Sunday, May 15, 2011

Posted on the ORTHOSuperSite May 6, 2011
Concomitant SLAP, infraspinatus tears offer poor prognosis for return to play in overhead athletes

Although overhead throwing athletes with isolated SLAP tears typically have encouraging prognoses for returning to previous playing levels, a recently presented study shows that those with concomitant SLAP and infraspinatus tears are less likely to experience similar success.

Jonathan P. Van Kleunen, MD, shared his team’s findings at the 2011 Annual Meeting of the Arthroscopy Association of North America, in San Diego.

Van Kleunen added, however, that there has been limited discussion regarding concomitantinfraspinatus tendon tear in the same population. Presence of a concomitant infraspinatus tear has served as an indicator for a more guarded prognosis, he said, and may be a negative predictor for returning to pre-injury level of play.

The team performed a retrospective review on a series of overhead athletes who had been diagnosed with and undergone surgical treatment of both a SLAP tear and a significant — defined in the study as being greater than 50% — tear of the infraspinatus tendon. They were able to identify 20 overhead, high-level throwing athletes younger than 25 years of age who met the study criteria, having undergone simultaneous arthroscopic repairs of a SLAP tear with standard suture anchor technique and an infraspinatus tear with PDS suture between 2005 and 2008.

According to Van Kleunen, all 20 patients in the study made an attempt to return to their prior sport after the completion of postoperative rehabilitation. Of the 20 patients, only five (25%) were able to return to a similar or superior level of performance they had experienced prior to injury. Among the remaining 15 patients, six returned to play at a lower level. These patients were able to play the same position or forced by a decline in throwing velocity to switch to another position, the abstract noted. Nine of the 20 patients were unable to return to play. There were no reported complications or reoperations.

Van Kleunen’s team concluded through their study that significant — meaning greater than 50% — tears of the infraspinatus in combination with GIRD and SLAP tears caused a significant worsening of the prognosis in same-level return to play for overhead throwing athletes.

For further information: http://www.orthosupersite.com/view.aspx?rid=83327

ORTHOPEDICS May 2011;34(5):397.
Transphyseal Anterior Cruciate Ligament Reconstruction in a Skeletally Immature Knee Using Anterior Tibialis Allograft
by Yool Cho, MD; Soo-Jin Jang, MD; Jung-Hwan Son, MD, PhD

Abstract

Anterior cruciate ligament (ACL) injury in the skeletally immature individual is being recognized with increasing frequency. Nonoperative treatment of ACL injuries in skeletally immature patients have not been favorable. Surgical treatment options for complete ACL tears include primary ligament repair, extraarticular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal-sparing reconstruction. The advantage of transphyseal reconstruction is placement of the graft tissue in an isometric position, which provides better results, according to the literature. The potential disadvantage is angular or limb-length discrepancy caused by physeal violation. Controversy exists in allograft selection about whether bone or soft tissue passes into physes. The use of standard tunnels provides reliable results, but carries the risk of iatrogenic growth disturbance from physeal injury.

This article presents 4 cases of transphyseal ACL reconstruction using anterior tibialis allograft in skeletally immature patients that had satisfactory functional outcomes with no growth disturbances. This is the first report of transphyseal ACL reconstruction using anterior tibialis allograft in skeletally immature patients in the English-speaking literature. All patients underwent transphyseal ACL reconstruction using anterior tibialis tendon allograft. None of the patients had angular deformities. No early physeal arrest was measured between the preoperative and postoperative radiographs. At last follow-up, the results of the Lachman test were normal for 3 patients and nearly normal for 1 patient. All patients demonstrated full range of knee motion (comparing the reconstructed knee to the contralateral knee). The results of the pivot-shift test were normal for 3 patients and nearly normal for 1 patient. No patients reported giving way.

Anterior cruciate ligament (ACL) injury in the skeletally immature individual is recognized with increasing frequency.1-3 Nonoperative treatment of ACL injuries in skeletally immature patients has not been favorable.1,4,5 Surgical techniques to address ACL injuries in these patients include primary ligament repair, extraarticular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction and physeal-sparing reconstruction.3-11 Transphyseal reconstruction is similar to the procedure performed in adults with standard bone tunnels that pass the physes. The use of standard tunnels provides reliable results, but carries the risk of iatrogenic growth disturbances from physeal injury.6,9,12-14

In primary ACL reconstruction, allografts are comparable with autografts as equivalent clinical results show consistent efficacy.15-17 Various allograft tissue types exist, including patellar, Achilles, tibialis, and peroneus longus tendons. Controversy exists in allograft selection about whether bone or soft tissue pass into physes. To the best of our knowledge, this is the first report of transphyseal ACL reconstruction using anterior tibialis allograft in skeletally immature patients in the English-speaking literature.

