrated a false negative J-sign where the patella was radio- graphically subluxated at 30° of flexion as well as at hyperextension. In this group, the TT-TG underestimated the transfer required for congruency on average 5mm even when using the 1:1 ratio.The preoperative use of the J-sign is of value when determining the role of the TT-TG measurement and estimating the distance required to intraoperatively achieve congruency when using the femoral nerve stimulation technique. Those that demonstrated a positive J-sign of 5mm or greater, a 1:1 ratio of TT-TG to medialization is most reliable at establishing congruency of the patellofemoral joint. Whereas, those that demonstrated a false negative J-sign even the 1:1 ratio remains inadequate at producing congruency and more medialization is required.Level III, Retrospective Observational/Comparative Study.

The goal is to introduce a reproducible exam technique that allows clinical diagnosis of symptomatic plical bands and associated synovium about the knee. We then aimed to assess the accuracy of the exam technique through arthroscopic confirmation of these tissues. Lastly, we hope to determine whether arthroscopic plicectomy and partial synovectomy is an effective treatment for alleviating the pain associated with symptomatic plica.This retrospective study evaluated 80 consecutive symptomatic knees under the care of a single physician diagnosed with symptomatic plica and associated painful synovium from 2001-2011. These patients underwent diagnostic and therapeutic arthroscopy to verify the presence of a plica and painful synovium with plicectomy and partial synovectomy if necessary. Statistical analysis was performed to determine the sensitivity and positive predictive value of the exam.The medial parapatellar region was the most common location for symptomatic plica and associated synovial tissue. The exam technique described in this study had a sensitivity of 83.8% with a positive predictive value of 98.6% in the specific patient population described.This study suggests that while the medial plical band is the most common, there is frequently sensitive synovial tissue found in multiple locations about the knee. This study also suggests that a thorough exam technique can accurately diagnose both the plical bands as well as the sensitive synovial tissue.Level II, Diagnostic Study. See the Guidelines for Authors for a complete description of levels of evidence.

Rupture of the pectoralis major muscle is a rare clinical entity. Only few reports have discussed its MRI or CT features. We have reviewed the imaging features of four cases of complete rupture of the pectoralis major muscle. One case of acute injury underwent surgical repair. MRI is useful in delineating the site and extent of the rupture in relation to the musculotendinous junction, which will help the surgeons with possible treatment options and surgical planning. Because of the complex anatomy of the pectoralis major muscle near its insertion on the humerus and the signal characteristics of hematoma and edema in the muscle, axial T2-weighted images were most valuable for the evaluation of acute and subacute injuries. Axial T1-weighted images were helpful in delineating chronic injuries. CT is inferior to MRI for direct visualization of muscle rupture.

This article provides a review of the progress that has been made on the biomechanical, functional performance and epidemiological investigations into the effectiveness of prophylactic knee braces (PKBs) since the position statement against their use was issued in 1987 by the American Academy of Orthopaedics and a review of this subject was last published in Sports Medicine in 1989 by Montgomery and Korziris. The evolution of the salient design features of three surrogate knee models are reviewed along with the results of PKB effectiveness and safety factor testing. While still too limited in scope to be totally realistic, major advances have been made in the sophistication of the present biomechanics laboratory testing conditions. The on-the-field functional performance effects of wearing a knee brace are not always manifest in all individuals. The efficacy of PKBs remains in question but recent studies have taught us enough to put their use into perspective. While they may play some role, PKBs probably represent the least important factor in influencing the likelihood that a medial collateral ligament (MCL) sprain will occur. On the other hand, there is no evidence that such braces put added valgus pressure on some knees, or that wearing a brace is associated with an increased frequency or severity of knee or ankle injury. All else being equal, from the biomechanical studies, we know that whilst some braces are better than others, currently available PKBs can provide 20 to 30% greater resistance to a lateral blow, with the possibility that the anterior cruciate ligament (ACL) is given even greater protection than the MCL. This appears to be true when the lateral blow is of sufficient magnitude to cause significant medial joint line opening, but is not as great at the very lowest levels of impact. Regardless of the material they are made of, the most effective PKBs are those sufficiently stiff to prevent an external blow at the joint line from causing brace hinge contact with the knee tissues. Based on the superior results of the custom-fit functional braces, the most important future design feature appears to be the sizing and fitting of the thigh and tibial cuffs. On the negative side, the presence of a brace may slow an athlete's straight-ahead sprint speed and cause early fatigue to its wearer. This effect appears to vary from one brace to another according to its weight, design features, and pressure from the leg and thigh straps. However, it appears that knee braces do have the potential to restrict performance of the athlete for high-speed running but the effect is related to several factors. The weight of the brace resultant friction of the hinges, completeness of fit, and tightness of straps appear to be important. The most measurable effects include: increased muscular relaxation pressures; increased energy expenditure; and a related increase in blood lactate levels, maximal torque output, oxygen consumption and heart rate. On the other hand, experienced brace wearers and larger, stronger individuals displayed fewer, or no effects of donning a brace. Improvements in the protectiveness of the PKB are likely to accompany improvements in the ability to contour the braces to fit each individual's leg in the equipment room without the added expense of the cast-moulding process. Further improvement may be realised by friction-free polycentric joints, as well as an attachment system that minimises thigh and calf soft tissue compression perhaps by incorporating the braces into the trousers of the uniform to provide suspension from the waist.