Case Report

Four girls 13.6 years or younger presented with injuries. Of the 4 patients, 2 were injured during athletic activites, 1 was injured in a motor vehicle accident, and 1 was injured due to a fall. Radiographs showed wide open physes. The patients underwent tibial and femoral transphyseal ACL reconstruction using anterior tibialis allografts. The patients’ ages ranged from 10.3 to 13.6 years, with a mean age of 12.4 years at the time of surgery. The mean duration of the operation was 103.8 minutes (range, 90-110 minutes), and mean bleeding amount was 33.8 cc (range, 30-40 cc). Three of 4 patients had midsubstance ACL tears and 1 had a femoral attachment site ACL tear on arthroscopy. One patient underwent concurrent partial meniscectomy due to a medial meniscus tear during ACL reconstruction.

All patients underwent a standard preoperative and postoperative evaluation that included a physical examination (Lachman test and pivot-shift test), whole scanogram, and standing AP, lateral, and patellar axial view radiographs. All patients had a complete radiolucency at the tibial and femoral physes (Figure 1). We evaluated physical and physiologic maturity according to the presence menarche onset in girls. None of the girls had reached menarche. One girl was in Tanner stage II and 3 were in Tanner stage III at the time of surgery. Height measurements were taken preoperatively and at most recent follow-up to assess growth. Magnetic resonance imaging was performed preoperatively on all patients to confirm the diagnosis of ACL disruption and to identify associated injuries, including meniscal tears.

Figure 1
Figure 1:Preoperative AP radiograph of ACL injury with wide open physes indicating the patient is skeletally immature.

All patients underwent transphyseal ACL reconstruction using anterior tibialis tendon allograft. Additional knee injuries were identified and additional procedures recorded. Eight mm bone tunnels were made through the proximal tibia and distal femoral physis. Grafts were placed in the over-the-top arthroscopic femoral tunnel point using the posterior aspect of the ACL footprint as a tibial guide at a 45° position. The free edge of the tibial tunnel was débrided, and a transtibial femoral offset guide positioned to leave a 1- to 2-mm back wall was hooked in the over-the-top position. A guidewire was placed and then overreamed with an EndoButton reamer (Smith and Nephew Endoscopy, Andover, Massachusetts). Anterior tibialis tendon allografts were prepared by whipstitching the proximal end and placing the graft over a 30- or 35-mm continuous-loop EndoButton under tension. The EndoButton and graft were brought through the tibial tunnel across the joint and through the femoral tunnel. Then the EndoButton was flipped, and tension was applied to the graft to assess its stability, after which the knee was fully extended to assess notch impingement (Figure 2). After that, tibial fixation was achieved with screws-and-washers in 3 cases and a biodegradable interference screw in 1 case (Figure 3).

Figure 2
Figure 2: On the second arthroscopy, 25 months after ACL reconstruction, no evidence of graft failure was found.

Figure 3
Figure 3: AP radiograph of a patient’s open distal femoral and proximal tibial physes 28.9 months postoperatively.

Postoperatively, the patient was allowed toe touch-down weight bearing as tolerated with the knee in an brace until quadriceps function returned and with early progression of range of motion and strengthening exercises as tolerated. Daily activity without a brace and crutch was allowed at 3 months postoperatively, and sports activity involving running and pivoting were permitted at 6 months postoperatively.

The mean postoperative duration of follow-up was 32.3 months (range, 27.8-37.5 months). No superficial or deep infections, deep vein thrombosis, nerve injury, arthrofibrosis, or other perioperative complications were found. None of the patients underwent revision reconstructions for graft failure.

At last follow-up, the results of the Lachman test were normal for 3 patients and nearly normal for 1 patient. All patients demonstrated full range of knee motion (comparing the reconstructed knee to the contralateral knee). The results of the pivot-shift test were normal for 3 patients and nearly normal for 1 patient. No patients reported giving way.

The mean modified Lysholm score was 96.8 (range, 94-99). The most common deduction scale on the score was slightly impaired squatting, which was demonstrated at last follow-up. Two patients reported slight pain during severe exertion.

The mean International Knee Documentation Committee subjective knee score was 92.2 (range, 88.5-95.4). All patients have returned to their preinjury level of activity and athletic participation. The score of the patient who reported nearly normal on the Lachman test and the pivot-shift examination was 90.8, but she had no limitations of activities of daily living and athletic participation except skiing due to fear of reinjury. None of the patients had angular deformities or early physeal arrest measured between preoperative and postoperative radiographs. No limb length discrepancies >1 cm clinically and radiographically were found (Figure 4).

Figure 4
Figure 4: Subclinical limb-length discrepancy (1 mm) measured by whole scanogram at last follow-up.

Discussion

There is controversy regarding the management of ACL injuries in patients with open physes. Nonoperative management of complete tears have a poor prognosis, with recurrent instability leading to further meniscal and chondral injury.1,4,5,10 Similarly, when comparing the results of operative and nonoperative management of complete ACL injuries in adolescents, McCarroll et al15 and Pressman et al18 found that those managed with ACL reconstruction had less instability, higher levels of activity and return to sports, and lower rates of subsequent reinjury and meniscal tears.

Surgical treatment options for complete ACL tears include primary ligament repair, extraarticular tenodesis, transphyseal reconstruction, partial transphyseal reconstruction, and physeal-sparing reconstruction.3-11,19 The advantage of transphyseal reconstruction is placement of the graft tissue in an isometric position to provide better results, according to literature reviews.1,6,9,12-14,20 The potential disadvantage is angular or limb-length discrepancy caused by physeal violation.6,9,12-14 Kocher et al12reported 15 cases of growth disturbance: 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, 2 cases of genu valgum without arrest, and 2 cases of leg-length discrepancy. But, multiple studies describe the use of this technique in >160 skeletally immature patients, with good results.1,6,9,13,20

For the tunnel position and graft selection, the use of standard tunnels should be reserved for the skeletally immature patient nearing skeletal maturity and soft tissue graft is recommended to avoid physeal bar formation. McCarroll et al15 reported transphyseal ACL reconstruction using bone-patellar tendon-bone autograft. No postoperative angular deformities or limb-length discrepancies >1 cm were reported. Gaulrapp and Haus8 reported bone-patellar tendon-bone autograft and semitendinosus autograft for ACL reconstruction in skeletally immature patients. Both groups had a high rate of good to excellent results with no reported growth disturbances. Simonian et al21 believed that use of small, centrally placed tunnels and soft tissue grafts minimize the risk of physeal closure. Stadelmaier et al22studied the effect of transphyseal drilling and soft tissue grafting across open growth plates duplicating ACL reconstruction in the canine model. They found that fascia lata placed in drill holes across open growth plates prevented formation of a bony bridge and found no histologic evidence of physeal arrest. These findings support transphyseal drilling with soft tissue grafting across open growth plates.

Allografts have been used for adult ACL reconstruction with acceptable success.17 Allograft tissue is an attractive alternative in the skeletally immature athlete because it avoids using autogenous tissue.6,21Allograft tissue has certain advantages, including lack of donor-site morbidity and reduced operative time. In primary ACL reconstruction, allografts are comparable with autografts as equivalent clinical results show consistent efficacy.15-17

However, allograft use for ACL reconstruction is a controversial issue. Borchers et al3 reported allograft use for ACL reconstruction as a risk factor for ACL graft failure and suggested that soft tissue allografts should be avoided in patients who desire a return to high activity level.

Various allograft tissue types exist including patellar, achilles, tibialis, and peroneus longus tendons, depending on the surgeon’s preference. Achilles tendon and bone-patellar tendon-bone allograft is useful, but bone tissue could affect physeal bar formation when the transphyseal technique was performed. Soft tissue grafts such as anterior tibialis and hamstring allograft could save operation time because the Endobutton technique is simpler than the interference screw fixation technique.

Transphyseal ACL reconstruction using anterior tibialis tendon allograft in skeletally immature patients provides considerable functional outcome with no growth disturbance.

For further information: http://www.orthosupersite.com/view.aspx?rid=82952

Friday, May 6, 2011

Posted on the ORTHOSuperSite May 3, 2011
Young athletes who specialize in one sport may be at higher risk for injury

Focusing specifically upon one sport could potentially result in a higher risk of injury for younger athletes, according to a recently presented study.

Neeru Jayanthi, MD, shared his group’s findings at the 2011 Annual Meeting of the American Medical Society for Sports Medicine in Salt Lake City, Utah.

“Young athletes who were injured tended to have more intense specialized training in one sport,” he stated in a Loyola University Health System press release.

Sport specialization survey

Neeru Jayanthi, MD
Neeru Jayanthi

According to the study abstract, Jayanthi and his colleagues performed a prospective cohort study on athletes 18 years of age and younger who presented to their sports medicine clinic for a sports-related injury, comparing the patients to healthy athletes who presented for sports physicals.

Participants completed a baseline survey that evaluated their participation in sports, as well as their height, weight and degree of sports specialization. Retrospective data concerning height and weight, if available, were obtained from electronic medical records and used to calculate rate of growth. Injured athletes completed an injury survey to examine both their injury and their training. The results of these surveys were compared with the uninjured control group.