This is the second of 2 articles on a 3-year investigation of medial collateral ligament sprains of the knee to as sess the effectiveness of prophylactic knee braces in NCAA Division I college football players. Position, string, type of session, and daily brace wear were re corded. The injury rates for braced and unbraced knees were used to create an incidence density ratio. The data were stratified and simultaneously controlled for posi tion, string, and session and evaluated for their statis tical significance. The 987 Big Ten players generated 155,772 knee exposures over the study period (50% braced). Noticeable differences existed in the rates of injury for the braced and unbraced knees in almost ev ery position during practices, depending on player or nonplayer status. When the influential factors of posi tion, string, and session are considered, there is a con sistent but not statistically significant tendency for the players wearing preventive knee braces to experience a lower injury rate than for their unbraced counterparts. For starters and substitutes in the line positions, as well as the linebackers and tight ends, there was a consis tent trend toward a lower injury rate in both practices and games. The braced players in the skill positions (backs/kickers), at least during games, exhibited a higher injury rate.

In this prospective, multiinstitutional analysis of medial collateral ligament sprains in college football players, we categorized 987 previously uninjured study subjects according to frequency of wearing preventive knee braces, studied the patterns by which 47 of 100 injuries occurred to unbraced knees, and identified several ex trinsic, sport-specific risk factors shared for both braced and unbraced knees. The attendance, brace wear choice, position, string, and session of each participant were recorded daily; medial collateral ligament sprains were reported whenever tissue damage was confirmed. Both the likelihood of wearing braces and risk of injury without them was highly dependent on session (games/ practices), position group (line, linebacker/tight end, skill), and string group (players/nonplayers). Subjects wearing braces often faced a high injury risk to their unbraced knees, a finding compatible with the opinion that braces were a necessary evil, best worn when con cern over danger of injury outweighed desire for speed and agility. It is concluded that to avoid misinterpreta tions due to the confounding influence of brace wear selection bias, accurate investigation of daily brace wear patterns is required. Then, before considing the impact of preventive knee braces, a repartitioning of the data base is essential to assure that only similar groups will be compared.

Stress fractures are overuse injuries of bone. Basketball players are particularly prone to develop the notoriously "troublesome" stress fractures of the foot and leg. This article reviews the pathogenesis, epidemiology, diagnosis, and treatment of stress fractures, with specific emphasis on the care of the basketball athlete.

A prospective study was established to record the patterns of injury incurred by all members of a women's college gymnastics team. Twenty-six women were fol lowed over a 4-year period (53 gymnast seasons) from 1983 to 1987. To identify which injuries resulted in persisting impairment, these same athletes were con tacted again 3 years later. The 26 athletes sustained 106 injuries. Sixty (57%) of these were of acute onset and were related to an identifiable gymnastics event. The remaining 46 (43%) were of gradual onset or overuse injuries. For the follow-up phase, 22 of the 26 women were contacted from 10 to 70 months (38.5 average) after completion of their gymnastics careers. Forty-five percent of the injuries recorded in their com petitive years still bothered them at the time of followup, especially low back, ankle, great toe, shoulder, and knee injuries. Athletic and recreational activity exacer bated the complaints. Twenty-nine percent felt that their sports activity level was now limited. Forty-six percent felt that their injury was at less than full recovery, yet most felt that they were capable of strenuous physical activity and continued to be active despite complaints such as pain and stiffness.

The evaluation of distal transfer procedures relies primarily on qualitative clinical findings. Although quantitative MRI measurements provide an objective supplement to qualitative clinical findings, an association between qualitative clinical findings and quantitative patellofemoral indices has yet to be established.A 21-year-old man presented with frequent episodes of patellar dislocation. Clinical and radiographic findings identified the patient as a candidate for realignment. MR images were obtained with the quadriceps contracted at 30° flexion and in full extension preoperatively and postoperatively. The procedure eliminated the clinical J-sign, defined as lateral movement of the patella over the lateral femoral condyle during active leg extension, which was confirmed quantitatively using established patellofemoral indices in conjunction with MRI.Movement of the patellofemoral joint is complex and dependent on many factors, including skeletal geometry, dynamic muscle action, and soft tissue restraints. Therefore, proper clinical and radiographic evaluation of patellar tracking requires observation during active quadriceps contraction. However, it is unclear whether there is any association between quantitative radiographic indices and qualitative clinical assessment during active quadriceps contraction.We believe objective measurements are valuable in determining the radiographic assessment of patellar realignment procedures. Lateral patellar edge appears to quantify the clinical J-sign. The association between radiographic medialization of the patella and clinical improvement postoperatively in this patient warrants additional investigation in a larger group of patients with longer followup.