A six-point sports specialization score was used. It checked for factors, such as training more than 75% of the time in one sport, training to improve skill or missing time with friends, quitting other sports to focus on one sport, considering one sport more important than other sports, regularly traveling out of state, and training more than 8 months a year or competing for more than 6 months of the year.

Consider multiple sports

The group recruited 156 participants — 93 male and 63 female — with a mean age of 13 years. There were no reported significant differences between the injured and uninjured cohorts in terms of height, weight, body mass index, number of sports played and age.

Jayanthi noted two relationships trended toward significance. The injured cohort spent more hours per week playing sports (19.8 hours per week vs. 17 hours per week), and the injured cohort spent more hours per week in organized sports (11 hours per week vs. 8.8 hours per week).

Jayanthi also reported a higher mean specialization score for the injured group, as well as a significant difference between the injured and uninjured groups when they were stratified by specialization scores. In all, 60.38% of individuals in the study with injury were considered by their score to be highly specialized.

“More highly specialized participation in sports may be a risk for development of injury in young athletes,” the authors concluded in the study abstract. “This effect may be influenced by training intensity, reflected in annual weekly hours of sports participation and organized sports.

“We should be cautious about intense specialization in one sport before and during adolescence,” Jayanthi stated in the release. “Parents should consider enrolling their children in multiple sports.”

For further information: http://www.orthosupersite.com/view.aspx?rid=83183

Posted on the ORTHOSuperSite April 25, 2011

Study finds physeal-sparing method for ACL reconstruction of pediatric patients

SAN FRANCISCO — A combination of two techniques could spare the physis of skeletally-immature patients when drilling the femoral tunnel during anatomic ACL reconstruction, according to a study presented here.

Kyle E. Hammond, MD, shared his group’s findings at the 2011 Annual Meeting of the Arthroscopy Association of North America.

Hammond said his study aimed to develop a reliable and easily reproducible anatomic technique that used intra- and extra-articular landmarks to construct a femoral tunnel that avoided the physis.

“There is an increasing number of reported pediatric ACL injuries and reconstructions performed,” Hammond said. “Concern remains over injury to the physis. There is also an increasing interest in anatomic ACL reconstructions.”

Kyle E. Hammond, MD
Kyle E. Hammond

Landmarks in the knee

The investigators studied 188 MRIs from children aged 6 years to 17 years and examined multiple anatomic landmarks in the effort to locate optimal landmarks for ACL reconstruction. Hammond reported the femoral origin of the popliteus tendon and the lateral epicondyle were used as extra-articular landmarks, with the intra-articular landmark defined as the central portion of the femoral ACL origin.

Multi-plane computer software was used to plot points at the three landmarks in multiple planes, and lines were then drawn to depict potential femoral tunnels connecting the ACL origin to the popliteal insertion and the lateral epicondyle. The investigators then used these lines to calculate distances for tunnel lengths, the shortest distance from the physis to the tunnels, width of the femoral notch, and width and height of the femoral condyles.

Hammond said the group used 3-D MRI physeal reconstruction to confirm the physis was spared when these landmarks were used.

Safe and reliable

Hammond's group found significantly differing results across age groups and sexes for total femoral widths, notch widths, condylar heights, tunnel lengths from the ACL origin to the popliteus insertion and tunnel lengths from the ACL origin to the lateral epicondyle.

Hammond noted the average distance from the femoral physis to the tunnel that ran from the ACL origin to the popliteus was 12 mm — a finding that was independent of patient age or gender. The tunnel length averaged 30.1 mm in male subjects and 27.4 mm in female subjects. Hammond also reported an average tunnel length of 25.6 mm in 6-year-olds and 30.2 mm in 17-year-olds.

The tunnel leading from the ACL origin to the lateral epicondyle was 8.8 mm from the femoral physis in male patients and 8.9 mm from the femoral physis in female patients, with an average tunnel length of 34.3 mm in male patients and 31.6 mm in female patients.

“So even with the shortest distance we found to the femoral physis from the center of the popliteal femoral tunnel, which was 8 mm seen in one 6-year-old patient, you are still able to safely drill at least an 8 mm tunnel using this technique,” Hammond said. “Also, we found that the distance to the physis increased as the children matured — allowing even larger tunnels.”

The findings, Hammond said, show that drilling from the ACL origin to the popliteal insertion will produce an average tunnel length of 27 to 30 mm — allowing “at least” an 8 to 10 mm diameter tunnel in patients from 6 years to 17 years old. Use of the landmarks identified in the study, he noted, should allow for anatomic ACL reconstructions to be safely and reliably performed without intraoperative X-rays.

For further information: http://www.orthosupersite.com/view.aspx?rid=82907