In brief Shin splints, or more precisely, medial tibial stress syndrome (MTSS), are painful and troublesome. Despite treatment or activity modification, they often recur. Distinguishing MTSS, the most common running overuse injury, from other overuse injuries can help focus treatment, which starts conservatively. Recommending activity modification, ice massage, NSAIDs, and stretching is a good first step. Patients who don't respond to treatment may need additional diagnostic workup and more restrictive activity guidelines.

An analysis of 2 years of injury surveillance data on female and male high school varsity basketball players gathered by certified athletic trainers at 196 schools around the nation is presented. In contrast to previous reports, the rate of sport-related injury (game and practice combined) was approximately the same for both sexes. The girls had a slightly higher proportion of moderate and major injuries than had the boys. Sprains were the most frequent type of injury for both sexes, and the most frequently injured body part was the ankle. The majority of injuries were new vs reinjuries. The rate of injury was twice as great for game-play as for practice in both sexes. The rate of major injury in game-play was higher for the girls, and these injuries involved the knee 58% of the time. Certain body characteristics and the player's sex were associated with knee and ankle injuries. More injury surveillance studies are needed that contain specific injury diagnoses and data on player fitness, strength...

Medial transfer of the tibial tubercle is commonly implemented to correct patellar alignment in patients with patellar instability. However, the extent of transfer needed is difficult to determine. This article reports a pilot-study experience with a novel technique employing intraoperative femoral nerve stimulation to better determine the distance of tubercle transfer required for proper patellar tracking. this pilot study is a case series involving seven knees, all with a clinical history of dislocation, evidence of maltracking, and excessive medial patellofemoral ligament (MPFL) laxity to the point of producing a positive apprehension sign. All seven knees received femoral nerve stimulation for patellar tracking assessment as part of a modified Fulkerson osteotomy. All knees received clinical follow-up for a minimum of 24 months. six of the seven cases in this series remained stable during two years of follow-up. through these findings we conclude that the use of femoral nerve stimulation for patellar tracking assessment may be associated with a sufficiently high rate of success to warrant more extensive investigation.

We describe a method of dynamic assessment of patellar tracking intraoperatively during a Fulkerson osteotomy. We utilize an electrically conductive catheter intraopertively to directly stimulate the femoral nerve to cause quadriceps muscle contraction. The resultant active knee extension allows dynamic assessment of patellofemoral tracking prior to and after final Fulkerson fixation. This dynamic intraopertive technique allows us to approximate in vivo patellofemoral motion better than with passive motion assessment.

Capsular attenuation has been seen after thermal capsulorrhaphy surgery. The purpose of this study was to evaluate the mechanical, histologic, and morphologic effects on capsular tissue after cumulative applications of radiofrequency energy. Ovine patellofemoral capsular tissue was treated with 1, 2, 4, or 8 applications of bipolar radiofrequency energy and then analyzed. No acute capsular ablation or destruction was seen grossly, even in the 8-application group. No definitive visual clues that excessive radiofrequency energy had been applied were seen. There was significant shrinkage and loss of tensile stiffness for all thermal application groups. Given the small sample sizes, post-application failure load, percent relaxation, and stiffness were not observed to be significantly different among the groups. Cumulative applications produced minimal further tissue shrinkage but were accompanied by larger, though not statistically significant, mechanical property losses and increased depth of tissue penetration. These findings suggest that there is no benefit to repeated applications of radiofrequency energy to capsular tissue.

Surrogate knee model biomechanical studies have indicated that off-the-shelf braces provide 20% to 30% greater resistance to a lateral blow when the knee is in full extension. Custom functional braces doubled the protective effects and proved effective with the knee in some flexion. Although functional performance studies are not consistent, preventive knee braces may slow straight-ahead sprint speed, cause early fatigue, and increase muscular relaxation pressures, energy expenditure, blood lactate levels, maximal torque output, oxygen consumption, and heart rate. Two epidemiologic studies have been performed. At West Point, a randomized control study of 71 injuries in 1396 cadets indicated knee brace effectiveness with a statistically higher rate of injury in the control group (3.4/1000 exposures) than in the braced group (1.5/1000 exposures), with the most significance for medial collateral ligament sprains in defensive players. The Big Ten Conference conducted a descriptive study of 100 medial collateral ligament sprains among 987 players in different positions, strings, and types of session. Brace-wear tendency varied directly with the unbraced player counterpart's risk of medial collateral ligament sprain, with the nonplayer linemen experiencing both the greatest risk of unbraced practice session injury (0.0801 injuries/1000 exposures) and the highest incidence of brace wear (85%). During practices, there was a nonsignificant but very consistent reduction in injury rate for braced players in every position and string. During games, there was also a reduced rate for linemen and the linebacker/tight end group. The study concluded that although the issue is not closed, preventive knee braces appear to offer some protection to the medial collateral ligament from a contact injury involving a valgus blow, but there may be negative effects on performance level, leg cramping, and fatigue symptoms.

Where Are We Now?The current study by Won and colleagues concluded thatpatients undergoing revision ACL surgery have a greaterincidence of significant varus alignment compared withpatients undergoing primary ACL reconstruction. Theauthors also observed that this varus alignment was asso-ciated with meniscal pathology and degenerative changesof the knee. The report of varus alignment provides aninteresting observation that goes a step beyond the findingsof the Multi-center Anterior (C)ruciate Revision Study(MARS) [1], but leads to more questions than answers. Thearticle does not tell us about the results of performing ahigh tibial osteotomy at the time of the revision ACL. Itmerely points out that these patients are potential candi-dates for such a procedure.The strength of the manuscript is that it reminds us thatvarus malalignment is a potential variable to be mindful of.It also serves to warn surgeons they should be aware ofpossible failure of the graft, and continuing pain related tomedial compartment degeneration. Won and colleagues’attention to detail in establishing an effective protocol forthe long-leg films is important because standing long-legradiographs are fickle in terms of being able to demonstrateconsistently the true amount of coronal plane alignment.Where Do We Need to Go?Kimandcolleagues[3]reportedthatasidefromextremecaseswith varus thrust (without medial compartment arthritis) thestability and functional scores were not adversely affected byprimary varus alignment. Kim and colleagues [3]alsoreported that aside from extreme cases where varus thrust isnoted, (in addition to the post meniscectomy changes) theradiographic features of unicompartmental osteoarthritis areinsufficient to be associated with graft failure.Another MARS study [2] indicated that a significantnumber of revision surgeries were related to technicaldifficulties in graft tunnel placement in the primary pro-cedure. This raises a number of questions. Was thedegenerative process and progressive varus at fault incausing the ligament failure in the other revision surgeriesnot related to graft tunnel placement? Which patients needproximal tibial osteotomies at the time of revision ACLsurgery? Should a high tibial osteotomy be performed toavoid postsurgical medial joint line pain? Will concomitantrealignment increase the chance of establishing stability orwould staging the two procedures not only eliminate the

We studied midfoot sprains in collegiate football players to define and document incidence, mechanisms, injury patterns, and disabilities. Twenty-three athletes with 24 injuries from 1987 through 1991, with a mean followup of 30.8 months, were identified for the study. The inju ries occurred in 4% of the football players per year with offensive linemen incurring 29.2% of the injuries. The location of maximal tenderness on physical examina tion was an important prognostic indicator such that in juries with medial and global midfoot tenderness to pal pation had the longest time loss from participation and time until full healing. Lateral midfoot sprains required short periods of disability, and players were able to re turn to participation with the use of an orthosis. Nineteen athletes with 20 injuries responded to a questionnaire. Four players reported residual functional problems. Only 1 of these players had to modify his recreational activities because of pain. The other players remained very active with only mild complaints of pain after high- demand activities. Midfoot sprains were associated with acute disability that required prolonged restriction from competition, but for most players the long-term residual problems were minor.

We evaluated the relationship of cervical spinal stenosis with the occurrence of "stingers" in collegiate football players who participated at our institution from 1987 through 1991. Preparticipation cervical spine radio graphs of 266 players were used to measure Torg ratio. Forty players with stingers were identified: 34 had an extension-compression mechanism; 6 had a brachial plexus stretch mechanism. Time-loss neck injuries oc curred in 31 players; the remaining 195 players were asymptomatic. The mean Torg ratio was significantly smaller for the stinger group (P = 0.02). The Torg ratio was less than 0.8 at 1 or more levels in 47.5% of the stinger group, 32.3% of the time-loss neck pain group, and 25.1 % of the asymptomatic group. No player with a brachial plexus stretch mechanism had a mean Torg ratio less than 0.8, but 20.6% of the players with an extension-compression mechanism had a mean Torg ratio less than 0.8. Players with a Torg ratio less than 0.8 had 3 times the risk of incurring stingers. We con clude that cervical spinal stenosis increases the risk for having stingers with complicated clinical courses.